Topic: Clinical Ethics
January 12, 2016 | Posted By Bruce White, DO, JD

As is their publishing practice, the American Journal of Bioethics recently invited submissions for an Open Peer Commentary to an article they plan to publish in the next few months. The article is entitled “A Pilot Evaluation of Portfolios for Quality Attestation of Clinical Ethics Consultants” and authored by Joseph J. Fins, MD, Eric Kodish, MD, and the other members of the American Society for Bioethics and Humanities (ASBH) Quality Attestation Presidential Task Force (QAPTF). This paper is a sequel to their earlier paper “Quality Attestation for Clinical Ethics Consultants: A Two-Step Model from the American Society for Bioethics and Humanities” which was published in The Hastings Report. [http://www.ncbi.nlm.nih.gov/pubmed/24092588] The first paper described the ASBH plans to “attest” to the “quality” of self-identified, randomly-selected pilot clinical ethics consultants who submit a “portfolio” illustrating their consultation activities. When the article appears, all involved in clinical ethics consultation and the training of future clinical ethics consultants should read the paper. The QAPTF and the ASBH should be congratulated for doing this work and sponsoring the activity.

However, in thinking through this process again, one wonders how much of this is about the past and not about the future. Shouldn’t any process be more prospective and less retrospective? Maybe this is not possible? But how important is it really to show that people who are currently offering clinical ethics consultation services and recording their efforts in portfolios for other “experts” to review and compare do their consultations satisfactorily? Will this “attestation” somehow change their employment or practice circumstances or patterns? Will their employers dismiss them if they fail to obtain “attestation” status and hire clinical ethics consultants are meet the attestation standard? Will it add public recognition? In truth, is “attestation” really a quality standard that matters?

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

January 4, 2016 | Posted By Valerye Milleson, PhD

"I now know that if you describe things as better as they are, you are considered to be romantic; if you describe things as worse than they are, you are called a realist; and if you describe things exactly as they are, you are called a satirist." – Quentin Crisp

A theme that has run through many of my blog posts so far is the concept of eudaimonia. This New Year, which not only highlights the annual rituals of goal setting and actively plotting to become the best person you can be in the year to come but also is a reminder of the birth of famed raconteur and master of wit, Quentin Crisp, seems to me like the perfect time to discuss this concept in greater detail.

"If I have any talent at all, it is not for doing but for being." – Quentin Crisp

Despite his humble self-description, Quentin Crisp has been a hero to many, and in his vocation of being he was one of the strongest advocates of “living well” in recent times. Living well (or “good spirit”, happiness, human flourishing, etc.) is roughly what ancient Greek philosophers meant by eudaimonia. Aristotle’s definition in the Nicomachean Ethics of “living well and doing well” (Book I, Chapter IV) is apt and fairly uncontroversial; but it is far from self-explanatory. After all, “living well” can mean different things to different people. For Aristotle, living well basically meant living a life of excellence in reason (along with certain external goods necessary to keep this virtuous activity going smoothly). The Stoics agreed with Aristotle’s account on the role of excellence in reason, but disagreed with him about the importance of such things as wealth, family, friends, power, beauty, etc. in one being able to achieve eudaimonia. The Cynics and the Stoics held fairly similar views of eudaimonia, but in general the Cynics seemed to actively disavow these external things, and living well to a Cynic would have been more akin to the life of a virtuous ascetic. The Cynics also tended to be, like Mr. Crisp, satirists, cosmopolitans, and lovers of excellence and humanity.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

December 24, 2015 | Posted By Paul Burcher, MD, PhD

I was surprised to read recently in the New York Times that a woman has undergone a cesarean section despite her refusal to consent to the procedure.  While the details of the case are not entirely clear in the article, so I do not want what follows to be understood as a specific comment on this case, my surprise arises because I thought the ethics of refusal of consent were not in dispute.  The American College of Obstetrics and Gynecology has taken a clear position of this: it is not justifiable to perform surgery on a patient with decisional capacity without her consent. ACOG’s committee opinion, “Maternal Decision Making, Ethics, and the Law,” strongly discourages even attempting to seek a court order for treatment when a pregnant woman refuses cesarean section, and concludes with a statement that:

Pregnant women's autonomous decisions should be respected. Concerns about the impact of maternal decisions on fetal well-being should be discussed in the context of medical evidence and   understood within the context of each woman's broad social network, cultural beliefs, and values. In the absence of extraordinary circumstances, circumstances that, in fact, the Committee on Ethicscannot currently imagine, judicial authority should not   be used to implement treatment regimens aimed at protecting the fetus, for such actions violate the pregnant woman's autonomy. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

December 14, 2015 | Posted By Wayne Shelton, PhD

The role of family surrogates in providing a voice for incapacitated patients is of crucial importance. Usually, surrogates have the best interests of the patient in mind and try to work with the physician in charge to provide the best treatment possible for the patient. In most cases there is agreement between the surrogate and the physician about the treatment plan and the goals of care. But as those of us who do clinical ethics consultations know, there are some cases, maybe 5% or fewer, where there are serious conflicts between surrogates of patients lacking capacity and physicians. I want to briefly explore a type of conflict that we seem to be seeing more often—when the surrogate attempts to get too involved in the medical management of the patient. Let me use a couple of sample cases to illustrate the type of conflict I have in mind.

