The Ethics Committee

This semester I have the privilege of serving as a student member of the Ethics Committee here at Mission Hospitals. As I have mentioned before, the eight of us are very lucky to have an ongoing Ethics course as part of this third year program. Most of what is learned about medical ethics is taught in the first two years at most schools (if at all), but these are the "pre-clinical" years. Why are we learning ethics at a time when we can't apply that knowledge? A concurrent course surely makes more sense to me. However, this program is one of the few that has that curriculum built into the clinical years. The eight of us get together monthly to discuss interesting cases, relevant issues (such as patient autonomy, end of life care, etc.), and delve into the inner med student animus. This is where we work out the numerous dilemmas we have seen or faced, so we are ready to meet these challenges in real-time later in our careers.

As part of the Ethics Committee, a few of us will participate in monthly meetings and (hopefully) be part of ethics consults in the hospital. Any employee can ask for an ethics consult (I believe), and the Chair, as well as a few other members, meet to discuss the case at the bedside. In March, we will be trained in "Ethics 101" to prepare for these encounters. I see myself as listening exclusively (I see you cringing when you think of me weighing in on ethical decisions...), but these are the experiences that can make me a better physician. These are delicate issues that can be handled with skill, or very poorly. I hope to learn how to do the former.

To get us started, the following case was found by our ethics professor, Dr. Meacham. It is taken from a recent report of the Hastings Center, a nonpartisan research institution for bioethics and public interest. In their latest edition (January-February 2012), this scenario was carefully considered. This, and other free articles, can be found at their website. While this case is not one that I have heard in a committee meeting, it is very similar to the type of cases that Mission deals with. Take a look today, and then I'll comment next week...

Mr. A arrives at the emergency department of Mercy Hospital, feeling run down and fatigued. He is a 35 year old African male who appears apprehensive and withdrawn. He says he is from Tanzania and that his first language is Swahili; however, he also speaks English. He tells the physician on call that he has headaches, no appetite, and nausea. He has also lost weight and his feet and hands are swollen. After numerous tests, the physician informs Mr. A that he has end-stage renal disease. 

End-stage renal disease is the final stage of chronic kidney, or renal, disease. It occurs when the kidneys are no longer able to function at the level needed for daily life - usually at less than 10 percent of normal. The most common causes of kidney disease in the U.S. are diabetes and high blood pressure. A person may have gradually worsening kidney function for 10-20 years or more before progressing to this final stage, but end-stage renal disease almost always follows chronic kidney disease. Patients who have reached this stage need dialysis or a kidney transplant to live. 

Mr. A's physician recommends immediate dialysis. However, Mr. A then tells the physician that he is in the U.S. illegally, that he has no family living in the area, and that he is unemployed. The physician consults a social worker, but he tells her that illegal immigrants are not eligible for any health care benefits. The physician is well aware that the Emergency Medical Treatment and Labor Act requires her hospital to not only examine Mr. A, but to provide him with any needed stabilizing treatment without considering his lack of insurance coverage or ability to pay. The needed treatment to stabilize Mr. A is dialysis. Therefore, the physician admits him and starts treatment. 

Following this, the social worker that Mr. A's physician spoke with tells the hospital administration that Mr. A has started dialysis and will need to continue indefinitely. Because he has no insurance and is an illegal immigrant, he is not eligible for any outpatient dialysis units. He is also unable to afford any medical treatments. Once Mr. A is stabilized, should he be discharged? He will need dialysis three times a week in order to stay stable. Will he have to be readmitted through the emergency room each time, or can he stay in the hospital until some other accommodations can be determined? Without dialysis or a kidney transplant - both which have serious risks and possible consequences - the buildup of fluids and waste products in his body will cause Mr. A's death. 

His physician and social worker turn to the hospital ethics committee for help. Given the situation, what should Mercy Hospital do?" 

Thoughts?