Sunday, September 27, 2009

Considering Provider Autonomy and Conscientious Objection

This is adapted from a Lunch and Learn presentation sponsored by my hospital's Ethics Committee.

Our topic is provider autonomy; or as it is often phrased, “conscientious objection.” That is, objecting to some act in professional practice on grounds of conscience.

The standard principles we use in medical ethics are the Georgetown Mantra:

I found myself wondering just we might think of comparable categories from a provider’s point of view.

AUTONOMY: From a patient’s perspective, “autonomy” is a matter of the patient’s rights - primary the rights to choose or decline care, and to participate in decisions.

We would also say that a provider has “autonomy” – rights in exercising professional judgment. As a general principle, a professional has the right to accept or not accept a patient, and not to provide inappropriate care. For example, these are the provisions of the American Medical Association’s (AMA) Code of Medical Ethics:

(3) In situations not covered above [emergencies, what the AMA calls “invidious discrimination,” and certain contractual arrangements], it may be ethically permissible for physicians to decline a potential patient when:
(a) The treatment request is beyond the physician’s current competence.
(b) The treatment request is known to be scientifically invalid, has no medical indication, and offers no possible benefit to the patient (Opinion 8.20, "Invalid Medical Treatment").
(c) A specific treatment sought by an individual is incompatible with the physician’s personal, religious, or moral beliefs. (From section 10.05)

A similar provision is found in the Code of Ethics for Nurses of the American Nursing Association (ANA):

Where nurses are placed in situations of compromise that exceed acceptable moral limits or involve violations of the moral standards of the profession, whether in direct patient care or in any other forms of nursing practice, them ay express their conscientious objection to participation. Where a particular treatment, intervention, activity, or practice is morally objectionable to the nurse, whether intrinsically so or because it is inappropriate for the specific patient, or where it may jeopardize both patients and nursing practice, the nurse is justified in refusing to participate on moral grounds. (From Section 5.4)

NON-MALEFICENCE: This is our expression of the principle, “First, do no harm.”

From a professional’s perspective, we have a clear image of what harms a patient. Indeed, one of the clear categories in which a professional can refuse to provide an intervention is when the intervention will harm the patient. However, in the most common situations where conscientious objection becomes a matter of contention, it is because the patient is convinced that the given intervention will not harm the patient, but instead will provide benefit.

That raises another question: what harms the professional? What are the risks that the professional faces – personal, financial, legal, moral? Many physicians, certainly, have anxiety about lawsuits for inappropriate care, and most commonly for not providing enough care or that one alternate intervention. A few providers have faced physical risks in their practice, and in their choices about interventions to provide or deny. We are familiar with the recent death of Dr. George Tiller, assassinated by a person who felt justified by Dr. Tiller’s practice of providing abortions in less than perfect circumstances. However, it applies no less to the doctors and nurses who served AIDS victims before we knew what it was; or to the doctors and nurses who have taken care of swine flu victims before we knew its mortality rate.

Which brings us to BENEFICENCE: which for patients we traditionally phrase as acting in the patient’s “best interest.” Again, professionals may run into conflict with patients about the patients’ best interest.

That said, we can ask the question as to what is in the best interest of the professional. Most often we consider answers to that question that are about income or about freedom to practice. Those are enhanced by the licensure, registration, and certification that limit the number of competitors in our various practices. What other categories might be appropriate? For example, what is in the best interest of the professional’s integrity? What about social benefits of professional practice? We do, after all, receive a certain level of social benefit as professionals, a certain level of social standing.

JUSTICE is the final category of the Georgetown Mantra. I usually contrast this with Autonomy. If Autonomy is about the patient’s rights, Justice is about how this affects the rest of us. So, it is under the category of Justice that we discuss limited resources, costs of care, and other social concerns.

Justice is also an issue for providers. While there is Autonomy in practice, there are also professional expectations of service. It comes under the broad category of “fiduciary responsibility,” which is not solely about money. The word is based in the Latin for faith, fide; and it speaks of keeping faith with the patient and acting in the best interest of the patient, even if it is not in the interest of the provider.

