Ethics and Quality and Potential

One thing I am watching in my field is the tie-in to Quality (with a capital Q). Several years ago, a mentor of mine made this connection evident for me. There is a clear link between a mindful environment, with ethical and moral space, and Quality Improvement (yes, that sentence was 90% buzz-word). This is to say that diminishing moral distress (generally, know what the right thing to do is, but being unable to it) increases the frequency of good care experiences. My mentor got Lean Six Sigma certified because, it appears, “quality” is more than a descriptive term—it’s an approach to assess problems and to facilitate change.

Once I got clued-in, I began seeing the link everywhere. The Veteran Affairs Hospitals and clinical ethics programs are doing wonderful things (too lengthy to describe) and creating evidence. You see, high-level health-care people like evidence and measures and metrics, which has always been an area where clinical ethics has traditionally had problems producing. I love the VA because it has lots of potential, and does really good work: it’s actually very hard not to like and sets the standard in the field. The call now is for everyone else to catch-up, or even better yet, to innovate. That’s what my team has been working hard on, though we at times look back on what’s come before for inspiration.

I guess the link-in for up-and-coming JDs would be QI that exists in legal fields. Looking at QI as a meta-analysis by practitioners (at my hospital, most QI analysts are RNs) to improve the delivery of service, are there opportunities in this field for lawyers (I am sure there are) that can be taken advantage of? The underlying point I suppose I am making is that this is one approach to finding fulfilling work.

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Respecting Others’ Positions

Professor Calboli made an interesting point in her comment to one of my previous posts, where she used the phrase “respecting others’ positions.” This gave me an idea for another post. What does it mean to respect others’ positions? Values-based disputes are often very hard to negotiate and accordingly, mediators are introduced to help bridge the gap. A problem I have witnessed, at least in my work, is that mediation is overly used and valued. Consensus is sought for consensus’ sake and mediation is implemented without any regard to negotiative theory. There are times when people will not, and based on their values, should not agree. If one’s best alternative is preferable to what is offered at the table, one should walk away from the table. If one’s bottom-line cannot or will not be met, it is both self-deceptive and disrespectful to continue to push for “consensus.” Having twenty conversations in order to change the plan of care to something more in-line with what you want is not truly consensus—in some ways, it’s possibly coercive.

This does not mean people should shut down and stop working toward their goals; it merely means that people should seek to achieve their goals away from the table.

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National Health Care Decisions Day, Jehovah’s Witnesses & Mature Minors

April 16th is the 4th Annual National Health Care Decisions Day, a day when health-care practitioners reach out and express the importance of having discussions about personal values and treatment preferences, especially in the event of loss of function and end-of-life circumstances. I encourage every adult to complete an advance directive because any adult can fall down and go boom. (Remember: all of the seminal “withdrawal of care” cases involved young women: Karen Ann Quinlan, Nancy Cruzan, and Terri Schiavo were all under 35 when they suffered their respective traumas.)  So here is my pondering for the occasion:

Recently I assisted in a case of a 15-year-old Jehovah’s Witness rushed into the emergency department “bleeding out.” Jehovah’s Witnesses (JWs) regard blood transfusions as a violation that has profound spiritual implications, and accordingly, refuse such transfusions even when such treatments can be life-saving. Supporting JWs in their refusal is an early-learned bioethics lesson as students explore issues of patient autonomy and respecting cultural values. Competent individuals have the right to refuse unwanted medical treatments, even when refusal will lead to death. But this was a 15-year-old.

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