Saturday Morning Postmortem

To the Editor

“Good ethics starts with good facts.” I cannot count the number of times I heard that in graduate school and how many times I have repeated it since. Reading Kyle Galbraith and Joshua Perry’s “Saturday Morning in the Clinic” (Sept–Oct 2009) reminded me of that maxim again. I hesitate to comment on the case they describe as I am without all of the facts; 2,700 words likely cannot convey the full complexity of any case. Yet because the authors themselves question their success as ethics consultants, the educator in me must at least raise some questions.

The authors admit to their discomfort in the clinical setting, acknowledge and even rationalize limiting their discussion with the attending surgeon, and note regret for not having sought more explanation from the attending, other health care team members, and the patient’s husband. As self-described “novices” at clinical ethics consultation, I have to wonder why they were responding to the consultation request without support or mentorship. While it’s not unusual for well-intentioned but insufficiently trained committee members to take ethics calls, I wonder why two inexperienced consultants were assigned together. Were they ready? Were others with more experience available?

Galbraith and Perry use the question “What do I need to know?” to frame their approach to ethics consultation. Yet their description of events suggests they were not guided by this question—at least not persistently. Their reasons for not pressing the attending surgeon for more information may be accurate, and even justifiable: they note that he was “not amenable to a lengthy conversation,” and that “we never did find an opportunity (or the courage) to inquire” further. But there was much more they needed to know. Beyond how long Mrs. K would have to endure the ostomy, they also needed to understand what her life with it might be like—particularly whether the bag would be as malodorous as feared. They also needed more information from the health care team about her condition, medical course, and prognosis. Similarly, they needed more information from the family regarding her fears and perceptions, the family’s own perspectives, and the impact of illness and this procedure on their relationships. For example, would Mrs. K object to wearing a bag if it meant the difference between life and death? Did she fully understand the ramifications of the ostomy, and did Mr. K? Was his consent informed by medical fact, and not just by personal anecdote? Without that information, it is difficult to identify the range of options available to address the situation, much less to make any recommendations.

The story takes a dramatic turn, with surgery interrupted when consent is rescinded and the patient ultimately dying. The authors ask that we not evaluate this case by its outcome or the preservation of ethical principle, but by considering its complexity and tragedy. They suggest some of the good that came of this consultation and imagine potential “greater failures.” Yet I am troubled by any outcome that results from a less-than-fully informed process. These consultants appeared to undermine their own framework, and perhaps success. What would have happened if they had known more, had more discussion, and had obtained thorough informed consent? We cannot know all that we need to know unless we ask, even when asking requires diplomacy, fortitude, and time. Success need not be measured by having the right answers, but by an informed and reflective process.

• To the Editor
• Mark Aulisio

To the Editor

Having found myself in circumstances similar to those described by Galbraith and Perry, I read with interest their laudably honest and self-critical account of the ethics consultation they did in the case of Mrs. K. I appreciate their candor in revealing that they were left without at least one important piece of information that might have helped answer the primary question that guides them (“What do we need to know?”): the nature of Mr. K’s conversation with the attending surgeon that resulted in his misunderstanding of the reversibility of his wife’s ostomy...