Clinicians have good moral and professional reasons to contribute to pragmatic clinical trials (PCTs). We argue that clinicians have a defeasible duty to participate in this research that takes place in usual care settings and does not involve substantive deviation from their ordinary care practices. However, a variety of countervailing reasons may excuse clinicians from this duty in particular cases. Yet because there is a moral default in favor of participating, clinicians who wish to opt out of this research must (...) justify their refusal. Reasons to refuse include that the trial is badly designed in some way, that the trial activities will violate the clinician’s conscience, or that the trial will impose excessive burdens on the clinician. (shrink)

Background Older patients are often vulnerable and highly dependent on healthcare professionals’ assessment in the event of acute illness. In the context of ambulance services, this poses challenges as the assessment is normally conducted with a focus on identifying life-threatening conditions. Such assessment is not fully satisfactory in a patient relationship that also aims to promote and protect patient autonomy. Aim To describe ambulance clinicians’ understanding of older patients’ self-determination when the patient’s decision-making ability is impaired. Research design A qualitative (...) design with an inductive approach, guided by descriptive phenomenology. Participants In total, 30 ambulance clinicians, comprised of 25 prehospital emergency nurses, 1 nurse and 4 emergency medical technicians participated in 15 dyadic interviews. Ethical considerations The research was conducted in accordance with the Declaration of Helsinki, and permission was granted by the Swedish Ethical Review Authority. Findings The findings are presented in two themes: (1) Movement between explicit and implicit will; and (2) Contradictions about the patient’s best interests. The clinicians’ interpretations are based on an understanding of the patient’s situation using substitute decision-making in emergency situations and conversations that reveal the patient’s explicit wishes. Sometimes the clinicians collaborate to validate the patient’s implicit will, while they at other times subordinate themselves to others’ opinions. The clinicians find themselves in conflict between personal values and organisational values as they try to protect the patient’s self-determination. Conclusion The results indicate that older patients with an impaired decision-making ability risk losing the right to self-determination in the context of ambulance services. The clinicians face challenges that significantly affect their ability to handle the older patient’s unique needs based on a holistic perspective and their ability to be autonomous. (shrink)

In many countries, including patients are legally entitled to request copies of their clinical notes. However, this process remains time-consuming and burdensome, and it remains unclear how much of the medical record must be made available. Online access to notes offers a way to overcome these challenges and in around 10 countries worldwide, via secure web-based portals, many patients are now able to read at least some of the narrative reports written by clinicians. However, even in countries that have implemented (...) the practice many clinicians have resisted the idea remaining doubtful of the value of opening notes, and anticipating patients will be confused or anxious by what they read. Against this scepticism, a growing body of qualitative and quantitative research reveals that patients derive multiple benefits from reading their notes. We address the contrasting perceptions of this practice innovation, and claim that the divergent views of patients and clinicians can be explained as a case of epistemic injustice. Using a range of evidence, we argue that patients are vulnerable to epistemic injustice. Nonetheless, we conclude that the marginalisation of patients’ access to their health information exemplifies a form of epistemic exclusion, one with practical and ethical consequences including for patient safety. (shrink)

In many countries, including patients are legally entitled to request copies of their clinical notes. However, this process remains time-consuming and burdensome, and it remains unclear how much of the medical record must be made available. Online access to notes offers a way to overcome these challenges and in around 10 countries worldwide, via secure web-based portals, many patients are now able to read at least some of the narrative reports written by clinicians (‘open notes’). However, even in countries that (...) have implemented the practice many clinicians have resisted the idea remaining doubtful of the value of opening notes, and anticipating patients will be confused or anxious by what they read. Against this scepticism, a growing body of qualitative and quantitative research reveals that patients derive multiple benefits from reading their notes. We address the contrasting perceptions of this practice innovation, and claim that the divergent views of patients and clinicians can be explained as a case of epistemic injustice. Using a range of evidence, we argue that patients are vulnerable to (oftentimes, non-intentional) epistemic injustice. Nonetheless, we conclude that the marginalisation of patients’ access to their health information exemplifies a form of epistemic exclusion, one with practical and ethical consequences including for patient safety. (shrink)

