A transplant surgeon was faced with a dilemma – he didn’t know if he should perform a liver transplant on a patient with a history of substance abuse.
On one hand, the patient’s body might have rejected the new liver because of his/her medical history. But the patient could have died without the transplant, too.
Dr. Ronald Busuttil, the surgeon at Ronald Reagan UCLA Medical Center who was dealing with the case, needed advice.
The UCLA Health System Ethics Center was established more than 10 years ago to provide consultation for issues like the one Busuttil was faced with and to educate health care professionals about ethical issues pertaining to patient care.
“Medical ethics are how our values come into play when making decisions for the well-being of a patient,” said Dr. Neil Wenger, a professor of medicine and health services research, and the director of the center. “These issues are not theoretical, but are real.”
The center has seen an increasing number of consults over the past several years. Cases are now more complex because they involve insurance entanglements and family dynamics, Wenger said.
The center operates as a 24-hour clinic comprised of Wenger, co-director Katherine Brown-Saltzman and clinical ethicist James Hynds.
Clinical ethicists give advice to patients, doctors and the public on the ethical aspects of their care, drawing from philosophy and the specifics of each individual case. The ethicists said they had past experience in ethical consultations or served on ethical committees before joining the UCLA ethics center.
Anyone with an ethical question can call the center, though the clinical ethicists typically receive the most calls from doctors, Wenger said.
A physician might call the center when working with a family whose loved one is on a life-preserving machine. The doctor feels as though the patient is suffering, but does not know if they should could continue keeping the patient alive, Wenger said.
After reviewing the patient’s case, the medical team reaches a decision by having an open discussion with the advisers.
In some instances, the center must conduct an intensive search for family members of patients who are treated at the hospital alone. They must find relatives who are able to make decisions on behalf of the patient.
When a patient’s case is particularly difficult to solve, the center will request the hospital’s ethics committee to convene to discuss the case. UCLA hospitals’ ethics committees are comprised of a diverse group of people knowledgeable in ethical issues, but the committees are not a part of the ethics center. Unlike the ethics committees, the ethics center is set up to respond to a consult request for any issue.
Busuttil said he feels ethical consultations are an invaluable part of making sure patients receive the best care.
Transplant surgeons often have to make tough decisions since the demand for organs is greater than the supply, he said.
“Say that a person who has substance abuse problems needs a new liver. But how do we know that same abuse will not happen again?” Busuttil said. “We need this kind of professional help.”
Patients who have a history of substance abuse – like the one Busuttil saw – do not receive the liver transplants because there is a possibility the patient could resume their behavior and waste the organ.
Wenger said he got involved in ethics because he did an apprenticeship for a doctor who conducted ethical consults at UCLA.
“I always thought ethics was an important part of medicine, and I wanted to improve the quality of care of a patient when an ethical issue came up,” Wenger said. “Ethics has a broad implication for the care we give and how we practice.”
In addition to consultation work, the ethics center organizes lectures and programs for health care professionals.
“Research has shown that when people have more education about ethics, they are more comfortable addressing ethical issues,” said Brown-Saltzman, a registered nurse.
Kevin Dirksen, a current clinical ethics fellow at the center, said he pursued a master’s degree in biomedical ethics because of an interest in how advances in technology affect patients. Ethics consultants typically study both science and philosophy to prepare for their involvement in ethics.
Dirksen works alongside doctors and nurses to address ethical issues and is involved in the consultation process.
“In a classroom, it’s so easy to see issues as black and white,” Dirksen said. “Working in a real clinical setting brings sense of humility to the task because you’re with real people.”
The center is also involved in research to show that educating health care professionals about ethical issues can improve the quality of care for the patient.
Brown-Saltzman collaborates with the UCLA School of Nursing to provide research to show that recognizing early indicators of ethical issues can prevent larger issues in the future.
Early indicators include recognizing whether or not a patient has decision-making capacity or has a family to make decisions for them.
“As our health care grows more complex, we continue to face more difficult questions,” Brown-Saltzman said. “Hopefully having ethics as part of the everyday discussion means that the care we are able to give can only be better.”