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March 28, 2014 | Posted By Marleen Eijkholt, PhD

Amber is a 70 year old woman. She is doing poorly. She has metastasized cancer, multiple co-morbidities and a pressure ulcer. Apart from her ulcer, she has no acute care needs that condone her to the hospital. Some predict that she is likely to pass over in 3 months. With the right type of medications Amber could go home. However, the pressure ulcer medications that she needs cost about 200 dollars a day and she does not have the right type of insurance to pay for this. As a result, she is confined to a hospital bed. 

Amber has always contributed diligently to society. She worked from age 17 in a bank and paid her taxes diligently. Amber and her husband, who died 3 years ago, raised 3 children and lived in a town upstate New York. They used to take holidays on the West-Coast, where Amber has a family summer home.  This house belonged to her great grand-mother and has been in her family for 120 years. All of Amber’s family is attached to this house.

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 20, 2014 | Posted By Lisa Campo-Engelstein, PhD

While assisted reproductive technologies (ART) are common in most “developed” countries (the global North), in the global South (“developing” countries), ART is generally not available for a variety of reasons, most of which center around money. These resource-poor countries typically lack both qualified health-care professionals and facilities necessary for ART. Although some countries do have ART centers, the cost of ART is prohibitive for all but the extremely wealthy. Indeed, infertility is usually seen as a treatable problem only for the upper class primarily because the poor cannot afford basic health care let alone expensive treatment like ART. The fact that the majority of people in the global South cannot afford basic health care, which is typically seen as the top priority in health-care allocation, is another reason why ART are not readily available in the global South. Most public and private health-care funding goes toward primary care and not treatments that are often seen as elective and cosmetic, like ART.

Yet, infertility can be considered a health problem according to the World Health Organization's broad definition of health – “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Infertility in the global South can have severe and interrelated social, economic, and health-related consequences for women. This is still the case when the woman is physiologically fertile but her partner has male factor infertility; she is the one who is generally blamed for the couple’s inability to have a biological child.

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 17, 2014 | Posted By John Kaplan, PhD

Three eminent bioethicists have proposed, in an article published in the New England Journal of Medicine last month, that some comparative effectiveness research should not require informed consent from patients. I do not agree, at least not yet. Drs. Faden, Beauchamp, and Kass have provided a thoughtful justification for their position. However the circumstances in which this new scenario would work does not yet exist.

Let’s be more specific. These authors have been among those advocating what they term a learning healthcare system which blurs the line between clinical care and research but predicates both on a common set of research and clinical ethics principles.  Research and medical practice allows the system to learn and implement improvements. They lay down seven ethical principles to guide such a health care system. The first of these principles is to “respect the rights and dignity of patients.” It does not seem to me that you can meaningfully respect the rights and dignity of people and use them in clinical trials, even comparative effectiveness trials, without their permission. The seventh principle, “contribute to the common purpose of improving the quality and value of clinical care and health care systems” seems in some ways laudable but is dubious in the context of respect for rights. The first six principles define obligations of the participants in the health care system. This seventh principle describes an obligation on the patients to “participate in certain types of learning activities that will be integrated with their clinical care.” 

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 13, 2014 | Posted By Wayne Shelton, PhD

Efforts to educate the public are based on the assumption that human beings can be persuaded by good reasons and evidence in formulating their responses to important questions about public health. But are things this straightforward? Are humans really this rational in how they make their decisions? 

Think of any social problem that is predicated on how people understand and use information to make good decisions for themselves, especially decisions that have significant social costs. For example, consider the question: does having a gun in one’s home make one more or less safe? A recent piece from the New York Times is typical of the clear evidence presented from social science research to show that guns in the home “were fired far more often in accidents, criminal assaults, homicides or suicide attempts than in self-defense. For every instance in which a gun in the home was shot in self-defense, there were seven criminal assaults or homicides, four accidental shootings, and 11 attempted or successful suicides.” Moreover, there is a strong risk factor of having a gun in the home for female homicides and intimidation of women. These data do not prevent gun rights advocates from passionately arguing against any limitations place on guns including assault rifles. In fact some pro-gun advocates falsely claim that any limitation of assault weapons would in fact make women less safe as though that the typical woman would not have the full ability to protect herself. It appears many people view the evidence through the lens of their preexisting set of assumptions, which makes them ignore the scientific evidence or to see it as biased; thus, they continue to believe that having guns in their homes make them safer.

