Hot Topics: Clinical Ethics

Blog Posts (66)

January 25, 2017

CPR and Ventricular Assist Devices: The Challenge of Prolonging Life Without Guaranteeing Health

by David Magnus and Danton Char

The woods decay, the woods decay and fall,
The vapours weep their burthen to the ground,
Man comes and tills the field and lies beneath,
And after many a summer dies the swan.

December 1, 2016

Moral Distress in Clinical Ethics: Expanding the Concept

by Alyssa M. Burgart & Katherine E. Kruse

As physician ethicists, we often receive consultations where there is no clear ethical question, but rather, discomfort around value judgments.…

October 12, 2016

Clinical Ethics Consultation Services and Expectations: Is It That Much Different From Other Clinical Services?

Two recent presentations at the 2016 Annual Meeting of the American Society for Bioethics and Humanities in Washington, DC – offered within just a couple of hours of each other – had a similar theme but approached the issue from different angles. The first presentation was a case review by David Kappel, MD, a surgeon at the University of West Virginia, and Valerie Satkoske, MSW, PhD, a bioethics professor at the University of West Virginia Center for Bioethics and Health Law. The case involved a 75-year-old-man admitted for surgery. Unfortunately, following the surgery, he was delirious. The delirium continued for several days. He had to be restrained and fed with a nasogastric tube. The situation was very upsetting to his family; they were completely taken aback by this complication. The delirium was so unexpected and surprising that the family wondered whether or not the patient would have agreed to the surgery if he had fully understood that the extended delirium might result. The title of this presentation was: “You Should Have Told Me! Struggling to Meet the Spirit of Informed Consent.” As one can imagine, the presenters asked if information about the possibility of an extended delirium should have be included as a part of the informed consent process. The delirium was not part of the patient’s and family’s expectations. Of course, even with a more extensive, informed consent process, the family still may have not been fully prepared to deal with the complication anyway. Perhaps the answer turns more on the likelihood of the complication arising in this patient’s case given the particulars and context? Some complications are more probable than others given the circumstances?

The second presentation, titled “I Never Promised You a Rose Garden: On the Necessity of Not Meeting Expectations Regarding Clinical Ethics Consultation,” was given by Virginia L. Bartlett, PhD, and Stuart G. Finder, PhD, of Cedars-Sinai Medical Center. This presentation too dealt with expectations: the expectations those who ask for a clinical ethics consultation might have of clinical ethics consultants. The presenters suggested that the expectations might range from “ethics policeman” to “ethics superhero.” The presentation ended with the relatively unsatisfactory mechanisms available to evaluate the effectiveness or helpfulness of clinical ethics consultation services interventions. From the presentation, it was clear that clinical ethics consultants should be prepared for not meeting expectations of those who request assistance.

Regardless, both presentations highlight how important it is for clinicians – whether physicians or surgeons directly caring for patients or clinical ethics consultants offering advice or recommendations to colleagues or patients or families – to understand stakeholder expectations as well as they can. With doctors and nurses it may be a bit easier: mostly likely the patient wants to be restored to health or a baseline with the least discomfort and minimal aggravation. With clinical ethics consultation services, the expectations are often not this clear. Moreover, with both clinical medicine and clinical ethics consultation service interventions, there are complications and unintended consequences. One cannot always fully anticipate which way a case may turn, or which word or phrase at a particular moment may result in a worse situation rather than a better situation.

For good or ill, there is no informed consent equivalent for clinical ethics consultation services when stakeholders ask for a consultation. The various stakeholders – when they request a clinical ethics consultation – may or may not know exactly what they are asking for anyway. But, most likely, what they are asking for is help with a very troublesome or thorny issue that has ethical implications or dimensions. In this respect, clinical ethics consultants perhaps should worry less about meeting expectations than other clinicians, since the goals of clinical ethics consultation services often times are much less clear – at least when the consultation is requested – than restoring the patient’s health or previous baseline with the least discomfort and minimal aggravation. However, may always be better for the clinical ethics consultant to ask, “How do you think we can help?” and try to set or reset expectations as well as one can at the beginning of the process.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

September 12, 2016

“Humanists,” Academic Philosophers, Critical Distance, and Clinical Ethicists

The October 2016 Annual Meeting of the American Society for Bioethics and Humanities (ASBH) announced its theme for the Washington, D.C., convocation several months ago: “After over half a century of work, and as ASBH celebrates its coming-of-age, we have chosen to focus on ‘critical distance’ and our ‘insider-outsider’ status at our 18th annual meeting.” Some may be relatively unfamiliar with these notions of “critical distance” and “insider-outsider” status.

            In the early 1970s, when medical center and medical school thought leaders began hiring “humanists” to teach, round with teams, and attend morning reports and noon conferences, it was unclear what – if any - specific outcomes might result. However, the center executives and deans wanted to try something to help inject human values and humanistic thought into the educational process to offset the very strong influences of advancing technologies, specialization, and materialism, and to assure the outraged public in the face of recently revealed research scandals.

