Hot Topics: Clinical Ethics

Blog Posts (76)

February 13, 2018

Want more efficient and cheaper medicine? Just outsource the doctor

by Craig Klugman, Ph.D.

A new medical school opening this fall in the University of Illinois system will focus on the tech revolution.…

February 9, 2018

BioethicsTV (January 29-February 9): #TheResident, #TheGoodDoctor, #ChicagoMed

by Craig Klugman, Ph.D.

The Resident (Season 1; Episode 3): The Cost of a Life The episode opens with residents and nurses attending a required meeting on billing by a “billing consultant”.…

January 26, 2018

A Reflection on Two-Physician Consent

In a recent series of clinical ethics consultations, some physicians expressed concerns over the possible unilateral nation of using two-physician consent for medical decisions for patients without capacity. This concern comes many physicians for a wide range of treatment decisions, a concern of acting without express consent.

Like many states, New York State Family Health Care Decisions Act authorizes two physicians to make medical decisions in the event that no one can be identified to act on behalf of a patient without capacity. It is a safety mechanism to ensure that even those who do not have anyone in their lives will have someone to make medical decisions on their behalf. Some states may use a different mechanism, such as an ethics committee or a surrogate decision-making committee, but the underlying goal is the same. The “unbefriend” patients are arguably one of the most vulnerable population of patients. They lack an advocate, someone to voice their preferences or to consider their best interests. At least in New York, it then becomes the moral responsibility of physicians to decide what is in the best interest of the patient.

For those who distrust the medical profession in general, mechanisms like two-physician consent may seem like a scary option, but then who else should be making these decisions? It is scary to think that maybe one day we will be alone with no family and friends but it is an unfortunate reality. Physicians have years of medical training that can guide a determination in the patient’s best interest. In addition, physicians have taken an oath to uphold a patient’s best interest and practice the standard of care. Physicians are ethically obligated to provide care that benefits and prevents harm to the patient. People who chose to practice medicine tend to have an inherent goodness as they are joining a profession that helps people. These individuals are committed to ensuring a patient’s best interest.

Yes, depending on the gravity of the medical decision and the potential impact it may have on the patient’s quality of life, making medical decisions is a burden. What is also important to note about the New York’s mechanism is it always two physician consent, one physician does not make the decision in isolation. Though there are concerns that the concurring physician will not disagree with his/her colleague.

I empathize with the physicians who express concern in making these decisions but I also think some of these physicians are too focused on the hypothetical legal consequences. This authority to make such decisions is codified in a law and is ethically supported by ancient notions of beneficence.  Maybe we have become too comfortable with the notion of autonomy and without an expression of autonomy, we become uncomfortable. We are forgetting the rest of medical ethics. This is why we have a best interest’s standard in healthcare decision-making and established standards of care.

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.

January 23, 2018

BioethicsTV (January 21-22, 2018): The Resident-Our Most Unethical Hospital System

The Resident (Season 1; Episode 1): The Most Unethical Hospital Ever

This new Fox show begins with newly minted MD Devon Pravesh’s first day at a fictional Atlanta hospital.…

January 11, 2018

Managing Expectations: Delivering the Worst News in the Best Way?

This post also appears in the January 2018 issue of the American Journal of Bioethics

by Alyssa M. Burgart & David Magnus

In this issue, Weiss and Fiester’s (2018) “From ‘Longshot’ to ‘Fantasy’: Obligations to Patients and Families When Last-Ditch Medical Efforts Fail” calls attention to the weight of clinician word choice when discussing interventions in the pediatric population.…

January 2, 2018

A Bioethicist by Any Name

by Craig Klugman, Ph.D.

A few months ago, I was attending a conference where the keynote speaker introduced herself as a bioethicist.…

November 17, 2017

BioethicsTV (November 12-17): Obligation to treat, assisting suicide, autonomy, and prejudice

Outlander (Season 3; Episode 9): Obligation to treat
In this time travel love story, Dr. Claire finds her ship crossing the Atlantic in the 1700s is stopped by a British Naval ship afflicted with “Ship’s Fever.” Her husband does not want her to go aboard the Navy vessel, fearing that she will be separated from him and be away from his protection.…

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.  

