Topic: Clinical Ethics
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.

June 18, 2015 | Posted By Wayne Shelton, PhD

Let me say emphatically at the outset of this blog, as someone who has been a clinical ethics consultant for over 20 years, I am quite sure that clinical ethics consultations overall improve the quality of patient care and currently are an important, even essential, part of the providing excellent patient care in hospitals. Contemporary medicine is filled with value laden questions and issues that often can be effectively addressed by someone with expertise and training in clinical ethics. Having said this, I am still somewhat skeptical about clinical ethics consultation becoming a professional area of healthcare that parallels other professional areas like medicine, nursing, and social work. I think there are some special considerations about the field of clinical ethics consultation that makes its future status as a professional activity uncertain.

First of all it is well-known that CEC’s come from a variety of backgrounds and training—from philosophers to physicians to social workers to nurses and lawyers and on and on. People enter the field of clinical ethics consultations from very different disciplinary backgrounds and seemingly learn a common vocabulary and methodology of clinical ethics and a basic familiarity with and ability to function in the clinical setting. They learn this vocabulary in very different ways—some informally, some through short 1-2 week long intensives, some with certificate programs, some with master’s degrees, and some with 1-2 year long fellowships. No other area of healthcare work admits of such diversity. Though this is a positive feature in some ways by providing diverse perspectives in understanding value dilemmas, it creates a challenge of considerable controversy when we try to define the kind of educational training a future CEC should have. At the moment there seem to be many pathways into the field and no clear answer has emerged.

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.

June 9, 2015 | Posted By Jane Jankowski, DPS, LMSW

Clinicians striving to help patients achieve healthcare goals often encounter the perplexing dichotomy of the patient’s stated goals and preferences and actions to the contrary. Some of these challenges can be overcome with education and close follow up to help reinforce adherence to medical recommendations, but other times, these barriers are more enigmatic.

Take for example, a patient who requires hemodialysis to sustain life. She sometimes shows up for her outpatient dialysis, but more often does not show up and is admitted to the hospital for emergent dialysis several months in a row. In consultation with her providers she is adamant that she does not want to die, and knows that she needs the dialysis to remain alive. She is discharged, and the pattern continues. Liberal scheduling with the outpatient service, transportation, reminders are all offered. Psychological tests and support are provided, and yet, her action pattern of not adhering to the treatment plan continues. Again, she is advised it is acceptable to halt and she will be offered palliative care. She refuses, and says she wants to live and will sit for dialysis. What is her genuine preference? Should we honor these statements, or accept her actions as the more authentic expression of her wishes? Though this hypothetical example is quite familiar to renal care providers, the dynamic spans many scenarios leaving many practitioners with a dilemma about the practical limits of honoring verbalized wishes that are not supported by congruent actions.

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 11, 2015 | Posted By Jane Jankowski, DPS, LMSW

In the most recent issue of The Journal of Clinical Ethics, authors Genes and Appel explore the ethical considerations at play when physicians might use the internet to gather patient information. They conclude, correctly I believe, that there are circumstances in which accessing information about a patient supports beneficent efforts to provide quality care, even in non-emergent circumstances. Rather than damaging the doctor patient relationship, an informed provider is better equipped to support the patient’s best interests if loved ones can be located, presentation of information can be confirmed as factual or not, and the context of this patient’s needs can be more fully understood by the care team.

Social media, such as the now ubiquitous Facebook, is often considered a forum where people may express thoughts and feelings they fail to articulate in person. Consider the posts of an angry or despondent partner after the end of a relationship. Should commentary become threatening – to self or others – this is considered cause for concern and these comments are taken as valid expressions that warrant immediate emergency intervention. Text messages carry the same weight as spoken words, and are preserved in electronic format to be shared by the recipient at will. Failing to consider such communications as part of the purview of healthcare providers could lead to harm for the patient or others. While these expressions might not be quickly discoverable by physicians, they can, in some instances, be lifesaving components adding to the overall clinical picture. 

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, 2015 | Posted By Jane Jankowski, DPS, LMSW

