Ethics Outside of Inpatient Care: The Needfor Alliances Between Clinical and OrganizationalEthics

Rachelle Barina

� Springer Science+Business Media Dordrecht 2014

Abstract The norms and practices of clinical ethics took form relative to the

environment and relationships of hospital care. These practices do not easily

translate into the outpatient context because the environment and relational

dynamics differ. Yet, as outpatient care becomes the center of health care delivery,

the experiences of ethical tension for outpatient clinicians warrant greater responses.

Although a substantial body of literature on the nature of the doctor–physician

relationship has been developed and could provide theoretical groundwork for an

outpatient ethics, this literature is not sufficient to support outpatient caregivers in

practical dilemmas. For physicians who are employed by or affiliated with a larger

organization, a stronger alliance between clinical ethics and organizational ethics,

identity, and mission will promote expansion of ethics resources in outpatient set-

tings and address structural constraints in outpatient clinical care.

Keywords Outpatient ethics � Organizational ethics � Goals of medicine �Clinical ethics

Introduction

Yaseen is a 34-year-old man with multiple sclerosis. Following a suicide attempt

wherein he sustained several minutes of anoxic brain injury, his group home called

an ambulance and he arrived in an emergency department in a United States

hospital. Previously, Yaseen conveyed through family conversation and a living will

that he wishes to refuse all life-sustaining treatment at all times. In fact, he had his

living will next to him as he attempted suicide. In spite of Yaseen’s poor prognosis,

R. Barina (&)

Albert Gnaegi Center for Health Care Ethics, St. Louis University, 3545 Lafayette Ave, Salus

Center, 5th Floor, Saint Louis, MO 63104, USA

e-mail: rbarina@slu.edu

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DOI 10.1007/s10730-014-9238-4

caregivers in the emergency department began to initiate life-sustaining care.

Several minutes later, the family barged into the emergency department and

demanded that life-sustaining measures be stopped and withdrawn. The mother of

the patient threatened to sue for battery if any invasive treatment was initiated or

continued. The attending physician attempted to delay an escalation of explosive

interaction as the resident called the clinical ethicist. The bedside dilemma

surrounding Yaseen exemplifies a quintessential clinical ethics case. Historically,

clinical ethics has proven helpful in situations like this one, which is why caregivers

may choose to call the ethicist in a moment like this.

Consider another case in a different context: Dr. Lopez is an internist who sees

Jan, a 29-year-old Medicaid patient with diabetes, chronic depression, and

schizophrenia. Jan lives alone, cannot maintain a job, and does not have family

in the area. Although he struggles to be compliant with his medications, he usually

gets himself to his appointments and promises to try to be more responsible. Dr.

Lopez has several noncompliant Medicaid and private pay patients like Jan.

Struggling with how to adequately care for them, he has become frustrated by their

noncompliance and dissatisfied with the reimbursement his practice receives for the

Medicaid patients relative to the amount of his time and energy they consume. The

amount of time he spends trying to promote compliance has not led to

improvements in their outcomes and has negatively impacted his quality metrics.

In the back of his mind, Dr. Lopez wonders if perhaps he should cap the number of

Medicaid patients seen to 5 %, or even stop seeing noncompliant Medicaid patients

altogether. He wants to take care of the disadvantaged and avoid discriminating

based on compliance, but he also wants to promote his practice and spend his time

with patients who follow through with medical guidance. Dr. Lopez feels

uncomfortable and does not know how to proceed.

Whereas ethicists have found a way to contribute their skills in the hospital

setting, they have shown relatively less interest and involvement in outpatient care

and its ethical challenges. Because the hospital ethicist has historically been

accessible throughout the hospital, she has been present in the epicenter of clinical

encounters. Today, however, the hospital ethicist is no longer in the center of care,

because outpatient settings are rapidly becoming the epicenter of health care

delivery in the US. As economic and legal realities encourage shifts in health care, a

smaller proportion of health care delivery will occur in hospital settings. Already,

outpatient volume amongst Medicaid beneficiaries has grown by an average of

4.2 % from 2004 to 2010 while inpatient admissions have declined 1 % during the

same time; these shifts involve a cumulative increase of 28 % in outpatient care and

a cumulative reduction of 6 % in inpatient care (Medicare Payment Advisory

Commission 2012, pp. 46-7, 51). Not only is outpatient care becoming increasingly

central to health care delivery, but it is quickly becoming the place where the

majority of clinical encounters will occur. Although outpatient clinicians may

pursue ethics literature and education on their own, many outpatient clinicians do

not have access to sufficient educational or consultative ethics resources. Thus, in a

2002 article, Potter and Kaiser write, ‘‘Outpatient ethics is the next stage of

evolution of bioethics…Outpatient ethics is a way to bring moral order to the

ordinary’’ (p. 274). Papanikitas and Toon add, ‘‘Ethical decisions in primary (and all

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outpatient) care may seem less dramatic than those in high-tech medicine, but their

cumulative impact is profound because there are far more of them’’ (2011). Ethics in

the outpatient context should be a high concern in health care ethics today.

