I suggest that we may want to strive, over time, to change our present professional-cultural view, from one that sees an expression of moral distress as a threat, to a professional-cultural view that welcomes these challenges. Such an effort to better medicine would not only include dissenting clinicians, but patients (and their loved ones) as well.

This introduction to The Journal of Clinical Ethics highlights and expands four articles within this issue that propose somewhat new and radical innovations to help and further the interests of patients and families worst off. One article urges us to enable historically marginalized groups to participate more than they have in research; a second urges us to allocate limited resources that can be divided, such as vaccines and even ventilators, in a different way; a third urges us to help families (...) find greater meaning when their loved ones are dying; and a fourth urges us to treat patients who illegally use drugs as caringly as is possible, though there may be limits to what providers can do. This piece also addresses the importance of providers bonding with patients, recognizing that some providers may be better at eliciting patients’ trust than others, and thus the importance of connecting these patients with these providers since this may be the sole way these patients can optimally respond and do well. Finally, providers taking time away from their patients to oppose and reduce social stigma is considered. (shrink)

Physicians who are impaired, engage in unprofessional behavior, or violate laws may be barred from further practice. Likewise, medical students may be dismissed from medical school for many infractions, large and small. The welfare of patients and the general public must be our first priority, but when we assess physicians and students who have erred, we should seek to respond as caringly and fairly as possible. This piece will explore how we may do this at all stages of the proceedings (...) physicians and students may encounter. This may include helping them to resume their medical careers if and when this would be sufficiently safe and beneficial for patients. (shrink)

How might clinicians best try to retain the trust of patients and family members after clinicians oppose giving a treatment? If clinicians can maintain the trust of patients and families in these situations, this may soften what may be the greatest possible loss—the death of a loved one.I discuss what clinicians seeking to retain trust should not do—namely impose their values and reason wrongly—and introduce strategies that clinicians may use to reduce both. I present five principles that clinicians can follow (...) to try to retain trust, with examples that illustrate each. I suggest specific interventions that clinicians can make, especially when they anticipate that a patient and/or family may, in time, want a treatment that is futile. (shrink)

Shared decision making (SDM) is the state of the art for clinicians’ communication with patients and surrogate decision makers. SDM involves give and take, in which all parties interact to maximize the autonomy of patients. In this article I summarize the core steps of SDM and explore ways to use it to benefit patients to the greatest extent. I review three articles included in this issue of The Journal of Clinical Ethics that highlight additional approaches we can use to help (...) patients and parents to see what may be in their own or their child’s best interest. I describe how these approaches can be used in most other medical fields. I explore ways to share information with patients that are outside the usual scope of SDM. Finally, I discuss how we might look, together with patients, at what all parties are feeling before we begin the process of SDM. (shrink)

BackgroundMulti-centre studies generally cost more than single-centre studies because of larger sample sizes and the need for multiple ethical approvals. Multi-centre studies include clinical trials, clinical quality registries, observational studies and implementation studies. We examined the costs of two large Australian multi-centre studies in obtaining ethical and site-specific approvals.MethodsWe collected data on staff time spent on approvals and expressed the overall cost as a percent of the total budget.ResultsThe total costs of gaining approval were 38 % of the budget for (...) a study of 50 centres (mean cost AUD $6960 per site) and 2 % for a study of 11 centres (mean cost AUD $2300 per site). Seventy-five and 90 % of time was spent on repeated tasks, respectively, and many time-consuming tasks, such as reformatting documents, did nothing to improve the study design or participant safety.ConclusionsImprovements have been made to the ethical approval application system, but more gains could be made without increasing risks of harm to research participants. We propose that ethical review bodies and individual sites publish statistics on how long they take to process approvals which could then be nationally benchmarked. (shrink)

After COVID-19 first began to spread in the United States, dentists developed new guidelines that limited whom they could treat under these emergency conditions. Patients who faced greater limits to accessing treatment included children. Using a case of a child who was not able to access treatment, I discuss how careproviders might best seek to maintain their emotional bonding with patients and their loved ones, even if they must turn them down for an intervention.I also address whether and when to (...) give patients and their loved ones warning that access to treatment could be limited, using illness caused by COVID-19 as an example of how careproviders may better anticipate patients’ needs at all times.Finally, I discuss careproviders’ needs. I suggest that medical professionals’ culture should make it as easy as possible for them to acknowledge their feelings of vulnerability, so that they may better determine, in times of disaster, whether they should treat or triage patients. Careproviders who triage may choose to share with patients and loved ones that they also feel pain when they deny patients an intervention. (shrink)

A face transplant is as challenging a surgical procedure as any patient can undergo. In this introduction I present the medical aspects of this surgery, the profound ethical issues it raises, and optimal interventions that clinicians can pursue to help these patients and their loved ones. I then discuss how to help other kinds of patients and loved ones who confront similar stresses. I end by presenting a goal that author Sharrona Pearl puts forth after she studied many face transplant (...) patients. The efforts she urges should maximize our capacity to see face transplant patients—and anyone—as they are, as opposed to how they look. (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.

