Extracorporeal membrane oxygenation (ECMO) is typically viewed as a time-limited intervention—a bridge to recovery or transplant—not a destination therapy. However, some patients with decision-making capacity request continued ECMO support despite a poor prognosis for recovery and lack of viability as a transplant candidate. In response, critical care teams have asked for guidance regarding the ethical permissibility of unilateral withdrawal over the objections of a capacitated patient. In this article, we evaluate several ethical arguments that have been made in favor of (...) withdrawal, including distributive justice, quality of life, patients’ rights, professional integrity, and the Equivalence Thesis. We find that existing justifications for unilateral withdrawal of ECMO support in capacitated patients are problematic, which leads us to conclude that either: (1) additional ethical arguments are necessary to defend this approach or (2) the claim that it is not appropriate to use ECMO as a destination therapy should be questioned. (shrink)

This article discusses the triage response to the COVID-19 delta variant surge of 2021. One issue that distinguishes the delta wave from earlier surges is that by the time it became the predominant strain in the USA in July 2021, safe and effective vaccines against COVID-19 had been available for all US adults for several months. We consider whether healthcare professionals and triage committees would have been justified in prioritising patients with COVID-19 who are vaccinated above those who are unvaccinated (...) in first-order or second-order triage. Given that lack of evidence for a correlation between short-term survival and vaccination, we argue that using vaccination status during first-order triage would be inconsistent with accepted triage standards. We then turn to notions of procedural fairness, equity and desert to argue that that there is also a lack of justification for using vaccination status in second-order triage. In planning for future surges, we recommend that medical institutions base their triage decisions on principles meant to save the most lives, minimise inequity and protect the public’s trust, which for the time being would not be served by the inclusion of vaccination status. (shrink)

Significant challenges arise for clinical care teams when a patient or surrogate decision-maker hopes a miracle will occur. This article answers the question, “How should clinical bioethicists respond when a medical decision-maker uses the hope for a miracle to orient her medical decisions?” We argue the ethicist must first understand the complexity of the miracle-invocation. To this end, we provide a taxonomy of miracle-invocations that assist the ethicist in analyzing the invocator's conceptions of God, community, and self. After the ethicist (...) appreciates how these concepts influence the invocator's worldview, she can begin responding to this hope with specific practices. We discuss these practices in detail and offer concrete recommendations for a justified response to the hope for a miracle. (shrink)

Readers have much to consider when evaluating Greenblum and Hubbard’s conclusion that ‘physicians have no business doing theology’.1 The two central arguments the authors offer are fairly convincing within the confines they set for themselves, the provisos they stipulate and their notions of ‘privacy’ and ‘public reason’. However, I would ask readers to consider two questions, the answers to which I believe the authors leave opaque. First, what is theological negotiation? Second, what makes chaplains the singular group of healthcare professionals (...) responsible for theological negotiation? In this Commentary, I explore these questions not with the goal of rejecting the authors’ conclusion, but rather with the goal of highlighting relevant considerations when evaluating the authors’ central tenets. First, I would like readers to consider Greenblum and Hubbard’s descriptions of theological negotiation. They categorise theological negotiation into metaphysical, normative and alternative responses, and hold that this kind of negotiation is, for the most part, impermissible for healthcare professionals, save chaplains.1 The examples of Dr Chatterjee and Dr Thompson expand theological negotiation to include instances where physicians add a theological veneer to their clinical recommendations. In both the examples, the physician has made the case for accepting or rejecting a certain intervention—for Dr Chatterjee, accepting …. (shrink)

Although shared decision-making is a standard in medical care, unilateral decisions through process-based conflict resolution policies have been defended in certain cases. In patients who do not stand to receive proportional clinical benefits, the harms involved in interventions such as cardiopulmonary resuscitation seem to run contrary to the principle of non-maleficence, and provision of such interventions may cause clinicians significant moral distress. However, because the application of these policies involves taking choices out of the domain of shared decision-making, they face (...) important ethical and legal problems, including a recent challenge to their constitutionality. In light of these concerns, we suggest a re-conceptualization of informed non-dissent as an alternative approach in cases where the application of process-based policies is being considered. This clinician-directed communication model still preserves what is valuable in such policies and salvages professional integrity, while minimising ethical and legal challenges. (shrink)

Volume 20, Issue 7, July 2020, Page 202-204.

Mr. M is an eighty-five-year-old who presented to the hospital with congestive heart failure exacerbation, pneumonia, altered mental status, and sepsis. A physician determines that he lacks capacity, and the team in the intensive care unit looks to the patient's daughter, Celia, as his surrogate decision-maker because she is named as an agent in his medical power of attorney form. While in the ICU, Mr. M suffers acute respiratory distress secondary to pneumonia and thus requires intubation. Celia accepts several life-sustaining (...) interventions, but she sporadically refuses other medically indicated therapies. Although providers explain the importance of the ICU insulin regimen for glucose control, she either refuses the insulin or requests a lower dose. The health care team believes that it is providing substandard care and that Celia's medical decisions are not in the patient's best interests, so they request an ethics consultation. When the clinical ethicist attempts to talk with Celia, she refuses to speak with him, saying flatly, “I am not interested in talking with you.” The clinical ethicist meets with Celia on a couple of occasions, but she consistently refuses to have a conversation with him. He wonders if the patient's surrogate decision-maker can refuse a clinical ethics consultation and is unsure what his next steps should be. (shrink)

