This book is about the ethical issues that clinicians encounter as they care for patients and is written to assist those who serve on hospital ethics committees as they deliberate about appropriate action in difficult ethical cases.

This book is about the ethical issues that clinicians encounter as they care for patients and is written to assist those who serve on hospital ethics committees as they deliberate about appropriate action in difficult ethical cases.

In November 2018 the American Society for Bioethics and Humanities (ASBH) administered the first Healthcare Ethics Consultant Certification examination to 138 candidates, 136 of whom (98.5 percent) passed and were “certified” as “healthcare ethics consultants.” I believe this certification process is both premature and inadequate.Certification for ethics consultants is premature because, as Kornfeld and Prager state repeatedly in their article in this issue of The Journal of Clinical Ethics, “The Clinician as Clinical Ethics Consultant: An Empirical Method of Study,” there (...) is a lack of “empirical data on the nature of the problems that prompt ethics consultation requests and on the functions required to address them.” These authors proceed to provide a model for the kind of empirical data collection that is needed.Even more relevant, the ASBH model that certifies clinical ethics consultants is inadequate. First, it is inappropriate for a nonclinical organization such as the ASBH to claim the right to certify a clinical process, ethics consultation, involving patients and health professionals. Second, the current certification process requires only a written examination in contrast to the two-step quality attestation process proposed in 2013 by Eric Kodish, MD, and 11 other senior members of the ASBH, including its then president.Third and most importantly, the eligibility criteria for being certified to work on hospital units and to make clinical recommendations for patients and families are minimal and insufficient. The only stated requirements are a bachelor’s degree and 400 hours of healthcare ethics consulting experience. By contrast, practicing physicians and nurses train for many years to gain clinical experience that enables them to apply clinical ethical standards in the care and management of all inpatients and outpatients, not just the small percent for whom an ethics consultation is requested. (shrink)

In 1972, I created the new field of clinical medical ethics (CME) in the Department of Medicine at the University of Chicago. In my view, CME is an intrinsic part of medicine and is not a branch of bioethics or philosophical ethics or legal ethics. The relationship of patients with medically trained and licensed clinicians is at the very heart of CME. CME must be practiced and applied not by nonclinical bioethicists, but rather by licensed clinicians in their routine, daily (...) encounters with inpatients and outpatients. CME addresses many clinical issues such as truth-telling, informed consent, confidentiality, surrogate decision making, and end-of-life care, while also encouraging personal, humane, and compassionate interactions between experienced clinicians and patients.The goals of CME are to improve patient care and outcomes by helping physicians and other health professionals Clinical Medical Ethics: Its History and Contributions to American Medicine Mark Siegler, Guest Editor identify and respond to clinical-ethical challenges that arise in the ordinary care of patients. As Edmund Pellegrino, Peter A. Singer, and I wrote in the first issue of The Journal of Clinical Ethics, 30 years ago: “The central goal of CME is to improve the quality of patient care by identifying, analyzing, and contributing to the resolution of ethical problems that arise in the routine practice of clinical medicine.” Similar to cardiology and oncology consultations, ethics consultations are a small component of a much larger field, and the process of consultations is certainly not at the core of cardiology or oncology or CME.In this article, I intend to discuss the origins of the field of CME, its goals and methods, the relationship between the broad field of CME and the much narrower practice of ethics consultation, the contributions of the MacLean Center at the University of Chicago in developing the field of CME, and, finally, how CME has improved the practice of medicine in the United States. (shrink)

Extracorporeal membrane oxygenation (ECMO) is a form of life support for cardiac and/or pulmonary failure with unique ethical challenges compared to other forms of life support. Ethical challenges with ECMO exist when conventional standards of care apply, and are exacerbated during periods of absolute ECMO scarcity when “crisis standards of care” are instituted. When conventional standards of care apply, we propose that it is ethically permissible to withhold placing patients on ECMO for reasons of technical futility or when patients have (...) terminal, short-term prognoses that are untreatable by ECMO. Under crisis standards of care, it is ethically permissible to broaden exclusionary criteria to also withhold ECMO from patients who have a low likelihood of recovery, to maximize the overall number of lives saved. Unilateral withdrawal of ECMO against a patient’s preferences is unethical under conventional standards of care, but is ethical under crisis standards of care to increase access to ECMO to others in society. ECMO should only be rationed when true scarcity exists, and allocation protocols should be transparent to the public. When rationing must occur under crisis standards of care, it is imperative that oversight bodies assess for inequities in the allocation of ECMO and make frequent changes to improve any inequities. (shrink)

Many states prohibit patients from appointing their physicians as health care proxies, fearing paternalism and conflict of interest. But the potential for conflict is not unique to physicians, and patients may have compelling reasons to prefer that their doctor make decisions on their behalf. Managing potential conflicts serves patients better than denying them the right to choose who will make health care decisions for them when they are no longer competent.

