Ethics
Rounds
in a Children’s
Medical
Center:
Evaluation
of a Hospital-Based
Program
for Continuing
Education
in
Medical
Ethics
Melvin D. Levine, M.D., Lee Scott, Ph.D., and William J. Curran, J.D., S.M.Hyg.
From the Harvard Interfaculty Pmgram in Medical Ethics and the Department of Medicine, Children’s
Hospital Medical Center, Boston
ABSTRACT. Clinical rounds in medical ethics were
estab-lished in 1971 in a large medical center to provide a forum for the multidisciplinary discussion of moral dilemmas in health care. The rounds consisted of case presentations and
analyses by professionals primarily from the fields of law,
pediatrics, religion, and philosophy. Five years of experience
with these rounds were reviewed. Certain predominant themes emerged from the discussions. The most common involved the process of selecting a decision-maker. The rounds were evaluated with regard to their impact and educational value. Although these sessions often did not lead to diametric change in position by participants, they did help
to sensitize participants and to clarify and expose critical issues. Ethics rounds may offer a constructiv’ response to the
current outcry for more stringent consideration of moral values in hospital settings. Pediatrics 60:202-208, 1977, MEDICAL ETHICS, ETHICS ROUNDS, DECISION MAKING.
With the continuing expansion of diagnostic and therapeutic options, there has been a growing interest in the formal application of human values to medical decision making. In the last decade, this has been associated with a proliferation of
university biomedical ethics programs.
Educational efforts have focused largely on three populations: premedical students, medical students, and nonmedical undergraduates or advanced students with an interest in ethical and
moral issues. Medical ethics teaching activities in this country have been reviewed in two recent reports.”2 University programs include formal
courses, lectures on specific issues, analyses of
illustrative cases, topic-oriented workshops, and intensive staff seminars. Curriculum developers have as a common goal the preparation of morally informed and sensitized individuals who will ultimately exert an influence on medical care.
With the surge of interest in biomedical ethics, it is ironic that clinicians and clinical investigators receive the least formal medical-ethical educa-tion. Hospital-based ethics programs for interns, residents, practicing physicians, and academic
medical personnel have been slow to emerge. The heightened awareness of ethical issues in the
noncimcal academic community and among
consumer groups has affected physicians through
measures that limit their autonomy in decision
making. Continuing education in ethics emerges
exclusively in potentially threatening contexts
such as malpractice suites, peer reviews, and
experimentation committee meetings. There exist few organized mechanisms for the nondefensive, ongoing, informed scrutiny of ethical and moral
dilemmas by those directly engaged in medical care and investigation. In a recent study, Maka-rushka and Lally3 found that physicians working in clinical research were unlikely to have had any formal training in ethics.
Received November 22, 1976; revision accepted for publica-tion January 31, 1977.
Supported by the Joseph P. Kennedy, Jr. Foundation.
To meet the need for continuing teaching in
biomedical ethics and to enhance communication
between clinicians and those in other disciplines, an ongoing educational program was developed at Children’s Hospital Medical Center in Boston. This was organized by the hospital’s Department of Medicine and the Harvard Interfaculty Program in Medical Ethics. The model consisted of regularly scheduled “ethics rounds” in the form of organized case presentations with
multidisci-plinary discussions. The sessions lasted from 75 to
90
minutes. Participants included postgraduate fellows and faculty members in philosophy, relig-ion, law, and the health professions. Whenrele-vant, representation was obtained from other fields including social work, rehabilitation,
psychology, sociology, economics, and medical
history.
THEFORMAT
Rounds were held during the university’s academic year. Before each semester, health professionals in the clinical and administrative sections of the medical center were contacted and
asked to attend on prearranged dates to present actual cases containing specific ethical problems that exemplified the type of issues faced in their
particular areas. An effort was made to select from a wide sample of programs and disciplines in the medical center. Professionals from other hospitals and from private practice also were invited to select and present cases. The presenters were encouraged to request that other staff with whom they work attend the rounds. Notification of ethics rounds was sent to interns, residents, and other hospital personnel the week before each session. In an effort to prevent the rounds from
being misinterpreted as having decision-making responsibility, the presenters were discouraged from using patients currently in the hospital or presently under care for the problem described. It was requested that they select inactive cases or
those in which a decision had already been made. The description and identity of patients were
withheld or altered significantly to preserve confidentiality.