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Published Articles (90)

AJOB Primary Research: Volume 8 Issue 1 - Mar 2018

“God is the giver and taker of life”: Muslim beliefs and attitudes regarding assisted suicide and euthanasia Chaïma Ahaddour, Stef Van den Branden & Bert Broeckaert

American Journal of Bioethics: Volume 18 Issue 3 - Mar 2018

The Default Position: Optimizing Pediatric Participation in Medical Decision Making Aleksandra E. Olszewski & Sara F. Goldkind

American Journal of Bioethics: Volume 18 Issue 3 - Mar 2018

Pediatric Participation in Medical Decision Making: Optimized or Personalized? Maya Sabatello, Annie Janvier, Eduard Verhagen, Wynne Morrison & John Lantos

American Journal of Bioethics: Volume 18 Issue 2 - Feb 2018

Resolving Ethical Dilemmas in a Tertiary Care Veterinary Specialty Hospital: Adaptation of the Human Clinical Consultation Committee Model Philip M. Rosoff, Jeannine Moga, Bruce Keene, Christopher Adin, Callie Fogle, Rachel Ruderman, Heather Hopkinso & Charity Weyhrauch

American Journal of Bioethics: Volume 17 Issue 11 - Nov 2017

To Whom Do Children Belong? John Lantos

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

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News (209)

April 6, 2018 9:00 am

To treat some diseases, researchers are putting immune cells on a diet (Science)

Once triggered into action, an immune cell overhauls its metabolism, making changes that could be exploited for treatment.

March 23, 2018 9:00 am

Mississippi bans abortions at 15 weeks, earliest in the nation (CNN)

With a swipe of a pen Monday, Mississippi Gov. Phil Bryant signed into law a bill that prevents women from getting abortions after 15 weeks of pregnancy. His state, effective immediately, now holds the distinction of having the earliest abortion ban in the nation.

March 15, 2018 9:00 am

FDA authorizes, with special controls, direct-to-consumer test that reports three mutations in the BRCA breast cancer genes (FDA)

Test only reports 3 out of more than 1,000 known BRCA mutations and negative result doesn’t rule out increased cancer risk

March 12, 2018 9:00 am

Fast genome tests are diagnosing some of the sickest babies in time to save them (MIT Technology Review)

Genetic diseases are the leading cause of death for infants in North America, affecting an estimated 4 percent of newborns. So while the work at Rady is still in the research stage, costing the hospital about $6,000 per baby, the hope is that it could lead to a standard medical test with the potential to save thousands of lives.

March 9, 2018 9:00 am

Why Crisis Pregnancy Centers Are Legal but Unethical (AMA Journal of Ethics)

Although crisis pregnancy centers enjoy First Amendment rights protections, their propagation of misinformation should be regarded as an ethical violation that undermines women’s health.

February 28, 2018 9:00 am

Worms living in your veins? Seventeen volunteers said ‘OK’ (Science)

A research group in the Netherlands is infecting healthy volunteers with Schistosoma mansoni, one of five tiny waterborne worm species that cause schistosomiasis. They hope to create a human model that could help speed up the development of new drugs and vaccines against the disease, which sickens millions of people and kills thousands each year. The team says the risk to volunteers is very low because the study is designed to prevent the parasites from reproducing. But some scientists argue that it’s not low enough because there is no guarantee that subjects will get rid of their parasites when the study is over.

February 23, 2018 9:00 am

Nursing homes sedate residents with dementia by misusing antipsychotic drugs, report finds (CNN)

Former administrators admitted doling out drugs without having appropriate diagnoses, securing informed consent or divulging risks.

February 15, 2018 9:00 am

Gene therapy field hit by fresh safety concern (Science)

A virus that buoyed the gene therapy field when it led to dramatic benefits in babies born with a fatal neuromuscular condition is under scrutiny. A small animal study suggests that high doses of the virus, called adeno-associated virus 9, can cause severe liver and neuron damage in young monkeys and pigs. The results drew attention in part because they come from the lab of James Wilson at the University of Pennsylvania, who led a 1999 trial in which a teenager died from an immune reaction to a different gene therapy vector.

February 14, 2018 9:00 am

Talk to Your Doctor About Your Bucket List (The New York Times)

A bucket list is an itemized list of goals people want to accomplish before they “kick the bucket” — or die. Making a bucket list allows us to reflect on our values and goals and identify important milestones and experiences that we want to have in our lifetime.

February 9, 2018 9:00 am

Student dies of flu after NHS warning over A&E visits (The Guardian)

A young engineering student reportedly died of flu after her family followed NHS warnings over Christmas not to attend A&E unless it was an emergency.

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