Types of Clinical Ethics Consultations

Clinical ethics consultations can take many forms, and there’s no pathway they all must take. Instead, the ethicist, in consultation with the care team, will determine what level of involvement is most appropriate for the ethicist. In this article, I describe three levels of consultation and give some examples of each.

Individual Advising

Most consultations start with the requester phoning the ethicist. Some of the time, the intake phone call is sufficient to address the ethical issue. This might be because the most ethically appropriate option is clear enough that further involvement is unnecessary, or because the nature of the consultation concerns only what the requester should do, where no other information is necessary. In other cases, the requester is giving the ethicist early warning about a situation that might worsen. The ethicist can then provide suggestions for next steps, and no further action from the ethicist is necessary.

Here’s an example of peripheral advising. An emergency department physician has a patient who has influenza-like symptoms and is awaiting a Covid-19 test result. The patient tells the physician that she is on her way to visit a family member in hospital. When told that she won’t be allowed to enter because of screening criteria, the patient says, “Oh, I don’t intend to tell the truth!” The physician wants to know if he should report the patient for violating quarantine requirements, even though that will violate the patient’s privacy. In this sort of case, the ethicist has access to the information necessary to make a recommendation. 

For any consult, the ethicist must decide whether further action is warranted. Part of the value of bringing in an ethicist is that they will add fresh eyes to the situation, and so, in some cases, speaking with the requester won’t be enough to ensure that the ethicist has the full picture.

Team Meetings

If the ethicist requires more information or the nature of the situation warrants it, a common next step is to speak with other members of the care team. This is particularly common when there are many providers involved in a patient’s care (such as in an ICU), since there’s increased likelihood of gaps in communication and different perspectives.

After speaking with the rest of the team, a team meeting might be warranted to discuss the situation. Often, this type of meeting is effective at obtaining consensus about next steps.

Patient/Family Meetings

The most difficult and complex consultations often involve disagreements between the patient or their family and the care team. Sometimes, family members lack trust in the team, which leads them to take steps to prevent perceived mistakes, such as wanting to record all of the team’s interactions with the patient and questioning the providers’ decisions. This causes additional tension, which exacerbates the situation. As communication breaks down, it gets harder to provide effective care.

An ethicist can be a helpful resource in this type of situation, since they can help reframe the issues, focus on coming up with a plan of care, and reopen dialogue. Importantly, an ethicist has the training to have these difficult conversations, and can dedicate time to them that members of the care team often cannot.

The Main Ethical Issue

It’s common for a clinical ethicist to be consulted about a situation where the requester believes that the most pressing ethical issue is x, but, on investigation, the ethicist determines that a different factor is more significant. For instance, sometimes a team will be disagreeing with a patient’s family member. Multiple meetings have failed to make progress. The situation gets bad enough that the team consults the ethicist, who determines that the family member the team has been speaking to isn’t the appropriate substitute decision-maker, so the team shouldn’t be going to them for consent. Sometimes, simple ethical errors can have far-reaching consequences.

It’s hard to anticipate this type of error in advance. However, good processes, such as regular, brief education sessions about the importance of verifying the substitute decision-maker, can help.