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, 2014 | Posted By Jane Jankowski, LMSW, MS

As a clinical ethicist, many of the requests for assistance that come my way have to do with advance directives, either the lack of any documented wishes, incomplete or unfamiliar forms, or otherwise confusing messages about what a patient truly wants when it comes to life sustaining medical treatment. Too often, my help is needed when the patient is no longer able to tell others what he or she wants and does not want. On one such call, a group of compassionate nurses and I sifted through a charts to see what we could learn about a particular patient’s known wishes. In the course of our conversation, a nurse asked me if I had heard about LaCrosse, Wisconsin where 98% of the town’s population has advance directives. After giving me a quick summary between her own patient charting, delivering meds, and coordinating a pending admission, she printed the article. For anyone who missed it (like me) the link is here: LaCrosse Wisconsin on NPR.

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 7, 2014 | Posted By Bruce White, DO, JD

New York Times article by Katie Thomas published on December 16, 2013 led with this sentence: “The British drug maker GlaxoSmithKline will no longer pay doctors to promote its products and will stop tying compensation of sales representatives to the number of prescriptions doctors write, its chief executive said Monday, effectively ending two common industry practices that critics have long assailed as troublesome conflicts of interest.” Might one ask: Are these really conflict of interests problems?

conflict of interest (so sometimes, conflict of interests) is often defined as: “a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest.”  In a short introduction to conflicts of interests, written for a business ethics class at the McCombs School of Business at the University of Texas at Austin, Dr. Lamar Pierce (Associate Professor of Strategy, Olin Business School, Washington University, St. Louis) said:

Incentives are pervasive in every aspect of society. People are rewarded for taking certain actions, and not rewarded for taking others. Workers are paid for their effort and productivity, salespeople are paid for their sales, and small business owners are rewarded with profits for successful ventures. So long as these incentives are well-understood by everyone, they work reasonably well. They motivate effort, performance, and social welfare. But sometimes, individuals have incentives that conflict with their professional responsibilities, often in ways that are not transparent to the public or in their own minds. These conflicts of interest produce serious economic and social problems.

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 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 27, 2014 | Posted By Aidan B. Ferguson, LCSW and Zubin Master, PhD

Before research involving humans can commence, the ethical aspects of the research study are reviewed by local ethics boards in the United States known as Institutional Review Boards (IRBs). IRBs review many factors surrounding the ethics of research involving humans, including whether the science is valid, there is a favorable benefit-to-risk ratio, participants are recruited fairly and have retained the right to withdraw from research, privacy is protected, and the informed consent process will be performed such that participants are fully informed and understand the nature of the study. IRBs are located within institutions that perform human research such as universities and colleges, research centers, government agencies, and others. IRBs consist of individuals with a diversity of scientific, clinical, ethics, and legal expertise. The advantage of performing ethics review at the local level is that IRB members know their community, including the prevalence of health issues and the average educational level allowing them to be able to effectively communicate with community members and ensure they can access beneficial research. As trust is an essential element to voluntary community participation, an absence of it might lead to decreased enrolment in clinical trials. Knowing that a body of experts has reviewed the ethical aspects of research is likely to promote trust between participants and the research institution.

While local review certainly has its advantages, more research is being performed at multiple institutions, such as large phase 3 and 4 clinical trials that can be performed at dozens of research sites across the country. Currently, this means that researchers will have to submit their protocol to every individual IRB for approval. Several studies surrounding multisite ethics review have been performed and many question whether a more efficient system cannot be developed. Below we discuss some of the issues with multisite ethics review and outline a few reform strategies.

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 24, 2014 | Posted By Lisa Campo-Engelstein, PhD

There is a cultural perception that women are very likely to cause fetal harm, reflected in limitations on women’s participation in clinical trials and certain jobs, public service announcements telling women not to drink alcohol while pregnant, and extensive media coverage of ‘‘crack babies.’’ The long history of the medical realm treating women’s bodies as weak, permeable, and inherently diseased contributes to the worry that women’s bodies will ‘‘infect’’ fetuses. Men’s bodies, in contrast, are as seen as stable, bound, and healthy; therefore, they are not a risk to fetuses. However, this belief is scientifically inaccurate. Men’s behaviors and characteristics can cause paternal-fetal harm. For instance, paternal smoking and drinking can result in an increased chance of birth defects and low birth weight. Paternal use of illegal drugs (such as cocaine, hashish, opium, and heroin) can also lead to fetal health problems because of abnormal sperm. Additionally, older paternal age has been associated with a higher risk of children with autism, Down syndrome, and schizophrenia.  

Despite these scientific facts, there is little public and academic discussion of men and fetal harm, which implies that men do not (or cannot) cause such harm. The cultural narrative that men are not causally or ethically responsible for fetal harm has been reified in law, policy, medicine, and the media.  Even the language we use to discuss reproduction and childcare minimizes the role men play in reproduction. The verb “to father” is synonymous with ‘‘to sire’’ and refers to impregnating a woman, that is, the one time event of fertilization. In contrast, “to mother” refers to constant caregiving and nurturing. 

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.

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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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