            These pioneer “humanists” were theologians, religious studies scholars, and philosophers. In just a few years, the philosophers were predominating in this growing field of applied ethics educators and scholars. In explaining this transition, Art Caplan wrote: “It proved very difficult to do bioethics in public in anything approximating a religious voice. ... [I]t quickly became clear that to command the attention of scientists and physicians, as well as policy-makers, a more secular voice was required. Philosophy, emerging out of decades of mainly futile wrangling about meta-ethical issues, was more than happy to oblige ... .” Caplan AL. The birth and evolution of bioethics. In Ravitsky V, Fiester A, Caplan AL. The Penn Center Guide to Bioethics. New York: Springer Publishing Co., 2009, p. 5.

            But, the philosophers who taught applied ethics or their philosophy colleagues in the academy challenged medical ethics in the classroom and at the bedside. The academic philosophers were concerned that the medical school philosophers might be losing their bearings. This difference of opinion was stated by Harvard philosophy professor F.M. Kamm in 1988: “[P]hilosophers should try to bring ‘real-life’ problems (and those that have them) up to the abstractions of philosophy, rather than just bring philosophy down to the level of the problems. [Emphasis in original.]” Kamm FM. Ethics, applied ethics, and applying applied ethics. In Rosenthal DM, Shehadi F, eds. Applied Ethics and Ethical Theory. Salt Lake City: University of Utah Press, 1988, p. 170.  To be even clearer, she continued: “[C]reative solutions to practical problems come only after a period of detaching ourselves from them to consider more fundamental concepts. ... [E]mphasizing the discovery of solutions to problems conflicts with a detached interest that goes wherever an illuminating, but not obviously or immediately useful, aspect of a questions leads one.” Ibid, p. 170-171. “If philosophers who do applied ethics do not maintain such attitudes, in common with academic philosophers, they run the risk of being bad philosophers and becoming merely the bearers of simplified, falsely reassuring news from the theorists.” Ibid, p. 171.

            In thinking back, it must have been a phenomenal trial for several medical school philosophers to attempt to satisfy the academic philosophers while taking a new path. For the academics the question must have been how does one comment upon the matters at hand without learning so much about related topics and processes or becoming deeply enmeshed in the milieu that one is no longer an “outsider” but an “ insider” without critical distance? This turf battle must have been particularly worrisome for some distinguished philosophers who gained national and international reputations as academic philosophers and who then moved to medical school and clinical settings. Of course, a good many philosophers and theologians thought doctors were too close to the problem  (that is, lacked critical distance) to be part of any solution. (And quite naturally, some of the doctors thought the theologians and philosophers lacked a sufficient clinical knowledge base to fully understand the contexts in which they were involved.) History has shown that many of the medical school philosophers transitioned and cared little about what the academic philosophers said anyway.

            By the early and middle 1980s, other professionals joined the philosophers and theologians in broadening the bioethics or clinical ethics base and voice: physicians, nurses, social workers, chaplains and pastoral care workers, and lawyers, just to name a few. For health care professionals, chaplains, and lawyers, this notion of “critical distance” as not an overriding factor. If these bioethicists gave any thought to “detachment,” they probably interpreted it as “objectivity.” Objectivity calls to mind: “impartiality,” “lack of bias,” “fairmindedness,” “neutrality,” “open-mindedness,” “fairness,” and “justice.”

            Today, as clinical ethics consultants move toward professionalization, the outsider-insider issue has lost its relevance. Few may even understand the context of the initial problem now. Clinical ethics consultants exist in great part to improve patient care and the patient care experience; they are undoubtedly insiders. And, whether one thinks in terms of critical distance or not, objectivity in providing service to others remains critically important.

August 12, 2016

Twisted Self-Deception

By: J.S. Blumenthal-Barby

 In his book, Self-Deception Unmasked, philosopher Ale Mele writes about two types of self-deception. There is the straight-forward kind, where a person falsely believes—in the face of strong evidence to the contrary—things that she would like to be true.…

July 13, 2016

Reason, Emotion, and Implanted Devices

by John D. Lantos, MD

Pullman and Hodgkinson present a case that, it seems, should have been an easy one. A competent adult makes a simple request to discontinue a medical therapy.…

May 27, 2016

Why America Needs Bioethics Right Now

by Craig Klugman, Ph.D.

From the title, you probably assumed I’m going to talk about the fast changing pace of medical technology, whether we should be working on human embryos, claims that scientists will be able to do head transplants within 2 years, or even whether the Olympics should be postponed because of Zika.…

April 26, 2016

BioEthicsTV: A night of consent issues on ChicagoMed

by Craig Klugman, Ph.D.

On this week’s episode of ChicagoMed (Season 1; Episode 15) issues of consent was the main focus.…

April 21, 2016

Clarifying the Rules: No media in patient treatment areas

by Craig Klugman, Ph.D.

In January, I wrote about the case of Mark Chanko, a patient run over by a truck whose death was recorded for a real-life medical show and was later viewed on television by his horrified widow who had never been asked for permission for the airing.…

April 20, 2016

Stinging Doctors: Recording Your Own Surgery

by Craig Klugman, Ph.D.

