BioethicsWalk addresses
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Editor's Note: This is a longer than usual BioethicsWalk. As you read through it, you will see the reason for the length. Rather than break this into two articles, we thought it better to keep as one longer article.
E Pluribus Utrum
When I was in seminary, the required course in systematic theology included an exercise called the “utrum” paper. The goal of this exercise, which was based on Thomas Aquinas’s Summa Theologiae, was to teach us how to frame and analyze theological arguments, to understand what was required to make a compelling case for a particular position. (“It’s all good” and “it depends” were not acceptable arguments.) Our professor told us that the utrum exercise had uses beyond this course: a former student, uncertain about accepting a job offer, had found that writing up an utrum in the middle of the night had helped him make his decision.
A few months ago, a reader proposed a column idea on a “perplexing” topic: how should chaplains use charts and other medical records? As she wrote:
Do we really need access? I see the utility of our access, but I don't necessarily see the necessity. Couldn't it be argued that there is an advantage to our not knowing the patient through the medical lens? That as blank slate[s] we allow the patient to write his or her own story?
This is a superb topic for an utrum paper: Are chaplains “blank slates,” receivers of stories, or are they peering through the same “medical lens” as doctors and nurses? What are the ethical consequences of committing to either of these identities, or to another identity? The beauty and challenge of the utrum is that you have think through what you believe to be true – and then think through what you must disbelieve as a result. So here is an abbreviated utrum as an introduction to this ancient and still useful tool:
Utrum (“Whether”)
Whether it is the case that all chaplains should always read a patient’s chart (or other readily available medical record) prior to a visit with a patient.
The utrum must state a real issue with more than one plausible answer. This statement frames the issue unequivocally: should everyone (or no one) do this? In this respect, the utrum statement is like Immanuel Kant’s “categorical imperative,” which analyzes ethical questions by asking, what if everyone was required by law to do the thing you are proposing to do?
Videtur (“It seems”)
It seems appropriate for the chaplain to rely on the patient for an account of the patient’s clinical situation, rather than first obtaining this information from the chart. Listening to patients is central to the work of chaplains. Narrative ethicists argue that attention to the patient’s own voice, story, and perspective is integral to honoring and caring for the whole, suffering person, not simply for “the disease in the body in the bed.”
The videtur presents a detailed argument in favor of one plausible answer to the utrum, here, the one suggested by the reader. It should include references to recognized authorities, by citing scholarly articles that can support this argument. The videtur can also include references to personal experience, to religious tradition, and even to common sense, if these provide convincing support for the argument. An argument supported only by the writer’s personal experience will probably not be convincing: the utrum exercise requires the writer to identify authorities, traditions, and standards that are broadly recognized as morally legitimate.
Sed contra (“But on the other hand”)
But on the other hand, chaplains are health care professionals, not blank slates. It would be unethical for other health care professionals, such as physicians or nurses, to fail to acquaint themselves with the clinical facts of a case when these facts are readily available in a chart. No one would want to be treated by a doctor or nurse who didn’t read charts. Nor are patients responsible for mastering the clinical details of their illness and treatment and for sharing these details with professionals. Nor are all patients “reliable narrators”: their stories, even if “true” from their perspectives, may omit relevant details, or may be factually inaccurate. If chaplains wish to be recognized as health care professionals, they must abide by the same ethical standards to which other health care professionals are held – which means they must get, and work from, the known facts.
The sed contra presents another detailed argument in favor of a different plausible answer to the utrum. Here, the appeal is made to an ethic of responsibility for health care professionals, as well as to norms of medical ethics (do no harm), and to common sense (we expect clinical professionals to read clinical charts). There is also a reminder that a patient’s story, if not integrated with other information, could lead a listener to draw inaccurate conclusions and make faulty decisions: “blank slates” do not make decisions, but “professionals” – including other professionals whose work centers on listening – must be prepared to make decisions.
Responsio (“The answer”)
The answer to this utrum is that chaplains, if they are health care professionals with the right to read patients’ charts in the interest of providing safe, clinically appropriate care, have the responsibility to acquaint themselves with the relevant clinical facts when such facts are available to them. Not all information that is charted is relevant to the care provided by chaplains, while some information relevant to the care provided by chaplains may never be charted: therefore, chaplains should develop healthy working relationships with physicians, nurses, and other professionals with immediate knowledge of particular patients, to ensure they can obtain relevant facts verbally or through referrals. They should be able to distinguish between a clinical privilege, such as having access to charts, and the positive obligations that follow from this privilege, and strive to articulate professional practice standards that can guide chaplains in the appropriate use of clinical information to provide patient-centered care.
The responsio states how the author proposes to answer the utrum. It may follow one of the preceding arguments, or describe a compromise position. This responsio follows from the sed contra argument, but offers a more nuanced position: if chaplains are professionals, they must read charts, in the interest of providing safe, effective care – but medical records are not the only way chaplains should try to get information relevant to patient care.
Ergo (“Hence”)
Hence, it is not acceptable for chaplains to rely solely on the accounts of patients to obtain accurate information about a patient’s clinical situation. Reading charts, or obtaining clinical information from other sources, in no way conflicts with the chaplain’s core activity, listening to the patient. There is no responsible argument from ethics that would allow a clinical professional to avoid clinical information when this information is available. While chaplains and other professionals may have successfully cared for patients without prior information about these patients (during a mass trauma, for example), a clinical practice that routinely fails to consider patients’ clinical information is an unsafe practice. Physician Jerome Groopman has written about the errors that result from “confirmation bias,” when doctors rely too much on their own past experience of seemingly like cases and fail to notice the particulars of a specific case. Chaplains must strive to avoid similar mistakes.
The ergo section states what cannot be believed if the responsio is to be believed. The writer must look back at the entire document, and explain why the arguments that were considered but not accepted have been rejected. Here, the three arguments offered in the videtur are each reexamined and refuted, because they cannot be reconciled with the responsio.
I welcome your comments on this utrum, and encourage you to try one of your own.
With thanks to Christopher Morse, Dietrich Bonhoeffer Professor of Theology and Ethics, Union Theological Seminary, who taught us how to write an utrum paper.
Nancy Berlinger is Deputy Director and Research Associate at The Hastings Center. Her research interests focus on clinical ethics and include end of life care; ethics in health care chaplaincy; conscientious objection and moral distress in health care; and patient safety and the resolution of medical harm. Her broader interests include bioethics issues in cancer care, narrative ethics, and medical humanities.
As Deputy Director, she manages the Center’s organizational capacity-building initiative, Bioethics and the Public Interest, which has received major support from the Ford Foundation.
Berlinger is the author of After Harm: Medical Error and the Ethics of Forgiveness
(Johns Hopkins, 2005), which will be released in paperback in fall 2007. She serves on the ethics research group of the Joint Commission, the ethics faculty of the American Society of Healthcare Risk Managers (ASHRM), the bioethics committees at Montefiore Medical Center, Bronx, New York and at Richmond of New York, and the editorial board of Medical Ethics Advisor
. She is a frequent presenter at grand rounds and other ethics education programs for health care professionals. She volunteers on the Chaplaincy Service at Memorial Sloan-Kettering Cancer Center in New York City.
She is a graduate of Smith College and holds the Ph.D. in English Literature from the University of Glasgow and the M.Div. in Christian Ethics from Union Theological Seminary.
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