Using methods from anthropology and cognitive psychology, this study investigated the relationship between clinicians’ folk taxonomies of mental disorder and the Diagnostic and Statistical Manual of Mental Disorders (DSM). Expert and novice psychologists were given sixty-seven DSM-IV diagnoses, asked to discard unfamiliar diagnoses, put the remaining diagnoses into groups that had “similar treatments” using hierarchical (making more inclusive and less inclusive groups) and dimensional (placing groups in a two-dimensional space) methodologies, and give names to the groups in their taxonomies. Clinicians (...) were familiar with a substantially smaller number of diagnoses than are in the DSM. Cultural consensus analysis and follow-up residual agreement analysis revealed similarities across clinicians’ folk taxonomies. Correlations between folk taxonomies and the DSM were moderate. Cluster analysis showed that clinicians preserved DSM higher order categories (e.g., mood disorders) but not the Axis I–Axis II distinction. This study suggests important differences between the way clinicians conceptualize mental disorders and the organization of the DSM-IV. (shrink)

As a gynecologic surgeon with a focus on infertility, I frequently hold complex discussions with patients, exploring with them the risks and benefits of surgical options. In the past, we physicians may have expected our patients to simply defer to our expertise and choose from the options we presented. In our contemporary era, however, patients frequently request options not favored by their physicians and even some they've found themselves online. In reproductive endocrinology and infertility, the range of options that may (...) be offered or that patients may themselves seek out is continuously widening. Physicians certainly seek to find the option that will result in the best outcome for their patients, but the information to guide us in achieving the best outcome can be vague or conflicting. Add to this the financial and emotional pressures bearing on patients seeking assisted reproduction. In this essay, I explore the extent to which clinicians in reproductive medicine should follow patient requests with which they disagree or instead try to persuade the patient to do something else or simply refuse outright to meet the request. And if persuasion is to be used, what would be legitimate methods? Clearly, coercion is unacceptable, but the line between persuasion and coercion can be elusive. At what point can or should clinicians resist such requests—and to what degree? (shrink)

In their thoughtful and well-supported target article, Andrew Garland, Stephanie Morain, Jeremy Sugarman (2023) argue that clinicians have a duty to participate in pragmatic clinical trials. This d...

Objective: To audit doctors’ knowledge of informed consent.Design: 10 consent scenarios with “true”, “false”, or “don’t know” answers were completed by doctors who care for children at a large district general hospital. These questions tested clinicians’ knowledge of who could give consent in different clinical situations.Setting: Royal United Hospital, Bath, UK.Results: 51 doctors participated . Paediatricians scored higher than other clinicians . Only 36% of paediatricians and 8% of other clinicians realised that the biological father of a child born before (...) 1 December 2003 needed a court order or a parental responsibility agreement to acquire parental responsibility, and thus be able to consent on behalf of his child, if he was not married to the child’s mother. Non-paediatric clinicians were unsure or incorrect when tested on situations where people with parental responsibility do not agree, or where young people , who are Fraser competent do not want to consult their parents. Most clinicians did not know that the parents of a 20-year-old man with severe learning difficulties are unable to consent to surgery on his behalf, and many non-paediatricians were unclear on who could give consent when a child lived with foster parents.Conclusion: Clinicians who obtain consent for the treatment of children need to increase their knowledge on who is able to give informed consent to ensure best practice. (shrink)

Background Even though the traditional focus in emergency care is on life-threatening medical crisis, ambulance clinicians frequently encounter patients with mental illness, including suicidal ideation. A suicide is preceded by a complex process where most of the suicidal ideation is invisible to others. However, as most patients seek healthcare in the year before suicide, ambulance clinicians could have an important part to play in preventing suicide, as they encounter patients in different phases of the suicidal process. Aim The aim of (...) this study was to describe ambulance clinicians’ conceptions of responsibility when encountering patients in a suicidal process. Research design A qualitative inductive design using a phenomenographic approach was used. Participants and research context Twenty-seven ambulance clinicians from two regions in southern Sweden were interviewed. Ethical considerations The study was approved by the Swedish Ethical Review Authority. Findings Three categories of descriptions captured a movement from responding to a biological being to responding to a social being. Conventional responsibility was perceived as a primary responsibility for emergency care. In conditional responsibility, the patient’s mental illness was given only limited importance and only if certain conditions were met. Ethical responsibility was perceived to have its primary focus on the encounter with the patient and listening to the patient’s life story. Conclusions An ethical responsibility is favourable regarding suicide prevention in ambulance care, and competence development in mental illness and conversation skills could enable ambulance clinicians to have conversations with patients about suicidal ideation. (shrink)

