Interviewee

Dr Margaret Moon, Assistant Professor of Paediatrics, Department of Pediatrics, The Johns Hopkins School of Medicine and Berman Institute of Bioethics, The Johns Hopkins University, Baltimore MD USA

Article

Moon, M., Taylor, HA., Hughes, MT., Carrese, JA. (2009) Everyday Ethics Issues in the Outpatient Clinical Practice of Pediatric Residents, Archives of Pediatrics & Adolescent Medicine, 163(9):838-43

Summary

When Dr Margaret Moon was given the task of developing a new ethics curriculum for paediatric residents at the John Hopkins Medical School, she found that existing ethics education, with its focus on end of life and beginning of life issues, was not helpful for the residents, who were struggling with 'everyday' moral conflicts over how to provide adequate care for their child patients, without jeopardising the safety and functioning of fragile families living in poverty. Margaret found that residents at John Hopkins Hospital faced challenges in managing the therapeutic alliance with parents and caregivers, sometimes having to 'bend the rules' for angry parents in order not to lose access to a child in need of care. They also faced ethical challenges in protecting patient privacy and confidentiality and using professional authority appropriately. This week, Michael Bouwman talks with Margaret about her findings; about the importance of understanding ethics in clinical practice, and about the need to use research to inform ethics education.

Transcript

Michael Bouwman: I’m Michael Bouwman, and today I’m introducing Doctor Margaret Moon, Assistant Professor of Paediatrics, in the Division of General Paediatrics and Adolescent Medicine, at the Johns Hopkins School of Medicine; and Freeman Scholar in Clinical Ethics, at the Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland, USA. I am speaking with Margaret about her study and article: Everyday Ethics Issues in the Outpatient Clinical Practice of Pediatric Residents. Published in the Archives of Pediatrics and Adolescent Medicine, and co-authored with others listed on our website. Welcome. Margaret Moon: Thank you very much. Michael Bouwman: Could you start by talking about the need for a description of ethical issues encountered in paediatric practice? Margaret Moon: Sure. There’s actually two reasons I think that we embarked on this bit of research: one is we were given a new, sort of, a challenge in developing a new curriculum in ethics education for trainee residents at the John’s Hopkins Hospital; and in looking at our plans for ethics education, we realised that education of any sort if best when it’s based on an empirical understanding of what the learner’s needs are. And as we tried to figure out what that was for ethics, we realised there really hadn’t been very much written that was going to be useful for us. So, we started to look, again, at exactly what the residents were experiencing in the outpatient setting, so that we could develop teaching that spoke to their needs. Interestingly, most of the education in ethics really is based on, sort of, a pretty traditional understanding of ethics, and it usually focuses on, what we call, big ticket items—sort of, end of life issues and beginning of life issues, you know, life and death issues, as opposed to the things that occur on an everyday basis that makes physicians stumble over the care that they provide. Most medical care, in the US and other countries, is delivered in the outpatient setting; specifically most paediatric care is delivered in the outpatient setting. We realise it was incredibly important to take a look at the outpatient setting and to take a very close look at, what we call, everyday ethics, not the big ticket items but really just the simple everyday things that physicians encounter that, sort of, stand in the way of them providing the care that they feel is most appropriate. Michael Bouwman: Fantastic, And the findings from your study, on ethical issues in the outpatient clinical practice of paediatric residents, posits the theme of promoting the child's best interest in complex and resource-poor home and social settings. Could you talk about that? Margaret Moon: Sure. Just to set it up a little bit: when we did this bit of research, we were looking at ethics issues as issues that arose out of conflicting moral obligation—so physicians would be seeing a complicated patient in the outpatient setting, and find out that the moral duty that they felt was so important and the care of that patient actually were in conflict. And so, in the setting that we have, John’s Hopkins Hospital is in Baltimore City, which is, you know, very much an urban setting, marked by poverty and complex social situations, so a lot of the children that we were caring for were living in families that were struggling with very significant social and economic issues. For instance, I mean one situation was homelessness: many of our families are, sort of, facing the threat of homelessness in a persistent fashion; some of our children live in homes that really are not under the control of their parents, they’re living off the kindness of neighbours or relatives, and so, sometimes we would have to change the care that we were providing because the home situation of the child was so unstable that we had to be very careful not to threaten it. I remember one child in the study who had a lot of complex psycho-social problems, in addition to complex medical problems, and we were hoping to get more effective social work involvement in the family, but it turned out that this family lived with an elderly aunt who would put them out if there was any more confusion, anymore social work involvement, anymore people coming to the home trying to help care for this child. The residents had to figure out how to change their approach to this patient and meet, both, the conflicting demands of looking out for the welfare of the child, but