Author Archives: billhill

Key Ethics Term: Surrogate Decision Making

When patients are lacking in decisional capacity, we depend on others to make decisions for them. This surrogate decision maker may be formally appointed by the patient (e.g. through durable power of attorney or DPOA), may be a legal next of kin (LNOK) as defined by the state, or (in absence of the former options) a guardian appointed by the state.

Surrogate decision makers are expected to make decisions for the patient using a (1) substituted judgment standard (i.e. deciding as the patient would under the circumstances, e.g. did the patient ever talk about not wanting to be on a ventilator?) or (2) best interest standard (i.e. deciding according to what seems to be in the best interests of the patient based on what we know about the patient, e.g. does an intervention provide reasonable benefit and minimal risk based on the patient’s circumstances?).

Key Ethics Term: Decision Making Capacity

Decisional capacity is decision specific (e.g. one might be able to choose what one wants for lunch but not whether or not a surgical interventions is appropriate) and it can wax/wane over time (e.g. directly following TBI I may not have decisional capacity, but may regain it over time).

Decisional capacity depends on the following (Applebaum 2007):

  1. ability to communicate a choice
  2. ability to understand the relevant information
  3. ability to appreciate consequences
  4. ability to reason about treatment choices.

Decisional capacity also comes in degrees and requires support. A number of things can affect one’s ability to demonstrate capacity or be capable (e.g. language barriers, fear of medical professionals, depression, etc.). But many patients with internal or external impairments that affect decisional capacity in the above regards can be capable with sufficient support. This is often called supported decision making and is growing formal legal support/actualization across the country.

Key Ethics Term: Respectfulness

Respectfulness is a kind of virtue, which can be broadly understood as a trait of character in which one recognizes, assumes, or even promotes the moral worth of others. A respectful person consistently and reliably treats others as “ends in themselves” (to use Kant’s language) or valuable in their own right. This can come in a number of different forms. While we commonly think of respect in bioethics in relation to respect for autonomy, we can also be respectful of person’s beliefs, emotions, relationships, etc. Thus, while ‘respect for autonomy’ is an integral principle in bioethics, we must also think more broadly about how to be respectful in the clinical setting.

Key Ethics Term: Empathy

Empathy is about knowing or understanding how another person feels. Unlike sympathy (feeling badly for another), or emotional sharing (sharing in an emotion with another), they key is that we come to some understanding of how another person feels in their own shoes (i.e. NOT how you would feel in another person’s shoes aka “perspective taking”).

Empathy is controversial. Some argue it isn’t possible or that it requires too much of us (e.g. is overburdensome in the clinical context). Others worry about its tendency to rely on stereotypes (e.g. greater accuracy with ‘in-groups’) or the potential for false/paternalistic empathy (e.g. a failure to ask another but just assume to know how they feel). However, the medical profession also relies on empathy for two important reasons:

  1. When appropriately sensitive and responsive, it can lead to knowledge about how a patient feels that can be critical to medical care.
  2. When appropriately sensitive and responsive, empathic engagement, on its own, manifests respect for the patient and can be critical to building a trusting relationship.

Key Ethics Term: Value

The term ‘value’ distinguishes descriptive statements/beliefs (e.g. the world is spherical) from normative statements (e.g. clinicians ought/should be compassionate). In the latter case we are making evaluative judgments or calling something good/bad.

Sometimes we take value to be intrinsic (e.g. we might say happiness is valuable in itself, not for some other goal), and sometimes we take value to be extrinsic (e.g. when we say x job is good because it pays well, or e.g. empathy is good because it helps patients heal more quickly).

We can also say that value is subjective or objective. For instance, wealth may be a subjective value that one person holds but not another (the value is relative to the subject/person). Whereas, we might say that compassion is objectively valuable because we all agree to its value, or because there is evidence that it makes persons and communities live well/ flourish, or because it is dictated by religious text, etc. (though some might disagree about whether compassion is an objective value, or whether anything can have objective value).