The discussion leader was physician (M.D.L.) with a senior-faculty ethicist as a major discus-sant. From year to year, this role was assumed by
different faculty members who were philosophers or theologians. They were academically based but had little prior experience in medical settings.
A lawyer specializing in the field of legal medicine (W.J.C.) also participated in most years. His role was to clarify and distinguish between legal and ethical issues and responsibilities. The
lawyer participants (both faculty and fellows) were found to take quite naturally to the case method used in the rounds, and they were often the most adept at sorting out the issues of decision making. It was also the role of the lawyer-discussant to deflect the analysis from using the law to provide complete “answers” to ethical and moral problems, and to point out where the law itself was uncertain or open to serious criticism and need for reform.
Each ethics rounds session began with a five- to ten-minute case presentation. An elucidation of
the medical decision-points or critical moments was then pursued. Key moral or ethical issues were defined at these points. However, there were no detailed discussions of ethical theory. Although frequently a consensus emerged from the discussion, there was no formal attempt to arrive at a majority or unanimous decision. A record of each case presentation was kept on file, along with notes on the discussion.
It was determined early that ethics rounds should have well-defined objectives and limita-lions. They were not intended to replace or
supplement existing decision-making processes.
At other centers, efforts to have a committee
make clinical ethical decisions were ineffective and short-lived. The rounds were not designed to proselytize for a point of view, to launch campaigns for causes, or to instigate broad reform in medical care. Instead, it was anticipated that these discussions might help to elucidate the
ethical content and moral implications of medical choices. If successful, the rounds could influence future decision making or policy and provide an accessible forum for chronic, difficult-to-resolve
dilemmas. Additionally, these sessions could
facil-itate ongoing communication between faculty members and trainees in medical ethics and
pediatrics.
CONTENT ANALYSIS
During the first five years of ethics rounds (1971-1976), with minor variation in scheduling, the mean frequency of sessions was once every two weeks during the academic year.
Within this time, 36 professional divisions or
departments presented cases. There were also cases from four pediatricians in the community, three other hospitals, and one public school system. Included in the in-hospital presentations were several administrative divisions such as the director’s office, the medical record room, and the computer center.
TABLE I
MOST FREQUENTLY RECURRING ISSUES AT ETHICS ROUNDS (1971-1976)
Issue or Topic Frequency of Emergence
Cases Involving Issue#{176}(%)
1 Who should decide? 29 37
2 Ethics of innovation 17 21
3 Truth telling 15 19
4 Balancing relative risks 13 17
5 Rights of retarded children 12 15
6 Quality control in health care 12 15
7 Prolongation of life 12 , 15
8 Limits of parental authority 11 13
9 Rights of children 11 13
10 Behavior control in children 8 10
11 Qualityoflife 7 9
12 Resource allocation priorities 6 8
13 Interprofessional interactions 5 6
14 Issues in dying 5 6
15 Access to care 5 6
16 Acting on uncertain prognosis 5 6
17 Confidentiality 5 6
#{176}Basedon total of 79 cases, some including multiple issues.
emerged most frequently in the discussions. There were 79 cases presented. Table I lists the issues which were discussed on five or more occasions during the five years under study. Many of the cases involved multiple issues. Three typical cases and some points that arose in their discussion are described below:
Case 1
A 7-year-old boy was taken to his pediatrician because of “hyperactive behavior.” The boy had shown destructive tendencies in school and at home. He was having a great deal of difficulty learning basic reading skills and showed very poor pencil control. His teachers were concerned that he was unable to concentrate long enough to learn very much. His parents were distressed and felt that they had no idea of how to control him. The pediatrician was quite rushed that day, but had time to perform a complete physical examination on the child. He felt that he was probably a little delayed in his development, but that he really was a rather likeable child. He noted several “soft signs” and made the diagnosis of minimal cerebral dysfunction. He decided to place the child on dextroamphetamine sulfate (Dexedrine) pills. He and the child’s mother discussed whether the child should be told what medications he was taking. The mother was against this. It was decided to tell the child that the pills were vitamins. The parents and physician were concerned that if
the child were told the truth about the pills, he might feel
“different” from other children.
