Tables of contents of previous issues

 

Winter 2016, Volume 27, Number 4

 

At the Bedside

New Paradigms in Medical Ethics

Edmund G. Howe

      As new technologies develop, new ethical paradigms may be needed. This article considers several examples, such as stopping venoarterial extracorporeal membrane oxygenation (VA-ECMO), treating patients who are in a locked-in-like state who have awareness, purposefully deceiving patients who have dementia, meeting the needs of transgender persons, showing loved ones patients’ wounds, and doing research on controlled substances. I suggest that clinicians should identify the practices underlying their value assumptions so they can alter their assumptions when this might improve the care they offer to their patients.

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Features

A Survey of Physicians’ Attitudes toward Decision-Making Authority for Initiating and Withdrawing VA-ECMO: Results and Ethical Implications for Shared Decision Making

Ellen C. Meltzer, Natalia S. Ivascu, Meredith Stark, Alexander V. Orfanos, Cathleen A. Acres, Paul J. Christos, Thomas Mangione, and Joseph J. Fins

      Objective:  Although patients exercise greater autonomy than in the past, and shared decision making is promoted as the preferred model for doctor-patient engagement, tensions still exist in clinical practice about the primary locus of decision-making authority for complex, scarce, and resource-intensive medical therapies: patients and their surrogates, or physicians. We assessed physicians’ attitudes toward decisional authority for adult venoarterial extracorporeal membrane oxygenation (VA-ECMO), hypothesizing they would favor a medical locus.

      Design, Setting, Participants: A survey of resident/fellow physicians and internal medicine attendings at an academic medical center, May to August 2013.

      Measurements: We used a 24-item, internet-based survey assessing physician-respondents’ demographic characteristics, knowledge, and  attitudes regarding decisional authority for adult VA-ECMO. Qualitative narratives were also collected.

      Main Results: A total of 179 physicians completed the survey (15 percent response rate); 48 percent attendings and 52 percent residents/fellows. Only 32 percent of the respondents indicated that a surrogate’s consent should be required to discontinue VA-ECMO; 56 percent felt that physicians should have the right to discontinue VA-ECMO over a surrogate’s objection. Those who self-reported as “knowledgeable” about VA-ECMO, compared to those who did not, more frequently replied that there should not be presumed consent for VA-ECMO (47.6 percent versus 33.3 percent, p = 0.007), that physicians should have the right to discontinue VA-ECMO over a surrogate’s objection (76.2 percent versus 50 percent, p = 0.02) and that, given its cost, the use of VA-ECMO should be restricted (81.0 percent versus 54.4 percent, p = 0.005).

      Conclusions: Surveyed physicians, especially those who self-reported as knowledgeable about VA-ECMO and/or were specialists in pulmonary/critical care, favored a medical locus of decisional authority for VA-ECMO. VA-ECMO is complex, and the data may (1) reflect physicians’ hesitance to cede authority to presumably less knowledgeable patients and surrogates, (2) stem from a stewardship of resources perspective, and/or (3) point to practical efforts to avoid futility and utility disputes. Whether these results indicate a more widespread reversion to paternalism or a more circumscribed usurping of decisional authority occasioned by VA-ECMO necessitates further study.

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Covert Administration of Medication to Persons with Dementia: Exploring Ethical Dimensions

Jenny M. Young and David Unger

      The literature, although sparse, reports that covert administration of all types of medications is prevalent in nursing homes. Whether it is ever ethically defensible, however, to administer medications covertly to persons with significant dementia is a complex and contentious question. Some scholars contend that deception is inherently wrong and is never acceptable, while others believe that deception is intrinsic to providing care to persons with dementia. With an aim to begin to reconcile these polarized positions and to objectively study this contentious issue, the authors undertake an ethical analysis of the covert administration of medications by utilizing the principles of respect for autonomy, nonmaleficence, beneficence, and justice. Our approach examines covert administration within the context of all persons with significant dementia who are administered medications, and is aimed at providing ethical and practical guidance to clinicians who, when confronted with a patient who refuses medication, must choose the “least bad” option from among various courses of action, all of which have ethical implications. Components of a possible guideline for practice are proposed.

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Covert Medications: Act of Compassion or Conspiracy of Silence?

Robert C. Macauley

      As the population in the United States gets older, more people suffer from dementia, which often causes neuropsychiatric symptoms such as agitation and paranoia. This can lead patients to refuse medications, prompting consideration of covert administration (that is, concealing medication in food or drink). While many condemn this practice as paternalistic, deceptive, and potentially harmful, the end result of assuming the “moral high ground” can be increased suffering for patients and families. This article addresses common criticisms of covert medication and presents a detailed algorithm by which to determine whether the practice is ethically permissible in specific cases. It also explores why so little attention has been paid in the U.S. to this presumably common practice, and reviews professional statements from Europe that endorse the practice. Finally, it presents a compelling argument for the role of Ulysses clauses in advance care planning, not only for patients with psychiatric illness but also for those who may suffer from dementia, which is far more common.

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Stakeholders’  Views on Barriers to Research on Controversial Controlled Substances

Evelyn Rhodes, Michael Andreae, Tyler Bourgiose, Debbie Indyk, Rosamond Rhodes, and Henry Sacks

      Many diseases and disease symptoms still lack effective treatment. At the same time, certain controversial Schedule I drugs, such as heroin and cannabis, have been reputed to have considerable therapeutic potential for addressing significant medical problems. Yet, there is a paucity of U.S. clinical studies on the therapeutic uses of controlled drugs. For example, people living with HIV/AIDS experience a variety of disease- and medication-related symptoms. Their chronic pain is intense, frequent, and difficult to treat. Nevertheless, clinical trials of compassionate management for their chronic symptoms, which should be a research priority, are stymied.

      We employed qualitative methods to develop an understanding of the barriers to research on potential therapeutic uses of Schedule I drugs so that they might be addressed. We elicited the perspectives of key stakeholder groups that would be involved in such studies: people living with HIV/AIDS, clinicians, and members of institutional review boards. As we identified obstacles to research, we found that all of the stakeholder groups arrived at the same conclusion, that clinical research on the therapeutic potential of these drugs is ethically required.

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The Evolution of American Hospital Ethics Committees: A Systematic Review

Andrew Courtwright and Martha Jurchak

      During the 1970s and 1980s, legal precedent, governmental  recommendations, and professional society guidelines drove the formation of hospital ethics committees (HECs). The Joint Commission on Accreditation of Health Care Organization’s requirements in the early 1990s solidified the role of HECs as the primary mechanism to address ethical issues in patient care. Because external factors drove the rapid growth of HECs on an institution-by-institution basis, however, no initial consensus formed around the structure and function of these committees. There are now almost 40 years of empirical studies on the composition, administration, and activities of HECs in the United States. We conducted a systematic review of the available empirical literature on HECs to describe their evolution. As HECs changed over time, they increased their total number of members and percentage of members from nursing and the community. Although physicians increasingly chaired these committees, their presence as a percentage of overall members declined. The percentage of administrative members remained steady, although committees became increasingly likely to have at least one administrative member. HECs were also increasingly likely to report to an administrative body or to the board of trustees or directors rather than to the medical staff. Finally, consultation volume increased steadily over time. There has not, however, been a national survey of the composition of ethics committees, their administration, or volume of consultation in more than 10 years, despite increasing calls for professional standards and quality improvement assessments among HECs.

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Cultivating Administrative Support for a Clinical Ethics Consultation Service

Courtenay R. Bruce, Mary A. Majumder, Ashley Stephens, Janet Malek, and Amy McGuire

      Hospital administrators may lack familiarity with what clinical ethicists do (and do not do), and many clinical ethicists report receiving inadequate financial support for their clinical ethics consultation services (CECSs). Ethics consultation is distinct in that it is not reimbursable by third parties, and its financial benefit to the hospital may not be quantifiable. These peculiarities make it difficult for clinical ethicists to resort to tried-and-true outcome-centered evaluative strategies, like cost reduction or shortened length of stay for patients, to show a “need” for ethics consultation. Likewise, it can be difficult for clinical ethicists to “speak the same language” as healthcare administrators and managers, which, in turn, means that CECSs run the risk of being unable to demonstrate value to those who pay for the service.

      The purpose of this descriptive article is to provide practical guidance to clinical ethicists and program directors on how to cultivate administrative support for a CECS. Specifically, we discuss two elements that clinical ethics leaders must critically appraise and successfully argue to meet the expectations of administrators—the value of a CECS and its fit in clinical workflow.

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Cases from the Cleveland Clinical Foundation

What’s Knowledge Got to Do with It? Ethics, Epistemology, and Intractable Conflicts in the Medical Setting

Bryan Kibbe and Paul J. Ford

      This article utilizes the case of Ms H. to examine the contrasting ways that surrogate decision makers move from simply hearing information about the patient to actually knowing and understanding the patient’s medical condition. The focus of the case is on a family’s request to actually see the patient’s wounds instead of being told about the wounds, and the role of clinical ethicists in facilitating this request. We argue that clinical ethicists have an important role to play in the work of converting information into knowledge and that this can serve as a valuable way forward in the midst of seemingly intractable conflicts in the medical setting.

