Abstract
Every day around the country, patients are discharged from hospitals without difficulty, as the interests of the hospital and the patient tend to align: both the hospital and the patient want the patient to leave and go to a setting that will promote the patient’s continued recovery. In some cases, however, this usually routine process does not go quite as smoothly. Patients may not want to leave the hospital, or they may insist on an unsafe discharge plan. In other cases, there may simply be no good place for the patient to go. These complex hospital discharge situations often involve ethical, legal, financial, and practical considerations, but the ethical issues inherent in these dilemmas have received only sporadic attention from clinical ethicists at best, leaving patients, providers, administrators, and caregivers unsure about what to do. When the ethical issues are in fact brought to light, analysis usually proceeds based on a consideration of the principles of autonomy, beneficence, nonmaleficence, and justice. However, principled analysis often fails to present patients and providers with a satisfactory solution, as the principles inevitably conflict (for example, when the patient’s autonomous desire to remain in the hospital conflicts with the principles of beneficence and justice). In this paper, I argue that difficult discharges are ethical dilemmas worthy of scholarly attention that goes beyond principlism, and I argue that providers and those involved in discharge planning ought to cultivate what philosopher Alasdair MacIntyre calls “virtues of acknowledged dependence” in order to care for these patients and their families. I first trace the current conversation about difficult discharge and show that the principled approach to resolving discharge dilemmas is not sufficient. I then argue that a new approach is needed, and to that end, I offer practical ways in which MacIntyre’s account of the virtues of acknowledged dependence may help patients, providers, and family members to navigate issues of difficult discharge.
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Notes
While discharge planning can also be difficult for children, especially children with complex needs who cannot be cared for at home, the ethical issues are not as stark, given that there is no imperative to respect patient autonomy as there is for adult patients. I will thus be focusing this paper on difficult discharges for adults over the age of eighteen.
One US study suggests that a lack of available rehabilitation beds could contribute to delayed discharge, estimating that each delayed patient could cost the hospital an additional $14,599 [20]. In Massachusetts, patients with excessively prolonged hospitalization (ExProH) were found to incur higher hospital costs (mean: $54,646) than non-ExProH patients (mean: $18,444) [21].
In a response to Swidler et al., Ferdinand Yates describes this scenario as “holding the hospital hostage” and wonders “whose autonomy, whose beneficence, whose non-maleficence, and whose justice” should take priority, arguing that the principles fail to offer an adequate resolution to this case [22, p. 36].
I encountered this case while working in the clinical ethics department of a large Midwestern teaching hospital. Certain facts of the case have been changed to protect privacy.
In a response to Swidler et al. [1], Monique Lanoix points to the gulf that separates restorative services from those aimed at maintenance. She argues that our society needs better options for custodial care, which she defines as “on-going care of a non-acute nature” [24], and better integration of acute and non-acute services. If there were a local facility willing and able to accept Mr. Jackson, his mother may have agreed to that plan, making it unnecessary for the care team to consider sending Mr. Jackson to an out-of-state facility that would separate him from his mother. But alas, there is no such facility, and the patient’s mother adamantly refuses to permit a DNR/DNI order, eventuating in a stalemate and causing a breakdown of the relationships between the mother and providers.
In After Virtue, MacIntyre argues that virtues are exercised in practices, or types of “socially established cooperative human activity” [27, p. 187]. By striving to be excellent in any given practice, one can realize “the goods internal to the practice” [27, p. 188], or goods that are worthwhile for what they provide not only to individuals but also to the broader community in which the practice takes place. However, this account becomes problematic when communities conflict: Who is more virtuous or excellent, and how should the conflict be adjudicated? Thus, in Dependent Rational Animals, MacIntyre attempts to locate virtues in a biological account of humans in and of themselves (apart from a particular community or tradition).
Gregory Poore criticizes MacIntyre’s use of misericordia here by claiming that he does not sufficiently ground his use of the concept of “neighbor,” having neglected to explain what this involves or why one should adopt this perspective [28]. The concept of misericordia found in Aquinas’s account comes from the theological virtue of charity, and neighbor has a deep theological and biblical context. Poore argues that MacIntyre simply coopts the concept of neighbor and tries to use it as a grounding for caring for the disabled because “it could have been us,” but this coopted concept does not do the work that MacIntyre wants it to do. While Poore’s critique is well-taken, I argue that the concept of neighbor can be understood apart from its rich theological context within the medical setting, as providers enter into specific relationships of care and duty when they accept a patient.