Ethel Easter expressed outraged this week at what her health care team said about her during her surgery in Texas last year.…

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Published Articles (67)

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

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

AJOB Primary Research: Volume 8 Issue 1 - Feb 2017

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

AJOB Primary Research: Volume 8 Issue 1 - Feb 2017

Decision making in pediatric oncology: Views of parents and physicians in two European countries Domnita O. Badarau, Katharina Ruhe, Thomas Kühne, Eva De Clercq, Anca Colita, Bernice S. Elger & Tenzin Wangmo

AJOB Primary Research: Volume 8 Issue 1 - Feb 2017

Better to know than to imagine: Including children in their health care Tenzin Wangmo, Eva De Clercq, Katharina M. Ruhe, Maja Beck-Popovic, Johannes Rischewski, Regula Angst, Marc Ansari & Bernice S. Elger

American Journal of Bioethics: Volume 17 Issue 2 - Feb 2017

Irrational Exuberance: Cardiopulmonary Resuscitation as Fetish Philip M. Rosoff & Lawrence J. Schneiderman

American Journal of Bioethics: Volume 17 Issue 2 - Feb 2017

LVAD-DT: Culture of Rescue and Liminal Experience in the Treatment of Heart Failure Frances K. Barg, Katherine Kellom, Tali Ziv, Sarah C. Hull, Selena Suhail-Sindhu & James N. Kirkpatrick

American Journal of Bioethics: Volume 17 Issue 2 - Feb 2017

CPR and Ventricular Assist Devices: The Challenge of Prolonging Life Without Guaranteeing Health David Magnus & Danton Char

American Journal of Bioethics: Volume 16 Issue 12 - Dec 2016

A Broader Understanding of Moral Distress Stephen M. Campbell, Connie M. Ulrich & Christine Grady

American Journal of Bioethics: Volume 16 Issue 12 - Dec 2016

Moral Distress in Clinical Ethics: Expanding the Concept Alyssa M. Burgart & Katherine E. Kruse

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

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

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News (140)

February 10, 2017 9:00 am

Brain researchers fight National Hockey League’s demand for records (Science)

A pair of Boston University (BU) brain researchers is pushing back against demands by the National Hockey League (NHL) that they release data, brain pathology slides, and interview records of former NHL players and their families. The scientists accumulated the records during their research on chronic traumatic encephalopathy (CTE), a neurodegenerative disease that has been linked to repetitive head trauma.

February 2, 2017 9:00 am

Gene drives thwarted by emergence of resistant organisms (Nature)

By studying the insects under more-natural conditions, scientists hope to better understand how to eradicate them — and malaria — using an emerging genetic-engineering technology called gene drives. The technique can quickly disseminate genetic modifications in wild populations through an organism’s offspring, prompting some activists to call for it to be shelved. Yet gene drives might not be as effective as activists think. Recent research has identified a major hurdle to using them to eliminate diseases and vanquish invasive pests: evolution.

January 26, 2017 9:00 am

Human tissues in a dish: The research and ethical implications of organoid technology (Science)

Growing functional human tissues and organs would provide much needed material for regeneration and repair. New technologies are taking us in that direction. In addition to their use in regenerative medicine, stem cells that grow and morph into organ-like structures known as organoids can be used in drug development and toxicology testing. The potential developments and possibilities are numerous and affect not only biomedicine but also areas of ongoing ethical debate.

January 19, 2017 9:00 am

Pharmacological rescue of diabetic skeletal stem cell niches (Science)

Stem cells: The key to boosting bone healing in diabetes

January 16, 2017 9:00 am

How Gene Editing Could Ruin Human Evolution (Time)

CRISPR may be used to repair a gene that has a deficient product, such as an enzyme or receptor, or alter code that merely suggests of risk. Ideas on how to use it change hourly. The method is here to last. The ethics will only get more fraught.

January 13, 2017 9:00 am

Successful Ebola vaccine will be fast-tracked for use (BBC News)

Trials conducted in Guinea, one of the West African countries most affected by an outbreak of Ebola that ended this year, show it offers 100% protection. The vaccine is now being fast-tracked for regulatory approval.

January 9, 2017 9:00 am

Fact-checking Congress’s fetal tissue report (Science)

They interviewed senior physicians from Planned Parenthood, who spoke bluntly about their provision of fetal tissue from legal abortions for medical research

December 20, 2016 9:00 am

OxyContin goes global — “We’re only just getting started” (LA Times)

Former U.S. Food and Drug Administration commissioner David A. Kessler has called the failure to recognize the dangers of painkillers one of the biggest mistakes in modern medicine.

November 17, 2016 9:00 am

CRISPR gene-editing tested in a person for the first time (Nature)

A Chinese group has become the first to inject a person with cells that contain genes edited using the revolutionary CRISPR–Cas9 technique.

November 11, 2016 8:00 am

Colorado passes medical aid in dying, joining five other states (Denver Post)

Colorado passed a medical aid in dying measure Tuesday that will allow adults suffering from terminal illness to take life-ending, doctor-prescribed sleeping medication.

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