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The internist as clinical ethics consultant: An antidote to “the barbarism of specialisation” in hospital practice
El internista como consultor de ética clínica: un antídoto contra «la barbarie del especialismo» en la práctica hospitalaria
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Are these emerging diseases?" 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Malignancies related to viral infections can be seen in the inset.</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: EBV, Epstein Barr virus; HCV, hepatitis C virus; HBV, hepatitis B virus; HIV, human immunodeficiency virus; HPV, human papilloma virus.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.E. Valencia Ortega" "autores" => array:1 [ 0 => array:2 [ "nombre" => "M.E." 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Phase I Unit, Bayer AG, Wuppertal, Germany.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "B. Gil-Extremera, P. Jiménez-López, J.D. Mediavilla-García" "autores" => array:3 [ 0 => array:2 [ "nombre" => "B." "apellidos" => "Gil-Extremera" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Jiménez-López" ] 2 => array:2 [ "nombre" => "J.D." 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Real de Asúa, P. Rodriguez del Pozo, J.J. Fins" "autores" => array:3 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Real de Asúa" "email" => array:1 [ 0 => "diego.realdeasua@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "Rodriguez del Pozo" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J.J." "apellidos" => "Fins" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Division of Medical Ethics, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, Cornell University, Nueva York, NY, United States" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Weill Cornell Medicine-Qatar, Doha, Qatar" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Yale Law School, Yale University, New Haven, CT, United States" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El internista como consultor de ética clínica: un antídoto contra «la barbarie del especialismo» en la práctica hospitalaria" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">“By forcing [men of science] to specialize, society has made them insular and satisfied with their own limitations; however, this intimate feeling of dominion and worth will lead them to want to dominate other areas outside their specialty. (…) Whoever can observe the stupidity with which they think, judge and act today (…) in the general problems of life and the world of “men of science”, and obviously, after them physicians, engineers, financiers, teachers, etc. That condition of “not listening” (…) reaches its peak precisely in these partially qualified men.”</p><span class="elsevierStyleSource">José Ortega and Gasset, The Barbarism of Specialization (1930)<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a></span></span></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical ethics in Spain needs hospital care</span><p id="par0010" class="elsevierStylePara elsevierViewall">Practical clinical ethics (at the bedside) in Spain has foundered. After a highly promising start in the 1990s, proclaimed by the creation of numerous dynamic healthcare ethics committees (HECs), and after a period of institutional consolidation, recent years have witnessed a phase of palpable lack of activity.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">2</span></a> The activity of HECs in numerous institutions has been reduced by structural difficulties and limitations,<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">3</span></a> viewed with bitterness and disenchantment by new generations of physicians.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this article, we reflect on how to strengthen the clinical ethics practice and on the essential role of the internist as a motor for this change. To this end, we first propose a shift from the current model of care focused on the deliberations of HECs towards a model that concentrates its actions on clinical ethics consultants, who might be better positioned to resolve specific cases and can follow the patient's progress and situation in real time. Later, we will analyze who, by their training and role in the healthcare team, are best positioned to assume the role of consultants. Lastly, we will propose that internists are in the best position, although not exclusively, to lead this initiative and, therefore, remain invested in this responsibility.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Both in English-speaking and continental European settings, HECs have demonstrated operational difficulties in the real-time assistance of morally complex decision making. The rhythm of clinical practice, with its temporal pressures and emergency care, leaves no margin for calm reflection. However, bioethics must take shape “not only in specific knowledge but also in knowing how to act or, better said, in conscious action”,<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">5</span></a> which should be applied at a specific time. A recent intervention with Spanish physicians and ethics specialists analyzed the communication between ethics committees and consultants within the hospital from the United States perspective,<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">6</span></a> in which, to address a growing number of difficult cases with appropriate speed, numerous institutions have chosen a model outlined by the HECs as the deliberation table and the consultant as its delegate for daily practice.</p><p id="par0025" class="elsevierStylePara elsevierViewall">These proposals, which continue to be focused on HECs, add the new option of consultants dedicated to addressing the numerous daily needs of the practitioners and their patients, in the consultants’ area of competence in clinical ethics. Consultants and HECs thus form a valuable and synergistic unit.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">7</span></a> We believe that this scheme, which we will defend below, will revitalize HECs.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Current situation of healthcare ethics committees</span><p id="par0030" class="elsevierStylePara elsevierViewall">One of the main criticisms leveled at HECs is their ineffectiveness in resolving problems in real time. The committees serve as the center for deliberations on values and responsibilities and fulfill a significant task of training<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">8</span></a> but lack the operational immediacy required by clinical practice.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">9</span></a> While these collegiate bodies deliberate, health professionals face numerous ethical problems alone, some of which can be significant.