The Journal of Clinical Ethics, Volume 29, Number 3, Fall 2018


At the Bedside


How We May Become Detached from Our Patients and What We Can Do If This Happens

Edmund G. Howe, The Journal of Clinical Ethics 29, no. 3 (Fall 2018): 167-78.

When clinicians provide clinical care or participate in ethics consultations, they may feel exceptionally painful emotions. When they do, they may distance themselves emotionally from patients and families. This distancing may harm these parties profoundly. It is therefore critical that clinicians avoid this distancing. In this piece, I present an approach that lies outside traditional practice that clinicians may use to try to avoid and even reverse this distancing, if and when they sense that this may be occurring. This approach may also benefit patients and families. It may increase their sense that their clinicians are working with them as allies to achieve their shared medical goals.

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Deathbed Confession: When a Dying Patient Confesses to Murder: Clinical, Ethical, and Legal Implications

Laura Tincknell, Anne O’Callaghan, Joanna Manning, and Phillipa Malpas, The Journal of Clinical Ethics 29, no. 3 (Fall 2018): 179-84.

During an initial palliative care assessment, a dying man discloses that he had killed several people whilst a young man. The junior doctor, to whom he revealed his story, consulted with senior palliative care colleagues. It was agreed that legal advice would be sought on the issue of breaching the man’s confidentiality. Two legal opinions conflicted with each other. A decision was made by the clinical team not to inform the police.

      In this article the junior doctor, the palliative medicine specialist, a medical ethicist, and a lawyer consider the case from their various perspectives.

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Ethical Challenges in Acute Evaluation of Suspected Psychogenic Stroke Mimics

Alexandra J. Sequeira, Michael G. Fara, and Ariane Lewis, The Journal of Clinical Ethics 29, no. 3 (Fall 2018): 185-90.

Tissue plasminogen activator (tPA) is administered to patients with suspected ischemic stroke to improve blood flow to the brain In rare cases, patients present with complaints of stroke symptoms that appear to be non-organic due to malingering, factitious disorder, or conversion disorder (psychogenic stroke mimics). Deciding whether or not to administer tPA to these patients can be challenging. The risk of hemorrhage after administration of tPA is low, but not zero. The ethical principles of beneficence and nonmaleficence need to be weighed carefully in these situations. We present two cases of patients with suspected psychogenic stroke mimics to illustrate the ethical challenges faced in identifying and managing psychogenic stroke mimics. Further research is needed to demonstrate effective treatment strategies for patients with acute stroke symptoms of psychogenic etiology.

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Positive HIV Test Results from Deceased Organ Donors: Should We Disclose to Next of Kin?

Anne L. Dalle Ave and David M. Shaw, The Journal of Clinical Ethics 29, no. 3 (Fall 2018): 191-5.

In the context of deceased organ donation, donors are routinely tested for HIV, to check for suitability for organ donation. This article examines whether a donor’s HIV status should be disclosed to the donor’s next of kin.

      On the one hand, confidentiality requires that sensitive information not be disclosed, and a duty to respect confidentiality may persist after death. On the other hand, breaching confidentiality may benefit third parties at risk of having been infected by the organ donor, as it may permit them to be tested for HIV and seek treatment in case of positive results.

      We conclude that the duty to warn third parties surpasses the duty to respect confidentiality. However, in order to minimize risks linked to the breach of confidentiality, information should be restrained to only concerned third parties, that is, those susceptible to having been infected by the donor.

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Posthumous HIV Disclosure and Relational Rupture

Laura K. Guidry-Grimes and D. Micah Hester, The Journal of Clinical Ethics 29, no. 3 (Fall 2018): 196-200.

In response to Anne L. Dalle Ave and David M. Shaw, we agree with their general argument but emphasize a moral risk of HIV disclosure in deceased donation cases: the risk of relational rupture. Because of the importance that close relationships have to our sense of self and our life plans, this kind of rupture can have long-ranging implications for surviving loved ones. Moreover, the now-deceased individual cannot participate in any relational mending. Our analysis reveals the hefty moral costs that disclosure can bring, which should influence what information is given to would-be donors and how organ procurement coordinators approach these conversations.

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Plain Anabaptists and Healthcare Ethics

James Benedict, The Journal of Clinical Ethics 29, no. 3 (Fall 2018): 201-5.

Plain Anabaptists are a small but rapidly growing ethnoreligious society with significant concentrations of population in a number of regions in North America. Among the most widely known of the various groups of Plain Anabaptists are the Amish and the Old Order Mennonites. It is the purpose of this article to provide insight into the culture and values of the Plain Anabaptists so that those who may be called upon to address ethical conflict involving Plain Anabaptists can do so with appropriate knowledge and sensitivity. The discussion of the culture and values of the Plain Anabaptists will be organized as follows: first we will explore the implications of Plain Anabaptist culture and values for applying the ethical principles of respect for autonomy and beneficence/nonmaleficence. Second, a brief description of several elements of Plain Anabaptist culture will be discussed with attention to the potential they create for ethical conflict in the healthcare setting.

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Refusal of Vaccination: A Test to Balance Societal and Individual Interests

Kavita Shah Arora, Jane Morris, and Allan J. Jacobs, The Journal of Clinical Ethics 29, no. 3 (Fall 2018): 206-16.

While all states in the United States require certain vaccinations for school attendance, all but three allow for religious exemptions to receiving such vaccinations, and 18 allow for exemptions on the basis of other deeply held personal beliefs. The rights of parents to raise children as they see fit may conflict with the duty of the government and society to protect the welfare of children. In the U.S., these conflicts have not been settled in a uniform and consistent manner. We apply a test that provides a concrete and formal rubric to evaluate such conflicts. For some vaccinations, based on the individual medical characteristics of the disease and the risks of being unvaccinated, the test would suggest that permitting conscientious exemptions is ethical. However, for vaccinations protecting against other diseases that are more severe or easily transmitted, the test would suggest that the federal government may ethically impose laws that deny such exemptions.