at the same time, protecting the safety of the family. So those sorts of situations we encountered a lot and those are not things we typically teach in ethics, but they’re really, very much, creating conflicting moral obligations in providing the very best care for a child, but at the same time, yielding to the facts of the family’s situation. Michael Bouwman: Yes, and your findings also note the themes of managing the therapeutic alliance with parents and caregivers, and protecting patient privacy and confidentiality. Would you elaborate on these findings? Margaret Moon: Sure, the therapeutic alliance is, actually, one of my very favourite themes within clinical medical ethics, not just in paediatrics but also in the adult medicine world, but in paediatrics, in particular, because physicians only really have access to children through their parents, so instead of just the doctor/patient relationship, it’s a relationship between the doctor, the parent and the patient, so it’s a triad, and, as you might guess, sometimes that triad is remarkably difficult to manage: I know many many people who decided not to become paediatricians because they couldn’t stand having to balance between the child and the parent. So, in order to be a good paediatrician you really have to identify and accept that need to balance. So, therapeutic alliance is often very tenuous—you know, in our study there were several examples of parents who presented to the clinical with distrust, or anger at the clinical setting, anger at the system of medicine, or parents who had their own mental health problems, parents who were not very good parents, who were on the border of even caring for their children adequately. So our trainees really had to look at those situations very carefully and try again to balance respect for the parents—respect for the autonomy that the parents deserved, respect for their skills as parents, respect for their needs as parents, all the time trying to balance the best interests of the child. So, sometimes having to, sort of, bend the rules a little bit for the parent who is, you know, crazy and angry and misbehaving, just so we wouldn’t lose access to a child who was in need of care. That’s a very difficult situation, but the lesson has to be, over and over again, that we only have access to children through their parents, and the wellbeing of the child very much depends on the wellbeing of his or her parents. So, there’s a lot of... a lot of balancing going on there. Michael Bouwman: Yes, it’s a dilemma and there’s no easy answer. Margaret Moon: There is no easy answer but it’s a constant fascination, that’s for sure. Michael Bouwman: Using professional authority appropriately is the last theme identified in your study. Could you please explain this to our listeners? Margaret Moon: The theme about using professional authority appropriately, it’s again something that is tremendously challenging. So, we teach a lot about advocacy, we teach our residents that their job is to advocate for their patients and try and make the world a little bit better for their patients. As you might guess, sometimes parents come in asking for things that are an unfair, so one example from our study was a parent who asked a resident to write a letter to the housing authority saying that she needed a bigger apartment because her two children both had attention deficit disorder and were too rambunctious to share a bedroom. So, you know, having a bigger apartment would make this family’s life better, but it was very difficult for the resident to say that there was a medical need for it. They had to find a way to, both, advocate for the child’s wellbeing, the family’s wellbeing, at the same time promoting their duty to be fair and just and honest. So, these sorts of pressures, to misuse professional authority, are very commonplace in many outpatients. Michael Bouwman: And finally Margaret, what do you think are the practice implications of your research? Margaret Moon: Yeah, so we started this study with an eye to education: our project—within the Bermen Bioethics Institute, at John’s Hopkins University, and then again, with our teaching in the School of Medicine—is all about coming up with a better approach to keeping clinical ethics to medical trainees. We’re hoping that the implications of this are twofold: one that we will encourage people to recognise ethics education is better when it starts from an empirical basis, and that we ought not to waste residents’ time by teaching things that really aren’t going to be applicable to the care that they’re trying to provide. So, that empirical basis ethics education is one of the very practical points that we’re hoping will come out of this. The other one is to just engage further in this conversation about everyday ethics, and the importance of understanding everyday ethics in clinical practice, as opposed to the limits of the quandary ethics, or the big ticket item ethics, has really been the focus of education in the past and even still today. So those are the two very practical points that we’re hoping to come out. We’re doing more work along the same lines, trying to expand our understanding of everyday ethics in other settings—the adult medicine setting and the surgery setting—and then also on the inpatient setting. So, there’s a lot more work to come of this, but I think we have a good start on trying to expand the empirical basis for ethics education and really trying to encourage training programs to train people to identify ethics issues, be sensitive to ethics issues and to develop some framework for analysis of ethics issues in the everyday settings, part of everyday clinical practice. Michael Bouwman: Well, congratulations and thank you very much for sharing your research with IPP-SHR podcasts today. Margaret Moon: Yeah, it’s very interesting stuff.

Podcast Keywords

bioethics, ethics, principlism, morals