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Perspective

Medical Futility: A Contemporary Review

Ellen Coonan

      As medical technology has advanced, the question of medical futility has become a topic of intense debate both within the medical community and within society as a whole. However, a unanimous definition thereof is yet to be decided—some commentators are sceptical as to whether an agreement will ever be reached—and this continues to lead to difficulties, tension, and even legal action when a treating physician disagrees with a patient and/or a patient’s family regarding care and treatment options. Although living in a pluralistic society presents one of the major reasons as to why, despite 30 years of intense discussion, no consensus has been made; the issue of medical futility will always be complex as it is, by nature, multifaceted, and numerous elements—including possible risks, evidence of the probability of benefit, the wishes of the patient (and family), professional standards, and cost—interact. Nevertheless, the global medical community has seen the development of two distinctly different approaches to medical futility: one in which the autonomy of patients is of paramount importance in the decision whether or not to pursue a treatment; and one in which beneficence and primum non nocere—first do no harm—are almost entirely the clinician’s prerogative, and whereby he/she has a duty to refuse any treatment for which the potential risks outweigh the potential benefits for the patient. Recently, however, there has been a rejection of this dichotomous view of medical futility and the apparent “power struggle” between physician and patient, and a positive movement towards a more collaborative decision-making process that highlights the necessity of communication, aiming to result in the obtainment of the best possible outcome for each patient as an individual.

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Fall 2016, Volume 27, Number 3

 

At the Bedside

Harmful Emotional Responses that Patients and Physicians May Have When their Values Conflict

Edmund G. Howe

      One of the most difficult decisions a clinician may face is when, if ever, to decline what a patient wants, based on the clinician’s own moral conscience. Regardless of what the clinician decides, the outcome may be deeply emotionally painful for both parties, and the pain may last. I will discuss this pain, how it occurs, and what we can do to try to reduce it before, during, and after a conflict arises. Approaches include explaining how we are like the patient or doctor, that no one is perfect, and that what we do is not who we are.

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Features

Moral Agency, Moral Imagination, and Moral Community: Antidotes to Moral Distress

Terri Traudt, Joan Liaschenko, and Cynthia Peden-McAlpine

      Moral distress has been covered extensively in the nursing literature and increasingly in the literature of other health professions. Cases that cause nurses’ moral distress that are mentioned most frequently are those concerned with prolonging the dying process. Given the standard of aggressive treatment that is typical in intensive care units (ICUs), much of the existing moral distress research focuses on the experiences of critical care nurses. However, moral distress does not automatically occur in all end-of-life circumstances, nor does every critical care nurse suffer its damaging effects. What are the practices of these nurses? What specifically do they do to navigate around or through the distressing situations? The nursing literature is lacking an answer to these questions. This article reports a study that used narrative analysis to explore the reported practices of experienced critical care nurses who are skilled at and comfortable working with families and physicians regarding the withdrawal of aggressive treatment. A major finding was that these nurses did not report experiencing the damaging effects of moral distress as described in the nursing literature. The verbal communication and stated practices relevant to this finding are organized under three major themes: (1) moral agency, (2) moral imagination, and (3) moral community. Further, a total of eight subthemes are identified. The practices that constitute these themes and subthemes are further detailed and discussed in this article. Understanding these practices can help mitigate critical care nurses’ moral distress.

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Towards a New Narrative of Moral Distress: Realizing the Potential of Resilience

Cynda Hylton Rushton and Alisa Carse

      Terri Traudt, Joan Liaschenko, and Cynthia Peden-McAlpine’s study contributes to a much-needed reorientation in thinking about and working with the challenges of moral distress. In providing a vital example of nurses able to navigate morally distressing situations in positive and constructive ways, and offering an analysis of the component elements of these nurses’ success, the study helps identify promising directions we might take in addressing the epidemic of moral distress. It also invites important questions, concerning the challenges faced by clinicians who do not who work in healthy “moral communities,” who lack the ethical competencies, and who don’t have the presumptive authority and recognition enjoyed by the seasoned clinicians studied here. We explore some of these questions, and suggest ways we might build on the insights of Traudt and colleagues’ study.

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Special Section: Physicians’ Exercise of Conscience: Commentaries on the

AMA’s Code of Medical Ethics

Report by the American Medical Association’s Council on Ethical and Judicial Affairs on Physicians’ Exercise of Conscience

BJ Crigger, Patrick W. McCormick, Stephen L. Brotherton, and Valarie Blake

      As practicing clinicians, physicians are expected to uphold the ethical norms of their profession, including fidelity to patients and respect for patients’ self-determination. At the same time, as individuals, physicians are moral agents in their own right and, like their patients, are informed by and committed to diverse cultural, religious, and philosophical traditions and beliefs. In some circumstances, the expectation that physicians will put patients’ needs and preferences first may be in tension with the need to sustain the sense of moral integrity and continuity that grounds a physician’s personal and professional life.

      This article examines the implications for patients, physicians, and the medical profession when tensions arise between a physician’s professional commitments and his or her deeply held personal moral beliefs. It offers guidance on when a physician’s professional commitments should outweigh personal beliefs as well as when physicians should have freedom to act according to the dictates of conscience while still protecting patients’ interests.

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Accommodating Conscientious Objection in Medicine—Private Ideological Convictions Must Not Trump Professional Obligations

Udo Schuklenk

      The opinion of the American Medical Association (AMA) Council on Ethical and Judicial Affairs (CEJA) on the accommodation of conscientious objectors among medical doctors aims to balance fairly patients’ rights of access to care and accommodating doctors’ deeply held personal beliefs. Like similar documents, it fails. Patients will not find it persuasive, and neither should they. The lines drawn aim at a reasonable compromise between positions that are not amenable to compromise. They are also largely arbitrary. This article explains why that is the case. The view that conscientious objection accommodation has no place in modern medicine is defended.

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Professional Ethics, Personal Conscience, and Public Expectations

Claudia E. Haupt

      Examining to what extent physicians are, or ought to be, defined by the profession when giving advice to patients, this commentary seeks to offer a better understanding of the potential conflicts that the American Medical Association’s (AMA’s) “Opinion 1.1.7, Physician Exercise of Conscience,” addresses. This commentary conceptualizes the professions as knowledge communities, and situates the physician-patient relationship within this larger conceptual framework. So doing, it sheds light on how and when specialized knowledge is operationalized in professional advice-giving. Physicians communicate the knowledge community’s insights to the patient. Thus, departures from professional knowledge as a matter of the professional’s personal conscience are appropriately circumscribed by the knowledge community.

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Who Judges Harm?

Nadia N. Sawicki

      The American Medical Association’s (AMA’s) “Opinion 1.1.7, Physician Exercise of Conscience” attempts to help physicians strike a reasonable balance between their own conscientious beliefs and their patients’ medical interests in an effort to minimize harms to both. However, some ambiguity still remains as to whether the severity of harms experienced by physicians and patients is to be assessed externally (by policy makers or by a professional body like the AMA), or internally by the subjects of those harms. Conflicts between conscientious physicians’ self-assessments of the moral harm associated with various actions and the AMA’s external assessments of such harms are likely to lead to challenges in the implementation of some provisions of its opinion. This commentary argues, however, that provisions (b) and (e) of the opinion, which describe the information physicians should provide about their own scope of practice and about the existence of controversial procedures, are less likely to conflict with physicians’ subjective assessments of moral harm, and therefore will face fewer challenges in implementation.

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Action Steps and Solutions for Physicians’ Exercise of Conscience

Eliza Blanchard and Lynn Stoller

      Conscience can influence physicians’ interactions with patients in myriad ways and, by extension, can influence the interactions and internal dynamics of a health care team. The AMA’s opinion around physicians’ exercise of conscience appropriately balance the obligations physicians have to their patients and profession, and the rights of physicians as moral agents to exercise their conscience. While the opinion is an effective starting point, further guidance is necessary to clarify the process by which physicians should identify, manage, and, if necessary, report their conscientious refusals to patients, supervisors, or colleagues. In addition to laying out a proposed process for identifying and managing issues of conscience, this article will use relevant and timely examples to help clarify how a physician could apply this process in an instance of conscientious refusal.

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Conscientious Objection: Widening the Temporal and Organizational Horizons

Armand H. Matheny Antommaria

      Conscience can influence physicians’ interactions with patients in myriad ways and, by extension, can influence the interactions and internal dynamics of a health care team. The AMA’s opinion around physicians’ exercise of conscience appropriately balance the obligations physicians have to their patients and profession, and the rights of physicians as moral agents to exercise their conscience. While the opinion is an effective starting point, further guidance is necessary to clarify the process by which physicians should identify, manage, and, if necessary, report their conscientious refusals to patients, supervisors, or colleagues. In addition to laying out a proposed process for identifying and managing issues of conscience, this article will use relevant and timely examples to help clarify how a physician could apply this process in an instance of conscientious refusal.

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Thinking about Conscience

BJ Crigger

      The path to consensus about physicians’ exercise of conscience was not linear. It looped back on itself as new insights illuminated earlier deliberations and in turn led to further insights. In particular, coming to agreement about physicians’ responsibility in regard to referral charted a route through many course corrections.

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Law

Legal Briefing: Stopping Nonbeneficial Life-Sustaining Treatment without Consent

Thaddeus Mason Pope and Kristin Kemmerling

      In the United States, authoritative legal guidance remains sparse on whether or when clinicians may stop life-sustaining treatment without consent. Fortunately, several significant legislative and judicial developments over the past two years offer some clarity. We group these legal developments into the following seven categories:

1.   Lawsuits for Damages

2.   Amendments to the Texas Advance Directives Act

3.   Constitutional Attack on TADA

4.   Legislation Prohibiting Clinicians

5.   Legislation Authorizing Clinicians

6.   Cases from Canada

7.   Cases from the United Kingdom.

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Summer 2016, Volume 27, Number 2

 

At the Bedside

What Do We Owe Medical Students and Medical Colleagues Who Are Impaired?

