1. Ethics Facilitation Boundaries of Facilitators Part 2 Philip Boyle, Ph.D. Vice President, Mission & Ethics www.CHE.ORG/ETHICS

2. Etiquette Press * 6 to mute; Press # 6 to un-mute Keep your phone on mute unless you are dialoging with the presenter Never place phone on hold If you do not want to be called on please check the red mood button on the lower left of screen

3. Goals for today’s conversation Part 1: The nature of ethics facilitation –The nature of ethics –The nature of ethics facilitation –Are you tracking your self- understanding? Part 2: Responsibilities of those engaging in ethics facilitation –Role confusion –Conflicts of interest –Boundaries

4. Commonly performed tasks Navigating clinical setting Gathering information Evaluating, interpreting, and analyzing info Facilitating meetings, understanding each perspective, assessing options for moral acceptability Promoting ethically acceptable plan of action Implementing quality assurance measures

5. “Qualified facilitation model” Identify and analyze nature of value uncertainty –Gather relevant data –Clarify relevant conceptual issues –Clarify related normative issues –Help identify range of morally acceptable options Resolve value uncertainty by building consensus –Ensure concerned parties have voices heard –Assist in clarifying values –Help build morally acceptable share commitment

6. The consultation Ability to facilitate meetings Introducing oneself properly, explaining what an ethics consultation is and what a person taking the lead does, the purpose and limitation of the consultation and his or her recommendations, and the relationship between the ethics consultation mechanism and institution. Ensure that all relevant parties have been invited and encouraged to participate. Ensure that all parties are introduced and explain their perspective roles Explain the goals and process of meeting and what can be expected. Elicit medical facts Elicit views and values of principles regarding issue Facilitate reflective listening, clarifications, summarizing interests.

7. The consultation Ability to build moral consensus Help individuals to critically analyze their underlying assumptions Negotiate between competing moral views Recognize possible areas of conflicts between personal moral views and one role in consultation

8. Limits to consensus People do not give up political rights –Patient’s autonomy –Employees’ conscientious objection

9. Place of personal views Cannot remain value neutral Do you offer your personal views? How to attend to sociological power and authority?

10. Potential risks Scope & limitation of role Conflicting interests Challenges of the role Responding to unethical practice Evaluation & accountability

11. Role Limitations Institutional role v. ethics consultation Misperception & misuse of role Explaining the role Appearance, comportment, interpersonal skills Power & ethics consultations

12. Role Limitations Role confusion –Primary institutional role Administrator Chaplain, Lawyer Nurse Physician Social worker –How could there be role confusion? –How do you avoid role confusion?

13. Case Dr. Doe a palliative care specialists also serves as an ethics consultant. He is called to the ICU by staff where an African-American family is requesting that everything be done for a 75-yr-old incapacitated Mrs. Church. She had told staff on a previous admission that she want to be kept comfortable but she was ready to meet her maker.

14. Role Limitations Misperception & misuse of role –Should ethics consultants be held to a higher standard of comportment? –Common presumptions: Moral police Exemplar Fixing the institution –Common requests that are inappropriate? –How do you or institution describe consultations?

15. Case Dr. Soo, who practices in an other-than- Catholic hospital refuses to follow the advance directives of a 60-yr-old alcoholic who suffered a serious head bleed. Family demands his wishes be followed. Ethics consultation team offers a facilitation and makes clear the state law that says a person can refuse life sustaining treatment, even if they are not dying. Dr. Soo states that the team should “clean up their own act.” One team members suggest this is a credentials matter & should be referred.

16. Role Limitations Appearance, comportment, interpersonal skills –Implications of wearing white coat, scrubs, stethoscope, clericals –How does appearance of gender, ethnicity influence consultation? Can you name a time that appearance, gender or ethnicity influenced a consultation?

17. Case Fr. Dave is a respected member of the hospital staff and member of the consultations team, often providing “curbside” consults. The difference between pastoral counseling and an ethical issues with the patient is a blurred line. When a nurse pulls Fr. Dave aside for an ethics consult about nutrition and hydration, what should he say?

18. Role Limitations Power & ethics consultations –Expertise as power –Negotiator as power –Insider as power What are the reasons why judgments & actions of consultant be misinterpreted and misunderstand and lead to abuse of power? How do you limit the abuse?

19. Continued Case of Dr. Soo If the ethicist who is part of the consultation teams clarifies all the relevant legal information and tells Dr. Soo that she intends to inform the CEO and CMO is that appropriate?

20. Conflicting interests What situations would be considered conflicts of interest? –Under what set of circumstances would you recuse yourself? Competing obligations –Name primary obligations What ways to avoid –Individually –By all members of team –During the actual consultation

21. Conflicts of interest Fiduciary obligation Something of “value” overrides fiduciary obligations Confuses decision making Appearance of a conflict of interest

22. Continued case of Dr. Doe Dr. Doe often works in the ICU. He has been dating an ICU nurse who was the person to initiate the consultation request. What should Dr. Doe do?

23. Conflicting interests & commitments Underlying values, commitments, interests Competing obligations

24. Challenges to the role Boundaries & moral weight of consultations Distinctions among –Moral uncertainty: is there a dilemma, which values apply –Dilemmas: good reasons for opposing actions –Distress: discomfort & unable to act Experience of marginalization –Silencing –“Obviously unethical”

25. Responding to unethical practice Integrity and unethical situations –Errors in medical judgment –Abuse of power –Breaches of confidentiality –Errors in clinical ethics consultation Disclosure & transparency –Integrity

26. Case As a consultant you have been called on a case of where the physician who knew the patient was a practicing Muslim prescribed a gel caplet made from pork products. The patient took the medicine and a nurse on another shift realized the mistake and thought the patient should be informed.

27. Evaluation & accountability Accountability in consults –What are the goals, purposes, & reporting structures of ethics consultation at your institution? –What do you want to learn though an evaluation process? –How will you use the info from the evaluations? Errors in consultations

28. Potential risks Scope & limitation of role Conflicting interests Challenges of the role Responding to unethical practice Evaluation & accountability