Everyday Ethics: 35000 choices
I can remember talking about ethics briefly in high school. I definitely had a course during my first undergraduate program. I remember a few other ethics discussions, a paper about an ethical dilemma during covid, and a couple posts to student discussion boards. There were certainly some in class mentions and brief debates. When I actually think about how much time was actually spent on this during my formal education, it seems almost laughable considering the areas where I have worked; sexual assault nursing, obstetrics. insurance, and mental health. Certainly, these are areas where ethical dilemmas happen often. It got me thinking about how many times during the day I am making decisions that are really based in ethics. For those of us working in mental health, it is quite honestly, all day most days. According to the American Medical Association, decision fatigue is the idea that the more decisions you make throughout the course of a day, the less ability you to make decisions. The more decisions you make, the more fatigued you become and the harder it gets to make decisions. It is estimated that in regular daily life the average person makes 35,000 decisions per day. No surprise we are tired! No surprise that when i go home after a day of seeing clients, choosing medications, ordering lab tests and deciding which client issue to tackle first I can’t even decide what to make for dinner.
So, how do decision fatigue and ethics interact and how do we make sure that when we make a decision it is ethical, and responsible even when it might be decision number 34,999 of the day? In my career I make decisions like to admit someone to the hospital or not, to call children’s services or not, to commit someone involuntarily or not, to order a drug screen or not, to change medications or not. These are not decisions I take lightly and they are not decisions I want to make without a clear mind, but if I am honest about the way we practice healthcare, (even though I work in am incredible place) that is not reality.
It’s quite troublesome, wondering how a provider can ever know all the things they need to know about ethical practices. It seems as simple as doing the right thing but it is so much more than that. Its recognizing that sometimes what seems right doesn’t take in to account a client’s right to choose their own path. Its understanding that a new medicine might be the best option but there are insurance and cost considerations outside of your control. Its understanding that even when you want to save a life there are boundaries that you can’t cross. Its realizing you aren’t the best provider for a particular case. Its even knowing its time to end your relationship with a client because they are better and you have a waiting list. And its so much more. There are caveats and grey areas. There are differing state laws and exceptions to most of it. There is just no way as providers we can know everything. Its not possible, and even if it was things change so often you still could not keep up.
All of this leads to the question of how you protect yourself as a provider.
First off, join a practice or find colleagues where others have different experiences than you. Maybe you have not faced every situation but you can call on others who may have.
Don’t rush. Rarely, is a decision needed in the next 3 seconds. If it is, call 911. When in doubt, stop for a minute. Find a way to center yourself and then decide. If you can, wait to decide until you have labs back. Its a good stall tactic and you probably need then anyway.
Debrief after complex cases.
Get out of your own way. Don’t ever feel bad for asking for help and other opinions. It is not a sign of weakness to ask how someone else would proceed. If you ask for advice you are not obligated to follow it BUT you are obligated to thoughtfully consider it.
In the really complicated situations have a collaborator and document that you did.
Read anything you can!
Schedule your most complex clients early in the day or after lunch if possible. 5pm on Friday you will not be at your freshest.
All of the suggestions above are helpful, but I would also argue that decision making and ethics need to be larger parts of the formal education process. I realize, adding more to programs that are already intense might sound impossible but I firmly believe the change could make the early years of practice less exhausting and the quality of practitioners better.
Bring ethical discussions into every course. Constantly remind students that making hard choices will be a large part of every day.
Have a weekly ethical dilemma posted. It will give students a glimpse at different ways of handling situations.
Set up practice scenarios where there isn’t one right answer, but you need to defend your choice.
Encourage students to meet in small groups to talk ethical issues through.
Add some ethical curveballs into simulations; a child who reports something that may or may not be reportable, a person living with addiction that wants a stimulant, a 17 year old who needs to be inpatient but is days from their 18th birthday or a sex offender who needs an antidepressant.
Challenge your students when they start wanting to fix everything and when they seem to see only 1 right path.
When I look back at my first 8 months in practice the thing that stands out is how mentally exhausted I am after a day seeing clients. I wasn’t nervous to talk with clients or their parents, I felt I had a good knowledge base with medications, my previous work had taught me some valuable psychotherapy techniques and I knew I had a good education. BUT, I would arrive home at the end of the day and fall asleep on the couch. More than anything it was the weight of all the decisions I made each day. Its getting better. I am starting to understand not every decision requires extensive processing. I am starting to have a process I follow for clients in certain categories. I am becoming more confident in my gut and instincts and I have some clients I have seen for several months so not every appointment is a new intake. What I have come to realize though, is that the decisions are most likely always going to be the thing that makes me the most tired and I have to be very mindful of when I need to press pause and regroup to keep everyone safe.