Journal of Internal Medicine 1995: 237: 487-492

The medical hierarchy and perceived influence on technical and ethical decisions

S0REN HOLM From the Department of Medical Philosophy and Clinical Theory. Faculty of Health Sciences. University of Copenhagen. Copenhagen. Denmark

Abstract. Holm S (Department of Medical Philosophy ence in discussions about technical and ethical issues and Clinical Theory, Faculty of Health Sciences, in connection with decisions to terminate treatment University of Copenhagen, Copenhagen, Denmark). for patients with terminal malignant illness. The medical hierarchy and its perceived influence on Results. The odds ratio for perceived influence technical and ethical decisions. Intern Med 1995; between consultants and house officers is 14.9 for 237: 487-92. ethical issues, 44.9 for technical issues, and 652.3

Objective. To investigate the influence of hierarchial position and perceived influence on ethical and technical decisions. Design. The study was conducted as a postal ques- tionnaire survey. Subjects. A random sample of 329 Danish physicians working at departments of internal medicine and

for questions concerning departmental policy. Gender plays no role, when one controls for hierarchial position. Conclusions. Hierarchial position is the major de- terminant of perceived influence on technical and ethical decisions. Position seem to play a larger role in technical than in ethical decisions.

related subspecialties. Of these, 2 70 (82%) returned a completed questionnaire. Main outcome measure. Self-reported perceived influ-

Keywords: medical decision making, medical ethics, medical hierarchy, termination of treatment.

Introduction Medical decisions are no longer taken by a single doctor treating his or her ‘private’ patient. In the modern hospital physicians work together in large teams having hierarchial structures. This is especially the case in many European health care systems where hospital consultants are salaried, and where individual patients do not ‘belong’ to one specific consultant. Important decisions will therefore often be discussed at departmental conferences in which several doctors participate. The present study was prompted by an analysis of 33 interviews with Danish doctors concerning the ethical problems they perceive in their work. A recurrent theme was the effect of the medical hierarchy on ethical decision making, and the various ways in which junior doctors try to negotiate the system when they disagree with decisions taken. In the interviews, ethical problems concerning decisions to withdraw and/or withhold treatment from terminally ill

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patients were often cited as a common, important, and salient class of ethical problems.

It was therefore decided to perform a quantitative investigation of how doctors in different positions in the hierarchy perceive their influence on decisions concerning withdrawal of treatment from terminally ill patients, and of what actions they would take if the decisions made were contrary to their ethical convictions.

Material and methods The study was conducted as a postal questionnaire during September and October of 1993. It was felt that a high response rate was necessary to give valid and interpretable quantitative results. The ques- tionnaire was therefore explicitly designed to be short and easy to fill in [l].

In order to obtain a manageable size of study, it was decided to include only physicians working in departments of internal medicine and related sub-

48 7

488 %HOLM

specialties, thereby excluding the possibly quite large differences between different medical and surgical specialties from the scope of the study. From the 1993 membership list of the Danish Medical As- sociation, a file was made of all physicians employed at departments of internal medicine and related subspecialties. The information extracted from the membership list included name, address, position, year of graduation, and sex. The total file contained 2051 physicians. From this file a random sample of 329 physicians was drawn.

Each person in the sample was mailed a ques- tionnaire, an accompanying letter, and a stamped and coded return envelope. If the questionnaire was not returned within 3 weeks, a reminder was sent. Anonymity was ensured in the following way. All returned envelopes were opened by a secretary and the envelope with the code number separated from the questionnaire, so that no questionnaire could be connected to any specific person.

No formal pilot study was performed, but the project protocol and preliminary versions of the questionnaire were discussed with a number of medical and non-medical colleagues.

Contents 01 questionnaire

The questionnaire used asked for demographic in- formation: age, sex, position, and size of the hospital in which the respondent was employed. A case was presented :

‘A 56-year-old man with terminal, small-cell ana- plastic carcinoma of the lung for whom the de- partment of oncology has no further therapeutic options. He is now in hospital with his second bout of pneumonia within 2 months and his condition has not improved despite 4 days of intensive antibiotic treatment directed against the organisms cultured from tracheal suction samples. He has been delirious throughout this admission, and neither he nor his family has expressed any wishes concerning the future. His wife just asks the doctors to “do what is best for my husband”. His survival if he overcomes the present pneumonia is estimated to be 1-2 months. During ward rounds, it is decided to discuss this patient at the daily departmental conference and consider whether treatment should be withdrawn.’

