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Topic: Clinical Ethics
May 29, 2014 | Posted By Marleen Eijkholt, PhD

Imagine you or your partner want to take your placenta home after birth. You feel that the placenta is part of your (partner’s) body and you should be allowed to take it home.  Maybe to eat it: ‘I ate my wife's placenta raw in a smoothie and cooked in a taco’ (Guardian 30 April 2014) or to bury it for cultural reasons, as protection of the soul and the newborn (LA times 31 December 2013). In Oregon you are legally allowed to take it home. In some hospitals elsewhere, you are not. Imagine that due to circumstances, you end up in a hospital that prohibits you from obtaining the placenta. What’s next?

Requests to take placentas home after birth are increasing. Human placentophagy is on the rise. Kim Kardashian spoke about it in her soap series not too long ago.  Newspapers are full of stories about placentas, their use and ability, and significant amounts of websites discuss the pros and cons of bringing placentas home. Different sources report on the alleged benefits of eating your placenta and other reasons to take it home. The public exposure to this ‘appetite’, its context and the rise in requests, raise concerns about prohibitive practices. Prohibitive policies are likely to come under increased scrutiny. My question in this context: What about eating placentas, what about policies prohibiting this?

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.

April 29, 2014 | Posted By Marleen Eijkholt, PhD

Earlier this month, the New York Times (NYT) reported on individuals in a minimally conscious state (MCS). Although the article headed: ‘PET Scans offer clues on Vegetative States’, its contents addressed the technologies around MCS: a ‘newly’ diagnosed state of consciousness. The paper commented that PET scans would be more beneficial than functional Magnetic Resonance Imaging (functional M.R.I.) in diagnosing this state. Around the same time, the NYT published a paper that headed: ‘Cost of treatment may influence doctors’. This paper quoted a doc saying: “There should be forces in society who should be concerned about the budget, about how many M.R.I.s we do, but they shouldn’t be functioning simultaneously as doctors,”

In this blog post I want to focus on the cost and price of consciousness. I do not only want to focus on the economic costs, but also on costs in a more holistic sense, including the psychological and emotional costs. In the end, I want to ask you: how much is consciousness worth to you?

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.bvg

March 3, 2014 | Posted By Marleen Eijkholt, PhD

If someone asked me: What is my philosophy of clinical ethics? I would initially be dumbstruck for an answer. In response, I would probably try to define an answer from my background in bioethics and philosophy. I would pick frameworks in philosophy that represent my approach. For example, I would be inclined to refer to pragmatism and casuistry, as frameworks that determine my clinical ethics approach. My last blogpost about Marlise Munoz, the brain dead woman in Texas is a good example of this. My philosophy as a clinical ethicist is based on the facts of the case, a subsequent calculation of rights and wrongs. The outcome of this sum guides my ethics advice about what is practically possible, conform short-handed pragmatism. In responding to a case, I start with the specifics of a case and formulate answers that may be acceptable by multiple stakeholders, instead of relying on general theoretical outcomes, as a short-handed casuist. Finally, I reason along the lines of several relevant principles, such as autonomy, beneficence, non-maleficence, justice and dignity, and seek to apply these principles to the specifics of a case.

However, given that the background of clinical ethicists lies over a broad spectrum, I doubt that this answer would be satisfactory.  If I hadn’t had a background in bioethics, what would I have answered to this question? Does the fact that I am an ethicist in the clinic mean that I have to frame my answers along philosophical and ethical theories? Would a social worker, an accountant or an attorney equally have a philosophy in their work? Asking myself this latter question, I think that those professions do have a professional philosophy, but that they would be less likely to phrase it in philosophical language. Instead, probably they would describe their philosophy in more layman’s terms and would narrate about their approach in the different cases they see. So how do I approach my cases as a clinical ethicist?