Key Ethics Term: Virtue

Virtue Ethics can be traced back to Mencius and Confucius, as well as Plato and Aristotle. In this course, we will be primarily using an Aristotelian framework for understanding virtue. The virtues are defined as excellent traits of character. Though there is disagreement over what it means for a trait of character to be excellent, most agree that it is the sort of trait that is fundamental to flourishing or living well (what Aristotle calls eudaemonia). For instance, courage, compassion/sympathy, truthfulness, trustworthiness, humility, empathy, respectfulness, these are all traits that are taken to be critical to flourishing as individuals and as a society.

The key for Aristotle is that our traits of character depend on excellent habitualization (we learn from others and practice habits with others). So, virtues are significantly dependent on social support. This can mean that being trustworthy is something that comes easily to you in part because you were raised to be trustworthy, but it also means choosing to be trustworthy because it is an excellent trait as you develop greater capacity to make choices. Some contemporary interpretations of Aristotle add that virtue can be dependent on sociality in another sense, virtue requires normative structures and systems that encourage and support it. For instance, when hospitals place higher value on numbers of patients than time with patients, it could be at the cost of empathy. Likewise, oppressive -isms (racism, chauvinism, ablism, etc.) can hamper virtue (e.g. being respectful of someone when social norms tell us that a feature of their identity is not worthy of equal respect, or e.g. being trustworthy when no one trusts me).

Some key virtues in the medical profession include (but are not limited to): empathy, sympathy, compassion, beneficence, respectfulness, justice, curiosity, humility, courageousness, trustworthiness, truthfulness, etc.

Review these Key Ethics Terms:

Read: Excerpts from Aristotle’s Nicomachean Ethics

Reading Aristotle is hard! But we think you can do it! It will create some discomfort for everyone. We do NOT expect you to master these concepts – it is more important in this session to be open, brave, vulnerable, and interested in growth than it is to be ‘right’. See what you can gather from the reading and use the PDF’s highlighting and prompts to guide you if you’re having trouble.

Consider: the role of empathy in medical student education while reading Walking a mile in their patients’ shoes:empathy and othering in medical students’ education. The article discusses the barriers for medical education to promote empathy and offers up a paradigm that may help trainees deal with these barriers and possible ideas of how they could be surmounted.

 

Read over this Facebook Post and reflect on how values and virtues can or cannot be demonstrated on social media. This was a post by a fellow student.

 

If you’re feeling eager for more… explore this article on How to Teach Doctors Empathy which talks about the growing emphasis on empathy training for health care professionals and describes a few such trainings across the country.

Responding to Bias: Strategies and Skills

Start by reading this JAMA Piece of My Mind “Speak Up” which describes one physician’s experience with speaking up when witnessing micro-aggressions or biased comments or behavior in the clinical workplace.

Then read this post from STAT News that describes a medical student’s experience with racist comments during her clinical training and how it felt when no one spoke out against it.

Tools for Responding to Bias

Goal: Communicate a message of disapproval without damaging interpersonal relations

Be ready 

  • Rehearse what you would do or say in situations before they occur
  • You know what feels most natural for you
  • Remember the Bystander effect
  • No one else will probably say anything
  • Consider saying something, even if it is a small effort

Decide whether to say anything 

  • Silence is often interpreted as passive complicity
  • Consider saying something simple like “that’s not cool” or “I don’t appreciate that”
  • You don’t have to take a dramatic stand if you’re not comfortable or not able

Consider taking more time if:

  • You know you respond badly in the heat of the moment
  • You fear retaliation or mistreatment and need more support
  • The situation is not appropriate (ie during a patient care emergency)

Stay calm 

  • Try to speak calmly, or consider waiting until another time
  • Try to avoid inducing defensiveness

Clarify or Restate what was said  

  • Make sure you are understanding what was said
  • Make the speaker think about what they said
  • “So I am hearing you say….” Or even “excuse me, what was that you just said?”
  • If a joke was made, ask the speaker to explain it to you
  • When identifying the behavior, avoid labeling, name-calling or the use of loaded terms.
  • Describe the behavior; don’t label the person.

Appeal to principles 

  • “I’m surprised to hear you say that.  I think of you as more… (egalitarian, open-minded, etc).”