This is also expressed in the Codes of Ethics of the various professions. There are limits to autonomy in professional practice. The various codes of ethics agree, for example, that there is a requirement to provide care in an emergency that transcends the principles of the provider. Consider, for example, the passage above from the ANA Code of Ethics for Nurses. After noting that under appropriate circumstances, “the nurse is justified in refusing to participate on moral grounds,” the very next sentence states, “Such grounds exclude personal preference, prejudice, convenience, or arbitrariness.” In a similar vein, we can note that the passage above from the AMA Code of Ethics is from a section titled, “Potential Patients.” The implication is such decisions can be made before the doctor-patient relationship is established. Once established, however, the doctor’s fiduciary responsibility limits autonomy. So, “Opinion 8.115 - Termination of the Physician-Patient Relationship” states,

Physicians have an obligation to support continuity of care for their patients. While physicians have the option of withdrawing from a case, they cannot do so without giving notice to the patient, the relatives, or responsible friends sufficiently long in advance of withdrawal to permit another medical attendant to be secured.

Note this principle that when a professional wishes to decline care there is an obligation to assist the patient until an alternative is found, and perhaps to assist the patient in finding that alternative. Paragraph 5.4 of the ANA Code concludes, “The nurse is obliged to provide for the patient’s safety, to avoid patient abandonment, and to withdraw only when assured that alternative sources of nursing care are available to the patient.”

So, where does this leave us? We use these categories to consider the ethical principles that serve the needs of patients. Do these categories give us a framework in which to discuss provider rights and conscientious objection? How would we analyze specific instances in these categories? What do you think?

Sunday, September 20, 2009

A Church for Adults

Some years ago I was speaking with a dear friend about his marriage and his future family. We talked about the couple and their plans for children. Being a priest, I also asked about their worship. My friend, raised in a Southern Baptist Church when it was still a bastion of freedom of thought, said, “Well, I’m sure we will join the church when we have children. I certainly want them to learn to live ethically.”

Now, I had and continue to have two problems with this statement. The second, as you will imagine, was the thought that the only point of the Church was to teach good morals. However, I was also struck by the first: the thought that participation in Church was determined by the needs and interests of children.

I’ve seen that attitude lived out often enough. We’ve observed it for years in families that fell away as soon as the youngest child finished the Sunday School curriculum, or left to go away to college. The most egregious case I recall was the parents who timed their Sunday morning tennis to coincide with Sunday School. Two children were dropped off at the back door of the parish, clean and polished and well dressed. Their parents, in their tennis whites and court shoes, smiled, waved them on, and drove off to the club. They were, though, quite observant and punctual: they had finished their play and were waiting again in the car when the children came out an hour or so later.

I was not raised that way. As soon as my parents thought I could stay home alone without burning the house down (at a young age that would be thought scandalous today), I was responsible for my own church attendance. After all, the church we attended was just under a block away. I could walk there easily and safely. If I wanted to stay home, I could. However, if I stayed home, I stayed home alone. My parents went to church with or without me, because it was important to them. Church wasn’t dependent on the needs or the interests of the children. Church was for adults.

This has long seemed to me a principal we might explore. What would it mean if we understood that Church was for adults? I mean, how far could we take that? It convinced me at an early age that Church was worth my time and effort; for as a child what did I want to be but an adult? I have speculated before about not allowing children to attend worship until they were sixteen. However, that was reflecting on the supposed power of exclusion, a power I did not and do not think the Episcopal Church would embrace. Rather, what would a Church for adults look like?

Certainly, it would engage in adult Christian Education. That might seem obvious, and yet as a supply priest I have seen many congregations that offered little if any. Many times I have heard concerns about having a Sunday School program for children, as much to attract their parents as to teach the children. Too often I have heard little about educating adults in Christian living. I am one who thinks many of our current difficulties have come because too many of our lay people have had too little education about the faith as this Episcopal Church has received it. As a corollary, I think too few have had the opportunity to be engaged, to share their own questions and thoughts as part of the educational process.

I think such adult education would be made available to high school and perhaps even junior high students. I’m not thinking here of intergenerational events, as valuable as they might be in themselves. Rather, I’m thinking of that those adolescents who are so close to adulthood, and from whom we are expecting more and more mature behavior, should see it modeled in the adults with whom they worship. They need to see that in this Church adults are seeking to grow in faith. They also need to see adults raising questions about the faith, and discussing those questions with one another, as acceptable within the context of our life together. In Church and out we need them to see how Christian adults live out their faith; and we need them to see it from all the congregation, not just the youth work “experts.”