Since some care providers give colleagues’ interests priority over patients’ and families’, they are at risk of imposing their bias on patients without knowing this. In this piece I discuss how the risk increases when care providers have greater discretion and how they can best avoid this risk. I discuss identifying these situations, assessing them, and then, based on what they have concluded, intervening and use their having inadequate resources, their seeing what patients want as futile, and their making decisions (...) regarding surrogate decision makers as paradigmatic examples. As “remedies,” I suggest that care providers share with patients their rationales, validate adaptive aspects of difficult behaviors, self-disclose, and sometimes even go beyond their usual clinical practices. (shrink)

The author, editor-in-chief of The Journal of Clinical Ethics, recalls the contributions of Albert R. Jonsen, PhD, one of the founding members of the editorial board of the journal.

Consensus documents may be extremely helpful. They may, however, also do harm. They may, for example, suggest interventions that are less than optimal, especially when they apply to patients whose situations are at the “outer margins” of their applicability. Yet, even in these instances, clinicians and ethics consultants may still feel pressure to comply with a guideline. Then, we may not do what we think is best for our particular patient because we fear departing from a guideline. In this article (...) I discuss the risks of departing from guidelines and suggest what we can do to overcome those possible risks. I suggest that while guidelines may help, we should continue to put, above all else, tailoring our interventions to our patients’ individual needs and wants. With our patients, together, we should decide what to do, notwithstanding what the most applicable guidelines propose. (shrink)

The COVID-19 pandemic may have left many of us needing closeness with others more than we have before. Three contexts in which we may especially need this closeness are (1) when we must triage and some but not all will benefit, (2) when families may be separated from loved ones who have COVID-19, and (3) when people for any reason experience shame. In this article I examine sources of present, harmful emotional distancing. I suggest how we might do better in (...) each of these contexts due to what the COVID-19 pandemic can teach us. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Hume, Shaftesbury, and the Peirce-James Controversy EDMUND G. HOWELLS I. ACCORDING TO HUME, the "religious hypothesis" is "a particular method of accounting for the visible phenomena of the universe''1 that is "mere conjecture and hypothesis," (Enquiry, 145) and "both uncertain and useless" (Enquiry, 142). But there was one version of this hypothesis that seemed to pose particular difficulties for him in making these claims convincing. This was Shaftesbury (...) 's view of the world as the object of "divine passion." Besides Shaftesbury's massive influence at the time, Hume was wrestling with the peculiar disadvantage of having agreed with him on so many points, particularly in the attempt to solve the problem of personal identity. He attempted to discredit Shaftesbury's "particular method" on several levels: viz., it cannot be rationally justified, deductively or inductively ; it is not really a belief, so afortiori it is not a natural belief; to the extent it is confused with a genuine belief, its effects are very rare and transitory unless it degenerates into superstition or enthusiasm, which are demonstrably pernicious. 2 These attacks were frequently reinforced with arguments ad hominem. Shaftesbury's theism is extremely ambiguous. In the Essay Concerning Virtue or Merit he pronounced, "to believe therefore that everything is governed, ordered, or regulated for the best, by a designing principle or mind, necessarily good or permanent, is to be a perfect theist" (CH I:240). This is merely the least common denominator of what all eighteenth-century natural theologians agreed could be inferred a posteriori from some form of design argument. Shaftesbury used several analogies to support this view, each based upon a comparison of a part of the universe to the whole:(l) an artifact, for example, a watch (CH I: 190), a ship (CH i Enquiry Concerning Human Understanding, ed. L. A. Selby-Bigge,2nd ed. (Oxford: Clarendon Press, 1902),p. 139;hereafter cited as Enquiry. The quotes in my opening statement are technically not from Hume himself but from his "sceptical friend who lovesparadoxes." But the closest Hume comes to a single refutation of all forms of the "religious hypothesis," comparable to Cleanthes' "entirely decisive" refutation of Demea's version of the ontological argument (Dialogues, 189),is stated by Hume in his own person in the final paragraph of this section (Enquiry, XI). Other abbreviations used in this paper are: Treatisefor.4 Treatiseof Human Nature, ed. L. A. SelbyBigge {Oxford: Clarendon Press, 1949);Abstract for An Abstract of a Treatiseof Human Nature, 1740, ed. J. M. Keynesand P. Sraffa (Cambridge: Cambridge University Press, 1938);G&G for David Hume: The Philosophical Works, ed. T. H. Green and T. H. Grose, 4 vols. (London, 1886); Dialogues for Dialogues ConcerningNatural Religion, ed. Norman Kemp Smith, 2nd ed. (Indianapolis: Bobbs-Merrill, 1947); Letters for The Letters of David Hume, ed. J. Y. T. Grieg, 2 vols. (Oxford: Clarendon Press, 1932); CH for Characteristics of Men, Manners, Opinions, Times, ed. J. M. Robertson, 2 vols. (Indianapolis : Bobbs-Merrill, 1964). A roman numeral followed by a colon denotes volume; other roman numerals denote parts or sections; arabic numbers denote pages. 2For a striking exampleof one of their many points of agreement cf. Hume's essay(G&G 111: 144-150) with CH 11: 178-180. [4491 450 HISTORY OF PHILOSOPHY II:66), "a pile of regular architecture" (CH II:66-67), is to the artisan as the universe is to God. (2) A work of art, for example, a symphony (CH II :66), is to the artist as the universe is to God. (3) An organ is to the organism as the organism or species is to the teleologically structured and intelligent whole (CH I:243ff.) 3 (4) Microcosm (man) to Macrocosm (God), that is, man's mind is the governing principle over the other parts of his nature as God's mind is to the universe: though "all else may be only dream and shadow. All which even sense suggests may be deceitful.... Reason subsists." We are "in a manner conscious" that our reason is part of the pervasive world soul which inhabits our own, and "all nature's wonders serve to excite and perfect this idea of their author" (CH II : 112). In keeping with... (shrink)

