In this month’s Pediatrics(10.1542/peds.2020-1087), Pamela Nathanson, Jennifer Walter, Donna McKlindon, and Chris Feudtner describe a series of ethics consultations at Children’s Hospital of Philadelphia. Their results and the further questions they raise will be of significant interest to ethics consultants.
Investigators report 245 clinical ethics consultations between 2013 and 2018 or an average of 41 consultations per year over 6 years. This is a large volume of consultations for a children’s hospital and raises the question of what components of institutional culture and consultation services contribute to this large number of requests?
In addition to commonly used categories of core problematic issues and pertinent ethical considerations, the investigators also characterize consultations in terms of a novel typology of contextual attributes. They describe the attributes as “emotional, relational, or pragmatic underlying concerns” and they include “simple lack of knowledge,” “genuine confusion,” and “entrenched positions.”
This is an interesting proposal that may benefit from further refinement. The boundaries between “discord,” “entrenched positions,” and “articulate disagreement” are, for example, indistinct. The use of multiple categories to code a single consultation make it difficult to discern what percentage of consultations primarily involve a lack of information, a dilemma, or a conflict. Collaboration to develop valid, widely used analytical schemes for ethics consultation is sorely needed.
Furthermore, the authors conducted an exploratory analysis of the potential association between contextual attributes and core problematic issues, pertinent ethical considerations, and the consult process; the analysis is exploratory in the sense that the investigators used a P value of < 0.1 as the threshold for significance. They found that “acknowledged dilemma” was least prevalent in cases of non-adherence and most prevalent in-patient safety issues, and that “lack of knowledge” was most prevalent where the process was a one-on-one discussion with the requestor and least likely when it was separate meetings with the patient or family and the clinical team.
I hope that the authors will use their existing data to examine potential associations between requestor type and other factors. Developing a typology of outcomes might also prove valuable. It may be productive to examine which characteristics and processes are associated with intractable conflicts and which with mutual agreement. This data and analysis are intriguing, and I look forward to the investigators’ and collaborators’ future contributions.