Edmund G. Howe

      Physicians who are impaired, engage in unprofessional behavior, or violate laws may be barred from further practice. Likewise, medical students may be dismissed from medical school for many infractions, large and small. The welfare of patients and the general public must be our first priority, but when we assess physicians and students who have erred, we should seek to respond as caringly and fairly as possible. This piece will explore how we may do this at all stages of the proceedings physicians and students may encounter. This may include helping them to resume their medical careers if and when this would be sufficiently safe and beneficial for patients.

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Features

Untangling Uncertainty: A Study of the Discourses Shaping Clinical Ethics Consultation as a Professional Practice

Salla Saxén

      This qualitative social scientific interview study delves into the ways in which professional vision is constructed in clinical ethics consultation (CEC). The data consist of 11 semi-structured interviews that were conducted with clinical ethics consultants currently working in hospitals in one major urban area in the U.S. The interviews were analyzed with the qualitative research method of critical discourse analysis, with a focus on identifying the cultural structures of knowledge that shape CEC as a professional practice. The discourses were first identified as belonging to two higher discourse categories, order and agency. Order was divided into three lower categories, emotional, managerial, and rational order, and discourses of agency into the lower categories of exploration, technique, deliberation, and distancing. An additional discourse of neutral interaction was identified as a bridging discourse, activated to level tensions emerging out of conflicting goals and agencies embedded in CEC practice. This analysis brings out as its main observation that clinical ethics consultants draw on and shift between potentially ideologically conflicting social positions that can create built-in tensions within the professional domain. The study calls attention to these tensions and suggests for the professional group to discuss the possibility of defining priorities between different kinds of order, identified in this study, that shape the CEC domain.

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How Can Clinical Ethics Committees Take on Organizational Ethics? Some Practical Suggestions

James E. Sabin

      Although leaders in the field of ethics have for many years pointed to the crucial role that organizations play in shaping healthcare ethics, organizational ethics remains a relatively undeveloped area of ethics activity. Clinical ethics committees are an important source of potential expertise, but new skills will be required. Clinical ethics committees seeking to extend their purview to organizational issues will have to respond to three challenges—how to gain sanction and support for addressing controversial and sensitive issues, how to develop an acceptable process, and how to make a difference on the ground. The article presents practical suggestions for how clinical ethics committees meet these challenges.

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What Is Everyday Ethics? A Review and a Proposal for an Integrative Concept

Natalie Zizzo, Emily Bell, and Eric Racine

      “Everyday ethics” is a term that has been used in the clinical and ethics literature for decades to designate normatively important and pervasive issues in healthcare. In spite of its importance, the term has not been reviewed and analyzed carefully. We undertook a literature review to understand how the term has been employed and defined, finding that it is often contrasted to “dramatic ethics.” We identified the core attributes most commonly associated with everyday ethics. We then propose an integrative model of everyday ethics that builds on the contribution of different ethical theories. This model proposes that the function of everyday ethics is to serve as an integrative concept that (1) helps to detect current blind spots in bioethics (that is, shifts the focus from dramatic ethics) and (2) mobilizes moral agents to address these shortcomings of ethical insight. This novel integrative model has theoretical, methodological, practical, and pedagogical implications, which we explore. Because of the pivotal role that moral experience plays in this integrative model, the model could help to bridge empirical ethics research with more conceptual and normative work.

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Medical Education and Professionalism

The Medical Ethics Curriculum in Medical Schools: Present and Future

Alberto Giubilini, Sharyn Milnes, and Julian Savulescu

      In this review article we describe the current scope, methods, and contents of medical ethics education in medical schools in Western English speaking countries (mainly the United Kingdom, the United States, and Australia). We assess the strengths and weaknesses of current medical ethics curricula, and students’ levels of satisfaction with different teaching approaches and their reported difficulties in learning medical ethics concepts and applying them in clinical practice. We identify three main challenges for medical ethics education: counteracting the bad effects of the “hidden curriculum,” teaching students how to apply ethical knowledge and critical thinking to real cases in clinical practice, and shaping future doctors’ right character through ethics education. We suggest ways in which these challenges could be addressed. On the basis of this analysis, we propose practical guidelines for designing, implementing, teaching, and assessing a medical ethics program within a four-year medical course.

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Medical Boards and Fitness to Practice: The Case of Teleka Patrick, MD

Katrina A. Bramstedt

      Background: Medical boards and fitness-to-practice committees aim to ensure that medical students and physicians have “good moral character” and are not impaired in their practice of medicine.

      Method: Presented here is an ethical analysis of stalking behavior by physicians and medical students, with focus on the case of Teleka Patrick, MD (a psychiatry resident practicing medicine while under a restraining order due to her alleged stalking behavior).

      Conclusions: While a restraining order is not generally considered a criminal conviction, stalking behavior is clearly unprofessional and a marker of inappropriate character and fitness, yet the reporting obligations for such matters are complex. Medical schools and training programs that fail to assess, record, and report matters of moral conduct such as this potentially allow impaired students to graduate and enter the work force (unless a robust licensing process identifies them). Patrick’s case should be a wake-up call for medical schools and medical boards to better integrate the professionalism domain into their operations. Further, the professionalism of students and doctors need to be integrated into the legal domain, so that those who are unfit to practice are, in fact, prevented from doing so. Guidance for integration is provided.

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Clinical Ethics Consultation

Gender and Race in the Timing of Requests for Ethics Consultations:

A Single-Center Study

Bethany Spielman, Christine Gorka, Keith Miller, Carolyn A. Pointer, and Barbara Hinze

      Background: Clinical ethics consultants are expected to “reduce disparities, discrimination, and inequities when providing consultations,” but few studies about inequities in ethics consultation exist.1 The objectives of this study were (1) to determine if there were racial or gender differences in the timing of requests for ethics consultations related to limiting treatment, and (2) if such differences were found, to identify factors associated with that difference and the role, if any, of ethics consultants in mitigating them.

      Methods: The study was a mixed methods retrospective study of consultation summaries and hospital and ethics center data on 56 age-and gender-matched Caucasian and African American Medicare patients who received ethics consultations related to issues around limiting medical treatment in the period 2011 to 2014. The average age of patients was 70.9.

      Results: Consultation requests for females were made significantly earlier in their stays in the hospital (6.57 days) than were consultation requests made for males (16.07 days). For African American patients, the differences in admission-to-request intervals for female patients (5.93 days) and male patients (18.64 days) were greater than for Caucasian male and female patients. Differences in the timing of a consultation were not significantly correlated with the presence of an advance directive, the specialty of the attending physician, or the reasons for the consult request. Ethics consultants may have mitigated problems that developed during the lag in request times for African American males by spending more time, on average, on those consultations (316 minutes), especially more time, on average, than on consultations with Caucasian females (195 minutes). Most consultations (40 of 56) did result in movement toward limiting treatment, but no statistically significant differences were found among the groups studied in the movement toward limiting treatment. The average number of days from consult to discharge or death were strongly correlated with the intervals between admission to the hospital and request for an ethics consultation.

      Conclusion: Our findings suggest race and gender disparities in the timing of ethics consultations that consultants may have partially mitigated.

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Measuring Quality in Ethics Consultation

Sally E. Bliss, Jane E. Oppenlander, Jacob M. Dahlke, Gordon J. Meyer, Eva M. Williford, and Robert C. Macauley

      For all of the emphasis on quality improvement—as well as the acknowledged overlap between assessment of the quality of healthcare services and clinical ethics—the quality of clinical ethics consultation has received scant attention, especially in terms of empirical measurement. Recognizing this need, the second edition of Core Competencies for Health Care Ethics Consultation1 identified four domains of ethics quality: (1) ethicality, (2) stakeholders’ satisfaction, (3) resolution of the presenting conflict/dilemma, and (4) education that translates into knowledge. This study is the first, to our knowledge, to directly measure all of these domains. Here we describe the quality improvement process undertaken at a tertiary care academic medical center, as well as the tools developed to measure the quality of ethics consultation, which include post-consultation satisfaction surveys and weekly case conferences. The information gained through these tools helps to improve not only the process of ethics consultation, but also the measurement and assurance of quality.   

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Defining Patient Advocacy for the Context of Clinical Ethics Consultation:

A Review of the Literature and Recommendations for Consultants

Tracy Brazg, Taryn Lindhorst, Denise Dudzinski, and Benjamin Wilfond

      The idea of patient advocacy as a function of clinical ethics consultation (CEC) has been debated in the bioethics literature. In particular, opinion is divided as to whether patient advocacy inherently is in conflict with the other duties of the ethics consultant, especially that of impartial mediator. The debate is complicated, however, because patient advocacy is not uniformly conceptualized. This article examines two literatures that are crucial to understanding patient advocacy in the context of bioethical deliberations: the CEC literature and the literature on advocacy in the social work profession. A review of this literature identifies four distinct approaches to patient advocacy that are relevant to CEC: (1) the best interest approach, (2) the patient rights approach, (3) the representational approach, and (4) the empowerment approach. After providing a clearer understanding of the varied meanings of patient advocacy in the context of CEC, we assert that patient advocacy is not inherently inconsistent with the function of the ethics consultant and the CEC process. Finally, we provide a framework to help consultants determine if they should adopt an advocacy role.

