Skip to main content
SpringerLink
Log in

A national survey of U.S. internists’ experiences with ethical dilemmas and ethics consultation

  • Original Articles
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

OBJECTIVE: To identify the ethical dilemmas that internists encounter, the strategies they use to address them, and the usefulness of ethics consultation.

DESIGN: National telephone survey.

SETTING: Doctors’ offices.

PARTICIPANTS: General internists, oncologists, and critical care/pulmonologists (N=344, 64% response rate).

MEASUREMENTS: Types of ethical dilemmas recently encountered and likelihood of requesting ethics consultation: satisfaction with resolution of ethical dilemmas with and without ethics consultation.

RESULTS: Internists most commonly reported dilemmas regarding end-of-life decision making, patient autonomy, justice, and conflict resolution. General internists, oncologists, and critical care specialists reported participating in an average of 1.4, 1.3, and 4.1 consultations in the preceding 2 years, respectively (P<.0001). Physicians with the least ethics training had the least access to and participated in the fewest ethics consultations; 19% reported consultation was unavailable at their predominant practice site. Dilemmas about end-of-life decisions and patient autonomy were often referred for consultation, while dilemmas about justice, such as lack of insurance or limited resources, were rarely referred. While most physicians thought consultations yielded information that would be useful in dealing with future ethical dilemmas (72%), some hesitated to seek ethics consultation because they believed it was too time consuming (29%), might make the situation worse (15%), or that consultants were unqualified (11%).

CONCLUSIONS: While most internists recall recent ethical dilemmas in their practices, those with the least preparation and experience have the least access to ethics consultation. Health care organizations should emphasize ethics educational activities to prepare physicians for handling ethical dilemmas on their own and should improve the accessibility and responsiveness of ethics consultation when needed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Lo B, Schroeder S. Frequency of ethical dilemmas in a medical inpatient service. Arch Intern Med. 1981;141:1062–4.

    Article  PubMed  CAS  Google Scholar 

  2. Connelly J, DalleMura S. Ethical problems in the medical office. J Am Med Assoc. 1988;260:812–5.

    Article  CAS  Google Scholar 

  3. Purtilo R. Ethics consultation in the hospital. N Engl J Med. 1984;311:983–6.

    Article  PubMed  CAS  Google Scholar 

  4. La Puma J. The clinical ethicist at the bedside. Theor Med. 1991;12:141–9.

    Article  PubMed  Google Scholar 

  5. Singer P, Pelegrino E, Siegler M. Ethics committees and consultants. J Clin Ethics. 1990;1:263–7.

    Google Scholar 

  6. Organizations JCfAoH. 2000 Hospital Accreditation Standards. Oakbrook Terrace, Ill: Joint Commission; 1999.

    Google Scholar 

  7. Ausilio M, Arnold R, Youngner S. Health care ethics consultation: nature, goals, and competencies. A position paper from the Society for Health and Human Values-Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation. Ann Intern Med. 2000;133:59–69.

    Google Scholar 

  8. Day J. An assessment of a formal ethics committee consultation process. HEC Forum. 1994;6:18–30.

    Article  PubMed  CAS  Google Scholar 

  9. La Puma J. Community hospital ethics consultation: evaluation and comparison with a university hospital service. Am J Med. 1992;92:346–51.

    Article  PubMed  Google Scholar 

  10. La Puma J. An ethics consultation service in a teaching hospital. Utilization and evaluation. J Am Med Assoc. 1988;260:808–11.

    Article  Google Scholar 

  11. Orr R, Moon E. Effectiveness of an ethics consultation service. J Fam Pract. 1993;36:49–53.

    PubMed  CAS  Google Scholar 

  12. Orr R. Evaluation of an ethics consultation service: patient and family perspective. Am J Med. 1996;101:135–41.

    Article  PubMed  CAS  Google Scholar 

  13. McClung J. Evaluation of a medical ethics consultation service: opinions of patients and health care providers. Am J Med. 1996;100:456–60.

    Article  PubMed  CAS  Google Scholar 

  14. Schneiderman L, Gilmer T, Teetzel H. Impact of ethics consultation in the intensive care setting: randomized, controlled trial. Crit Care Med. 2000;28:3920–4.

    Article  PubMed  CAS  Google Scholar 

  15. Dowdy M, Robertson C, Bander J. A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Crit Care Med. 1998;26:252–9.

    Article  PubMed  CAS  Google Scholar 

  16. Schneiderman LJ, Gilmer T, Teetzel HD, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial. JAMA. 2003;290:1166–72.

