Medical Ethics – Best Practices and Wiggle Room: Not Everything That Counts Can Be Counted


March / April 2007

Medical Ethics

Best Practices and Wiggle Room: Not Everything That Counts Can Be Counted

Spurred by reports from the Institute of Medicine (IOM, 2000) and other sources, virtually every healthcare institution has programs in place to measure and improve the safety and quality of the care patients receive. These programs have far-reaching consequences, including changes in how healthcare providers interact with patients. Although patients certainly stand to benefit from reduced errors and improved clinical outcomes, we should not let our programs distract us from the idiosyncrasies of patients’ goals, values, and attitudes.

When clinical practices are changed to improve safety and quality, variations in how patients are dealt with tend to be weeded out. We try to find the most effective and efficient ways of doing things, and everyone is encouraged — or required — to adopt these best practices. Anyone who is still doing things “the old way” or in some other fashion is assumed to be taking too long, costing too much, or creating unnecessary risks. In many cases that conclusion is correct, but we should be careful to allow ourselves enough flexibility to deal with special situations and the views of individual patients. Sometimes deviating from standard procedures is the right thing to do.

For example, consider those patients who are at risk of self-harm if not restrained (mechanically or pharmacologically). The institution’s quality improvement program (QI) monitors self-harm incidents carefully, and staff members are highly motivated to avoid them. As a result, they may use restraints in some borderline cases or leave the restraints in place longer than usual, “just to be on the safe side.” Although these measures may yield fewer incidents, they may also be very frustrating for patients and families who resent being restrained. Patient satisfaction surveys taken at the time of discharge may show that some are not entirely happy with their care, but without pinning down where problems arose.

Bear in mind that although people want safe, effective healthcare, they also value dignity, freedom, and other intangibles. The QI program’s graphs may show a clear drop in self-harm incidents, but it is much harder to measure the anger and dissatisfaction that may have resulted as well. Thoughtful programming may find ways to keep the incident count low while maintaining patients’ satisfaction. For instance, using friends and family members as “sitters” may prove to be an effective alternative to traditional restraints as well as keeping patients happier. (Maccioli, Dorman, Brown, et al, 2003)

Cultural Conflicts
Situations get stickier when keeping patients satisfied requires surrendering some level of safety or adherence to “best practices.” This can be seen in some of the cultural conflicts that arise between Western medical practices and patients’ views of health, illness, therapy, and the patient/provider relationship. Anne Fadiman (1997) documents such conflicts in her account of Lia Lee’s treatment for severe epilepsy. This little girl was a member of a Hmong family, and the interactions between her parents and her healthcare providers were characterized by miscommunication, misunderstanding, condescension, frustration, and anger. Although the physicians’ actions were motivated by their concern for the child’s wellbeing (e.g., frequent blood draws and complex medication regimens), the parents were convinced that these actions put their daughter at serious risk, and were furious with what they perceived as physicians’ irresponsible behavior. With the benefit of hindsight, several physicians now acknowledge that Lia’s care would have been better overall if some of the usual medical procedures had been modified or perhaps even omitted.

Many of the processes that take place in a hospital have been standardized, but medical staff repeatedly find themselves dealing with the quirks, exceptions, and complications of individual patients. This variability is inescapable, and shows up in medical details; in the relationships between patients, families, and their healthcare providers; and in patients’ goals, attitudes, and values. Consequently, situations arise in which the established procedures either fail to address a need, or instruct the medical staff to act in ways that the patient or family find objectionable.

This is not to say that our safety and quality programs should be dropped or that participation in them is not important. Instead, there are three lessons here about the ethical limits of these programs:

First, what counts as a good outcome, a risk worth taking, or as quality healthcare is determined by patients and their families (Mills, Rorty, & Werhane, 2006). We must take seriously their views about what the goals of treatment are, what types of treatments are acceptable, and which interventions are just not worth it.

Second, sometimes the right thing to do is what the patient wants, not what the procedures dictate.

Third, our programs and procedures should build in some “wiggle room”; we should not punish or unduly pressure medical staff who make exceptions for their patients.

Careful record keeping, which is central to safety and quality improvement programs, must not distract us from the fact that not everything that matters can be measured. Hospital procedures are increasingly uniform, but the populations we serve remain diverse. Safety and quality are vitally important, but so is a healthy respect for individuals’ goals and attitudes. Wiggle room allows us to balance these concerns for each patient.

Ralph Baergen received his PhD in philosophy from Syracuse University in 1990, and is a professor at Idaho State University. He has authored numerous articles and three books, and teaches medical ethics at both graduate and undergraduate levels. He is also a member of the Portneuf Medical Center Ethics Committee, and chairs the university’s Institutional Review Board. His company, Baergen Consulting, provides ethics training for healthcare professionals and social workers. Baergen may be contacted at


Fadiman A. (1997) The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. New York: Farrar, Straus & Giroux.

Institute of Medicine. (2000) To err is human: Building a safer health system. Washington, DC: National Academy Press.

Maccioli G. A., Dorman, T., Brown, B. R., et al. (2003). Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: Use of restraining therapies. American College of Critical Care Medicine Task Force 2001-2002. Critical Care Medicine 31(11), 2665-2676.

Mills, A. E., Rorty, M. V., Werhane, P. H. (2006). Clinical ethics and the managerial revolution in American healthcare. Journal of Clinical Ethics 17(2), 181-190.