The first is the case of an elderly patient with dementia and with multiple medical problems, including severe pressure ulcers. This patient requires regular dressing changes for the pressure ulcers in order to keep them clean and well managed, requiring the patient to be turned, which causes her significant discomfort. When these dressing changes happen, the standard of care is to make sure the patient suffers as little as possible, so a small amount of morphine is given. But the family surrogate informed the nurse that she should not use morphine, as she wanted the patient to remain as alert as possible at all times. When the nurse tries to perform the dressing changes without giving morphine the patient groans, grimaces, and appears agitated and in pain. The nurse feels distraught that she is causing the patient to suffer unnecessarily.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

October 9, 2015 | Posted By Valerye Milleson, PhD

“People need to be made more aware of the need to work at learning how to live because life is so quick and sometimes it goes away too quickly.” – Andy Warhol

This past weekend was the last one for The Late Drawings of Andy Warhol: 1973-1987 exhibit at The Hyde Collection Museum in Glen Falls, and I almost didn’t go to it. I told myself there were far too many other things to do: the stack of recent journal articles I’ve been meaning to get to; student assignments that are in need of grading; the upcoming presentations for which I haven’t even begun putting together powerpoints; the apartment that, despite ongoing efforts, never seems to be completely clean; the piles of unwashed or unfolded laundry; and so on. In terms of triaging my limited time, a two-hour round trip trek to see a handful of sketches hardly seemed sufficiently important.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

July 7, 2015 | Posted By Bruce White, DO, JD

In his last AMBI blog posted on June 18, 2015, Wayne N. Shelton, PhD, MSW, discussed recent movement toward the professionalization of clinical ethics consultants. He noted the adoption of a Code of Ethics for Health Care Ethics Consultants by the American Society for Bioethics and Humanities (ASBH), which has been praised as important milestone toward the professionalization of clinical ethics consultants. Moreover, Dr. Shelton listed several challenges that “professionals” who call themselves “clinical ethics consultants” currently face, including: “[1] how to make sense of the diverse educational backgrounds and training of those who perform clinical ethics consultations and how far to push such requirements; [2] the lack of a national body to set requirements that leaves local hospital leaders with little incentive to pay for highly qualified CECs and view this as a sound investment; and finally [3], most seriously, the way in which many problems in patient care are misidentified as clinical ethical problems while other serious clinical ethical problems may be entirely overlooked or if recognized, not viewed as requiring the expertise of a CEC.” He concluded his post with: “These challenges are indications that clinical ethics consultation will not likely achieve professional status in the healthcare system in the near future.” Of course, Dr. Shelton is correct in his analysis, but some might see the challenges he listed as surmountable if those who practiced clinical ethics consultation were to: (1) establish minimum uniform educational standards for new clinical ethics consultants; (2) create national certification and accreditation standards so employers would more fully understand the nature and value of their work; and (3) provide consultants themselves and other stakeholders unmistakable guidance on what clearly constitutes the work of clinical ethics consultants. (This third point sounds very much like a “scope of practice” definition found in state professional licensing statutes.) However, it may take something much more for clinical ethics consultants to be a separate professional category.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

June 18, 2015 | Posted By Wayne Shelton, PhD

Let me say emphatically at the outset of this blog, as someone who has been a clinical ethics consultant for over 20 years, I am quite sure that clinical ethics consultations overall improve the quality of patient care and currently are an important, even essential, part of the providing excellent patient care in hospitals. Contemporary medicine is filled with value laden questions and issues that often can be effectively addressed by someone with expertise and training in clinical ethics. Having said this, I am still somewhat skeptical about clinical ethics consultation becoming a professional area of healthcare that parallels other professional areas like medicine, nursing, and social work. I think there are some special considerations about the field of clinical ethics consultation that makes its future status as a professional activity uncertain.

