The Accidental Ethicist: In Defense of the Unlettered.

Abstract

The Accidental Ethicist: In Defense of the Unlettered Gretchen M. Spars, Ellen L. Schellinger, Ann Flemmer, and Connie Byrne-Olson The sun was shining brightly through the office window when the phone rang. The jingle was startling, as we had been mesmerized by a band of glistening snow dancing through the air outside our window, heralding the storm lurking at the edge of the horizon. On the other end of the line was a person with yet another story, asking, “Did I do the right thing?” While here the beauty of an approaching prairie snowstorm lay before us, we were quickly reminded of its companion, namely the danger and violence that even the most beautiful snow can cause in the remote areas of our plains state. Over 200 miles away from the ethics offices was a small town practitioner experiencing the gut-wrenching turmoil that accompanies the ethical deliberations that occur at the cusps of life and death. The storm had reached them the evening prior, and a major car accident had occurred along a barren stretch of interstate. With one fatality already, the other passenger had been taken by volunteer responders to the nearest facility in a small rural town. The snow and ice made travel difficult, and the patient was critical. Both of these factors landed the injured patient in a remote rural clinic. Once examined, it was clear that the rural clinic was not appropriately equipped with the life-sustaining interventions this patient would require, and a call was placed to request an airlift to one of our regional tertiary care hospitals with the necessary resources. As the flight team prepared to leave, they were promptly delayed by the snowstorm, unable to take off. Our colleague on the other end of the call was not the admitting provider but had been quickly called in as one recognized with a keen ability to assist during times of moral distress. As such, our colleague dove in, helping guide the medical decisions that were made within the constraints of limited resources, skills, availability, knowledge, and experience. The voice on the phone was not asking for permission; the actions had already taken place. Much like emergency medicine, where one does the best that they can and reflects in hindsight in order to better practices for the next time, the practitioner was calling to debrief, to seek support and counsel from colleagues about the ethical aspects of the case. The voice on the other end of the line was a physician who had taken an ethics course in medical school that piqued his interest; a physician so challenged by the critical thinking that occurs through ethical deliberation that he had invested personal time reading articles and teleconferencing [End Page 104] into available opportunities to discuss ethical issues in medicine. The voice on the other end of the line was that of an “accidental ethicist.” Accidental ethicist is a term we have coined to describe one who exists in the remote distances between ethical issues in medicine and areas in which healthcare access is limited. The accidental ethicist is, by default, recognized as the community’s “expert to turn to when ethical issues arise” because of their ability to identify and address ethical issues in medicine. Often their only background in medical ethics is an introductory ethics course or two in medical school. Sometimes the background, or experience, stems simply from personal interest and investment. While we recognize this accidental ethicist could exist in any location at a distance from resources, colleagues, and institutions of higher learning, and is not dependent on geographic specificities within the United States, we birthed this term by looking critically at the relationship between rural communities with limited resources and the bestowed title, ethicist. To explore the concept of the “accidental ethicist” we had conversations with many of our rural and frontier providers who had incredible examples of how they navigate through the intersection of ethical issues in rural and frontier medicine. At the most basic level, the accidental ethicist’s extracurricular interests put them in the sometimes uncomfortable position of recognizing an ethical problem when others may overlook it. For instance, the varied, overlapping relationships in...