Hot Topics: Clinical Ethics

Blog Posts (60)

May 27, 2016

Why America Needs Bioethics Right Now

by Craig Klugman, Ph.D.

From the title, you probably assumed I’m going to talk about the fast changing pace of medical technology, whether we should be working on human embryos, claims that scientists will be able to do head transplants within 2 years, or even whether the Olympics should be postponed because of Zika.…

April 26, 2016

BioEthicsTV: A night of consent issues on ChicagoMed

by Craig Klugman, Ph.D.

On this week’s episode of ChicagoMed (Season 1; Episode 15) issues of consent was the main focus.…

April 21, 2016

Clarifying the Rules: No media in patient treatment areas

by Craig Klugman, Ph.D.

In January, I wrote about the case of Mark Chanko, a patient run over by a truck whose death was recorded for a real-life medical show and was later viewed on television by his horrified widow who had never been asked for permission for the airing.…

April 20, 2016

Stinging Doctors: Recording Your Own Surgery

by Craig Klugman, Ph.D.

Ethel Easter expressed outraged this week at what her health care team said about her during her surgery in Texas last year.…

March 21, 2016

The Unbearable Whiteness of Bioethics: Exhorting Bioethicists to Address Racism

by Kayhan Parsi, Ph.D.

To be ignorant of what occurred before you were born is to remain always a child.

March 18, 2016

Meditations on the Flood

When I first moved to Albany several months ago in pursuit of the exciting and glamorous life of a clinical ethics fellow, I brought with me only a handful of my earthly possessions; if the Fates have their way with me, I will likely leave with even less.

During this past month, in the late-night hours one night I awoke from my slumber to discover that while I had slept the majority of my basement apartment had been transformed into a bog. Yes, I was experiencing wintery real-life application of the law of thermal expansion as it applies to dihydrogen monoxide (i.e., a water pipe burst). After an emergency call to my landlord, I proceeded with my own separation of sheep from goats: what could be saved and salvaged was transported to the little dry land remaining in my now water-logged kingdom, while those items clearly destined to doom and decay were left languishing amidst the advancing liquid army. Few of my books survived, but among them was one I thought quite fitting to the circumstances: Marcus Aurelius’ Meditations.

Essential reading for any good Stoic (and, to my mind, useful if not essential reading for all human beings), Meditations, and the ancient words of wisdom it contains, helped me to navigate through and reflect upon my experience of the flood and its corresponding aftermath. Some choice morsels include:

Casting aside other things, hold to the precious few; and besides bear in mind that every man lives only the present, which is an indivisible point, and that all the rest of his life is either past or is uncertain. Brief is man’s life and small the nook of earth where he lives… (Book III, Number 10)

But among the things readiest to hand to which you should turn, let there be these two: One is that things do not touch the soul, for they are external and remain immovable; so our perturbations come only from our inner opinions. The other is that all the things you see around you change immediately and will no longer be; and constantly bear in mind how many of these changes you have already witnessed. The universe is transformation: life is opinion. (Book IV, Number 3)

Everything is only for a day, both that which remembers and that which is remembered. (Book IV, Number 35)

“I am unhappy, because this has happened to me.” Not so: say, “I am happy, though this has happened to me, because I continue free from pain, neither crushed by the present nor fearing the future.” For such a thing as this might have happened to every man; but every man would not have continued free from pain on such an occasion. Why then is that rather a misfortune than this a good fortune? (Book IV, Number 49)

One of the main life lessons Marcus Aurelius (and indeed all stoics) reiterates time and again is that the essential nature of our human existence is flux and fleetingness. Another is that our ability to respond to this flux and fleetingness, and how we choose to respond, constitute a great human power and our capacity for nobility. Our ability to bear the small things – minor losses of time, possessions, or our sense of control – help to prepare us for the inevitable big things with which we will one day be faced. The major losses.

I sometimes think that one of the most valuable things we can do as clinical ethicists is to help people – patients, families, physicians, etc. – with these particular life lessons. For many, the hospital experience is the epitome of flux, the reason for hospitalization a reminder of life’s fleetingness. Whatever the official reason for requesting an ethics consultation, minor and major losses are always there, whether in the present situation or looming on the horizon. We are consulted, I believe, in large part to help people bear these losses. 

And this becomes another part of my meditation: that this experience, and indeed each of my experiences, has the potential to become a tool for me to help others. The patient’s flood or the family’s flood may not be the same as my own flood, but in reflecting on how I could bear my flood, hopefully I can help guide or companion others as they bear theirs.

