Last week I had the privilege to attend the Canadian Bioethics’ Society yearly conference, and present my work on poetry and microethics. During the week, I made some great connections with fellow bioethicists, healthcare practitioners, and patients. Many challenges with how healthcare is currently practiced were raised and discussed, and I’m sure more than a few of these will be explored in subsequent posts, but for now I want to talk about the dangers of enacting policy.
Normally, we think of ethical policies as being a good thing. Policies give everyone easy roles and instructions to follow. They can sometimes anticipate problems before they arise, and by discharging the responsibilities/going through a checklist/whathaveyou many ethically salient errors can be avoided both at the individual and institutional level. But sometimes, these policies have real, detrimental impacts to patient experience because they are inflexible and do not take into account the context of the case.
Take for example, this case study from the Winnipeg Regional Health Authority’s “Case of the Month” blog:
You are working with a young pregnant girl. Her parents are residential school survivors and she has had negative experiences with the health care system in the past. She is in her third trimester and has had very little family support and no prenatal care to date. You make a good connection with her and sense she is beginning to trust you. You encourage her to come back the next week, but she doesn’t show up, and she does not return your phone calls. When you run into her a few days later, you gently ask how you can best support her. She says she forgot about the appointment, and tells you that if you texted her, it would be easier to remember what she is supposed to be doing.
Your organization’s policy prevents texting with clients, but you realize this may be your only opportunity to establish and maintain a good connection with her before her baby is born. What should you do?
The organization’s policy may be well-intentioned. Having previously worked in a field where confidential student data was handled and kept private from university donors, I can say there are real reasons why sensitive information cannot simply be handed out, and should generally go through secure channels where the information is stored on a secure server, password protected etc. While Canada does not share the same health insurance difficulties as the US, one can imagine the dangers of having insecure health data.
However, what is true about all of these dangers is that they are hypothetical ones. These dangers depend on a) a security breach on either the physician’s or patient’s phone actually occurring and b) that security breach being weaponized against the patient in some way. What is a real and present danger to the girl in this scenario however, is the risk of a dangerous pregnancy without any prenatal care.
The job of policy is to deal with hypothetical harms, but they can never anticipate all of the real harms that might come to pass, or the ways in which they might conflict with certain patient needs. They are like rights that way.
Imagine a different policy, one that is obviously immoral, like “biased counselling” laws in over 20 US states which mandate healthcare providers lie to women about the health implications of abortions. Does a doctor need to follow that policy, simply because it is policy? Of course not. While it might be prudent to pay some lip service to such a policy if only in a harm reduction sense to allow abortion practitioners to continue to serve women in these states, it is obviously immoral and contrary to one of the most foundation principles in ethics which requires that physicians not lie to patients.
Similarly, the conflict in the scenario above is not actually a conflict of ethics, because ethics does not and cannot mean “following policy”. Policies may be useful ethical tools in certain scenarios, but ethics involves a much more nuanced understanding. Ethics means doing what is right: promoting patient’s autonomy, supporting their welfare, preventing harm, and helping to promote justice.
In this case, the patient’s wish is not unreasonable, she is not asking for treatment that will harm her, rather, she is asking for assistance in complying with what the physician believes is the best course of treatment. She is from a vulnerable population that has been historically disadvantaged and mistreated by the medical profession. She is asking to take charge of her own medical destiny by using the (incredibly common) technological tools that are available to her. If she is able to access care via this simple request, it will likely prevent harm and promote her welfare, as well as the welfare of her future child. If the privacy risks of releasing her information have been explained, then there simply is no other option but to comply with her request.
Obviously, violating other policies may not be so straightforward, but here are some questions I believe may be useful to consider when deciding whether or not the policy should in any given situation be enforced:
- Who was this policy designed for?
- What is its intended effect?
- Is the policy patient-centered or provider centered? (e.g. is it simply concerned with preventing liability?)
- What are the consequences or potential consequences of not following policy?
- What are the benefits or potential benefits of not following policy?
- What are the patient’s wishes (assuming the patient is competent)?
- Why are the patient’s wishes such that they are?
- Are the patient’s wishes within the scope and ability of the healthcare provider’s mandate?
Finally, after considering these questions, if the policy is not in service of ethics and/or the patient’s best interests, consider if the policy could be revised in such a way as to be more inclusive of edge cases such as those you experienced, if the policy is fundamentally flawed and needs to be scrapped, or if your case is simply an outlier and a special exception. This classification may also assist in decisions as to whether or not to proceed with policy or breaking it in the first place.
Remember, policies are tools, and we are their wielders. We cannot simply obey them blindly or else we risk becoming mere tools ourselves.
Please note: Moral Guillotines will be on hiatus through June so that I can take a real vacation! I expect to return to writing sometime in July- which will also be MG’s 2 year anniversary, which is incredibly exciting. In the meantime, if you’re missing all that good philosophy, check out the archives here: Archive.