Topic: Clinical Ethics
March 18, 2016 | Posted By Valerye Milleson, PhD

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:

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.

March 10, 2016 | Posted By Jane Jankowski, DPS, LMSW

According to the American Society of Addiction Medicine, drug overdose is the leading cause of accidental death in the US with close to 50,000 deadly overdoses in 2015 alone.  Opioid addiction accounted for nearly 20,000 of these and heroin alone was a factor in just over 10,500 deaths. The magnitude of opioid abuse related hospitalizations, sales of prescription pain killers and deaths have increase exponentially between 1999 and 2008 according to ASAM. Increased access to Narcan (naloxone) to reverse life threatening effects of opioid for first responders has now expanded to making Narcan available to the general public as well. In some areas, Narcan can be purchased without a prescription by family members and friends who expect they may need to quickly rescue a loved one. While I support this program because it can and will likely save lives, it does not address the need for effective rehabilitation of persons who suffer the all-consuming and devastating effects of opioid addiction. Regulations which will allow persons with opioid addictions to be detained involuntarily in health care setting are also being discussed, but pose some dilemmas as well.

 

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.

March 4, 2016 | Posted By Wayne Shelton, PhD.

As a philosopher who works in a large health science center where the scientific method and perspective reign supreme, it is common to hear comments about the abstract and ideal nature of philosophy. As though those who think about human problems from a philosophical perspective do so from an abstract, insular perspective with little or no practical impact. Though I hear such dismissive comments about philosophy less often than I used to, say 20 or more years ago, I sense there is still a commonly held view that those who think from a philosophical perspective as not well oriented to practical affairs. And with some justification do people have this view of philosophy.

 

As I have written in previous blogs, philosophy has long and even proud part of its tradition for being, well, useless. If we assume that the basis of philosophical truth and wisdom lay in some ultimate, objective form that only those who think in certain ways can grasp, then knowledge becomes privileged to the philosophical few as an end it itself. This type of Platonic philosophical truth quickly divides the here and now inferior world from the more exclusive understandings of reality. Because of this basic influence of Platonic philosophy, much of the history of philosophy in the Western tradition has been focused on the search for a rational, objective basis of truth, value, and reality. Not surprisingly, the goal has not been reached. But the quest continued through most of last century and philosophical got its more or less justified reputation for being an insulated, esoteric, and detached form of intellectual activity. Put bluntly, philosophers, with a few exceptions, rarely got their hands dirty in the real world of practical activity.

 

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.

February 12, 2016 | Posted By Claire Horner, JD, MA

When patients lack capacity, physicians look to family and friends to step in and provide consent for treatment on behalf of the patient. These surrogates, whether they were appointed by the patient as their health care agent or become health care surrogates by default under state law based on their relationship to the patient, have the right to receive information related to the care and treatment of the patient and have the corresponding responsibility to make health care decisions for the patient based on either the patient’s previously expressed wishes or her best interests.  What they don’t have, however, is the right to control and direct every minute aspect of the patient’s care in the hospital.  It would take several blog posts to discuss the conflicts that occur between surrogates and health care providers because of this (such as DNR orders, barriers to discharge, and demands for certain medications, to name a few), but perhaps the most concerning example of surrogate over-reach is the issue of inadequate pain management.

The use of pain medication can be difficult for both patients and providers, especially with the rate of opioid abuse in this country. Patients and their families are often afraid of the possibility of addiction, while physicians are reticent to prescribe narcotics for fear of misuse.  Whether or not a patient is a “drug-seeker” is a common question that arises when physicians are deciding what to prescribe. However, in the context of terminal illnesses – particularly at the very end of the illness – the shift in focus from curative to palliative care highlights the need for sufficient pain control in the face of nearly intractable pain.  It is in this context that denial of pain medication, or poor pain management, is most clearly an ethical issue.

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.

January 12, 2016 | Posted By Bruce White, DO, JD

As is their publishing practice, the American Journal of Bioethics recently invited submissions for an Open Peer Commentary to an article they plan to publish in the next few months. The article is entitled “A Pilot Evaluation of Portfolios for Quality Attestation of Clinical Ethics Consultants” and authored by Joseph J. Fins, MD, Eric Kodish, MD, and the other members of the American Society for Bioethics and Humanities (ASBH) Quality Attestation Presidential Task Force (QAPTF). This paper is a sequel to their earlier paper “Quality Attestation for Clinical Ethics Consultants: A Two-Step Model from the American Society for Bioethics and Humanities” which was published in The Hastings Report. [http://www.ncbi.nlm.nih.gov/pubmed/24092588] The first paper described the ASBH plans to “attest” to the “quality” of self-identified, randomly-selected pilot clinical ethics consultants who submit a “portfolio” illustrating their consultation activities. When the article appears, all involved in clinical ethics consultation and the training of future clinical ethics consultants should read the paper. The QAPTF and the ASBH should be congratulated for doing this work and sponsoring the activity.

However, in thinking through this process again, one wonders how much of this is about the past and not about the future. Shouldn’t any process be more prospective and less retrospective? Maybe this is not possible? But how important is it really to show that people who are currently offering clinical ethics consultation services and recording their efforts in portfolios for other “experts” to review and compare do their consultations satisfactorily? Will this “attestation” somehow change their employment or practice circumstances or patterns? Will their employers dismiss them if they fail to obtain “attestation” status and hire clinical ethics consultants are meet the attestation standard? Will it add public recognition? In truth, is “attestation” really a quality standard that matters?