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, 2016

A Shot of Hope: Efforts to Address the Opioid Addiction Crisis

According to the American Society of Addiction Medicine, drug overdose is the leading cause of accidental death in the US with close to 50,000 deadly overdoses in 2015 alone.  Opioid addiction accounted for nearly 20,000 of these and heroin alone was a factor in just over 10,500 deaths. The magnitude of opioid abuse related hospitalizations, sales of prescription pain killers and deaths have increase exponentially between 1999 and 2008 according to ASAM. Increased access to Narcan (naloxone) to reverse life threatening effects of opioid for first responders has now expanded to making Narcan available to the general public as well. In some areas, Narcan can be purchased without a prescription by family members and friends who expect they may need to quickly rescue a loved one. While I support this program because it can and will likely save lives, it does not address the need for effective rehabilitation of persons who suffer the all-consuming and devastating effects of opioid addiction. Regulations which will allow persons with opioid addictions to be detained involuntarily in health care setting are also being discussed, but pose some dilemmas as well.

Massachusetts Governor Charlie Baker has taken a strong stand to help limit access to the powerful pain medication by placing statutory limits on the quantity of opioid pain medication that can be prescribed to a patient to a 72 hour supply the first time opioids are prescribed to them – with exceptions.  Physicians have had a mixed response according the October 2015 Boston Globe article. Some cite that placing prescribing restrictions on prescribing pain killers is an invasion of the state into the doctor-patient relationship and dismisses the clinical judgment of physicians to discern a given patient’s need for pain relieving medications. Others indicate that this is a public health matter and deserves statutory supports as have other issues that post a risk to the wellbeing of the population at large. Who is helped and who is harmed by restricting opioid prescriptions and providing naloxone without a prescription to the public? It seems these are just the tip of the iceberg in terms of a robust program for addressing the opioid addiction crisis in the US. Prevention will be more complicated than limiting the supply that flows from a physicians prescription pad and rescue will ultimately require more than easily access to Narcan.

 

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 4, 2016

Clinical Ethics Consultation As Practical Philosophy

As a philosopher who works in a large health science center where the scientific method and perspective reign supreme, it is common to hear comments about the abstract and ideal nature of philosophy. As though those who think about human problems from a philosophical perspective do so from an abstract, insular perspective with little or no practical impact. Though I hear such dismissive comments about philosophy less often than I used to, say 20 or more years ago, I sense there is still a commonly held view that those who think from a philosophical perspective as not well oriented to practical affairs. And with some justification do people have this view of philosophy.

 

As I have written in previous blogs, philosophy has long and even proud part of its tradition for being, well, useless. If we assume that the basis of philosophical truth and wisdom lay in some ultimate, objective form that only those who think in certain ways can grasp, then knowledge becomes privileged to the philosophical few as an end it itself. This type of Platonic philosophical truth quickly divides the here and now inferior world from the more exclusive understandings of reality. Because of this basic influence of Platonic philosophy, much of the history of philosophy in the Western tradition has been focused on the search for a rational, objective basis of truth, value, and reality. Not surprisingly, the goal has not been reached. But the quest continued through most of last century and philosophical got its more or less justified reputation for being an insulated, esoteric, and detached form of intellectual activity. Put bluntly, philosophers, with a few exceptions, rarely got their hands dirty in the real world of practical activity.

 

The role of philosophy vis-à-vis practical life began to change with the advent of applied ethics in the 1970’s. In the field of bioethics and clinical ethics, after a few decades of many philosophers actually working closely with practitioners, learning their language and the nature of their concerns about value laden dilemmas that arise in the experience of carrying out their responsibilities to patients and to society, philosophers I think are less useless. In fact I am pretty sure we are helpful, at least at times. Most of the time I interact with physicians and nurses about clinical cases in the hospital, or even with basic scientists about issues related to scientific integrity, I feel pretty sure we usually have constructive conversations and there is a sense of mutual respect as I attempt to make a recommendation that might help manage problematic situations. As someone nearing retirement (nothing definite) I am part of the first generation of bioethicists or as I prefer to think of myself, clinical ethics consultants, who were first trained as philosophers and then went on to become deeply involved in the practical and complex world of medicine and scientific research.