Although the ethical issues that arise in outpatient settings may not involve the

same degree of bedside urgency as the hospital, they still produce difficult moral

issues that lead practitioners to experiences of moral uncertainty. As more care

shifts to the outpatient setting, the patients seen outside the hospital actually become

sicker patients on average and require more challenging decisions and conversations

(Felder 2002). Refining the theory of John La Puma and Schiedermayer (1989),

Fetters and Brody (1999) argue that there are seven main categories of outpatient

clinical ethics areas: conflicts of dual loyalty, communication, professional and

social responsibility, behavior, sexual attraction, personal space, and patient/

guardian conflicts. Illustrating this taxonomy, a fair amount of literature has

provided qualitative and quantitative descriptions of the kinds of ethical issues that

outpatient practitioners experience. For example, in primary care, common moral

issues involve deciding how much time to spend with each patient, financial

constraints due to noncompliance, inappropriate use of services, requests for

unneeded services, and inadequate follow-up, to name a few (Robillard et al. 1989).

Controversial topics such as genetic testing and aid in dying pertain to outpatient

care (Young 1997). In pediatrics, issues involve responding to unstable home

settings, managing frustration with parents, and adolescent care such as sexual

health (Moon et al. 2009). Systemically, replication of services between health care

professionals and lack of coordination of care between practitioners also raise

ethical issues.

In this paper, I will show that current clinical ethics trends are most applicable to

the hospital because they arose in a context that attributed normative priority to the

hospital. Then, I will argue that as more physicians are employed by or affiliated

with larger health care organizations in the US context, a stronger alliance between

clinical ethics and organizational ethics, identity, and mission will enable the

expansion of ethics resources into outpatient settings and address structural

constraints in outpatient clinical care. To make this argument, I will first discuss the

historical context out of which bioethics emerged and the ways in which the hospital

shaped practices of clinical ethics. Second, I will show that these practices do not

conform to the context of outpatient care. Finally, I will illustrate that the doctor–

patient relationships of outpatient care warrant a commitment to supporting

outpatient clinicians in ethical issues. Rather than a clinical ethics modeled after that

which is practiced in the hospital, I will suggest that organizations make greater

efforts in reaching out to their outpatient clinicians to foster solutions to ethical

distress outside of the hospital.

The Origin of Secular Bioethics

Bioethics emerged as a response to the context of the mid-twentieth century.

Engelhardt (2002) argues that although disease has classificatory and pathological

meanings, disease—and therefore medicine—also has a profoundly social character.

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The social character of medicine creates the most foundational condition for the

possibility of the need for a discipline of moral expertise, which Engelhardt believes

characterizes bioethics.1 Engelhardt (2013, p. 55) argues that several developments

in the twentieth century created an ‘‘intellectual vacuum’’ that invoked the efforts

that became bioethics. The ‘‘intellectual vacuum’’ emerged for several reasons.

First, Engelhardt (2002, p. 63) argues that medicine became a technologically

innovative as well as an institution socially supported by government and business.

Technologies such as dialysis, organ transplantation, and the ventilator raised moral

questions. Moreover, technologies like prenatal genetic testing became available

and abortion became safer, thus becoming a consideration for more people. As

technology developed at challenging speeds, the practice of medicine gained

profound power to shape, destroy, and create human life. Yet, the expansion of the

social nature of medicine through governmental and employer payment structures

and health care institutions meant that the moral questions surrounding medicine’s

ability to control human life became shared moral questions not easily definable

through the moral claims of a particular tradition.

Second, the authority for self-regulation was both mismanaged by and removed

from the medical profession. As Engelhardt (2002, p. 63) shows, medicine was

forced out of its guild-like status and its ability to self-govern. Medicine had been

able to direct ethics practices and police these practices. Engelhardt emphasizes that

this trend changes in the mid-twentieth century when federal courts began to apply

antitrust practices to medicine, such that it could no longer self-regulate or resist

third-party payers. Subsequently, third-party payers gained a subtle governance

power within certain medical practices. With rising costs, physicians also came to

be governed by third party forces. As a result, the patient–physician relationship was

no longer a bond that could be interpreted exclusively through medicine. Engelhardt

writes, ‘‘The rising importance in medicine of external third parties created a need

for medical-moral norms that were independent of the health-care professions’’ (p.

74). Moreover, the worldwide exposure of research abuses that took place in

hospitals and institutions exposed a vacant space wherein the medical profession

failed to monitor and enforce a level of ethics deemed acceptable. Thus, as the

image of the independently regulating physician-healer faded away and medicine

lost its self-regulatory power, physicians and physician scientists were no longer

exemplars of morality or authorities on health care policy. The values and norms of

medical ethics were neither legitimate nor sufficient in the context of the socially

sanctioned institutional health care and biomedical research. Another set of values

was necessary to support and inform decisions and policy.

Third, as values and content-full morality became increasingly necessary for

navigating contemporary health care, the traditional modes of moral reasoning had

been and were continuing to become delegitimized. Engelhardt (1996, p. 68) argues

that a moral fragmentation originating in the Reformation led to a loss of shared

moral viewpoints available both through particular religious authorities and through

rational argumentation. Subsequently, as shared moral perspectives shattered,

1 The degree to which bioethics constitutes a discipline of ‘‘moral expertise’’ and the grounding for its

‘‘moral expertise’’ are, of course, debated.