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">10</span></a> Although many of these problems could be classified as basic conflicts, as a whole they can become intolerable for many healthcare practitioners. Moral stress punishes physicians, jeopardizes the patients’ experience and puts the quality of medical care at risk.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The distance between the patient's bedside and HECs appears to be one of the main causes for the low number of consultations these committees receive. A 2007 survey conducted on health professionals in Norway, Switzerland, Italy and the United Kingdom revealed that while 99% of those surveyed stated that they faced ethical problems daily, only 11% asked for formal assistance from their committees.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> In Spain, the Bioethics Institute of Borja documented barely 283 consultations with 25 HECs in Catalonia in 3 years, which represents an approximate mean of 4 consultations per center per year.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">13</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The confusing of the HECs’ mission with that of other institutional committees (such as those of clinical research ethics), its invisibility within the institutions, the lack of follow-up of consulted cases, the varying degree of training of its members and the perception that HECs are only useful as a last resort also prevent these committees from having a larger role.<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14–16</span></a> The gap between HECs and the day-to-day activities of the hospital leads to the question as to whether HECs, in their present operating format, are the most appropriate instrument for providing actual support to health professionals and their patients in day-to-day ethical-clinical conflicts.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Why do we need to ask for help on ethical issues?</span><p id="par0045" class="elsevierStylePara elsevierViewall">If health professionals have integrated the patient's autonomy into the clinical relationship, why not stay with a model in which the physician, along with the patient and their family, resolves the ethical-clinical issues through moral deliberation and dialogue? The answer is because this ideal physician, patient and family no longer exist,<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">17</span></a> if they ever existed at all.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Progressive professional specialization, the fragmentation of the healthcare process and the increase in complexity and comorbidity of hospitalized patients have made medical interconsultations indispensable. The patient's various clinical aspects are typically treated with this instrument to reach a diagnosis, prognosis and treatment whose success depends largely on multidisciplinary deliberation.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> An isolated practitioner is in no position to resolve all clinical problems by themselves. Similarly, they are not in the best position for identifying and solving all ethical problems inherent in each case. They have partial vision, which is inevitably biased by their objectives and interests. Add to this the growing cultural and moral diversity of our societies and it is understandable that the gradual increase in difficulty of the ethical conflicts in medical practice demand interconsultations on ethical-clinical issues.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">19</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Ortega and Gasset admonished physicians because their progressive specialization impeded them from cultivating “active listening” and made them incapable of maintaining “a global point of view”.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a> Placing reflection in the current context, one of the dangers of progressive medical specialization is that this shortsightedness atrophies our ability to connect different fields. By deepening our understanding of the medical technique, we unconsciously ignore other equally essential aspects, not only those directly related to patient care (such as moral deliberation) but also other cultural settings, which is precisely the “barbarism of specialization”.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">As indicated by a European survey, many health professionals privately recognize their limitations and informally seek help among trusted colleagues before taking complicated decisions.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> Except for practitioners with formal training in bioethics, few seek support from HECs. However, camaraderie ensures honest advice but does not ensure correct advice. Perhaps we need to recognize the limitations of friendship for giving advice on issues of ethics.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Committees and consultants</span><p id="par0065" class="elsevierStylePara elsevierViewall">The HECs’ mission is to improve patient care by identifying, analyzing and resolving ethical problems that emerge during patient care.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">20</span></a> Some committees are excellent forums for doctrinal and casuistic deliberation, while simultaneously excelling in the development of general recommendations and guidelines for approaching ethical problems. Beyond the local recommendations of each HEC, it is worth highlighting the reflections of the Bioethics Committee of Spain, whose reports deal with a range of issues, from specific topics (such as the use of mechanical-pharmacological restraints) to overall considerations on the sustainability of the Spanish National Health System, to give just 2 recent examples.<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">21,22</span></a> Nevertheless, it is difficult for these collegiate bodies of institutional deliberation to provide the required promptness for the daily needs of healthcare practitioners and their ethical conflicts, given the logistic impossibility of summoning their members (either as a whole or in part) to assess each individual case.</p><p id="par0070" class="elsevierStylePara elsevierViewall">To make their mission effective, HECs must delegate the operational issues to one or more of their members, who will represent them at the patient's bedside. This is the place for clinical ethics consultants, who will be a pragmatic link between the theoretical moral deliberation of the HECs and everyday clinical practice.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The ethics consultant's authority emanates from the status and reputation of the HEC, represented by the consultant and under whose supervision and normative consensus the consultant operates.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">7</span></a> The committee should continue being the entity for controlling and supervising the consultant's actions. The committee's prestige and credibility are essential for mediating conflicts between specialists, between departments and between the medical team and the patient and their family.