Change the subject (more effective than it sounds) 

  • You may not change beliefs but you may change behavior

Reflect on what happened 

  • Journaling or meditation
  • Debriefing with a peer or college mentor

It’s never too late to bring it up 

  • Defer until later: “let’s talk about this when we have more time”
  • Bring it up later: “I’ve been thinking about what you said last week…”

Don’t get discouraged 

  • You won’t know the lasting impact you’ll have later on, both for the speaker and those who were present

Know your resources 

  • College mentors and college heads
  • Other trusted faculty
  • Student Affairs office

Traps to Avoid

Avoid making light of any comments, making jokes (which often backfire!), or getting defensive

Values to Norms

What makes a good community?  What values do communities hold? In thinking about building and enriching our own medical school community, and working together to establish some ‘norms’ of how we would like to engage, it is helpful to look for lessons from other academic communities.

The concept of a community agreement in higher education was advanced by the work of Earnest Boyer and other researchers and published in their report Campus Life: In Search of Community in 1990, funded by the Carnegie Foundation for the Advancement of Teaching. In their study, Boyer and colleagues identified six characteristics that define a positive academic community:

Boyer’s Principles of Community 

Purposeful 

A college is an educationally purposeful community, a place where faculty and students share academic goals and work together to strengthen teaching and learning on the campus

Open 

A college is an open community, a place where freedom of expression is uncompromisingly protected and where civility is powerfully affirmed.

Just 

A college is a just community, a place where the sacredness of the person is honored and where diversity is aggressively pursued.

Disciplined 

A college is a disciplined community, a place where individuals accept their obligations to the group and where well-defined governance procedures guide behavior for the common good.

Caring 

A college is a caring community, a place where the well-being of each member is sensitively supported and where service to others is encouraged.

Celebrative 

A college is a celebrative community, one in which the heritage of the institution is remembered and where rituals affirming both tradition and change are widely shared.

Taken from Ernest L. Boyer’s Campus Life: In Search of Community, 1990

IPE: Teamwork and Values Conflicts, Working with Challenging Patients

Teamwork and Values Conflicts

  1. We share core professional values but sometimes our values conflict with those of another (perfectly reasonable) team member. The training and practice of an occupational therapist emphasizes safety, which was in direct conflict with patient autonomy in this specific patient case.
  2. Conflicting opinions are a normal part of working in teams.  Successful teams a) assume positive intent, b) listen to each other, c) make sure every person on the team expresses their view, and d) concludes conflicts by negotiating a plan for next step/s.
  3. Place the patient at the center of the team.  Understanding the patient’s perspective on health and healthcare places the patient at the center of the team’s conversation, and can help all team members get behind a plan that meets the patient’s needs.
  4. Listening and speaking up are critical team skills.  Listen as much (or more) than you speak.  But speaking up is important for all team members to share their concerns or new information.
  5. We can’t always be the hero.  Sometimes we can’t “save” a patient. When we have different goals or health beliefs than a patient, we may not always feel good about our what we are able to do (allowed to do) for a patient or the patient’s outcome.
  6. Don’t take it personally.  When you feel challenged by a patient, ask other team members how it’s going for them. Don’t assume you’re the problem, or are the only one having difficulty.  If you’re frustrated, it’s likely others on the team are too.
  7. Talk to your team first.  When you feel challenged by a patient, don’t go it alone. Use your team to help you problem solve. Difficult patients can split us as teams. Knowing other’s roles and responsibilities and using them to full potential can share the burden of high maintenance patients.
  8. Think broadly when you think “team”.  Physicians, nurses, pharmacists and social workers practice in close proximity, often rounding together, but other team members may not be in the loop.  Remember to include everyone in challenging care decisions.
  9. Support your team members.  Especially when we have a challenging patient, we need to rely on and trust our team members to do their jobs.  Work together to adopt a common approach.

Working with Challenging Patients

  1. “Difficult” patients:  Challenging behavior is often a sign that, from the patient’s perspective, her/his needs aren’t being met.
  2. Engaging patients:  Exploring patient’s preferences in a non-judgmental way is key to enhancing motivation and engagement, both of which are essential to effective care.
  3. Respect for patient autonomy:  Ultimately, patients make their own decisions. The challenge for providers is to take the journey with them, work creatively to bridge medical aims and patient priorities, and provide support.