Hot Topics: Clinical Ethics

Blog Posts (66)

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.…

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.…

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Published Articles (75)

AJOB Primary Research: Volume 8 Issue 2 - Apr 2017

The interactions of Canadian ethics consultants with health care managers and governing boards during times of crisis Chris Kaposy, Victor Maddalena, Fern Brunger, Daryl Pullman & Richard Singleton

AJOB Primary Research: Volume 8 Issue 2 - Apr 2017

Growing an ethics consultation service: A longitudinal study examining two decades of practice Christine Gorka, Jana M. Craig & Bethany J. Spielman

AJOB Primary Research: Volume 8 Issue 2 - Apr 2017

Adolescent oncofertility discussions: Recommendations from a systematic literature review Dorit Barlevy, Bernice S. Elger, Tenzin Wangmo & Vardit Ravitsky

AJOB Primary Research: Volume 8 Issue 2 - Apr 2017

Primary care physicians' views about gatekeeping in clinical research recruitment: A qualitative study Marilys Guillemin, Rosalind McDougall, Dominique Martin, Nina Hallowell, Alison Brookes & Lynn Gillam

AJOB Primary Research: Volume 8 Issue 2 - Apr 2017

When bins blur: Patient perspectives on categories of results from clinical whole genome sequencing Leila Jamal, Jill O. Robinson, Kurt D. Christensen, Jennifer Blumenthal-Barby, Melody J. Slashinski, Denise Lautenbach Perry, Jason L. Vassy, Julia Wycliff, Robert C. Green & Amy L. McGuire

AJOB Primary Research: Volume 8 Issue 2 - Apr 2017

Does experience matter? Implications for community consultation for research in emergency settings Victoria M. Scicluna, Mohammed K. Ali, Rebecca D. Pentz, David W. Wright & Neal W. Dickert

American Journal of Bioethics: Volume 17 Issue 5 - May 2017

Ethical Issues in Fecal Microbiota Transplantation in Practice Yonghui Ma, Jiayu Liu, Catherine Rhodes, Yongzhan Nie & Faming Zhang

American Journal of Bioethics: Volume 17 Issue 5 - May 2017

Caring for Patients or Organs: New Therapies Raise New Dilemmas in the Emergency Department Arjun Prabhu, Lisa S. Parker & Michael A. DeVita

American Journal of Bioethics: Volume 17 Issue 3 - Mar 2017

The Precautionary Principle and the Tolerability of Blood Transfusion Risks Koen Kramer, Hans L. Zaaijer & Marcel F. Verweij

AJOB Primary Research: Volume 8 Issue 1 - Feb 2017

When are primary care physicians untruthful with patients? A qualitative study Stephanie R. Morain, Lisa I. Iezzoni, Michelle M. Mello, Elyse R. Park, Joshua P. Metlay, Gabrielle Horner & Eric G. Campbell

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News (154)

May 19, 2017 9:00 am

For Tuskegee Syphilis Study Descendants, Stigma Hasn't Faded (The New York Times)

For 40 years starting in 1932, medical workers in the segregated South withheld treatment for unsuspecting men infected with a sexually transmitted disease simply so doctors could track the ravages of the horrid illness and dissect their bodies afterward. Finally exposed in 1972 , the study ended and the men sued, resulting in a $9 million settlement. Twenty years ago this May, President Bill Clinton apologized for the U.S. government. It seemed to mark the end of this ugly episode, once and for all. Except it didn’t.

May 12, 2017 9:00 am

Integrity starts with the health of research groups (Nature)

Last month, the US National Academies of Sciences, Engineering, and Medicine published a report called Fostering Integrity in Research. Later this month, the 5th World Conference on Research Integrity will be held in Amsterdam. Over the years, universities have followed some funders’ mandates to improve the prevention and investigation of misconduct. Many discussions have been held about unreliable research. None of these initiatives pays sufficient attention to a specific issue: the research health of research groups and the people who lead them. This includes technical robustness of lab practices, assurance of ethical integrity and the psychological health and well-being of group members.

May 10, 2017 9:00 am

Pocket laboratories (Nature)

Mobile phones are helping to take conventional laboratory-based science into the field, the classroom and the clinic.

May 2, 2017 9:00 am

$10 million settlement over alleged misconduct in Boston heart stem cell lab (Science)

A research misconduct investigation of a prominent stem cell lab by the Harvard University–affiliated Brigham and Women’s Hospital (BWH) in Boston has led to a massive settlement with the U.S. government over allegations of fraudulently obtained federal grants. As Retraction Watch reports, BWH and its parent health care system have agreed to pay $10 million to resolve allegations that former BWH cardiac stem cell scientist Piero Anversa and former lab members Annarosa Leri and Jan Kajstura relied on manipulated and fabricated data in grant applications submitted to the U.S. National Institutes of Health (NIH).

April 28, 2017 9:00 am

Society labels harassment as research misconduct (Science)

April 24, 2017 9:00 am

CRISPR studies muddy results of older gene research (Nature)

Scientists face tough decisions when the latest gene-editing findings don’t match up with the results of other techniques.

April 21, 2017 9:00 am

Young human blood makes old mice smarter (Nature)

Blood from younger humans may have similar rejuvenating effects on older animals as blood from young mice.

April 14, 2017 9:00 am

Japanese man is first to receive 'reprogrammed' stem cells from another person (Nature)

On 28 March, a Japanese man in his 60s became the first person to receive cells derived from induced pluripotent stem (iPS) cells donated by another person. The surgery is expected to set the path for more applications of iPS-cell technology, which offers the versatility of embryonic stem cells without their ethical taint. Banks of iPS cells from diverse donors could make stem-cell transplants more convenient to perform, while slashing costs.

April 12, 2017 6:00 am

Study finds some significant differences in brains of men and women (Science)

Do the anatomical differences between men and women—sex organs, facial hair, and the like—extend to our brains? The question has been as difficult to answer as it has been controversial. Now, the largest brain-imaging study of its kind indeed finds some sex-specific patterns, but overall more similarities than differences. The work raises new questions about how brain differences between the sexes may influence intelligence and behavior.

April 10, 2017 9:00 am

First medical diagnosis often incomplete or outright wrong, study finds (The San Diego Union-Tribune)

When your doctor gives a diagnosis of a complicated disease, it often pays to get an independent second look, according to a study from Mayo Clinic published Tuesday.

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