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Spring 2016, Volume 27, Number 1

At the Bedside

How Clinicians Can Reduce “Bullied Acquiescence”

Edmund G. Howe

      Clinicians and patients and their families may disagree about a course of treatment, and the ensuing conflict may seem intractable. The parties may request mediation, or use mediation-based approaches, to help resolve the conflict. In the process of mediation, and at other times, parties in conflict may feel so pressured to accept a resolution that they acquiesce unwillingly—and such resolutions often unravel. In this article I investigate how “bullied acquiescence” might happen, and how to avoid it.

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Features

The Effectiveness of Standardized Patient Simulation in Training Hospital Ethics Committees

David Y. Harari and Robert C. Macauley

      Clinical simulation using standardized patients has become standard in medical education—and is now being incorporated into some graduate programs in bioethics—for both formative and summative evaluation. In most hospitals, though, clinical ethics consultation is done by the ethics committee (or a subset of it). This study is the first, to our knowledge, to examine the effectiveness of standardized patient simulation in training hospital ethics committees to deal with ethically complex and emotionally fraught clinical situations. Following a substantial revision of the institution’s nonbeneficial treatment policy, ethics committee members underwent a simulation to determine whether a specific requested treatment should be withheld on the basis of futility. Pre- and post-intervention surveys showed improvement in all domains, although the small sample size limited the power of the study, with only one measure showing a statistically significant difference. An interesting incidental finding was that one-quarter of committee members voted against a determination of futility, even though the case clearly met the definition set forth in the policy. This highlights the emotional challenges in implementing an ethically rigorous, unanimously accepted policy that ultimately determines the timing and manner of a patient’s death.

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Clinical Recommendations in Medical Practice: A Proposed Framework to Reduce Bias and Improve the Quality of Medical Decisions

David Alfandre

      Patients rely on, benefit from, and are strongly influenced by physicians’ recommendations. In spite of the centrality and importance of physicians’ recommendations to clinical care, there is only a scant literature describing the conceptual process of forming a clinical recommendation, and no discrete professional standards for making individual clinical recommendations. Evidence-based medicine and shared decision making together are intended to improve medical decision making, but there has been limited attention to how a recommendation is discretely formulated from either of those processes or how patients’ preferences ought to be considered and how much weight they should hold. Moreover, physicians’ bias has been reported to strongly influence how a recommendation is derived, thereby undermining the quality of healthcare decisions and patients’ trust. To demonstrate a potential for improving the quality of decisions, this article proposes a conceptual framework for how physicians should reach a clinical recommendation and apply the process in practice. For preference-sensitive clinical decisions—that is, clinical decisions when patients’ values and preferences are relevant—the process for reaching a recommendation should be transparent to patients and should be based solely on the medical evidence and patients’ values and preferences. When patients’ preferences for care do not prioritize health, physicians decide whether their recommendation will prioritize a welfare-enhancing versus an autonomy-enhancing approach. When there are gaps in understanding how physicians derive their clinical recommendations and how to further improve the quality of the decisions, the author calls for further empiric research.

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The Role of Communication and Interpersonal Skills in Clinical Ethics Consultation: The Need for a Competency in Advanced Ethics Facilitation

Wayne Shelton, Cynthia Geppert, and Jane Jankowski

      Clinical ethics consultants (CECs) often face some of the most difficult communication and interpersonal challenges that occur in hospitals, involving stressed stakeholders who express, with strong emotions, their preferences and concerns in situations of personal crisis and loss. In this article we will give examples of how much of the important work that ethics consultants perform in addressing clinical ethics conflicts is incompletely conceived and explained in the American Society of Bioethics and Humanities Core Competencies for Healthcare Ethics Consultation and the clinical ethics literature.

      The work to which we refer is best conceptualized as a specialized type of interviewing, in which the emotional barriers of patients and their families or surrogates can be identified and addressed in light of relevant ethical obligations and values within the context of ethics facilitation.

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A Case of Attempted Suicide in Huntington’s Disease: Ethical and Moral Considerations

Kristin Furfari, Nichole Zehnder, and Jean Abbott

      A 62-year-old female with Huntington’s disease presented after a suicide attempt. Her advance directive stated that she did not want intubation or resuscitation, which her family acknowledged and supported. Despite these directives, she was resuscitated in the emergency department and continued to state that she would attempt suicide again. Her suicidality in the face of a chronic and advancing illness, and her prolonged consistency in her desire to take her own life, left careproviders wondering how to provide ethical, respectful care to this patient.

      Tension between the ethical principles of autonomy and beneficence is central in this case. The patient’s narrative demonstrated that her suicide was an autonomous decision, free from coercion or disordered thinking from mental illness. Beneficence then would seem to necessitate care aligned with the patient’s desire to end her life, which created ethical uneasiness for her family and careproviders.

      The case highlights several end-of-life ethical considerations that have received much recent attention. With ongoing discussions about the legalization of aid in dying across the country, caregivers are challenged to understand what beneficence means in people with terminal illnesses who want a say in their death. This case also highlights the profound moral distress of families and careproviders that arises in such ethically challenging scenarios.

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Mediation

Story of a Mediation in the Clinical Setting

Haavi Morreim

      Conflicts in the clinical setting can spiral downward with remarkable speed, as parties become ever more incensed and entrenched in their positions. Productive conversations seem unlikely at best. Nevertheless, such situations can sometimes be turned into collaborative problem solving with equally remarkable speed. For this to happen, those providing conflict-resolution services such as mediation need to bring, not just a set of skills, but also some key norms: the process must be voluntary for all; the mediator must abjure giving advice or taking sides, and must honor the privacy of privately offered thoughts.

      This article describes a conflict that had reached the point of a hospital’s requesting judicial coercion. However, a conflict-resolution process was then initiated that, in the end, led to amicable resolution and mended relationships, obviating the need for court orders. This article describes that conflict and the resolution process in detail, along the way annotating specific strategies that are often highly effective.

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Cases from MedStar Washington Hospital Center

The Case of Ms D: A Family’s Request for Posthumous Procurement of Ovaries

Laura Guidry-Grimes

      The MedStar Washington Hospital Center clinical ethics team became involved in a case when the family requested the posthumous removal of a patient’s ovaries for future reproductive use. This case presents a novel question for clinical ethicists, since the technology for posthumous female reproduction is still in development. In the bioethics literature, the standard position is to refuse to comply with such a request, unless there is explicit consent or evidence of explicit conversations that demonstrate the deceased would have wanted this option pursued. Ms D’s case, we suggest, offers an exception to this default position; complying with the family’s request could have been ethically permissible in this case, had it been medically feasible.

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Analysis: OB/GYN-Genetics

Melissa Fries

      Ovarian salvage from a patient with brain death is not available and will not preserve viable ova for future reproduction. Previous interest in assisted reproductive technology is only the first step in this process, which requires careful assessment of maternal risks and potential for recurrent genetic disease.

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Analysis: Fertility Preservation

Veronica Gómez-Lobo

      This commentary considers the viability of ovarian tissue cryopreservation (OTC) in the case of an adult who qualified for brain death. Although there has been some success with OTC in achieving pregnancy when the tissue is reimplanted in the original donor, attempting OTC in the case under discussion would have not been medically feasible.

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Analysis: A Legal Perspective

Jack Schwartz

      This commentary summarizes the uncertain state of the law regarding consent for posthumous gamete retrieval. The emergence of a legal framework will be aided by the kind of ethical analysis prompted by this family’s request for removal and preservation of a deceased patient’s ovaries.

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Perspectives

Ethical Considerations of Whole-Eye Transplantation

Wesley N. Sivak, Edward H. Davidson, Chiaki Komatsu, Yang Li, Maxine R. Miller, Joel S. Schuman, Mario G. Solari, Gerard Magill, and Kia M. Washington    

      Whole eye transplantation (WET) remains experimental. Long presumed impossible, recent scientific advances regarding WET suggest that it may become a clinical reality. However, the ethical implications of WET as an experimental therapeutic strategy remain largely unexplored. This article evaluates the ethical considerations surrounding WET as an emerging experimental treatment for vision loss. A thorough review of published literature pertaining to WET was performed; ethical issues were identified during review of the articles.

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Let’s Not Forget about Clinical Ethics Committees!

Franco A. Carnevale

      The aim of this article is to highlight the under-recognized merits of clinical ethics committees (CECs), to help ensure that the development of roles for clinical ethics consultants do not unwittingly compromise the valuable contributions that CECs can continue to provide.

      I argue that CECs can offer distinctive contributions to the clinical ethics consultation process that can complement and enrich the input provided by a clinical ethics consultant. These distinctions and complementarities should be further examined and developed. This will help to optimize the synergistic contributions that CECs and clinical ethics consultants can make to promote the ethical treatment of patients and their families.

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Moving Clinical Deliberations on Administrative Discharge in Drug Addiction Treatment Beyond Moral Rhetoric to Empirical Ethics

Izaak L. Williams

      Patients’ admission to modern substance use disorder treatment comes with the attendant risk of being discharged from treatment—a widespread practice. This article describes the three mainstream theories of addiction that operate as a reference point for clinicians in reasoning about a decision to discharge a patient from treatment. The extant literature is reviewed to highlight the pathways that patients follow after administrative discharge. Little scientific research has been done to investigate claims and hypotheses about the therapeutic function of AD, which points to the need for empirical ethics to inform clinical addictions practice.

