Extracorporeal membrane oxygenation (ECMO) is typically viewed as a time-limited intervention—a bridge to recovery or transplant—not a destination therapy. However, some patients with decision-making capacity request continued ECMO support despite a poor prognosis for recovery and lack of viability as a transplant candidate. In response, critical care teams have asked for guidance regarding the ethical permissibility of unilateral withdrawal over the objections of a capacitated patient. In this article, we evaluate several ethical arguments that have been made in favor of (...) withdrawal, including distributive justice, quality of life, patients’ rights, professional integrity, and the Equivalence Thesis. We find that existing justifications for unilateral withdrawal of ECMO support in capacitated patients are problematic, which leads us to conclude that either: (1) additional ethical arguments are necessary to defend this approach or (2) the claim that it is not appropriate to use ECMO as a destination therapy should be questioned. (shrink)

Ethical reasoning is an integral part of the work of a clinical ethics consultant. Ethical reasoning has a close relationship with an individual’s beliefs and values, which, for religious adherents, are likely to be tightly connected with their spiritual perspectives. As a result, for individuals who identify with a religious tradition, the process of thinking through ethical questions is likely to be influenced by their religious worldview. The connection between ethical reasoning and one’s spiritual perspective raises questions about the role (...) that CECs’ personal religious worldviews should play in their professional lives and their consultative work. This paper offers numerous arguments critiquing the inclusion of a consultant’s own spiritual perspective in her work and has identified only limited circumstances under which such inclusion might be permissible. In particular, these arguments lead to the conclusion that a CEC’s personal beliefs should never influence her ethical analysis or development of a recommendation. Further, religious appeals should not be used in communication during decision-making conversations other than to describe the patient or surrogate’s stated perspective. There may be limited cases in which a CEC may share her spiritual worldview with a patient with the intent of building a collaborative relationship, but such situations should be approached with extreme caution. (shrink)

Efforts to professionalize the field of bioethics have led to the development of the Healthcare Ethics Consultant-Certified (HEC-C) Program intended to credential practicing healthcare ethics consultants (HCECs). Our team of professional ethicists participated in the inaugural process to support the professionalization efforts and inform our views on the value of this credential from the perspective of ethics consultants. In this paper, we explore the history that has led to this certification process, and evaluate the ability of the HEC-C Program to (...) meet the goals it has set forth for HCECs. We describe the benefits and weaknesses of the program and offer constructive feedback on how the process might be strengthened, as well as share our team’s experience in preparing for the exam. (shrink)

This article explores the possibility that there is a parental duty to use preimplantation genetic diagnosis (PGD) for the medical benefit of future children. Using one genetic disorder as a paradigmatic example, we find that such a duty can be supported in some situations on both ethical and legal grounds. Our analysis shows that an ethical case in favor of this position can be made when potential parents are aware that a possible future child is at substantial risk of inheriting (...) a serious genetic condition. We further argue that a legal case for a duty to use PGD for medical benefit can be made in situations in which potential parents have chosen to conceive through in vitro fertilization and know that any children conceived are at substantial risk of having a serious genetic condition. (shrink)

Scholars and professional organizations in bioethics describe various approaches to “quality assessment” in clinical ethics. Although much of this work represents significant contributions to the literature, it is not clear that there is a robust and shared understanding of what constitutes “quality” in clinical ethics, what activities should be measured when tracking clinical ethics work, and what metrics should be used when measuring those activities. Further, even the most robust quality assessment efforts to date are idiosyncratic, in that they represent (...) evaluation of single activities or domains of clinical ethics activities, or a range of activities at a single hospital or healthcare system. Countering this trend, in this article we propose a framework for moving beyond our current ways of understanding clinical ethics quality, toward comprehensive quality assessment. We first describe a way to conceptualize quality assessment as a process of measuring disparate, isolated work activities; then, we describe quality assessment in terms of tracking interconnected work activities holistically, across different levels of assessment. We conclude by inviting future efforts in quality improvement to adopt a comprehensive approach to quality assessment into their improvement practices, and offer recommendations for how the field might move in this direction. (shrink)