On the basis of this case, the respondents were asked

a series of questions concerning withdrawal of treatment for terminally ill patients. These questions concerned the frequency of this kind of situation in their work, the role of nurses in such decisions, their perception of their own influence in discussions about such cases, and their choice of action if they disagree with the decision made. All questions had closed categories for answering, except two questions where respondents were asked to specify the exact content of their choice. Space was provided for any comments the respondent wanted to make.

Statistical analysis

Statistical analysis was performed using the chi- squared test for discrete data and the Mann-Whitney U-test for data on ordinal or interval scales.

A standard log-linear model with position and sex as the explaining variables was used for the analysis of data on participation of nurses in the decision process [2].

A McCullagh proportional odds model with position and sex as the explaining variables was used for the analysis of data on perceived influence. The model is a natural extension of the standard logistic model for binary responses to cases with more than two ordered responses [ 3 ] .

All statistical analyses were performed using the program CSS : Statistica for DOS, except the analysis using the McCullagh model which was performed in SAS. The significance level was set at the con- ventional 5%.

Results A total of 329 questionnaires were sent out. Two

Table 1 Demographic data of respondents

Male Female

Age (years) 42 (9.4)* 3 5 (6.2) Position

Consultant 58 4 Senior registrar 6 6 22 Registrar/House officer 72 4 5

Type of Hospital University 82 42 Large community 50 2 8 Small community 25 3 1

*Mean (SD) n(male) = 171. n(female) = 9 9 (the number of non-respondents varies between questions).

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HIERARCHY AND ETHICAL DECISIONS 489

Table 2 Results of questions regarding termination of treatment

Questions Answer

How often do you encounter situations of this kind in the department where you work?

Is it normally a nurse or a physician who first takes the initiative to discuss withdrawal of treatment in such situations?

Do you believe that such questions are suitable for discussion at a departmental conference?

Would you yourself take the question to the departmental conference, if you were doing the ward rounds? Should the nurses who care for the patient participate in the conference

f If you raise the question about treatment withdrawal at a departmental conference, how great would your influence then be on the final decision if the discussion centred around an ethical question ?

g If you raise the question about treatment withdrawal at a departmental conference, how great would your influence then be on the final decision if the discussion centred around a technical question ?

h How great would your influence be on the final decision if the discussion was not about a particular patient, but about the establishment of a departmental policy?

i What aspect would dominate the discussion at the departmental conference?

j If the decision taken at the departmental conference was in strong disagreement with your ethical convictions, what would you then do? (The respondents could mark 2 of the options.)

1 2 3 4 5 1 2 3

1 2 3 1 2 3 1 2 3 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 1 2 3

4 5

Each day A couple of times a week A couple of times a month A couple of times a year Never

Nurse Physician Don’t know

Yes No Don’t know Yes No Don’t know

Yes No Don’t know

Decisive influence Great influence Some influence Small influence No influence Decisive influence Great influence Some influence Small influence No influence

Decisive influence Great influence Some influence Small influence No influence

Technical aspect Ethical aspect Equal Nothing Raise the discussion again Delay the implementation of the decision

Move the patient Other Specification : Delay and discuss again Veto decision Ask the patient and family

Ask other doctor to carry out

Act according to personal ethics Leave conference Change job Other and no specification

(Cont. on page 490)

again

decision

11 70

152 28

1 54

134 79

247 12

5 233

32 2

1 74 63 29 29

130 85 22

2 41 96 85 39

7 20 60 77 88 23

32 87

144 109 254

49

10 59

20 9 7

5

3 2 2

11

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490 %HOLM

Table 2 (cont.)

Questions Answer

k Can you imagine (legal) decisions about 1 No, not at all 2 Yes, in very special ethical questions which you would find so

wrong, that you would try to circumvent them ? 3 Yes, in some circumstances

circumstances

4 Don't know Specification of 2 and 3 : Euthanasia Aggressive treatment of

terminally ill patients Conflicts between duties of non- disclosure and duty to warn in the case of HIV

of Jehova's Witnesses

interests of the patient and the interests of society

Blood transfusions to members

If there is conflict between the

Other No specification

75

92 15 8 4

11 9

5

4

4

1 9 55

n = 270 (the number of non-respondents varies between questions)

persons had moved and could not be located. Of the remaining 327 ,2 76 returned a questionnaire, and of these six were blank. The answer rate for completed questionnaires was thus 82% (Table 1).

