Hot Topics: Clinical Ethics

Blog Posts (38)

June 17, 2015

Does Clinical Ethics Consultation Lend Itself to Professionalization?

<p style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">Let me say emphatically at the outset of this blog, as someone who has been a clinical ethics consultant for over 20 years, I am quite sure that clinical ethics consultations overall improve the quality of patient care and currently are an important, even essential, part of the providing excellent patient care in hospitals. Contemporary medicine is filled with value laden questions and issues that often can be effectively addressed by someone with expertise and training in clinical ethics. Having said this, I am still somewhat skeptical about clinical ethics consultation becoming a professional area of healthcare that parallels other professional areas like medicine, nursing, and social work. I think there are some special considerations about the field of clinical ethics consultation that makes its future status as a professional activity uncertain.</span></p> <p style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">First of all it is well-known that CEC’s come from a variety of backgrounds and training—from philosophers to physicians to social workers to nurses and lawyers and on and on. People enter the field of clinical ethics consultations from very different disciplinary backgrounds and seemingly learn a common vocabulary and methodology of clinical ethics and a basic familiarity with and ability to function in the clinical setting. They learn this vocabulary in very different ways—some informally, some through short 1-2 week long intensives, some with certificate programs, some with master’s degrees, and some with 1-2 year long fellowships. No other area of healthcare work admits of such diversity. Though this is a positive feature in some ways by providing diverse perspectives in understanding value dilemmas, it creates a challenge of considerable controversy when we try to define the kind of educational training a future CEC should have. At the moment there seem to be many pathways into the field and no clear answer has emerged.</p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; line-height: 19.0400009155273px; font-size: 12px;">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 <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong></p>
June 8, 2015

Actions vs. Words: What counts most in understanding patient preferences?

<p class="MsoNormal" style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">Clinicians striving to help patients achieve healthcare goals often encounter the perplexing dichotomy of the patient’s stated goals and preferences and actions to the contrary. Some of these challenges can be overcome with education and close follow up to help reinforce adherence to medical recommendations, but other times, these barriers are more enigmatic.</span></p> <p class="MsoNormal" style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">Take for example, a patient who requires hemodialysis to sustain life. She sometimes shows up for her outpatient dialysis, but more often does not show up and is admitted to the hospital for emergent dialysis several months in a row. In consultation with her providers she is adamant that she does not want to die, and knows that she needs the dialysis to remain alive. She is discharged, and the pattern continues. Liberal scheduling with the outpatient service, transportation, reminders are all offered. Psychological tests and support are provided, and yet, her action pattern of not adhering to the treatment plan continues. Again, she is advised it is acceptable to halt and she will be offered palliative care. She refuses, and says she wants to live and will sit for dialysis. What is her genuine preference? Should we honor these statements, or accept her actions as the more authentic expression of her wishes? Though this hypothetical example is quite familiar to renal care providers, the dynamic spans many scenarios leaving many practitioners with a dilemma about the practical limits of honoring verbalized wishes that are not supported by congruent actions.</span></p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;">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 <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong></p>
May 29, 2015

“Should I feel badly that I acted unethically?”

Ms. Barnard is a business woman who has opened a medical clinic across the street from an existing facility. She suspects that the Other Clinic is “playing unfairly” by not having a physician on site.…

May 10, 2015

Social Media and Patient Information

<p style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">In the most recent issue of </span><em style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><a href="http://www.clinicalethics.com/">The Journal of Clinical Ethics</a></em><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">, authors Genes and Appel explore the ethical considerations at play when physicians might use the internet to gather patient information</span><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">. They conclude, correctly I believe, that there are circumstances in which accessing information about a patient supports beneficent efforts to provide quality care, even in non-emergent circumstances. Rather than damaging the doctor patient relationship, an informed provider is better equipped to support the patient’s best interests if loved ones can be located, presentation of information can be confirmed as factual or not, and the context of this patient’s needs can be more fully understood by the care team.</span></p> <p class="MsoNormal" style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">Social media, such as the now ubiquitous </span><a style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;" href="http://www.facebook.com">Facebook</a><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">, is often considered a forum where people may express thoughts and feelings they fail to articulate in person. Consider the posts of an angry or despondent partner after the end of a relationship. Should commentary become threatening – to self or others – this is considered cause for concern and these comments are taken as valid expressions that warrant immediate emergency intervention. Text messages carry the same weight as spoken words, and are preserved in electronic format to be shared by the recipient at will. Failing to consider such communications as part of the purview of healthcare providers could lead to harm for the patient or others. While these expressions might not be quickly discoverable by physicians, they can, in some instances, be lifesaving components adding to the overall clinical picture. </span></p> <p style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; line-height: 19.0400009155273px; font-size: 12px;">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 <a style="text-decoration: underline; color: #000099;" href="/Academic/bioethics/index.cfm">website</a>.</strong><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; line-height: 19.0400009155273px; font-size: 12px;"> </span><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 11.1999998092651px; line-height: 19.0400009155273px;"> </span></p>
March 10, 2015

Actions or Words? What counts when patients give inconsistent signals?