Australian immigration detention has been called state sanctioned abuse, cruel and degrading and likened to torture. Clinicians have long worked both within the system providing healthcare and outside of it advocating for broader social and political change. It has now been over 25 years and little, if anything, has changed. The government has continued to consolidate power to enforce these policies and has continued to attempt to silence dissent. It was in this context that a boycott was raised as a (...) possible course of action. Despite discussions among the healthcare community about the merits of such action, a number of questions have been overlooked. In this article, I will examine whether a boycott is both ethical and feasible. Taking into account the costs and benefits of current engagement and the potential impact of a boycott, more specifically the potential it has to further harm those detained, I conclude that under current circumstance a boycott cannot be justified. This however does not mean that a boycott should be dismissed completely or that the status quo should be accepted. I discuss potential ways forward for those seeking change. (shrink)

Clinicians, operating within complex systems, make mistakes, as people do in every human endeavor, and when they do, patients are sometimes harmed. One important question is how we as clinicians can find resolution in the wake of an error. The published literature has divided errors into those caused by “systems” and by “individuals.” But whereas both “systems” and “individual” approaches are important in understanding the cause of an error, neither alone can fully lead to resolution once an error has occurred. (...) Instead, both are necessary to understand, resolve, and prevent errors. (shrink)

Clinical ethics committees have existed in Norway since 1996. By now all hospital trusts have one. An evaluation of these committees’ work was started in 2004. This paper presents results from an interview study of eight clinicians who evaluated six committees’ deliberations on 10 clinical cases. The study indicates that the clinicians found the clinical ethics consultations useful and worth while doing. However, a systematic approach to case consultations is vital. Procedures and mandate of the committees should be known to (...) clinicians in advance to ensure that they know what to expect. Equally important is bringing all relevant facts, medical as well as psychosocial, into the discussion. A written report from the deliberation is also important for the committees to be taken seriously by the clinicians. This study indicates that the clinicians want to be included in the deliberation, and not only in the preparation or follow-up. Obstacles for referring a case to the committee are the medical culture’s conflict aversion and its anxiety of being judged by outsiders. The committees were described as a court by some of the clinicians. This is a challenge for the committees in their attempt to balance support and critique in their consultation services. (shrink)

A number of recent developments in our understanding of the biology of heritability question commonly held views on the immutability of genetic factors. These have numerous potential implications for improving understanding and practice in pre- and postconceptional care and for infant and child mental health, and they carry a cautionary message against overgeneralization.

As of 2019, ten jurisdictions in the United States—Oregon, Washington, Montana, Vermont, California, Colorado, the District of Columbia, Hawaii, New Jersey, and Maine—have authorized physicians to...

Well-designed pragmatic clinical trials (PCTs) are critical for improving healthcare delivery and patient outcomes (Haff and Choudhry 2018), and the article written by Garland et al. (2023) advance...

Notwithstanding fundamental methodological advancements, scientific information about disorders of consciousness (DOCs)—e.g. Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS) and Minimally Conscious State (MCS)—is incomplete. The possibility to discriminate between different levels of consciousness in DOC states entails treatment strategies and ethical concerns. Here we attempted to investigate Italian clinicians’ and basic scientists’ opinions regarding some issues emerging from the care and the research on patients with DOCs. From our survey emerged that Italian physicians working with patients with DOCs give a central role (...) to ethics. Current Italian regulation regarding basic research conducted in patients with DOCs apparently risks to be inadequate to support scientific advancement, and would deserve a different assessment compared to ordinary treatments. We think the results of our survey deserve attention from an international audience because they exemplify the difficulty to define a shared approach to the issues related to patients with DOCs and the necessity to better assess both the ordinary and experimental treatment of patients with DOCs at the ethical and legal level. (shrink)

