This is the first national survey examining the nature of the ethical issues physicians confront and their utilization of ethics consultation services. Four findings are noteworthy.
First, nearly 90% of physicians in this study encountered ethical dilemmas recently. However, physicians have a wide range of skills and available resources with which to address them. Most importantly, physicians with the least training and experience are the least likely to have access to and request ethics consultative advice. In light of the frequency with which physicians encounter ethical dilemmas and handle them on their own, it is important that health care organizations focus considerable effort on teaching ethics and training clinicians to resolve ethical dilemmas. While much has been written about ethics curricula in medical training,20–26
the results of this study highlight the need to provide and evaluate ethics education in medical school, residency, or subsequently in continuing education programs.
Second, physicians encounter different types of ethical dilemmas to varying extents depending upon their subspecialty. While end-of-life care issues are most common, nearly a quarter of dilemmas encountered by general internists and an eighth of those encountered by oncologists entail questions of justice. It may be that general internists, who are more often primary care providers and gatekeepers, are more likely to face ethical dilemmas related to lack of insurance for their patients and limited reimbursement for their services. Another noteworthy finding is that critical care/pulmonary specialists encounter more ethical dilemmas around end-of-life care than oncologists do. It may be that patients who have lived with a diagnosis of cancer are more adjusted to mortality and death, while the acute course of patients admitted to the intensive care unit frequently leads to a more tumultuous dying process generating more questions and conflicts about the ethically appropriate approach to care. Aside from encountering differing types of ethical questions, the extent to which physicians refer these dilemmas for ethics consultation varies depending upon the type of ethical dilemma.
Third, a significant minority of physicians report a lack of access to ethics consultation services. Despite the Joint Commission on Accreditation of Healthcare Organizations requirement that all health care organizations provide a mechanism for resolving ethical problems, 19% of physicians in this study reported that, to their knowledge, ethics consultation services are not available to them.
Finally, in evaluating ethics consultation, most internists report positive experiences and consider ethics consultation useful, productive of satisfactory solutions, and instructive for the future. However, a significant minority of physicians (41%) expresses reservations, about either ethics consultation generally, or the quality of the service offered at their particular institution.
In considering how ethics consultants should interact with clinicians, several authors have argued that the role of the ethicist is not to dictate the “right” solution, but to help create the environment and time in which ethical deliberation and mediation can take place.7,27–29
A consultative atmosphere that fosters fair, open, and unhurried discussion is likely to be time consuming.30
This recommendation is in tension with the views of the physicians in this study. Instead, these data suggest that ethics consultation could be made more responsive to physicians by 1
) making the process more expeditious; 2
) offering more specific recommendations in addition to theoretical analysis; 3
) ensuring that ethicists have strong ethics training and clinical experience; and 4
) better informing institutional members about available services. The challenge for ethicists is to make consultation more efficient to accommodate the need for an expeditious resolution, while providing a forum for thoughtful and inclusive deliberation.
This study has several limitations. Although the findings of this study are generalizable to the medical specialties surveyed and our sample reflects their demographic composition,31
they may not apply to other specialist groups. Second, data were collected through physician self-reports. There was no validation of the reports, which may have differed from actual behavior. In particular, the frequency with which physicians reported requesting and participating in ethics consultations was not verified and may be high. In a national survey of U.S. hospitals conducted by the Department of Veterans and reported by Ellen Fox to the American Society of Bioethics and Humanities in 2002, the median number of consultations performed annually by ethics consultation services was 3 (range 0 to 300). Third, while the response rate in the study is similar or better than that reported for other physicians surveys,32,33
we cannot exclude the possibility of response bias. Responders were more likely to be working in larger practices than nonresponders and may be more familiar with ethics consultation services, which have become prevalent in large health care organizations. Finally, the exploratory nature of the analysis warrants conservative interpretation of its significance.
In summary, ethical dilemmas commonly arise in the course of today's internal medical practice, and while the availability of ethics consultation has become the norm, it is not available for a fifth of practitioners at their predominant practice site. Furthermore, some kinds of ethical issues are brought to ethicists’ attention more often than others. Clinicians who might find ethicists’ opinions most useful are the least likely to avail themselves of this resource. Perhaps attention to this pattern of encounter with ethical issues and use of consultation might serve as a stimulus for improving the contribution of ethics consultants in today's ethically charged practice environment.