When an Attending Orders You Not to Call an Ethics Consult

When an Attending Orders You Not to Call an Ethics Consult

What do you do when you genuinely think a patient’s rights or safety are on the line—and your attending looks you in the eye and says, “Do not call ethics”?

This is not theoretical. I’ve seen this exact thing play out:

• ICU fellow: “We should get ethics involved.”
• Attending, flat: “We’re not doing that. Drop it.”
• Intern, looking at the floor, wondering if they’re complicit now.

If you are that intern, resident, or student, you’re stuck between two very real forces:

1. Your duty to the patient and your own ethical spine.
2. The power your attending has over your evals, letters, and future.

You are not crazy for feeling trapped. But you’re also not powerless. Let’s walk through how to think about this and exactly what to do.

---

First: Understand What’s Actually at Stake

You’re not just fighting about whether a consult gets placed. You’re in the middle of a collision between ethics, hierarchy, and self‑preservation.

Typical scenarios where this comes up:

• Withholding or withdrawing life support when the family’s not on the same page.
• Proceeding with a high‑risk procedure when consent is… let’s say “optimistic.”
• Limiting care for a patient with disability in a way that feels discriminatory.
• Pressuring a patient to discharge or go to a facility they clearly do not understand or want.
• Overriding a prior expressed wish (“He said DNR before, but family wants everything”).

You feel the pit in your stomach. You think: “Someone objective needs to look at this.” Ethics.

Then the attending: “Do not call ethics. It will just complicate things.”

Here’s the problem. Your obligations are layered:

• You have a duty to your patient (and to the law and institutional policies).
• You have a duty to yourself—not to destroy your training or career over every battle.
• You’re working inside a system that technically encourages ethics consultation but practically punishes “troublemakers.”

So you need a strategy, not just a moral stance.

---

Step 1: Get Clear On the Ethical and Legal Issue (Quietly)

Before you act, sharpen your own understanding. “This feels wrong” is not enough when you’re going against an attending.

Ask yourself, specifically:

• Is this about capacity and consent?
• Is this about goals of care and code status?
• Is this about futility or resource use?
• Is this about surrogate decision‑making and conflict?
• Is there possible abuse, neglect, or discrimination?

You want to be able to say, “I’m concerned that ___” in clear terms, not vague distress.

If you have time, pull up your hospital policies:

• Search your intranet for “Ethics Consult,” “Bioethics Committee,” “Patient Rights.”
• Check for language like “Any member of the care team may request an ethics consult.”

That phrasing matters. Many hospitals explicitly say any team member can request ethics. Which means: you usually are allowed to do this without attending approval. Whether that’s wise is different from whether it’s permitted.

---

Step 2: Have the Hard Conversation With the Attending (Once)

If there’s any chance of resolving this without going to war, take it. But do it deliberately.

You are not there to “win.” You’re there to:

• Document (mentally) that you raised concern.
• Clarify the attending’s reasoning.
• Give them one clean chance to course‑correct.

Pick a moment that is not in the middle of a code or a hallway rush. Even 60 seconds after rounds, aside, is better than blurting it out in front of everyone.

You might say:

“Dr. X, I want to circle back on Ms. Y. I’m feeling uneasy about proceeding without ethics. I’m worried there’s a serious conflict about her goals of care and her prior statements, and I think we could use help from ethics in clarifying that.”

Then stop. Let them talk.

Common attending responses (I’ve heard all of these):

• “Ethics will just slow everything down; we don’t have time.”
• “This is not an ethics issue, this is a medical judgment issue.”
• “Family wants this, we’re done. Ethics can’t change that.”
• “The last thing we need is a committee. This is my call.”

Your job in that moment isn’t to debate every sentence. It’s to:

1. Show you’re thinking about the patient, not attacking the attending.
2. State once, clearly, that your concern rises to an ethics level.

If you feel up for it, one more push:

“I understand your concern about delays. I still feel this meets criteria for ethics consultation based on the conflict between her prior expressed wishes and the current plan. Would you be open to me at least calling them for advice, even off the record?”

Many ethics services do informal curbside consults. Some attendings are less defensive about a “quick ethics input” than a formal consult order.

If they still say no?

You now have a choice: comply, or escalate without their blessing. That’s the fork in the road.

---

Step 3: Quietly Map Your Actual Options

You have more levers than you think, but they carry different risks.

Here’s a rough comparison.