Despite medical leaders’ increasing acceptance of the idea that the whole person should be the focus of care, empirical studies show clinicians generally remain focused on narrower goals: disease categories, standardized treatment procedures, and objective measurements of health improvements. We assume doctors want to do a good job, consistent with their perception of the goals and norms of their profession, so they practice medicine based on the illusion that clinical medicine is “knowledge treating disease,” not people treating people. We believe (...) that doctors’ seeming reduction of patients to clinical objects results from not seeing themselves as leaders for their patients or accepting their constructive power in clinical encounters. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinicians’ “Folk” Taxonomies and the DSM: Pick Your PoisonG. Scott Waterman (bio)Keywordsnosology, classification, diagnosis, psychopathologyWith attention turning to the process of formulating the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V; e.g., Kendler et al. 2008), the study by Flanagan and Blashfield (2007) of the similarities and differences between clinicians’ “folk” taxonomies and psychiatry’s official one is timely, and its lessons are in need of (...) analysis. In this commentary I first address questions raised by the existence of multiple de facto taxonomies, and by the characteristics of those taxonomies themselves, before focusing attention on the DSM diagnostic system and its attributes that make acceptance by its constituencies far less than complete. Although the aim of Flanagan’s and Blashfield’s study is explicitly descriptive rather than normative, it provides an important opportunity to examine the extent to which our taxonomies serve the purposes for which they were constructed—whether by experts or by clinicians.There are certainly reasons to expect significant deviations between clinicians’ everyday taxonomies and the official one. Perhaps the most glaring reason is the fact that—even if it were desirable—no one can be familiar with the enormous number of categories codified by the DSM. On the other hand, the remarkable hegemony of the DSM—in the education and training of physicians and clinical psychologists, in clinical communication, and in the ubiquitous administrative functions of billing and coding—makes such deviations at least somewhat surprising and in need of scrutiny and explanation. The first question, however, is whether one should be concerned by the existence (surprising or otherwise) of multiple taxonomies. Flanagan and Blashfield make the compelling case that, given the high rate at which Americans seek clinical attention for psychiatric problems, the stakes are commensurately high for our efforts at categorizing those problems in valid and useful ways. And the extent to which a gulf exists between the way psychiatry and clinical psychology are written about and taught on the one hand, and conceptualized and practiced by clinicians on the other, invites a multitude of problems—among which cynicism about our disciplines may be one of the most pernicious.At least as important as their finding of only moderate correlations between clinicians’ taxonomies [End Page 271] and that of the DSM are the characteristics of clinicians’ diagnostic systems themselves. One potentially major artifact of their methodology, however, must be borne in mind: the instruction to the clinicians in their study to “[p]ut together the diagnoses that have similar treatments…” (emphasis mine). Although they cite previous work (Flanagan and Blashfield 2006) in defense of the proposition that such instruction did not unduly influence their findings, it was certainly an avoidable potential problem, which itself likely reflects the history of our clinical disciplines in which the treatment cart frequently pulled the diagnosis horse. It is, therefore, not unlikely that clinicians’ taxonomies might emphasize treatment considerations even if they had not been directed to do so. The fallacious reasoning behind such intuitively appealing practice, however, must be exposed. The implicit assumption that treatment response is a proxy for other important characteristics of illnesses is predicated on the false proposition that our treatments exert their effects via similar mechanisms across the various indications for their uses, thus allowing us to infer from such responses that what was awry in the first place among the conditions for which a given treatment is effective must be closely related. Categorizing mania and trigeminal neuralgia together by virtue of their shared responses to anticonvulsant therapy, or considering autoimmune platelet deficiencies to be closely related to abdominal trauma due to the fact that each sometimes requires splenectomy, are examples of the potential results of acting on that false premise.Another parameter on which the clinicians in the current study based their nosologies—most explicitly by the “dimensional experts”—is the “environmental” versus “biological” one. Given that a coherent dichotomy would either distinguish environmental from genetic etiological factors, or would contrast psychological (i.e., subjective or first-person) from biological (i.e., objective or third-person) manifestations of illness, a taxonomy one of whose axes purports to represent an environmental/biological continuum cannot... (shrink)

Clinicians and patients and their families may disagree about a course of treatment, and the ensuing conflict may seem intractable. The parties may request mediation, or use mediation-based approaches, to help resolve the conflict. In the process of mediation, and at other times, parties in conflict may feel so pressured to accept a resolution that they acquiesce unwillingly—and such resolutions often unravel. In this article I investigate how “bullied acquiescence” might happen, and how to avoid it.

The antiabortion movement is increasingly using ostensibly scientific measurements such as ‘fetal heartbeat’ and ‘fetal pain’ to provide ‘objective’ evidence of the moral status of fetuses. However, there is little knowledge on how clinicians conceptualise and operationalise the moral status of fetuses. We interviewed obstetrician/gynaecologists and neonatologists on this topic since their practice regularly includes clinical management of entities of the same gestational age. Contrary to our expectations, there was consensus among clinicians about conceptions of moral status regardless of specialty. (...) First, clinicians tended to take a gradualist approach to moral status during pregnancy as they developed and viewed viability, the ability to live outside of the uterus, as morally significant. Second, in contrast to ‘fetal pain’ laws and philosophical discussions about the ethical salience of sentience, the clinicians in our study did not consider the ability to feel pain as a morally relevant factor in moral status determinations. Third, during previability and perviability, clinicians viewed moral status as a personal value decision, which should be made by pregnant people and parents of neonates. (shrink)

Caruso Brown brings forward an argument that clinicians and ethicists have a duty to consider decision-makers marginalized by hierarchical structures. The author presents a pragmatic approac...

