Hot Topics: Clinical Ethics

Blog Posts (69)

September 14, 2017

Perceived Ethical Dilemmas from Labels

Ever hear the expression it’s all in your head? In witnessing a pattern of ethics consults, I have been wondering lately how much of ethical dilemmas are truly perceived dilemmas and not really dilemmas at all. We are our own worst enemies in many ways and health care providers are no exceptions to the flaws of humanity. We perceive a conflict and therefore a conflict arises. Then comes the need for an ethics consultant. Perceptions drive much of society, including ethical dilemmas. 

A physician will hear a label, whether it is ‘drug-addict,’ ‘Christian,’ ‘illiterate,’ ‘difficult,’ ‘noncompliant,’ and he/she will assume all the characteristics that go with that label. This will then create a perceived conflict between the provider and patient based on the presumed characteristics. These labels could have attached to the patient years prior to the current admission but yet, they remain in a patient’s record as past medical history. The classic example is ‘wanting everything done’ when it comes to end-of-life care. Many jump to the conclusion based on particular faiths (or even just hearing that the patient is religious) that patients and families want everything done and will not be open to a conversation about comfort care and hospice. They assume based on a label, that may not be true. A perceived conflict has emerged. These assumptions change how the conversation will go, whether the physician realizes it or not, because the physician is preparing for a challenge. A simple question or inquiry by a family or friend about the medical information may then seem like push-back, since that is what the physician is expecting, when in reality it is just a question. 

I joke that it’s part of the ethics magic of just appearing in a room and problems are solved, but yet, there is more to it. Many would argue that it is the comforting and supporting presence just in case something goes wrong in conversations with patients and families. The presence being the ethics consultant. Much of it is facing the perceived dilemma only to realize there is no conflict at all. This is also the role of the ethics consultant, to face the conflict with the provider and to show that nothing’s wrong. There has many family meetings where providers have asked for an ethics consultant for a variety of reasons and it turns out that the providers could handle the conversation without any assistance. Some may say this is a good provider because the physician is recognizing his/her own limits and asking for help. And maybe it is but maybe labeling it as a conflict is not the best approach either. 

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

July 24, 2017

When a doctor calls a patient a racial slur, who is hurt?

by Keisha Ray, Ph.D.

Last week Lexi Carter, a black woman from Tennessee had an experience that so many other black people have had, a racially charged visit with a doctor.…

May 31, 2017

He’s NOT a Ward of the State: Legal Significance of Words in Clinical Setting

As a lawyer by training and working as a non-lawyer in a clinical setting, I hear legal words of art tossed around without knowledge of their meaning.  In many cases, wrong terminology is the least of the healthcare team’s concerns and it is not an issue.  However, there are times when correct understanding of the legal significance of a phrase resolves an ethical dilemma all on its own.  

The phrase I have been hearing lately in the clinical setting is “ward of the state.”  This phrase has significance for the health care team because it determines who has authority to make decisions for a patient who lacks capacity, such as patients with development disabilities (“DD”). The legal meaning of “ward of the state” means that the patient has a public legal guardian (as opposed to a family member or friend as guardian). For those who do not understand its meaning, those using the term are usually referring to someone who is receiving health care services from a state agency or living in a group home.  The key misunderstanding is that receiving state services does not automatically deem one a “ward of the state” in the eyes of the law. A patient could be receiving services from Office for People with Developmental Disabilities without having a legal guardian. According to the New York Health Care Decisions Act, a 17-A guardian is the one who makes decisions for anyone with an intellectual or developmental disability, including health care decisions.  This is a legal process. It is common for a facility with patients with disabilities to begin a guardianship process for their residents who lack capacity as part of their admission process, but this is not always the case. This difference in understanding becomes an issue when the medical team is looking to make a major medical decision, such withdrawal of care, and no one understands with whom to discuss the plan of care. One may go down a rabbit hole of investigation to find who has guardianship only to learn that there was no public guardian at all. 

