By Jena Jolissaint, 3L
July 12, 2012
[NOTE: This essay is the author's final reflection paper on her experiences in an independent study project she undertook with Professor Paul Lombardo in the spring semester 2012, during which she had the opportunity to shadow Grady Health System's medical ethicist, Jason Lesandrini. For a news story about this project, see Law Students Shadow Grady Health System Medical Ethicist.]
Sitting in Professor Lombardo's "Great Cases in Bioethics" course (and I use "sitting" loosely, as the course more often than not found me actively listening and/or gesticulating wildly in a manner that can hardly be described as mere sitting), the same question came up for me again and again. Whether we were discussing beginning-of-life-issues, end-of-life issues, or all the issues in between, the overarching issue was always one of who should decide. Who should make decisions about abortion and contraception? What if a patient is unable to provide informed consent due to a lack of capacity and the family disagrees with the medical team, or with one another?
In the context of decision making with the hospital, whenever there is a value uncertainty or complexity, the families and staff have the ethics committee as a resource to "elucidate issues, aid in communication, and fashion a plan that respects the stakeholders within the bounds of ethical and legal standards." Apparently Professor Lombardo got so tired of me pressing him for details about this magical council of ethicists that he decided to give me the chance to see one for myself, which is how I found myself spending several hours a week this semester shadowing Jason Lesandrini, Grady Health System's medical ethicist.
This independent study project did seem tailor-made for the likes of me, and not only because I loved the Bioethics course so much. I am an ethicist of sorts myself, having completed a Ph.D. in Philosophy with a focus on feminist ethics before coming to law school. "Introduction to Ethics" is on the short list of courses that is offered at almost every institute of higher learning that acknowledges the liberal arts, and some time is generally spent on ethical theories in every Introduction to Philosophy course as well. I have taught normative ethical theories so many times I can recite the basic ideas in my sleep. Many of my current students work in the medical field and/or are studying nursing, and so I have had some opportunity to see the intersections of ethics and medicine in my day job.
That said, applied ethics is a whole other beast, one largely eschewed by the Ivory Tower in favor of the old adage that philosophers are here to tell you how, rather than what, to think. Thus, I imagined the medical ethics committee at Grady Health System to be something like a cross between a faculty meeting at my alma mater and an emergency consultation on the TV show House, peopled by an interdisciplinary, highly-organized group of doctors, nurses, social workers, lawyers, and philosophers seated around a glass-and-chrome conference table resolving some of the pressing ethical conundrums of our time.
As with so much in law school and in life, my expectations were way off, although this did not stop me from having a richly educational experience at Grady Health System. The medical ethics committee meets monthly to conduct committee business and review some of the more significant cases the committee has heard in the month prior. My first surprise (besides the conspicuous absence of the shiny conference table I imagined) was that there is no one on the committee who is designated to advise the committee of the legal boundaries that necessarily inform the process of medical decision-making. In fact, while there were two J.D.s on the committee, neither one participates primarily in her capacity as an attorney.
It turns out that the work of the ethics committee begins where the need for legal expertise ends, which provided me with a fascinating view into how the law and ethics interact. For example, when I sat in on an ethics consult for a terminally-ill patient without a designated decision maker, the legal options were discussed, but it was soon clear that either decision the medical team could make would be well within the medical standard-of-care. That said, it was also clear that ethics could drive the law, as was clear in the fact that we saw doctors again and again affirming the ethical belief that life should generally be sustained regardless of the quality of life, an ethical value that is evident each time a state tries (and usually fails) to pass a statute permitting physician-assisted suicide.
In addition to sitting in on the monthly committee meetings, I also had the opportunity to sit in on a patient consult, which is when a small sub-group of the committee (usually the ethicist and any medical staff on call at the time) gets together discuss ethical issues in a particular case. In addition to these meetings, I attended grand rounds (not unlike our own student group lunch-and-learns), entered ethics data from past cases (note to aspiring ethicists: work on your handwriting), and rounded with the doctors from the Marcus Stroke and Neuroscience Center Neurocritical Care Unit.
I also attended a couple of medical ethics classes Jason teaches to physician-assistant students at Mercer. The funny thing about being a law student in a room full of aspiring health care practitioners' is that one commands the kind of rapt attention usually reserved for visiting dignitaries. Apparently physician assistant students are as confused about law as I am about the circulatory system. Luckily I knew better than to give them any legal advice.
Another interesting aspect of medical ethics is that often the first challenge is deciding that there is in fact an ethical issue. Many of the issues brought to the committee by the medical team are better suited to resolution by the social worker, legal counsel, or the doctors themselves. For example, during a data-entry marathon, only a handful of the dozens of cases I entered into the database had an actual ethical problem. It seems as though many times the ethicist is called in for an issue that is really better suited for the social worker, as when the medical team cannot locate a next of kin. Since the ethicist is involved in so many aspects of the hospital and interacts with both staff and patients, he is often a hub for patient care issues that fall within the strict lines of other staff positions. In this way, they are not unlike attorneys, who find themselves connecting clients to community resources and exploring non-legal alternatives in order to best meet their client's needs.
For the final reflection paper by another student who took this independent study project, Danny Vincent, 3L, see Why the Gray Matters: The Relationship Between Law and Ethics.
Jena Jolissaint, PhD
 American Society for Bioethics & Humanities. (2011). Core competencies for healthcare ethics consultation (2nd ed.). Glenview, IL: American Society for Bioethics and Humanities.