In the fall of 1970 Philip Tumulty, a Johns Hopkins’ internist, gave a lecture to the 3rd year medical school class at Johns Hopkins. His lecture was published in the same year in the New England Journal of Medicine under the title of “What is a clinician, and what does he do?” (Tumulty PA. What is a clinician and what does he do? N Engl J Med. 1970 Jul 2;283(1):20-4.) In this classic piece, this eminent physician of his era claimed that the primary role of the clinician is to “manage a sick person with the purpose of alleviating the total effect of his illness”. 

This paper, probably better than any other paper I have ever read gets to the essence of what a patient needs from an expert clinical caregiver; it lays out eloquently and robustly the characteristics of a good clinician and what is involved in excellent clinical care of patients. As Tumulty says, it is not a diseased body organ that shows up for physical diagnosis and treatment; rather, it is an anxious, fearful, wondering person concerned about her personal life, including her family, work, friends as well as her hopes and dreams. This means the clinician must be a thoughtful and systematic fact finder, a careful listener, a keen analyst of the facts and a prudent planner regarding which tests and treatment options make the most sense for this particular patient. Moreover, Tumulty rightly assumes that these skills should be embodied in the clinician as natural traits that the clinician genuinely enjoys performing. 

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.

Medical situations can instantly change. This can be for the better or for the worse:  A patient who consistently refused to eat, now suddenly decides to eat. A patient who is delirious or manic threatens a staff member at 11:50, but subsequently seems rational and reasonable when we arrive in his room 15 minutes later. A stroke patient who does not communicate or respond, and who is likely to develop into a permanent vegetative state (PVS), perks up, talks and leaves. A patient, who is on the mend, develops a fever, requires a rapid response and dies. 

The ethical issues, similarly, change instantly in these situations. It requires me, as a new clinical ethics, to constantly redefine my perspectives. Where we plan to discuss placement of a feeding tube, the patient’s mood alteration resolves issues around placement and resolves the ethical questions. Where we address concerns around a safe discharge, we find out that the patient’s mood changes at 12 o' clock, and awareness of this time frame allows for a safe discharge. Where have family meetings to discuss quality of life in a PVS, this discussion is no longer necessary as the patient can be discharged.

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.

Two articles in the New York Times raise a disturbing question regarding the ethics of cancer treatment in this country.  The first on ovarian cancer treatment noted that despite significantly better survival data with intraperitoneal chemotherapy (IP) over intravenous chemotherapy (IV) for ovarian cancer, most oncologists were still using IV chemotherapy. The reason given is that IP chemotherapy is more difficult to give, and more labor intensive, but is not reimbursed at a higher rate.  That is, physicians are routinely withholding the more effective treatment for economic reasons.  Another recent article describes how oncologists tend to choose more expensive chemotherapy even when it is not more effective because they are paid a percentage of the drug’s cost. 

It is an often-repeated truism that physician behavior will follow economic incentives perfectly—if you wish to reduce physician procedures capitate patient care, if you wish to increase patient procedures, pay physicians on a fee-for-service basis.  While this has been empirically demonstrated, it is a bit hard to accept that this adage remains true even when physicians seems to be crossing the line into unethical behavior in order to follow the almighty dollar.  The IP chemotherapy issue is most troubling because it represents physicians giving care they know to be inferior because the better treatment costs more to deliver, and this reduces their own income.

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.

A story last week from Bakersfield, California received an enormous amount of attention and seemed to capture the public’s imagination. The story was in both the print and electronic media as though a great injustice has been unearthed.  People were outraged that no action was taken to provide cardiopulmonary resuscitation (CPR) on an 87 year-old woman who had arrested in an independent living facility where she was a resident. The story was the rage on Facebook and other social media—people weighing in with their concerns, which again was mostly outrage and disbelief that something like this could have happened. Now that we are a week or so out from when this event happened, I thought it might be worth thinking about what happened in this story and see what lessons we can learn.

The story begins when Lorraine Bayless, the 87 year-old resident of Glendale Gardens, a Bakersfield independent living facility, collapsed and someone, presumably an employee, called 911. Apparently the employee called to report this emergency and was expecting the paramedics to respond quickly. The dispatch operator, realizing the importance of a quick response, admonished the caller to begin CPR herself, before the paramedics arrived. The caller, who identified herself as a nurse, told the dispatcher that she was not permitted by the facility to provide CPR for patients. Glendale Gardens is an independent living facility that says by law they are "not licensed to provide medical care to any of its residents." So in the cool light of calm reflection, did something wrong take place?

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.

As a new clinical ethicist in training, I’m allowed to take some looks in the metaphorical kitchen of the hospital where things really happen: seeing research and treatment in practice. This is an amazing experience, as I always thought of myself in the court room (my primary degree is in law) and I had never pictured myself in an operating room. Thanks to all the compassionate and generous physicians in this hospital, who allow me to peek in their kitchen (as long as I don’t function as the ethics police), I get an understanding of the difference between the ivory tower of academic (bio) medical ethics and the real ethical issues of the work floor.  

Not too long ago I observed a WADA test in the epilepsy department. The WADA test is used to establish where language and memory are located in the brain; in which hemisphere do these capacities ‘reside’. (When we think simplistically and typically, a right-handed individual has memory and language on the left side of the brain, but there are a lot of exceptions and mixed brains). During the WADA test, doctors try to mimic a stroke of the brain; while the patient is awake, one hemisphere is temporarily sedated (around 2 minutes) and a series of tests are done to see how the patient memorizes and describes objects, based on the functioning of only 1 side of the brain. Subsequently, the other hemisphere is sedated and a similar test is performed. These tests are done, for example, to assess what would happen if a particular part of the brain is surgically removed; i.e. the area that contains the origin of the epileptic episodes.

