The Journal of Clinical Ethics, Volume 29, Number 2, Summer 2018
At the Bedside
Edge-of-the-Field Ethics Consulting: What Are We Missing?
Edmund G. Howe, The Journal of Clinical Ethics 29, no. 2 (Summer):81-92.
Ethics consultants’ grasp of ethical principles is ever improving. Yet, what still remains and will remain lacking is their ability to access factors that lie outside their conscious awareness and thus still effect suboptimal outcomes. This article will explore several ways in which these poor outcomes may occur. This discussion will include clinicians’ implicit biases, well-intentioned but nonetheless intrusive violations of patients’ privacy, and clinicians’ unwittingly connoting to patients and families that clinicians regard their moral values and conclusions as superior. I shall suggest several ways in which clinicians may seek to reduce these sources of bad outcomes or at least to do better when they occur.
Psychiatric Diagnoses and Informed Consent
Andrew Clark, The Journal of Clinical Ethics 29, no. 2 (Summer): 93-9.
Although informed consent for treatment has become a cornerstone principle of psychiatric care, the process of diagnosis has remained largely in the hands of the physician alone. While the conferring of a psychiatric diagnosis has historically not been considered a form of medical intervention, the potential impact of a diagnosis for any particular patient may be substantial. This article explores the challenges involved in balancing respect for patients with the physician’s duty of truth-telling and clinical accuracy.
Response to “Psychiatric Diagnoses and Informed Consent”
David Brendel, The Journal of Clinical Ethics 29, no. 2 (Summer): 100-1.
A patient’s rights to informed consent and self-determination in psychiatric treatment are well enshrined, but the same rights have not yet been meaningfully extended to patients with regard to psychiatric diagnosis. Andrew Clark’s essay entitled “Psychiatric Diagnoses and Informed Consent” in The Journal of Clinical Ethics empowers both psychiatrists and patients to rethink who “owns” the process of clinical assessment and of bestowing diagnostic labels that may have far-reaching consequences. Clark’s article represents a noteworthy breakthrough in the field’s ongoing journey toward enhancing informed consent, personal dignity, and patients’ active involvement in their own care.
TTaPP: Together Take a Pause and Ponder: A Critical Thinking Tool for Exploring the Public/Private Lives of Patients
Leslie Kuhnel, The Journal of Clinical Ethics 29, no. 2 (Summer): 102-13.
The broad use of social networking and user-generated content has increased the online footprint of many individuals. A generation of healthcare professionals have grown up with online search activities as part of their everyday lives. Sites like Facebook, Twitter, and Instagram have given the public new ways to share intimate details about their public and private lives and the lives of their friends and families. As a result, careproviders have the ability to find out more about their patients with just the tap of a key or the click of a mouse. This type of online searching for patient information is known as patient-targeted googling or PTG.
This article provides an overview of the emergence of PTG, identifies the potential benefits and possible pitfalls of engaging in PTG, and explores current ethical frameworks that guide decisions about PTG. The article describes the development of a critical thinking tool developed by the Behavioral Health Ethics Committee at CHI Health, that can serve as a best-practice model for other hospitals and health systems. Called TTaPP (Together Take a Pause and Ponder), this tool is designed to help healthcare professionals across settings practice collaborative critical thinking skills as they consider the ethical questions of whether or not to engage in PTG. Finally, this article suggests areas for further study, including ways to prompt collaboration and appropriate documentation by maximizing electronic medical records systems, exploring the effectiveness of the TTaPP tool as a way to promote a culture of collaborative critical thinking practices, and the attitudes of patients and the public regarding PTG.
Medical Futility in Concept, Culture, and Practice
Grattan T. Brown, The Journal of Clinical Ethics 29, no. 2 (Summer): 114-23.
This article elucidates the premises and limited meaning of medical futility in order to formulate an ethically meaningful definition of the term, that is, a medical intervention’s inability to deliver the benefit for which it is designed. It uses this definition to show the two ways an intervention could become medically futile, to recommend an even more limited usage of medical futility, and to explain why an intervention need not be futile in order to be withdrawn over patient-based objections. If an intervention retains some benefit, then patients or surrogates might legitimately consider that benefit in their case and request the intervention. Physicians might still be justified in declining it on the grounds that the burdens greatly outweigh the benefits, but not on the grounds of futility. Finally, the article uses bioethics research and healthcare litigation to clarify the meaning of futility in practice and recommends alternative language when possible.
Action Guide for Addressing Ethical Challenges of Resource Allocation Within Community-Based Healthcare Organization
Krista L. Harrison, Holly A. Taylor, and Maria W. Merritt, The Journal of Clinical Ethics 29,
no. 2 (Summer): 124-38.