It is a clinician’s cliché that a physician only challenges a patient’s capacity to make a treatment decision if that decision is not what the physician wants. Agreement is proof of decisional capacity; disagreement is proof or at least evidence of capacity’s absence. It is assumed that this asymmetry cannot be justified, that the asymmetry must be a form of physicians’ paternalism. Instead what is at issue when patient and physician disagree are usually two laudable impulses. The first is physicians’ (...) commitment to patients’ well-being: physicians have a professional obligation as well as, ideally, a personal commitment to take care of patients—to do their best to bring about a positive medical outcome. The second impulse is common to much of human life, namely, the urge to find and to understand the source of our disagreements with one another. In this article we argue that, jointly, these impulses justify the asymmetry with regard to examining patients’ capacity. (shrink)

Siegler identifies the elderly as a population vulnerable to discrimination as society seeks to contain health care costs by rationing medical care. Traditional decision making by physicians and patients, which is based upon medical indications and the wishes of the patient, may yield to decision making based upon institutional and social expediency and economic concerns. Siegler predicts that as a consequence of cost containment measures, certain groups of patients, of whom the elderly constitute a large percentage, will find (...) their access to medical care limited, and the extent of that care reduced. He suggests that this threat to the elderly can be counteracted by retaining the traditional physician patient relationship, by basing care decisions upon clinical criteria, and by beginnning rationing with those groups of patients best able to defend themselves. (shrink)

Book reviewed in this article: Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. By Albert R. Jonsen, Mark Siegler, and William J. Winslade.

Volume 19, Issue 12, December 2019, Page 1-2.

Liver transplantation is the treatment of choice for many forms of liver disease. Unfortunately, the scarcity of cadaveric donor livers limits the availability of this technique. To improve the availability of liver transplantation, surgeons have developed the capability of removing a portion of liver from a live donor and transplanting it into a recipient. A few liver transplants using living donors have been performed worldwide.Our purpose was to analyze the ethics of liver transplants using living donors and to propose guidelines (...) for the procedure before it was introduced in the United States. We used a process of research ethics consultation that involves a collaboration between clinical investigators and clinical ethicists. We concluded that it was ethically appropriate to perform liver transplantation using living donors in a small series of patients on a trial basis, and we published our ethical guidelines in a medical journal before the procedure was introduced. We recommend this prospective, public approach for the introduction of other innovative therapies in medicine and surgery. (shrink)

Novel cellular therapy techniques promise to cure many haematology patients refractory to other treatment modalities. These therapies are intensive and require referral to and care from specialised providers. In the USA, this pool of providers is not expanding at a rate necessary to meet expected demand; therefore, access scarcity appears forthcoming and is likely to be widespread. To maintain fair access to these scarce and curative therapies, we must prospectively create a just and practical system to distribute care. In this (...) article, we first review previously implemented medical product and personnel allocation systems, examining their applicability to cellular therapy provider shortages to demonstrate that this problem requires a novel approach. We then present an innovative system for allocating cellular therapy access, which accounts for the constraints of distribution during real-world oncology practice by using a combination of the following principles: maximising life-years per personnel time, youngest and robust first, sickest first, first come/first served and instrumental value. We conclude with justifications for the incorporation of these principles and the omission of others, discuss how access can be distributed using this combination, consider cost and review fundamental factors necessary for the practical implementation and maintenance of this system. (shrink)

A decade ago, we reviewed the field of clinical ethics; assessed its progress in research, education, and ethics committees and consultation; and made predictions about the future of the field. In this article, we revisit clinical ethics to examine our earlier observations, highlight key developments, and discuss remaining challenges for clinical ethics, including the need to develop a global perspective on clinical ethics problems.

