Hot Topics: Clinical Ethics

Blog Posts (72)

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.  


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.

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Published Articles (86)

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

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

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News (194)

January 18, 2018 9:00 am

First treatment approved for breast cancer with BRCA genetic mutation (Washington Post)

The Food and Drug Administration on Friday cleared the first treatment for patients with advanced breast cancer caused by BRCA mutations, which are genetic defects that raise the risk of malignancies.

January 17, 2018 9:00 am

In Pakistan, surveillance for polio reveals a paradox (Science )

January 16, 2018 9:00 am

Chasing Seasonal Influenza — The Need for a Universal Influenza Vaccine (The New England Journal of Medicine)

As clinicians in the United States prepare for the start of another influenza season, experts have been watching the Southern Hemisphere winter for hints of what might be in store for us in the North. Reports from Australia have caused mounting concern, with record-high numbers of laboratory-confirmed influenza notifications and outbreaks and higher-than-average numbers of hospitalizations and deaths.

January 8, 2018 9:00 am

Washington state offers third gender option on birth certificates (CNN)

Washington state residents who don’t identify as male or female will soon be able to choose X as their gender on birth certificates.

January 4, 2018 9:00 am

Safety concerns derail dengue vaccination program (Science)

Efforts to control dengue suffered a major setback in late November when Sanofi Pasteur announced that its vaccine, the only one on the market, should only be given to those who have already had one infection with the mosquito-borne disease that affects millions of people in the tropics each year.

January 3, 2018 9:00 am

A boy’s basketball-size tumor is slowly suffocating him. Doctors will attempt a risky removal. (Washington Post)

The tumor is benign but, if left untreated, it will kill Emanuel. As it grows, it is slowly suffocating the teen.

January 1, 2018 9:00 am

Will Gathering Vast Troves of Information Really Lead To Better Health? (NPR)

The Mayo Clinic is building its future around high-tech approaches to research known as “precision medicine.” This involves gathering huge amounts of information from genetic tests, medical records and other data sources to ferret out unexpected ideas to advance health. But one longtime scientist at the Mayo Clinic isn’t playing along. Dr. Michael Joyner is a skeptical voice in a sea of eager advocates.

December 15, 2017 9:00 am

After mistakenly declaring newborn dead, New Delhi hospital loses license (CNN)

The Delhi government has canceled the license of a private hospital where a newborn baby was mistakenly declared dead.

December 13, 2017 9:00 am

Gut molecule that blocks ‘hunger hormone’ may spur new treatments for diabetes, anorexia (Science)

Scientists once had high hopes that inhibiting a hormone named ghrelin would be the key to preventing obesity. Ghrelin didn’t turn out to be a weight loss panacea. But now, the discovery of the first molecule naturally made by the body that blocks ghrelin’s effects may open up new avenues for treating other conditions, including diabetes and anorexia. The finding may also explain some of the benefits of bariatric surgery, which shrinks or reroutes the stomach to control weight.

December 5, 2017 9:00 am

A man collapsed with ‘Do Not Resuscitate’ tattooed on his chest. Doctors didn’t know what to do. (Washington Post)

Doctors in Miami faced an unusual ethical dilemma when an unconscious, deteriorating patient was brought into the emergency room with the words “Do Not Resuscitate” across his chest.

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