Educational efforts in bioethics are prevalent, but little is known about their efficacy. Although previous work indicates that courses in bioethics have a demonstrable effect on medical students, it has not examined their effect on health care professionals. In this report, we describe a study designed to investigate the effect of bioethics education on health care professionals. At the Intensive Bioethics Course, a six-day course held annually at Georgetown University, we administered a questionnaire requiring open-ended responses to vignettes both before (...) and after the course. Following the course, respondents defended their responses more carefully and articulated their thoughts more clearly. In addition, after the course respondents seemed to have a more subtle understanding of the relevant issues in the cases and applied theory to these cases more frequently. These findings help to formulate an understanding of the effect of bioethics education on health care professionals. (shrink)

This paper focuses on one objection to the use of reproductive genetic technologies (RGTs): the argument known as the expressivist objection. According to this argument, the choice to use reproductive genetic technologies to prevent the birth of individuals with disabilities is an expression of disvalue for existing people with disability. Many have been persuaded by this impassioned perspective. This paper shows that this argument is misguided and so does not constitute a sound objection to the use of RGTs to prevent (...) disability in future children. It first identifies some responses to the objection that may be sound but not completely convincing to proponents of the expressivist position. It then describes a thought experiment designed to demonstrate more clearly that choosing to use RGTs to prevent disability in future children does not convey a negative message about people who have disabilities. After describing a decision that clearly does not send such a message, the paper walks through a series of cases and shows how, despite differences that might seem to be morally relevant, each is morally equivalent to the previous one with respect to the extent that it expresses disvalue for such individuals. (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)

A number of authors have objected to potential parents' use of reproductive genetic technologies on the grounds that the use of these technologies reflects a morally problematic attitude toward parenting. More specifically, proponents of this view have argued that such a choice is inconsistent with the unconditional acceptance that lies at the heart of praiseworthy parental attitudes. This paper offers a rebuttal of this view by arguing that it is possible for a parent to exhibit unconditional acceptance of the child (...) herself without accepting each of that child's traits. If this is true, the use of reproductive genetic technologies does not inherently undermine appropriate parental attitudes. Further, by working to change some of a child's specific traits, a parent may instead exemplify an aspirational aspect of praiseworthy parenting and so demonstrate appropriate parental attitudes. (shrink)

The controversial question of whether a future child can be harmed by the use of reproductive technology turns on the way that the future child's identity is understood. As a result, analysis of the ethical and legal obligations to the children of reproductive technology that are based upon the possibility of such harm depends upon the conception of identity that is used. This paper reviews the contributions of two recent books, David DeGrazia's Human Identity and Bioethics (2005) and Philip Peters' (...) How Safe is Safe Enough? (2004) to this area of inquiry. It suggests that the use of a narrative rather than numerical conception of identity makes it possible to coherently claim that future children can be harmed by the use of reproductive technologies and that, as a result, potential parents can have obligations regarding the use of those technologies based upon that possibility of harm. (shrink)

In his thought-provoking piece, ‘Expressivism at the Beginning and End of Life’, Philip Reed contrasts the application of the expressivist objection to the use of reproductive technologies with its application to interventions that bring about death. In the process of supporting his comparative conclusion, that ‘expressivism at the end of life is a much greater concern than at the beginning’, he makes some interesting observations and offers some convincing arguments. Further examination, however, shows that his arguments actually support conclusions far (...) beyond the modest one he intends to draw. The absurdity of these conclusions can be used to identify the flaws in Reed’s argument. Reed summarises the expressivist objection in the context of physician-assisted suicide as follows: > When we allow PAS for individuals who are terminally ill or facing some severe disease or disability, we send a message of disrespect to all individuals who face such adversities in that we imply that they are inferior or their lives are not worth living. Analogous arguments have been made about decisions to use reproductive technology to prevent the birth of people with disabilities. Reed describes a common rebuttal to the …. (shrink)

Volume 19, Issue 11, November 2019, Page 82-84.

Minkoff, Vullikanti, and Marshall (2024) worry that assumptions about fetal personhood used to justify states’ restrictions on a pregnant person’s right to request certain interventions (i.e. abort...