Much of the discussion of this case was focused on the issue of truth telling and of a child’s “right” to truth. Most participants questioned the deceit in this case, feeling that the child had a basic right to know about the pills he was taking. it was felt that, with appropriate counseling, the stigma of
taking medication could be removed. There were a few participants who insisted that the parents had the authority to protect their child from truths that might, in fact, damage the boy’s self-esteem. There was some comparison of the ethical
issues in this case with issues that might emerge in the use of placebos. In both instances, deception is practiced for the purpose of an optimum therapeutic result.
This case provoked a conflict that was common in ethics rounds. It involved the tendency of many
clinicians to assume a utilitarian position or one in which an act is justified in terms of the total
amount of good or comfort resulting from it.
Often philosophers in the discussion opposed this, adhering to a deontologic position or one in which a decision is based on adherence to an a priori moral principle (e.g., there is an inviolate right to keep living or to hear the whole truth). A
utilitarian argument was advanced in this case. It
was said to be the physician’s duty to shelter patients and families from damaging truths. A philosopher at the rounds presented a deontologic point of view. It was his conviction that
that with proper counseling, the boy could benefit from the truth, thus justifying honesty even from a utilitarian viewpoint.
There was some incidental questioning in this case about the use of medications to control
behavior, and about the scantiness of the evidence that led to the physician’s diagnosis.
Case 2
A 10-week-old boy was admitted to a medical center on
the first day of life. He had been delivered by emergency
cesarean section because of fetal distress. Intubution and resuscitation were required in the delivery room. At age 6 hours, he was placed on a respirator and remained on mechanical ventilation for six weeks. A diagnosis of broncho-pulmonary dysplasia was made. At age 6 weeks, an attempt
was made to wean him from the respirator, but his pulmo-nary status deteriorated. His parents insisted that he be placed back on the respirator. This was done, but, despite maximal efforts at pulmonary management, his status continued to deteriorate. He developed congestive heart failure and began to have seizures. At age 8 weeks, the parents revealed that they were both Christian Scientists, and that they were contemplating removing the child from the hospital. They wanted to know if anyone would accuse them of “killing their baby” if they took him home and allowed Christian Science to help the infant. At that point, there was consensus among the medical and nursing staff that the baby would not survive for more than a week or two
with maximal medical care in the hospital. In was felt, however, that if the baby were disconnected from the
respirator and taken home, he would have frequent seizures
and would die much sooner. This was explained to the parents, but they continued to insist on the discharge. The physicians were very concerned about psychological trauma
to the parents that could ensue with the child at home.
In this case, a major issue emerged: who should decide? It was not clear whether the ultimate decision as to whether the child would be
removed from the hospital should rest with the
parents, the physician, the courts, a committee, or a child advocate. An attempt was made to
differ-entiate between various legal positions and the
moral components of the case. A lawyer pointed
out that the parents might be held liable for the death of the infant if they signed him out of the hospital, although the poor prognosis could be taken as a mitigating circumstance. The rights of the young infant were discussed although there was some dispute as to what would really
repre-sent “the best interests” of the patient. The role or presumption of the physician in attempting to protect parents from suffering was scrutinized. It was pointed out that the physician is somewhat limited in the capacity to determine what is
“best” for the parents. On the other hand, it was noted that there may be a discrepancy between what a parent “needs” (i.e., to be protected from
suffering) and what represents a justifiable claim (i.e., to take the baby home to die without
medical treatment). No consensus was reached in
this case. The group was split on the degree to which the physicians should attempt to deny the parents their expressed desire. The infant’s own right to life, the effects of a bleak prognosis, concerns about allocation of scarce resources, and curbs on the “rights of parents” were explored in the discussion.
Case 3
A 5-year-old girl had been a patient in a medical center for
three years because of progressive renal failure secondary to glomerulonephntis. She had been on chronic renal dialysis, and the possibility of a renal transplantation was considered.