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secularization took hold and began to impede resolutions to disagreements,

including those about medicine and science. The void in moral authority entangled

with secularization and the prioritization of rationality culminated in the irresolv-

ability of moral questions raised by the conditions of medicine in the twentieth

century. Because people no longer bowed to traditional sources of moral authority

and because the physician no longer had the legitimate ability to self-regulate, an

abyss in moral guidance on new questions about life and technology appeared.2

Thus, as the quasi-guild nature of medicine faded away and secularization

reinforced the erosion of theological authority figures, the need for a secular

bioethics emerged.

Secular bioethics emerged out of the intellectual vacuum created by technological

innovation, the convergence of medicine with governmental and business structures,

the medical profession’s failures to self-regulate, the legally imposed governance of

third party payers, and the secularization of society. In the role of the bioethicist,

people gained the legitimized authority to provide guidance on ethical conduct and

policy. Generally, they considered the interests of the state and pursued a morality to

guide all health care choices rather than particular moralities arising out of particular

and mutually exclusive traditions. Those perspectives that arose out of particular

traditions made efforts to speak to a broad audience far beyond their tradition. Thus,

subsequent bioethical discourses occurred under the presumption that ‘‘a rationally

discursive reflection on the moral and public-policy choices facing health care could

produce canonical normative guidance through the use of conceptual analysis and

sound rational argument’’ (Engelhardt 2002, p. 77). That canonical normative

guidance, however, was highly reflective of the context within which clinical ethics

emerged—the spaces and relationships of the hospital. To this context we now turn.

The Content of Clinical Ethics and the Context of the Hospital

Bioethics emerged in the context of the conditions that created the intellectual

vacuum. The context was primarily the inpatient setting or the abstract setting of

policy, not the outpatient office. The challenging technologies were mostly

delivered in the hospital setting. The medical and technological innovations that

were not bedside issues for the long-term hospital patient were largely issues that

were engaged on the level of policy.3 The majority of patient volume and financial

2 This is somewhat odd, given that the original leaders in bioethics were theologians. In spite of this

irony, I still find Engelhardt’s claim to be true. The secularization of the West did lead to the need for a

kind of public morality. The need for a public and shared morality that took the secularization of the West

as a given was a primary factor in shaping the kinds of bioethical arguments that theologians made.

Although they arose out of their traditions, the early theologians commenting on medical ethics and

bioethics made arguments that were largely accessible and applicable to a wider community. Their

arguments were content-full, but the particularities of their arguments were made less explicit through a

rhetoric of non-theological argumentation.3 One major exception to this claim may appear to be dialysis. Dialysis was an ‘‘out-patient’’ procedure

that did instigate the formation of a quasi-ethics committee; however, insofar as dialysis was considered

by the quasi-ethics committee, it was a matter of abstract policy about the criterion by which dialysis was

to be rationed.

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gain occurred in the inpatient setting. Consequently, the inpatient setting was the

area of focus for third party payers. The most heinous research abuses occurred in

institutions and hospitals (which had and have remarkable similarities). The loss of

the medical profession’s exclusive privileges in self-regulation were filled by

regulations and practices aimed at the hospital ethics dilemma. The role of the

ethicist as the expert in managing moral issues replaced that of the physician or the

pastor, but the ethicist did not reach every location that the physician practiced.

Because the terrain of the ethicist was primarily the hospital and policy debate, the

moral issues of non-hospital settings were sometimes overlooked or assumed

parallel to the hospital. The norms, practices, and goals most prevalent in clinical

ethics emerged in great part out of experiences and problems of the hospital setting.

Alasdair MacIntyre argues that rules ‘‘are less fundamental than roles and

relationships and that it is the context which roles and relationships provide which

alone makes sense of rules’’ (1978, pp. 44). As clinical ethics developed to fill part

of the intellectual vacuum, its content and practices reflect the spatial and relational

qualities of the hospital in several ways. First, the clinical care team holds a

tremendous degree of power in regards to the patient and the environment. These

relational dynamics conform especially well to a theoretical model of principlism.

Second, the hospital care team involves a large number of caregivers. Inevitably,

they will not only conflict with the patient and/or family, but they will also conflict

with or fail to clearly communicate with each other. Within this dynamic of a

clinical care team, the patient and/or her family is only one stakeholder at the table

seated next to other stakeholders, who are actually present. The degree of illness

common amongst hospital patients means that in many cases, the problem cannot be

indefinitely avoided. An impasse exists, conflict abounds, and a resolution and way

forward is needed. Third, the nature of the hospital environment is one of

empirically based decisions and monitoring of practices and outcomes. I will now

further explicate these three influences to show the ways in which they contribute to

the clinical ethics practices and discourses.

First, the spatiality of the hospital involves a relational dynamic wherein the

patient is often vulnerable, incapable, immobile, and less powerful and the caregiver

asserts control, expertise, and power in constituting the patient according to medical

norms (Foucault 1994). The patient’s existence is directed by the caregivers; her

schedule is subject to the affairs of the caregivers and the rules of the hospital.

