Shana Moore-Pierre, MA '22, MPH '23, has a rewarding career as a medical ethicist for Northwell Health, ensuring that the most ethical decisions possible are made in difficult cases, and that patient voices are heard. She advises healthcare teams and patients on complex decisions, engages with policy research to help make standards for care more ethical, and teaches at medical institutions to give healthcare providers a foundation in ethics.
Read on to learn more about Shana’s love of medical ethics and what her public health career looks like.
What do you do as a medical ethicist?
A lot of the work is teaching healthcare teams about ethical dilemmas, and how to recognize when they should call us for a consultation. Sometimes the patient requests an ethics consult, but other times the healthcare team will say, We think this patient would benefit from talking to you. When I’m called in for a consult, I advocate for the patient and make sure the patient’s voice is heard, that we're doing the best thing for them. I’m often dealing with complex and challenging decisions. When do we start or stop a patient’s life-sustaining treatment, based on their values? Who's the best advocate for this patient—or what if there’s no one to advocate for them? As a neutral participant, I read the situation holistically and weigh in based on objective, ethical principles.
What motivates you in your work every day?
Making sure that patient voices are being heard, and that they’re comfortable with the treatment decision-making process is what motivates me. In the healthcare system, we follow the ethical principle of autonomy: the ability to make your own decisions about your bodily integrity. There are laws to protect your autonomy when you can't make decisions; they let you name someone who can make them for you. But where it backfires is in policy; there’s nothing policy-wise that explicitly tells patients they can push back. Clinical decisions are made by doctors, but patients also know their own bodies, and if they're dismissed when they say they need something, will they actually get it? I want to make sure that they do, and that they’re comfortable with how these decisions are being made.
How do you navigate complex dynamics with healthcare teams?
The way I explain it, I'm not the ethics police, I'm more of a firefighter. We can’t tell the team what to do, we provide recommendations only; they make the clinical decisions. For maybe two out of every 10 consults, there’s pushback: Sometimes it's ego, sometimes the team gets what you’re saying, but their experience says otherwise. Usually, teams are good at being self-aware and monitoring their own bias. And if I agree with the team and not the family, I have to check my own bias and say, I wouldn't do that as a patient, but I have to advocate for what my patient wants.
A lot of times there's a disconnect in communication. The patient says, I want all aggressive measures taken; CPR, intubation, etc. But the medical team knows none of that will help them. They don’t want to cause pain when it’s not in the patient’s best interest, so you help the team reframe the situation; you aim to alleviate their moral distress and validate their feelings when they don’t agree with what the patient wants. It’s a challenge to empower teams to understand their own biases, but when they say, 'Maybe we’re not thinking about this the right way, we might need another set of eyes,' it’s a beautiful thing.
Tell us about a case that has really stuck with you.
I had a patient who came to the hospital from a correctional facility; he had a complex course of treatment that prevented him from talking or engaging with us at all. He had been in a maximum security prison for over 20 years, and didn’t have any family, to our knowledge. I had to figure out, based on the law and policy, who could make decisions for him? After a lot of due diligence, we found out the patient had a friend who was incarcerated with him, was listed as his emergency contact, and knew the patient best. He could speak to how he lived his life, what he valued and what he would want.
There was no one else, so it seemed straightforward that he would make decisions for him; but the hardest part was challenging the bias of everyone involved. When the friend visited, he was still 'a prisoner in a hospital,' so guards from the prison were with him and he was handcuffed to a bed. When the shifts changed I had to say, “Hey, be mindful of your bias; this is the patient's advocate, he's speaking for the patient.” It was challenging.
Then the prison called and said they were supposed to make decisions for the patient. But that's a huge conflict of interest: would they decide in his best interest, or in theirs? Eventually I told the warden and medical director about the New York State Family Health Care Decision Act from 2010, which specifies who can make decisions for you if you can’t, and is the law we follow. They thanked me for pointing it out and assured me they'll apply it going forward, but it was disheartening to realize that this law wasn’t already widely known. At least now, an individual who leaves that facility and goes into a hospital has a decent chance that a friend or family member will be able to make decisions for them. Eventually, the patient couldn't take care of himself in the same way and didn't return to the same prison, but if officials had made the decisions instead of his friend, I don’t know if he would be able to live the life that he does now.
I think about him and his case all the time; sometimes educating people can help more than one patient, even if they’re not aware it involves ethics at all.
What are the hardest cases for you?
When we don’t know what the patient would want, or the outcome we hope for doesn’t happen. I had a patient whose family had seen her struggle and watched her decline to the point where she was suffering, but not improving. They wanted to take her off the ventilator and make her as comfortable as possible—and even though she consented to these measures, it also seemed like she wanted to fight. Eventually, she was taken off the ventilator and died soon afterward. We advocated for what she said she wanted, but would acting faster have minimized her suffering?
Ultimately, the purpose of a clinical ethicist is not to guarantee an outcome, but to help with the process of deciding. At the end of the day, patients and families have to live with, and be comfortable with, the decisions that are made. Not necessarily how they end, but how we got to that process.
Want to learn more about Shana's journey from GPH student to clinical ethicist? Read her Changemaker story to see how her advocacy is giving a voice to patients.