One of the challenges clinicians must learn to manage is the patient who does not adhere to medical recommendations while expressing the desire to be well. It is widely accepted that patients with the capacity to make informed decisions retain the right to make choices that are good for them and choices that are not, there are instances where capacity to make a choice becomes less relevant than the practical considerations related to achieving the patient’s goals. When patients state they wish to recover from illness but refused to comply with the necessary treatments this disconnect poses a different kind of dilemma. Morally, it is simpler to digest that that some patients will refuse treatment, and there is robust support for respecting refusals. But what do we do when a patient asks for one thing but does another? Such cases pose intractable impasses for providers who arrange care plans based on the patient’s stated goals of recovery, yet encounter what seem to be enigmatic refusals to adhere to recommendations and interventions. There is a clear obligation to attempt to understand the patient’s perspective and thoroughly as possible. What may appear to be inconsistencies in preference may very well have a logical explanation. Once efforts to unpack dissonant expressions have been exhausted, a different approach may be needed to figure out what may be possible for such a patient. The first question is often about capacity – does a patient who asks for one thing but does another possess the ability to make an informed decision? In some cases, the resolution ends here if the patient is found to be unable to make an informed decision – or does it? If the objection is strong, and the intervention requires a high degree of cooperation from the patient, capacity may be moot because there is no practical way to proceed without cooperation. For example, a patient who insists she does not want to die, but simultaneously resists life sustaining dialysis leaves providers with very few options. A patient receiving a temporary intervention to buy time for recovery may in fact, not achieve the desired healing – how long must a bridge therapy continue? In such cases, capacity may be part of the picture, but I would argue it sometimes becomes a red herring we chase instead of taking a hard look at the medical facts and practical considerations in such cases. 

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, 2015 | Posted By Wayne Shelton, PhD

It is my sense that the majority, perhaps the vast majority, of cases on which clinical ethics consultants (CECs) are asked to consult and make an ethics recommendation, there is, or would be, a general consensus on the part of the CECs about what counts as the appropriate recommendation. However, the question arises of how clinical ethics as a field should deal with issues that come up about which there is not a clear consensus, such as in cases where a basic right to have an autonomous choice respected by the patient is pitted over and against the obligation of the physician to do no harm—the traditional tension between respect for patient autonomy and beneficence/nonmaleficence. This tension or conflict often occurs in cases of alleged medical futility where the patient or the patient’s surrogate requests a treatment option the physician deems will only cause harm and no benefit to the patient. For example, consider a patient’s surrogate who insists that she will not consent to a DNR order and in fact expects the physician to perform CPR if the patient arrests. For a patient without capacity dying of metastatic disease, this directive by the surrogate presents a stark dilemma to the physician—is it a violation of the physician’s obligation to the patient to “do no harm” (nonmaleficence)? Or is respect for the patient’s wishes or her representative’s wishes so sacrosanct that the physician’s obligation to follow the patient’s wishes is paramount and outweighs the obligation to do no harm?

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 11, 2014 | Posted By Jane Jankowski, DPS, LMSW

In Peter D. Kramer’s New York Times piece published in the ‘Couch’ section on October 18, 2014 (Why Doctors Need Stories) he affirms the experience of learners, educators, and researchers in his arguments that a case vignette can provide a kind of instruction that cannot be duplicated by data collection alone. While we do still need evidence based material to assure safety and efficacy of treatments, the case study offers contextual material that makes the evidence come to life.

As a Clinical Ethicist each clinical encounter is rich with substantive information that is part of an individual or family story intersecting with the healthcare setting. When invited to provide input, support, or recommendations in any given case, the most informative elements of any case are the story of the patient. What was before, what is now, and what the future may require is different for each patient, and I am often awed by the ‘before.’ The contextual landscape of each story is often where we come to understand the psychosocial factors that weigh heavily in how a patient, family, or community interacts with the healthcare community. Hard data is not as useful as hearing the story that belongs to the 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.

October 3, 2014 | Posted By Paul Burcher, MD, PhD

I was at a conference last week in medical ethics, and I was surprised by, or perhaps appalled at, the attitude displayed by many of the philosophers regarding the importance of medical knowledge in medical ethical decision making. Several of them proudly announced a total ignorance of the medical issue they were speaking on, and also showed no interest in what I would call “real world” implications of their conclusions.  Although I have a PhD in philosophy, I am not a philosopher in the sense that I am capable of, or interested in, spinning arguments from “thin air” with no grounding in medical facts, and no implications for real medical practice.  Medical ethics must begin in real life issues and problems, and end with equally real and meaningful conclusions that can be applied, and sometimes even empirically tested. 

This is not to say that philosophers cannot make good, or even great, medical/clinical ethicists. But they need to begin with a healthy respect for the way in which the “facts on the ground” inform the ethical decision-making.  A brief example illustrates my point.  In Hilde Lindemann Nelson’s famous article explaining narrative ethics, she discusses the case of Carlos and Consuela. Carlos is an HIV positive gang member wounded in gang violence, who is recovering from his injuries in a hospital.  He is now ready for discharge, but needs dressing changes at home.  He wants his sister Consuela to do the dressing changes, but he insists that she not be told about his HIV status.  While Dr. Lindemann Nelson uses this case to make several excellent points about the limitations of principle based ethics, one aspect of the question, crucial to any ethical reasoning on the case, is obviously the transmissibility of HIV infection through dressing changes.  This “fact” is an essential aspect that underpins any ethical judgment regarding the case.  The conflict between patient confidentiality and duty of nonmaleficence (toward Consuela) pivots in part on the fact that HIV is not readily contagious, and simple universal precautions should make the risk to Consuela essentially nil.

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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