When the COVID-19 surge hit New York City hospitals, the Division of Medical Ethics at Weill Cornell Medical College, and our affiliated ethics consultation services, faced waves of ethical issues sweeping forward with intensity and urgency. In this article, we describe our experience over an eight-week period (16 March through 10 May 2020), and describe three types of services: clinical ethics consultation (CEC); service practice communications/interventions (SPCI); and organizational ethics advisement (OEA). We tell this narrative through the prism of time, (...) describing the evolution of ethical issues and trends as the pandemic unfolded. We delineate three phases: anticipation and preparation, crisis management, and reflection and adjustment. The first phase focused predominantly on ways to address impending resource shortages and to plan for remote ethics consultation, and CECs focused on code status discussions with surrogates. The second phase was characterized by the dramatic convergence of a rapid increase in the number of critically ill patients, a growing scarcity of resources, and the reassignment/ redeployment of staff outside their specialty areas. The third phase was characterized by the recognition that while the worst of the crisis was waning, its medium- and long-term consequences continued to pose immense challenges. We note that there were times during the crisis that serving in the role of clinical ethics consultant created a sense of dis-ease as novel as the coronavirus itself. In retrospect we learned that our activities far exceeded the familiar terrain of clinical ethics consultation and extended into other spheres of organizational life in novel ways that were unanticipated before this pandemic. To that end, we defined and categorized a middle level of ethics consultation, which we have termed service practice communication intervention (SPCI). This is an underappreciated dimension of the work that ethics consult services are capable of in times of crisis. We believe that the pandemic has revealed the many enduring ways that ethics consultation services can more robustly contribute to the ethical life of their institutions moving forward. (shrink)

Debates regarding clinical ethicists’ scope of practice are not novel and will continue to evolve. Rapid changes in healthcare delivery, outcomes, and expectations have necessitated flexibility in clinical ethicists’ roles whereby hospital-based clinical ethicists are expected to be woven into the institutional fabric in a way that did not exist in more traditional relationships. In this article we discuss three emerging roles: the ethicist embedded in the interdisciplinary team, the ethicist with an expanded educational mandate, and the ethicist as a (...) therapeutic presence in the patient care space. Such expanded capacities offer more robust, positive contributions to institutional culture, stakeholders’ relationships, and patient-centered care. (shrink)

Hastings Center Report, Volume 52, Issue 3, Page 37-48, May–June 2022.

Mrs. Smith's eyes filled with tears as she said, “I feel like I've done something wrong. Are they punishing me because I've been refusing therapy and won't go to a nursing home?” She acknowledged that she hadn't always listened to her doctors but said that she knew better now and wanted to go home and see if she could make it work. Many staff members at our rehabilitation hospital had explained their safety concerns to her, and some had enlisted her (...) adult daughter, with whom she lived, to convince her too. The rehabilitation team had called on the ethics consultation service, of which I am a part, to help figure out whether Mrs. Smith had the capacity to make an informed refusal of discharge recommendations. (shrink)

As ethics consultants on a busy consult service in a large urban setting, we would approach this case by gathering more information and context. This involves clarifying the clinical facts, underst...

Vijay is a forty-eight-year-old man with profound mental retardation and cerebral palsy. He uses a wheelchair, cannot speak or eat by mouth, and requires constant care. He lived in a group home for twenty-eight years. During the last year, Vijay has required two visits to the emergency room on average per month and has been hospitalized for two hundred days in total. These hospitalizations are the result of a number of painful and dangerous complications related to the gastrostomy tube that (...) provides his nutrition. The last time he was in the hospital, doctors had to give him a peripherally inserted central catheter, or PICC line, to provide nutrition because the gastrostomy tube was no longer effective .. (shrink)

As I organize a pile of ethics consult chart notes in New York City in mid‐April 2020, I look at the ten cases that I have co‐consulted on recently. Nine of the patients were found to be Covid positive. The reasons for the consults are mostly familiar—surrogate decision‐making, informed refusal of treatment, goals of care, defining futility. But the context is unfamiliar and unsettling. Bioethicists are in pandemic mode, dusting off and revising triage plans. Patients and potential patients are fearful—of (...) the disease itself and of the amplification of health disparities and inequities. There is much to contemplate, but as I go through my cases, I worry about disability, about biases and racist stereotypes. In this pandemic, historically marginalized communities are at risk of further disenfranchisement. (shrink)

Dignity of risk is a simple concept that is surprisingly hard to enact, honor, and prioritize in health care. The term was coined 50 years ago by Robert Perske in an article entitled "The Dignity of Risk and the Mentally Retarded". And as I have written in "Discharge Decisions and the Dignity of Risk", "the concept involves respect for persons, self-determination, and attempts to minimize paternalism or parentalism". Most simply, the dignity of risk embraces respecting or honoring an individual's choices (...) or decisions even in the face of potential harms.The central tension between safety/protection and autonomy/self-determination is at the core of the concept, but it also involves appraisals... (shrink)

I am leading a debriefing session—the second part of a three-part model we have started for ethics consultations at our rehabilitation hospital. The debriefing is loosely organized. We begin with follow-up from a recent ethics consultation. For some team members, this is a time to learn how ethics was involved and how things got resolved. I then ask for their responses to the case: what went right, what went wrong.One team member remarks, "I was angry at Maria's daughter. She never (...) let anyone get a word in edgewise, including her mother." Another says, "I was emotionally exhausted. Her daughter was manipulative. She was good at splitting the team and playing us against each other." Respecting the patient's .. (shrink)