Jeffrey Bishop offers a critique of MacIntyre on this point [29], claiming that MacIntyre moves too quickly to the political dimension of community instead of adequately establishing why families are at the foundation. Bishop argues that because families are where the virtues of acknowledged dependence are most fundamentally nurtured, family-oriented decision-making ought to be the norm, as “families are the primary community for meeting the bodily needs of its members, but also the family is the font from which the values and practices of evaluating moral decisions spring forth” [29, p. 40]. While I agree, family-oriented decision-making is not always enough to resolve difficult discharge dilemmas, as illustrated by the case of Mr. Jackson. The mother, who no doubt wants what is best for her son, has different ideas about what “best” means as compared to the medical team, and this results in an impasse. Additionally, she is not able to care for her son at home, so she will necessarily rely on a broader community beyond the community of family, and this is where MacIntyre’s wide communal understanding of the virtues of acknowledged dependence is particularly important.
Gregory Poore offers a compelling critique of MacIntyre’s account of why one should care for the disabled [28], addressing two points that he finds particularly troubling. First, Poore claims that MacIntyre’s account lacks adequately compelling reasons to care for the severely disabled simply because of who they are [28, p. 470]. According to Poore, the first three justifications given by MacIntyre are self-focused (I owe because of what I have received, it could have been me, and I could learn something from the disabled). Second, Poore claims that there is no clear place for the severely disabled stranger in MacIntyre’s communities of practices and practical reasoners. Thus, Poore ultimately suggests the need for an alternative understanding of community based on a richer account of human nature (see also Stanley Hauerwas [30] on obligations to the disabled based on our shared human nature). Although Poore’s critiques of MacIntyre’s account are strong, I do not find MacIntyre’s account quite so problematic in that I argue that patients are already accepted into the medical community of care. The difficulty, however, lies in determining where the responsibilities of that community end and those of another community begin. Because patients often inhabit multiple communities at once (such as a family community, a religious community, or even the human community), providers can work with different communities to create a transition of care tailored to the individual patient.
While some may claim that the moral community of medicine is nothing more than a vestigial structure that can do no real work in our present-day medical context, I argue that the distress that providers feel when facing discharge dilemmas arises precisely because they do not consider the moral dimension of the medical community in which they work. By bracketing their moral concerns in an effort to solve discharge dilemmas, providers do a disservice both to themselves and to their patients. A resurgence of Pellegrino’s concept of a robust medical moral community may thus prove fruitful in thinking through issues of difficult discharge and alleviating provider distress.
However, given the inherent power disparity between the care team and the patient, I would argue that the onus of responsibility lies more squarely on the former when exercising the virtues of acknowledged dependence. In this way, patient and family requests should be honored to whatever extent possible, even if at times doing so engenders provider distress.
While this conclusion (keeping Mr. Jackson in the hospital) may not seem to differ in practice from according primacy to autonomy under a principled approach, the justification is much different. The care team is not simply acquiescing to the patient’s autonomous request, as exercised by his mother; rather, the team is acknowledging his dependence and working with his mother to best support that dependence. This shift in perspective may ease some of the distress engendered by the case and can situate discharge decisions within a larger framework of dependence and responsibility.
Again, such considerations point to the need for policymakers to address resource issues, especially the lack of long-term care resources for the elderly and severely disabled.
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Acknowledgements
I would like to thank the faculty at the Albert Gnaegi Center for Health Care Ethics at Saint Louis University, as well as two anonymous reviewers, for their valuable feedback on a prior version of this article.
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Friedrich, A.B. Addressing complex hospital discharge by cultivating the virtues of acknowledged dependence. Theor Med Bioeth 41, 99–114 (2020). https://doi.org/10.1007/s11017-020-09525-w
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DOI: https://doi.org/10.1007/s11017-020-09525-w