Whereas the hospitalist may uphold a certain principle or action against or without

the consent of a patient (for example, in the upholding of nonmaleficence over

autonomy through the involuntary admission of a psychiatric patient or with a

unilateral Do Not Resusitate order), an outpatient practitioner can achieve very little

without the collaboration of her patient. Outpatient caregivers may encourage the

patient to make autonomous decisions in alternative ways that promote health;

however, the caregiver has little ability to override the patient’s autonomy when she

makes decisions that detract from the efficacy of her health care. In the hospital

context, the method of principlism is particularly helpful in guiding conversation

about ethical conflicts. Weighing and balancing principles fits the controlled

dynamics of the hospital, because physicians and caregivers hold the power to

prioritize principles in a way that the outpatient caregiver typically does not. For

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example, a hospitalist may frequently decide that a patient’s preference cannot be

granted in order to serve her medical benefit. Yet, it is a significantly rarer action for

an OB to attempt to force inpatient care upon a pregnant woman who is endangering

the life of her fetus (perhaps by court order). The outpatient caregiver may override

autonomy in cases such as mandatory disease reporting, but this is not an action for

deliberation but a requirement of law. The physician has less power over the patient

in the outpatient office, and instead must negotiate that which is good for the patient

in a more mutual and dependent manner.

Second, situations in the hospital context involve a large number of

stakeholders, including medical professionals and patients/families. Because

problems create impasses which cannot be ignored, clinical ethics emphasized

facilitation and mediation of conflict rather than discernment of robust goods

against a substantive metaphysical or epistemological framework. The kinds of

problems that incited the need for the ethicist (withdrawing care, determining

death, organ donation, etc.) involved many stakeholders with conflicting interests.

The ethicist emerged as a person who could help negotiate differences and

disagreements as well as move these disagreements onto an institutional or

structural level. Illustrating this aim, the American Society for Bioethics and

Humanities recommendations for clinical ethics (2011) note facilitation as a

primary (although not exclusive) role of the ethicist. A body of literature has

subsequently emerged that instructs the ethicist not how to think philosophically

about the prioritization of goods, but about the practical negotiation of complex

decisions. For example, in Bioethics Mediation, Dubler and Liebman (2011)

provide tools by which the ethicist can learn to negotiate conflict, manage tense

situations, and lead towards a consensus decision.

Because cases often involve multiple stakeholders and resolutions are often

necessary, reflection on the irreducible and plural goods of various metaphysical and

epistemological frameworks is often neglected. Instead, the need to resolve a

dilemma with a large number of stakeholders means that discussion often centers on

practical steps towards an outcome that all stakeholders can tolerate; the problem

may or may not actually be a robust moral dilemma. The ethicist may have training

in philosophy, theology, law, psychology, or ethics; however, the ethicist draws on

such training more to gauge, understand, and exclude the perspectives being

negotiated than to supply the content for decisions. Regardless of whether or not a

robust moral dilemma exists, the ethicist has her tools—of mediation, facilitation,

and consensus building—that will prove useful in tense scenarios. The point of

interest in this paper is that it is precisely the hospital context that leads clinical

ethics towards the path of mediation and facilitation of immanent conflicts in pursuit

of consensus. The large number of stakeholders and the necessity of agreeing on a

plan of action lead clinical ethics to an emphasis on coming to consensus on a way

forward rather than exploring and probing complex moral and metaphysical

commitments.

Third, the orientation of the hospital environment towards empirically based

decisions and monitoring of outcomes has influenced clinical ethics. Jeff Bishop

(Bishop et al. 2009; Bishop 2012) and his colleagues suggest that the context of

empirically based medicine contributes to the immanent orientation of clinical

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ethics towards measurable goals, rather than less measurable goods. As the

profession has evolved in the context of empirical clinical medicine oriented

towards quantitatively and qualitatively measurable goals, the aim of the clinical

ethicist has also become to achieve certain measurable goals: securing and

implementing patient’s right to control treatment, achieving and mediating

consensus in a decision, promoting the ability of physicians to withhold non-

indicated care, reducing ICU stays, developing practices for informed consent, etc.

These goals are measures of the ethicists’ success in the same way that reduced

mortality rates are a measure of the surgeon. The qualities of the relational

encounters within which the goals are achieved is largely overlooked, because the

achievement of the outcomes themselves become attestations of good practice.

Thus, the goals of clinical ethics are not the transcendent goods that arise out of

particular moral and metaphysical traditions and commitments; rather, they are a

kind of desired outcome that is definable and measurable in the domain of the

immanent. Some goals may promote more robust goods, while others are desired

ends simply for convenience or consequence. In any case, the achievement of these

goals depends not primarily on discernment of the good from a particular moral

perspective, but on mediation aimed towards clear, immediate, and objective goals.

Ultimately, Bishop et al. (2009, pp. 277–278) argue that insofar as clinical ethics

aims at goals rather than at goods, ethics practices emphasize procedural tasks and

then become oriented toward quality improvement. In short, they show that the

evolution of clinical ethics mirrors the evidence-based decision making of medicine

through the articulation of procedural tasks oriented toward quality and efficiency.

The procedural goals of clinical ethics ultimately aim not towards the good, but

towards immanent goals defined in relationship to quality improvement. Desirable

relationships or actions are not articulated in and of themselves, but in reference to

their usefulness in achieving quality improvement. Clinical ethics itself seeks its

own defense in self-justifying ends. For example, a well-known article (Fox et al.

