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Topic: Clinical Ethics
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.

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 18, 2013 | Posted By Paul Burcher, MD, PhD

Most practicing physicians learn the four principles of biomedical ethics at some point during medical school or residency training.  Despite the original intent of Tom Beauchamp and James Childress when they first described the four principles as co-equal in importance, we physicians tend to think first about patient autonomy and view it as the most critical of the four principles.  The least understood and appreciated of the four principles is nonmaleficence. (Even my word processor wants to change it to malfeasance, and so do many medical students I teach). 

The reason nonmaleficence is misunderstood, and therefore often ignored, is that the duty to “do no harm” seems impossible to follow.   Beauchamp and Childress are clear that harm is anything that counts as a setback to a patient—any pain or injury is therefore a harm—and practically everything we do to our patients is in some sense a harm.  The duty to nonmaleficence must be more complicated that simply doing no harm or it would be a duty to stop practicing medicine.\

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 12, 2013 | Posted By Wayne Shelton, PhD

I have probably done several hundred clinical ethics consultations since I began doing them in the early 90’s. Though I have had some second thoughts about some of the recommendations I have made, by and large, I have usually been confident that they represented viable moral options, given the range of limited, mostly bad options that were available.  Thus, I rarely if ever thought of myself as anything but fully supportive of the recommendations made in ethics consultation.  That is, until a few months ago when I heard about a case from another ethics consultant at another location where the right ethical recommendation seemed apparent, yet somewhat problematic. The case shows the almost boundless, and at times problematic, latitude of the negative right to refuse treatment and to be left alone, even when others may be negatively affected by the decision. I thought the general fact pattern of this case would be worth discussing in this forum. 

The case involved a 40 year-old woman with full capacity who was near full term with twins. She was showing signs of pre-eclampsia, a condition “when a pregnant woman develops high blood pressure and protein in the urine after the 20th week (late 2nd or 3rd trimester) of pregnancy.” (National Library of Medicine) When this condition occurs, it is important to get the babies out as soon as possible; otherwise, both the mother and babies would be at risk of dying. So labor was induced and she was being prepared for delivery. But given that she was having twins there was the possibility of excess bleeding from hemorrhaging and other complications, so the patient was informed that a blood transfusion might be necessary. As it turns out based on her religious beliefs she stated she did not wish to be transfused with blood products and that she understood the consequence: she could possibly die. Her babies would in all likelihood be saved. Should the fact that two babies will not have a mother be counted as ethical considerations against respecting her right to autonomy? Given our current ethical environment, a patient with capacity has a right to refuse any and all medical treatments and interventions. Are there ever countervailing reasons to not honor a patient’s autonomous wishes in such a situation? Let’s proceed with the general facts of this case, as it gets even more complex.

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 2, 2013 | Posted By Bruce D. White, DO, JD

Recall the June 7, 2013 New York Times article by Andrew Pollock titled “An Experimental Drug’s Bitter End”? The author reminds us again about how difficult it is for patients and those involved in their care to understand that new drug clinical trials are experiments and not therapeutic interventions.

The goals of researchers in conducting new drug clinical trials – experiments – are clearly not the same as the goals of a physician who prescribes an approved drug as a therapeutic modality. How better can we help patients and their families understand this primary goal of medical research? In clinical trials, when the experiment ends, the patient may worsen clinically, or the patient may get better clinically, and the improving patient probably will no longer have access to the perceived beneficial drug as a therapy option. Regardless, after sufficient data is collected – whether good or bad – the experiment ends.

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 24, 2013 | Posted By Wayne Shelton, PhD

The moral basis for competent, clinical ethics consultation, I would like to argue, is largely derived from the moral premises of our normative understanding of what it means to be a “good doctor” as reflected in a self-conscious commitment of a good physician to treat patients as best as one can according to prevailing standards of professionalism and medical ethical principles. The good doctor stands in relationship to a patient, within a well-defined framework of moral rights and professional obligations. This linkage between the activity of clinical ethics consultation and our understanding of a good physician further defines the work of the ethics consultant squarely in framework of clinical, medical competencies.  

To further see this linkage, it is useful to consider how and when value conflicts arise in the physician-patient relationship. For the vast majority of physician-patient encounters, there is agreement and absence of conflict. But in the less frequent cases of moral conflict, there are competing visions of what should happen—regarding the goals of care and who has the moral authority to define those goals. In short, how are competing rights and obligations to be balanced between the patient and physician, but also the surrogate, the hospital and potentially many other interests, especially in the midst of the emotion and stress that illness and impending death can induce both to patients and their families? It is the latter contextual aspect of grounding value conflicts within a patient’s and family’s illness experience, and the necessary ability to function effectively in clinical encounters, that requires the competent ethics consultant to also possess the general qualities of a caregiver, and to understand the moral perspective of a good physician.

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 9, 2013 | Posted By Wayne Shelton, PhD

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.

April 23, 2013 | Posted By Marleen Eijkholt, PhD

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.

March 28, 2013 | Posted By Paul Burcher, MD, PhD

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.

March 14, 2013 | Posted By Wayne Shelton, PhD

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.

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ABOUT BIOETHICS TODAY
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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