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Law

Legal Briefing: Mandated Reporters and Compulsory Reporting Duties

Thaddeus Mason Pope

      This issue’s “Legal Briefing” column, one product of a Greenwall Foundation grant, reviews recent developments concerning compulsory reporting duties. Most licensed clinicians in the United States are “mandated reporters.” When these clinicians discover certain threats to the safety of patients or the public, they are legally required to report that information to specified government officials. Over the past year, several states have legislatively expanded the scope of these reporting duties. In other states, new court cases illustrate the vigorous enforcement of already existing duties. I have organized all these legal developments into the following eight categories:

1.   Overview of Mandatory Reporting Duties

2.   Controversy over the Benefits of Mandatory Reporting

3.   New and Expanded Duties to Report

4.   Criminal Penalties for Failing to Report

5.   Civil Liability for Failing to Report

6.   Disciplinary Penalties for Failing to Report

7.   Legal Immunity for Good-Faith Reporting

8.   Protection against Employers’ Retaliation

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The Journal of Clinical Ethics

Winter 2015, Volume 26, number 4

 

At the Bedside

Mediation Approaches at the Beginning or End of Life

Edmund G. Howe

Open access article--click here.

 

Features

The “Commitment Model” for Clinical Ethics Consultations: Society’s Involvement in the Solution of Individual Cases Stakeholders’ Perspectives on Preclinical Testing for Alzheimer’s Disease

Jalayne J. Arias, Jeffrey Cummings, Alexander Rae Grant, and Paul J. Ford

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Patient Decision Aids: A Case for Certification at the National Level in the United States

Urbashi Poddar, Shannon Brownlee, Dawn Stacey, Robert J. Volk, John W. Williams, and Glyn Elwyn

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Special Section: Mediation Techniques for Managing Clinical Conflict

Teaching and Learning the Techniques of Conflict Resolution for Challenging Ethics Consultations

Edward J. Bergman and Autumn Fiester

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Identifying Sources of Clinical Conflict: A Tool for Practice and Training in Bioethics Mediation

Edward J. Bergman

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Contentious Conversations: Using Mediation Techniques in Difficult Clinical Ethics Consultations

Autumn Fiester

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A Second Opinion: A Case Narrative on Clinical Ethics Mediation

Michael S. Weinstein

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Patient-Centered Care and the Mediator’s Skills

Mary K. Walton

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In the Ethos of the Safety Net: An Expanded Role for Clinical Ethics Mediation

Jolion McGreevy

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Mediation Training for the Physician: Expanding the Communication Toolkit to Manage Conflict

Joshua B. Kayser

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Preventing and De-Escalating Ethical Conflict: A Communication-Training Mediation Model

Tomer T. Levin and Patricia A. Parker

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Intensive Care, Intense Conflict: A Balanced Approach

Erin Talati Paquette and Irini N. Kolaitis

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Cases from the Cleveland Clinic

“She Just Doesn’t Know Him Like We Do”: Illuminating Complexities in Surrogate Decision Making

Margot M. Eves and Bryn S. Esplin

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Perspective

Medical Decision Making for Patients Without Proxies: The Effect of Personal Experience in the Deliberative Process

Allyson L. Robichaud

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Law

Legal Briefing: Medicare Coverage of Advance Care Planning

Thaddeus Mason Pope

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The Journal of Clinical Ethics

Fall 2015, Volume 26, number 3

    Click on the article for an abstract.

 

At the Bedside

How to Help Parents, Couples, and Clinicians When an Extremely Premature Infant Is Born

Edmund G. Howe

 

Features

COAST (Coordinating Options for Acute Stroke Therapy: An Advance Directive for Stroke

Ilana Spokoyny, Lynette Cederquist, Brian Clay, and Brett C. Meyer

Assessing Advance Care Planning: Examining Autonomous Selections in an Advance Directive

Craig M. Klugman and Nicole M. Tolwin

Informed Consent, Deaf Culture, and Cochlear Implants

Lauren Pass and Abraham D. Graber

 

Clinical Ethics Consultation

Case Complexity and Quality Attestation for Clinical Ethics Consultants

Bethany Spielman, Jana Craig, Christine Gorka, and Keith Miller

 

Pediatrics

Prenatal Consultation for Extremely Preterm Neonates: Ethical Pitfalls and Proposed Solutions

Jennifer C. Kett

Ethical Bargaining and Parental Exclusion: A Clinical Case Analysis

Laura Guidry-Grimes and Elizabeth Victor

 

Case Analysis

The Least Bad Option: Unilateral Extubation after Declaration of Death by Neurological Criteria

Sally E. Bliss and Robert C. Macauley

 

Commentary

Clarifying an Expanded Use of Continuous Sedation Until Death: A Reply to the Commentary by McCammon and Piemonte

Samuel H. LiPuma and Joseph P. DeMarco

 

Letter

Response to Stephens and Heitman

Jason Adam Wasserman

 

The Journal of Clinical Ethics

Summer 2015, Volume 26, number 2

    Click on the article for an abstract.

 

At the Bedside

How to Retain the Trust of Patients and Families When We Will Not Provide the Treatment They Want

    Edmund G. Howe

 

Features

A Justifiable Asymmetry

    Daniel Brudney and Mark Siegler

On Not Taking “Yes” for an Answer

    Alexander M. Capron

Moral Reasoning among HEC Members: An Empirical Evaluation of the Relationship of Theory and Practice in Clinical Ethics Consultation

    Jason Adam Wasserman, Shannon Lindsey Stevenson, Cassandra Claxton, and Ernest F. Krug, III

Reasoning Backwards by Design: Commentary on “Moral Reasoning among HEC Members”

    Ashley L. Stephens and Elizabeth Heitman

Expanding the Use of Continuous Sedation Until Death: Moving Beyond the Last Resort for the Terminally Ill    

    Samuel H. LiPuma and Joseph P. DeMarco

Continuous Sedation Until Death Should Not Be an Option of First Resort

Susan D. McCammon and Nicole M. Piemonte

“Let Me Keep My Dead Husband’s Sperm”: Ethical Issues in Posthumous Reproduction

    Nikoletta Panagiotopoulou and Stamatios Karavolos

 

Cases from the Harvard Ethics Consortium

The Value of Virginity

    Christine Mitchell

When Bleeding Is Vital: Surgically Ensuring the “Virginal” State

    Sohaila Bastami

A Hymen Epiphany

    Farrah Jarral

On Hymenoplasty

    Mary-Jo DelVecchio Good

Hymen Restoration: “My” Discomfort, “Their” Culture, and Women’s Missing Voice

    Sylvie Schuster

The Value of Virginity and the Value of the Law: Accommodating Multiculturalism
    Pablo de Lora

Is Hymenoplasty Anti-Feminist?

    Gretchen Heinrichs

Doctoring the Genitals: Towards Broadening the Meaning of Social Medicine

    Richard A. Shweder

 

Law

Legal Briefing: Adult Orphans and the Unbefriended: Making Medical Decisions for Unrepresented Patients without Surrogates

    Thaddeus Mason Pope

 

Letters

Possible Unintended Consequences of Including Equal-Priority Surrogates

    Steven Perry and Arvind Venkat

Response to Perry and Venkat

    Autumn Fiester

 

 

The Journal of Clinical Ethics

Spring 2015, Volume 26, number 1

 

Professionalism: One Size Does Not Fit All

Edmund G. Howe

      When a child is born with or acquires special needs, the parents may find some parental tasks more difficult. They may not know how to make their tasks easier, or that some parents find it exceptionally rewarding and meaningful to raise their children with special needs. This piece explores how clinicians might share this potentially life-altering information. It also explores when and why clinicians might want to make one-of-a-kind exceptions to their usual professional practices. (Click here to access this article.)

  

A Quality of Life Quandary: A Framework for Navigating Parental Refusal of Treatment for Co-Morbidities in Infants with Underlying Medical Conditions

Sarah N. Kunz, Ryan M. McAdams, Douglas S. Diekema, and Douglas J. Opel

      Parental refusal of a recommended treatment is not an uncommon scenario in the neonatal intensive care unit. These refusals may be based upon the parents’ perceptions of their child’s projected quality of life. The inherent subjectivity of quality of life assessments, however, can exacerbate disagreement between parents and healthcare providers. We present a case of parental refusal of surgical intervention for necrotizing enterocolitis in an infant with Bartter syndrome and develop an ethical framework in which to consider the appropriateness of parental refusal based upon an infant’s projected quality of life. (Nonsubscribers may click here to purchase the full text.)

     

Witnesses to Mute Suffering:  Quality of Life, Intellectual Disability, and the Harm Standard

Lisa C. Freitag

      Decisions to override a parental request to withhold or withdraw treatment in the neonatal intensive care unit are often made based on the harm standard, with death being cast as the ultimate harm. However, often the treatment itself is not without harm, and the suffering engendered is undergone by an infant who is neither able to understand it nor express its presence. We can draw upon anticipated future quality of life to justify the present suffering, but are in a quandary when that future is not guaranteed or is likely to hold little but further suffering. I propose that conflicts over continuing treatment are based both on disagreements about the desirability of possible futures, and on differing perceptions of the infant’s current level of suffering. Those of us who witness the suffering of these tiny, mute infants all bear some responsibility to insure that their suffering is not without purpose. (Nonsubscribers may click here to purchase the full text.)