2007, p. 16) describes 10 primary goals evident in clinical ethics. These goals

include protecting patient rights, resolving conflict, improving quality, improving

patient satisfaction, preventing problems, education, meeting staff’s perceived

needs, supporting staff, suspending unwanted or wasteful treatment, and reducing

legal liability. Clearly, many of these goals are concerned with (the clearly desirable

goals of) safety and quality, not with discerning particular moral goods.

The goals of clinical ethics become standardized, theorized, and encoded in

institutional and disciplinary policies, rules, and codes. Alasdair MacIntyre argues

that ‘‘the kind of regulation which is concerned with the safety or the quality of

goods and services is not an expression of any particular moral standpoint, but is

rather a substitute for morality at just those points in our social fabric where we no

longer possess adequate moral resources’’ (1980, p. 31). Insofar as ethics has

become largely reducible to law, as Annas (1997, pp. 3–12) argues, and insofar as

clinical ethics aims to standardize its practices as a field in pursuit of quality,

MacIntyre’s claim applies to the tendencies of clinical ethics. If ethics has come to

serve the goal of quality improvement through the monitoring of quasi-legal or

policy based hospital regulations, ethics is largely devoid of a robust morality. In

fact, to the degree that ethical discernment is valued because it promotes quality

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improvement, such discernment shifts from virtue to vice. MacIntyre (1975, p. 106)

argues that a virtue becomes a vice when having once been valuable in and of itself,

it ‘‘comes to be valued only or primarily for its employment as part of a technique.’’

The relational power dynamics, the number of stakeholders who are presented or

often at least represented, the need for a resolution to conflicts, and the drive for

quality improvement or procedural goals are qualities of the hospital that influence

the form of clinical ethics. This context contributed to the prioritization of

facilitation and consensus, within the bounds of absolutely unacceptable options and

prima facie absolutes (such as informed consent). Clinical ethics practices tend to

aim at immanent goals, and more robust goods rise to consideration when they

promote or detract from these goals. The reticence to invoke rich moralities and

other goods may come from the necessity of paving an agreeable way forward, the

plurality of moralities amongst stakeholders, or simply because the value of quality

improvement.

Ethics in Outpatient Settings

A clinical ethics grounded in the needs and characteristics of the hospital fails to

translate to the outpatient setting in two primary ways. First, the clinical ethicist’s

consultation and mediation are less practical in the logistics of outpatient care. In

many large tertiary hospital contexts, the ethicist is a specialist who is available to

consult just like another physician and space permits meetings to negotiate and

mediate for the goals of consensus or resolution. In the outpatient office, however,

consulting another practitioner is a less routine action and gathering involved parties

is often an impossibility. The large care team is simply not a reality. Stakeholders

are fewer or not immediately present, and many outpatient caregivers are

geographically isolated. Moreover, the relationship of clinician and patient—a

relationship that provides the foundation for norms—is far more mutual. The

clinician does not control the environment of the patient, and the caregiver does not

hold as much power in relation to the patient. An ethics for outpatient care has to

account for the relationship of outpatient caregiver to patient.

Second, moral dilemmas in outpatient care are often subtle dilemmas or moments

of discomfort rather than impassable problems. The procedures of clinical ethics are

satisfying in the hospital because they do involve actions that make clinicians feel as

though something is done to address a major problem or conflict. Actions can be

taken to ensure problems are addressed. Quality Improvement measures can be set

to gauge ethics’ effectiveness: Have advance directives been completed? Are

patients moved out of ICU faster? Do more care conferences occur for ICU

patients? Are fewer patients dying in the ICU? In the outpatient office, the

relationship between patient and doctor is paradoxically more prolonged and

momentary and procedural ethics or quality measures are less clear. What, for

example, would be the measure to signify that Dr. Lopez has acted more

‘‘ethically’’? The best and most ethical physicians may have noncompliant patients,

and the best and most ethical physicians may choose not to see Medicaid and/or

noncompliant patients. Moreover, the structural influences on the patient cannot be

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controlled to the degree that the hospital’s environment allows. Whereas an

inpatient caregiver can consult ethics to effect real change, an outpatient clinician

may be relatively powerless to address structural elements that cause moral distress.

Overall, the clinical ethics of the hospital is grounded in the assumptions and

dynamics of the hospital physician and patient relationship. The space of the

hospital and nature of this relationship make a procedural ethics aimed at consensus

very effective in promoting quality, efficiency, and safety and minimizing cost,

waste, and harm. Moreover, theories based on the weighing of principles are

particularly suitable to this context, because the control that caregivers exercise in

terms of the environment practically allow for the prioritization of one principle

over another. Yet, the practices of clinical ethics have largely come to function as

substitutes. The rich and pluralistic goods of various moralities are set aside to

promote the task of delineating intolerable decisions (usually based on law or

regulation) and then mediating conflict within the remaining space with the aim of

quality improvement. The controlled dynamics of the hospital help ensure decisions

are enacted. These clinical ethics practices are not as helpful in the outpatient

context because they do not fill the same kind of void that existed in the hospital

space and its roles and relational dynamics. The void in the hospital arose out of

impassable questions of how to proceed in the larger context of an ‘‘intellectual

vacuum.’’ Clinical ethics continues to thrive on the remnants of these impassable

questions, facilitating a way forward when people disagree or proactively

implementing procedures through which impassable dilemmas are altogether

avoided. But the void in the outpatient office is not the same void; it is a void

wherein subtle dilemmas and conflicts between patients, professional obligations,

goods, and moral commitments leave practitioners with experiences of distress or

discomfort.

