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Solving ethical problems
MARCH 1986, VOL. 43, NO 3
AORN JOURNAL
Ethics Solving ethical problems
E
very action or decision has intended and unintended consequences. Defining a problem in ethical terms has the unintended consequence of making it more difficult to solve. As we become more sophisticated in ethical discourse, our tendency is to define more problems in ethical terms which compounds the unintended consequences. There are several reasons ethical problems are more difficult to solve. In any society as diverse as ours in religion, economics, culture, and ethnics, it is very difficult to reach a consensus. Also, ethics are abstract, ambiguous, relativistic,subjective,and emotional. And because ethics flow from religious, cultural, and professional authority, they are endowed with legitimacy, sanctity, and emotional power. Accordingly, people feel those authorities allow them to “stand on principle” and to view ethical positions as nonnegotiable. Thus, goodwill and flexibility, two important aspects of problem solving, are lost. Language presents additional problems. Ethical definitions are usually idiosyncratic. For example, the phrase “quality of life” has no consensus definition. Our language also limits the word “ethical” to one qualifier-you are either ethical or unethical. There are no words like “semiethical” to deal with the many shades of gray in human behavior. Because no one wants to be labeled unethical, we are under pressure to sound and appear ethical. That pressure can take precedence over discussions of other motives involved in decisions such as ambition, job security, and money. Ethics, in the secular sense, are operationalized
values. And values, because of their subjectivity, sanctity, and emotional power, elicit highly conflictual behavior; behavior that is not conducive to problem solving.
Levels of Conflict
C
learly, ethical issues cannot be avoided. On the contrary, the debate about ethical problems in health care must be expanded at the policy and practice levels. There are ways to make it easier to negotiate and solve ethical problems. If we assume a seven level conflict scale and further assume that problems are more easily solved at lower levels of conflict, then we may be able to redefine problems at lower levels of conflict and thus facilitate solutions. Starting with the most volatile level, these are the seven levels. Survival. When people feel their physical, economic, or professional survival is at stake, they feel justified in taking extreme measures to protect themselves.At this level, we can expect combative, primitive, and self-centered behavior. Values. Values are deeply held beliefs that govern behavior and provide the basis for the social fabric. They often are articulated in religious or political statements. Because of their sources, values carry a finality and sanctity that makes it possible for people to take strong, nonnegotiable positions. Resources. This level of conflict includes money, space, tenure, access, staff, participation, etc. People will tight for resources such as grazing or water rights often by converting them into
MARCH 1986, VOL. 43, NO 3
AORN JOURNAL
Legislators and regulators are writing laws and regulations fully expecting that courts will make the final decision. survival issues. Mostly, resources are distributed through competition. Although the competition involves a good deal of conflict, it rarely becomes life threatening. Turf. This includes roles, functions, prerogatives, jurisdiction, expertise, and specialty. The conflicts are like friction generating heat, but not tire. Priorities. At this level, there is a discernible cooling of conflict because there is a strong sense of equity (ie, justice will be served, it is just a matter of time). This will probably be the way the American health care system will deal with rationing. Priorities can always be debated and rearranged. Those two facts lend a sense of flexibility to priorities and a sense of flexibility lends itself to optimism rather than desperation. Communication. Labeling a problem as a communication problem is the classic way of crawling back off the limb. When you define a problem as a communication problem, you take most of the conflict out and give yourself time to regroup. Semantics. Word choice has great power to escalate or de-escalate conflict. We can de-escalate a situation by choosing words that do not tap into emotions. For example, the words “passive euthanasia” are unacceptable to many people. However, the words “watchful waiting” can describe similar behavior but are not inflammatory or have death as an intention.