The question I investigate concerns the ethics of clinical ethics consultation. To begin, I reconstruct and critically assess a widespread understanding of clinical medical ethics, one most prominently advanced by Mark Siegler. That examination reveals an overtly political strategy designed to reinforce physician authority. Next, John La Puma's work is discussed. Arguably the most prominent of Siegler's students, and certainly the most prolific, La Puma appears attentive to the problems in Siegler's view regarding clinical judgment. I (...) conclude, however, that La Puma assumes a relatively flexible system of formal rules and more extensive informal codes which define the concepts and procedures of medical consultation and which he simply transcribes for ethics consultation. ;Albert Jonsen and Stephen Toulmin have apparently endorsed this medicalized strategy. They contend that the view of ethics advocated by these physicians represents a "new" casuistry consistent if not identical to their own theory. I show that the casuist method of clinical ethical decision making simply appropriates features of the diagnostic apparatus embedded in the political economy of the enterprise of medicine and makes the role of ethicist parasitic on that of the physician as expert. Their casuistry, I argue, merely serves as a means to reinforce the standardized apparatus of professional authority exercised in medical procedures and concepts. ;Finally, I sketch an alternative way to think about how experience with other persons informs ethical decision making. On the basis of an extensive and nuanced account of an ethics consultation, I argue that to consult as a clinical philosopher in any situation is, necessarily, to be focused on that individual situation for its own sake. Clinical philosophy, as a result, must be done by attending strictly to what appears as it appears: the issues, concerns, and questions expressed, in their own terms, by those individuals whose situation it is. (shrink)

Hume's Reception in Early America: Expanded Edition brings together the original American responses to one of Britain's greatest men of letters, David Hume. Now available as a single volume paperback, this new edition includes updated further readings suggestions and dozens of additional primary sources gathered together in a completely new concluding section. From complete pamphlets and booklets, to poems, reviews, and letters, to extracts from newspapers, religious magazines and literary and political journals, this book's contents come from a wide variety (...) of sources published in colonial America and the early United States between 1758 and 1850. As well as classics by Thomas Jefferson, John Adams and Alexander Hamilton, it contains scores of unknown and hard-to-locate items, many of which have not been reprinted since their original publication. These responses are divided into four parts covering Hume's Essays; his Philosophical Writings; his History of England; and his Character and Death. Each of those parts has a separate introductory essay, and every selection is introduced by a short headnote that sets the piece in its historical context and provides bibliographical references. Packed with new insights into Hume and American thought and culture, Hume's Reception in Early America reveals the relevance and impact of Hume on American political, philosophical, historical, religious, and aesthetic debates. (shrink)

Prologue, invitation to thinking about God In the Hebrew Bible? -- Part I, questions about God? -- Why does God in the Bible have a body? -- What do God's body parts in the Bible mean? -- Why is God angry in the Bible? -- Does God in the Bible have gender or sexuality? -- Part II, questions about God in the world? -- What can creation tell us about God? -- Who-or what-is the Satan? -- Why do people suffer (...) according to the Hebrew Bible? -- Epilogue, God in the Bible and beyond. (shrink)

This paper offers a new way to make sense of disagreement expansion from a polylogical perspective by incorporating various places in addition to players and positions into the analysis. The concepts build on prior implicit ideas about disagreement space by suggesting how to more fully account for argumentative context, and its construction, in large-scale complex controversies. As a basis for our polylogical analysis, we use a New York Times news story reporting on an oil train explosion—a significant point in the (...) broader controversy over producing oil and gas via hydraulic fracturing. (shrink)

A specific issue for argumentation theory is whether information and communication technologies play any role in governing argument — that is, as parties engage in practical activities across space and time via ICTs, does technology matter for the interplay of argumentative content and process in managing disagreement? The case made here is that technologies do matter because they are not merely conduits of communication but have a role in the pragmatics of communication and argumentation. In particular, ICTs should be recognized (...) as communication-information services that are delegated degrees of responsibility for managing disagreements arising from practical activities. These services are organized around practical theories for designing disagreement space. However, recognizing this relationship between argument and technology requires accounting for procedures, techniques, or rules and speech acts that are not argumentative propositions in any strict sense but that are consequential for what becomes argumentation in any setting. An account about designing disagreement space, grounded in Jackson and Jacobs’s theory of Disagreement Management, is put forward to address these issues while more generally contributing to understanding argument in context. (shrink)