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">23</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The figure of consultant as an extension of the HEC carries major advantages. The first is their proximity to specific cases and their ability to provide flexible and versatile care to more cases. Thanks to this accessibility and availability, the consultant facilitates coordination and communication with the medical team, the patient and their family. Furthermore, the ethics consultation at the patient's bedside enables a joint, real-time assessment of the case, which incorporates the viewpoints of the responsible team, nurses, social workers and other agents. The consultant thus serves as an amiable compositor between the parties, facilitating the search for consensus.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">23</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In traditional HECs, the patient's viewpoint is discussed numerous times without the patient themselves explaining their circumstances, which results in a harmful narrative bias. In contrast, the consultant's participation helps in understanding first hand the patient's values, principles and motives. The consultant's task not only consists of obtaining a report of values but also, on many occasions, helping patients identify these values and interpret their preferences in light of a specific clinical context.<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">24</span></a> Thus, the ethics consultant becomes an instrument for true patient empowerment, actively inserting the patient's voice into the deliberative process.<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">25</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Furthermore, the consultant's function should be understood as not just a “mediator” between practitioners and patients. The mediation systems seek to arrive at a consensus to prevent conflicts from developing, which is an essential task for the consultant in many ethical conflicts. However, this task should not be confused with the consultant's ultimate mission, which is to conduct an ethical analysis of the choices in each case. The consultant's real objective is to propose an optimal course of action that puts the maximum or, depending on the need, puts at risk the minimum number of values in play. To achieve this, mediation and the search for consensus between parties will be essential tools.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Field studies have shown that ethics interconsultations can resolve most moral problems that emerge in daily practice.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">26</span></a> A number of studies have indicated that health professionals perceive consultants as playing an important role beyond resolving conflicts, helping in the clinical management of patients, improving the team's perception of ethical problems and changing the approach of the various actors.<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">27</span></a> Patients and their families have also positively assessed ethics interconsultations.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">28</span></a> One of the settings where these interconsultations have been shown to be of greatest use is in the care of patients at the end of life. Schneiderman et al. observed that the systematic support provided by ethics consultants to intensive care units significantly decreased the number of conflicts between the medical team, patients and relatives. The support also reduced the use of advanced life support measures and decreased the mean stay of patients at the end of life.<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">The internist as clinical ethics consultant</span><p id="par0100" class="elsevierStylePara elsevierViewall">We need a change in the consultation format and real clinical ethics professionals to consult. In the items below, we will show how internists trained in bioethics can be ideal candidates for this delicate task.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The first thing that health professionals ask of an ethics consultant is broad clinical knowledge.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">30</span></a> One of the main reasons that the influx of third parties into the physician-patient relationship is never comfortable is that many ethical conflicts arise “from an incomplete interpretation or knowledge of the facts”.<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">23,31</span></a> It stands to reason, therefore, that a general practitioner with an understanding of ethics or an <span class="elsevierStyleItalic">ethicist</span> with general clinical knowledge is requested as a spokesperson. An ethics consultant, however, requires more. The consultant must unquestionably have a solid specialized training in bioethics. In our setting, this training can be achieved through master's degree programs or, as least, specific training courses on ethics consulting. It would be useful and highly beneficial in the future to have bioethics training incorporated into graduate complementary education as a field of study, although we are far from reaching this objective.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The nature of the consultation process requires communication skills and a tolerance for various points of view. Moderation, an interdisciplinary view and the ability to seek an open consensus through dialogue with all parties and without imposing one's own view are essential instruments for interpreting the roadmap for ethics consultations.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">32</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Given that these qualities should also be applied in the specific setting of the hospital, the consultant's task requires a good understanding of the relationships and customs that model the institutional dynamics in which each ethical-clinical case occurs. Thus, the differences established by the hierarchical structures will be tempered, and the participation of all those involved in each case can be encouraged, from the department head to the resident physician and nursing staff. As we stated in a previous article, promoting inclusive deliberation is more than a democratic impulse; it is a practical necessity.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">23</span></a> Inclusive deliberation consists of the mediating and catalytic power of ethics interconsultations in the hospital.</p><p id="par0120" class="elsevierStylePara elsevierViewall">It is therefore not surprising that surveys have shown how all the previously mentioned facets are considered more important than the specific training in ethical, legal and religious matters. Health professionals and practical ethicists seek unbiased individuals from outside the medical team who have clinical knowledge, an overall vision, a commitment to patient care and an understanding of ethics.