In November 2018, the practice of health care ethics consultation crossed a major threshold when 138 candidates took the inaugural Healthcare Ethics Consultant Certification Examination. This accomplishment, long in the making, has had and continues to have both advocates and critics. The Healthcare Ethics Consultant Certification Commission, a functionally autonomous body created and funded by the American Society for Bioethics and Humanities, was charged with overseeing creation of the certification process, developing the exam, and formulating certification standards and policies to (...) assess candidates’ qualifications. In this essay, as members of the commission, we describe the process of developing, administering, and scoring the certification examination as well as the historical context and the outlook for certification. By detailing the decisions and actions of the commission, we aim to provide a transparent account of the commission's efforts to develop a psychometrically sound, reliable, and secure examination through a deliberative, fair, and data‐driven process. (shrink)

We describe the ethics consultation service (ECS) at the Cleveland Clinic and report on its activities over a 24-month period in which 478 consultations were performed. To our knowledge, this is the largest case series of ethics consultations reported to date. Established more than 25 years ago, the ECS at the Cleveland Clinic is staffed by multiple consultants with advanced training in bioethics. Several of these ethicists work closely with specialized clinical units and research departments, where they participate in multidisciplinary (...) meetings and provide specialized assistance. This combination of historical experience, large numbers of consultation requests, and specialized clinical ethicists suggests that the experience at the Cleveland Clinic may be helpful to ethicists and others who may be considering how to structure and sustain a vibrant ECS. Our results highlight the diversity of activities performed by a high-volume ECS at a tertiary care facility. Our hope in sharing the inner workings of the ECS at the Cleveland Clinic is to promote dialogue on common practices and approaches across medical institutions that support ethics consultation. (shrink)

It is generally accepted that appropriate documentation of activities and recommendations of ethics consultants in patients’ medical records is critical. Despite this acceptance, the bioethics literature is largely devoid of guidance on key elements of an ethics chart note, the degree of specificity that it should contain, and its stylistic tenor. We aim to provide guidance for a variety of persons engaged in clinical ethics consultation: new and seasoned ethics committee members who are new to ethics consultation, students and trainees (...) in clinical ethics, and those who have significant experience with ethics consultation so that they can reflect on their practice. Toward the goal of promoting quality charting practices in ethics consultations, we propose recommendations on a broad array of questions concerning clinical ethics consultation chart notes, including whether and when to write a chart note, and practical considerations for the tenor, purpose, and content of a chart note. Our broader aim is to promote discussion about good charting practices in clinical ethics, with the hope of contributing to clear standards of excellence in clinical ethics consultation. (shrink)

The authors work in a variety of clinical ethics consultation services (CECSs) that employ a range of methods and approaches. This article discusses the approach to ethics consultation at the Center for Medical Ethics and Health Policy at Baylor College of Medicine and describes the development and transformation of the authors’ CECSs. It discusses how one CECS shifted from a nascent program with only fifty consultations a year to a vibrant, heavily staffed service with five hundred ethics consultations a year.

While valuable work has been done addressing clinical ethics within established healthcare systems, we anticipate that the projected growth in acquisitions of community hospitals and facilities by large tertiary hospitals will impact the field of clinical ethics and the day-to-day responsibilities of clinical ethicists in ways that have yet to be explored. Toward the goal of providing clinical ethicists guidance on a range of issues that they may encounter in the systematization process, we discuss key considerations and potential challenges in (...) implementing system-wide ethics consultation services. Specifically, we identify four models for organizing, developing, and enhancing ethics consultation activities within a system created through acquisitions: train-the-trainer, local capacity-building, circuit-riding, and consolidated accountability. We note each model’s benefits and challenges. To our knowledge, this is the first paper to consider the broader landscape of issues affected by consolidation. We anticipate that clinical ethicists, volunteer consultants, and hospital administrators will benefit from our recommendations. (shrink)

Developing a care plan in a critical care context can be challenging when the therapeutic alliance between clinicians and families is compromised by anger. When these cases occur, clinicians often turn to clinical ethics consultants to assist them with repairing this alliance before further damage can occur. This paper describes five different reasons family members may feel and express anger and offers concrete strategies for clinical ethics consultants to use when working with angry families acting as surrogate decision makers for (...) critical care patients. We reviewed records of consults using thematic analysis between January 2015 and June 2016. Each case was coded to identify whether the case involved a negative encounter with an angry family. In our review, we selected 11 cases with at least one of the following concerns or reasons for anger: perceived or actual medical error, concerns about the medical team’s competence, miscommunication, perceived conflict of interest or commitment, or loss of control. To successfully implement these strategies, clinical ethics consultants, members of the medical team, and family members should share responsibility for creating a mutually respectful relationship. (shrink)

