Hot Topics: Clinical Ethics

Blog Posts (34)

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>
September 3, 2014

A Distinction for the Debate over Brain-Death

<p style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">There has been a good bit of debate lately in bioethics circles over the concept and proper definition of death.   The disagreement is between those who think that the cessation of brain activity or ‘brain-death’ is sufficient for death, on the one hand, and those who think that brain-dead patients whose circulatory systems continue to function are still alive, on the other.  Consider, for example, the recent tragic case of Jahi McMath.  McMath suffered complications from a surgery to correct sleep apnea which resulted in cardiac arrest and her being placed on a ventilator.  Shortly after physicians at Oakland Children’s Hospital pronounced her brain-dead and so legally dead.  Her family, however, disagreed, and appealed to the courts for Jahi to be maintained via mechanical ventilation and PEG tube.</span></p> <p style="line-height: 19.0400009155273px;">Although Jahi’s family disagrees with the claim that she is brain-dead (insisting that she is merely ‘brain-damaged’), suppose the Oakland physicians are correct in their diagnosis of brain death.  Nonetheless, even after the pronouncement of brain-death Jahi’s body continued to exhibit the sort of homeodynamic equilibrium—at least for the time being, and with assistance from mechanical ventilation and other life-sustaining interventions—characteristic of living organisms.  It was warm to the touch; her heart continued to pump blood through her veins; and so on.  Indeed the bodies of brain dead patients have in some cases remained functional for weeks and even months, performing such surprising feats as undergoing puberty and even gestating fetuses. This has led certain physicians and philosophers to question whether brain death is really sufficient for death.  Patients who are truly dead, after all, could not be warm to the touch or gestate fetuses.  Could they?  </p> <p style="line-height: 19.0400009155273px;"><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 20px;">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: 20.3999996185303px;"> </span></p>
August 11, 2014

What Is Philosophical Ethics Doing?

<p>In my last blog I asked the question, “What is ethics doing?” where I contrasted the armchair, academic ethics that I knew as a graduate student with the clinical ethics cases in which I am now involved in clinical ethics consultations. I alluded to the famous paper by Stephen Toulmin (1922-2009), “How medicine saved the life of ethics” by providing ethics with many practical value laden problems to address. The very process of becoming involved with applied ethics and ethical problems of practicing physicians in the healthcare system was itself as, or perhaps more, transformational for ethics than it was for medicine. Even though medicine needed a serious study of its value-laden issues, which has evolved into bioethics and clinical ethics, the very activity of doing applied ethics has evolved into a better defined field of inquiry with a clearer purpose. But what about the armchair, academic pursuits of philosophical ethics of old? Is there anything left for it to do? This is the question I will attempt to answer in this blog.</p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 20px;">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: 20.399999618530273px;"> </span></p>
July 22, 2014

What Is Ethics Doing?

<p class="MsoNormal" style="text-align: left;">I recall being a PhD candidate in philosophy in the 1970’s, I often pondered the subject matter of my graduate courses in ethics. I would ask myself, what does any of this have to do with ethics? What are we doing?</p> <p class="MsoNormal" style="text-align: left;">As our courses went from Kant to Mill to G.E. Moore to the Emotivists and others, I couldn’t help but have a sense of unreality about the content of what I was learning.</p> <p class="MsoNormal" style="text-align: left;">How can we use reason to find a basis for knowing right action? What are the ways we can define right action based on a normative moral theory?</p> <p class="MsoNormal" style="text-align: left;">What is the meaning of good? Right? And obligation? Can these terms be defined within a theoretical, substantive moral framework or are they just expressions of feelings and emotions without any cognitive content? If they are more than the latter, what do they mean?</p> <p class="MsoNormal" style="text-align: left;"><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 20px;">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></p>
June 25, 2014

Challenge Business of Ethics

<p>Ethics here, ethics there, ethics nearly everywhere. Welcome to the world of hyphenated ethics: business-ethics, medical, environmental, media, sports, advertising, legal, even military-ethics. With ethics commissions, committees, councils, consultants, certificates, etc., ethics is big business. Just about anyone can claim to be an "<a href="http://tinyurl.com/ncekfl9">ethicist</a>," a term I decried years ago.</p> <p>Who are these "ethicists"? What qualifies to be one? In my field, health care ethics, the stakes are high. Recommendations regarding right, wrong, and in-between can be matters of life and death. While ethicists disclaim moral expertise, their views carry weight in bureaucratic institutions. We expect them to be competent in the demanding task of moral analysis, with in-depth experience and interpersonal skills.</p> <p>But are they?</p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 20px;">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 (36)

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

American Journal of Bioethics: Volume 11 Issue 11 - Nov 2011

Should the “Slow Code” Be Resuscitated? John D. Lantos & William L. Meadow

American Journal of Bioethics: Volume 14 Issue 9 - Sep 2014

Addressing Dual Agency: Getting Specific About the Expectations of Professionalism Jon C. Tilburt

American Journal of Bioethics: Volume 14 Issue 8 - Aug 2014

Changing the Conversation About Brain Death Robert D. Truog & Franklin G. Miller

American Journal of Bioethics: Volume 14 Issue 8 - Aug 2014

Whither Brain Death? James L. Bernat

American Journal of Bioethics: Volume 14 Issue 7 - Jul 2014

The Principle of Equivalence Reconsidered: Assessing the Relevance of the Principle of Equivalence in Prison Medicine Fabrice Jotterand & Tenzin Wangmo

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News (97)

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.

January 8, 2015 8:29 pm

Connecticut Supreme Court upholds ruling that teen must undergo chemo

The Connecticut Supreme Court upheld a prior ruling Thursday that a 17-year-old cancer patient cannot refuse chemotherapy treatment for Hodgkin’s lymphoma.

January 8, 2015 8:23 pm

TV medical advice not always backed by evidence

A Canadian analysis of advice from two popular health shows has stirred controversy with its conclusion that roughly half of the celebrity doctors’ recommendations are not based on solid evidence.

October 7, 2014 2:16 pm

'Decision fatigue' may lead docs to prescribe unnecessary antibiotics

As the day wears on and doctors get tired, they’re about 25 percent more likely than early in their shifts to prescribe antibiotics to patients who don’t need them, according to a new study.

September 30, 2014 2:27 pm

Videos explain concepts of clinical research

When a doctor asks a patient if he or she would like to be randomized into an arm of a standard-of-care treatment study, does the patient really understand the question?

August 11, 2014 1:31 pm

Ethical questions emerge over who gets Ebola drug

In a development that raises a host of ethical issues, Spain announced it had obtained a scarce U.S.-made experimental Ebola drug to treat a Spanish missionary priest infected with the killer virus.

July 10, 2014 3:59 pm

Do doctors understand test results?

Are doctors confused by statistics? A new book by one prominent statistician says they are – and that this makes it hard for patients to make informed decisions about treatment.

July 9, 2014 2:11 pm

San Francisco passes law allowing forced treatment of mentally ill

San Francisco lawmakers approved a law late on Tuesday allowing the forced treatment of mentally ill patients under certain conditions, drawing swift criticism from patient advocacy groups who say the measure tramples civil rights.

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