Checklists in clinical and research ethics: Good news??
Today’s blog posting isn’t purely about research ethics but bear with me. I read today in the American Medical News how enthusiastic the bioethics and health care community are with the creation of “ethics check lists” for physicians and health care professionals to use, to help avoid ethical dilemmas in acute care settings like the ICU.
Here’s the story: Success from surgical checklists breeds idea for ethical checks
The eight-item checklist at Washington Hospital Center — actually an ID-sized badge that residents wear on lanyards — covers ethical issues that commonly arise in the hospital setting. Is the patient able to make medical decisions? Is there a do-not-resuscitate order? Is there a disagreement among family members about how care should proceed?
So these lanyard “checklists” are designed to, like surgical checklists, make sure that all the important and necessary issues are addressed prior to an adverse event. In the case of surgical checklists, they usually cover things like checking the patient’s most recent bloodwork to ensure it’s within normal limits, ensuring that the patient hasn’t eaten since midnight, that their intravenous is working and that their pre-operative medication has been given. Understandably, you don’t want to find out in the middle of surgery, when the patient’s kidneys are failing, that no one bothered to check the patient’s baseline kidney function by doing a simple pre-operative serum creatinine.
But checking off ethical issues that have been addressed isn’t at all like checking off that simple blood tests have been done. Exploring issues of fairness, best interests, goals of care or unclear wishes involves meaningful, difficult and often time consuming conversations that need to often be continued later with time for thought and reflection. A simple “check list” upon admission to an ICU gives an inaccurate impression that dealing with ethical issues is easy, straightforward and a “one time only” kind of activity.
Checklists are wonderful things in some contexts. They’re great if you’re grocery shopping, party planning or if you’re Santa Claus. In other contexts, they tend to diminish the notion of the individual, negate the possibility of dynamic reactions based on diverse values and they trivialize the importance of sensitive, tailored attention to patients and families that health care professionals must be doing on an ongoing and iterative basis. So while, on one hand, we acknowledge and embrace the idea that diverse persons have unique and yet equally relevant values, we’re also pushing the notion of a standard “checklist”? This seems incongruous.
In research ethics, there is also a trend towards the ubiquitous checklist. Some ethics review boards have checklists for researchers to refer to prior to their submission to the board. There are “checklists” for consent forms and checklists for recruitment strategies and postings to ensure that coercion, influence and undue obligation are avoided. But is this a good trend? I would say, without hesitation, no. While a checklist might help some researchers, my sense is that it will alienate more researchers then it will assist.
Why? Researchers, especially those conducting qualitative or creative research, (and many justifiably so) feel that the processes involved in the review of research are designed mainly for clinical or biomedical research and are not relevant to research methods in the social sciences or less “empirical” research methods, such as more emergent qualitative methods. So a checklist, instead of assuring researchers, will very likely, be unable to adequately address all possible kinds of research submitted to an ethics review board and will, yet again, cause many researchers to feel alienated and dismissed by the process. Furthermore, checklists for research documents like consent forms are problematic and reduce the notion of consent down to a form and a list, instead of a process and a conversation between a researcher and a participant. Just as a checklist in clinical care will not address the diverse and very dynamic situations of individual patients, a checklist from an ethics review board will only negate the kinds of anecdotal and unique issues that every research protocol raises that requires time and thoughtfulness to deal with, effectively.
I’d posit here that these kinds of checklists, both the ones on the lanyards of ICU residents and the ones on the websites of ethics review boards, serve one purpose only: To try to save the time and effort that is required to deal with individual cases and unique persons, both in areas of clinical ethics and research ethics. Let’s think twice before we embrace the checklists in either of these contexts.
Please note: This posting has been altered slightly from the original posting. It seems that I inadvertently posted a draft when I originally published the entry.