The Emotion of Clinical Ethics Consultation

Steven is the medical social worker on the cardiac rehab unit at a medium-sized hospital. Because of his undergraduate studies in philosophy and religion, Steven joined the ethics committee about eight years ago, and assists in responding to ethics consultation requests as part of his role on the committee. He receives a page for consultation in the intensive care unit where he learns there is serious conflict between the patient’s son and the treating physician about a patient’s goals of treatment. When he arrives on the unit, the senior resident snarkily tells him “Good luck!” as she passes in the hallway. When Steven enters the room, the patient’s son immediately spins to face him and screams, “Are you the ethical person?!? If so, you can get the hell out!”

The topic of how to help healthcare providers manage the emotional toll of their work is receiving increased attention in both the popular media and academic literature. For example, it is not uncommon to see articles like the recent JAMA editorial by Amy-Lee Bredlau, a pediatric oncologist entitled “Where Do You Put the Pain?”Footnote ⁵ Bredlau reflects on the challenging emotions and routine tragedies associated with treating cancer in children. She shares the many coping skills she has developed to maintain her own emotional health. There is robust evidence that physicians, residents and trainees suffer from higher rates of depression and suicide than the general population.Footnote ^{6 ,} Footnote ^{7 ,} Footnote ⁸ The situation is significant enough that there is now a national day of solidarity for the prevention of physician suicide organized by several physician wellness organizations.Footnote ⁹

In many healthcare systems, terms like ‘moral residue,’ ‘compassion fatigue,’ and ‘burnout’ have become part of the everyday lexicon. One of the more taxing aspects of being a clinical ethicist is dealing with the emotions of patients, family members, as well as healthcare providers. Generally, by the time a clinical ethicist is called into a case, emotions are running high, patience is low, and interpersonal communication is strained. In many cases, these characteristics are precisely the reason for triggering consultation requests, and many hospitals and healthcare systems offer ethics consultation services as a way to combat providers’ emotional distress and reduce burnout.

The cases which result in clinical ethics consultation requests are not only emotionally laden, but among some of the most difficult and troubling for healthcare providers. Gordon DuVal et al. conducted a 2001 survey of 190 physicians, asking why they seek ethics consultation. The results clustered into two groups. 57 percent of consultation requests were for what the authors considered to be emotionally-laden reasons. The second cluster of responses were for what the authors described as cognitive reasons. They concluded: “As physicians are prompted to seek consultation to resolve conflicts and defuse emotionally charged situations, the ethicist will often have the intricate task of mediating a conflict-laden situation, while at the same time offering ethical analysis to shed light on the dilemmas at hand.”Footnote ¹⁰ Although there are many different types of ethics consultant training programs, including mediation and dispute resolution, and there is evidence that many providers find ethics consultations to be useful, it would be naïve to presume that clinical ethicists are better prepared to manage the personal emotional toll of difficult cases than the healthcare providers who ask for their assistance. In fact, there is almost no discussion of managing the emotional distress of clinical ethics consultants themselves in the clinical ethics literature, and it does not appear to be a focus of clinical ethics training.

Since the development of the ASBH Clinical Ethics Consultation Core Competencies, there has been increasing emphasis on mediation and conflict resolution as part of the ethics consultation process. It is now clearly recognized that the role of ethics consultant is broader than simply providing rational arguments in favor of or against specific actions. Rather, the Core Competencies endorses an Ethics Facilitation model for consultation.Footnote ¹¹ That model places a heavy emphasis on consultant interpersonal communication and mediation skills, with the goal of the consultant being able to aid in defusing the emotional tension and improve communication associated with difficult cases.