Option	Upside	Risk Level
Do nothing and comply	Protects evals, least conflict	High moral distress, possible patient harm
Call informal ethics curbside (no formal order)	Gets expert input, lower visibility	Moderate if attending finds out
Involve senior resident/fellow	Shared responsibility, support	Depends on culture and personalities
Go to another attending on service	May get backing to override	Can be seen as undermining
Call formal ethics consult anyway	Maximum protection for patient	Highest personal/political risk

You’re not choosing between “hero” and “coward.” You’re choosing how to balance real obligations in a very asymmetrical power structure.

Now let’s walk each one.

---

Step 4: Use the Chain of Command Intelligently

Before you jump straight to ethics, there’s often an intermediate step that’s smart: use your chain of command.

If you’re a med student:
Your attending is not your only lifeline. You can talk to:

• Your senior resident or chief: “I’m really uncomfortable with X. Can we talk?”
• The clerkship director, if this is major: “This is an ethics issue I don’t know how to handle safely as a student.”

If you’re an intern or resident:

• Start with your senior/chief if they weren’t present.
• If they shrug it off or agree with the attending, your next person is often the program director or associate PD—not to snitch but to ask for guidance.

Phrase it as:

“I’m facing a situation where I think a patient’s rights and prior wishes might not be respected. I raised ethics, my attending explicitly told me not to call. I’m unsure how to balance my duty to the patient with hierarchy. How should I proceed?”

You’re not saying, “Dr. X is evil.” You’re saying, “I’m in an ethical bind and need guidance.”

Sometimes this alone fixes the issue. A PD calls the attending. A senior quietly places the ethics consult. The pressure isn’t landing solely on you anymore.

---

Step 5: Use Ethics Curbside Before You Go Nuclear

Most ethics committees have an on‑call ethicist or at least a pager. And many are absolutely fine with a “curbside” conversation:

“I’m a PGY‑1 on medicine. We have a patient who had previously stated she did not want intubation, but the family is now pushing for full aggressive care, and the attending refuses ethics consult. Can I run the case by you and ask what the committee would recommend or expect in this situation?”

What this does:

• Gives you an expert read: Is this a real ethics case or just uncomfortable medicine?
• Clarifies risk: “Yes, you absolutely should get us involved” vs “This is within reasonable professional discretion.”
• Sometimes, the ethicist themselves will say, “I’ll reach out to your attending,” taking the spotlight off you.

And if they say, “You’re right, this is serious,” you’ve just gained a huge ally if things go bad later.

---

Step 6: The Line You Cannot Ethically Cross

There are situations where “I don’t want to upset my attending” just doesn’t cut it anymore. Where you’re no longer just a trainee trying to stay afloat—you’re a professional who can be held accountable.

Clear red lines:

• You’re being asked to forge or alter documentation (e.g., back‑date consent, falsify capacity evaluation).
• You’re helping carry out a plan that clearly contradicts documented patient wishes (like an advance directive or POLST) with no emergency justification.
• There’s clear discrimination (e.g., “We’re not offering X to this patient because of their disability or insurance status, not medical reasons”).
• You’re being told not just “don’t call ethics” but also “don’t tell anyone else,” “don’t chart that,” or “keep this off the record.”

At that point, you’re not just in an awkward ethical gray zone. You’re drifting toward legal and professional jeopardy. Your name is on those notes.

That’s when a formal ethics consult—or even risk management/legal—is not optional anymore. It’s self‑defense.

---

Step 7: If You Decide to Call Ethics Against Orders

If you reach this point, do it intentionally, not impulsively.

Here’s how to minimize collateral damage while doing the right thing.

1. Clarify your hospital’s rules.
   Check if there is explicit policy that anyone can request ethics. If so, you’re on stronger footing.

2. Document neutrally, not dramatically.
   In the chart, you do NOT write: “Attending refused ethics consult; unsafe practice.”
   You write something like:

   “Complex goals of care situation with potential conflict between prior expressed wishes and current plan. Ethics consult requested for assistance with clarification and facilitation of discussion.”

3. Notify someone, but choose wisely.
   If you’re a resident, tell your senior or chief:

   “Given X, I felt obligated to involve ethics. I understand Dr. X prefers not to, but I’m very concerned about honoring the patient’s prior wishes and felt I had a duty to request their input.”

4. Prepare for the fallout.
   Your attending may be angry. They may tell you you’re “out of line,” “not a team player,” or that you “went behind their back.”

   Do not argue emotionally. Just return to the patient:

   “I understand you’re frustrated. I was very troubled by the conflict between her prior stated wishes and the current plan, and I thought ethics could help us clarify that. My goal was to protect the patient and support the team.”

You may get dinged on an eval. I won’t sugarcoat it. Some attendings will absolutely do that.