 

As I think about my work during the past 25 years and the nature of the problems that I now think about in my work experience, I am becoming more convinced that I am getting in touch with philosophy in a way I did not expect as a gradate student: as a natural human, practical activity meant to make a difference for the better. To be honest, I have always been attracted to a less influential lineage of philosophers, who believed philosophy is grounded in the most human concerns. Philosophy from this view, beginning in pre-Socratic philosophy, was very much like a medical art—in the same way medicine sought to treat bodily ills, philosophy sought to treat illnesses of the soul. Epicurus (341–270 BC) for example, famously said, “empty is that philosopher’s argument by which no human suffering is therapeutically treated.” Schools of philosophy sought to understand the world and human beings for the purpose of living a better life and relieving the soul of its natural tendency to be disturbed in a myriad of ways. Thus, philosophers who followed the teachings of Epicureanism, Stoicism, Skepticism, as well as Aristotelianism, were trained individuals who could be helpful in this regard—who could coach their students and prepare them for a life that brought out the most important characteristics necessary for well being, which always included prominently the emotions. In all of these philosophies, there is a keen focus on how the emotions could be regulated by correct or constructive belief, which leads to desired action and habit formation, and a change of internal disposition. The central focus for these schools of philosophy was eudaimonia, which generally means for those who study ethics, those actions that lead to a state of well-being or ataraxia (undisturbed soul or inner tranquility). The task of being a philosopher from this perspective is to learn those methods and approaches that would lead those being served or taught to such ends.

 

Perhaps the closest iteration of such a philosophy in recent times is American Pragmatism, particularly the works of William James and John Dewey, which unlike the pre-Socratics, particularly Dewey, is colored profoundly by the modern scientific method. Truth becomes a matter of what works based in experimental methods and that can bring about desire ends for better human living. Dewey’s hope was that philosophy would become part of the fabric of democratic life and be used to make a positive practical difference in society. His hope did not happen during his lifetime, but with the rise of applied ethics, this philosophical perspective of philosophy being connected the practical world, much like the ancient pre-Socratics, is now able to take a new contemporary shape in bioethics.

 

In spite of the obvious constraints of working in a contemporary hospital where patients have well articulated ethical and legal rights and physicians have clear professional obligations and responsibilities, many of the encounters I have as an ethics consultant involve individuals facing many of the same challenges that motivated ancient philosophers to develop remedies for treating their distressed emotions. When a family member of a dying patient is facing the loss of a loved one and the obligation to make excruciatingly difficult decisions about when to discontinue life supportive treatments, there is a deep emotional disturbance. Individuals in these situations are stressing, grieving, and often confused. The beliefs they have relative to the decisions they must make can have an enormous impact on their emotional state. For example if someone falsely believes that their making a decision to follow their loved one’s wishes and to withdraw ventilatory support for a dying patient was tantamount to them being personally responsible for the patient’s demise, the feelings of guilt and indecisiveness can be overwhelming.

 

In talking to individuals in these situations, much my goal is to help ease their emotional suffering if possible, or as Epicurus would say, is to offer words that provide therapy for the soul. There is nothing necessarily deeply philosophical to grasp. I start by seeing where the individual is. Why he or she is so distressed. What is the source of the disturbed emotions? Then a dialogue can occur to examine the beliefs he or she has that is connects to those emotions. As the ethics consultant, my role is facilitate, lead the dialogue, and allow the individual to critically examine his or her belief and to come to new understandings. Following someone’s stated wishes, for example, can be construed as a way of showing respect for your loved one; permitting the physicians to disconnect artificial life supports is not the cause of the patient’s death; it is rather the removal of burdens that are only prolong his terminal illness. A new narrative can often emerge. A new understanding that sheds light on one’s former beliefs and that brings some relief to suffering.

 

In a very different historical context than ancient philosophy, one of high technology and democratic life, applied ethicists have similar functions and practice with similar methods as practical philosophers of the past. The next time you hear someone disparaging philosophy as irrelevant or impractical, don’t believe them.

 

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 3, 2016

Finding the Right Tools for Assessing Quality of Clinical Ethics Consultation

by David Magnus, Ph.D.

This issue of the American Journal of Bioethics contains two extremely important Target Articles in the history of clinical ethics consultation.…

March 1, 2016

Code Black Ends the Season on Bioethics

BioethicsTV is an occasional bioethics.net feature where we examine bioethical issues raised in televised medical dramas.

by Craig Klugman, Ph.D.

The season finale of Code Black (season 1; episode 18 – February 24, 2016) presented a plethora of ethical challenges for the hard working doctors and nurses of Angels Memorial Hospital’s emergency department.…

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Published Articles (51)

American Journal of Bioethics: Volume 16 Issue 7 - Jul 2016

Moral Hazard in Pediatrics Donald Brunnquell & Christopher M. Michaelson

American Journal of Bioethics: Volume 16 Issue 3 - Mar 2016

A Pilot Evaluation of Portfolios for Quality Attestation of Clinical Ethics Consultants Joseph J. Fins, Eric Kodish, Felicia Cohn, Marion Danis, Arthur R. Derse, Nancy Neveloff Dubler, Barbara Goulden, Mark Kuczewski, Mary Beth Mercer, Robert A. Pearlman, Martin L. Smith STD, Anita Tarzian & Stuart J. Youngner