<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">30,32</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">If the internist's mission, by education and professional training, is “to be a reference (…), guide and defender for the patient in their complex trajectory through the hospital system” and “act as consultant (…) and offer innovative aspects in areas other than conventional hospitalization”,<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">33</span></a> we believe that it optimally embodies all the recently mentioned traits. In a practical sense, internists represent the largest proportion of general practitioners in the hospital setting, and their function as mediator between numerous hospital departments is already well developed.</p><p id="par0130" class="elsevierStylePara elsevierViewall">However, internists <span class="elsevierStyleItalic">are not the only professionals</span> who have the necessary ingredients to ensure the quality of an ethics interconsultation. The central position in hospital care, the patient's overall view and the ability to mediate and facilitate efforts between departments are also traits of other specialists, such as geriatricians, palliative care experts and intensivists and nonmedical health professionals, such as nurses and social workers. We believe the role of ethics consultants should reflect a plural and open vocation and that many practitioners in these and other settings can also be sufficiently qualified for working as ethics consultants.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Work method and institutional support</span><p id="par0135" class="elsevierStylePara elsevierViewall">The implementation of a system of ethics consultants is necessary but not sufficient to invigorate the ethical-clinical practice in Spain. The consultants’ efforts are not exempt from the risk of becoming a theoretical exercise. To prevent this outcome, we need the support of 2 robust pillars: a rigorous analysis method and the institutional support and monitoring from HECs.</p><p id="par0140" class="elsevierStylePara elsevierViewall">The method for analyzing and resolving ethical–clinical cases must be adapted to the peculiarities of clinical practice and enable the effective resolution of cases in real time. In the 1990s, <span class="elsevierStyleItalic">clinical pragmatism</span> was developed as a possible method of ethical analysis.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">34</span></a> Like the clinical method, <span class="elsevierStyleItalic">clinical pragmatism</span> starts with the identification of an ethical problem and uses the clinical information, the preferences of the patient and relatives and information on the family and institutional dynamics to generate a “differential ethical diagnosis” before suggesting potential courses of action. The method's particular characteristic lies in that it is an inductive cross-sectional method, which considers the ethical principles not as irrefutable moral maxims but rather as tools, whose application depends on the specific clinical context.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">34</span></a> In Spain, similar methods with a more deontological character and a strong deliberative component are more widely implemented.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">35</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">As with physical examinations, the analysis can start with the head or with the feet, provided it is performed systematically. Regardless of the deliberative method employed, the essential issue is that the method be used systematically and rigorously. To this end, we need solid competence in bioethics, expertise in handling the tools and methods of ethical analysis and the development of certain skills, such as interpersonal communication and the ability to lead multidisciplinary meetings, among others.<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">36</span></a> This need has led the American Society for Bioethics and Humanities to develop a framework document on the essential competencies of consultants and a standards model for the accreditation of these competencies.<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">32,36</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The support and supervision of HECs for their consultants is essential for the success of this format. It would be wrong to interpret the incorporation of consultants as a threat to HECs. On the contrary, the consultant's authority depends on the HEC's visible presence behind them. It is expected that by implementing the figure of ethics consultant, the visibility and importance of HECs will gradually increase. The consultants serve as an extension and a palpable presence of the HEC in the hospital wards. When implementing the new format, it is equally essential that the HEC empower the consultant by developing guidelines and directives for resolving the countless problems or situations which, without the consultant's urging, would have been left unattended. Furthermore, the HEC cannot ignore the fact that consultants will be subjected to institutional and societal pressures that will complicate their task, from the natural discomfort caused by opposing a colleague, to being the target of lobbying in favor of a specific result for the interconsultation or the continuous perception of biases in favor of others, to the detriment of the medical or nursing teams. The committee must therefore be prepared to channel these pressures and mediate the potential conflicts and stress that can arise in the consultant's tasks.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Finally, an essential component in the success of the present format is that HECs make it clear that they continue to exert their tasks of institutional surveillance and supervision of particularly complex or difficult cases and of those that require deeper deliberation. The true strength of the consultant and committee lies in working together on tasks that encompass advisory, institutional and educational functions.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">37</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Financial feasibility</span><p id="par0160" class="elsevierStylePara elsevierViewall">A possible threat to this proposal are the issues of financial feasibility in a health system with scarce means. However, various models have shown that a desirable side effect of ethics consulting is financial efficiency, because it makes better use of resources and contains overall expenditures.