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Balancing Act

We just finished the report, Balancing Act: Ethics in Medicine, so I've been thinking lately about balancing act as an apt metaphor for the times, and for me personally.

In clinical medical ethics, balancing act refers to weighing the pros and cons in various ethically charged cases where values and goals can come into conflict (e.g., end-of-life, futility of care) and then making some kind of reasoned, all-things-considered judgment about which course of action to follow.

We certainly found this weighing of reasons in our interviews and focus groups, but what really jumped out was the high level of moral distress - the feeling you get from knowing the right thing to do but being unable to do it - that many caregivers experienced from working in what one physician described as "a system of strangers taking care of strangers."

A nurse practitioner in a long-term care facility spoke of the moral anguish of knowing that a patient needed to be on palliative care and moved to hospice, but was forbidden to even mention hospice as an option because the facility needed to fill beds. An internist talked about the guilt she sometimes felt because of not seeing a patient who was screened out because she was uninsured, illegal, not in the right health plan, or some other excluded category. An emergency room physician talked about the moral anguish of having to go along with the wishes of the family and keep a basically dead person alive on a ventilator when some of those wasted end-of-life resources could be used to feed starving children.

There is a tipping point in any balancing act. Some people can't live with high levels of moral distress in health care, and get out. Others feel the moral distress but balance it with other benefits, such as making good money or being able to help people in a great many cases. Still others get angry and become advocates and leaders for changing the balance of power through health care system reform.

Balancing acts are hardly limited to medical ethics. They occur in community development, where the assets and interests of people living in the community are balanced against the requirements of funders and agencies that want to help them, but only if they fall into certain categories and follow the rules. People are always much more than being labeled as low income, Hispanic, elderly or disabled; but that is how they are classified in order to meet somebody's program requirements for tracking and accountability.

As in health care, the community development system has its own logic, honed over decades of identity politics, categorical funding and needs-based assessment. People become objects and data points, not subjects. It's hard to balance their categorically defined needs with their assets as autonomous subjects if agencies don't recognize and celebrate those assets at the start.

Eventually it comes down to a balancing act for each us, as we weigh what we owe to ourselves with what we owe to others. This month I turn 65 and enter another of those defining "categories" -- Medicare-eligible, retirement age, senior citizen. This brings a new set of options to weigh in balance - family obligations with personal desires, lifestyle choices with reduced income, the familiar and comfortable with the risky and unknown. Many face these choices, but they take on more of a sense of immediacy as one gets older.

Time is precious. What is most important to you, and what are you going to do about it?

The greatest gift is simply being aware that one has choices, and having the courage to act on them. My friend, Dave, whom I have written about before, is confined these days to his family room, hooked up to a tank of oxygen, without which he would be dead in a matter of minutes. He knows he's dying, and takes pleasure from simply being able to see the mountain view outside and watch the birds.

"I don't have a lot of options, but I can change my attitude," he says. "I'll be damned if I'm going to die bitter."

Near the end, Dave is bringing his life into balance: making the most of the options available, and striving to do what's right and good. This is perhaps the greatest balancing act of them all.

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*The Drift reflects the views of the author, and does not represent the official view of SLHI's Board of Trustees and staff.