<p style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">One of the challenges clinicians must learn to manage is the patient who does not adhere to medical recommendations while expressing the desire to be well. It is widely accepted that patients with the capacity to make informed decisions retain the right to make choices that are good for them and choices that are not, there are instances where capacity to make a choice becomes less relevant than the practical considerations related to achieving the patient’s goals. When patients state they wish to recover from illness but refused to comply with the necessary treatments this disconnect poses a different kind of dilemma. Morally, it is simpler to digest that that some patients will refuse treatment, and there is robust support for respecting refusals. But what do we do when a patient asks for one thing but does another? Such cases pose intractable impasses for providers who arrange care plans based on the patient’s stated goals of recovery, yet encounter what seem to be enigmatic refusals to adhere to recommendations and interventions. There is a clear obligation to attempt to understand the patient’s perspective and thoroughly as possible. What may appear to be inconsistencies in preference may very well have a logical explanation. Once efforts to unpack dissonant expressions have been exhausted, a different approach may be needed to figure out what may be possible for such a patient. The first question is often about capacity – does a patient who asks for one thing but does another possess the ability to make an informed decision? In some cases, the resolution ends here if the patient is found to be unable to make an informed decision – or does it? If the objection is strong, and the intervention requires a high degree of cooperation from the patient, capacity may be moot because there is no practical way to proceed without cooperation. For example, a patient who insists she does not want to die, but simultaneously resists life sustaining dialysis leaves providers with very few options. A patient receiving a temporary intervention to buy time for recovery may in fact, not achieve the desired healing – how long must a bridge therapy continue? In such cases, capacity may be part of the picture, but I would argue it sometimes becomes a red herring we chase instead of taking a hard look at the medical facts and practical considerations in such cases. </span></p> <div style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;">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 <a style="text-decoration: underline; color: #000099;" href="http://www.amc.edu/Academic/bioethics/index.cfm">website</a>.</strong><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;"> </span></div>
February 20, 2015

The Physician-Patient Relationship: The basis for moral clarity in clinical ethics

<p><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">It is my sense that the majority, perhaps the vast majority, of cases on which clinical ethics consultants (CECs) are asked to consult and make an ethics recommendation, there is, or would be, a general consensus on the part of the CECs about what counts as the appropriate recommendation. However, the question arises of how clinical ethics as a field should deal with issues that come up about which there is not a clear consensus, such as in cases where a basic right to have an autonomous choice respected by the patient is pitted over and against the obligation of the physician to do no harm—the traditional tension between respect for patient autonomy and beneficence/nonmaleficence. This tension or conflict often occurs in cases of alleged medical futility where the patient or the patient’s surrogate requests a treatment option the physician deems will only cause harm and no benefit to the patient. For example, consider a patient’s surrogate who insists that she will not consent to a DNR order and in fact expects the physician to perform CPR if the patient arrests. For a patient without capacity dying of metastatic disease, this directive by the surrogate presents a stark dilemma to the physician—is it a violation of the physician’s obligation to the patient to “do no harm” (nonmaleficence)? Or is respect for the patient’s wishes or her representative’s wishes so sacrosanct that the physician’s obligation to follow the patient’s wishes is paramount and outweighs the obligation to do no harm?</span></p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;">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 <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;"> </span></p>
January 6, 2015

Cassandra C: Right to refuse treatment or protecting a minor*

by Craig Klugman, Ph.D.

In Connecticut, a 17-year-old girl is being kept in a hospital room under court order. She is restrained to her treatment bed when she is given chemotherapy that neither she nor her mother want.…

November 18, 2014

Elderspeak: Words Can Hurt

by Craig Klugman, Ph.D.