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.

January 4, 2016 | Posted By Valerye Milleson, PhD

"I now know that if you describe things as better as they are, you are considered to be romantic; if you describe things as worse than they are, you are called a realist; and if you describe things exactly as they are, you are called a satirist." – Quentin Crisp

A theme that has run through many of my blog posts so far is the concept of eudaimonia. This New Year, which not only highlights the annual rituals of goal setting and actively plotting to become the best person you can be in the year to come but also is a reminder of the birth of famed raconteur and master of wit, Quentin Crisp, seems to me like the perfect time to discuss this concept in greater detail.

"If I have any talent at all, it is not for doing but for being." – Quentin Crisp

Despite his humble self-description, Quentin Crisp has been a hero to many, and in his vocation of being he was one of the strongest advocates of “living well” in recent times. Living well (or “good spirit”, happiness, human flourishing, etc.) is roughly what ancient Greek philosophers meant by eudaimonia. Aristotle’s definition in the Nicomachean Ethics of “living well and doing well” (Book I, Chapter IV) is apt and fairly uncontroversial; but it is far from self-explanatory. After all, “living well” can mean different things to different people. For Aristotle, living well basically meant living a life of excellence in reason (along with certain external goods necessary to keep this virtuous activity going smoothly). The Stoics agreed with Aristotle’s account on the role of excellence in reason, but disagreed with him about the importance of such things as wealth, family, friends, power, beauty, etc. in one being able to achieve eudaimonia. The Cynics and the Stoics held fairly similar views of eudaimonia, but in general the Cynics seemed to actively disavow these external things, and living well to a Cynic would have been more akin to the life of a virtuous ascetic. The Cynics also tended to be, like Mr. Crisp, satirists, cosmopolitans, and lovers of excellence and humanity.

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.

December 24, 2015 | Posted By Paul Burcher, MD, PhD

I was surprised to read recently in the New York Times that a woman has undergone a cesarean section despite her refusal to consent to the procedure.  While the details of the case are not entirely clear in the article, so I do not want what follows to be understood as a specific comment on this case, my surprise arises because I thought the ethics of refusal of consent were not in dispute.  The American College of Obstetrics and Gynecology has taken a clear position of this: it is not justifiable to perform surgery on a patient with decisional capacity without her consent. ACOG’s committee opinion, “Maternal Decision Making, Ethics, and the Law,” strongly discourages even attempting to seek a court order for treatment when a pregnant woman refuses cesarean section, and concludes with a statement that:

Pregnant women's autonomous decisions should be respected. Concerns about the impact of maternal decisions on fetal well-being should be discussed in the context of medical evidence and   understood within the context of each woman's broad social network, cultural beliefs, and values. In the absence of extraordinary circumstances, circumstances that, in fact, the Committee on Ethicscannot currently imagine, judicial authority should not   be used to implement treatment regimens aimed at protecting the fetus, for such actions violate the pregnant woman's autonomy. 

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.

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 9, 2015 | Posted By Valerye Milleson, PhD

“People need to be made more aware of the need to work at learning how to live because life is so quick and sometimes it goes away too quickly.” – Andy Warhol

This past weekend was the last one for The Late Drawings of Andy Warhol: 1973-1987 exhibit at The Hyde Collection Museum in Glen Falls, and I almost didn’t go to it. I told myself there were far too many other things to do: the stack of recent journal articles I’ve been meaning to get to; student assignments that are in need of grading; the upcoming presentations for which I haven’t even begun putting together powerpoints; the apartment that, despite ongoing efforts, never seems to be completely clean; the piles of unwashed or unfolded laundry; and so on. In terms of triaging my limited time, a two-hour round trip trek to see a handful of sketches hardly seemed sufficiently important.

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 7, 2015 | Posted By Bruce White, DO, JD

In his last AMBI blog posted on June 18, 2015, Wayne N. Shelton, PhD, MSW, discussed recent movement toward the professionalization of clinical ethics consultants. He noted the adoption of a Code of Ethics for Health Care Ethics Consultants by the American Society for Bioethics and Humanities (ASBH), which has been praised as important milestone toward the professionalization of clinical ethics consultants. Moreover, Dr. Shelton listed several challenges that “professionals” who call themselves “clinical ethics consultants” currently face, including: “[1] how to make sense of the diverse educational backgrounds and training of those who perform clinical ethics consultations and how far to push such requirements; [2] the lack of a national body to set requirements that leaves local hospital leaders with little incentive to pay for highly qualified CECs and view this as a sound investment; and finally [3], most seriously, the way in which many problems in patient care are misidentified as clinical ethical problems while other serious clinical ethical problems may be entirely overlooked or if recognized, not viewed as requiring the expertise of a CEC.” He concluded his post with: “These challenges are indications that clinical ethics consultation will not likely achieve professional status in the healthcare system in the near future.” Of course, Dr. Shelton is correct in his analysis, but some might see the challenges he listed as surmountable if those who practiced clinical ethics consultation were to: (1) establish minimum uniform educational standards for new clinical ethics consultants; (2) create national certification and accreditation standards so employers would more fully understand the nature and value of their work; and (3) provide consultants themselves and other stakeholders unmistakable guidance on what clearly constitutes the work of clinical ethics consultants. (This third point sounds very much like a “scope of practice” definition found in state professional licensing statutes.) However, it may take something much more for clinical ethics consultants to be a separate professional category.

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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