MacIntyre notes that the substitutes for morality are born at the moment where

moral resources are inadequate. In the hospital, I have suggested that clinical ethics

has evolved into a helpful substitution for rich reflection on particular moral goods

and moralities. But, when outpatient providers experience moral distress, the

clinical ethics of the hospital—substituting for morality—largely fails to provide

resources that can aid in ethical deliberation. The danger in failing to augment

outpatient care with robust tools for moral reflection and ethical action is that it will

fall into the same fate as its predecessor in the hospital: outpatient ethics too could

develop a substitute for ethics. After all, now is the moment wherein outpatient

setting is expanding as the epicenter of health care delivery and moral resources

may be inadequate as new questions are faced. An approach to outpatient ethics is

necessary before a substitute for ethics emerges in outpatient care.

Clinical Ethics and Outpatient Medicine

If we follow MacIntyre’s claim and begin with roles and relationships, a robust body

of literature already provides the foundation for ethics in outpatient clinical care.

Much has already been written on the nature of the doctor–patient relationship. For

example, Emanuel and Emanuel (2012) note four models of the physician–patient

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relationship: paternalism, informative, interpretive, and deliberative. They elucidate

these models in terms of the goals of the relationship, the physician’s obligations,

and the patient’s values and autonomy. These models provide tangible ways of

considering how physicians are to interact with patients and what the goals of the

interactions are. They propose the following goals: to ensure the patient receives

care that promotes health (paternalistic), to provide information and enact the

patient’s choices (informative), to identify the patient’s values and help discern

choices that reflect values (interpretive), and to help the patient uncover her values

in the process of decision making (deliberative). The models have significant

implications for outpatient ethical issues, such as the ways of approaching informed

consent. Quill and Brody (1996) make a similar point about doctor–patient

interactions that may prove helpful for outpatient care. They propose a decision

making model of enhanced autonomy rather than independent choice. They note

that this model encourages ‘‘patients and physicians to actively exchange ideas,

explicitly negotiate differences, and share power and influence to serve the patient’s

best interests’’ (p. 763). Similarly, many medically oriented accounts of virtue

provide insight about the duties of the physician. This literature is exceptionally

helpful in elucidating how physicians ought to approach and interact with patients.

MacIntyre emphasizes the importance of considering goods alongside relation-

ships. He notes, ‘‘…roles and relationships themselves require elucidation in terms

of goods’’ (1978, p. 44). Literature on the doctor–patient relationship like that of

Emanuel, Emanuel, Quill, and Brody makes intimations about the goods of clinical

care. A Hastings Center Report (Allert et al. 1996) further articulates four primary

aims of medicine. These aims may also be applicable to outpatient care (perhaps

most applicable to outpatient care): the prevention of disease and injury and the

promotion and maintenance of health, the relief of pain and suffering, the cure of

those with a malady and the care of those who cannot be cured, and the avoidance of

premature death and the pursuit of a peaceful death. Nevetheless, articulating goods

of medicine can be problematic insofar as they reflect a limited perspective. For

example, we might envision a more expansive view of various goods that move far

beyond these four points. The doctor–patient relationship, the cohesion of the

family, the protection of public health, or the spirituality of the person could be

recognized as goods and priorities. Perhaps equality may also be named as a good

internal to the practice of medicine (Benjamin 1992). Others have historically

understood the goods of medicine from a theological approach. The Sisters of

Providence articulated what was true for many Christian communities: ‘‘Salvation

of souls is still our most important blessing’’ (Wall and Nelson 2003, p. 325).

A second problem with attempting to name goods pertaining to medicine, as

Veatch (2001) notes, is that an intrinsic, conceptual ambiguity exists in each named

good; this ambiguity would extend to any other goods that are added to the often

cited list given by the Hastings Center. For example, some may understand merciful

pain relief as or even requiring the sanction of physician assisted suicide. That

vision of the good of merciful pain relief may be understood by others as a

deprivation of consciously experienced meaning or even as an act of killing. At

times, the various interpretations of goods may even be contradictory and mutually

exclusive. So, goods shape the form of right relationships, and right relationships

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shape moral norms and principles; but because goods are neither universally

accepted nor conceptually clear, appropriate patient–physician relationships and

subsequent norms of moral action cannot be universally discerned from reflection

on goods relevant to medicine.

If the patient–physician relationship depends upon goods and a singular vision of

the goods relevant to the practice of medicine does not exist, how and where ought

the goods to be defined such that a vision for outpatient ethics can emerge? First,

practitioners must discern the goods for themselves, and then develop an

understanding of their role as a caregiver in relationship to patients. In this

discernment, the particularities of outpatient relationships and spaces will be

presumed by outpatient practitioners and the literature on the doctor–patient

relationship is helpful. Nevertheless, depending upon the discernment of practitio-

ners is insufficient for the cultivation of ethics in outpatient care for several reasons:

ethics is not simply an individual endeavor about which people have the liberty to

choose and enact their intentions. Structural and organizational influences can both

challenge practitioners to more sophisticated ethical considerations, and structural

forces can also influence, constrain, and prohibit decisions made by a well-intended

caregiver. In other words, practitioners also need support to enact actions discerned

to be right when those actions have social, political, or volitional constraints or

consequences. And yet, in giving such support, organizations cannot be unbiased

regarding the goods of medicine. Practitioners will be limited and challenged by

certain epistemological, social, moral, and political commitments (in both negative

and positive forms) of the organization.