Comparisons between respondents (including the six blanks) and non-respondents show no significant differences with regard to sex, position, graduation year, or place of residence.

Statistical analysis using McCullagh models indi- cates that position is the main determinant of perceived influence and that sex plays no role when one controls for position. In the final models, only position was therefore used as the explaining vari- able. The general goodness-of-fit for the three models was tested and found to be acceptable (P > 0.05 in all three cases).

Log-linear analysis of three-way tables using the answers about participation of nurses as response, and sex and position as explaining variables, shows that position is the main determinant of whether one thinks that nurses should participate in the de- partmental conference making the decision about withdrawal of treatment and of whether one believes that nurses or physicians usually are the first who raise questions about withdrawal of treatment. In both cases, the final reduced model contains the significant two-way interactions sex :position and position :answer but not an interaction between sex and answer. The goodness-of-fit of the models was

estimated by maximum likelihood chi-squared and found to be acceptable (P > 0.05 for both models).

Discussion

More than 98% of all Danish doctors are members of the Danish Medical Association, so the bias intro- duced by using the membership register as the basis for the present study is minimal. The answer rate is high, and the comparisons between respondents and non-respondents show no major differences. The results found here should therefore reflect the opinions amongst Danish internists.

The results show that the problem raised by the case is commonly encountered by physicians work- ing at departments of internal medicine. More than 85% of the respondents see this kind of situation a couple of times a month or more frequently (Table 2). Almost all respondents believe that such a problem can appropriately be discussed at a departmental conference, and would themselves take the problem to a conference.

One can therefore expect that the respondents have participated in several departmental confer- ences discussing this kind of problem, and that they have some estimate of the influence they themselves have had on the final decisions in these cases. The purpose of using a case with this content as the basis

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HIERARCHY A N D ETHICAL DECISIONS 491

Table 3 The influence of hierarchial position on perceived influence and opinions about nursing participation

Registrar/ Senior House

Influence Consultant Registrar Officer

Ethical. issues'

Technical issuest

Departmental policy$

Who asks first

Should nurses take part in the conference

Decisive 17 Great 39 Some 6 Small 0 No 0

Decisive 23 Great 37 Some 2 Small 0 No 0 Decisive 19 Great 40 Some 3 Small 0 No 0

Nurse 10 Physician 35 Don't know 16 Yes 52 No 8 Don't know 2

10 2 49 41 26 52

3 185 0 2

16 2 39 20 31 51

2 35§ 0 7 1 0

16 4 50 23 18 70 3 18

2 1 2 1 49 49 18 45 57 62 25 30

5 22

Discrepancies in numbers between this table and Table 1 are due to respondents not having stated their position. Odds ratio (95% confidence limits): *Consultant vs. Registrar/House Officer. 14.9 (7.4-30.3): Senior Registrar v. Registrar/House Officer 4.0 (2.3-6.9). t Consultant vs. Registrar/House Officer, 44.9 (12.8-157.5): Senior Registrar vs. Registrar/House Officer, 10.2 (3.7-28.2). $Consultant vs. Registrar/House Officer. 652.3 (195.6-21 75.3): Senior Registrar vs. Registrar/House Officer, 9.3 (5.0-1 7.2). 5 Because of low numbers in each cell, the categories 'small' and 'no ' were collapsed for the McCullagh analysis.

for an analysis of perceived influence is therefore fulfilled.

According to Danish legislation, a physician can legally decide to withdraw futile treatment. The legislation offers no definition of futility, but the case used in this study would definitely fall within the scope of the rules. Legal considerations are therefore unlikely to have played any significant role in the deliberations of the respondents.

A number of similar comments by respondents claim that the questionnaire gave no valid infor- mation about attitudes towards withdrawal of treat- ment. This observation is true, but as it was not the aim of the study to investigate these attitudes, it is

not a problem which will affect the interpretation of the data.