Disclosing unpublished research findings to participants during an ongoing clinical study requires careful consideration. As researchers, we are obliged to provide study participants with informati...

The historical relationship between health care professionals and people with disabilities is fraught, a fact all the more troubling in light of the distinctive roles clinicians play in both establishing and responding to that which is considered normal or abnormal by society at large. Those who wish to improve their clinical practice might struggle, however, to keep up with developments across numerous disability communities as well as the ever-growing body of disability studies scholarship. To assist with this goal, I offer (...) an overview of recent disability theory, outline a set of responsibilities clinicians have to disability communities, and provide recommendations for clinicians who hope to justly treat patients with disabilities and improve their care and health outcomes. (shrink)

Bioethics, Volume 35, Issue 7, Page 696-703, September 2021.

OBJECTIVE: This paper addresses the question of the circumstances which lead clinicians to use legal coercion in the management of patients with severe anorexia nervosa, and explores similarities and differences between such formal coercion and other forms of 'strong persuasion' in patient management. METHOD: Logistic regression and other statistical analysis was undertaken on 75 first admissions for anorexia nervosa from a sample of 117 successive admissions to an eating disorder facility in New South Wales, Australia, where an eating disorder was (...) the primary diagnosis. Admissions with other primary diagnoses, such as bulimia nervosa (25 episodes), and entries with a co morbid diagnosis (e.g. depression or opiate overdose), were discarded, leaving 96 admissions by 75 individuals. RESULTS: Resort to measures of legal coercion into treatment was found to be associated with three main indicators: the patient's past history (number of previous admissions); the complexity of their condition (the number of other psychiatric co morbidities); and their current health risk (measured either by Body Mass Index or the risk of re-feeding syndrome). CONCLUSIONS: Our study is consistent with the few earlier studies about indicators for legal coercion in anorexia nervosa management, and suggests that clinicians use legal coercion very sparingly, distinguishing legal coercion from other forms of close clinical management of patients. (shrink)

Physicians, nurses, and other clinicians readily acknowledge being troubled by encounters with patients who trigger moral judgments. For decades social scientists have noted that moral judgment of patients is pervasive, occurring not only in egregious and criminal cases but also in everyday situations in which appraisals of patients' social worth and culpability are routine. There is scant literature, however, on the actual prevalence and dynamics of moral judgment in healthcare. The indirect evidence available suggests that moral appraisals function via a (...) complex calculus that reflects variation in patient characteristics, clinician characteristics, task, and organizational factors. The full impact of moral judgment on healthcare relationships, patient outcomes, and clinicians' own well-being is yet unknown. The paucity of attention to moral judgment, despite its significance for patient-centered care, communication, empathy, professionalism, healthcare education, stereotyping, and outcome disparities, represents a blind spot that merits explanation and repair. New methodologies in social psychology and neuroscience have yielded models for how moral judgment operates in healthcare and how research in this area should proceed. Clinicians, educators, and researchers would do well to recognize both the legitimate and illegitimate moral appraisals that are apt to occur in healthcare settings. (shrink)

The current experiments examine mental health clinicians’ beliefs about biological, psychological, and environmental bases of the DSM‐IV‐TR mental disorders and the consequences of those causal beliefs for judging treatment effectiveness. Study 1 found a large negative correlation between clinicians’ beliefs about biological bases and environmental/psychological bases, suggesting that clinicians conceptualize mental disorders along a single continuum spanning from highly biological disorders (e.g., autistic disorder) to highly nonbiological disorders (e.g., adjustment disorders). Study 2 replicated this finding by having clinicians list what (...) they thought were the specific causes of nine familiar mental disorders and rate their bio–psycho–environmental bases. Study 3 further found that clinicians believe medication to be more effective for biologically based mental disorders and psychotherapy to be more effective for psychosocially based mental disorders. These results demonstrate that even expert mental health clinicians make strong distinctions between psychological and biological phenomena. (shrink)

