The Value of Ethics
In a hospital room filled with people who work on behalf of the patient, the law, and the institution, the clinical ethicist is the voice of ethics.
When I was an undergrad, I had the opportunity to shadow a hospital ethicist and was fascinated by the complex ethical dilemmas we encountered. Seven years later, as an MPH student in the department of Health Policy and Management, I was granted a new opportunity to deepen my understanding and enroll in a 3-day Clinical Ethics Immersion at MedStar Washington Hospital Center.
The immersive program was comprised of a series of lectures, guest speakers, skill-building workshops, case studies, and clinical rounds. We explored dilemmas where a clinical ethicist may act as a facilitator or advisor. These cases involve thinking beyond a traditional prognosis timeline.
In a simplified example, imagine a son who hesitates on signing a “do not resuscitate” order for his incapacitated elderly mother, hoping that she will recover from her illness. The ethicist takes in all the facts of the case and considers several issues before coming to a conclusion: who is actually able to make this decision; does that person have the information they need; has the severity of the situation been accurately expressed; do we have any evidence to suggest the patient had an opinion?
If this sounds like a job for a physician, a social worker, or even a lawyer, you are not alone in your confusion. The best way I can explain it, is that the ethicist answers only to ethics. This is not to say that the intentions, incentives, or interests of each of the professionals are misaligned, but the unique role of the Clinical Ethicist is that their duty is to bring ethical considerations to the forefront.
I believe this is an essential role and voice to have in our healthcare facilities. As a Policy and Management student, I enrolled in the Clinical Ethics Immersion program, in part, because I wanted to know how a robust clinical ethics program like MedStar’s could be replicated at other hospitals. I wanted to understand how and why administrators at this large hospital system value clinical ethics so highly that they support an entire Center for Ethics, which conducts ethics consults, hosts medical residency rotations, and produces a peer-reviewed journal.
So in the weeks after I finished the immersion, I have been considering the roles of leadership, management, and our thirst for evidence in healthcare.
No doubt many of us have heard the saying that “if you can’t measure it, you can’t manage it.” This mentality has been gaining a lot of traction in the field of public health as we encounter more and more reimbursement policies that require robust measurement of projects, programs, and performance.
Evidence is important for many reasons, not the least of which is efficacy. However, I was shocked to learn, from a guest lecture by Dr. Robert Berenson of the Urban Institute, during Prof. Jack Rowe’s class Transforming the Delivery of Healthcare, that this oft-repeated saying is a misquote. The true quote from The New Economics (p. 35) is, “It is wrong to suppose that if you can’t measure it, you can’t manage it – a costly myth.” (Dr. Berenson has written about this misquote and its importance in JAMA).
So what does this mean? Well, I do not begin to suggest that we have wasted our time focusing on outcomes. Instead, I am inspired to know that we must also trust in our managerial instincts to be effective practitioners of public health. We learn the important skills of research and measurement here at Mailman, but we can also use the rest of what we learn to build intuition and leadership.
Perhaps there will be more quantitative evidence in the future as centers such as MedStar, Cleveland Clinic, and The University of Pennsylvania, work to gather outcomes data of their Clinical Ethics programs. However, as I continue to appreciate the value of leadership and managerial instinct, I'm getting a better sense of how we can value the yet unmeasured, and perhaps, immeasurable.
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