 

Home Birth of Infants with Congenital Anomalies: A Case Study and Ethical Analysis of Careproviders’ Obligations

Jane Jankowski and Paul Burcher

      This article presents the case of a mother who is planning a home birth with a midwife with the shared knowledge that the fetus would have congenital anomalies of unknown severity. We discuss the right of women to choose home birth, the caregivers’ duty to the infant, and the careproviders’ dilemma about how to respond to this request. The ethical duties of concerned careproviders are explored and reframed as professional obligations to the mother, infant, and their profession at large. Recommendations are offered based on this case in order to clarify the considerations surrounding not only home birth of a fetus with anticipated anomalies, but also to address the ethical obligations of caregivers who must navigate the unique tension between respecting the mother’s wishes and the duty of the careproviders to deliver optimal care. (Nonsubscribers may click here to purchase the full text.)

 

Of Missing Voices and the Obstetric Imaginary: Commentary on Jankowski and Burcher

Melissa Cheyney

      In this commentary, I respond to an ethical analysis of a case study, reported by Jankowski and Burcher, in which a woman gives birth to an infant with a known heart anomaly of unknown severity, at home, attended by a midwife. Jankowski and Burcher argue that the midwife who attended this family acted unethically because she knowingly operated outside of her scope of practice. While I agree that the authors’ conclusions are well supported by the portion of the story they were able to gather, the fact that the midwife and mother declined to engage in the ethics consult that informs their piece means that critical segments of the narrative are left untold. Some important additional considerations emerge from these silences.

      I explore the implicit assumptions of the biotechnical embrace, the roles of the political economy of hope and the obstetric imaginary in driving prenatal testing, and institutional blame for the divisiveness of the home-hospital divide in the United States. The value of Jankowski and Burcher’s case study lies in its ability to highlight the intersections and potential conflicts between the principles of beneficence, patients’ autonomy, and professional ethics, and to begin to chart a course for us through them. (Nonsubscribers may click here to purchase the full text.)

 

Hinduism and Death with Dignity: Historic and Contemporary Case Examples

Rajan Dewar, Nancy Cahners, Christine Mitchell, and Lachlan Forrow

      An estimated 1.2 to 2.3 million Hindus live in the United States. End-of-life care choices for a subset of these patients may be driven by religious beliefs. In this article, we present Hindu beliefs that could strongly influence a devout person’s decisions about medical care, including end-of-life care. We provide four case examples (one sacred epic, one historical example, and two cases from current practice) that illustrate Hindu notions surrounding pain and suffering at the end of life. Chief among those is the principle of karma, through which one reaps the benefits and penalties for past deeds. Deference to one’s spouse or family is another important Hindu value, especially among Hindu women, which can impact the decision-making process and challenge the Western emphasis on autonomy. In addition, the Hindu embrace of astrology can lead to a desire to control the exact time of death. Confounding any generalizations, a Hindu patient may reject or accept treatments based on the individual patient’s or family’s interpretation of any given tradition. Through an awareness of some of the fundamental practices in Hinduism and the role of individual interpretation within the tradition, clinicians will be better able to support their Hindu patients and families at the end of life. (Nonsubscribers may click here to purchase the full text.)

 

Medical Professionalism in China and the United States:

A Transcultural Interpretation

Jing-Bao Nie, Kirk L. Smith, Yali Cong, Linying Hu, and Joseph D. Tucker

      As in other societies, medical professionalism in the Peoples’ Republic of China has been rapidly evolving. One of the major events in this process was the endorsement in 2005 of the document, “Medical Professionalism in the New Millennium: A Physician Charter,” by the Chinese Medical Doctor Association (hereafter, the Charter).1 More recently, a national survey, the first on such a large scale, was conducted on Chinese physicians’ attitudes toward the fundamental principles and core commitments put forward in the Charter. Based on empirical findings from that study and comparing them to the published results of a similar American survey, the authors offer an in-depth interpretation of significant cross-cultural differences and important transcultural commonalities. The broader historical, socio-economic, and ethical issues relating to salient Chinese cultural practices such as family consent, familism (the custom of deferring decisions to family members), and the withholding of medical information, as well as controversial topics such as not respecting patients’ autonomy, are examined. The Chinese Survey found that Chinese physicians supported the principles of the Charter in general. Here we argue that Chinese culture and traditional medical ethics are broadly compatible with the moral commitments demanded by modern medical professionalism. Methodologically and theoretically—recognizing the problems inherent in the hoary but still popular habit of dichotomizing cultures and in relativism—a transcultural approach is adopted that gives greater (due) weight to the internal moral diversity present within every culture, the common ground shared by different cultures, and the primacy of morality. Genuine cross-cultural dialogue, including a constructive Chinese-American dialogue in the area of medical professionalism, is not only possible, but necessary. (Nonsubscribers may click here to purchase the full text.)

 

Re-Evaluating Ethical Concerns in Planned Emergency Research Involving Critically Ill Patients: An Interpretation of the Guidance Document from the United States Food and Drug Administration

Nathan J. Smischney, James A. Onigkeit, Richard F. Hinds, and

Wayne T. Nicholson

    Background: U.S. federal regulations require that certain ethical elements be followed to protect human research subjects. The location and clinical circumstances of a proposed research study can differ substantially and can have significant implications for these ethical considerations. Both the location and clinical circumstances are particularly relevant for research in intensive care units (ICUs), where patients are often unable to provide informed consent to participate in a proposed research intervention.

    Purpose: Our goal is to elaborate on the updated 2013 U.S. Food and Drug Administration (FDA) guidance document regarding an exemption from the requirement of obtaining informed consent from patients or their surrogates and to address certain elements within that document, thereby assisting clinicians in developing a framework for emergency research in accordance    with the regulatory bodies at their own institutions and in the United States.

    Methods: Review of the 2011 and updated FDA guidance document on exemption from informed consent.

    Results: The current process of obtaining informed consent within  ICUs needs to be revisited, especially for research in which timely informed consent is not likely. In particular, the process of obtaining informed consent may not be appropriate or even ethical for critically ill patients in extremis who require an intervention for which there is no current acceptable standard of care and clinical equipoise exists. We provide clinicians with a viewpoint that further elaborates on the FDA guidance document.

    Limitations: The viewpoints provided herein are those of the authors and are therefore inherently limited by the personal views of a selected few. Other clinicians or researchers may not interpret the FDA guidelines in a similar manner. Moreover, the discussion of a guideline document is a limitation in and of itself. The guidelines set forth by the FDA are precisely that—guidelines. Therefore, they may not be followed as outlined in the guidance document within one’s own institution. Our goal is that, by elaborating on the guidelines for planned research involving human subjects in the ICU, institutional regulatory bodies may gain a better understanding in drafting their own document when faced with a clinician or a researcher who wishes to conduct planned research in an ICU.

    Conclusions: We believe that the interpretations provided will allow clinicians to safely undertake planned research in ICUs without endangering the main tenets of ethical research involving human participants. This research is needed for the advancement of care in the critically ill. (Nonsubscribers may click here to purchase the full text.)

     

The Ethics of Physicians’ Web Searches for Patients’ Information

Nicholas Genes and Jacob Appel

      When physicians search the web for personal information about their patients, others have argued that this undermines  patients’ trust, and the physician-patient relationship in general. We add that this practice also places other relationships at risk, and could jeopardize a physician’s career.

      Yet there are also reports of web searches that have unambiguously helped in the care of patients, suggesting circumstances in which a routine search of the web could be beneficial. We advance the notion that, just as nonverbal cues and unsolicited information can be useful in clinical decision making, so too can online information from patients. As electronic records grow more voluminous and span more types of data, searching these resources will become a clinical skill, to be used judiciously and with care—just as evaluating the literature is, today.

      But to proscribe web searches of patients’ information altogether is as nonsensical as disregarding findings from physical exams—instead, what’s needed are guidelines for when to look and how to evaluate what’s uncovered, online. (Nonsubscribers may click here to purchase the full text.)

 

Legal Briefing: Coerced Treatment and Involuntary Confinement for Contagious Disease

Thaddeus Mason Pope and Heather Michelle Bughman

      This issue’s “Legal Briefing” column covers recent legal developments involving coerced treatment and involuntary confinement for contagious disease. Recent high profile court cases involving measles, tuberculosis, human immunodeficiency virus, and especially Ebola, have thrust this topic back into the bioethics and public spotlights. This has reignited debates over how best to balance individual liberty and public health. For example, the Presidential Commission for the Study of Bioethical Issues has officially requested public comments, held open hearings, and published a 90-page report on “ethical considerations and implications” raised by “U.S. public policies that restrict association or movement (such as quarantine).”1 Broadly related articles have been published in previous issues of JCE.2 We categorize recent legal developments on coerced treatment and involuntary confinement into the following six categories:

1.   Most Public Health Confinement Is Voluntary

2.   Legal Requirements for Involuntary Confinement

3.   New State Laws Authorizing Involuntary Confinement

4.   Quarantine Must Be as Least Restrictive as Necessary

5.   Isolation Is Justified Only as a Last Resort

6.   Coerced Treatment after Persistent Noncompliance.

(Nonsubscribers may click here to purchase the full text.)

