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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New Paradigms in Medical Ethics

Edmund G. Howe

 

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