Navigating Complexities in Health Care Ethics
By: Jacob Dahlke
Have you heard the one about five blind men who were asked to describe a new animal – an elephant – to each other? One grabbed the leg and said, “It’s like a great pillar!” Another grabbed the tail and yelled, “It’s like a rope!” Another grabbed the trunk and thought it like a snake; the one who grabbed the tusk thought it like a spear. Finally one grabbed the ear and declared an elephant to be like a palm leaf. While each of these experiences are real and true to the ones that experienced it, it is limited in its scope of the whole animal. This could have serious consequences for the next person who stands in front of a charging elephant and thinks, “It’s nothing more than a rope coming my way.”
Modern medicine, it seems, has gone the way of trying to blindly describe an elephant. It is so specialized and advanced that each body system, even organ, has its own specialties and subspecialties. This is altogether a good thing: the more we can understand about the heart, for example, the better we can be at treating and preventing its debilitating conditions. But in the fragmenting of the human body into its various parts, health care in America seems to have lost sight of the whole. This can have serious implications when an individual is hospitalized with serious illness, or when their medical condition is fraught with multiple complications. I am sometimes asked, as a health care ethics consultant, how I ‘fit in’ to the picture. To help clarify that answer, consider a not-so-uncommon scenario in intensive care units (ICUs) across hospitals today.
A 77 year old woman is hospitalized after a fall and suffers a bleed on her brain in addition to broken bones. She was already managing Type II diabetes and congestive heart failure. All of this means that in the hospital she will be seen be many different specialists to treat her conditions: an orthopedic surgeon, a neurosurgeon, an endocrinologist (for her diabetes) and a cardiologist for her heart. As it happens, she may develop an infection, meaning she will be seen by an infectious disease specialist.
All of these health care professionals are, across the spectrum, very good at what they do. The amount of training to prepare them – both academically and in practical training – is staggering. They are attuned to the minutest detail of each part of the human body, how it works, how it doesn’t, and how to manipulate it back to health. But in combination with each other, the situation can quickly become complex. An orthopedist may likely perform heroic measures on a broken body, but all for naught if the heart is failing. The cardiologist may likely masterfully tune the heart, but for what if the liver fails. What is required is coordinated communication with the patient, in the context of the patient has a whole individual. Such a role, in such a complex situation, can sometimes be a lot to ask of the current members of the medical team. This is where a health care ethics consultant can help. I do not measure the tail, or the trunk per se. Instead, I clarify that there may be different descriptions of the same situation, and I can attempt to consolidate them back into a single story. With our patient described above, that could mean connecting factors outside of the hospital experience with factors from the medical team’s judgments about the patient’s diagnosis and prognosis for her current illnesses. This could include helping to clarify what are some guiding values for the woman that might guide her goals? How did she view her quality of life prior to the accident? With a general understanding of her prognosis, how does she anticipate it upon discharge? And more importantly, is it an acceptable level to her? These can be particularly challenging questions when the patient cannot speak for herself, and we must rely on discussions with friends, a primary care physician, and family members who know her and can speak to those values she held.
Each group then, can continue on in their roles, as surgeons, nurses, and other providers, but with a different view of how they fit into this particular situation, with this particular patient. The goal, for me, is to construct a narrative that includes all the players, however seemingly insignificant, and clarify roles in a broader sense to provide better, excellent care. It may be sometimes considered too global or aspirational. But in situations with patients who have complicated or complex stories, anything less is describing an elephant like a rope.
Jacob Dahlke is a clinical ethicist for Nebraska Medicine in Omaha, Nebraska, and an instructor and associate for the Center for Health Policy and Ethics at Creighton University. The views shared here are his own and do not represent those of the organizations.