This article proposes an action guide to making decisions regarding the ethical allocation of resources that affect access to healthcare services offered by community-based healthcare organizations. Using the filter of empirical data from a study of decision making in two community-based healthcare organizations, we identify potentially relevant conceptual guidance from a review of frameworks and action guides in the public health, health policy, and organizational ethics literature. We describe the development of this action guide. We used data from a prior empirical study of the values that influence decision making about the allocation of resources in particular types of community-based healthcare organizations. We evaluated, organized, and specified the conceptual guidance we found in 14 frameworks for ethical decision making. The result is an action guide that includes four domains that are relevant to the context of the decision to be made, eight domains that are relevant to the process of the decision to be made, and 15 domains that are relevant to the criteria of the decision to be made. We demonstrate the potential use of this action guide by walking through an illustrative resource allocation decision. The action guide provides community-based healthcare organizations with a conceptually grounded, empirically informed framework for ethical decision making.
Treating Vulnerable Populations
Medical Decision Making for Medically Complex Children in Foster Care: Who Knows the Child’s Best Interests?
Rebecca R. Seltzer, Rachel A.B. Dodge, and Renee D. Boss, The Journal of Clinical Ethics 29, no. 2 (Summer): 139-44.
Approximately one in 10 children in foster care are medically complex and require intensive medical supervision, frequent hospitalization, and difficult medical decision making. Some of these children are in foster care because their parents cannot care for their medical needs; other parents are responsible for their child’s medical needs due to abuse or neglect. In either case, there can be uncertainty about the role that a child’s biological parents should play in making serious medical decisions. Here we highlight some of the ethical challenges inherent in making these decisions for children in foster care, as seen through the lenses of a child welfare provider, an inpatient care physician, and a primary care pediatrician.
Medically Complex Children in Foster Care: Do Research “Protections” Make This “Vulnerable Population” More Vulnerable?
Rebecca R. Seltzer, Megan Kasimatis Singleton, Erin P. Williams, and Renee D. Boss, The Journal of Clinical Ethics 29, no. 2 (Summer): 145-9.
Children in foster care are considered a “vulnerable population” in clinical care and research, with good reason. These children face multiple medical, psychological, and social risks that obligate the child welfare and healthcare systems to protect them from further harms. An unintended consequence of the “vulnerable population” designation for children in foster care is that it may impose barriers on tracking and studying their health that creates gaps in knowledge that are key to their receipt of medical care and good outcomes. These gaps in knowledge have implications for justice, beneficence, and maleficence and serve to undermine “protection” of this population. Here we review the challenges of research regarding children in foster care, particularly medically complex children, and offer specific recommendations to include children in foster care in medical research.
Ethics Consultation Practice
The Work of ASBH’s Clinical Ethics Consultation Affairs Committee: Development Processes Behind Our Educational Materials
Courtenay R. Bruce, Jane Jankowski, Barbara L. Chanko, Anne Cordes, Barrie J. Huberman, Liza-Marie Johnson, Deborah L. Kasman, Aviva Katz, Ellen M. Robinson, Katherine Wasson, and George E. Hardart, The Journal of Clinical Ethics 29, no. 2 (Summer): 150-7.
The authors of this article are previous or current members of the Clinical Ethics Consultation Affairs (CECA) Committee, a standing committee of the American Society for Bioethics and Humanities (ASBH). The committee is composed of seasoned healthcare ethics consultants (HCECs), and it is charged with developing and disseminating education materials for HCECs and ethics committees. The purpose of this article is to describe the educational research and development processes behind our teaching materials, which culminated in a case studies book called A Case-Based Study Guide for Addressing Patient-Centered Ethical Issues in Health Care (hereafter, the Study Guide). In this article, we also enumerate how the Study Guide could be used in teaching and learning, and we identify areas that are ripe for future work.
The Development and Rationale for CECA’s Case-Based Study Guide
George J. Agich, The Journal of Clinical Ethics 29, no. 2 (Summer): 158-61.
This article discusses the approach of the Clinical Ethics Consultation Advisory Committee (CECA) in developing A Case-Based Study Guide for Addressing Patient-Centered Ethical Issues in Health Care. This article addresses the processes used by the CECA, its use of pivot questions intended to encourage critical reflection, and the target audience of this work. It first considers the salience of case studies in general education and their relevance for training ethics consultants. Second, it discusses the enfolding approach used in presenting the case material designed to engage the trainee in the details of the case while stimulating critical reflection. And, third, this article briefly comments on the target audience with the caveat that even superbly developed cases are prone to misuse, although that prospect should not deter their development.
Can Islamic Jurisprudence Justify Procurement of Transplantable Vital Organs in Brain Death?
Mohamed Y. Rady, The Journal of Clinical Ethics 29, no. 2 (Summer): 162-3.
In their article, “An International Legal Review of the Relationship between Brain Death and Organ Transplantation,” in The Journal of Clinical Ethics 29, no. 1, Aramesh, Arima, Gardiner, and Shah reported on diverse international legislative approaches for justifying procurement of transplantable vital organs in brain death. They stated, “In Islamic traditions in particular, the notion of unstable life is a way to justify organ donation from brain-dead patients that we believe has not been fully described previously in the literature.” This commentary queries the extent to which this concept is valid in accordance with the primary source of Islamic law, that is, the Quran.
Introduction to the Current Issue
Edge-of-the-Field Ethics Consulting:
What Are We Missing?
Edmund G. Howe