<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">38,39</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Given this and as an explicit theoretical exercise, we offer the following estimate in the context of a standard internal medicine department. We start with the fact that approximately 10–12 patients are typically treated on a daily basis by an internal medicine team consisting of a staff physician and a variable number of residents. Therefore, a single team (among all those that make up an internal medicine department) is limited to a daily burden of care of 6–8 patients. It would therefore be feasible for a staff physician with special training in bioethics to dedicate 1–2<span class="elsevierStyleHsp" style=""></span>h a day to address the potential ethics interconsultations that might arise, at least initially. The necessary workload redistribution (which would represent 33–50% of the burden of a single medical team) could be spread among the rest of the department's teams, with the benefit of providing the institution with a new and necessary service. The following step would be for each institution to develop a model adjusted to its own needs, depending on the number of consultations and the rate of observed growth. Implemented modestly, gradually and progressively, we believe that this model could be sustainable.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusions: an antidote to the “barbarism of specialization”</span><p id="par0170" class="elsevierStylePara elsevierViewall">Maintaining the present structure of resolving ethical conflicts based only on consultations with HECs is similar to attempting to resolve all interconsultations within a department exclusively through department meetings. We need to promote the creation of the figure of ethics consultant as an operating delegate of the HEC, to resolve problems in real time and at the bedside. There are reasons to believe that, when available, general practitioners are the best equipped to meet the challenge.</p><p id="par0175" class="elsevierStylePara elsevierViewall">HECs, through their consultants, can be true antidotes to the “barbarism of specialization”. If we seek to keep practical clinical ethics abreast of the times, as Ortega and Gasset aspired for Spain, we must transform the current applied bioethics to one that is involved, close, real and in the moment. We need to reflect on the future of generalism in clinical practice through a new perspective that better handles the population's increasing health needs.<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a> The “barbarism of specialization” can serve as a metaphorical and valuable warning for understanding the internist-ethicist's role and place in the hospital. Without this effort, “not even the intimate progress of science is assured, because this (…) requires an increasingly difficult task of unification, which increasingly complicates vaster regions of total knowledge.” (Ortega and Gasset).<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflict of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest regarding the publication of this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres1009458" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec968995" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1009457" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec968994" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical ethics in Spain needs hospital care" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Current situation of healthcare ethics committees" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Why do we need to ask for help on ethical issues?" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Committees and consultants" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "The internist as clinical ethics consultant" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Work method and institutional support" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Financial feasibility" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusions: an antidote to the “barbarism of specialization”" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interest" ] 13 => array:2 [ "identificador" => "xack340546" "titulo" => "Acknowledgements" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-06-08" "fechaAceptado" => "2017-09-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec968995" "palabras" => array:3 [ 0 => "Clinical ethics" 1 => "Healthcare ethics committees" 2 => "Ethics consultant" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec968994" "palabras" => array:3 [ 0 => "Ética clínica" 1 => "Comités de ética asistencial" 2 => "Consultor de ética" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The development of hospital clinical ethics in Spain depends almost exclusively on the healthcare ethics committees, which have been criticized for a lack of proximity to the patient's bedside in day-to-day ethical conflicts and for their scarce practical operation, reflected in the low number of consultations they receive.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In this study, we reflect on the need to change the current healthcare model in clinical ethics so as to reactivate it and call attention to the essential role of internists as the engine for this change. To this end, we propose a model in which the healthcare ethics committees incorporate ethics consultants, who are better positioned to discuss cases at the patient's bedside. We then analyze the characteristics that these consultants should have.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El desarrollo de la ética clínica hospitalaria en España depende casi exclusivamente de los comités de ética asistencial. Estos han sido criticados por su falta de cercanía a la cabecera del paciente en los conflictos éticos cotidianos y por su escasa operatividad práctica, que se refleja en el escaso número de consultas que reciben.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">En el presente trabajo reflexionamos sobre la necesidad de modificar el modelo actual de atención en ética clínica para reactivarlo y llamar la atención sobre el papel primordial del internista como motor de dicho cambio. Para ello proponemos un modelo en que los comités de ética asistencial incorporen consultores de ética, mejor posicionados para la discusión de casos a la cabecera del enfermo. Seguidamente analizamos las características que dichos consultores deberían poseer.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Real de Asúa D, Rodriguez del Pozo P, Fins JJ. El internista como consultor de ética clínica: un antídoto contra «la barbarie del especialismo» en la práctica hospitalaria. Rev Clin Esp. 2018;218:142–148.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:40 [ 0 => array:3 [ "identificador" => "bib0205" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "La rebelión de las masas" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. 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| 2023 March | 3 | 6 | 9 |
| 2021 October | 1 | 0 | 1 |
| 2020 September | 0 | 1 | 1 |
| 2018 April | 0 | 1 | 1 |
| 2017 November | 0 | 1 | 1 |