Patients who enter the health care system for acute care may become “permanent” patients of the hospital when a lack of resources precludes discharge to the next level of post-acute care. Legal, professional, and ethical norms prohibit physician and acute care hospital “dumping” of these patients. However, limitless use of hospital resources for indefinite stays is untenable. In the absence of hospital policy addressing this specific issue, the availability of financial support will be determined by health care professionals' willingness to (...) advocate for the patient and negotiate with hospital administrators and the ability and willingness of administrators to authorize the use of hospital resources. We propose five mid-level ethical principles to guide advocacy and administrative decision-making about provision of financial support for post-acute care for those patients who cannot afford it. We use two actual, de-identified cases to illustrate how these principles can be used to make reasoned, consistent decisions about the provision of post-acute financial support. (shrink)

Patients who enter the health care system for acute care may become “permanent” patients of the hospital when a lack of resources precludes discharge to the next level of post-acute care. The care of these patients contributes to the rising costs of health care and will remain largely unaffected by the Affordable Care Act. For example, some resources may be available for treatment of undocumented persons, but Medicaid enrollment is unavailable for this population. Even where patients have access to Medicaid, (...) it takes up to three months between applying for and actually receiving Medicaid benefits. During that time, patients may be ready for hospital discharge. However, post-acute care facilities have no financial incentive or legal obligation to accept patients with no insurance or only pending Medicaid coverage. (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)

The clinical ethicist met with Ms. H to clarify what information she wants and does not want to know. First, she wants to receive any treatment that could prolong her life, regardless of how the treatment affects her ability to engage in activities of daily living. Second, she wants to be included in the decision‐making process as much as possible, as long as clinicians use only “positive” language. Ms. H considers the words “dying,” “chemotherapy,” “radiation,” and “cancer” to be “bad (...) words.” For conversations in which these words cannot be avoided, she wants her clinicians to talk to her son. Her desired engagement includes hearing about risks, benefits, and alternatives to treatments if clinicians use only “positive” language. Finally, she says that she rarely sees doctors and that she is “very scared” of hospitals, despite exhibiting a comfortable demeanor.Should clinicians honor Ms. H's waiver of specified information and, if so, to what degree? (shrink)

In their article “Structuring a Written Examination to Assess ASBH Health Care Ethics Consultation Core Competencies” (2014), White, Jankowski, and Shelton argue that a written examination to evalu...

The authors of this article are previous or current members of the Clinical Ethics Consultation Affairs (CECA) Committee, a standing committee of the American Society for Bioethics and Humanities (ASBH). The committee is composed of seasoned healthcare ethics consultants (HCECs), and it is charged with developing and disseminating education materials for HCECs and ethics committees. The purpose of this article is to describe the educational research and development processes behind our teaching materials, which culminated in a case studies book called (...) A Case-Based Study Guide for Addressing Patient-Centered Ethical Issues in Health Care (hereafter, the Study Guide). In this article, we also enumerate how the Study Guide could be used in teaching and learning, and we identify areas that are ripe for future work. (shrink)

Hospital administrators may lack familiarity with what clinical ethicists do (and do not do), and many clinical ethicists report receiving inadequate financial support for their clinical ethics consultation services (CECSs). Ethics consultation is distinct in that it is not reimbursable by third parties, and its financial benefit to the hospital may not be quantifiable. These peculiarities make it difficult for clinical ethicists to resort to tried-and-true outcome-centered evaluative strategies, like cost reduction or shortened length of stay for patients, to show (...) a “need” for ethics consultation. Likewise, it can be difficult for clinical ethicists to “speak the same language” as healthcare administrators and managers, which, in turn, means that CECSs run the risk of being unable to demonstrate value to those who pay for the service. The purpose of this descriptive article is to provide practical guidance to clinical ethicists and program directors on how to cultivate administrative support for a CECS. Specifically, we discuss two elements that clinical ethics leaders must critically appraise and successfully argue to meet the expectations of administrators— the value of a CECS and its fit in clinical workflow. (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)

A collection of critical essays by English and American scholars, including such controversial academic political theorists as Gutmann, Barry and Nussbaum, that raises questions about the current theoretical reassessment of political liberalism.