 

The Journal of Clinical Ethics

Winter 2014, Volume 25, number 4

 

New Approaches with Surrogate Decision Makers

Edmund G. Howe

Who’s at the Table? Moral Obligations to Equal-Priority Surrogates in Clinical Ethics Consultations

Meghan O’Brien and Autumn Fiester

Developing and Testing a Checklist to Enhance Quality in Clinical Ethics Consultation

Lauren Sydney Flicker, Susannah L. Rose, Margot M. Eves, Anne Lederman Flamm, Ruchi Sanghani,

and Martin L. Smith

Surrogate Decision Making and Intellectual Virtue

Gregory L. Bock

Identifying Challenges to Communicating with Patients about Their Imminent Death

Lena Hoff and Göran Hermerén

Medical Missions to Ghana: The Ethics of Choosing Children for Cardiac Surgery

Christine Mitchell           

How Do We Choose?

Beverly M. Small, Judith Hurley, and Christine Placidi 

Great Need, Scarce Resources, and Choice: Reflections on Ethical Issues Following a Medical Mission

Ravi R. Thiagarajan, Mark A. Scheurer, and Joshua W. Salvin       

Ethical Aspects of Arranging Local Medical Collaboration and Care

Samuel Blay Nguah

Pediatric Heart Surgery in Ghana: Three Ethical Questions

Nir Eyal

Epilogue: Ethical Goals for the Future

Edmund G. Howe

 

 

The Journal of Clinical Ethics

Fall 2014, Volume 25, number 3

 

What Should Careproviders Do When a Patient "Won’t Budge"?

    Edmund G. Howe

Empirical Bioethics Research Is a Winner, But Bioethics Mission Creep Is a False Alarm

    Anne Lederman Flamm and Eric Kodish

Power and Jurisdiction

    John H. Evans

When Should We Not Respect a Patient’s Wish?

    Stephen Napier

The Ethical and Clinical Importance of Measuring Consciousness in Continuously Sedated Patients

    Kasper Raus, Martine de Laat, Eric Mortier, and Sigrid Sterckx

The Proportionate Value of Proportionality in Palliative Sedation

    Jeffrey T. Berger

Family Members’ Requests to Extend Physiologic Support after Declaration of Brain Death: A Case Series Analysis and Proposed Guidelines for Clinical Management

    Anne Lederman Flamm, Martin L. Smith, and Patricia A. Mayer

A Survey of Healthcare Industry Representatives’ Participation in Surgery: Some New Ethical Concerns

    Jeffrey Bedard, Crystal Dea Moore, and Wayne Shelton

Legal Briefing: Brain Death and Total Brain Failure

    Thaddeus Mason Pope

 

 

The Journal of Clinical Ethics

Summer 2014, Volume 25, number 2

 

How to Help Patients and Families Make Better End-of-Life Decisions

    Edmund G. Howe

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Stumbled, Fumbled, Bumbled, Grumbled, and Humbled: Looking Back at the Future History of Clinical Ethics

   Jeffrey T. Berger

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A Protocol and Ethical Framework for the Distribution of Rationed Chemotherapy

   Andrew Hantel

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Detoxifying the Concept of Rationing

   James Sabin

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Uncharted Terrain: Preference Construction at the End of Life

   Mary T. White

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Aetna’s Compassionate Care Program and End-of-Life Decisions

    Barak Krakauer, Joseph Agostini, and Randall Krakauer

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Chinese Physicians’ Attitudes toward and Understanding of Medical Professionalism: Results of a National Survey

    Linying Hu, Xiuyun Yin, Xiaolei Bao, and Jing-Bao Nie

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Ethics Pocket Cards: An Educational Tool for Busy Clinicians

    Rebecca L. Volpe, Benjamin H. Levi, George F. Blackall, and Michael J. Green

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Legal Briefing: Informed Consent in the Clinical Context

    Thaddeus Mason Pope and Melinda Hexum

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Letter: Improving Patient-Doctor Communication about Risk and Choice in Obstetrics and Gynecology through Medical Education: A Call for Action

    Macey L. Henderson, Jennifer Chevinsky, Rizwana Biviji-Sharma, and Kathryn Mills

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The Journal of Clinical Ethics

Spring 2014, volume 25, number 1

 

Ethically Optimal Interventions with Impaired Patients

Edmund G. Howe

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DNR and ECMO: A Paradox Worth Exploring

Ellen Cowen Meltzer, Natalia S. Ivascu, and Joseph J. Fins

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Defending the Jurisdiction of the Clinical Ethicist

John H. Evans

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Can the Social Sciences Save Bioethics?

Daniel Callahan

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Clinical Ethicists: Consultants or Professionals?

William J. Winslade

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Response to Callahan and Winslade

John H. Evans

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The Desire to Die: Making Treatment Decisions for Suicidal Patients Who Have an Advance Directive

Erica K. Salter

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Beyond Privacy: Benefits and Burdens of E-Health Technologies in Primary Care

Julie M. Aultman and Erin Dean

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The Side-Effects of the "Facebook Effect": Challenging Facebook’s "Organ Donor" Application

Adam M. Peña

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Legal Briefing: Voluntarily Stopping Eating and Drinking

Thaddeus Mason Pope and Amanda West

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The Journal of Clinical Ethics

Winter 2013, volume 24, number 4

 

Families, Strangers, and Those Most Alone: Insights from Cultures, Including Our Own

      Edmund G. Howe

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On the Lingua Franca of Clinical Ethics

      Joseph J. Fins

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Surrogates and Extra-Familial Interests

      Ralph Baergen and William Woodhouse

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Familiar Interests and Strange Analogies: Baergen and Woodhouse on Extra-Familial Interests

      James Lindemann Nelson

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Challenges to Culturally Sensitive Care for Elderly Chinese Patients: A First-Generation Chinese-American Perspective

      Karen C. Chan

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Patients’ Experiences with Disclosure of a Large-Scale Adverse Event

      Carolyn D. Prouty, Mary Beth Foglia, and Thomas H. Gallagher

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Organ Donation among Undocumented Hispanic Immigrants: An Assessment of Knowledge and Attitudes

      Joshua S. Baru, Brian P. Lucas, Carmen Martinez, and Daniel Brauner

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Ethically Informed Pragmatic Conditions for Organ Donation after Cardiocirculatory Death: Could They Assist in Policy Development?

      Jeffrey Kirby

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Why We Should Continue to Worry about the Therapeutic Misconception

      Larry R. Churchill, Nancy M.P. King, and Gail E. Henderson

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Problems with the Consensus Definition of the Therapeutic Misconception

      David S. Wendler

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Modern Clinical Research: Guidelines for the Practicing Clinician or Source of Confusion?

      Ilia Volkov

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The Journal of Clinical Ethics

Fall 2013, volume 24, number 3

 

Special Issue on Place of Birth

Guest Edited by Elizabeth Bogdan-Lovis, Charlotte de Vries, and Raymond G. de Vries

 

When a Mother Wants to Deliver with a Midwife at Home

      Edmund G. Howe

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Planned Home Birth in the United States and Professionalism: A Critical Assessment

      Frank A. Chervenak, Laurence B. McCullough, Amos Grünebaum, Birgit Arabin,

      Malcolm I. Levene, and Robert L. Brent

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Ethics and the Architecture of Choice for Home and Hospital Birth

      Elizabeth Bogdan-Lovis and Raymond G. de Vries

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Revisiting “The Maximin Strategy in Modern Obstetrics”

      Howard Brody and Carol Sakala

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A Reconsideration of Home Birth in the United States

      Howard Minkoff and Jeffrey Ecker

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The Absolute Power of Relative Risk in Debates on Repeat Cesareans and Home Birth

in the United States

      Eugene Declercq

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Moral Science: Ethical Argument and the Production of Knowledge about Place of Birth

      Raymond G. de Vries, Yasaswi Paruchuri, Kathleen Lorenz, and Saraswathi Vedam

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Women’s Perceptions of Childbirth Risk and Place of Birth

      Mary Regan and Katie McElroy

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Exceptional Deliveries: Home Births as Ethical Anomalies in American Obstetrics

      Claire L. Wendland

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Being Safe: Making the Decision to Have a Planned Home Birth in the United States

      Judith A. Lothian

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Facilitating Women’s Choice in Maternity Care

      Marianne Nieuwenhuijze and Lisa Kane Low

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Personal Perspective: One Obstetrician’s Look at a Polarizing Birth Arena

      Annette E. Fineberg

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Personal Perspective: Seeking an Alternative Baseline for Birth

      Darcia Narváez

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Personal Perspective: Individual versus Professional Preferences

      Julie Sharon-Wagschal

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Personal Perspective: The Industry Take-Over of Home Birth and Death

      Merilynne Rush

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Personal Perspective: On the Need for a Real Choice

      Steve Calvin

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Legal Briefing: Home Birth and Midwifery

      Thaddeus Mason Pope and Deborah Fisch

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The Journal of Clinical Ethics

Summer 2013, volume 24, number 2

 

Why Careproviders May Conclude that Treating a Patient Is Futile

Edmund G. Howe

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Repetitive Foreign Body Ingestion: Ethical Considerations

Sarah Lytle, Susan J. Stagno, and Barb Daly

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The Intensity and Frequency of Moral Distress Among Different Healthcare Disciplines

Susan Houston, Mark A. Casanova, Marygrace Leveille, Kathryn L. Schmidt,

Sunni A. Barnes, Kelli R. Trungale, and Robert L. Fine

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“He Got His Last Wishes”: Ways of Knowing a Loved One’s End-of-Life Preferences and Whether Those Preferences Were Honored

