Ethicists: Clinicians aren’t wrong to expect involvement from certain patients’ families—but they wouldn’t be right to request it, either
Many nurses have spent untold hours at the bedsides of frail and fading inpatients who, despite having blood relatives in the vicinity, rarely receive visitors. In these scenarios, it’s only human for a healthcare worker to feel some measure of resentment toward the absentee family.
Researchers at Baylor College of Medicine in Houston explore the moral and ethical dimensions of the conundrum in a paper published in the July-August edition of The Hastings Center Report.
Focusing on cases in which the patient is barely responsive or not responsive at all, medical ethicist Jennifer Blumenthal-Barby, PhD, and colleagues write from firsthand experience in such situations as well as accounts from clinicians they’ve counseled.
It’s not uncommon, the authors report, for clinical teams to express frustration in these situations.
The negative feelings are understandable, they suggest, when the patient’s kin and/or close friends seem to be shirking their “duty” to their minimally conscious loved one, leaving the full burden of human caring to nurses and other clinicians.
Heady questions, practical answers
The authors ask:
‘What is the nature of this duty? Is it morally defensible to request or, more demandingly, require family members to be present with the unresponsive patient to bear witness to their actual or perceived suffering? If so, on what grounds?
In a section concentrating on “moral reckoning,” Blumenthal-Barby and co-authors offer several important insights. Among them are these three.
1. Moral reckoning can involve coming to terms with one’s own moral accountability.
When clinicians are compelled to provide treatments that they perceive as prolonging suffering or lacking benefit, they may feel that those requesting the care should confront the consequences of these decisions, the authors state.
“Statements along the lines of ‘If I have to see this every day, so should they’ can reflect a frustration that borders on a desire for the family to experience a moral reckoning or even retribution,” they write. “Clinicians’ distress can be further amplified by the reality of functioning in an environment that requires careful allocation of their time, attention and emotional energy.”
2. The desire for others to undergo moral reckoning for their perceived wrongs has been well-documented in the psychological literature.
Here Blumenthal-Barby and co-researchers cite two prior peer-reviewed articles. One explores how individuals use punitive actions, such as exposing others’ moral failings, to “compel them toward moral accountability.” The other highlights how moral outrage can motivate individuals to demand retributive justice, “especially when the outrage is combined with feelings of dehumanization and disgust about the perceived offenders.”
“Within clinical settings,” Blumenthal-Barby et al. note, “moral outrage may manifest as a desire to force surrogate decision-makers to confront the moral weight of their decisions by witnessing the suffering that their choices prolong.”
3. The instinct to seek moral reckoning from a patient’s family members may be rooted in professional and logistical causes of distress.
However, “requesting that a surrogate witness suffering for this purpose is ethically indefensible,” Blumenthal-Barby and co-authors state flatly.
“The demand for carers at the bedside must not be construed as a punitive measure or a means to assign blame,” they add. “Requiring such individuals to endure the distress of witnessing suffering as a form of payback or moral accountability distorts the nature of the clinician-surrogate relationship and can undermine trust not only within this dyad but also in the healthcare system more broadly.”
Further, they urge clinicians to:
- approach surrogate absence with a spirit of compassion and curiosity rather than judgment; and
- ask themselves whether requesting or demanding the presence of a family member would risk exploiting the family member’s presence for ethically questionable—or even overtly indefensible—reasons.
“In the end, we remain largely skeptical of the view that family members have an uncomplicated moral obligation to be present at the bedside of a barely conscious or unconscious patient whom clinicians believe to be suffering,” Blumenthal-Barby and colleagues conclude.
“At the very least, scrutiny of the instinct to blame those who are not present is needed.”
Dave P. has worked in journalism, marketing and public relations for more than 30 years, frequently concentrating on hospitals, healthcare technology and Catholic communications. He has also specialized in fundraising communications, ghostwriting for CEOs of local, national and global charities, nonprofits and foundations.