ETHICS MADE REAL

Gordon Self

November 22, 2010

In recent months there has been a surprising amount of public interest regarding so-called "angel cradles" where babies may be safely abandoned at hospitals (see "Will abandoned babies get a home? WCR, Oct. 4).

As I reflect on public attention regarding infant safe havens, both supportive and cautionary, I wonder, what does this say about care for other abandoned persons in society? Thoughts of a baby abandoned in a back alley understandably pulls at our heartstrings, compelling us to do something to protect a vulnerable human being.

Yet, are we equally passionate about the fate of other vulnerable persons? Who is there to provide safe haven for the distraught mother, when, in a moment of desperation feels she has no place to turn and leaves her baby to an uncertain fate? Or the absentee father of the child who has been victimized by a cycle of abandonment and betrayal himself throughout life?

What of the drug addict, the sex-trade worker, the homeless person, the frail elderly or the person living with mental illness who too may feel alone and abandoned?

Last month, I wrote about another form of abandonment that is equally unacceptable. The ethics literature has documented the harm done when persons are expected to go against their conscientious beliefs.

COMPROMISE ETHICS

For example, telling a clinician to accommodate a very important person (VIP) that requires compromising their independent clinical judgment, and risks harming a dying or immuno-compromised patient currently occupying the sole private room by moving them into the hallway, would be totally unethical.

Expecting our staff to comply with administrative orders like this would cause people to leave our organization in droves. Worse still would be those who elect to stay, abandoning some part of their souls in order to put up with the abuse.

In a perfect world, there would always be a private bed for everyone who requested one. Unfortunately, health care involves resource allocation decisions - trying to balance an unlimited demand for services given the limited number of beds, space, staff or funding dollars to go around.

Without careful ethical discernment, establishment of clear policies and demonstrated administrative will to stand by our clinicians and staff, we can abandon good people who must allocate their limited time and resources justly, knowing at times tough decisions must be made. Remaining silent and letting our staff "figure it out" on their own also constitutes abandonment.

GO FORWARD

Real ethics instead must provide people with direction and a way forward. When someone calls for an ethics consult they are looking for an educated opinion, and ethicists must be prepared to offer one, with a recommended course of action. This means being prepared to challenge assumptions and group think.

While there are many grey areas in ethics, there are clearly non-negotiables, too.

One fundamental commitment is not walking away from those we serve. Given the specialized training health care professionals possess, there is a greater moral obligation to continue providing care for vulnerable patients and residents even when staff is under-resourced.

This is easier said than done.

Nor is such messaging always appreciated. Just ask any physician or staff member working in Emergency or any other clinical area about their duty to provide care when they are feeling exhausted, overwhelmed and demoralized. Any reasonable person would want to walk away from such an untenable situation.

Probably the ultimate form of abandonment however is the levying of judgment on those who have to make such tough resource allocation and clinical decisions, without appreciating the reality in which they operate. Too often we demonize those who have to triage or make financial plans about what can be done when everything can't (or should) be done.

I recall once when parents of a young teen with an irreversible brain injury faced the decision to withdraw therapy, a wise ethics colleague warned them that possibly later some well-meaning family member might question the decision. "Why didn't you wait longer?" "You should have prayed harder."

For parents already facing such a horrendously difficult decision, the last thing they needed was judgment and doubt. Doing the right thing does not mean it is easy nor always universally understood.

Ethics must be rooted in compassion. We must be willing to stand with people at the most vulnerable times of their lives, or when providing care under less than ideal circumstances.

While our heart naturally goes out to abandoned infants, we must ensure we also do not abandon those caregivers, professional and family alike, who strive to do the right thing given a finite amount of resources.

(Gordon Self is vice president, mission, ethics and spirituality for Covenant Health and can be reached at mes@covenanthealth.ca.)