ContentTruth-telling is an integral part of medical practice in many parts of the world. However, recent public inquiries, including the Francis Inquiry reveal that a duty of candour in practise, are at times compromised. Consequently, the duty of candour became a statutory requirement in England. This study aimed to explore clinicians’ perspectives of the implications of the legislation for medical ethics education, as raising standards to improve patient safety remains an international concern.MethodsOne-to-one interviews with clinical educators from various specialties who (...) contribute to the MBChB programme at the authors’ university. Once data saturation had been assessed, transcripts were analysed using a thematic approach by the following concurrent activities: data reduction and coding into themes. Example quotations are used to illustrate that key themes are grounded in the data.ResultsEleven clinical educators were interviewed; three general practitioners, six physicians and two surgeons. Thematic... (shrink)

Using methods from anthropology and cognitive psychology, this study investigated the relationship between clinicians’ folk taxonomies of mental disorder and the Diagnostic and Statistical Manual of Mental Disorders (DSM). Expert and novice psychologists were given sixty-seven DSM-IV diagnoses, asked to discard unfamiliar diagnoses, put the remaining diagnoses into groups that had “similar treatments” using hierarchical (making more inclusive and less inclusive groups) and dimensional (placing groups in a two-dimensional space) methodologies, and give names to the groups in their taxonomies. Clinicians (...) were familiar with a substantially smaller number of diagnoses than are in the DSM. Cultural consensus analysis and follow-up residual agreement analysis revealed similarities across clinicians’ folk taxonomies. Correlations between folk taxonomies and the DSM were moderate. Cluster analysis showed that clinicians preserved DSM higher order categories (e.g., mood disorders) but not the Axis I–Axis II distinction. This study suggests important differences between the way clinicians conceptualize mental disorders and the organization of the DSM-IV. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Should Clinicians’ Views of Mental Illness Influence the DSM?Elizabeth H. Flanagan (bio) and Roger K. Blashfield (bio)Keywordsclinicians, DSM, values, psychopathology, scienceThe relationship between clinicians and the DSM is complex. Clinicians are the primary intended audience of the DSM. However, as Widiger (2007) pointed out in his commentary, there is a tension associated with trying to meet the clinical goals of the DSM and also trying to optimize the scientific (...) goals of the DSM. Most commentators would agree that the recent editions of the DSM (from the DSM-III onward) have favored scientific values (e.g., Sadler 2005). Some commentators have taken sides and aligned themselves with either clinicians or with the science of classification. For instance, Garb (2005) has argued that clinicians should receive incentives to align themselves more closely with the science of the DSM. In contrast, Westen and Shedler (1999) have favored a clinician-based approach to the DSM and have argued that an ideal classification should be based on the prototypes that clinicians use to conceptualize diagnostic categories. Perhaps an extreme suggestion on how to deal with this tension between the values of clinicians and the values of scientists is to adopt the ICD-10 solution and create two versions of the next DSM. One version would be written for clinicians and another for researchers (Phillips et al. 2003).Widiger (2007) wondered whether the two of us as authors are on the fence about how the views of clinicians should affect the DSM. As clinical psychologists who are both clinicians and researchers, we understand his comment, especially in light of our attempt in our article not to overgeneralize from the time-consuming, labor-intensive, yet methodologically limited study we reported in our major paper.Nonetheless, our answer to the question asked in the title of this response, “Should clinicians’ views of mental illness influence the diagnostic manual?” is a clear and unequivocal yes. In our view, too much of the research literature stimulated by the recent DSMs has primarily used the diagnostic criteria in these DSMs to specify patient samples and then perform various experiments to study the DSM categories. We favor a different approach to research which is consistent with a comment once made by the philosopher of science, Karl Popper: “scientific theories originate from myths, and... a myth may contain important anticipations of scientific theories” (1963, 39). We believe that clinicians, with their years [End Page 285] of experience dealing with the ambiguities, the emotionality, and the chaos of psychopathology, have formed complex conceptual systems to try to understand the mysteries of abnormal behavior. We strongly support increased research attempts that will use clinicians as subjects and that will attempt to understand how clinicians use diagnostic concepts to understand patients.Although research on clinicians has not attracted a large amount of attention in the field, there is a long history of such research studies. For instance, in the 1970s, Overall used multivariate techniques to create graphical maps of how clinicians represented relationships among diagnoses (Overall et al. 1977). Widiger has used a similar strategy in some of his research (Widiger et al. 1987). In the early 1980s, a view of concept formation from cognitive psychology was used by Cantor et al. (1980) to look at psychiatric diagnoses as representing prototypes. Horowitz and colleagues extended this research. Blashfield and his colleagues had a grant to use the prototype model to study personality disorders and performed research investigating both case histories (Blashfield et al. 1985) and analyses of diagnostic criteria (Blashfield and Breen 1989; Davis, Blashfield, and McElroy 1993). Westen and colleagues have attempted to reconceptualize DSM personality disorder categories using the prototype model (Westen and Shedler 1999). Ahn and her colleagues (Ahn et al. 2006; Kim and Ahn 2002) have taken more recent applications of ideas from cognitive psychology to study how clinicians use and understand diagnostic categories. Finally, Flanagan and colleagues (Flanagan and Blashfield 2006; Flanagan, Keeley, and Blashfield, in press; Flanagan, Miller, and Davidson, submitted) have used qualitative and quantitative data analysis techniques to try to understand the diagnostic concepts held by experienced clinicians.Besides empirical studies of how clinicians use diagnostic concepts, we also support the increased interest in... (shrink)