Philosophers who specialize in bioethics face a distinctive set of challenges in our work: to bring the theoretical insights of philosophical work and methodology to practical dilemmas affecting a diverse group of stakeholders every day. This article describes some of the key contributions that philosophy can make to the field of bioethics. It also identifies some of the pitfalls that can undermine the value of a philosophical approach when used to analyze questions arising in the real world. Recognition of the (...) importance of individual context, practical implications, and social considerations can help successfully bridge the gap between theory and practice. Using this wide-angle lens to view bioethical problems can enable philosophers working in our field to offer insights that are both rigorous and relevant. (shrink)

Respecting patient autonomy through the process of soliciting informed consent is a cornerstone of clinical ethics. In pediatrics, until a child becomes an adult or legally emancipated, that ethical tenet takes the form of respect for parental decision-making authority. In instances of respecting religious beliefs, doing so is not always apparent and sometimes the challenge lies not only in the healthcare provider’s familiarity of religious restrictions but also their knowledge of medical interventions themselves which might conflict with those restrictions. We (...) examine a case of a newborn receiving animal-derived surfactant, a common scenario in neonatology, and present considerations for providers to weigh when confronting when such an intervention might conflict with parent’s religious beliefs. We end with strategizing ways to address this issue as a medical community. (shrink)

How should clinical ethicists be trained? Scholars have stated that clinical ethics fellowships create well-trained, competent ethicists. While this appears intuitive, few features of fellowship programs have been publicly discussed, let alone debated. In this paper, we examine how fellowships can foster effective mentoring relationships. These relationships provide the foundation for the fellow’s transition from novice to competent professional. In this essay, we begin by discussing our pedagogical commitments. Next, we describe the structures our program has created to assist our (...) fellows in becoming competent ethicists. We then outline the kinds of knowledge, skills, and professional attributes mentors should possess. Following this, we focus on the knowledge, skills, and professional attributes that fellows develop as they co-create effective mentoring relationships. We will not prescribe a single approach to fellowship training; instead, our perspective will, we hope, become a catalyst for further conversation on training and mentoring clinical ethics fellows. (shrink)

Mrs. Duong had coronary artery disease, ischemic cardiomyopathy, and mildly altered mental status when her case was presented before an advanced heart therapy medical review board. She was accepted for left ventricular assist device placement pending additional insight into her cognitive state. Before the LVAD could be implanted, however, Mrs. Duong went into cardiogenic shock, and her heart failure team placed an intra‐aortic balloon pump in her subclavian artery. Within two weeks, Mrs. Duong became IABP dependent and deconditioned. The attending (...) deemed her as lacking capacity to make complex medical decisions, and the medical review board officially declined her for LVAD placement. The heart failure and CICU teams feel that Mrs. Duong is not being helped by the care they are giving her. They recommend terminal weaning of the IABP and initiation of comfort care. Her family disagrees, pointing to activities like continued eating and interacting with family. At an impasse after yet another family meeting, the attending for the heart failure team asks the clinical ethics consultant, “Do we have to replace the balloon pump when it fails?”. (shrink)

Fox, Danis, Tarzian, and Duke have made a substantial contribution to the field of bioethics through the project described in this issue’s target articles (Fox, Tarzian, et al. 2022; Fox, Danis, et...

Volume 20, Issue 7, July 2020, Page 156-158.

Robert Sparrow’s argument that, for the foreseeable future, genome editing will be an identity-affecting intervention subject to the critique of the nonidentity problem (Sparrow 2022) is convincing...

The American Journal of Bioethics, Volume 11, Issue 6, Page 23-25, June 2011.

Research protocols must have a reasonable balance of risks and anticipated benefits to be ethically and legally acceptable. This article explores three characteristics of research on reproductive genetic technologies that complicate the assessment of the risk-benefit ratio for such research. First, a number of different people may be affected by a research protocol, raising the question of who should be considered to be the subject of reproductive genetic research. Second, such research could involve a wide range of possible harms and (...) benefits, making the evaluation and comparison of those harms and benefits a challenging task. Finally, the risk-benefit ratio for this type of research is difficult to estimate because such research can have unpredictable, long-term implications. The article aims to facilitate the assessment of risk-benefit ratios in research on reproductive genetic technologies by proposing and defending some guidelines for dealing with each of these complicating factors. (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)

Evolving Clinical Ethics: A Working UnConference, held 5 through 7 February 2020 in Houston, Texas, brought together 91 participants from a variety of institutions, many of whom are engaged in clinical ethics work. The event followed the success of the first Clinical Ethics UnConference hosted by the Cleveland Clinic Center for Bioethics in 2018, and offered an opportunity for ethicists to share both their challenges and their solutions to clinical ethics issues. In this article we explore the emerging themes of (...) the second UnConference and identify the top 10 questions currently faced by the field. We address both unresolved issues and areas of agreement and highlight new collaborations that have been developed to work toward greater standardization in our field. (shrink)