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Nursing Ethics Huddles to Decrease Moral Distress among Nurses in the Intensive Care Unit

Marianne C. Chiafery, Patrick Hopkins, Sally A. Norton, and Margie Hodges Shaw, The Journal of Clinical Ethics 29, no. 3 (Fall 2018): 217-26.

Background: Moral distress (MD) is an emotional and psychological response to morally challenging dilemmas. Moral distress is experienced frequently by nurses in the intensive care unit (ICU) and can result in emotional anguish, work dissatisfaction, poor patient outcomes, and high levels of nurse turnover. Opportunities to discuss ethically challenging situations may lessen MD and its associated sequela.

Objective: The purpose of this project was to develop, implement, and evaluate the impact of nursing ethics huddles on participants’ MD, clinical ethics knowledge, work satisfaction, and patient care among ICU nurses.

Sample and Setting: The sample, 32 nurses from three ICU settings in an 800-bed tertiary academic medical center, participated in six nursing ethics huddles over a two-month period.

Methods: Alvita K. Nathaniel’s Theory of Moral Reckoning guided development of the nursing ethics huddle process. The Moral Distress Thermometer was administered at three data points: baseline level of MD, and pre- and post-huddle to determine changes in the subjects’ level of MD. Focused content analysis was used to analyze qualitative responses from questionnaires about the subjects’ perception of the effect of the huddles on work satisfaction and patient care. Knowledge attainment was evaluated via open-ended short-answer questions.

Results: Overall, use of nurse-ethicist-led nursing ethics huddles was associated with improved quality of work life, patient care, and clinical ethics knowledge. The change in pre- and post-nursing ethics huddles MD scores was statistically significant (p < 0.0001).

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”I Would Do It All Over Again”: Cherishing Time and the Absence of Regret in Continuing a Pregnancy after a Life-Limiting Diagnosis

Charlotte Wool, Rana Limbo, and Erin M. Denney-Koelsch, The Journal of Clinical Ethics 29, no. 3 (Fall 2018): 227-36.

Parents, after learning of a life-limiting fetal condition (LLFC), experience emotional distress and must consider options that impact the remainder of the pregnancy, their future lives, and family members. For those who continue, little is known about their long-term presence or absence of regret about their choice, the reasons for this feeling, or its impact on their life. The aim of this research was to examine the concept of decision regret in parents who opted to continue a pregnancy affected by an LLFC. The contextual factors, conditions, and consequences surrounding the presence or absence of regret were analyzed.

      Data were retrieved from a cross-sectional study using the Quality of Perinatal Palliative Care and Parental Satisfaction Instrument. Participants were parents (N = 405) who experienced a life-limiting prenatal diagnosis and opted to continue their pregnancy. Secondary data analysis examined qualitative responses (121/402) to an item addressing regret. Dimensional analysis was used to examine data, identifying context, conditions, and consequences associated with the presence or absence of regret.

      Absence of regret was articulated in 97.5 percent of participants. Parents valued the baby as a part of their family and had opportunities to love, hold, meet, and cherish their child. Participants treasured the time together before and after the birth. Although emotionally difficult, parents articulated an empowering, transformative experience that lingers over time.

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The Mission of Safety Net Hospitals: Charity or Equity?

Thea James, The Journal of Clinical Ethics 29, no. 3 (Fall 2018): 237-9.

The traditional mission of safety net hospitals has been charity, providing the best healthcare for all individuals no matter their ability to pay. The focus has been on vulnerable populations that are low-income, uninsured, and other upstream circumstances that manifest downstream as poor health, poor health outcomes, and repeated high-cost interventions that fail to break cycles of perpetual health instability. Safety net hospitals are committed to serving their populations, even if only temporarily, through provision of subsidies and filling gaps that exist in patients’ lives. These interventions do not lead to the elimination of gaps, hence cyclical health instability persists. It is a new day in healthcare and what it means for people to be well. The focus is on improving health outcomes by addressing root causes of health instability such as unstable housing, income, education, and access to affordable healthy foods. This gives us pause to reflect on the traditional mission of safety net hospitals and the impact of charity in isolation. Are safety net hospitals missing an opportunity to mitigate and eliminate perpetual health instability? Can they shift the paradigm of healthcare for vulnerable populations to alter their quality-of-life course? To move forward, safety net hospitals have to change their mind set and existing narratives about what is possible for vulnerable populations to achieve. These historic giants in healthcare have an opportunity to use their assets and employ a methodology of disruption and innovation to shift the mission of safety net healthcare from charity to equity.

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Scribes, Electronic Health Records, and the Expectation of Confidentiality

Paul M. Wangenheim, The Journal of Clinical Ethics 29, no. 3 (Fall 2018): 240-3.

Electronic health record (EHRs) have largely replaced obsolete paper medical charts. This replacement has produced an increased demand on physicians’ time and has compromised efficiency. In an attempt to overcome this perceived obstacle to productivity, physicians turned to medical scribes to perform the work required by EHRs. In doing so, they have introduced an uninvited participant in the physician-patient relationship and compromised patients’ confidentiality. Scribes may be a successful work around for physicians frustrated by EHRs, but patients’ confidentiality should not be sacrificed in the process.

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Introduction to the Current Issue


How We May Become Detached from Our Patients and What We Can Do If This Happens

Edmund G. Howe


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