    Article  PubMed  CAS  Google Scholar 

  17. Sinnott-Armstrong W. Moral Dilemmas. New York, NY: Basil Blackwell, INC; 1988.

    Google Scholar 

  18. Fowler FJ. Improving Survey Questions: Design and Evaluation. Thousand Oaks, Calif: Sage Publications; 1995.

    Google Scholar 

  19. Sirken M, Hermann D, Schechter S, Schwarz N, Tanur J, Tourangeau R, eds. Cognition and Survey Research. New York, NY: Wiley Publishers; 1999.

    Google Scholar 

  20. Arnold R. Teaching clinical medical ethics: a model programme for primary care residency. J Med Ethics. 1988;14:91–6.

    PubMed  CAS  Google Scholar 

  21. Loewy E. Teaching medical ethics during residency. J Med Educ. 1986;61:661–5.

    PubMed  CAS  Google Scholar 

  22. Perkins H. Teaching medical ethics during residency. Acad Med. 1989;64:262–6.

    Article  PubMed  CAS  Google Scholar 

  23. Perkins H, Geppert C, Hazuda H. Challenges in teaching medical ethics in medical schools. Am J Med Sci. 2000;319:273–8.

    Article  PubMed  CAS  Google Scholar 

  24. Howe K. Medical students’ evaluations of different levels of medical ethics teaching: implications for curricula. Med Educ. 1987;21:340–9.

    Article  PubMed  CAS  Google Scholar 

  25. Jacobson J. Internal medicine residents’ preferences regarding medical ethics education. Acad Med. 1989;64:760–4.

    Article  PubMed  CAS  Google Scholar 

  26. Jennett P, Crelinsten G, Kinsella T. Advanced training in biomedical ethics: a curriculum in clinical specialty programmes. Med Educ. 1993;27:484–8.

    PubMed  CAS  Google Scholar 

  27. Fletcher J, Siegler M. What are the goals of ethics consultation? A consensus statement. J Clin Ethics. 1996;7:122–6.

    PubMed  CAS  Google Scholar 

  28. Casserett D, Daskel F, Lantos J. The authority of the clinical ethicist. Hastings Cent Rep. 1988;28:6–11.

    Google Scholar 

  29. Walker M. Keeping moral open space: New images of ethics consulting. Hastings Cent Rep. 1993;23:33–40.

    PubMed  CAS  Google Scholar 

  30. Spike J, Greenlaw J. Ethics consultation: high ideals or unrealistic expectations. Ann Intern Med. 2000;133:55–7.

    PubMed  CAS  Google Scholar 

  31. Association AM. Physician Characteristics and Distribution in the U.S. 2000/2001. Chicago, Ill: AMA; 2001.

    Google Scholar 

  32. Asch D, Jedrziewski M, Christakis N. Response rates to mail surveys published in medical journals. J Clin Epidemiol. 1997;50:1129–36.

    Article  PubMed  CAS  Google Scholar 

  33. Field T, Cadoret C, Brown M, et al. Surveying physicians: do components of the ‘Total Design Approach’ to optimizing survey response rates apply to physicians? Med Care. 2002;40:596–605.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Joint Centre for Bioethics, Received from the University of Toronto, Toronto, Canada

    Gordon DuVal SJD

  2. University of Massachusetts, Boston, Massachusetts

    Brian Clarridge PhD

  3. EMMES Corporation, Rockville, Maryland

    Gary Gensler MS

  4. Department of Clinical Bioethics, National Institutes of Health, Building 10 Room 1C118, 20892-1156, Bethesda, MD

    Marion Danis MD

Authors
  1. Gordon DuVal SJD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Brian Clarridge PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Gary Gensler MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Marion Danis MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Marion Danis MD.

Additional information

This study was conducted while Dr. DuVal was a fellow in the Department of Clinical Bioethics at the Clinical Center of the National Institutes of Health. Funding was provided by the Clinical Center of the National Institutes of Health.

The opinions expressed here are solely those of the authors and do not reflect the views or policies of the Department of Health and Human Services or the National Institutes of Health.

Rights and permissions

Reprints and permissions

About this article

Cite this article

DuVal, G., Clarridge, B., Gensler, G. et al. A national survey of U.S. internists’ experiences with ethical dilemmas and ethics consultation. J GEN INTERN MED 19, 251–258 (2004). https://doi.org/10.1111/j.1525-1497.2004.21238.x

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1111/j.1525-1497.2004.21238.x

Key Words

Search

Navigation