Arising from a particular vision of goods and taking particular contexts into

consideration, ethics challenges and exceeds—even precedes—the individual

because ethical choices are made in social and structural contexts. The clinical

ethics of inpatient care clearly reflects the context of the hospital. In outpatient care,

a systematic kind of clinical ethics has not become commonplace. On one hand,

organizations could leave ethics to the full discretion of their physicians, who

become responsible for knowing how to navigate outpatient moral issues. The

breadth of moral perspectives within the employed physicians will necessarily

expand as the number of employed physicians expands. Although virtue ethics and

literature on the patient–physician relationship will prove helpful, concepts of virtue

and the good physician will become increasingly ambiguous and contradictory with

the articulation of differing goals of medicine. On the other hand, organizations

could facilitate an outpatient clinical ethics that builds upon the doctor–patient

relationship literature by increasing alliances with organizational ethics. Accord-

ingly, individuals would not be left alone to navigate ethical dilemmas that arise

from epistemological uncertainties, structural constraints, or social dynamics.

Organizations could take a stronger role in forming and influencing ethical

perspectives (which, of course, will be deeply biased), but physicians in turn would

gain the benefits of organizational support in addressing clinical challenges. This

paper suggests that health care organizations need to make greater efforts to extend

ethics to the outpatient context and consider how they can better support these

clinicians. Ethical decisions are always enabled or resisted through contextual

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factors that exceed the individual’s control. As more physicians are employed by

larger health care organizations, these contextual factors increase.

A clinical ethics allied with organizational ethics that reaches out to outpatient

clinicians will give input into the defining, interpreting, and prioritizing of goods as

well as power to addressing the obstacles of these goods. As such, certain

considerations will expand or contract as having moral relevance for the roles and

responsibilities of caregivers. As MacIntyre writes, ‘‘…insofar as choices between

forms of organizations have implications for role-definition, they at least partially

determine moral problems we will encounter’’ (1978, p. 46). For example, if the

goods understood by a particular organization do not involve equality, excluding

Medicaid or noncompliant patients may be permissible for the sake of fiscal stability

or spending more time with other patients. On the other hand, if the goods of

medicine for another organization involve a particular concern for the disadvan-

taged, caregivers will be encouraged to see issues they may have otherwise

overlooked. Accordingly, an outpatient ethics that allies with organizational ethics

could leverage resources for practical solutions that promote both the development

of conscience and organizational mission.

Outpatient physicians often experience ethical issues and moral dilemmas. In

discerning how to respond to the ethical issues, physicians must consider their roles

and responsibilities to various stakeholders; however, such discernment cannot occur

without discernment of goods and actions that accords with their responsibilities. In

many instances, outpatient caregivers lack the leverage and authority to promote the

goods of medicine or address the sources of ethical tension. Resources of

organizational ethics can help align ethical concerns in the clinic or nontraditional

setting with wider efforts or strategies of the organization. In this way, outpatient

ethics is not just an aspiration or a disposition of the caregiver, but holds the power to

transform the most challenging outpatient dilemmas for the sake of more robust goods.

Conclusion

Although clinical ethics has secured itself as a legitimate practice in the modern

hospital, it has failed to equally reach outpatient settings which are quickly become

the locus of health care delivery. Several reasons exist for this reality. First, the

moral issues faced in outpatient care are generally less urgent and impassable than

in the hospital. Second, the practices generated through the evolution of clinical

ethics as a subspecialty of bioethics are less applicable to outpatient care. In large

part, clinical ethics presumes the space of the hospital and the kinds of relationships

the hospital facilitates. When transferred to the outpatient office, these practices,

theories, and norms provide less help in navigating ethical issues.

In beginning an approach for the renegotiation of the underpinnings of an outpatient

ethics, this paper has relied upon MacIntyre’s claim that norms require the context of

relationships, and understanding relationships requires a robust vision of the goods of

those relationships. The procedural ends and the mediation and negotiation used by the

clinical ethicist do fulfill an important need in difficult hospital scenarios. Although

significant resources have been devoted to clinical ethics in the hospital context (by

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choice and force), outpatient practitioners sometimes lack support in addressing

challenging ethical dilemmas. I have argued that organizations need to attend more to

ethics in outpatient care and provide resources to aid outpatient clinicians in educative

and consultative ways. In these efforts, a new emphasis on the interplay between

organizational ethics and clinical ethics is necessary. This alliance may lead to the

invocation of more robust and particular moral content and a prioritization, exclusion, or

indifference relative to the goods that shape moral obligations and ethical resolutions.