In a 2015 American Journal of Bioethics (AJOB) article on closure at the end of clinical ethics consultation, Autumn Fiester notes that in order to decrease ‘negative moral emotions’ in those requesting consultation, the process of consultation matters as much as the ethical recommendations. In contrast to a “Recommendation-Focused Model of Clinical Ethics Consultation,” she recommends a ‘Dialogue-Focused Model’ that facilitates ‘closure’ following hospitalization.Footnote ¹² Referencing Paul Ford and Denise Dudzinski’s book Complex Ethics Consultations: Cases that Haunt Us, she states:

Fiester’s article highlights the fact that the consultation itself can take an emotional toll. We argue that the emotional overlay of challenging cases impacts the consultants as well. In few examples in the clinical ethics literature do consultants reflect on the intensity of their own emotional experiences.Footnote ¹⁴ Overall, this appears to be a neglected area of focus in consultant training, especially if consultants wish to avoid negative emotion or burnout. This raises the following question: How can clinical ethics consultants be better prepared to manage the intense negative emotion implicit to their role?

Psychology and Clinical Ethics

Steven, shocked by the immediate outburst of the patient’s son, quickly excuses himself and leaves the room. He can feel his face start to flush with embarrassment as other staff members witness his hurried departure. Feeling that he has disrupted the entire unit, he retreats to the nurses’ station, where he attempts to hide himself behind a computer monitor. The resident reappears and sympathetically tells him that she didn’t last much longer with the patient’s son than he did. Steven’s mind jumps back to a consult about 6 months earlier. In that case, he was yelled at and verbally threatened by the family member of a patient for whom the treatment team had recommended comfort-only care. He was accused of trying to murder the patient, and the family member’s size, demeanor, prison tattooing, and threats severely intimidated Steven. It took him several weeks for the fear and anxiety to subside after that case and, as he sat in the nursing station breathing quickly and with his heart racing, he recognized those same emotions washing over him the moment the patient’s son spun to face him with such hostility. An hour later, even after getting a glass of water and pacing the unit a couple of times, he couldn’t stop ruminating over what had just happened.

It may be argued that successful training in interpersonal skills will not only help to mitigate the emotional burden of healthcare providers requesting consultation but also to decrease moral residue formation in ethics consultants as well.Footnote ¹⁵ Wayne Sheldon, Cynthia Geppert, and Jane Jankowski argue convincingly that training in Clinical Ethics Consultation (CEC) should involve basic interpersonal skills with the explicit purpose of engaging the emotionally-laden aspects of complex cases, which is currently neglected in the ASBH’s list of Core Competencies.Footnote ¹⁶ These basic communication skills include asking open-ended questions and active listening techniques. Sheldon, et al. state that “the values and emotions that are expressed [during ethics consultations] are intertwined such that an ethical decision cannot be made apart from, and often not until, the participants’ emotional responses to the situation have been given an opportunity to be expressed in interpersonal interaction.”Footnote ¹⁷ They go on to argue that the tools of modern psychology most useful to clinical ethics consultation are solution-focused strategies, crisis intervention, and family-systems theory. Using these techniques, ethics consultants “who can empathically hear these strong emotions…[are] in the best position to discern and resolve hidden value conflicts.”Footnote ¹⁸ Successful consultation will result when patients or surrogates are able to “arrive at a reasonable decision that honors and validates the personal authenticity of the stakeholder’s emotions while it accommodates the ethical responsibilities and medical realities at hand.”Footnote ¹⁹ At least one tool intended to ensure quality assurance in clinical ethics consultation highly emphasizes the need for competent and reliable interpersonal skills.Footnote ²⁰ Further, George Agich notes that individual psychological dynamics in the patient or surrogate, often embedded in family dysfunction, may complicate cases and limit the individual’s ability to engage in ethical reflection. For example, recognizing the family is intellectualizing when they are preoccupied with the ventilator settings or in denial when they insist upon waiting for a miracle may assist the consultant in mediating a resolution to a conflict.Footnote ²¹ Identifying intellectualization is not the only technique commonly utilized in psychiatry and psychology that may be useful for clinical ethicists to reduce their emotional burden.

Transference and Counter-Transference in CEC

Steven reaches out to fellow consultant who has arrives to assist with the consultation. He explains the initial encounter with the patient’s son that morning and mentions how much difficulty he is having in controlling his emotions. His colleague asks him how he managed the previous case 6 months ago during which he felt similarly. Steven recalled that the previous situation improved when security was called to be present at subsequent family meetings. In encounters where security was present, the patient’s intimidating family member was more subdued and was eventually able to explain that part of his hostility stemmed from regret and anger about his years in prison, which caused him to be absent for a number of important family events. Ultimately, Steven recalled, the family member apologized for his inappropriate behavior. Over the course of the conversation with his colleague, Steven began to relax and was able to hypothesize that something similar may have triggered the immediate antagonistic reaction of the patient’s son this morning.