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 20, 2014 | Posted By Wayne Shelton, PhD

Over the past few decades, clinical ethics consultations have become an important component in providing quality care in cases where there are value conflicts that must be resolved before viable goals of healthcare can be accomplished. With the development of this service and its acceptance as a necessary part of patient care, questions arise as to how and when will clinical ethics consultation be recognized as a specialized professional service comparable to medicine, nursing, social work and pastoral care? For physicians, nurses, social workers, and chaplains there are well-established pathways for practitioners to take in each of these areas in order to be recognized as fully qualified professionals. There is no such pathway to date for those individuals who provide clinical ethics consultations. For those of us who have been involved in this area it is interesting to reflect upon the vast improvements made in providing clinical ethics consultations and whether the field is ready for professionalization.

I recall my early years of training in medical ethics as a graduate student in philosophy at the University of Tennessee. As part of the requirements for the PhD in philosophy with a concentration in medical ethics, students had to spend 3 months at the Health Science Center in Memphis where we participated in intensive internship in medical ethics. At that time I was fortunate to have one of the early pioneers in medical ethics as a mentor, Professor David Thomasma, who was beginning to do clinical ethics consultations. During the 1970’s philosophers and others in fields pertaining to ethics were being invited to enter the medical setting to help physicians and nurses grapple with some of the ethical dilemmas that were becoming more evident with the increasing use of dialysis machines and mechanical life supports. There seemed to be an assumption, perhaps naïve in retrospect, that philosophers like professor Thomasma and others had some special understanding of ethical issues that would shed light on the emerging medical ethical dilemmas and therefore would be in a position to give helpful advice.

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 30, 2014 | Posted By Marleen Eijkholt, PhD

When people asked my ethical opinion about Marlise Munoz’s case, the brain dead woman who was kept on support for her fetus, I believe they expected a quick answer: this is wrong. Clinical or medical ethicists are often called for a quick answer: this is right or this is wrong. However, answers about why X is right or why X is wrong do not come quickly. Often there are many rights and many wrongs in a story. My answer why it is unethical to keep Mrs Munoz on support is the result of a sum of rights and wrongs. In my opinion the ‘rights’ are less weighty than the ‘wrongs’, and I will set my arguments out below.

Marlise Munoz was 14 weeks pregnant when her husband found her unconscious and brought her to the hospital. The hospital found that she fulfilled the criteria of brain-death, but did not declare her brain death yet (according to the latest reports) . They kept her on ventilator and nutritional support and argued this was required under Texas law, suggesting that it was not allowed to withhold or withdraw life-sustaining treatment from a pregnant patient.

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 13, 2014 | Posted By Marleen Eijkholt, PhD

Understanding death is difficult. And this issue is an everyday occurrence for clinical ethicists. In questions around withdrawal of life support, or a shift towards comfort care if a patient’s death is imminent, such misunderstanding is a recurring problem. The case of Jahi McMath, which I will deal with later illustrates this. Death is not necessarily a flat line on a screen. Especially when machines interfere, the blibs and curves on the screen keep going. Also death might not mean a total absence of reflexes, such as reflexes to stimuli might not necessarily mean that something is alive or has consciousness.

In the clinic, I cannot necessarily rely on analogies from nature to explain that someone is no longer ‘alive’, for fear of being insensitive about loved ones. But in this blog I can draw on such analogies to illustrate my case. If you behead a chicken (for compassionate or consumerist reasons), it will continue to jump around for a couple of minutes until it bleeds out. This does not mean that the chicken is still alive after you beheaded it. The jumps are a response of the autonomic nervous system and come from a jolt of adrenaline. Similarly, a ‘sensitive-plant’ or the ‘mimosa pudica’ will retract its leaves after you touch it. It moves. See here. I don’t think that this means the plant is alive like a human being or that it ‘understands’ your touch. The retraction of the leaves is a natural reaction. Its movement does not imply consciousness. Finally, during winter time, the breaks of my bike contract and they push on the wheel. This makes it harder for me to cycle. During summer time the breaks expand and cycling is not a problem. The breaks of my bike respond to the weather, but I would not call them ‘alive’.  

