Donna Gentile O'Donnell: Learning medical ethics the hard way

One of Penn's major exports, or PNP (Penn National Product), is health care professionals. We graduate significant numbers of nurses, physicians, health care executives, medical researchers and other providers of mission-critical health services. So the recent brouhaha at Abington Memorial Hospital is likely to be a case study for many of the students that walk the hallowed halls of our university.

For those of you who missed it, the husband of a patient admitted to the hospital refused to permit his wife to be cared for by minority professionals on staff at the hospital. Because of patient/institutional confidentiality, many details are missing. But we know a few important things from other news reports:

The patient was pregnant, and possibly in active labor. The hospital receives federal funds and is obliged to operate in compliance with all federal anti-discrimination laws. The hospital administrators on duty at the time acquiesced to the husband's demand. The minority staff was offended. The NAACP weighed in. The hospital has apologized to the staff and community and will do whatever public penance is assigned... diversity training to follow.

The Abington Hospital situation has given rise to much high dudgeon about discrimination. Some of it is well justified. But before we get ready to tar and feather the folks who came to work that day and found that the hospital address had changed (now located between a rock and a hard place), let's consider the choices they had at their disposal.

A useful approach is something in which many health care curriculums engage: values clarification. Let's assume that the husband did not make his demands known previous to admission (generally, Neanderthals don't attend prenatal classes). The woman (who, at this point, is actually two patients: her and her unborn child) is in active labor and in no position to reason with her unreasonable husband. What is the hospital's obligation to the patient(s)? Does that obligation supercede its obligation to fairness to its professionals on staff and to obey the law?

In the event that the patient's labor was not advanced, and there was time to transfer her to another hospital, is the hospital obligated to inform the receiving hospital of the prejudicial views of the transfer patient's family, and how it will impact their ability to give care? If they do inform them, what are the chances that a receiving hospital would accept the transfer?

Suppose the hospital had refused the husband's unreasonable request, and the husband physically injured a staff member or administrator. Who is responsible for the escalation of this volatile circumstance?

Suppose the hospital had refused to treat the pregnant patient. The child is subsequently born, with significant complications, in the parking lot. What are the moral, ethical and legal ramifications for the decision makers?

The final and inevitable question is: what would you or I have done?

Having walked more than a mile in the shoes of a nursing supervisor, I believe that the first obligation is to the patient(s), both of whom (pregnant mother and her unborn child) are at a significant disadvantage to achieve a good outcome for themselves, given their less-than-optimal bargaining position. The second obligation is to the staff, with physical safety being a top priority. The third priority is to protect the integrity of the system and the institution.

So, what would I have done differently? I would have, if time permitted given the level of the patient's progression, explained the anti-discrimination policy to the husband and the patient. If I could not get a successful resolution (and I doubt I could have), I would have asked the husband to sign a release stating that the policy had been explained to him, that he refused to abide by it and that we were informing him that we would care for his wife and soon-to-be-born child under protest.

Further, after this admission, his family forfeited the right to any further treatment at our hospital. If he refused to sign it, I would have had a certified and witnessed letter sent to his residence explaining that, due to his wife's/neonate's emergent circumstance, we would treat and care for the patient(s) under protest. But, any further admissions by any member of his family would not be permissible.

Minority health care professionals have every right to feel offended by the behavior of that prehistoric husband. But all health care providers who are on the front lines will tell you: this is where you see the best and the worst of the human condition. If you're not ready to face the underbelly of our humanity; if you're not ready to confront the most ugly and unkind human capacity, if you're not prepared to see man's inhumanity to man... switch majors now.

But don't expect the administrators at Abington, or anywhere else, to shield you from emotional damage. Health care delivery can be an emotionally damaging business. It's tough stuff, not without reward... and not for the faint of heart.

Donna Gentile O'Donnell is studying for her Ph.D in health policy history at the School of Nursing. She is from Philadelphia, Pa.

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