Although clinical ethics consultation is a high-stakes endeavor with an increasing prominence in health care systems, progress in developing standards for quality is challenging. In this article, we describe the results of a pilot project utilizing portfolios as an evaluation tool. We found that this approach is feasible and resulted in a reasonably wide distribution of scores among the 23 submitted portfolios that we evaluated. We discuss limitations and implications of these results, and suggest that this is a significant step (...) on the pathway to an eventual certification process for clinical ethics consultants. (shrink)

Many adoptees face a number of challenges relating to separation from biological parents during the adoption process, including issues concerning identity, intimacy, attachment, and trust, as well as language and other cultural challenges. One common health challenge faced by adoptees involves lack of access to genetic-relative family health history. Lack of GRFHx represents a disadvantage due to a reduced capacity to identify diseases and recommend appropriate screening for conditions for which the adopted person may be at increased risk. In this (...) article, we draw out common features of traditionally understood “health disparities” in order to identify analogous features in the context of adoptees’ lack of GRFHx. (shrink)

What term is most appropriate in describing the limits of medicine? That depends on who determines the limits and the bases on which those limits are delineated and communicated. Schneiderman, Jecker, and Jonsen critique two recent policy statements by critical care providers—Bosslet et al. and Nates et al. —for their rejection of the use of the term futile for treatment. Both statements recommend using the adjective inappropriate for the problematic treatment, rather than futile, based on the lack of consensus of (...) just what constitutes futility. Schneiderman, Jecker, and Jonsen also assert that, despite a lack of consensus about the determination of futility, the definitions they have... (shrink)

The Wisconsin Supreme Court, after adopting the doctrine of the objective patient standard, expanded it in bold and innovative ways over nearly four decades, until the Wisconsin legislative and executive branches drastically reversed this course. The saga has implications for other jurisdictions considering adoption or expansion of the objective patient standard doctrine.

The problem of decision-making capacity in patients with dementia, such as those with early stage Alzheimer's, can be vexing, especially when these patients refuse life-sustaining medical treatments. However, these patients should not be presumed to lack decision-making capacity. Instead, an analysis of the patient's decision-making capacity should be made. Patients who have some degree of decision-making capacity may be able to make a choice about life-sustaining medical treatment and may, in many cases, choose to forgo treatment.

In this issue, Raphael Cohen-Almagor reviews some of the terms used in the discussion of bioethical issues at the end of a patient's life; he argues that they are “valueladen” and serve “primarily the physicians, at times at the expense of the patients’ best interest.” Each of the following terms comes under scrutiny: “death with dignity,” “persistent vegetative state,” “futility,” “double effect,” and “brain death.” He argues that these concepts, developed in recent decades, “have generated an unhealthy atmosphere for patients, (...) which might lead to undesirable actions at the end of patients’ lives.” He issues a plea to discontinue the use of the term “persistent vegetative state” because it is dehumanizing, to explain “double effect” and “futility” in detail and with sincerity, and to clarify the motivation for using these terms and others. He warns physicians not to use terminology that is offensive to patients and loved ones or that weakens their patients’ will to live. (shrink)

For over a decade, managed care has profoundly altered how healthcare is delivered in the United States. There have been concerns that the patient-physician relationship may be undermined by various aspects of managed care, such as restrictions on physician choice, productivity requirements that limit the time physicians may spend with patients, and the use of compensation formulas that reward physicians for healthcare dollars not spent. We have previously published data on the effects of managed care on the physician-patient relationship from (...) the physician's perspective. In 1999, we collected data on the impact of managed care arrangements on the physician-patient relationship from the patient's perspective. This article discusses our collective findings. (shrink)

In this issue, Raphael Cohen-Almagor reviews some of the terms used in the discussion of bioethical issues at the end of a patient's life; he argues that they are “valueladen” and serve “primarily the physicians, at times at the expense of the patients’ best interest.” Each of the following terms comes under scrutiny: “death with dignity,” “persistent vegetative state,” “futility,” “double effect,” and “brain death.” He argues that these concepts, developed in recent decades, “have generated an unhealthy atmosphere for patients, (...) which might lead to undesirable actions at the end of patients’ lives.” He issues a plea to discontinue the use of the term “persistent vegetative state” because it is dehumanizing, to explain “double effect” and “futility” in detail and with sincerity, and to clarify the motivation for using these terms and others. He warns physicians not to use terminology that is offensive to patients and loved ones or that weakens their patients’ will to live. (shrink)

From computerized medical records to databases of pharmacological interactions and automated provisional EKG readings, the emergence of information technology has significantly altered the practice of medicine. Information technology has been widely used to enhance diagnosis and treatment and to improve communication between providers. The advent of the Internet also brings far-reaching implications for patient–physician communication, challenging physicians, patients, and policymakers to consider its impact on the delivery of medical care and the therapeutic relationship. A new set of practices by patients (...) and physicians is unfolding in cyberspace, ranging from the use of e-mail to communicate between physicians and patients in an existing relationship to one-to-one consultations with an anonymous physician and ongoing online treatment, such as psychotherapy. These practices are emerging in both the for-profit and not-for-profit spheres. (shrink)

Over the past several years, healthcare has been profoundly altered by the growth of managed care. Because managed care integrates the financing and delivery of healthcare services, it dramatically alters the roles and relationships among providers, payers, and patients. While analysis of this change has focused on whether and how managed care can control costs, an increasingly important concern among healthcare providers and recipients is the impact of managed care on the physicianpatient relationship, but little data have been collected and (...) analyzed. We designed a survey for distribution to Wisconsin physicians to analyze the prevalence and types of managed care arrangements in the state, and the impact of these arrangements on physicians and their relationships with patients. (shrink)

There are at least three related issues that need to be resolved in this case: Who should be the patient’s medical decision-maker?, Should the patient be treated and possibly admitted?, and...

Appropriate concerns about cost and unequal access to healthcare have resulted in the creation of powerful managed networks seeking to share the risks of high healthcare costs among plans, providers, and patients. Much to their credit, these managed networks have slowed the rise in healthcare spending by as much as 44% in markets with high HMO penetration. However, whether these savings will materially improve access and quality remains to be seen.