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 10, 2014 | Posted By Wayne Shelton, PhD

The case of the 13 year-old California girl, Jahi McMath, declared brain dead following a tonsillectomy has created another media frenzy. This is truly a tragic story. Apparently Jahi underwent tonsil surgery and two other procedures on December 9, 2013 to help her better manage sleep apnea. Following the surgery she was awake but shortly thereafter went into cardiac arrest and was placed on a ventilator. By December 11, physicians made a medical determination of brain death.

From the parent’s point of view, one can only imagine the shock and disbelief they have been experiencing. Their young child went to a major medical center where highly skilled physicians were going to perform what was assumed to be relatively low risk procedures. Jahi had apparently had some worries herself about not waking up following anesthesia. Like all supportive, loving parents they assured she was in good hands and no doubt reminded her of how important it was to have these procedures done in order to deal with what could be a life threatening medical condition in sleep apnea. They fully expected she would be fine and return to normal. Instead, she is on a mechanical breathing machine, which is supporting her breathing and heartbeat, and her physicians now say she’s dead.

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 5, 2013 | Posted By Marleen Eijkholt, PhD

Early November 2013: TB, a 32 year old deer hunter from Indiana, falls 16 feet from a tree while on a hunting trip and crushes his spinal cord. He injures his C3,4 and 5 vertebrae, but does not suffer any brain damage. TB’s prognosis includes paralysis from the shoulders down and potentially life-long dependence on a ventilator. His family asks the physicians if they can get him out of sedation and remove his ventilator, so that he can decide about how to proceed with his treatment. Once awake, TB hears his prognosis and asks to stop treatment. He dies one day after incurring his injury.

Several factors seem to have sparked the headlines and stir controversy, and I would like to focus on one of these. I question whether TB’s decision was and could be informed. Using this case, I propose that TB’s decision was perhaps a shot in the dark. I raise some of the pressing questions about informed consent in the clinical ethics context. I ask how we should ensure informed decision making, what we should do to enlighten patient’s perspectives and what we should do if patients refuse information that we consider material in the decision making 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.

November 12, 2013 | Posted By Bruce White, DO, JD

With the endorsement of the American Society for Bioethics and Humanities (ASBH) Board of Directors, and the publication of a process to confer eventually a “quality attestation” credential on successful candidates, the ASBH Quality Attestation Presidential Task Force (QAPTF) has begun apilot procedure to assess those involved in providing clinical ethics consultation services. Importantly, it’s unclear at this point if the Task Force will be looking at those who provide consultation as an individual, or as a member of a small group of consultants or as a member of a larger ethics committee.

As part of the pilot to refine the process, the QAPTF has asked those interested to submit a letter of intent. (It is not a requirement that one be an ASBH member to submit a letter of intent.) The Task Force will review the submitted letters and select a representative sample (“a cross-section of eligible candidates whose professions represent the distribution of professions among Clinical Ethics Consultants”). 

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 26, 2013 | Posted By Paul Burcher, MD, PhD

Many of my obstetrical colleagues groan when a patient presents a birth plan during prenatal care, but I do not.  I see it as an opportunity to do what Frank Chervenak and Laurence McCullough have called “preventive ethics”—avoiding conflict later by addressing issues before problems arise.  Prenatal care is unique in medicine in that we spend so much time with generally healthy patients seeking to prevent medical complications that, if they arise at all, are likely to arise much later during labor.  The same mindset that propels and justifies prenatal care should direct our response to birth plans:  this is an opportunity to prevent problems, and misunderstandings during labor, and the fact that the patient has well-formed opinions about what kind of care she wishes to receive during labor means she is engaged and seeking to educate herself.  In short, women presenting with birth plans are generally our most conscientious and informed patients.

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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