Q&A: Getting to know CAMH’s ethicist, Kevin Reel
by Joan Chang
Q: What’s a health care ethicist?
A: What we do in the practice of healthcare ethics is help people think through really challenging decisions and situations and figure out what causes that sense of ‘yuck’ that we feel when ethical values are in conflict – our own, or each other’s.
The more official term for the ‘yuck’ factor is moral distress, but ‘yuck’ really tells it the way it is. The problem with the ‘yuck’ feeling is that it’s not always reliable. We may not feel it at all when we should, or the ‘yuck’ might be more emotional than ethical.
Ethical decisions are essentially about trying to figure what is the ‘good’ or ‘right’ thing to do in a situation. Such situations occur every day, and often go unnoticed because they are pretty straightforward. But sometimes they are much more complex.
Thinking through them can be much easier when an objective person helps you. The ethicist can be that objective person – part of, and familiar with, CAMH, but not in the middle of the situation.
Q: What drew you to the field of ethics?
A: I’ve always been drawn to it, probably starting with our family dinner table discussions – with nine people around, there were always plenty of opinions!
I love the ‘muck’ of challenging ideas, which is what I call it. To me it’s a bit like the way I have always preferred going out into a scary storm rather than staying inside – it never seems as bad when you’re in the middle of it.
I find ethics – often like a storm of ideas or conflicting values – to be much the same. I like getting into the muck with other people and helping them to sift through it.
Q: What kinds of issues do you deal with?
A: Very often the issues involve trying to figure out the capacity to consent to, or refuse, a plan of treatment.
Sometimes there are resource allocation issues – on an individual level, how can clinicians manage their wait lists fairly? On a broader level, how do directors redesign and reprioritize services knowing there may be people who lose out in some way in the future?
Sometimes people are bound by certain laws, policies or professional standards or regulations. In those situations, we often talk through the ‘yuck’ simply to understand where it is coming from. Understanding why it feels yucky can help avoid moral distress.
If you don’t deal with that distress, it can turn into ‘moral residue’. That residue is like the scale in a kettle that makes it work less efficiently. The ‘moral’ you isn’t able to work at your best when there’s residue building up over time.
Healthcare ethicists also help shape health related policies in their own organizations and in other contexts, through government panels and consultations. We are usually involved in reviewing research that involves human participants to be sure it meets ethical expectations.
The really important thing about ethics practice is that more often than not, usually a decision must be made. In practice, real people need real decisions – that’s why ethics practice can be so rewarding and educational. I am learning from everyone around me all the time.
One of the things I need to do is help people recognize when they’re doing the ethical decision making. It’s often done very habitually, very reflexively.
We each have a sort of practical wisdom we use without really knowing it. It’s important that people appreciate this – to be confident in themselves, but also to double check that they are seeing all the ethical dimensions in a situation.
Q: What do you have to weigh whenever you’re faced with an issue?
A: First of all, you have to know what laws and regulations might be relevant. They often shape your options.
Then you must figure out what principles and values are at play, because different principles might be more obvious than others, and some might carry different importance in different contexts. They’re less like strict rules or laws and more like guidelines.
And it’s often really important to seek the perspectives of others. I can see things as a clinician, or an ethicist, and it can feel really, really right from the position I’m sitting in. But when I explore the story of another person that is affected by the decision, they may have something to share that is really important, and which might never have occurred to me.
Q: What are some of the more contentious issues you’ve had to face?
A: Issues often include questions around how to proceed with somebody’s treatment planning when their capacity is unclear and who is acting as decision maker is not entirely clear.
There are laws to help with this, but there is still a lot of judgement involved. Taking away someone’s rights to choose is a big thing, so many clinical staff experience regular moral distress with this part of their job.
Issues around role boundaries also arise. Some clinicians or teams might extend their usual role because they’re trying to help. That feels right and good for a long time until it starts feeling wrong. Then the problem is getting back to where things should be.
And different members of the healthcare team can disagree. Getting through that can be hard when the issue is sensitive.
But getting through it well is important, because everyone needs to work together and be able to rely on each other in busy and stressful situations.
Q: Why is your role vital here at CAMH?
A: I think in all areas of health care, people who provide services and people who receive services are in special relationships – clients, family, visitors and providers.
The circumstances are special. There is a lot of vulnerability and stress.
That can be profoundly unsettling and disturbing for everyone involved. I think that the area of addictions and mental health practice gives rise to very special sorts of moral distress, and I like to think of the ethicist as the ‘distress buster’.
Having the objective perspective to offer can help with finding solutions, or simply understanding things more clearly. If nothing else, I’ve at least got chocolate and tissues.
Q: What do you want people to know about you and your work?
A: Ethics might sound like a sort of scary or intimidating thing, but try not to be put off by that.
It’s really just about seeking the right, or good thing. We all do it every day, we can all benefit from some help every now and again.
And we all get benefit from dialogue about ethics and values, so keep asking, thinking, talking and learning.