Angelina R. Wittich, Beverly Rosa Williams, F. Amos Bailey, Lesa L. Woodby, and

Kathryn L. Burgio

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Making Decisions for Hospitalized Older Adults: Ethical Factors Considered by Family Surrogates

Jenna Fritsch, Sandra Petronio, Paul R. Helft, and Alexia M. Torke

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The Threshold Moment: Ethical Tensions Surrounding Decision Making on Tracheostomy for Patients in the Intensive Care Unit

Arvind Venkat

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A Response to Dubler’s Commentary on “Surmounting Elusive Barriers: The Case for Bioethics Mediation”

Edward J. Bergman

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The Art of the Chart Note in Clinical Ethics Consultation and Bioethics Mediation: Conveying Information that Can Be Understood and Evaluated

Nancy Neveloff Dubler

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Legal Briefing: The New Patient Self-Determination Act

Thaddeus Mason Pope

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The Journal of Clinical Ethics

Spring 2013, volume 24, number 1

 

“The Best Place for Bare-Knuckled Ethics”

Edmund G. Howe

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“Surmounting Elusive Barriers: The Case for Bioethics Mediation”

Edward J. Bergman

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“Commentary on Bergman: ‘Yes . . . But' ”

Nancy Neveloff Dubler

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“The Chiaroscuro of Accountability in the Second Edition of the Core Competencies for Healthcare Ethics Consultation

Lisa Rasmussen

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“Prescribing for Coworkers: Practices and Attitudes of Faculty and Residents”

Carson Strong, Stephanie Connelly, and Laura R. Sprabery

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“The Ethics of Reality Medical Television”

Thalia Margalit Krakower, Martha Montello, Christine Mitchell, and Robert D. Truog

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“Not a ‘Reality’ Show”

Terence Wrong and Erica Baumgart

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 “First, Do No Harm”

Neal Baer

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“Watching Boston Med”

Walter M. Robinson

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“Legal Briefing: Shared Decision Making and Patient Decision Aids”

Thaddeus Mason Pope and Melinda Hexum

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The Journal of Clinical Ethics

Winter 2012, volume 23, number 4


A Different Approach to Patients and Loved Ones Who Request “Futile” Treatments

Edmund G. Howe

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Complex Discharges and Undocumented  Patients: Growing Ethical Concerns

Kayhan Parsi and Nina Hossa

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When Negative Rights Become Positive Entitlements: Complicity, Conscience,

and Caregiving

Andrew G. Shuman, Adam A. Khan, Jeffrey S. Moyer, Mark E. Prince,

and Joseph J. Fins

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A New Standard for Incapacitated Patient Decision Making: The Clinical Standard of

Surrogate Empowerment

Marc Tunzi

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Bedside Resource Stewardship in Disasters: A Provider’s Dilemma

Practicing in an Ethical Gap

Michelle Daniel

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Resource Stewardship in Disasters: Alone at the Bedside

Jeffrey T. Berger

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Tragic Choices in Humanitarian Health Work

Matthew R. Hunt, Christina Sinding, and Lisa Schwartz

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Endoscopy During a Missile Attack: A Military Dilemma for Physicians

Stephen Malnick, Orit Faraj, and Alan Jotkowitz

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Making “Social” Safer: Are Facebook and Other Online Networks Becoming

Less Hazardous for Health Professionals?

Daniel R. George

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Legal Briefing: POLST: Physician Orders for Life-Sustaining Treatment

Thaddeus Mason Pope and Melinda Hexum

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The Journal of Clinical Ethics

Volume 23, Number 3, Fall 2012

 

An Ethical Priority Greater than Life Itself

Edmund G. Howe

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Potential Subjects’ Responses to an Ethics Questionnaire in a Phase I Study

of Deep Brain Stimulation in Early Parkinson’s Disease

Stuart G. Finder, Mark J. Bliton, Chandler E. Gill, Thomas L. Davis,

Peter E. Konrad, and P. David Charles

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Regulatory Misconception Muddies the Ethical Waters:

Challenges to a Qualitative Study

Kimberly M. Yee and Paul J. Ford

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Fortitude and Community: Response to Yee and Ford

Stuart G. Finder and Mark J. Bliton

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Stories and the Longitudinal Patient Relationship: What Can Clinical Ethics Consultants Learn from Palliative Care?

Wynne Morrison and Sabrina F. Derrington

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The Rose of Sharon: What Is the Ideal Timing for Palliative Care Consultation

versus Ethics Consultation?

Jennifer La Via and David Schiedermayer

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HCEC Pearls and Pitfalls: Suggested Do’s and Don’t’s for Healthcare Ethics Consultants

Joseph A. Carrese and Members of the American Society for Bioethics and

Humanities Clinical Ethics Consultation Affairs Standing Committee

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Elective Delivery Before 39 Weeks’ Gestation:

Reconciling Maternal, Fetal, and Family Interests in Challenging Circumstances

S. Van McCrary, Shetal I. Shah, Adriann Combs, and J. Gerald Quirk

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Quality of Life and Elective C-Sections: Defining Limits to Maternal and

Family Interests

Jeffrey P. Spike

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Which Patient Groups Should Be Asked to Participate in First-in-Human Trials

of Stem-Cell-Based Therapies?

Kristina Hug and Göran Hermerén

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Time to Stop Worrying about the Therapeutic Misconception

David S. Wendler

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Letter: Providing More Reasons for Individuals to Register as Organ Donors

Macey Leigh Henderson

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The Journal of Clinical Ethics

Volume 23, Number 2, Summer 2012

 

How Should Careproviders Respond to Patients’ Requests That May Be Refused?

Edmund G. Howe

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Living Donation and Cosmetic Surgery: A Double Standard in Medical Ethics?

Giuliano Testa, Erica Carlisle, Mary Simmerling, and Peter Angelos

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Different Standards Are Not Double Standards: All Elective Surgical Patients Are Not Alike

Lainie Friedman Ross, Walter Glannon, Lawrence J. Gottlieb, and

J. Richard Thistlethwaite, Jr.

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The Effect of Completing a Surrogacy Information and Decision-Making Tool upon Admission to an Intensive Care Unit on Length of Stay and Charges

Carol W. Hatler, Charlene Grove, Stephanie Strickland,  Starr Barron,

and Bruce D. White

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Training in Clinical Ethics: Launching the Clinical Ethics Immersion Course at the Center for Ethics at the Washington Hospital Center

Nneka O. Mokwunye, Evan G. DeRenzo, Virginia A. Brown, and John J. Lynch

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Training in Clinical Ethics Consultation: The Washington Hospital Center Course

Jeffrey P. Spike

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Truly Intensive Clinical Ethics Immersion at the Washington Hospital Center

Christopher L. Church and Thalia Arawi

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Credentialing the Clinical Ethics Consultant: An Academic Medical Center Affirms

Professionalism and Practice

Cathleen A. Acres, Kenneth Prager, George E. Hardart, and Joseph J. Fins

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Ethics Been Very Good to Us

Giles R. Scofield

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Inside Baseball and Ethics Consultation: A Comment on “Ethics Been Very Good to Us”

Norman Quist

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Credentialing and Certification in Ethics Consultation: Lessons from Palliative Care

David Schiedermayer and John La Puma

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Always on Call: Thoughts from a Neophyte Physician

Jonathan R. Scarff and David W. Musick

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Legal Briefing: The Unbefriended: Making Healthcare Decisions for Patients Without Surrogates (Part 2)

Thaddeus Mason Pope and Tanya Sellers

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The Journal of Clinical Ethics

Volume 23, Number 1, Spring 2012

 

How Careproviders Can Acquire and Apply Greater Wisdom

Edmund G. Howe

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Clinical Wisdom in Psychoanalysis and Psychodynamic Psychotherapy: A Philosophical and Qualitative Analysis

Cynthia Baum-Baicker and Dominic A. Sisti

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Response: Clinical Wisdom and Evidence-Based Medicine Are Complementary

Julian De Freitas, Omar S. Haque, Abilash A. Gopal, and Harold J. Bursztajn

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Clinical Wisdom and Evidence-Based Medicine Are (Indeed) Complementary:

A Reply to Bursztajn and Colleagues

Cynthia Baum-Baicker and Dominic A. Sisti

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Attending to Clinical Wisdom

Jodi Halpern

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Her Own Decision: Impairment and Authenticity in Adolescence

Amy T. Campbell, Sabrina F. Derrington, D. Micah Hester, and Cheryl D. Lew

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Supporting Her Autonomy: The Obligations of Guardians and Physicians in Adolescents’ Refusals of Care

Jennifer K. Walter

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Intraoperative Conversion to Open Technique: Is Informed Consent Implied?

Chirag B. Patel and Davide Cattano

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Anesthesiological Ethics: Can Informed Consent Be Implied?

Jeffrey P. Spike

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Surrogate Medical Decision Making on Behalf of a Never-Competent, Profoundly Intellectually Disabled Patient Who Is Acutely Ill

Arvind Venkat

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Care versus Treatment at the End of Life for Profoundly Disabled Persons

Jeffrey P. Spike

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Legal Briefing: The Unbefriended: Making Healthcare Decisions for Patients without Surrogates (Part 1)

Thaddeus Mason Pope and Tanya Sellers

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