The effectiveness of this procedure in her case was
ques-tionable. On the other hand, it was the feeling of the professional staff that there was a clear possibility that a transplanted kidney would not undergo the same disease
process. After discussion with the parents, it was decided to
proceed with plans for transplantation. Tissue typing was performed on the patient; it was noted that she would be difficult to match. Two siblings, age 2 and 4, were thought to be too young to serve as donors. The girl’s mother turned out not to be histocompatible. The father, however, was found to be quite compatible with his daughter. He underwent an arteriogram, and it was discovered that he had anatomically favorable circulation for transplantation. The nephrologist met alone with the father and gave him these results. He informed the father that the prognosis for his daughter was quite uncertain. After some thought, the girl’s father decided
that he did not wish to donate a kidney to his daughter. He
admitted that he did not have the courage, and that, particularly in view of the uncertain prognosis, the very
slight possibility of a cadaver kidney, and the degree of suffering his daughter had already sustained, he would prefer not to donate. The father asked the physician to tell everyone else in the family that he was not histocompatible. He was afraid that if they knew the truth, they would accuse him of allowing his daughter to die. He felt that this would “wreck the family.” The physician felt very uncomfortable about this. However, he agreed to tell the man’s wife that “for medical reasons” the father should not donate a kidney.
As in case 1, the issue of truth telling emerged as the major concern. In this case, the physician was asked by the parent to distort the truth. Some
participants in the discussion felt that he should have worked harder to convince the father. This elicited doubt about the ethics of informed consent under pressure: it was the feeling of some
TABLE II
PERCEIVED HELPFULNESS OF EThICs ROUNDS IN Exi’osrrloN OF Moaj. IssuEs
Effects of Physician Group Other Health Non-Health-Care Discussion
,-Yes
(No. = 40)
-No Cannot
-‘
Say
ProfessionaLs (No. = 20)
Personnel (No. = 16)
,.
Yes No Cannot Say
,
Yes No Cannot Say
Helped identify primary 25 15 0 12 8 0 10 6 0
issue (63%) (37%) (60%) (40%) (63%) (37%)
Helped clarify issue(s) 25
(63%)
14 (35%)
1 (2%)
18 (90%)
2 (10%)
0 7
(44%)
7 (44%)
2 (12%)
Introducedaspectsnewto 23 15 2 12 7 1 11 4 1
participant (58%) (38%) (4%) (60%) (35%) (5%) (69%) (25%) (6%)
this case, the father had actually become a patient, and that the best medical and moral management involved protection of his confi-dence through the withholding of truth. One physician suggested that harboring this secret would not be in the best interests of the father, from the point of view of future mental health. This triggered considerable disagreement. There was discussion of the moral distinction between outright lying or truth distortion and the with-holding of a part of a truth to diminish or prevent discomfort. Most participants were opposed to active truth distortion by the physician, but there were wide differences in ethical tolerance for withholding damaging portions of the truth. It
was felt generally that the proposed complicity in deceit should be a joint decision that hopefully would reconcile the father’s right to confiden-tiality with the physician’s personal moral stan-dards.
IMPACT ON PARTICIPANTS
During year 1975-1976, a process study of ethics rounds was undertaken. There was a survey of participants to examine the effects of the discussions.
Fifteen ethics rounds sessions were held at
intervals of two weeks during the period under study. A total of 102 individuals participated. Of these, 41% were present more than once. Six
individuals attended 12 or more times. Of the 102
participants, there were 1 1 members of the full-time medical staff of the Children’s Hospital
Medical Center, 38 trainees (medical students, interns, residents, and fellows), and 37 nonphysi-cian hospital staff members (nurses, social work-ers, psychologists, administrators, etc.). There were 16 participants from medical ethics and related fields (e.g., law and religion). The medical
trainees included 42% of the hospital’s pediatric interns and residents.
To document the effects of ethics rounds, each week standardized interviews were administered by an ethicist (L.S.), who was a fellow in the Harvard Interfaculty Program in Medical Ethics. Within a week after the discussion, the case presenter was interviewed and four other partici-pants were selected randomly for questioning. They were asked to describe (1) the issues as they perceived them during ethics rounds; (2) whether
(
and so, how) the session helped to clarify moralconcerns for them; and (3) if the discussion altered their positions on the issues. They were invited to offer comments about the specific case and suggestions with regard to the format and opera-tion of ethics rounds in general.
