BioethicsWalk addresses
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No Harm Done?
Last month, “The Ethicist” column in The New York Times Magazine featured a letter from an anonymous hospital worker in St. Louis who asked several questions about the ethics of performing “healing touch” and “therapeutic touch” on hospitalized patients:
If the practitioners believe these practices are effective, can they tell patients that they are effective even if there is no scientific proof of this?
If the practices seem to make patients feel better, should practitioners withhold information about the lack of scientific evidence, in the interest of the placebo effect?
Columnist Randy Cohen replied that the sincerity of the nurses’ belief did not offer any ethical wiggle room. In a hospital setting, a person may reasonably assume that whatever a health care provider offers as “therapy” meets the same standards as any other therapy the hospital provides. Health care providers cannot lie to patients by telling them that a therapy is “effective” if there is no evidence to support this claim. And making a practice of withholding information from patients, in the interest of the placebo effect or for another reason, undermines patient autonomy: if patients aren’t given all the facts, how can they make informed decisions?
Reading this letter, I was reminded of a conversation I once had with a CPE resident about the ethics of badging. We were talking about what chaplains could, as a matter of ethics, tell patients about the effectiveness of prayer. The resident asked, can I tell a patient that “prayer heals,” if I believe that it does? Do I have to get into the science? Do they even expect that of me – a student, a chaplain?
I felt for this resident. Even as a mere pastoral care volunteer, I’d very quickly learned that one of the ways some – not all – patients use chaplains is for prayer: to pray with, to ask to be prayed for, to provide them with the space or ritual items they need to say their own prayers. Patients and families who rely on prayer themselves expect the chaplain (or the mere volunteer, even) to say “yes” to prayer.
But does it follow that the chaplain should tell patients that prayer “heals” or “works,” mindful that, in the context in which this conversation is taking place, “heal” can sound like “cure,” and mindful that there is no scientific basis for this assertion?
And this is where the badge matters.
A chaplain’s ID badge signifies to patients, families, and other badge-wearers that this person is part of the team and part of the institution: the logo on the building is the same as the logo on the badge. And because the institution that authorizes badge-wearers is a health care institution, any badge-wearer has a responsibility to uphold the well-established ethical principles that differentiate a health care institution from another place of employment. Because the first of these principles, respect for patient autonomy, includes the obligation to give patients accurate information so they can make informed decisions, and because other principles require health care providers to adhere to recognized standards of care in providing treatments that benefit and do not harm patients, health care providers must be mindful that, when they are badged, they are providing “health care,” not just “care.”
The solution is not equivocation: taking off the badge to say “I believe,” putting it back on to say “I know.” Rather, it is awareness of the line between supporting patients’ participation in practices that provide comfort or relieve stress, and endorsing a practice of unproven therapeutic value as if it had therapeutic value.
What do you think?
How do you handle issues like this in your own work, or when you observe practices that seem harmless but whose value is unclear?
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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