One unique technique used by mental health practitioners is to purposefully and critically reflect on the practitioner’s emotional state. The field has found ways to utilize one’s emotional response to provide information about the psychological dynamics between individuals present during the consultation, particularly in emotionally challenging circumstances where a patient or their family’s emotions are directed at the healthcare provider. Clinical ethics consultants can develop and apply the same skills and techniques that mental health practitioners use to mitigate the emotional impact of being exposed to hostile or unwanted emotion. Ethics consultants need only to be familiar with some basic psychological terms and general underlying assumptions about human psychodynamics.Footnote ²² These include:

1. 1) All people carry within them a host of different mental representations of aspects of themselves and others, many of which create characteristic patterns of interpersonal difficulties.

For example, a patient’s emotional response to an ethics consultant may reflect an unconscious link to their historical interactions with other individuals, particularly if there are similar circumstances (e.g., social hierarchies, settings, feelings of powerlessness). If the patient or their family member unconsciously perceives the consultant as an authority figure based on the consultant’s nonverbal communication or position within the healthcare team, the response may be based, in part, on the patient’s or family member’s relationship with their father, for example, with analogous emotional entanglements.

1. 2) Behaviors, both verbal and nonverbal, often reflect automatic and unconscious processes that are linked to implicit memory or bias.

Patient or their family members will not usually recognize why they have reactionary feelings, either positive or negative, toward the consultant, even if asked about it. A patient or family member’s unconscious and immediate negative response are often one of several defense mechanisms. The psychological term ‘transference’ refers to the misplacement of feelings and emotions, and especially those unconsciously retained from childhood, toward a new person due to similar characteristics shared by the new person and past figures. Similarly, ‘counter-transference’ refers to the unreflective reactionary emotional response from the second person toward the first. As an example, in the case scenario, transference refers to the unconscious reaction of the patient’s son toward the ethics consultant, based in the son’s lived experiences and emotional history. Steven’s emotional reaction toward the patient’s son, motivated by his experience with the previous case, is the counter-transference.

1. 3) Defense mechanisms are mental tools to protect against unpleasant emotions.

Defense mechanisms can be either mature or immature, depending on the stress of the situation and the psychological maturity of the individual. The more stressful a situation or psychologically troubled the individual, the more likely that an immature defense mechanism will be displayed. Immature defenses, such as denial, acting out, or projection, are more likely to increase conflict between the person utilizing the mechanism and those with whom they are interacting. Regardless of how psychologically healthy or mature an individual may be, there are times and circumstances in which immature defense mechanisms will be deployed. A healthcare provider’s, including ethics consultant’s, ability to recognize immature defense mechanisms, understand their origin, and respond in a mature fashion is an important tool to develop. In the example case scenario, the patient’s son’s verbal aggression and screaming at Steven is a psychologically immature defense mechanism. Steven removing himself from the confrontation with the patient’s son, reflecting in an emotionally safe place, and seeking the assistance of a colleague are more mature defense mechanisms.

1. 4) Childhood patterns persist into adult life

Finally, patients and their family members may revert back to childhood patterns of behavior during times of stress. For example, the adult who normally uses the mature defense mechanism of humor in times of low to moderate stress may revert to projection, an immature defense mechanism, at times of high stress. Reversion to childhood patterns may be more likely when the current cause of the stress, a parent’s illness, for example, also has connections to childhood. Not all individuals possess the ability to recognize when they have slipped into immature defense mechanisms. It is common to witness this in the clinical setting when following a negative encounter with a patient or family member, they will apologize for their inappropriate behavior with comments like, “I’m sorry, that’s not normally like me or how I handle situations.”