Respondents were separated into three catego-ries: physicians and physicians-in-training; other members of the health-care team; and faculty and fellows in the medical ethics program. Table II shows the responses of these groups with regard to the value of ethics rounds. It can be seen that individuals in all categories tended to feel that the rounds were helpful in the three respects. Discus-sions were more likely to clarify issues for hospi-tal-based personnel (physicians and others) and tended to introduce more new issues to the others. The groups were comparable in the proportion that felt that the rounds succeeded in identifying the moral issues in a case.
TABLE III
Err&rrs OF DISCUSSIONS ON ISSUE POSITIONS OF PARTICIPANTS
Physicians (No. = 40)
Diametric Change
2 (5%)
Broadening or Softening of
Position
10 (25%)
Strengthening of Prior
Position
13 (32%)
No Effects
15 (38%) Other health personnel
(No. = 20)
0 5
(25%)
13 (65%)
2 (10%) Nonhealth participants
(No. = 16)
0 4
(25%)
11 (69%)
1 (6%)
views on the issues broadened as a result of having attended the discussion. The nonphysicians were more likely to have strengthened their stance by attending the rounds than were the physicians. The physician group, however, showed the greatest tendency to acknowledge that the rounds had little or no effect on their positions in a
case.
Assessment of Satisfaction
The vast majority of the participants were supportive of ethics rounds. Typical of the posi-tive statements was the following by a physician: “The very impact of our coming together is important because it contributes to the changing perceptions of the situations with which we deal. It is important to provide a forum which legiti-mizes the discussion of these issues.” There were, however, negative comments, which came princi-pally from the physician group. One such state-ment typified criticism of the rounds: “The tech-nique is too deliberative, nondirective, and insufficiently action-oriented. Every session ought to end with a march on City Hall!” Disappoint-ment with ethics rounds most frequently was associated with concerns about the lack of an unequivocal decision or action. Some respondents were disillusioned when a group consensus was not reached and a position stated in each case.
Institutional Impact
On several occasions, ethics rounds did catalyze formal discussion in other parts of the hospital. Several other Boston hospitals began to conduct discussions modeled after Children’s Hospital Medical Center ethics rounds. Ethicists in the rounds occasionally were requested to visit
various locations in the medical center and other
institutions to offer “consultations.” As an
outgrowth of the program, a course in ethical case analysis has been taught to first-year Harvard
medical students. This is conducted by two of the
authors (W.C. and M.L.) and uses teaching cases from ethics rounds. In addition, the rounds helped stimulate ethical strategies for introducing inno-vative techniques. For example, a discussion of bone marrow transplantation led to the develop-ment of a system of informed consent for the procedure. This has been described elsewhere.4
DISCUSSION
In discussing ethics rounds as a prototype for continuing professional education, one should consider the question of whether medical ethics can be “taught,” particularly to a group of professionals at fairly advanced stages of training or practice. Are their ideals and values fixed such that a reexamination and change cannot be affected? One must also ask about the scope and limitations of medical ethics as a discipline. These questions have been addressed in recent commen-taries.5’6 Ingelfinger7 has pointed out that medical
ethicists sometimes can help physicians and inves-tigators to perceive more fully the alternative values and the spread of options between which they will have to choose.
Clouser8 has noted, medical ethics “helps to
‘structure’ the moral issues implicit in medical science and therapy.” This does not “necessarily mean making a decision on what to do in the
situation.” The medical ethicist recognizes that there are no “ideal observers” and no moral
experts.
The sessions have been characterized as “rounds” in the traditional medical sense, with the case presentation often being the responsi-bility of a resident who actually handled the clinical case. The moral decisions themselves and their consequences have been examined in the
context of actual institutional and personal
One of the first problems facing the new endeavor of teaching medical ethics was that of how to make ethics, a branch of philosophy, applicable and palatable to the hybrid scientists-craftsmen who practice medicine. This was solved by decreeing that ethics programs ought to address real or hypothetical cases, even if this makes it necessary to omit mention of the views of Plato or St. Thomas Aquinas.