Purpose Although surrogate decision-making is prevalent in intensive care units and concerns with decision quality are well documented, little is known about how clinicians help family members understand the surrogate role. We investigated whether and how clinicians provide normative guidance to families regarding how to function as a surrogate. Subjects and methods We audiorecorded and transcribed 73 ICU family conferences in which clinicians anticipated discussing goals of care for incapacitated patients at high risk of death. We developed and applied a (...) coding framework to identify normative statements by clinicians regarding what considerations should guide surrogates’ decisions, including whether clinicians explained one or more of Buchanan and Brock’s three standard principles of SDM to family members. Results Clinicians made at least one statement about how to perform the surrogate role in 24 conferences ). We observed three general types of normative guidance provided to surrogates, with some conferences containing more than one type of guidance: counselling about one or more standard principles of SDM ; counselling surrogates to make decisions centred on the patient as a person, without specifying how to accomplish that ; and counselling surrogates to make decisions based on the family’s values. Conclusions Clinicians did not provide normative guidance about the surrogate role in two-thirds of family conferences for incapacitated patients at high risk for death. When they did, clinicians’ guidance was often incomplete and sometimes conflicted with standard principles of SDM. Future work is needed to understand whether providing explicit guidance on how to perform the surrogate role improves decision-making or mitigates surrogates’ psychological distress. (shrink)

Wexler and Sullivan (2023) recommend integration as a guiding principle for translational neuroethics. We agree that collaboration between neuroethicists and other professionals can advance the fie...

Purpose Although surrogate decision-making is prevalent in intensive care units and concerns with decision quality are well documented, little is known about how clinicians help family members understand the surrogate role. We investigated whether and how clinicians provide normative guidance to families regarding how to function as a surrogate. Subjects and methods We audiorecorded and transcribed 73 ICU family conferences in which clinicians anticipated discussing goals of care for incapacitated patients at high risk of death. We developed and applied a (...) coding framework to identify normative statements by clinicians regarding what considerations should guide surrogates’ decisions, including whether clinicians explained one or more of Buchanan and Brock’s three standard principles of SDM to family members. Results Clinicians made at least one statement about how to perform the surrogate role in 24 conferences ). We observed three general types of normative guidance provided to surrogates, with some conferences containing more than one type of guidance: counselling about one or more standard principles of SDM ; counselling surrogates to make decisions centred on the patient as a person, without specifying how to accomplish that ; and counselling surrogates to make decisions based on the family’s values. Conclusions Clinicians did not provide normative guidance about the surrogate role in two-thirds of family conferences for incapacitated patients at high risk for death. When they did, clinicians’ guidance was often incomplete and sometimes conflicted with standard principles of SDM. Future work is needed to understand whether providing explicit guidance on how to perform the surrogate role improves decision-making or mitigates surrogates’ psychological distress. (shrink)

If the new and rapidly expanding discipline of neuroethics is to have a signii cant impact on patient care, the neuroscience clinicians must become familiar with the discipline, and be competent and comfortable in applying its cognitive base and principles to clinical decisionmaking. Familiarity with and practical experience in the application of basic biomedical knowledge and principles to clinical decision- making in the neurosciences becomes the essential foundation on which to begin to integrate neuroethics into medical education. The place where (...) the building of this foundation and the initial exposure to neuroethics must begin is in the residency program. This article describes the approach developed in the neurology residency education program at the University of Calgary to move toward achieving this goal. The key elements for the development and successful implementation of the program are outlined and a brief overview of the topics covered in the sessions is described. (shrink)