Yet, an approach that augments the doctor–patient relationship with organizationally

defined goods will enable outpatient practitioners and organizations to work together to

overcome a wider realm of ethical dilemmas and overcome structural contributors to

ethical tension. Perhaps, through the enactment of a creative solution promoted on a

level far above the outpatient office, Dr. Lopez can ensure that his Medicaid patients get

care that they need or that efforts are being made on their behalf.

References

Allert, G., Blasszauer, B., Boyd, K., & Callahan, D. (1996). The goals of medicine: Specifying the goals

of medicine. Hastings Center Report, 26, S9–S13.

The Report of the American Society for Bioethics and Humanities. (2011). Core Competencies for Health

Care Ethics Consultation (2nd ed.). Glenview, IL: American Society for Bioethics and Humanities.

Annas, G. J. (1997). Standard of care: The law of American bioethics. New York: Oxford University

Press.

Benjamin, W. W. (1992). Combining the best of two medical worlds: Canadian universality and United

States freedom. Humane Medicine, 8(4), 271.

Bishop, J. P. (2012). On the social construction of health care ethics consultation. In H. T. Engelhardt, Jr.

(Ed.), Bioethics critically reconsidered: Having second thoughts. Netherlands: Springer.

Bishop, J. F., Fanning, J. B., & Bliton, M. J. (2009). Of goals and goods and floundering about: A

dissensus report on clinical ethics consultation. HEC Forum, 21, 275–291.

Dubler, N. N., & Liebman, C. B. (2011). Bioethics mediation: A guide to shaping shared solutions.

Revised and Expanded Edition. Nashville, TN: Vanderbilt University Press.

Emanuel, E. J., & Emanuel, L. L. (2012). Four models of the physician–patient relationship. In E.

(Boetzkes) Gedge & W. J. Waluchow (Eds.), Readings in health care ethics (2nd ed.). ON:

Broadview Press, Peterborough.

Engelhardt, H. T. Jr., (1996). The foundations of bioethics. New York: Oxford University Press.

Engelhardt, H. T. Jr., (2002). The ordination of bioethicists as secular moral experts. Social Philosophy

and Policy, 19(02), 59–82. doi:10.1017.S026505250219203X.

Engelhardt, H. T. Jr., (2013). Bioethics as a Liberal Roman Catholic Heresy: Critical reflections on the

founding of bioethics. In J. R. Garrett, F. Jotterand, & D. C. Ralston (Eds.), The development of

bioethics in the United States. London: Springer.

Felder, M. (2002). Outpatient ethics: And the walls came tumbling down. The Journal of Clinical Ethics,

13(4), 282.

Fetters, M. D., & Brody, H. (1999). The epidemiology of bioethics. The Journal of Clinical Ethics, 10(2),

107.

Foucault, M. (1994). The birth of the clinic. New York: Vintage Books Edition.

Fox, E., Myers, S., & Pearlman, R. A. (2007). Ethics consultation in United States hospitals: A national

survey. The American Journal of Bioethics, 7(2), 13–25.

John La Puma, M. D., & Schiedermayer, D. L. (1989). Outpatient clinical ethics. Journal of General

Internal Medicine, 4(5), 413–420.

MacIntyre, A. (1978). What has ethics to learn from medical ethics? Philosophic Exchange, 2(4), 37–47.

MacIntyre, A. (1975). How virtues become vices: Values, medicine and social context. In H.

T. Engelhardt & S. F. Spicker (Eds.), Evaluation and explanation in the biomedical sciences, (pp.

97–111). Berlin: Springer.

HEC Forum

123

MacIntyre, A. (1980). Regulation: A substitute for morality. Hastings Center Report, 10, 31–33.

Medicare Payment Advisory Commission. (2012, March). Report to the Congress: Medicare Payment

Policy.

Moon, M., Taylor, H. A., McDonald, E. L., Hughes, M. T., & Carrese, J. A. (2009). Everyday ethics

issues in the outpatient clinical practice of pediatric residents. Archives of Pediatrics & Adolescent

Medicine, 163(9), 838.

Papanikitas, A., & Toon, P. (2011). Primary care ethics: A body of literature and a community of

scholars? JRSM, 104(3), 94–96.

Potter, R. L., & Kaiser, C. (2002). Bringing moral order to the ordinary: Outpatient ethics takes shape.

The Journal of Clinical Ethics, 13(4), 274–281.

Quill, T. E., & Brody, H. (1996). Physician recommendations and patient autonomy: Finding a balance

between physician power and patient choice. Annals of Internal Medicine, 125(9), 763–769. doi:10.

7326/0003-4819-125-9-199611010-00010.

Robillard, H. M., High, D. M., Sebastian, J. G., Pisaneschi, J. I., & Perritt, L. J. (1989). Ethical issues in

primary health care: A survey of practitioners’ perceptions. Journal of Community Health, 14(1),

9–17.

Veatch, R. M. (2001). The impossibility of a morality internal to medicine. Journal of Medicine and

Philosophy, 26(6), 621–642. doi:10.1076/jmep.26.6.621.2996.

Wall, B. M., & Nelson, S. (2003). Our heels are praying very hard all day. Holistic Nursing Practice,

17(6), 320–328.

Young, E. W. D. (1997). Ethics in the outpatient setting: New challenges and opportunities. Cambridge

Quarterly of Healthcare Ethics, 6(03), 293–298.

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