Another commonly misunderstood legal word is “proxy.”  Technically, proxy refers to the health care proxy form, a legal document, not the person. However, even lawyers sometimes call the appointed person “proxy,” even though the correct term would be “health care agent.” Proxy and surrogate have different legal meanings; proxy refers to a legal form and surrogate refers to someone who has health care decision making authority based on statute. If someone has health care decision making authority based on a proxy document, it means there was legal paperwork completed and it is evidence of the patient’s preferences. Both a health care agent and surrogate have the same authority; it just comes from a different source. Further, it is harder to remove a named health care agent’s authority than a surrogate’s authority. In order to remove a health care agent, one has to go through a legal proceeding, while removal of a surrogate would be an internal hospital process based on a series of factors, such as who is acting in the patient’s best interests. The difference matters in a clinical setting when there are multiple family members and the medical team is trying to determine who should be the decision maker. A health care agent would trump a surrogate, despite the familial relation. 

Language has meaning. This is not a new revelation.  Language has different meanings in different contexts.  A word in a court room means something very different from the same word in the clinical setting.  However, there are times when the legal meaning of a word has importance in the clinical setting as well. Understanding the legal meaning helps clarify conflict and in these two examples, who is the appropriate decision maker. It is important for health care providers to be precise in their language, as using such terms more carefully may result in better resolution of perceived ethical dilemmas.   

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 25, 2017

CPR and Ventricular Assist Devices: The Challenge of Prolonging Life Without Guaranteeing Health

by David Magnus and Danton Char

The woods decay, the woods decay and fall,
The vapours weep their burthen to the ground,
Man comes and tills the field and lies beneath,
And after many a summer dies the swan.

December 1, 2016

Moral Distress in Clinical Ethics: Expanding the Concept

by Alyssa M. Burgart & Katherine E. Kruse

As physician ethicists, we often receive consultations where there is no clear ethical question, but rather, discomfort around value judgments.…

October 12, 2016

Clinical Ethics Consultation Services and Expectations: Is It That Much Different From Other Clinical Services?

Two recent presentations at the 2016 Annual Meeting of the American Society for Bioethics and Humanities in Washington, DC – offered within just a couple of hours of each other – had a similar theme but approached the issue from different angles. The first presentation was a case review by David Kappel, MD, a surgeon at the University of West Virginia, and Valerie Satkoske, MSW, PhD, a bioethics professor at the University of West Virginia Center for Bioethics and Health Law. The case involved a 75-year-old-man admitted for surgery. Unfortunately, following the surgery, he was delirious. The delirium continued for several days. He had to be restrained and fed with a nasogastric tube. The situation was very upsetting to his family; they were completely taken aback by this complication. The delirium was so unexpected and surprising that the family wondered whether or not the patient would have agreed to the surgery if he had fully understood that the extended delirium might result. The title of this presentation was: “You Should Have Told Me! Struggling to Meet the Spirit of Informed Consent.” As one can imagine, the presenters asked if information about the possibility of an extended delirium should have be included as a part of the informed consent process. The delirium was not part of the patient’s and family’s expectations. Of course, even with a more extensive, informed consent process, the family still may have not been fully prepared to deal with the complication anyway. Perhaps the answer turns more on the likelihood of the complication arising in this patient’s case given the particulars and context? Some complications are more probable than others given the circumstances?

The second presentation, titled “I Never Promised You a Rose Garden: On the Necessity of Not Meeting Expectations Regarding Clinical Ethics Consultation,” was given by Virginia L. Bartlett, PhD, and Stuart G. Finder, PhD, of Cedars-Sinai Medical Center. This presentation too dealt with expectations: the expectations those who ask for a clinical ethics consultation might have of clinical ethics consultants. The presenters suggested that the expectations might range from “ethics policeman” to “ethics superhero.” The presentation ended with the relatively unsatisfactory mechanisms available to evaluate the effectiveness or helpfulness of clinical ethics consultation services interventions. From the presentation, it was clear that clinical ethics consultants should be prepared for not meeting expectations of those who request assistance.

Regardless, both presentations highlight how important it is for clinicians – whether physicians or surgeons directly caring for patients or clinical ethics consultants offering advice or recommendations to colleagues or patients or families – to understand stakeholder expectations as well as they can. With doctors and nurses it may be a bit easier: mostly likely the patient wants to be restored to health or a baseline with the least discomfort and minimal aggravation. With clinical ethics consultation services, the expectations are often not this clear. Moreover, with both clinical medicine and clinical ethics consultation service interventions, there are complications and unintended consequences. One cannot always fully anticipate which way a case may turn, or which word or phrase at a particular moment may result in a worse situation rather than a better situation.