Dealing with Conflict
E
thical conflicts can be downgraded by redefining them as turf problems, resource problems, priority problems, or semantic problems. In some cases, clinical teams are realizing that some ethical decisions are no longer their decisions to make. For example, in the case of developmentally disabled newborns, some of the decision610
making power has been preempted by federal regulations. With greater frequency, clinical teams, struggling with what they should do, are under instructions to consult with the hospital’s legal advisors to find out what they must do. Some medical-ethical judgements are being redefined as legal turf, a fact that clinical people are acknowledging with varying mixtures of sorrow and relief. Legislators and regulators are writing laws and regulations fully expecting that the courts will make the final decision. It is commonplace for a judge to break a deadlock between parents who reject treatment on religious grounds and physicians and hospitals who feel obligated to treat on medical-ethical grounds. Shifting the decision-making power from the clinical to the legal and administrative arm is a visible trend in health care today. Redefining an insoluble ethical problem into a resource problem may provide a solution to the abortion dilemma. Rapid advances in reproductive technology could make it possible to transplant an embryo from an unwilling female to a willing female. Thus, the embryonic life can be saved and the pregnant woman will be able to exercise her choice. There are a host of other ethical complexities lurking in such a solution. One obvious disadvantage is that embryo transplantation will be much more complex and costly than abortion and therefore vastly more difficult to obtain. But society will be able to address it as a resource problem and decide how to distribute the scarce funds and facilities. Nurses and physicians who control bed access
John W m , MA, is the chief of social work services at the Veterans Administration Medical Center, Palo Alto, CaliJ:He earned both his muster’s degree in social work and his bachelor’s degree in liberal arts at the University of Chicago.
AORN J O U R N A L
in intensive care units would be immobilized if they had to deliberate ethically about who to move to make room for a new trauma patient. Most have priority systems to make the decision. Often a patient’s risk (need) determines the first priority with anticipated clinical outcome and physician and family pressure also operating as priorities. Use of priorities facilitates decision making, especially where time pressure is involved. By now, it may be clear that I am speaking of a kind of two-track system for solving ethical problems, a system in which deliberative bodies such as ethics committees can address philosophical, legal, moral, and emotional issues and
MARCH 1986, VOL. 43, NO 3
develop and articulate knowledge and guidelines for their colleagues, institutions, and communities. The second track is for those whose roles impose requirements for prompt concerted action and who, by defining problems as resource, turf, or priority problems, may proceed with such action. Certainly, the two groups should not go their separate ways. The work of ethics committees will inform the world of practice and the world of practice will provide content and focus to the ethics committees. Both groups need to move with courage and humility. JOHN WAX,MA
Infection Outbreak Linked to Cool-mist Humidifiers An outbreak of Acinetobacter calcoaceticus var lwoffi infection at Mercy Hospital Medical Center, Des Moines, was linked to the use of coolmist himidifiers. No explanation could be found for the outbreak; this type of humidifier had been used for approximately five years without any problems. Its use was discontinued, though, and the occurrence of infection stopped. Ninety-two percent of the patients exposed to the cool-mist humidifier experienced definite or probable septicemia. Temperatures of all patients were 37.9 “C (100 O F ) or greater and the mean peripheral white blood cell count was 15,000/ mm3. The organism was found to have entered the body through percutaneous venipuncture along the intravenous cannula. The sites were dressed with sterile gauze and the tubings and dressings were changed every 24 hours. Each humidifier was discarded after each patient use; however, no in-use disinfection was carried out. Reservoirs were refilled during use with either distilled or tap water. During the investigation, alternative methods of cleaning, disinfecting, sterilizing, or otherwise reducing the risk associated with microbial colonization of humidifiers were considered. Previous studies on rigorous disinfection had failed, so there were no 612
further investigations. According to the authors of the article published in the October 1985 issue of American Journal of Infection Control, this outbreak emphasizes the value of thorough investigations of nosocomial infections due to unusual organisms. They call the lack of literature regarding therapeutic benefits from humidification troublesome, given the risks associated with humidifiers, particularly, cool-mist humidifiers. The authors call for hospitals to reevaluate their use of humidifiers because of the inability to document efficacy in humidifying the air.
Corrections to Radiation Recommended Practices The “Recommended practices for radiation safety” in the December Journal contain two errors. Both are in the section on Nonionizing Radiation: Laser, on page 924. In the second rationale for the first recommended practice, the numbers on the second line should be 400- 1,500 nm. In the third rationale, the information in parentheses should read (outside 0.4 to 1.4 pm).
