Hot Topics: Clinical Ethics

Blog Posts (64)

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.…

March 21, 2016

The Unbearable Whiteness of Bioethics: Exhorting Bioethicists to Address Racism

by Kayhan Parsi, Ph.D.

To be ignorant of what occurred before you were born is to remain always a child.

March 18, 2016

Meditations on the Flood

When I first moved to Albany several months ago in pursuit of the exciting and glamorous life of a clinical ethics fellow, I brought with me only a handful of my earthly possessions; if the Fates have their way with me, I will likely leave with even less.

During this past month, in the late-night hours one night I awoke from my slumber to discover that while I had slept the majority of my basement apartment had been transformed into a bog. Yes, I was experiencing wintery real-life application of the law of thermal expansion as it applies to dihydrogen monoxide (i.e., a water pipe burst). After an emergency call to my landlord, I proceeded with my own separation of sheep from goats: what could be saved and salvaged was transported to the little dry land remaining in my now water-logged kingdom, while those items clearly destined to doom and decay were left languishing amidst the advancing liquid army. Few of my books survived, but among them was one I thought quite fitting to the circumstances: Marcus Aurelius’ Meditations.

Essential reading for any good Stoic (and, to my mind, useful if not essential reading for all human beings), Meditations, and the ancient words of wisdom it contains, helped me to navigate through and reflect upon my experience of the flood and its corresponding aftermath. Some choice morsels include:

Casting aside other things, hold to the precious few; and besides bear in mind that every man lives only the present, which is an indivisible point, and that all the rest of his life is either past or is uncertain. Brief is man’s life and small the nook of earth where he lives… (Book III, Number 10)

But among the things readiest to hand to which you should turn, let there be these two: One is that things do not touch the soul, for they are external and remain immovable; so our perturbations come only from our inner opinions. The other is that all the things you see around you change immediately and will no longer be; and constantly bear in mind how many of these changes you have already witnessed. The universe is transformation: life is opinion. (Book IV, Number 3)

Everything is only for a day, both that which remembers and that which is remembered. (Book IV, Number 35)

“I am unhappy, because this has happened to me.” Not so: say, “I am happy, though this has happened to me, because I continue free from pain, neither crushed by the present nor fearing the future.” For such a thing as this might have happened to every man; but every man would not have continued free from pain on such an occasion. Why then is that rather a misfortune than this a good fortune? (Book IV, Number 49)

One of the main life lessons Marcus Aurelius (and indeed all stoics) reiterates time and again is that the essential nature of our human existence is flux and fleetingness. Another is that our ability to respond to this flux and fleetingness, and how we choose to respond, constitute a great human power and our capacity for nobility. Our ability to bear the small things – minor losses of time, possessions, or our sense of control – help to prepare us for the inevitable big things with which we will one day be faced. The major losses.

I sometimes think that one of the most valuable things we can do as clinical ethicists is to help people – patients, families, physicians, etc. – with these particular life lessons. For many, the hospital experience is the epitome of flux, the reason for hospitalization a reminder of life’s fleetingness. Whatever the official reason for requesting an ethics consultation, minor and major losses are always there, whether in the present situation or looming on the horizon. We are consulted, I believe, in large part to help people bear these losses. 

And this becomes another part of my meditation: that this experience, and indeed each of my experiences, has the potential to become a tool for me to help others. The patient’s flood or the family’s flood may not be the same as my own flood, but in reflecting on how I could bear my flood, hopefully I can help guide or companion others as they bear theirs.

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 (58)

American Journal of Bioethics: Volume 16 Issue 11 - Nov 2016

Diagnosis by Documentary: Professional Responsibilities in Informal Encounters Alistair Wardrope & Markus Reuber

American Journal of Bioethics: Volume 16 Issue 11 - Nov 2016

The Ethics of Organ Donor Registration Policies: Nudges and Respect for Autonomy Douglas MacKay & Alexandra Robinson

American Journal of Bioethics: Volume 16 Issue 11 - Nov 2016

Autonomy by Default Cass R. Sunstein

American Journal of Bioethics: Volume 16 Issue 9 - Sep 2016

Four Roles of Ethical Theory in Clinical Ethics Consultation Morten Magelssen, Reidar Pedersen & Reidun Førde

AJOB Primary Research: Volume 7 Issue 3 - Jul 2016

Improving third-year medical students' competency in clinical moral reasoning: Two interventions Paul J. Cummins, Katherine J. Mendis, Robert Fallar, Amanda Favia, Lily Frank, Carolyn Plunkett, Nada Gligorov & Rosamond Rhodes