During the season premiere of the HBO comedy, Getting On, I noticed the excessive use of toddler-speak toward patients portrayed as being elderly.…

November 11, 2014

Making a Case for Case Studies

<p class="MsoNormal" style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">In Peter D. Kramer’s New York Times piece published in the ‘Couch’ section on October 18, 2014 (</span><a style="line-height: 19.0400009155273px;" href="http://opinionator.blogs.nytimes.com/2014/10/18/why-doctors-need-stories/">Why Doctors Need Stories</a><span style="line-height: 19.0400009155273px;">) he affirms the experience of learners, educators, and researchers in his arguments that a case vignette can provide a kind of instruction that cannot be duplicated by data collection alone. While we do still need evidence based material to assure safety and efficacy of treatments, the case study offers contextual material that makes the evidence come to life.</span></p> <p class="MsoNormal" style="line-height: 19.0400009155273px;">As a Clinical Ethicist each clinical encounter is rich with substantive information that is part of an individual or family story intersecting with the healthcare setting. When invited to provide input, support, or recommendations in any given case, the most informative elements of any case are the story of the patient. What was before, what is now, and what the future may require is different for each patient, and I am often awed by the ‘before.’ The contextual landscape of each story is often where we come to understand the psychosocial factors that weigh heavily in how a patient, family, or community interacts with the healthcare community. Hard data is not as useful as hearing the story that belongs to the patient.</p> <p class="MsoNormal" style="line-height: 19.0400009155273px;"><strong style="line-height: 19.0400009155273px; color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px;">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 <a style="text-decoration: underline; color: #000099;" href="/Academic/bioethics/index.cfm">website</a>.</strong></p>
October 3, 2014

The Scylla and Charybdis of Medical Ethics: Not Enough Medicine, Not Enough Ethics

<p class="MsoNormal" style="line-height: 19.0400009155273px;"><span style="line-height: 22.3999996185303px;">I was at a conference last week in medical ethics, and I was surprised by, or perhaps appalled at, the attitude displayed by many of the philosophers regarding the importance of medical knowledge in medical ethical decision making. Several of them proudly announced a total ignorance of the medical issue they were speaking on, and also showed no interest in what I would call “real world” implications of their conclusions.</span><span style="line-height: 22.3999996185303px;">  </span><span style="line-height: 22.3999996185303px;">Although I have a PhD in philosophy, I am not a philosopher in the sense that I am capable of, or interested in, spinning arguments from “thin air” with no grounding in medical facts, and no implications for real medical practice.</span><span style="line-height: 22.3999996185303px;">  </span><span style="line-height: 22.3999996185303px;">Medical ethics must begin in real life issues and problems, and end with equally real and meaningful conclusions that can be applied, and sometimes even empirically tested.</span><span style="line-height: 22.3999996185303px;"> </span></p> <p class="MsoNormal" style="line-height: 22.3999996185303px;"><span style="line-height: 22.3999996185303px;">This is not to say that philosophers cannot make good, or even great, medical/clinical ethicists. But they need to begin with a healthy respect for the way in which the “facts on the ground” inform the ethical decision-making.  A brief example illustrates my point.  In Hilde Lindemann Nelson’s famous </span><a style="line-height: 22.3999996185303px;" href="http://link.springer.com/article/10.1023/A:1008844116526?LI=true">article</a><span style="line-height: 22.3999996185303px;"> explaining narrative ethics, she discusses the case of Carlos and Consuela. Carlos is an HIV positive gang member wounded in gang violence, who is recovering from his injuries in a hospital.  He is now ready for discharge, but needs dressing changes at home.  He wants his sister Consuela to do the dressing changes, but he insists that she not be told about his HIV status.  While Dr. Lindemann Nelson uses this case to make several excellent points about the limitations of principle based ethics, one aspect of the question, crucial to any ethical reasoning on the case, is obviously the transmissibility of HIV infection through dressing changes.  This “fact” is an essential aspect that underpins any ethical judgment regarding the case.  The conflict between patient confidentiality and duty of nonmaleficence (toward Consuela) pivots in part on the fact that HIV is not readily contagious, and simple universal precautions should make the risk to Consuela essentially nil.</span></p> <p class="MsoNormal" style="line-height: 22.3999996185303px;"><strong style="line-height: 19.0400009155273px; color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px;">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 <a style="text-decoration: underline; color: #000099;" href="/Academic/bioethics/index.cfm">website</a></strong></p>

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Published Articles (41)

American Journal of Bioethics: Volume 15 Issue 6 - Jun 2015

U.S. Complicity and Japan's Wartime Medical Atrocities: Time for a Response Katrien Devolder