In ethics rounds it was anticipated that partici-pants would enhance or develop skills in medical-ethical case analysis without undergoing formal training in moral theory.
The fact that it was rare for anyone to change his or her mind about a decision after analytic
discussion of cases may reflect negatively on the quality of the process. On the other hand, it may be that such an interdisciplinary forum should not expect to alter well-established perspectives but should seek to sensitize and occasionally to surprise participants with the moral complexity of medical decisions. This might lead to deeper reflection by both the clinicians who make deci-sions and the ethicists who might otherwise be tempted to indulge in moral reasoning isolated from actuality.
College and medical students are particularly
responsive to discussions of medical ethics. Once one has become active in clinical and investiga-tive work, moral dilemmas may lose some of their romantic allure. It may be difficult to attract and
continue to interest those physicians whose
par-ticipation is the most relevant. Such individuals tend to have the least time available for addi-tional conferences. This was seen in the ethics rounds experience. As was noted, only a small percentage of participants attended on a regular basis (12 or more times). The heavy scheduling of medical center conferences as well as the formi-dable work load made it difficult for physicians to have frequent involvement in rounds. In view of this, an effort was made to have various
physi-cians attend intermittently, especially when cases
.directly relevant to their area were to be presented. One could speculate that those people who already were most informed and sensitized to the ethical issues were the ones most likely to attend ethics rounds.
Another problem for ethics rounds involved the quality and structure of the discussion itself. The heterogeneity of the participating group some-times enriched and sometimes constrained discus-sion. The multidisciplinary input often helped to clarify the issues, but the fact that participants represented a range of degrees of ethical, legal, social, and medical sophistication often handi-capped the process. The challenge for the discus-sion leader was to help the group identify
concepts that would be meaningful to partici-pants of diverse backgrounds and experience.
if ethics rounds in a hospital cannot and should not make decisions regarding the care of mdi-vidual patients, should this process nevertheless
contribute to reevaluation of hospital and staff
practices and policies for chronic and recurring problems in the hospital? This phenomenon has arisen spontaneously from ethics rounds. Hospital administrators and heads of programs have welcomed the discussion of policy matters in the
context of rounds.
It would seem reasonable to conclude that if the expectations are defined clearly, ethics rounds can enrich teaching and dialogue in a medical center. Their ultimate impact on patient care is difficult to assess. In the future, actual effects on
physician behavior (in addition to attitude) will need evaluation. The methodology for this is
being developed.
By maintaining a forum in which ideas and
decisions can be reexamined, health care provid-ers may offer a constructive response to the current demand for more formal consideration of moral values in medical settings. The informed, retrospective scrutiny of medical-ethical deci-sions serves a useful function in continuing profes-sional education and program evaluation at the Children’s Hospital Medical Center. Its replica-lion or adaptation can be recommended for other
medical centers and health delivery facilities.
REFERENCES
1. Banks SA, Vastyan EA: Humanistic studies in medical education. J Med Ed 48:248, 1973.
2. Veatch RM: National survey of the teaching of medical ethics in medical schools, in Veatch RM, Gaylin W, Morgan C (eds): The Teaching of Medical Ethics. Hastings-on-Hudson, NY, Hastings Center, 1973. 3. Makarushka JL, Laity JJ: Medical schools, clinical
research, and ethical leadership. J Med Ed 49:411, 1974.
4. Levine MD, Camitta BM, Nathan D, Curran WJ: The medical ethics of bone marrow transplantation. J
Pediatr 86:145, 1975.
5. Clouser KD: Medical ethics courses: Some realistic expectations. J Med Ed 48:373, 1973.
6. Brody H: Teaching medical ethics. JAMA 229:177, 1974.
7. Ingelfinger F: Ethics and high blood pressure. N Engi J
Med 292:43, 1975.
8. Clouser K: Medical ethics: Some uses, abuses, and limitations. N Engl J Med 293:384, 1975.
ACKNOWLEDGMENT