For good or ill, there is no informed consent equivalent for clinical ethics consultation services when stakeholders ask for a consultation. The various stakeholders – when they request a clinical ethics consultation – may or may not know exactly what they are asking for anyway. But, most likely, what they are asking for is help with a very troublesome or thorny issue that has ethical implications or dimensions. In this respect, clinical ethics consultants perhaps should worry less about meeting expectations than other clinicians, since the goals of clinical ethics consultation services often times are much less clear – at least when the consultation is requested – than restoring the patient’s health or previous baseline with the least discomfort and minimal aggravation. However, may always be better for the clinical ethics consultant to ask, “How do you think we can help?” and try to set or reset expectations as well as one can at the beginning of the process.

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.

September 12, 2016

“Humanists,” Academic Philosophers, Critical Distance, and Clinical Ethicists

The October 2016 Annual Meeting of the American Society for Bioethics and Humanities (ASBH) announced its theme for the Washington, D.C., convocation several months ago: “After over half a century of work, and as ASBH celebrates its coming-of-age, we have chosen to focus on ‘critical distance’ and our ‘insider-outsider’ status at our 18th annual meeting.” Some may be relatively unfamiliar with these notions of “critical distance” and “insider-outsider” status.

            In the early 1970s, when medical center and medical school thought leaders began hiring “humanists” to teach, round with teams, and attend morning reports and noon conferences, it was unclear what – if any - specific outcomes might result. However, the center executives and deans wanted to try something to help inject human values and humanistic thought into the educational process to offset the very strong influences of advancing technologies, specialization, and materialism, and to assure the outraged public in the face of recently revealed research scandals.

            These pioneer “humanists” were theologians, religious studies scholars, and philosophers. In just a few years, the philosophers were predominating in this growing field of applied ethics educators and scholars. In explaining this transition, Art Caplan wrote: “It proved very difficult to do bioethics in public in anything approximating a religious voice. ... [I]t quickly became clear that to command the attention of scientists and physicians, as well as policy-makers, a more secular voice was required. Philosophy, emerging out of decades of mainly futile wrangling about meta-ethical issues, was more than happy to oblige ... .” Caplan AL. The birth and evolution of bioethics. In Ravitsky V, Fiester A, Caplan AL. The Penn Center Guide to Bioethics. New York: Springer Publishing Co., 2009, p. 5.

            But, the philosophers who taught applied ethics or their philosophy colleagues in the academy challenged medical ethics in the classroom and at the bedside. The academic philosophers were concerned that the medical school philosophers might be losing their bearings. This difference of opinion was stated by Harvard philosophy professor F.M. Kamm in 1988: “[P]hilosophers should try to bring ‘real-life’ problems (and those that have them) up to the abstractions of philosophy, rather than just bring philosophy down to the level of the problems. [Emphasis in original.]” Kamm FM. Ethics, applied ethics, and applying applied ethics. In Rosenthal DM, Shehadi F, eds. Applied Ethics and Ethical Theory. Salt Lake City: University of Utah Press, 1988, p. 170.  To be even clearer, she continued: “[C]reative solutions to practical problems come only after a period of detaching ourselves from them to consider more fundamental concepts. ... [E]mphasizing the discovery of solutions to problems conflicts with a detached interest that goes wherever an illuminating, but not obviously or immediately useful, aspect of a questions leads one.” Ibid, p. 170-171. “If philosophers who do applied ethics do not maintain such attitudes, in common with academic philosophers, they run the risk of being bad philosophers and becoming merely the bearers of simplified, falsely reassuring news from the theorists.” Ibid, p. 171.

            In thinking back, it must have been a phenomenal trial for several medical school philosophers to attempt to satisfy the academic philosophers while taking a new path. For the academics the question must have been how does one comment upon the matters at hand without learning so much about related topics and processes or becoming deeply enmeshed in the milieu that one is no longer an “outsider” but an “ insider” without critical distance? This turf battle must have been particularly worrisome for some distinguished philosophers who gained national and international reputations as academic philosophers and who then moved to medical school and clinical settings. Of course, a good many philosophers and theologians thought doctors were too close to the problem  (that is, lacked critical distance) to be part of any solution. (And quite naturally, some of the doctors thought the theologians and philosophers lacked a sufficient clinical knowledge base to fully understand the contexts in which they were involved.) History has shown that many of the medical school philosophers transitioned and cared little about what the academic philosophers said anyway.