Clinical ethics consultants would particularly benefit from recognizing when patients, their families, or members of the treatment team may be employing the defense mechanism of projection—when a negative emotion is inappropriately attributed to the consultant. When directed at the consultant, the emotional state of the consultant may be impacted because the consultant, in turn, may begin to unconsciously attribute the negative emotions to themselves, which can exacerbate the consultant’s emotional burden. For example, a family member may snap at a consultant when asked about progress toward a complicated discharge disposition, not because of anything that the consultant has done, but because they are misplacing, or projecting, their feelings of frustration or helplessness about the discharge process. In turn, the consultant may also begin to feel the same frustration or helplessness that the family member is experiencing, adding to the emotional burden of the case.

Mental health professionals presume that these factors are at play in every therapeutic encounter with patients. In fact, these emotional entanglements occur in nearly all relationships to some degree. Others have cited examples between patients and nonpsychiatric physicians, including situations in which negative counter-transference can be detrimental to patient care.Footnote ^{23 ,} Footnote ²⁴ The more emotionally charged the situation, the more likely immature defense mechanisms, transference and counter-transference, and emotional projection are likely to be present. Clinical ethics consultations are able to witness and identify these complications to the therapeutic relationship because they are often neutral third-parties entering later into a difficult case. Thus, it is even more important for clinical ethics consultants to be versed in this terminology, and able to identify these complications.

Because of the potential for these emotional entanglements to cause emotional distress, mental health professionals systematically reflect upon transference and counter-transference, and observe defense mechanisms to help them in the assessment and treatment of patients. By doing so, the self-reflective process helps them regulate their own emotions in the therapeutic relationship. Through this process, emotions can be addressed in a cognitive way that decreases their intensity, increases feelings of control, decreases the perception of being overwhelmed, and provides a tool for further engagement with the interlocutor. When the patient becomes angry and shouts, or another physician makes sarcastic comments about the benefit of a consult, instead of feeling defensive, the therapist has trained herself to take a step back and think about what previous relationship or experience is being recapitulated in this particular interaction. This process of critical self-reflection allows for improved communication, avoiding immature reactions, and healthier professional and personal relationships.

How We Feel: Processing Patient/Family/Surrogate Emotion with Intentionality

After discussing the situation with his colleague, Steven decides to reenter the room and despite initial hostility from the patient’s son, is able to engage him in conversation. Steven recognizes that the son’s initial hostility does not stem from any prior personal slight or insult, but is likely due to frustration about his mother’s illness as well as, potentially, a host of other factors. Steven is able to recognize that the son is unconsciously engaging in transference and projection. Steven tells the son, “I know you aren’t excited to see me, but I am here to help resolve this conflict about what kind of medical care your mother should receive.” Eventually, the son replies, “When I heard about ethics and when you walked in, I immediately felt like I was back in the principal’s office as a second grader. That someone had called the authorities on me. It just reminded me that I can’t do anything right.” Steven was able to reassure the son that he saw how much he loved his mother and that he was trying his best to do the right thing for her. Steven and the son were able to work well together for the remainder of the hospitalization. Finally, by explaining the background behind the son’s challenging demeanor, the consultant was able to educate the treatment team. This in turn decreased the emotional distress for everyone involved in the case. Following the case, Steven shared his experience with his fellow consultants at the next ethics committee meeting and solicited their suggestions about how to resolve similar cases in the future.

Unreflective, immature emotional responses to hostility or conflict exacerbate emotional distress for everyone involved, including the healthcare providers, the patient, and the family members. Having the skills and experience to proactively reflect on the emotional response of the persons involved in the consult, including the consultant’s own emotions, allows the consultant to optimize effective communication and to facilitate resolution. However, these tools also reduce acute emotional distress and can prevent the development of lasting emotional sequelae. Instead of reflexively reacting, the consultant can begin to rationally formulate an explanation and an appropriate response to the emotion displayed by the participants involved in the consultation.