American Journal of Bioethics: Volume 15 Issue 5 - May 2015

A Code of Ethics for Health Care Ethics Consultants: Journey to the Present and Implications for the Field Anita J. Tarzian, Lucia D. Wocial & The ASBH Clinical Ethics Consultation Affairs Committee

American Journal of Bioethics: Volume 15 Issue 5 - May 2015

Ethics Consultation in Pediatrics: Long-Term Experience From a Pediatric Oncology Center Liza-Marie Johnson, Christopher L. Church, Monika Metzger & Justin N. Baker

American Journal of Bioethics: Volume 15 Issue 5 - May 2015

The Proper Locus of Professionalization: The Individual or the Institutions? David Magnus & Bela Fishbeyn

American Journal of Bioethics: Volume 15 Issue 4 - Apr 2015

Ebola, Team Communication, and Shame: But Shame on Whom? Sarah E. Shannon

American Journal of Bioethics: Volume 15 Issue 1 - Jan 2015

Neglected Ends: Clinical Ethics Consultation and the Prospects for Closure Autumn Fiester

American Journal of Bioethics: Volume 15 Issue 1 - Jan 2015

Ethical Obligations and Clinical Goals in End-of-Life Care: Deriving a Quality-of-Life Construct Based on the Islamic Concept of Accountability Before God (Taklīf) Aasim Padela & Afshan Mohiuddin

American Journal of Bioethics: Volume 15 Issue 1 - Jan 2015

Clinical Ethics Consultation: A Need for Evidence David Magnus

American Journal of Bioethics: Volume 14 Issue 12 - Dec 2014

Alcohol and Drug Testing of Health Professionals Following Preventable Adverse Events: A Bad Idea John Banja

American Journal of Bioethics: Volume 14 Issue 12 - Dec 2014

Testing Madness: Shifting From a Punitive Approach to a Therapeutic One Kayhan Parsi

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News (104)

May 22, 2015 12:26 pm

Doctors may not fully explain risks of common heart procedure

Patients mulling whether to get a common procedure to unclog blocked arteries may not get enough information from their doctors to make the best choice, a small study suggests.

May 18, 2015 3:05 pm

How Doctors Deliver Bad News (http://www.wsj.com/articles/how-doctors-deliver-bad-news-1431970796)

The doctor in the grainy video is standing up, shifting uncomfortably as he spouts medical jargon that members of his patient’s family don’t understand.

May 7, 2015 2:25 pm

Talking to the Doctor About Treatment Harms

Whether preparing to undergo sensitive surgery or facing the prospect of spending a night in the hospital, patients often lack a critical piece of information to make an informed medical decision.

April 23, 2015 5:14 pm

Finding LGBT-competent doctors may be difficult

Finding doctors at U.S. teaching hospitals who consider themselves competent to care for lesbian, gay, bisexual and transgender (LGBT) patients may be difficult, suggests a new study.

April 22, 2015 4:55 pm

Death in Secret: California’s Underground World of Assisted Suicide

Physician-assisted suicide is illegal in California. But that doesn’t mean it doesn’t happen. Sick patients sometimes ask for help in hastening their deaths, and some doctors will explain, vaguely, how to do it.

April 16, 2015 1:59 pm

Meet the cancer patient in Room 52: His name is Joseph, but call him Joe

Lisa Mox and her husband, Joseph, who is now cancer-free after bouts of esophageal and colon cancer, are participating in a pilot program at Johns Hopkins Hospital to reduce “preventable harm” in the surgical intensive care unit. The program expands the definition of harm beyond medical complications to include loss of dignity and respect.

April 9, 2015 1:36 pm

When surgeons say ‘we can fix it,’ patients may misunderstand risks

When surgeons prepare patients for an operation by describing how it can fix a problem, patients may agree to procedures without fully understanding the risks, a small study suggests.

March 9, 2015 6:28 pm

Seeing medical records might ease hospital patients’ confusion

Letting patients see their medical records while they’re in the hospital might ease worry and confusion without extra work for doctors and nurses, a small study suggests.

March 4, 2015 6:23 pm

Stanford student earns national recognition for research on medical communication

Stanford medical student Genna Braverman won “best poster” at a recent meeting for her work examining communication challenges medical students encountered.

January 12, 2015 1:57 pm

E-learning matches traditional training for doctors, nurses: review

Millions more students worldwide could train as doctors and nurses using electronic learning, which is just as effective as traditional medical training, a review commissioned by the World Health Organization has found.

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