The bottom of the pyramid (BOP) concept suggests that business has a vital role to play in meeting the unmet needs of the 4 billion poorest people on the planet. Serious advances in research on bottom of the pyramid business will require effective evaluation of the social impacts these businesses are having on the people they are supposed to benefit. Evaluation will allow us to identify conditions in which specific business interventions can address unmet needs fairly and effectively. Theory-driven evaluation (...) offers an approach to assessing the successes and limitations of BOP businesses by exploring why a venture does or does not achieve its social objectives. The experience of AIG Uganda in the microinsurance business illustrates the insights possible from applying theory-driven evaluation. (shrink)

Business schools are slowly waking up to the reality that most of the products and services discussed in management curricula serve a small portion of humanity. A small number of business schools has begun to address businesses designed to meet the needs of the poor (the so called “base of the pyramid”) in business in society courses or in dedicated elective courses. As the world heads into an era defined by pervasive uncertainty, perhaps a business mindset focusing on management in (...) the face of inherent unpredictability is a better model for reflecting on business in society. Effectuation theory describes a decision process employed by entrepreneurs and the poor that differs substantially from the rational choice paradigm that dominates management education. This theory of problem solving that views the environment as constructible by choice in the face of pervasive uncertainty may be a better foundation for theories of business insociety than existing frameworks. (shrink)

We address three issues regarding the relationship between political party affiliation and returns in the equities markets, as measured by the NYSE Composite Index and its sub-indexes. First, we find a tendency for returns to be greater during Democratic presidential administrations; however, this result is statistically insignificant. Second, we conclude that returns during the last two years of presidential administrations are greater than during the first two years. Third, we examine the relationship between the majority party in each house of (...) Congress and equity returns. We raise the possibility that party affiliation of Congress is a factor in explaining returns. (shrink)

Here’s a problem that any reliability theory must face, whether it’s one that holds that beliefs are justified just when they’re products of belief-forming mechanisms with the potential of having good records of yielding true beliefs, or one that holds that a belief meets the standards for knowledge if and only if its causal basis rules out any relevant chance of mistake. The problem is made evident when cast in probabilistic terms. Let r be S’s reason for tokening the true (...) belief that p under conditions c. Then, according to reliabilism, Sis justified in believing that p under c iff r makes it sufficiently probable that p, whileS knows that p iff the conditional probability that p on r and c is unity. But how do we specify the belief context c to be counted as epistemically relevant? As urged recently by John Pollock, on the face of it there seems to be no principled reason for excluding mention of the truth value of the proposition believed. As he says, ‘The only obvious way to construct an objective non-epistemic kind of definite probability is to make it conditional on everything that is true [at the belief’s tokening]’ ; and, as he notes, ‘one feature of the present circumstances is a characterization of the belief as a belief in [p ], and another feature is the truth value of [p]’. But if we allow both the belief token and its truth value membership in the relevant belief context, we then have the hopeless task of explaining how the probability of the token’s being true can be anything but one or zero, one if what is believed is true, and zero if it’s false. This in tum would commit reliabilism to the foolish doctrines that a belief’s truth is sufficient for knowledge, while no false belief is ever even justified. No wonder, then, that Pollock says ‘there is no way to construct an intelligible notion of reliability which does the job required by the reliabilist’. And he is surely right in this: Neither knowledge nor justification can be explained as the chance of a belief’s being true if the relevant belief context is required to mention both the belief tokened and its truth value. We would be engaged in a comparably pointless task were we to try to explain the likelihood of a wager’s being a good bet on a horse race when we had to include among the givens both which horse was picked and its finish, or were we to try to make sense of the assertion that a theory’s predictions have a good chance of being true when both what the theory predicts and its outcome had to be included among the givens. (shrink)

The drastically increasing availability ofmodern computers coupled with the equally drasticallylower cost of a given amount of computer power inrecent years has resulted in the evolution of thetraditional experimental/theoretical dichotomy inchemistry into anexperimental/theoretical/computational trichotomy. This trichotomy can be schematically represented by atriangle with experimental,theoretical, and computational chemistry at the threevertices. The ET and EC edges of the ETC triangledepict the uses of theoretical and computationalchemistry, respectively, to predict and interpretexperimental results. The TC edge depicts therelationship between theoretical and computationalchemistry. Mathematics (...) plays an increasing role in allaspects of chemistry, particularly theoreticalchemistry, and has led to the evolution of thediscipline of mathematical chemistry. Research inmathematical chemistry can be considered to lie on achemistry-mathematics continuum depending on therelative depths of the underlying chemistry andmathematics. Examples of the author's own researchlying near each end of the chemistry-mathematicscontinuum include his work on applications of graphtheory and topology in inorganic coordination andcluster chemistry lying near the chemistry end and hiswork on chirality algebra lying near the mathematicsend. The general points in this essay are illustratedby an analysis of the roles of computational andtheoretical chemistry in developing an understandingof structure and bonding in deltahedral boranes andrelated carboranes. This work has allowed extensionof the concept of aromaticity from two dimensions asin benzene and other planar hydrocarbons to the thirddimension in deltahedral boranes. (shrink)