            By the early and middle 1980s, other professionals joined the philosophers and theologians in broadening the bioethics or clinical ethics base and voice: physicians, nurses, social workers, chaplains and pastoral care workers, and lawyers, just to name a few. For health care professionals, chaplains, and lawyers, this notion of “critical distance” as not an overriding factor. If these bioethicists gave any thought to “detachment,” they probably interpreted it as “objectivity.” Objectivity calls to mind: “impartiality,” “lack of bias,” “fairmindedness,” “neutrality,” “open-mindedness,” “fairness,” and “justice.”

            Today, as clinical ethics consultants move toward professionalization, the outsider-insider issue has lost its relevance. Few may even understand the context of the initial problem now. Clinical ethics consultants exist in great part to improve patient care and the patient care experience; they are undoubtedly insiders. And, whether one thinks in terms of critical distance or not, objectivity in providing service to others remains critically important.

August 12, 2016

Twisted Self-Deception

By: J.S. Blumenthal-Barby

 In his book, Self-Deception Unmasked, philosopher Ale Mele writes about two types of self-deception. There is the straight-forward kind, where a person falsely believes—in the face of strong evidence to the contrary—things that she would like to be true.…

July 13, 2016

Reason, Emotion, and Implanted Devices

by John D. Lantos, MD

Pullman and Hodgkinson present a case that, it seems, should have been an easy one. A competent adult makes a simple request to discontinue a medical therapy.…

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.…

View More Blog Entries

Published Articles (85)

AJOB Primary Research: Volume 8 Issue 3 - Sep 2017

Main outcomes of an RCT to pilot test reporting and feedback to foster research integrity climates in the VA Brian C. Martinson , David C. Mohr, Martin P. Charns, David Nelson, Emily Hagel-Campbell, Ann Bangerter, Hanna E. Bloomfield, Richard Owen & Carol R. Thrush

AJOB Primary Research: Volume 8 Issue 3 - Sep 2017

Consent for organ donation after circulatory death at U.S. transplant centers George E. Hardart, Matthew K. Labriola, Kenneth Prager & Marilyn C. Morris

AJOB Primary Research: Volume 8 Issue 3 - Sep 2017

Membership recruitment and training in health care ethics committees: Results from a national pilot survey Anya E. R. Prince, R. Jean Cadigan, Warren Whipple & Arlene M. Davis

AJOB Primary Research: Volume 8 Issue 3 - Sep 2017

The use of an online comment system in clinical ethics consultation Katrina Hauschildt, Trisha K. Paul, Raymond De Vries, Lauren B. Smith, Christian J. Vercler & Andrew G. Shuman

AJOB Primary Research: Volume 8 Issue 3 - Sep 2017

Moral conflict and competing duties in the initiation of a biomedical HIV prevention trial with minor adolescents Amelia S. Knopf , Amy Lewis Gilbert , Gregory D. Zimet, Bill G. Kapogiannis, Sybil G. Hosek, J. Dennis Fortenberry, Mary A. Ott & The Adolescent Medicine Trials Network for HIV/AIDS Interventions

American Journal of Bioethics: Volume 17 Issue 8 - Aug 2017

Saving or Creating: Which Are We Doing When We Resuscitate Extremely Preterm Infants? Travis N. Rieder

American Journal of Bioethics: Volume 17 Issue 8 - Aug 2017

What We Do When We Resuscitate Extremely Preterm Infants Jeremy R. Garrett, Brian S. Carter & John D. Lantos

American Journal of Bioethics: Volume 17 Issue 6 - Jun 2017

When Respecting Autonomy Is Harmful: A Clinically Useful Approach to the Nocebo Effect John T. Fortunato, Jason Adam Wasserman & Daniel Londyn Menkes

American Journal of Bioethics: Volume 17 Issue 6 - Jun 2017

Bringing Transparency to Medicine: Exploring Physicians' Views and Experiences of the Sunshine Act Susan Chimonas, Nicholas J. DeVito & David J. Rothman

American Journal of Bioethics: Volume 17 Issue 6 - Jun 2017

Shining Light on Conflicts of Interest Craig Klugman

View More Articles

News (173)

September 12, 2017 9:00 am

What Are Physicians’ Responsibilities to Patients Whose Health Conditions Can Influence Their Legal Proceedings? (AMA Journal of Ethics)

Correctional populations are disproportionately affected by conditions that affect cognition, such as psychiatric illness and head trauma. Honoring bioethical principles in the care of such patients can be particularly difficult in the correctional setting. However, the approach should not change markedly because a patient is incarcerated.

