Topic: Beneficence
December 14, 2015 | Posted By Wayne Shelton, PhD

The role of family surrogates in providing a voice for incapacitated patients is of crucial importance. Usually, surrogates have the best interests of the patient in mind and try to work with the physician in charge to provide the best treatment possible for the patient. In most cases there is agreement between the surrogate and the physician about the treatment plan and the goals of care. But as those of us who do clinical ethics consultations know, there are some cases, maybe 5% or fewer, where there are serious conflicts between surrogates of patients lacking capacity and physicians. I want to briefly explore a type of conflict that we seem to be seeing more often—when the surrogate attempts to get too involved in the medical management of the patient. Let me use a couple of sample cases to illustrate the type of conflict I have in mind.

The first is the case of an elderly patient with dementia and with multiple medical problems, including severe pressure ulcers. This patient requires regular dressing changes for the pressure ulcers in order to keep them clean and well managed, requiring the patient to be turned, which causes her significant discomfort. When these dressing changes happen, the standard of care is to make sure the patient suffers as little as possible, so a small amount of morphine is given. But the family surrogate informed the nurse that she should not use morphine, as she wanted the patient to remain as alert as possible at all times. When the nurse tries to perform the dressing changes without giving morphine the patient groans, grimaces, and appears agitated and in pain. The nurse feels distraught that she is causing the patient to suffer unnecessarily.

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.

October 21, 2015 | Posted By Jane Jankowski, DPS, LMSW

My original plan for this blog was to consider whether or not there remained a need for the old “Drunk Tank” way of managing persons who are acutely intoxicated by allowing them to sleep off or wait out their inebriation at the police station before determining whether or not further mental health care was needed, rather than bringing individuals to hospital emergency rooms for supervised sleep and conversation about detox services or psychiatric evaluation. Though the task of caring for acutely intoxicated persons, sometimes folks who are frequently seen in ERs repeatedly, can seem to be an inappropriate use of resources by clinicians we must appreciate that the motivation is often about safety, protection, and the welfare of the patient as well as the public. In the social context of fear and mistrust toward law enforcement following the many egregious cases of police brutality, my focus is a reminder of the ways in which police can, and often do, intervene with persons who have mental illness and addiction in order to protect these vulnerable mentally ill individuals. In no way do I condone the misconduct and violence we have come to hear about too often, but rather will focus on the important ways police can and very often do work with mental health professionals to assist persons in acute crises.

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.

May 27, 2014 | Posted By Paul Burcher, MD, PhD

In recent years there has been a push to teach professionalism to medical students, and this is in part a response to a perceived decrease in respect for physicians by the general public.  Much of the emphasis on teaching professionalism has been on treating patients with respect, and placing the needs of the patient over our own needs.  I support this effort, but I would like to emphasize a different aspect of professionalism that seems to get less attention: the relationship we have with our colleagues.  The duty of professionalism arises because medicine is a profession—we profess an oath to become members, we perform a task held in high regard by the public, and we promise to self-regulate.  Given that this is the nature of medicine, we can easily now say something about how we must treat our colleagues to best uphold our oath and to best maintain the reputation of our vocation.  For Aristotle, a virtue is often found as the mean between two excesses which are vices, and I think this model is appropriate for determining the virtuous, professional way we should treat our colleagues:  show respect, but do not protect incompetence or misbehavior. Put another way, we have dual duties to respect our colleagues, but also to protect our patients.  When these duties come into conflict, patients must come first, but we must also remember that failing to respect colleagues has negative effects on both the status of our profession, and on patient care itself.

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.

August 20, 2013 | Posted By Wayne Shelton, PhD

In my work as a clinical ethics consultant, I have seen many situations where dying patients or their surrogates make decisions that cause considerable concern and moral stress to physicians, and particularly to nurses who are continually at the patient’s bedside. In an era where respect for patient autonomy is the paramount ethical value, we are obligated to be respectful of these preferences and decisions. But what about the cases where those preferences and decisions lead to procedures and treatments at the end of life which are entirely contrary to sound medical advice? Should physicians follow these directives even if this means that the patient will suffer needlessly and the physician will be performing painful, futile treatment?

Ethics consultations are frequently called on to address issues at the end of life.  One of the most pressing issues involves dying patients for whom CPR would be medically inappropriate. The patient or surrogate will not give consent for a DNR order, insists on remaining full code and that “everything be done” in spite of a prognosis of imminent death.  A case I read about a few years ago illustrates this concern.

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.

July 31, 2013 | Posted By Marleen Eijkholt, PhD

You are mid 50ties, you have several university degrees from top universities, you have a PhD in Chemistry and are happily married. You seem to have a great life, but for one thing: while your legs are fully functioning, you do not want them. And it is not even that you just do not want them; you feel that they do not belong to you. They give you great suffering.

Earlier this week, the Huffington Post reports on Cloe Jennings who suffers from her healthy legs. Reportedly, she suffered from her legs since she was 4 years old and has held the desire to have them amputated or to be paralysed from that time. Jennings is raising money to travel to a surgeon who has offered to help her.

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.

May 7, 2013 | Posted By Bruce D. White, DO, JD

The FDA has banned generic availability of the original formulation of OxyContin® (Purdue Pharma LP’s brand of oral controlled-release oxycodone). OxyContin® was approved by the FDA in 1995 and was first marketed in the US in 1996. Within a very short time, OxyContin® was the most frequently prescribed brand name analgesic with annual sales in the billions of dollars. By 2005 retail purchases were six times the 1997 volume; by 2008, sales totaled $2.5 billion.

Purdue was very effective in marketing OxyContin®. The manufacturer used several “sales strategies” that have since been roundly criticized by regulators and some physicians: aggressive off-label detailing; technically misbranding the product so as to mislead prescribers and patients regarding abuse potential; applying “significant political pressure” to gain state Medicaid formulary approvals; and engaging nationally recognized pain management thought leaders which “encouraged more liberal prescribing of opioids, based on debatable evidence.” With the increased prescribing, more of the drug was available for potential diversion to illegitimate channels. Not surprisingly, the number of accidental deaths from opioid drugs – licit and illicit – have grown in just a few years into a national crisis of epidemic proportions.

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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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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