What else might be characteristic of a Church for adults? Well, adults should be able to address difficult issues, both of life and faith (an artificial distinction, to be sure). It would encourage independence of thought. There are those who understand “receiving the Kingdom like a child” as mandating avoidance of hard issues, and repetition of core articles of faith. However, in my experience children aren’t that trusting and credulous, at least initially. Adults aren’t usually, either; except when faith communities try to circumscribe the explorations of members. A Church for adults would face, and not shy away from, difficult issues.

And in facing those issues a Church for adults would manage discussions that were civil, intelligent, and mutually respectful. We tend to think that adults are able to be thoughtful, and to discuss and disagree; or at least we tend to think that behavior is adult (because not all people of age behave that way). So our debates and discussions should be serious, and also engaging; passionate, and also enlightening. (I’ll admit that I think that at our best we Episcopalians can do thoughtful discussion quite well; but I don’t think we’re alone in that.)

These are just some initial thoughts. What would you think would be the characteristics, values, and value of a Church for adults?

Friday, September 18, 2009

Outrage at Episcopal Cafe

My newest piece is up today at Episcopal Cafe. It is my expression of outrage relevant to the issue raised of health care for illegal immigrants. Of course, as my regular readers will know, I'm not outraged at the same things as the shouting critics.

So, link over to the Cafe. And while you're there, read what my colleagues have written there, and take the trouble to leave a comment. We want to reflect good ideas and good discussion in and about the Episcopal Church, and we want it to be as wide as possible. So, come and see.

Saturday, September 12, 2009

Suggested Reading

I don’t often comment here on what I’ve been reading. Well, that’s not exactly true. The fact is that I don’t read for recreation as often as I might, and then for escape and not edification. I spend an awful lot of time reading on line; and so perhaps I do comment here on what I’ve been reading.

That said, I did read a book this summer that I can recommend. I found myself reading Perfectly Imperfect by Lee Woodruff, and I enjoyed it. I received the book when she was the featured speaker at a fund raiser for my hospital.

Now, I’m no better than anyone else at reading books I receive in such circumstances. However, I had an opportunity before I gave the invocation (yes, I do find myself singing – er, praying – for my supper, as it were) for a good conversation with her. It was clear that she had had good experiences with chaplains when her husband Bob was in the hospital. You may remember that Bob, a correspondent for ABC News, was injured in Iraq, and recovered after a long hospitalization. Speaking with Lee I had some sense of what she felt she had learned in that experience about caring for families in such difficult circumstances. She particularly suggested I would be interested in the last chapter, “What I Know Now.”

So, I did read the book, and I did enjoy it. It is certainly honest and self-revealing. While I think most of her readers will be women, it is a book I can recommend to men – just be prepared for a woman’s observations about us, and about things in the lives of women that we don’t usually hear about. Lee was as engaging in print as she was in person, and in a way I felt honored, feeling that sense of intimacy when a personal story is shared.

But she was right about the last chapter, and I can especially recommend it, for readers in general but especially for chaplains and other clergy. Indeed, if I were still in that business, I think I would recommend it for CPE students. She confirms some principles of providing support that I have seen over the years - like, there are no magic words; and think before speaking of God in “all of this.” She has clearly thought through what was helpful to her, and what she has seen as helpful to others. In chaplaincy we say often that our patients are our best teachers. This last chapter, “What I Know Now,” is just that sort of opportunity.

So, take the time to read Perfectly Imperfect; and not just the last chapter. We are honored when individuals share with us the stories of their lives. That sense of being honored can blend with a distinct sense of pleasure in reading Lee Woodruff’s book.

Wednesday, September 09, 2009

Health Care Reform and the American Character: Reacting to the President's Address

All right, let me get down to brass tacks. Yes, I did watch the President’s address to Congress on health care. Some quick thoughts.

First, I was pleased. No, it wasn’t all I might have hoped for. Those who have read here regularly will know that I lean toward a single payer option. However, it was a doctor some years ago who said to me, “Don’t let perfect become the enemy of good.” That is, don’t get so hung up seeking perfection that you don’t do what good you can.

Second, this is clearly more about reforming and regulating insurance than about health care practices. That said, finding money to carve out of existing Medicare and Medicaid spending does have something to do with health care practices. While he didn’t use the words “medical effectiveness,” the thought was there. Now, in fact everyone in practice wants to know what treatments are effective, and among competing treatments which are more effective. I don’t know a doctor or nurse who doesn’t want to provide the most effective care possible.