AORN JOURNAL
Ethics Solving ethical problems
E
very action or decision has intended and unintended consequences. Defining a problem in ethical terms has the unintended consequence of making it more difficult to solve. As we become more sophisticated in ethical discourse, our tendency is to define more problems in ethical terms which compounds the unintended consequences. There are several reasons ethical problems are more difficult to solve. In any society as diverse as ours in religion, economics, culture, and ethnics, it is very difficult to reach a consensus. Also, ethics are abstract, ambiguous, relativistic,subjective,and emotional. And because ethics flow from religious, cultural, and professional authority, they are endowed with legitimacy, sanctity, and emotional power. Accordingly, people feel those authorities allow them to “stand on principle” and to view ethical positions as nonnegotiable. Thus, goodwill and flexibility, two important aspects of problem solving, are lost. Language presents additional problems. Ethical definitions are usually idiosyncratic. For example, the phrase “quality of life” has no consensus definition. Our language also limits the word “ethical” to one qualifier-you are either ethical or unethical. There are no words like “semiethical” to deal with the many shades of gray in human behavior. Because no one wants to be labeled unethical, we are under pressure to sound and appear ethical. That pressure can take precedence over discussions of other motives involved in decisions such as ambition, job security, and money. Ethics, in the secular sense, are operationalized
values. And values, because of their subjectivity, sanctity, and emotional power, elicit highly conflictual behavior; behavior that is not conducive to problem solving.
Levels of Conflict
C
learly, ethical issues cannot be avoided. On the contrary, the debate about ethical problems in health care must be expanded at the policy and practice levels. There are ways to make it easier to negotiate and solve ethical problems. If we assume a seven level conflict scale and further assume that problems are more easily solved at lower levels of conflict, then we may be able to redefine problems at lower levels of conflict and thus facilitate solutions. Starting with the most volatile level, these are the seven levels. Survival. When people feel their physical, economic, or professional survival is at stake, they feel justified in taking extreme measures to protect themselves.At this level, we can expect combative, primitive, and self-centered behavior. Values. Values are deeply held beliefs that govern behavior and provide the basis for the social fabric. They often are articulated in religious or political statements. Because of their sources, values carry a finality and sanctity that makes it possible for people to take strong, nonnegotiable positions. Resources. This level of conflict includes money, space, tenure, access, staff, participation, etc. People will tight for resources such as grazing or water rights often by converting them into
MARCH 1986, VOL. 43, NO 3
AORN JOURNAL
Legislators and regulators are writing laws and regulations fully expecting that courts will make the final decision. survival issues. Mostly, resources are distributed through competition. Although the competition involves a good deal of conflict, it rarely becomes life threatening. Turf. This includes roles, functions, prerogatives, jurisdiction, expertise, and specialty. The conflicts are like friction generating heat, but not tire. Priorities. At this level, there is a discernible cooling of conflict because there is a strong sense of equity (ie, justice will be served, it is just a matter of time). This will probably be the way the American health care system will deal with rationing. Priorities can always be debated and rearranged. Those two facts lend a sense of flexibility to priorities and a sense of flexibility lends itself to optimism rather than desperation. Communication. Labeling a problem as a communication problem is the classic way of crawling back off the limb. When you define a problem as a communication problem, you take most of the conflict out and give yourself time to regroup. Semantics. Word choice has great power to escalate or de-escalate conflict. We can de-escalate a situation by choosing words that do not tap into emotions. For example, the words “passive euthanasia” are unacceptable to many people. However, the words “watchful waiting” can describe similar behavior but are not inflammatory or have death as an intention.
