The Ethical Dimension of Burn Care

Introduction

Burns are a leading cause of accidental injury and death in the United States and worldwide, and they can often raise profound concerns about autonomy, mortality, quality of life, and suffering. In seeking optimum health for each patient, contemporary burn care aspires to integrate the highest standards of evidence-based medicine with excellence in patient care delivery and clinical research. Optimal care of patients with burns is a virtuous practice involving highly integrated, team-oriented, interdisciplinary, and humanistic encounters. It includes adherence to certain norms of professional conduct as well as a process of reflection on how to incorporate those norms in individual patient care or research settings. It involves increasingly complex layers of technological and professional sophistication, clinical judgment, and expertise and sensitive attention to the ethical values at the core of medicine. Clinical situations can be complex, not simply because of the wide range of medical facts and situational factors that constitute burn care, but because of the diversity of human needs that lay coiled beneath the surface of illness or trauma. Given that patients with burns are among the most vulnerable of patients and have needs that expand the full range of the human condition, all members of the healthcare team are called upon to offer care that is tender, skillful, comprehensive, and ethically conscientious. The core ethical ingredient of these encounters is the doctor–patient relationship and the underlying expectations of trust that patients and their families bring to the clinical setting.

Caring for the burned patient encompasses a long-standing commitment to the safety, healing, rehabilitation, and growth of patients. As such it is thoroughly infused with ethical values and goals. As conceived in ancient Athens and during most of its history, Western ethics involves the quest for achieving the good life, living it excellently, and setting forth ideals of human flourishing. In contemporary times, these ideals continue to inform the practice of medicine and contribute to the evolving field of clinical ethics. Clinical ethics is “the systematic identification, analysis, and resolution of ethical problems associated with the care of particular patients. Its goals include protecting the rights and interests of patients, assisting clinicians in ethical decision making, and encouraging cooperative relationships among patients and those close to patients, clinicians, and healthcare institutions.” Over the past several decades, the field of clinical ethics has become an essential part of hospital life and culture, reflecting the complexity and poignancy of the real-life ethical puzzles clinicians frequently encounter. It involves critical thinking about right and wrong and of what should or should not be done in terms of our responsibilities to others. It also legitimates the importance of ethics teaching and ethics dialogue in all phases of professional practice, whether that is in the classroom, the board room, or on “ethics rounds at the bedside.” Clearly caring for burned patients invites moral reflection and imagination, and clinical ethicists increasingly are part of the integrated approach.

In general, most healthcare providers hold certain values in common and are thus not in doubt about what morality requires. That is, we hold firmly to the conviction that it is a good thing to preserve life, to cure disease, or to lessen someone's pain or suffering. For the most part, we are clear about what our ethical responsibilities are: to respect the values and dignity of human life, to tell the truth, to avoid harming patients, and to treat them and their families fairly and with compassion. Indeed ethical decision-making for some is therefore like breathing, something we do without even thinking. At times however disagreements about what we ought to do or what we ought to value occur. That is, while we may be clear on the general principles of ethics, it is not always so clear how to apply them in a particular case. This uncertainty can give rise to ethical problems and dilemmas, some of which occur at the bedside of the patient and others that may involve questions of institutional policy, resource allocation, or even larger societal issues about how we ought to distribute goods and services.

What Is an Ethical Problem?

An ethical problem is present when it involves a conflict of two or more of the following: rights or rights-claims, obligations, goods, and/or values. For example, disputes about writing a “comfort-measures-only” order for a patient without decision-making capacity and with a very low probability of survival commonly involve a conflict between an obligation and a good: the obligation not to abandon aggressive therapy prematurely and the good of a maximally pain-free and unprotracted death. In this case, the burn team and the patient/surrogate are ordinarily the major stakeholders and appropriate decision-makers, and they are addressing a problem in clinical ethics . On the other hand, consider the burn center's or healthcare organization's (HCO's) responsibility to ICU patients when a safe nurse-to-patient ratio cannot be consistently met despite the burn center's best efforts. If discerning what should be done in such circumstances requires decision-making at the managerial level of the burn center or HCO, a problem in organizational ethics is the correct term to use.

As indicated, conflicts among rights, obligations, and the like are very common and vary greatly in difficulty. When should they be taken seriously? An ethical problem is serious when there are stakeholders involved who stand to be seriously affected by the problem or its outcome. Stakeholders working collaboratively without outside help can successfully manage the vast majority of such problems. When are such problems so serious that assistance should be sought from an ethics consultant or a healthcare ethics committee (HEC) or its equivalent? An ethical problem is serious enough to refer to an HEC:

• a.

  When you suspect the Smell Test would be positive; that is, ”What would the action or situation we are considering smell like if we read about it in a front page news article or in a popular blog? Would I be comfortable explaining it to my spouse, or my grandmother?” The problem with this, as the olfactory image reminds us, is that living with bad smells or unethical conduct for a long time may dull a person's ability to notice them.

• b.

  When there is persistent disagreement among the major stakeholders and codes, rules, laws, and more discussions fail to lead to a resolution within generally acceptable ethical boundaries in a reasonable amount of time.

How Should Clinical Ethics Problems Be Managed?

In the United States, the informed consent process was developed by the American judiciary to safeguard the legal rights and welfare of all the stakeholders participating in bedside decision-making. Throughout the United States, this legal process has become the foundation of the healthcare provider's approach to avoiding and managing serious ethical problems at the bedside. Its application in the burn center was explained and diagrammed in detail in the first edition of this book, and what follows should be considered an update and development of what is stated there.

On the vast majority of occasions, there is little or no difficulty achieving agreement and patient consent about a proposed course of burn management. There are many predictors of clinical outcomes that are without controversy. Occasionally, however, the process of obtaining informed consent leads to problems involving disagreements, anxieties, and/or controversies about what should or should not be done. At this point, the participants must give careful attention to the quality of the discussion in attempting to resolve the problem, part of which requires respect for the patient's underlying values.

Increasingly, ethics consultants are seen as important stakeholders in optimizing the care of patients suffering from burns, especially when treatment decisions are ethically complex or psychologically difficult. Through facilitated dialogue, the rights, interests, and needs of the patient are brought to the center and deliberated upon, but the values and concerns of the team are honored as well. Additionally, ethics consultants facilitate the process of making and justifying moral judgments on the basis of certain ethical principles that transcend individual personal opinion or perspective. That is, a judgment that a certain act—say, withdrawing life-saving treatment for a dying patient—is to be performed or not is justified on the basis of some rule or standard applicable in all relevantly similar cases. In this way, ethical dialogue becomes more than simply ensuring that a patient has provided an informed consent for treatment. Instead ethical dialogue becomes the means by which we examine the full range of our ethical responsibilities to others, drawing on principles of trust, autonomy, dignity, beneficence, justice, and care ( Fig. 61.1 ).