24 Hours in the Life of a Bioethicist

The Center for Practical Bioethics’ mission is “to raise and respond to ethical issues in health and healthcare.” What that means in real life, real time, is illustrated by the past 24 hours or so in the life of this Center staff ethicist.

Members of multiple Center constituent organizations engage me during that 24-hour period. Five of them and the issues they raise are summarized below, with confidences protected.

1. A medical student emails me about the summer research fellowship for which I am her designated faculty mentor, and the Principal Investigator for IRB approved research involving human subjects. Our research is qualitative using phenomenological methods I had learned and utilized for my dissertation research at Vanderbilt many years ago. This project is titled, “Studying the Experiences of Physician Politicians.” Email today involves the consent of two more physicians who chose to enter politics, both of them also longtime friends of the Center.

2. Email from a Center constituent hospital involves planning a 21^st celebration of the Physician-Clergy Dialogue Group I co-founded there with physician and clergy colleagues back in November 2002. We have met monthly at 7:00 AM, initially as a 1-year experiment just to see what might happen when physicians and clergy covenant to meet regularly and confidentially to share our experiences, both vocational and personal. The experiment continues nearly 21 years later.

3. A pager message is received from a palliative care physician at another hospital that contracts with the Center for clinical ethics consultation services. The request this time is to meet with the palliative care physician, a neurologist, and the critical care attending for an adult patient who had been found hanging in his prison cell a few days earlier. Despite successfully being resuscitated by EMS, the young man had suffered severe anoxic injury to his brain. The prognosis is most likely brain death in a few days, but with the possibility of surviving in a comatose state, eventually persistent vegetative state. PVS is the “best case scenario,” and no one, except a few family members who anticipate a miracle recovery, are seeing anything good about ongoing aggressive life supports. The ethics questions posed to me involve three issues:

1. 1. Decisional surrogacy, as the patient had left no advance directives and made no appointment of medical power of attorney prior to losing capacity. Also, he is a prisoner and it is not always clear to care providers who is legally permitted to visit or make decisions other than the warden.
   2. Code status, because the patient’s status is currently Do Not Attempt Resuscitation (DNAR), but some family members are asking why he is not Full Code.
   3. PEG and trach decisions, because those same family members have asked about placing a tube in the stomach for ongoing assisted nutrition and hydration; and they also wonder about a tracheostomy for long-term ventilator support.

Each of these matters raised with me are fundamentally ethical in nature. Things could be done, but ought they be done? The three physicians meet with me to raise ethical issues, expecting me to assist them with ethics response. I do so, in accordance with mission.

4. An email message received is from a third constituent hospital. This is a smaller facility which contracts with the Center at a basic level of services. . Nonetheless, since it is near my home and because of the Center’s mission, I not only participate in their hospital ethics committee but have also offered to be available virtually or on-site for ethics consultation. The email today is from the Senior Vice President who co-chairs the ethics committee, introducing me to their new Chief Medical Officer. I respond to both of them, suggesting that we meet together later this summer to discuss ethics optimization, and that I am available to come to the hospital for that meeting.

5. A phone call is received at the Center from the social worker at a skilled nursing facility. This organization is not yet a contracted Center constituent, but is one for which we have provided some services because it is our mission to do so—and in anticipation of possibly negotiating a contractual relationship sometime in the future as well. The question today involves a DPOA form that had been signed and notarized in May 2023, but by a patient who resides on the Memory Care unit and had been documented as medically incapacitated back in February. How should care providers regard that subsequent DPOA assignment? It is an ethics issue definitely, and legal also. While carefully delineating my own role as an ethicist not an attorney, I am able to respond with the ethics help requested, in keeping with the Center’s mission.

It is what we do. Again and again.

By Tarris Rosell, PhD, DMin
Rosemary Flanigan Chair, Center for Practical Bioethics