The Covid‐19 pandemic has brought about renewed conversation about equality and equity in the distribution of medical resources. Much of the recent conversation has focused on creating and implementing policies in times of crisis when resources are exhausted. Depending on how the pandemic develops, some communities may implement crisis measures, but many health care facilities are currently experiencing shortages of staff and materials even if the facilities have not implemented crisis standards. There is a need for shared conversation about equality (...) and equity in these times of contingency between conventional and crisis medicine. To respond well to these challenges, I recommend that institutions rely on policy, professional education, and ethics consultation. As is the case with crisis policies, creating contingency policies requires that health care professionals decide on how, specifically, to achieve equity. A policy is only as effective as its implementation; therefore, institutions should invest in context‐specific education on contingency policies. Finally, ethics consultation should be available for questions that contingency policies cannot address. (shrink)

How should clinical ethicists be trained? Scholars have stated that clinical ethics fellowships create well-trained, competent ethicists. While this appears intuitive, few features of fellowship programs have been publicly discussed, let alone debated. In this paper, we examine how fellowships can foster effective mentoring relationships. These relationships provide the foundation for the fellow’s transition from novice to competent professional. In this essay, we begin by discussing our pedagogical commitments. Next, we describe the structures our program has created to assist our (...) fellows in becoming competent ethicists. We then outline the kinds of knowledge, skills, and professional attributes mentors should possess. Following this, we focus on the knowledge, skills, and professional attributes that fellows develop as they co-create effective mentoring relationships. We will not prescribe a single approach to fellowship training; instead, our perspective will, we hope, become a catalyst for further conversation on training and mentoring clinical ethics fellows. (shrink)

Lei, a twenty‐seven‐year‐old Mandarin speaker, visits the United States seeking curative treatments for his acute myeloid leukemia. His mother, Hua, has traveled with him. Neither she nor Lei speak English, and the hospital does not have an onsite professional Mandarin‐speaking interpreter. Using a professional interpreter over the phone, Lei's oncologist, Dr. Branson, attempts to initiate a face‐to‐face goals‐of‐care conversation with Hua as the surrogate decision‐maker. Dr. Branson explains that Lei has “only weeks to months to live” and recommends initiating comfort‐care‐only (...) measures, but Hua says that she wants (and that Lei would want) continued aggressive measures. Hua says that her son might be a candidate for a phase I trial. Eventually, Dr. Branson brings in Dr. Chou, a Mandarin‐speaking resident to provide face‐to‐face interpretation. Hua insists that “there must be more standard therapies available” and says that she will wait until the trial begins. She begins crying, and the meeting disintegrates. Following this, Dr. Branson calls for an ethics consultation for “help in end‐of‐life communicating and reconciling discordance about prognostic information.”How should the ethicist use the institution's interpreter services? (shrink)

Mrs. Duong had coronary artery disease, ischemic cardiomyopathy, and mildly altered mental status when her case was presented before an advanced heart therapy medical review board. She was accepted for left ventricular assist device placement pending additional insight into her cognitive state. Before the LVAD could be implanted, however, Mrs. Duong went into cardiogenic shock, and her heart failure team placed an intra‐aortic balloon pump in her subclavian artery. Within two weeks, Mrs. Duong became IABP dependent and deconditioned. The attending (...) deemed her as lacking capacity to make complex medical decisions, and the medical review board officially declined her for LVAD placement. The heart failure and CICU teams feel that Mrs. Duong is not being helped by the care they are giving her. They recommend terminal weaning of the IABP and initiation of comfort care. Her family disagrees, pointing to activities like continued eating and interacting with family. At an impasse after yet another family meeting, the attending for the heart failure team asks the clinical ethics consultant, “Do we have to replace the balloon pump when it fails?”. (shrink)

Every clinical ethics consultant, no matter their own spirituality, will meet patients, families, and healthcare professionals whose spiritualities anchor their moral worldviews. How might ethicists respond to those who rely on spirituality when making medical decisions? And further, should ethicists incorporate their own spiritual commitments into their clinical analyses and recommendations? These questions prompt reflection on foundational issues in the philosophy of medicine, political and moral theory, and methods of proper clinical ethics consultation. Rather than attempting to offer definitive answers (...) to these questions, this essay prompts readers to consider their own answers to these questions. Specifically, it offers a taxonomic analysis of six (6) distinct responses: assessment, delegation, examination, translation, incorporation, and assertion. Furthermore, this essay describes the role of the ethicist’s own spiritual commitments during the responses. Each section also names several strengths and weaknesses that ethicists ought to consider when evaluating the purpose and scope of each response. This paper prompts readers to consider circumstances under which they might promote, critique, or incorporate spiritual worldviews—their own and those of their patients—when offering clinical analyses and recommendations. (shrink)

Despite the interpersonal nature of family meetings and the frequency in which they occur, the clinical ethics literature is devoid of any rich descriptions of what clinical ethicists should actually be doing during family meetings. Here, we propose a framework for describing and understanding “transitioning” facilitation skills based on a retrospective review of our internal documentation of 100 consecutive cases wherein a clinical ethicist facilitated at least one family meeting. The internal documents were analyzed using qualitative methodologies, i.e., “codes”, to (...) identify emergent themes. We identified four different transitioning strategies clinical ethicists use to reach a meaningful resolution. These transitioning strategies serve as a jumping-off point for additional analyses, future research, evaluating clinical ethics consultation, and overall performance improvement of a consultation service. (shrink)