A general problem in analysis of data of this kind is the skewed composition of i he physician population with regard to sex. The female physicians on average are younger and occupy lower positions in the hierarchy compared to male physicians. Because age and position are closely correlated, it was decided not to include age as an explaining variable in the statistical analyses. The results show, as could be expected, that position in the hierarchy is the main determinant of perceived influence, and that sex plays no role, when one controls for position (Table 3 ) .

The odds ratio for a consultant having decisive influence versus a registrar or house officer shows a consistent, although in most cases non-significant, pattern with odds being highest for decisions about departmental policy, intermediate for technical decisions, and lowest for ethical decisions.

The high odds for decisions about departmental policy require little explanation, because it is a normal part of the role of consultants to make this kind of decisions.

The tendency in the odds for technical and ethical decisions indicates a different influence of hierarchial position and/or experience on these decisions. Poss- ible explanations could be that decisions in ethical matters are more open for debate or that expertise is not conceived of in the same way as are technical decisions.

Sixty-three of the respondents do not believe that the nurses caring for the patient should participate in the final discussion concerning withdrawal of treat- ment, and this attitude is approximately twice as common amongst physicians at the two lower levels of the hierarchy as amongst consultants (Table 3 ) . A possible explanation is that consultants do not perceive nurses to be a threal to their authority and influence, whilst those lower in the hierarchy may do so. This could also explain why consultants and senior registrars think that questions about with- drawal of treatment are mosi often raised by physi- cians, whereas registrarslhouse officers are more uncertain.

The answers to the questions concerning reactions to decisions that are in strong disagreement with the ethical convictions of the respondents show a range of responses, which can best be classified by Hirschmans exit, voice, and loyalty classification of

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492 S.HOLM

available options for dissenters in organizations as later extended by Lundquist to include a fourth option called 'obstruction' [4. 51. This fourth option is important in strictly hierarchial organizations where it offers persons in the lower levels of the hierarchy an option, that is usually costless, to express dissent.

If this classification is used on the answers given to questions j and k (Table 2) it is found that most of the answers fall within the categories of loyalty and voice (do nothing/raise the discussion again), some can be classified as obstruction (delay the implemen- tation of the decision/move the patient), and only very few as exit. It is probable that the exit option would have been more popular if it had been stated explicitly as a possible option, so that the respondents would not have had to think of it themselves and specify it under 'other'.

On the other hand, it is obvious that exit is a very costly option for physicians because it entails a disruption of their career, whereas the other possible actions are either accepted or possible to disguise. Trying to raise the discussion again is acceptable in most cases, and there are many ways in which the implementation of a decision can be delayed without encountering the disapproval of ones superiors. Moving the patient is a more risky form of obstruction than just delaying and, as the present results show, also a less popular form.

Acknowledgements I gratefully thank Torben Martinussen of the De- partment of Biostatistics for performing the statistical analyses using the McCullagh model.

This research was supported by Anna og .Jakob Jakobsens Legat, Direktar Jacob Madsen og Hustru Olga Madsens Fond, Fonden af 18 70, and Lzgeforen- ingens Forskningsfond.

The author was supported by a research fellowship from the University of Copenhagen, Faculty of Health Sciences.

References 1 Converse JM. Presser S. Surveg Questions - Handcrafting the

Standardized Questionnaires. Newbury Park: Sage Publications, 1986.

2 Gilbert GN. Modelling Societg: an Introduction to Luglinear Analgsis for Social Researchers. London: G. Allen & Unwin. 1981.

3 McCullagh P. Regression Models for Ordinal Data. I R Stat Soc (Series B) 1980: 42: 109-42.

4 Hirschman AO. Exit. Voice and Loyalty: Responses to Decline in Firms, Organizations and States. Cambridge. MA : Harvard University Press. 1970.

5 Lundquist L. Bgrikratisk Etik. Lund: Studentlitteratur. 1988.

Received 19 July 1994: accepted 1 December 1994.

Correspondence: Ssren Holm. Department of Medical Philosophy and Clinical Theory. Faculty of Health Sciences, University of Copenhagen, Blegdamsvej 3. DK-2200 Copenhagen N. Denmark.

0 1995 Blackwell Science Ltd Journal oflnternal Medicine 237: 487-492