11 No. 3
December 2008/January 2009
Unraveling healthcare's knottiest problems
Researcher’s alleged transgressions lead to more ethics oversight
“Is it reasonable for [a patient] to be able to demand everything be done regardless of what that does to the healthcare system financially, or to its ability to serve a wider population?”
“I don’t think the main role of the ethicist is to tell people what’s right and wrong. One who does that in my opinion abdicates one’s responsibility.”
Medicine and Compassion
Reaching across the silos to teach the "art" of healing
Things I've learned while I couldn't do my research
Egypt and Emory
Small collection, large footprint
Academic Exchange: Describe your responsibilities as a clinical ethicist.
Elwood Spackman Jr.: If a family member, patient, physician, nurse, or other person in the hospital feels awkward about the ethics of a biomedical situation, they’ll call me and I’ll help them look at it from an ethics viewpoint and guide them to a decision, often a difficult one, especially around end-of-life issues. I often recommend family meetings where we bring the healthcare professionals and families together, which I moderate.
The most common dilemma we encounter is the appropriateness of withdrawing treatment and moving toward palliative care when attempts at a cure become futile. We also run into ethical issues when a person can’t make their own decisions and there are no surrogates available to make them. Then we’re faced with the ethics of providing or not providing treatment.
Another major issue is the use of scarce resources, whether it’s blood products, expensive medications, or even the allocation of hospital beds, which is more a business ethics issue but which has bioethical implications.
AE: What specific ethical dilemmas have been memorable?
ES: A few years ago Emory had to decide whether to disclose that a number of surgical patients were possibly exposed to Creutzfeldt-Jakob disease, though the chances were extremely low. We decided to do, in my opinion, the right thing and to make the disclosure, even though it might have brought on some negative views of the hospital.
In another case we dealt with the appropriateness of an organ transplant when the patient had no resources to pay for it. The transplant was done, and I remember that was one of the more difficult situations we’ve encountered.
AE: Your background in religion differs from that of your counterpart at Grady. How much of a difference does that make in your approaches to the work?
ES: Dr. Sexson and I often look at things out of the same set of values, but the lens I look through has more of a more theological bent. I have to rely on the physicians who are caring for the patient or other colleagues to get a clear medical picture and learn about issues of futility, for instance. I bring to the table the values of life, hope, and reality—that death is not the ultimate defeat—which is very helpful to families, who tend to trust clergy and appreciate a framing of the emotional dilemma they find themselves in.
AE: What influence does Emory’s historical foundations in the Methodist Church have on your approach?
ES: It doesn’t directly inform my approach as an ethicist. But the healthcare system, by nature of being attached to and having grown out of the university, has emerged as a very caring, person-centered healthcare system that is guided by the historic values of the Judeo-Christian tradition and is being influenced by the changing nature of the religious communities and other values as well. For instance, we are very sensitive to fact that there is a large Muslim population in Atlanta that we serve, a growing Buddhist population, and other faith groups that are emerging and bringing their own wisdom to the ethical dilemmas we face.
AE: How do you avoid falling back into the traditional role of a clergyman when interacting with people in great distress?
ES: Sometimes I do act as a counselor, but I try to bracket that in my role as a clinical ethicist. Sometimes I bring a chaplain along with me—even though I
am one—who takes on the role of nurturer so I can be more in my head and operating from an objective view.
AE: What are the most pressing issues in clinical ethics?
ES: The biggest change that’s raising questions today is whether or not autonomy is paramount in our decision making. Does a person or their surrogate have a right to make a decision of what they want regardless of the needs of the patient or the community at large? Is it reasonable for people to be able to demand everything be done regardless of what that does to the healthcare system financially, or to its ability to serve a wider population? To be very concrete, if the healthcare team deems that continuing a person on a ventilator is absolutely futile and the family demands he be continued on it
and kept in an intensive-care unit, and that prevents that bed or the expertise of the healthcare system from being available to someone else who needs that kind of care, is that beneficent, or should we look at the broader picture? That’s the type of things we’re facing fairly rapidly in my opinion.