A couple of weeks ago I participated in two case reviews for a community care organization, one of which dealt with issues that were identified at the point of transfer from hospital to the community. One of the cases unfortunately had a very tragic outcome for a patient; the other could have ended tragically too, if not for one very astute staff member who identified some significant and unaddressed issues with the consent process. The learning opportunities in these cases from an ethics point of view related to the fact that participants in both reviews spoke about the red flags that weren’t given proper consideration.
What do I mean by ethics red flags? They refer to anything that pops up in the care of a patient that makes you pause – that sometimes fleeting intuitive reaction that something isn’t quite right. That’s the first and often the most reliable sign of an ethical issue, or at least a potential ethical issue. It may manifest as a feeling of discomfort about something in the patient’s care – something that doesn’t sit right with you. Sometimes you are able to articulate exactly what the issue is but perhaps you’re not sure how serious it is, or you’re afraid to bring it up, or maybe you second-guess your own intuition if nobody else on the team is concerned.
One area where ethics red flags are very common is the consent process, as happened in one of the cases I helped review. There are a number of places throughout the consent process where the basic standards of consent can be and often are overlooked in a busy health care environment. For example, it is common for family members of a patient to be given decision making authority without first asking the patient whether he or she wants it this way or without determining whether the patient is capable of making his or her own decision. Another common example is the use of family members as translators, which can interfere with our ability to transmit accurate information back and forth with the patient. A third example involves assuming that the person who has accompanied the patient, or who visits the patient most often, is the appropriate substitute decision maker.
When these or other ethics red flags pop up in your work, please don’t ignore them. It is important to always remember that your primary ethical responsibility is to the patient, and fulfilling that responsibility means always paying attention to red flags when they arise. When they do arise that is the time to slow down, reflect on what is happening, and consult with people who can support you in your decision making (such as colleagues, your supervisor, or an ethicist). While it is always easier to give people benefit of the doubt, and the red flags can often be brushed aside without serious consequences, one preventable tragic outcome is too many.