I also know that this will be a challenge to the pharmaceutical and medical device industries. I think it’s a good challenge. There are those who claim that this is one of those things that will “stifle innovation.” I think that, on the contrary, it will stimulate innovation. Adding a decongestant to an antihistamine and patenting the “new combination” isn’t innovation. Reformulating a 4-hour dose to a 12-hour dose and patenting a “timed-release” dosage isn’t innovation. What we need are a new antihistamine that works in a different way, or a new antibiotic, or a new surgical procedure that uses less blood – these are innovation. Measuring effectiveness, and using first for each patient and in each situation the therapy that has been shown most effective for most folks, will focus our directions for innovation. We will, after all, need alternatives for second-line treatments and for patients with special needs. We just won’t use them except where they’re the justified choice.

Third, we can do it. More to the point, we can afford it. Affording it is a matter of political will, and not of absolute limits. The President put that in perspective when he compared generally the cost of this plan with the costs of the wars in Iraq and Afghanistan, and when he compared it specifically with the tax cuts for the wealthiest under the last Administration.

What makes that hard for some folks is the fear of one change or another on top of our current system. In fact, though, these changes will significantly change the landscape. For example, if we can effectively provide universal access to health care for all citizens, we can also largely eliminate cost shifting, that percentage providers must add to cover unreimbursed care. That, then, will in itself slow cost increases. Slowing cost increases slows what we pay for coverage, both in premiums and taxes. Or, we can realize that we pay for all this care one way or another. If we pay more in taxes and less in premiums, we’re not paying more over all. And if we involve the greatest number of people in the system, both as user but also as contributors – that’s what the employer and personal mandates do – we minimize relatively what each of us individually has to pay over all. The point is that these things are all connected, and improving one aspect has ramifications for all.

Fourth, I am glad the President presented this as a moral challenge. I’m especially glad that he raised as a counterpoint to America’s cult of individualism that other American tradition of concern and support for one’s neighbor. In my childhood community barn-raising and neighbors clearing land together were as much a part of American cultural history – indeed, more – than the ideal of the rugged individualist. I was raised not on the image of the gunslinger but of the volunteers who fought together at King’s Mountain and at New Orleans; on community action and not on individualism. For the better part of a generation politicians have played held up (small “l”) libertarian ideas in ways that played to individual greed, and that divided us into ever more fragmented clusters of “us and them.” They obscured those generations of Americans who knew how to balance “what’s in it for me?” with “We the People.”

So, the speech is over, and tomorrow morning the politics begin again. Please God, the Senators and Representatives will have listened, and will have been moved. Please God – whether they believe in God or not – they will see this as an opportunity to reflect their own characters in ways that support the President’s vision of the American character.

Tuesday, September 01, 2009

Oh, Those Ironic Republicans!

You ever have one of those surreal moments? One of those where the irony is thick and sweet, and essentially missed by those under discussion?

I had one of those when I saw my local paper today. It has this story of Senators Kit Bond, Mitch McConnell, and John McCain coming to hold a carefully controlled, invitation-only presentation on health care at Children's Mercy Hospital in Kansas City. The best and most ironic statements were these from Bond and McConnell:

Bond said Missourians “don’t want a government bureaucrat standing between them and their provider.”

McConnell, the Senate minority leader from Kentucky, said if government got into the insurance business, it would wipe out the private insurance industry.

“Then the doctors and hospitals will be working for the government,” he said.

What made these statements so ironic was their proclamation in the context of a children's hospital. While I don't know the specifics of Children's Mercy, I know that Medicaid and State Children's Health Insurance Program (SCHIP) funds are essential, even critical sources of revenue for children's health care. If it weren't for government supported insurance programs, many if not most children's hospitals wouldn't be able to keep their doors open. So, one could argue that these doctors and hospitals are already working for the government. Certainly, they wouldn't be able to provide care without those government dollars.

Which of course aren't ever enough. That's because the dollars are set by Federal funds provided to states, with legislators expected to provide matching funds from state revenues. Of course, with their many hard choices to make, state legislators are constantly setting limits on which children qualify, largely by parental income. They will also make distinctions by residence and by citizenship in enabling legislation. So, if government bureaucrats aren't standing between patients and providers, state legislators certainly are. Actually, because state legislators are, government bureaucrats have no choice.

So, these Republican senators have stepped out into an ironic moment worthy of the attention of Olbermann. The only thing sad is that they probably have no idea. It would be good if they realized their self-satire. It would be better if they were really committed to the health care of the children and families around them.