But you’re also creating something else: a track record that you stand up where it counts. A lot of people—PDs, other attendings, ethics folks—notice that, too.

---

Step 8: Protect Your Future While You Protect Patients

This part almost no one says out loud. You have to play the long game.

A few tactical points:

• Do not fight every battle.
  If you escalate every minor discomfort to ethics, you’ll be tuned out quickly. Reserve your capital for cases where there is real patient harm, rights violation, or serious disagreement about values.

• Document your attempts to handle things appropriately.
  Off the chart, keep a dated note to yourself (secure, private, not on hospital email) about what you saw, what you said, and how the attending responded. You’re not building a lawsuit; you’re building a memory backup and a pattern if you need to talk to a PD or GME later.

• Know your institutional allies.
  Many hospitals have:

  • A GME office that takes trainee mistreatment and ethical concerns seriously.
  • An ombudsperson.
  • A confidential hotline.

  These aren’t just corporate wallpaper. I’ve seen them used, and I’ve seen problematic attendings quietly corrected or removed.

• Get mentorship outside that single attending.
  One toxic or defensive attending can make you feel like the whole field is like this. It’s not. Talk to other faculty you trust, especially ones with ethics, palliative, or ICU backgrounds. They’ve all been in these fights.

---

Step 9: Take Care of Your Own Moral Distress

Even if nothing catastrophic happens, these situations stick. They’re the 3 a.m. cases you replay in your head.

Signs this is hitting harder than you think:

• You avoid that unit or service mentally, even after the rotation.
• You feel detached, cynical, or resentful toward patients or families.
• You keep thinking, “I should have done more,” or “I betrayed that patient.”

You can’t just brute‑force through that forever. It creeps into burnout.

What helps, in real life:

• Peer debriefs. Grab a co‑resident:
  “I need 10 minutes to unpack a case that’s really bothering me.”
  Not to gossip. To metabolize.

• Formal debrief / Schwartz rounds / ethics rounds.
  If your institution has these, bring the case (de‑identified). These sessions exist for exactly this reason.

• Therapy or counseling. Many residency programs have free, confidential mental health support. Use it. Not because you’re “weak,” but because you’re carrying other people’s lives and deaths around in your head.

You will have cases where you couldn’t win. Where the attending dug in, ethics never got called, and the outcome felt wrong. Your task is not to erase those. It’s to let them shape the kind of physician you become instead of hollowing you out.

---

Step 10: Build Your Own Ethics Muscle Before the Next Time

This situation will come up again, in some form. Better to be ready.

Concrete things you can do over the next year:

• Rotate through palliative care if you can. They live at the intersection of ethics, goals of care, and real‑world mess.
• Attend your hospital’s ethics committee meetings if they’re open to trainees. You’ll hear how they actually think and talk.
• Read one short book on clinical ethics (not 900 pages). Something like Jonsen’s “Clinical Ethics” or similar. Skim the chapters on capacity, futility, and surrogate decision‑making.
• Ask an ethicist for coffee (or a 20‑minute chat). Ask, “What do you wish trainees knew before they call you?”

You’ll start to recognize ethically loaded situations earlier, with more nuance. Then when an attending says, “Do not call ethics,” you’re not just going on gut. You’re going on principle and knowledge.

---

A Quick Visual: How This Often Flows

Escalation Path When Ethics Consult Is Blocked

Step	Description
Step 1	Recognize Ethics Concern
Step 2	Clarify Issue and Policy
Step 3	Talk to Attending Once
Step 4	Document and Move On
Step 5	Talk to Senior or PD
Step 6	Call Ethics With Support
Step 7	Call Ethics Curbside
Step 8	Accept Outcome Record Internally
Step 9	Formal Ethics Consult or Higher Escalation
Step 10	Resolved?
Step 11	Support for Ethics?
Step 12	Serious Risk?

---

One More Thing You Need to Hear

You’re not responsible for single‑handedly fixing a broken culture. You are responsible for not becoming part of it.

Sometimes that means you keep your head down and document your concern, because pushing harder would blow up your training for very little gain. Sometimes it means you take a real risk and call ethics anyway.

Both choices can be ethical—if you’re honest with yourself about why you’re choosing them.

---

Do This Today

Open your hospital’s intranet and find your ethics consultation policy. Read who is allowed to request a consult, how to reach them, and what they cover. Then, write down (physically, on a card or your badge reel) the ethics pager or number.

When the day comes and an attending says, “Do not call ethics,” you’ll at least know exactly what you are choosing not to use—or what you’re choosing to use anyway.