When you think of biomedical ethics, probably the first things that spring to mind are ‘sexy’ topics like human enhancement or eugenics. But what actually helps patients and doctors? Medical student Frances Butcher examines how ‘ground level’ ethics research is supporting the doctors, hospital directors and other healthcare professionals decisions about patient care.
A lot of attention in biomedical ethics focuses – rightly – on experimental and exciting new developments in biomedical science such as human enhancement, genetics and neuroscience to name a few. But while these topics are of vital importance, they often have little relevance to healthcare professionals’ everyday working lives.
Conversely, ‘ground level’ ethics does not always grab public or media interest – unless something goes wrong. Then highly emotive stories of perceived individual injustice fly across tabloid headlines (an exception here is perhaps the interesting and sensitive BBC Radio 4 series ‘Inside the Ethics Committee’). But these personal – and often accusatory – stories often don’t address the complicated resource and policy issues behind the decisions and mistakes made.
Clik here to view.
Operating theatre
As a medical student, I – and many of my peers – have seen practices that could be considered unethical. A fictional example:
During a caesarean section, two junior doctors contact a consultant for help. The consultant enters the operating theatre, puts on sterile gloves but does not ‘scrub in’ or put on a sterile surgical gown. He instructs his juniors at first, but then proceeds to take over the caesarean and deliver the baby. This was watched by medical students.
If this were an emergency situation, the failure to ‘scrub in’ would be justified if the extra time to do so would endanger the mother or baby. But as this was not an emergency, the failure to observe sterile techniques increased the risk of post-operative infections. The consultant’s practice could be seen as unprofessional: he would be breaking hospital policy. The medical students now face the ethical dilemma of how they ought to respond to witnessing the consultant’s behaviour.
One researcher considering dilemmas like this is Dr Suzanne Shale. As part of her Wellcome Trust-sponsored PhD studentship, she interviewed hospital medical directors, who help to set and enforce policies that uphold standards of care. Shale proposes that an ethical healthcare organisation is built through the narratives of the individuals that work for the organisation, both their ‘internal’ narratives of belief and their visibly ‘enacted’ narratives of action. She emphasises the difference between:
- Moral belief and ethical action: Positive moral beliefs are a good thing. But what really counts is how a person enacts their moral beliefs. This is what those around them will perceive as that person’s ‘morality’.
- Providing care for individual patients and organising care for populations: When providing care for one individual at any given time, it is possible to say that their interests should always come first. But when there are many people requiring care over unlimited periods of time there may have to be some trade-off between different people’s claims.
Few doctors go to work intending to do their patient harm that day. In the scenario above, the consultant may well have believed himself to be a morally good person committed to safe patient care, following his moral beliefs by stepping in to help his junior colleagues when needed. But if this is so, the way that he enacted his beliefs creates an altogether different narrative, one that the medical students – as observers – struggled to understand. The medical students now, in turn, need to enact upon their own beliefs about their responsibilities in this scenario.
The patient would probably have had her interests better served if the caesarean had been conducted by the consultant – scrubbed in – in the first place, rather than the juniors. This tension between the organisation’s responsibilities towards ‘all patients’ and ‘this patient’ is experienced by individual clinicians: Shale maintains that these individuals have to enact a fitting solution to it by balancing their responsibilities to ‘all patients’ with their responsibility towards individual patients. An inevitable example of this is clinical education: that junior doctors gain clinical experience is in the interests of the future organisation and future patients, but not in the interests of present patients.
Other work includes that of Professor Clare Williams, a social scientist who uses qualitative methods to reveal ethical issues that have practical policy implications. Again, she achieves this through actually talking to healthcare staff.
Williams leads the highly multidisciplinary London & Brighton Translational Ethics Centre (LABTEC), funded by a Wellcome Trust Strategic Award in Biomedical Ethics. A key feature of their work is ‘ethics discussion groups’, which give staff working in complex and ethically problematic areas a chance to discuss concerns within a structured setting. Although primarily a technique used for research purposes, this has the potential to be beneficial in clinical practice – and to be of use to the consultant and medical students in our scenario.
What should the students actually do? The obvious answer is to talk to the consultant or report the incident. However, I know that approaching your seniors or whistleblowing can be very hard to do. An ethics discussion group could supplement the established clinical ethics committee and formal procedures. We have ‘post-event groups’ for voicing concerns but these are not normally focused on ethics. Moreover ethics discussion groups, in LABTEC’s context, are facilitated by a philosopher – Professor Bobbie Farsides. This provides a neutral party to help bridge gaps between abstract principles and clinical practice, and hospital policy and individual action.
I once heard an up-and-coming topic in biomedical ethics (in this case human enhancement) referred to as ‘ethics with sex appeal’. While ‘ground level ethics’ might not inspire the same initial fervour, exciting partnerships between social scientists, ethicists and clinicians have the power to deliver real and imminent changes to clinical practice.
References
- Shale S. Doing right in difficult settings: an investigation into the organizational ethics of healthcare. Wellcome Trust PhD Studentship, Grant No. 077981.
- Williams C. Ethical frameworks for embryo donation: views, values & practices of IVF/PGD staff. Wellcome Trust Project, Grant No. 081414.
Frances Butcher
Frances Butcher is a summer intern at the Wellcome Trust.
The Wellcome Trust’s Ethics and Society Programme supports research that explores the ethical and social aspects of biomedical research and health interventions.
Image credit: Wellcome Photo Library. Wellcome Images
Filed under: Medical Humanities Tagged: Bioethics, Biomedical ethics, Dr Suzanne Shale, Ethics, Medical ethics, Professor Clare Williams Image may be NSFW.
Clik here to view.
Image may be NSFW.Clik here to view.