First of all it is well-known that CEC’s come from a variety of backgrounds and training—from philosophers to physicians to social workers to nurses and lawyers and on and on. People enter the field of clinical ethics consultations from very different disciplinary backgrounds and seemingly learn a common vocabulary and methodology of clinical ethics and a basic familiarity with and ability to function in the clinical setting. They learn this vocabulary in very different ways—some informally, some through short 1-2 week long intensives, some with certificate programs, some with master’s degrees, and some with 1-2 year long fellowships. No other area of healthcare work admits of such diversity. Though this is a positive feature in some ways by providing diverse perspectives in understanding value dilemmas, it creates a challenge of considerable controversy when we try to define the kind of educational training a future CEC should have. At the moment there seem to be many pathways into the field and no clear answer has emerged.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

June 9, 2015 | Posted By Jane Jankowski, DPS, LMSW

Clinicians striving to help patients achieve healthcare goals often encounter the perplexing dichotomy of the patient’s stated goals and preferences and actions to the contrary. Some of these challenges can be overcome with education and close follow up to help reinforce adherence to medical recommendations, but other times, these barriers are more enigmatic.

Take for example, a patient who requires hemodialysis to sustain life. She sometimes shows up for her outpatient dialysis, but more often does not show up and is admitted to the hospital for emergent dialysis several months in a row. In consultation with her providers she is adamant that she does not want to die, and knows that she needs the dialysis to remain alive. She is discharged, and the pattern continues. Liberal scheduling with the outpatient service, transportation, reminders are all offered. Psychological tests and support are provided, and yet, her action pattern of not adhering to the treatment plan continues. Again, she is advised it is acceptable to halt and she will be offered palliative care. She refuses, and says she wants to live and will sit for dialysis. What is her genuine preference? Should we honor these statements, or accept her actions as the more authentic expression of her wishes? Though this hypothetical example is quite familiar to renal care providers, the dynamic spans many scenarios leaving many practitioners with a dilemma about the practical limits of honoring verbalized wishes that are not supported by congruent actions.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

May 11, 2015 | Posted By Jane Jankowski, DPS, LMSW

In the most recent issue of The Journal of Clinical Ethics, authors Genes and Appel explore the ethical considerations at play when physicians might use the internet to gather patient information. They conclude, correctly I believe, that there are circumstances in which accessing information about a patient supports beneficent efforts to provide quality care, even in non-emergent circumstances. Rather than damaging the doctor patient relationship, an informed provider is better equipped to support the patient’s best interests if loved ones can be located, presentation of information can be confirmed as factual or not, and the context of this patient’s needs can be more fully understood by the care team.

Social media, such as the now ubiquitous Facebook, is often considered a forum where people may express thoughts and feelings they fail to articulate in person. Consider the posts of an angry or despondent partner after the end of a relationship. Should commentary become threatening – to self or others – this is considered cause for concern and these comments are taken as valid expressions that warrant immediate emergency intervention. Text messages carry the same weight as spoken words, and are preserved in electronic format to be shared by the recipient at will. Failing to consider such communications as part of the purview of healthcare providers could lead to harm for the patient or others. While these expressions might not be quickly discoverable by physicians, they can, in some instances, be lifesaving components adding to the overall clinical picture. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.  

March 10, 2015 | Posted By Jane Jankowski, DPS, LMSW

One of the challenges clinicians must learn to manage is the patient who does not adhere to medical recommendations while expressing the desire to be well. It is widely accepted that patients with the capacity to make informed decisions retain the right to make choices that are good for them and choices that are not, there are instances where capacity to make a choice becomes less relevant than the practical considerations related to achieving the patient’s goals. When patients state they wish to recover from illness but refused to comply with the necessary treatments this disconnect poses a different kind of dilemma. Morally, it is simpler to digest that that some patients will refuse treatment, and there is robust support for respecting refusals. But what do we do when a patient asks for one thing but does another? Such cases pose intractable impasses for providers who arrange care plans based on the patient’s stated goals of recovery, yet encounter what seem to be enigmatic refusals to adhere to recommendations and interventions. There is a clear obligation to attempt to understand the patient’s perspective and thoroughly as possible. What may appear to be inconsistencies in preference may very well have a logical explanation. Once efforts to unpack dissonant expressions have been exhausted, a different approach may be needed to figure out what may be possible for such a patient. The first question is often about capacity – does a patient who asks for one thing but does another possess the ability to make an informed decision? In some cases, the resolution ends here if the patient is found to be unable to make an informed decision – or does it? If the objection is strong, and the intervention requires a high degree of cooperation from the patient, capacity may be moot because there is no practical way to proceed without cooperation. For example, a patient who insists she does not want to die, but simultaneously resists life sustaining dialysis leaves providers with very few options. A patient receiving a temporary intervention to buy time for recovery may in fact, not achieve the desired healing – how long must a bridge therapy continue? In such cases, capacity may be part of the picture, but I would argue it sometimes becomes a red herring we chase instead of taking a hard look at the medical facts and practical considerations in such cases. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website. 
SEARCH BIOETHICS TODAY
SUBSCRIBE TO BIOETHICS TODAY
ABOUT BIOETHICS TODAY
BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
TOPICS