As we go to press, the threat of biological or chemical warfare in the Persian Gulf is no longer imminent. Yet the questions raised by the proposed use of “investigational drugs,” without informed consent, to protect U.S. troops remain. The article by Edmund G. Howe and Edward D. Martin presents the arguments that informed the Pentagon's thinking on the subject. It and the commentaries, by George J. Annas and Michael A. Grodin, and Robert J. Levine, explore, among others, issues (...) of informed consent, of distinguishing ‘research’ and ‘treatment,’ and of the nature and extent of the autonomy of military personnel.—B‐JC, HLN. (shrink)

Dementia is among the most terrible diseases humans can have. Of all of the things that careproviders could do to enhance the quality of life that persons with dementia have, which ones should they do?

In this article I will discuss how clinicians might best treat adolescents who may die. I initially discuss these patients’ cognition, emotional tendencies, and sensitivity to interpersonal cues. I next discuss their parents’ feelings of loss and guilt and their clinicians’ risk of imposing their own moral views without knowing this. I then address the practical concerns of helping these patients gain or regain resilience and to identify strengths they have had in the past. I finally explore who, among staff, (...) might be best able to do this. I highlight as the main goal that patients, their parents, and ideally also their clinicians are able to come to agree on the best course the patients should take. (shrink)

Ethics consultants’ grasp of ethical principles is ever improving. Yet, what still remains and will remain lacking is their ability to access factors that lie outside their conscious awareness and thus still effect suboptimal outcomes. This article will explore several ways in which these poor outcomes may occur. This discussion will include clinicians’ implicit biases, well-intentioned but nonetheless intrusive violations of patients’ privacy, and clinicians’ unwittingly connoting to patients and families that clinicians regard their moral values and conclusions as superior. (...) I shall suggest several ways in which clinicians may seek to reduce these sources of bad outcomes or at least to do better when they occur. (shrink)

In this piece I discuss two ways in which providers may become able to treat patients better. The first is for them to encourage all medical parties, including medical students, to always speak up. The second is to take initiatives to learn of pain that patients feel but neither show nor spontaneously report. They may refer to this pain as invisible pain, often bitterly, in that others not seeing their pain judge them wrongly and harshly. Providers, once seeing this pain, (...) are encouraged to then take additional measures to try to alleviate it. Clinical examples provided to illustrate the range of treatments providers may add are post-traumatic stress disorders, problems involving substance use, and hoarding disorders. Similar concerns regarding people who are deaf and hard of hearing are also addressed. (shrink)

In this introduction to this issue of The Journal of Clinical Ethics (JCE), I will discuss the legacy of our recently departed friend and colleague, Edmund D. Pellegrino, MD. In this light, I will discuss three articles in this issue of the journal that provide insight into the cultures of China, Mexico, and the U.S., and propose alternative approaches for careproviders in the U.S. to include in their practice as they work with patients and family members at the end (...) of life. (shrink)