American Journal of Bioethics: Volume 16 Issue 8 - Aug 2016

The Curious Case of the De-ICD: Negotiating the Dynamics of Autonomy and Paternalism in Complex Clinical Relationships Daryl Pullman & Kathleen Hodgkinson

American Journal of Bioethics: Volume 16 Issue 8 - Aug 2016

Reason, Emotion, and Implanted Devices John D. Lantos

American Journal of Bioethics: Volume 16 Issue 7 - Jul 2016

Moral Hazard in Pediatrics Donald Brunnquell & Christopher M. Michaelson

American Journal of Bioethics: Volume 16 Issue 3 - Mar 2016

A Pilot Evaluation of Portfolios for Quality Attestation of Clinical Ethics Consultants Joseph J. Fins, Eric Kodish, Felicia Cohn, Marion Danis, Arthur R. Derse, Nancy Neveloff Dubler, Barbara Goulden, Mark Kuczewski, Mary Beth Mercer, Robert A. Pearlman, Martin L. Smith STD, Anita Tarzian & Stuart J. Youngner

American Journal of Bioethics: Volume 16 Issue 3 - Mar 2016

Ethics Consultation Quality Assessment Tool: A Novel Method for Assessing the Quality of Ethics Case Consultations Based on Written Records Robert A. Pearlman, Mary Beth Foglia, Ellen Fox, Jennifer H. Cohen, Barbara L. Chanko & Kenneth A. Berkowitz

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News (128)

October 26, 2016 8:00 am

Cardiac Patient Aided by Bystanders Who Were Alerted by App (NPR)

If your heart is going to stop, right outside a hospital is not a bad place for it. And if 41 people within a 330-yard radius have a cellphone app alerting them to your distress, so much the better.

October 25, 2016 8:00 am

Can Ecstasy Help Relieve Social Anxiety Epidemic Among Autistic People? (NPR)

For a long time, Daniel Au Valencia got the message that she was wrong, wrong, wrong. She stood wrong. She talked wrong. She looked at people wrong. “There’s a lot of shame around autism,” she says. “There’s a lot of being told you look weird.”

October 17, 2016 8:00 am

Comparison of Physician and Computer Diagnostic Accuracy (JAMA)

The Institute of Medicine recently highlighted that physician diagnostic error is common and information technology may be part of the solution.1 Given advancements in computer science, computers may be able to independently make accurate clinical diagnoses.2 While studies have compared computer vs physician performance for reading electrocardiograms,3 the diagnostic accuracy of computers vs physicians remains unknown. To fill this gap in knowledge, we compared the diagnostic accuracy of physicians with computer algorithms called symptom checkers.

October 12, 2016 8:00 am

Excuse Me, Why Are You Wearing Those Surgical Scrubs Outside The Hospital? (WBUR)

I work in Boston’s Longwood Medical Area, one of the densest concentrations of hospitals in the country, and I often have this reaction when I’m out on the street among my work neighbors: “Dude. Ew.”

October 7, 2016 8:00 am

This 8-year-old is free of cancer — for now — after a ‘breakthrough’ treatment (Washington Post)

By the time 8-year-old Ava Christianson got to the National Institutes of Health this summer, she had lost several grueling rounds to leukemia and was bracing for the next one.

September 28, 2016 10:50 am

World's first baby born from new procedure using DNA of three people (The Guardian)

The world’s first baby to be born from a new procedure that combines the DNA of three people appears to be healthy, according to doctors in the US who oversaw the treatment.

August 31, 2016 8:00 am

When a Medical Test Leads to Another, and Another

A patient gets a CT scan to diagnose an abdominal pain. By chance the scan also reveals a small lesion in the kidney. Should the patient be told?

August 26, 2016 8:00 am

EpiPens are my armor against disaster. They shouldn’t be priced like a luxury. (Washington Post)

The last time I refilled my EpiPen, in November, I paid $365.63 out of pocket for two auto-injectors. I looked that number up Thursday morning after the news broke that Mylan, the company that makes EpiPens, is bowing to public pressure and will startoffering discounts after years of hiking prices.

June 28, 2016 8:31 am

End-Of-Life Care Better For Patients With Cancer, Dementia: Study Finds (Kaiser Health News)

A new study offers surprising findings about end-of-life care — specifically, physicians tend to be more likely to accommodate the advanced-care wishes of patients with cancer or dementia than renal disease, congestive heart failure, pulmonary disease or frailty.

March 16, 2016 1:33 pm

'Difficult' patients may tend to get worse care, studies find

What happens to medical care when the patient is a jerk?  Dutch researchers asked the question in two new studies, and the answer should make grumps think the better of their bad behavior: “Disruptive” patients may get worse care from physicians.

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