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.

Those involved in healthcare ethics consultation professionalism efforts face many challenges. Many – particularly academics involved in bioethics education – have been working on the notion that those who offer clinical ethics consultation services as individuals be appropriately credentialed, certified, or accredited in someway.

In re-reading an article by Diane Hoffmann, Anita Tarzian, and Anne O’Neil which appeared in the Journal of Law, Medicine & Ethics in 2000, one striking challenge is readily apparent: ethics committee members – with little or no formal training in clinical ethics, little or no actual consultation experience, some with not much more than a sufficient interest in biomedical ethics issues and a willingness to serve – already feel competent to participate in offering consultation services. Moreover, from the Hoffmann-Tarzian-O’Neill data set, ethics committee members who self-report that they are competent to participate in clinical ethics consultation – and in hospitals which average only three consultations per year – believe that they are meeting their obligations to patients, families, staff, and institutions reasonably 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.

Over the last thirty years or so, eating disorders have received increased attention both clinically and in the mainstream media. The apparent surge in diagnosing eating disorders has long been blamed on unrealistic social pressures, media representations equating body type and attractiveness, however, the effect on males has gone largely unnoticed until recently. A paper published in the journal Eating Disorders in 2012 offers some useful insight into the problematic gender disparities for men who have eating disorders. 

In the paper “Eating Disorders in Men: Underdiagnosed, Undertreated, and Misunderstood” by Strother, Lemberg, Stanford, and Turberville several issues that are unique to males with eating disorders. In order to address the issues specific to men, the authors propose several key topics which are notably relevant in these patients. First, understanding the patient’s weight history is presented because the research has indicated men who develop eating disorders were often overweight at one time in their life, unlike women with eating disorders who often have normal weight histories. Weight concerns for men are often associated with avoiding health problems experienced by their fathers or athletic achievement, unlike the goals of “achieving thinness” in females.

The issue of physician suicide has been on the public agenda in the United States for the past 25 years or more. Legitimate worries about medical overtreatment, unnecessary suffering and loss of dignity have motivated a growing number of Americans to consider this issue more favorably. People are rightly concerned about loosing control over what happens to them once they enter the hospital when the are very sick and risk dying. Instead of being at the mercy of technological forces beyond their control, free individuals want to have a say over how they make the final exit from life. The key factor, in my opinion, is more about self-control than it is about actually the strong desire to take a lethal dose of medications at the time of the patient’s choosing. But let’s be clear what we are talking about. 

Oregon was the first state to legalize physician-assisted suicide, which occurred in 1994 in the Death With Dignity Act. This law gives patients with capacity facing a clearly diagnosable terminal illness within 6 months or less to live the right to receive (and the right of the physician to prescribe) a prescription for a lethal dose of medication for the expressed purpose of ending their lives at the time of their choosing. Because we have had many years to collect empirical data about the effects of this law, we can use Oregon as a case study. As of 2011, 935 people have had prescriptions and 596 have died from ingesting medications they received based on this law. For about 90% of these patients, the primary concern about end of life care was “loss of autonomy”, but “inability to make life enjoyable” and “loss of dignity” were also major concerns. Moreover, based on the data, there is no evidence of any kind of abuse to any particular segment of the population, as some feared might happen. In fact the utilization rate of hospice care is up.  Following Oregon, Washington and Montana also have legalized physician-assisted suicide and we will have to wait and see the data of these laws continue to yield generally positive results. But overall the data gathered so far supports physician-assisted suicide a beneficial service. 

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.

A patient walks into her local Emergency Department complaining of back pain. She appears uncomfortable, and states that she was injured in a car accident about a year ago and now has chronic pain in her back. Her x-ray looks normal. She states that her pain is best managed with regular doses of oxycodone, but she ran out and has not been able to see her regular doctor for a refill. She came to the Emergency Department for a prescription instead. Imagine you are the physician. What action would you take?

a. Provide a dose of medication to the patient in the ER to be sure it will be adequate and give the patient a prescription for a couple days’ worth of the requested medication.

b. Call her regular doctor to confirm the medication and dose before providing any medication.

c. Check the state database to be sure this patient is not seeking prescriptions from multiple providers.

d. Offer only non-narcotic pain medications.

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.

We are pleased to announce the approval of the Doctorate of Professional Studies, with a concentration in Clinical Ethics Consultation, by the New York State Education Department. This program is, to our knowledge, the first online program of its kind to offer advanced level training in the knowledge and skills of clinical ethics consultation for qualified applicants. The new program is designed specifically for working, health care professionals who possess a master’s degree in bioethics, or equivalent, and who seek a fellowship level, advanced training in clinical ethics consultation. Students will use their professional work environments as the clinical training ground as they complete advanced fellowship courses related to clinical ethics consultation and mediation, elective courses and a doctoral research project.

The fellowship courses include clinical practica in coordination with AMBI faculty and agreed upon mentors at the student’s home institutions.  At the end of the program, graduates will have a portfolio of 32 case consultation reports and will have demonstrated advanced level mastery of the ASBH Core Competencies in Clinical Ethics Consultation.

For more information, visit our website or contact Wayne Shelton at sheltow@mail.amc.edu or 518-262-6423.

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