The importance of understanding these aspects of the relationships between mental health professionals and patients cannot be overstated. For example, a routine practice in psychiatric training is to consistently and intentionally reflect on the emotions experienced by the trainee and observed in patients. Psychiatric residents in the United States spend a minimum of an hour per week with senior practitioners discussing the emotional valence of their cases. The counter-transference of the resident directed toward the patient is a core component of the exercise and the more experienced practitioners are able to teach and model techniques to help the junior residents unpack and analyze how they feel about their patients, and how to use that information to explore the both patient’s and the resident’s psychological makeup. This routine practice facilitates the goal of patient healing and also acts to prevent the accumulation of emotional residue in the provider. This practice is routinely continued with colleagues following residency training as well, especially when psychiatrists recognize especially strong counter-transference toward a patient, such as significant anger, attachment, or sexual attraction. Those involved in the training of clinical ethics consultants may adopt an analogous process of regular discussion of the emotional burdens of clinical ethics consultation. Even at a novice level, systematic reflection on the emotional aspects of challenging cases is a useful skill that consultants can use to help with managing their own emotional burden, and to better understand the emotional positions of the individuals involved. Others have encouraged a similar process with nonpsychiatric physicians in order to improve patient care, prevent physician burnout, and expand clinical moral perception.Footnote ^{25 ,} Footnote ²⁶

When consultants identify cases that are likely to create emotional distress in themselves or cause them to lose sleep at night, they, by themselves or with the assistance of a colleague and in a situation conducive to thoughtfulness, may ask themselves a series of guided questions to aid in their reflection:

1. 1) How is the patient/family/surrogate reacting to me?

2. 2) Is this unique or similar to their previous interactions with other members of the healthcare team?

3. 3) Might it reflect prior experiences with the medical system?

4. 4) Might their reaction be more a reflection of their own internal emotional state, and less of a response to me specifically?

5. 5) What emotions am I feeling in response? Ideally, this question is asked prior to actions on the consultant’s part based on those reflexive emotions.

6. 6) If I am feeling a particular emotion, could the treatment team be feeling the same way?

7. 7) Perhaps the patient is feeling this as well? If so, naming and acknowledging the emotion may facilitate a connection with a patient or staff in a more meaningful way.

8. 8) When was the last time I felt this way? This question may enable consultants to make connections to prior cases that might not otherwise have been cognitively linked, perhaps leading to more creative solutions to a conflict or dilemma.

9. 9) How are family members reacting to each other?

10. 10) Is there information that suggests that the emotions directed toward me are actually how the person responds to everyone—indicating a more static, immature psychological state?

Following the reflection, the consultant will be better prepared to utilize many of the key insights that mental health professionals often recognize as pertinent to the encounter. Specifically, emotion directed from the patient to the consultant may not be based on the actions of the consultant but, rather, reflects some other previous unrelated experience. Similarly, reflexive emotion from the consultant to the patient likewise may reflect a prior experience. Notably, this mechanism can help explore potential implicit bias, in order to make what is implicit explicit. At times, consultants, may find it helpful to emulate their mental health colleagues by acknowledging and publically naming negative emotions present and engaging others by asking about the emotional states of everyone in the room. Statements like, “I am feeling frustrated about this situation and the lack of solutions available to us, and I can’t imagine I’m the only one. Is anyone else feeling the same way?” Or “Would you say you are frustrated as well, or something else?” can be very helpful for moving beyond the emotion into problem-solving. It may also facilitate closure at the end of consultations, either through debriefing or some other mechanism by ensuring that the resolution of the case is not impeded by negative emotion. Dedicated effort should be made to attempt to generate feelings of closure at the end of an ethics consultation, even when the ideal or recommended result was not accomplished.

Emotional distress and burnout may be reduced or prevented if clinical ethics consultants incorporate some of the skills and techniques routinely utilized by mental health professional colleagues. By consciously and purposefully utilizing mature defense mechanisms and positive coping skills, clinical ethics consultants will be in a better position to provide effective consultation service while maintaining their own emotional and mental health. Practicing acceptance, altruism, forgiveness, humor, mindfulness, moderation, and tolerance in their cognitive responses to stress and countering with practices known to help achieve positive well-being, such as maintaining healthy habits of exercise, nutrition, sleep, relaxation, and seeking social and spiritual supports are vital to the long-term health of all healthcare providers, and clinical ethicists in particular.Footnote ²⁷ In an era of rising clinician burnout, it is paramount that proactive steps be taken to address the emotional burden of clinical ethics consultation to ensure the availability of scarce clinical ethics resources in the future.