The terms used to describe and negotiate environmental quality are both ambiguous and value-laden. Stakeholders intimately and actively involved in the management of forested lands were interviewed and found to use ambiguous, tautological, and value-laden definitions of terms such as health, biodiversity, sustainability, and naturalness. This confusing language hinders public participation efforts and produces calls to regulate and remove discretion from environmental professionals. Our data come from in-depth interviews with environmental management professionals and other stakeholders heavily vested In negotiating the (...) fate of forested lands. We contend that environmental science and management will be more effective if its practitioners embrace and make explicit these ambiguous and evaluative qualities rather than ignore and disguise them. (shrink)

You would be hard-pressed to find someone who categorically opposes protecting the environment, yet most people would agree that the environmentalist movement has been ineffectual and even misguided. Some argue that its agenda is misplaced, oppressive, and misanthropic—a precursor to intrusive government, regulatory bungles, and economic stagnation. Others point out that its alarmist rhetoric and preservationist solutions are outdated and insufficient to the task of galvanizing support for true reform. In this impassioned and judicious work, R. Bruce Hull argues (...) that environmentalism will never achieve its goals unless it sheds its fundamentalist logic. The movement is too bound up in polarizing ideologies that pit humans against nature, conservation against development, and government regulation against economic growth. Only when we acknowledge the infinite perspectives on how people should relate to nature will we forge solutions that are respectful to both humanity and the environment. Infinite Nature explores some of these myriad perspectives, from the scientific understandings proffered by anthropology, evolution, and ecology, to the promise of environmental responsibility offered by technology and economics, to the designs of nature envisioned in philosophy, law, and religion. Along the way, Hull maintains that the idea of nature is social: in order to reach the common ground where sustainable and thriving communities are possible, we must accept that many natures can and do exist. Incisive, heartfelt, and brimming with practical solutions, Infinite Nature brings a much-needed and refreshing voice to the table of environmental reform. (shrink)

Both similarities and differences were observed when comparing scenic beauty evaluations of rural landscapes made by persons from different cultures. Differences seem due to the westernized tourists' misinterpretation or ignorance of the meaning associated with certain landscape features by the Balinese. This implies scenic beauty is dependent upon meanings assigned to landscape features, which in turn implies that scenic beauty is, to some extent, learned. Similarities between tourists' and Balinese' scenic evaluations are significant and correspond to consistencies found in other (...) landscape preference studies. Multiple methods were used, including participant photography, rating scales, and a variety of statistical analyses. A review of the literature reveals evidence and theory which suggests both similarities and differences are to be expected when comparing scenic evaluations made by persons of different cultures. This review also suggests three methodological concerns which should be addressed in landscape studies: a concern for the participant's purpose for evaluating a landscape; a concern for the participant's familiarity with a landscape; and a concern for the criterion's appropriateness to all participants. Research designs which ignore these concerns may mask true cultural differences. (shrink)

The writer responds to the essay “Developing, Administering, and Scoring the Healthcare Ethics Consultant Certification Examination,” by Courtenay R. Bruce et al., in the September‐October 2019 issue of the Hastings Center Report.

A reduction of chromosome number in meiosis is essential for genome transmission in diploid organisms. Reduction depends on a change in kinetochore configuration.1 A recent study2 connects changes in kinetochores with other changes in chromosome structure and raises the intriguing possibility that topoisomerase II, the DNA untangling enzyme, is involved. BioEssays 25:309–312, 2003. © 2003 Wiley Periodicals, Inc.

This paper examines an important issue facing academia-pay inversion. It discusses how inversion is accompanied by ethical issues including secrecy, moral dilemmas for faculty, honesty, and keeping promises. It then examines this issue from five ethical viewpoints: a legalistic perspective, ethical egoism, utilitarianism, distributive justice, and Kants deontological approach. As part of the discussion, the effect of the moral philosophy on the universitys corporate culture is examined, with attention given to morale and productivity. Finally, alternatives to pay inversion that universities (...) may want to consider are discussed. (shrink)

Ecological restoration is an inherently challenging endeavour. Not only is its underlying science still developing, but the concept itself raises complex questions about nature, culture and the role of humans in the landscape.

Over the course of his work, Graham Oppy developed numerous important criticisms of versions of the cosmological argument. Here I am not concerned with his specific criticisms of cosmological arguments but rather with his claim that cosmological arguments per se are not good arguments, for they provide no persuasive reason for believing the conclusion that God exists and are embedded in theories that already affirm the conclusion. I explore what he believes makes an argument good, contend that cosmological arguments can (...) have functions within worldviews other than persuasion, and consider his recent modifications of the discussion that address competing worldviews. (shrink)