American Journal of Bioethics: Volume 16 Issue 3 - Mar 2016

Ethics Consultation Quality Assessment Tool: A Novel Method for Assessing the Quality of Ethics Case Consultations Based on Written Records Robert A. Pearlman, Mary Beth Foglia, Ellen Fox, Jennifer H. Cohen, Barbara L. Chanko & Kenneth A. Berkowitz

American Journal of Bioethics: Volume 16 Issue 3 - Mar 2016

Finding the Right Tools for Assessing Quality of Clinical Ethics Consultation David Magnus

American Journal of Bioethics: Volume 16 Issue 1 - Jan 2016

Balancing Legitimate Critical-Care Interests: Setting Defensible Care Limits Through Policy Development Jeffrey Kirby

American Journal of Bioethics: Volume 16 Issue 1 - Jan 2016

Professional Judgment and Justice: Equal Respect for the Professional Judgment of Critical-Care Physicians David Magnus & Norm Rizk

: Volume Issue - Jan 1970

Professional Judgment and Justice: Equal Respect for the Professional Judgment of Critical-Care Physicians David Magnus & Norm Rizk

American Journal of Bioethics: Volume 15 Issue 10 - Oct 2015

Doctors, Patients, and Nudging in the Clinical Context—Four Views on Nudging and Informed Consent Thomas Ploug & Søren Holm

American Journal of Bioethics: Volume 15 Issue 10 - Oct 2015

Do Patients Want to Participate in Decisions About Their Own Medical Care? John D. Lantos

American Journal of Bioethics: Volume 15 Issue 9 - Sep 2015

Patient Perspectives on the Learning Health System: The Importance of Trust and Shared Decision Making Maureen Kelley, Cyan James, Stephanie Alessi Kraft, Diane Korngiebel, Isabelle Wijangco, Emily Rosenthal, Steven Joffe, Mildred K. Cho, Benjamin Wilfond & Sandra Soo-Jin Lee

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News (119)

March 16, 2016 1:33 pm

'Difficult' patients may tend to get worse care, studies find

What happens to medical care when the patient is a jerk?  Dutch researchers asked the question in two new studies, and the answer should make grumps think the better of their bad behavior: “Disruptive” patients may get worse care from physicians.

December 8, 2015 2:54 pm

More than half of U.S. doctors experience burnout

Burnout among U.S. doctors is becoming more common and now affects more than half of practicing physicians, according to a new study.  About 54 percent of U.S. doctors experienced at least one symptom of burnout in 2014, compared to about 46 percent of doctors in 2011, researchers report in Mayo Clinic Proceedings.

December 2, 2015 6:31 pm

When medical knowledge is at a crossroads, how research can take patient preferences into account

Neither drug is experimental; both are within the standard of care. Your doctor doesn’t have any medical reason to recommend one or the other.
November 10, 2015 4:48 pm

The Theranos mess: A timeline

How the blood-testing company went from hot to troubled in just a couple of weeks.

November 3, 2015 12:12 pm

A group of middle-aged whites in the U.S. is dying at a startling rate

A large segment of white middle-aged Americans has suffered a startling rise in its death rate since 1999, according to a review of statistics published Monday that shows a sharp reversal in decades of progress toward longer lives.

October 27, 2015 6:11 pm

Heaven over hospital: Dying girl, age 5, makes a choice

Julianna Snow is dying of an incurable disease. She’s stable at the moment, but any germ that comes her way, even just the common cold virus, could kill her. She’s told her parents that the next time this happens, she wants to die at home instead of going to the hospital for treatment.

October 26, 2015 7:24 pm

Clash in the name of Care

It was a battle pitting a star surgeon against a great hospital, MGH. The question: Is it right or safe for surgeons to run two operations at once? Is it right that their patients may have no idea? The conflict went on for years. And it isn’t over yet.

September 24, 2015 1:02 pm

Black patients fare better than whites when both get same healthcare, study finds

A nine-year study of more than 3 million veterans found that when black patients and white patients received the same level of healthcare, blacks fared better than whites.

September 16, 2015 4:01 pm

Poverty may increase odds of repeat hospitalizations

When patients are hospitalized more than once in the same month, it may have more to do with their income or education levels than the quality of care they received, a U.S. study suggests.

September 15, 2015 3:54 pm

Rise in crowdfunding lets patients seek help for medical treatment

When Esperanza Hannon was denied entrance to a clinical trial in June, it was another dashed hope in many attempts to find treatment for her fast-spreading breast cancer.

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