Ethicists as Advocates in the Case Against AMA Discharges
Thursday, October 12, 2023
2:30 PM – 3:45 PM ET
Location: Essex C (Fourth Floor)
Discharges against medical advice (AMA Discharges) frequently involve situations fraught with conflict, distress, and unideal outcomes that disproportionately impact marginalized populations. Ethicists often engage in consultations regarding AMA Discharges, and may also weigh in on policy development and best practices that pertain to AMA Discharges. Opportunities to address AMA Discharges better at organizational levels exist but collective action problems and perceived constraints by decision-makers often create barriers to change. In this paper, I argue that ethicists should be advocates for organizational changes to promote ethically advisable practices for AMA Discharges. Drawing on illustrative cases, I will outline the ethical arguments against handling complex refusals as “AMA Discharges”. Instead of utilizing a label of AMA, I argue that it is ethically preferable to adopt a name and process that honor informed refusal discharges. Ethicists should encourage institutions to go beyond protection of institutional liability and favor guidance that includes compassionate risk reduction strategies and maintains therapeutic alliances. To solidify these ethically advisable practices, there may be a need for culture change that centers on harm reduction and makes space for honoring dignity of risk. Ethicists are well positioned to catalyze such changes and to help promote discussion, shape policy development, and lead education to inform culture change. Advocacy for engagement within an informed refusal framework promotes patient autonomy, helps counter systemic factors that contribute to inequitable outcomes for marginalized populations, and paves the way for substantive changes to better address complex discharges.