September 11, 2017 9:00 am

She rejected chemotherapy and chose to die of cancer — so she could give birth to her child (Washington Post)

They had two options. They could try to prolong Carrie’s life through chemotherapy, but that meant ending her pregnancy. Or they could keep the baby, but Carrie would not live long enough to see the child.

September 1, 2017 9:00 am

Tanzania Gears Up To Become A Nation Of Medical Drones (NPR)

In early 2018, the nation will start using Zipline drones for on-demand delivery of blood, vaccines, medications and other supplies such as sutures and IV tubes.

August 28, 2017 9:00 am

Fewer antibiotic prescriptions are being filled, a new analysis finds (Washington Post)

The use of antibiotics among Americans with commercial health insurance has decreased during the past several years, according to a new analysis that nevertheless shows lingering variations for different ages and in different parts of the country.

August 23, 2017 9:00 am

Elderly couple got ‘deepest wish’ — to die together — in rare euthanasia case (Washington Post)

Nic and Trees Elderhorst knew exactly how they wanted to die. They were both 91 years old and in declining health. Nic Elderhorst suffered a stroke in 2012 and more recently, his wife, Trees Elderhorst, was diagnosed with dementia, according to the Dutch newspaper, De Gelderlander. Neither wanted to live without the other, or leave this world alone. So the two, who lived in Didam, a town in the eastern part of the Netherlands, and had been together 65 years, shared a last word, and a kiss, then died last month hand-in-hand — in a double euthanasia allowed under Dutch law, according to De Gelderlander.

August 7, 2017 9:00 am

Senate passes ‘right to try’ bill to help terminally ill patients get experimental drugs (Washington Post)

The Senate on Thursday passed by unanimous consent a measure designed to make it easier for terminally ill patients to get access to experimental treatments without oversight from the Food and Drug Administration. The “right-to-try” legislation has been championed by the libertarian Goldwater Institute, which has worked to pass similar legislation in 37 states. The federal version, now headed to the House, would bar the government from blocking patients from getting access to medications that have undergone only preliminary testing in humans. Patients first would have to try all other available treatments and be unable to participate in clinical trials.

August 3, 2017 9:00 am

How Should Physicians Help Gender-Transitioning Adolescents Consider Potential Iatrogenic Harms of Hormone Therapy? (Journal Of Medical Ethics)

Counseling and treatment of transgender youth can be challenging for mental health practitioners, as increased availability of gender-affirming treatments in recent years raises ethical and clinical questions. Is a gender identity diagnosis helpful? What is the right time to treat, and should the adolescent’s age matter in decision making?

August 2, 2017 9:00 am

After French drug trial tragedy, European Union issues new rules to protect study volunteers (Science)

The European Medicines Agency (EMA) has issued new, stricter rules for studies that test drugs in people for the first time. They aim to better protect participants in such first-in-human studies—often healthy volunteers who receive a financial reward. The guideline, which was issued on 25 July, will take effect in February 2018. It comes in the wake of a tragedy in a French drug study last yearthat led to the death of one man and serious neurological damage in four others. But some say the revision isn’t going for enough.

July 28, 2017 9:00 am

Ninety-nine percent of ailing NFL player brains sport hallmarks of neurodegenerative disease, autopsy study finds (Science)

The largest study of its kind has found damage in the vast majority of former football players’ brains donated for research after they developed mental symptoms during life. Of 202 former players of the U.S. version of the game whose brains were examined, 87% showed the diagnostic signs of chronic traumatic encephalopathy (CTE), a neurodegenerative disease associated with repetitive head trauma.

July 12, 2017 9:00 am

FDA chief to impose tougher doctor-training rules on opioid manufacturers (Washington Post)

Food and Drug Administration Commissioner Scott Gottlieb, stepping up the agency’s efforts against the nation’s opioid epidemic, announced plans Monday to require manufacturers of painkillers to provide more extensive education for physicians and other health-care professionals who prescribe the drugs.

View More News Items