Many state laws specify procedures for determining surrogate or proxy decision-makers for end-of-life care in the absence of an advance directive, living will, or other designation. Some laws also set forth criteria that the decision-maker must follow when making medical decisions for an incapacitated patient and determining whether to withdraw life-sustaining treatment. This article provides analysis of a medical ethics case on the question of how to address family allegations that the proxy decision-maker suffers from dementia and is unable to (...) make decisions for the patient. Cases such as this involve interwoven legal and ethical considerations including: how to address concerns that the proxy is making questionable or unreasonable decisions, how to evaluate the proxy's decisional capacity, strategies for enhancing communication, and standards for removing a proxy. This article suggests that “surrogacy ladders” in state law serve not only as a procedural mechanism, but also protect important ethical values such as tiers of moral authority for decision-making, relational autonomy, and privacy. (shrink)

With the introduction of artificial intelligence (AI) to healthcare, there is also a need for professional guidance to support its use. New (2022) reports from National Health Service AI Lab & Health Education England focus on healthcare workers’ understanding and confidence in AI clinical decision support systems (AI-CDDSs), and are concerned with developing trust in, and the trustworthiness of these systems. While they offer guidance to aid developers and purchasers of such systems, they offer little specific guidance for the clinical (...) users who will be required to use them in patient care.This paper argues that clinical, professional and reputational safety will be risked if this deficit of professional guidance for clinical users of AI-CDDSs is not redressed. We argue it is not enough to develop training for clinical users without first establishing professional guidance regarding the rights and expectations of clinical users.We conclude with a call to action for clinical regulators: to unite to draft guidance for users of AI-CDDS that helps manage clinical, professional and reputational risks. We further suggest that this exercise offers an opportunity to address fundamental issues in the use of AI-CDDSs; regarding, for example, the fair burden of responsibility for outcomes. (shrink)

Requiring family authorization for apnea testing subtracts health professionals control over death determination, a procedure that has traditionally been considered a matter of clinical expertise alone. In this commentary, we first provide evidence showing that health professionals’ (HPs) disposition to act on death determination without family’s prior consent could be much lower than that referred to by Berkowitz and Garrett (2020). We hypothesize that HPs may have reservations about their own expertise as regards death, and may thus hesitate to impose (...) their views on patients’ families. We then address the theoretical question of clinical expertise in death determination by distinguishing judgments about facts (e.g., the presence or absence of spontaneous breathing) from interpretations given of these facts (i.e., their meaning for the vital status of an individual). We argue that, while clinicians may claim some expert authority on the former, they hold no particular authority on the latter. (shrink)

Technological measures meant to change sexual orientation are, we have argued elsewhere, deeply alarming, even and indeed especially if they are safe and effective. Here we point out that this in part because they produce a distinctive kind of ‘clinical collective action problem’, a sort of dilemma for individual clinicians and researchers: a treatment which evidently relieves the suffering of particular patients, but in the process contributes to a practice that substantially worsens the conditions that produce this suffering in the (...) first place. We argue that the role obligations of clinicians to relieve the suffering of their patients put them in a poor position to solve this problem, though they can take measures to avoid complicity in the harms that would result from widespread use of individually safe and effective reorientation biotechnology. But in the end the medical community as a whole still seems obligated to provide these measures, if they become technologically feasible. Medical researchers are in a better position to prevent the harms that would result if reorientation techniques were safe, effective and widely available. We argue that the harms attendant on the development of safe and effective re-orientation techniques give researchers reason to avoid ‘applied‘ research aimed at developing these techniques, and to be careful in the conduct of basic orientation research which might be applied in this way. (shrink)

Here we present the personal perspectives of two authors on the important and unfortunately frequent scenario of ambulance clinicians facing a deceased individual and family members who do not wish them to attempt cardiopulmonary resuscitation. We examine the professional guidance and the protection provided to clinicians, which is not matched by guidance to protect family members. We look at the legal framework in which these scenarios are taking place, and the ethical issues which are presented. We consider the interaction between (...) ethics, clinical practice and the law, and offer suggested changes to policy and guidance which we believe will protect ambulance clinicians, relatives and the patient. (shrink)