Dealing with Conflict
E
thical conflicts can be downgraded by redefining them as turf problems, resource problems, priority problems, or semantic problems. In some cases, clinical teams are realizing that some ethical decisions are no longer their decisions to make. For example, in the case of developmentally disabled newborns, some of the decision610
making power has been preempted by federal regulations. With greater frequency, clinical teams, struggling with what they should do, are under instructions to consult with the hospital’s legal advisors to find out what they must do. Some medical-ethical judgements are being redefined as legal turf, a fact that clinical people are acknowledging with varying mixtures of sorrow and relief. Legislators and regulators are writing laws and regulations fully expecting that the courts will make the final decision. It is commonplace for a judge to break a deadlock between parents who reject treatment on religious grounds and physicians and hospitals who feel obligated to treat on medical-ethical grounds. Shifting the decision-making power from the clinical to the legal and administrative arm is a visible trend in health care today. Redefining an insoluble ethical problem into a resource problem may provide a solution to the abortion dilemma. Rapid advances in reproductive technology could make it possible to transplant an embryo from an unwilling female to a willing female. Thus, the embryonic life can be saved and the pregnant woman will be able to exercise her choice. There are a host of other ethical complexities lurking in such a solution. One obvious disadvantage is that embryo transplantation will be much more complex and costly than abortion and therefore vastly more difficult to obtain. But society will be able to address it as a resource problem and decide how to distribute the scarce funds and facilities. Nurses and physicians who control bed access
John W m , MA, is the chief of social work services at the Veterans Administration Medical Center, Palo Alto, CaliJ:He earned both his muster’s degree in social work and his bachelor’s degree in liberal arts at the University of Chicago.
AORN J O U R N A L
in intensive care units would be immobilized if they had to deliberate ethically about who to move to make room for a new trauma patient. Most have priority systems to make the decision. Often a patient’s risk (need) determines the first priority with anticipated clinical outcome and physician and family pressure also operating as priorities. Use of priorities facilitates decision making, especially where time pressure is involved. By now, it may be clear that I am speaking of a kind of two-track system for solving ethical problems, a system in which deliberative bodies such as ethics committees can address philosophical, legal, moral, and emotional issues and
MARCH 1986, VOL. 43, NO 3
develop and articulate knowledge and guidelines for their colleagues, institutions, and communities. The second track is for those whose roles impose requirements for prompt concerted action and who, by defining problems as resource, turf, or priority problems, may proceed with such action. Certainly, the two groups should not go their separate ways. The work of ethics committees will inform the world of practice and the world of practice will provide content and focus to the ethics committees. Both groups need to move with courage and humility. JOHN WAX,MA
Infection Outbreak Linked to Cool-mist Humidifiers An outbreak of Acinetobacter calcoaceticus var lwoffi infection at Mercy Hospital Medical Center, Des Moines, was linked to the use of coolmist himidifiers. No explanation could be found for the outbreak; this type of humidifier had been used for approximately five years without any problems. Its use was discontinued, though, and the occurrence of infection stopped. Ninety-two percent of the patients exposed to the cool-mist humidifier experienced definite or probable septicemia. Temperatures of all patients were 37.9 “C (100 O F ) or greater and the mean peripheral white blood cell count was 15,000/ mm3. The organism was found to have entered the body through percutaneous venipuncture along the intravenous cannula. The sites were dressed with sterile gauze and the tubings and dressings were changed every 24 hours. Each humidifier was discarded after each patient use; however, no in-use disinfection was carried out. Reservoirs were refilled during use with either distilled or tap water. During the investigation, alternative methods of cleaning, disinfecting, sterilizing, or otherwise reducing the risk associated with microbial colonization of humidifiers were considered. Previous studies on rigorous disinfection had failed, so there were no 612
further investigations. According to the authors of the article published in the October 1985 issue of American Journal of Infection Control, this outbreak emphasizes the value of thorough investigations of nosocomial infections due to unusual organisms. They call the lack of literature regarding therapeutic benefits from humidification troublesome, given the risks associated with humidifiers, particularly, cool-mist humidifiers. The authors call for hospitals to reevaluate their use of humidifiers because of the inability to document efficacy in humidifying the air.
Corrections to Radiation Recommended Practices The “Recommended practices for radiation safety” in the December Journal contain two errors. Both are in the section on Nonionizing Radiation: Laser, on page 924. In the second rationale for the first recommended practice, the numbers on the second line should be 400- 1,500 nm. In the third rationale, the information in parentheses should read (outside 0.4 to 1.4 pm).