Health disparities are primarily driven by structural inequality including systemic racism. Medical educators, led by the AAMC, have tended to minimize these core drivers of health disparities. Ins...

Volume 20, Issue 3, March 2020, Page W1-W2.

Incapacitated adult patients are commonly divided into two groups for purposes of decision making; those with a surrogate and those without. Respectively, these groups are often referred to as represented and unrepresented, and the relative ethics of decision making between them raises two particular issues. The first issue involves the differential application of the best interests standard between groups. Second is the prevailing notion that representedness and unrepresentedness are categorical phenomena, though it is more aptly understood as a multidimensional and (...) continuous variable based on relational moral authority. This paper examines the nature of representedness as it relates to ethical norms of surrogate decision making. (shrink)

Volume 20, Issue 7, July 2020, Page 112-114.

With narrow exception, physicians’ treatment of incapacitated patients requires the consent of health surrogates. Although the decision-making authority of surrogates is appropriately broad, their moral authority is not without limits. Discerning these bounds is particularly germane to ethically complex treatments and has important implications for the welfare of patients, for the professional integrity of clinicians, and, in fact, for the welfare of surrogates. Palliative sedation is one such complex treatment; as such, it provides a valuable model for analyzing the scope (...) of surrogates’ moral authority. Guidelines for palliative sedation that present it as a “last-resort” treatment for severe and intractable suffering yet require surrogate consent in order to offer it are ethically untenable, precisely because the moral limits of surrogate authority have not been considered. (shrink)

Current guidelines treat palliative sedation to unconsciousness as an effective medical treatment for terminally ill patients who need relief from severe symptoms, yet also restrict its use in ways that are extraordinary for medical treatments. A closer look at the kinds of cases in which palliative sedation is used suggests a way of adjusting the guidelines to resolve this seeming contradiction.

The ‘best interests’ decision making standard is used in clinical care to make necessary health decisions for non-capacitated individuals for whom neither explicit nor inferred wishes are known. It has been also widely acknowledged as a basis for enrolling some non-capacitated adults into clinical research such as emergency, critical care, and dementia research. However, the best interests standard requires that choices provide the highest net benefit of available options, and clinical research rarely meets this criterion. In the context of modern (...) norms of bioethics, the best interests standard rarely supports surrogate consent for research and should not be accepted as a routine provision. (shrink)

Proportionality, as it pertains to palliative sedation, is the notion that sedation should be induced at the lowest degree effective for symptom control, so that the patient’s consciousness may be preserved. The pursuit of proportionality in palliative sedation is a widely accepted imperative advocated in position statements and guidelines on this treatment. The priority assigned to the pursuit of proportionality, and the extent to which it is relevant for patients who qualify for palliative sedation, have been overstated.

Moral distress is a phenomenon increasingly recognized in healthcare that occurs when a clinician is unable to act in a manner consistent with his or her moral requirements due to external constraints. We contend that some experiences of moral distress are self-inflicted due to one’s under-assertion of professional authority, and these are potentially avoidable. In this article we outline causes of self-inflicted moral distress and offer recommendations for mitigation.

The American Journal of Bioethics, Volume 11, Issue 6, Page 46-47, June 2011.

A commentary on “Must We Be Courageous?,” by Ann Hamric, John Arras, and Margaret Mohrmann, and on “Patient-Satisfaction Surveys on a Scale of 0 to 10: Improving Health Care, or Leading It Astray?,” by Alexandra Junewicz and Stuart J. Youngner, bothin the May-June 2015 issue.

Preparations for large-scale disasters have tended to focus on triage schema, stockpiling of materials, and other logistical concerns. Less attention has been given to the myriad of distressing and almost unthinkable ethically charged dilemmas that will emerge at the bedside during a catastrophe, and how they may be best managed. Yet, it is these bedside issues that may limit or thwart the effectiveness of disaster planning, and, therefore, they ought to be carefully considered.

The health system is, in particular ways, a microcosm of society and both reflects and contributes to its ills of racism, inequities, and disparities. As such, the house of medicine is obligated to...

This retrospective of the last quarter century of clinical ethics offers an examination of some of the areas in which it should focus, and refocus, attention in the next.

During a catastrophe that disables the health system, ethically charged situations will undoubtedly emerge that will challenge patients, relatives, clinicians, and others involved in health delivery. This second of two special sections of The Journal of Clinical Ethics includes discussions of the implications of a system collapse on particularly vulnerable member of society, children, pregnant women, and those who are socio-economically, culturally, and linguistically disempowered. Additionally, it offers insights into the processes used by committees to plan for catastrophic care.

A number of influential reports on influenza pandemic preparedness include recommendations for extra-autonomous decisions to withdraw mechanical ventilation from some patients, who might still benefit from this technology, when demand for ventilators exceeds supply. An unintended implication of recommendations for nonvoluntary and involuntary termination of life support is that it make pandemic preparedness plans vulnerable to patients’ claims for assisted suicide and active euthanasia. Supporters of nonvoluntary passive euthanasia need to articulate why it is both morally different and morally superior (...) to voluntary active euthanasia if they do not wish to invite expansion of end-of-life options during health system catastrophe. (shrink)

Discussions about resource allocation commonly invoke concerns of unfair and variable decisions when physicians ration at the bedside. This concern is no less germane in disaster medicine, in which physicians make triage and allocation decisions under duress, and patients and their families may be challenged to self-advocate. Unfortunately, a real-time mechanism to support a process for ethical decision making may not be available to medical relief workers. Yet, resources for ethics decision support can be important for the moral well-being of (...) the clinician, the ethical integrity of the relief effort, and to bolster the trust and confidence of the population receiving medical services. The need for clinical ethical support should be anticipated in disaster preparedness planning. (shrink)

(2010). Insult to Injury: Ethical Confusion in American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. The American Journal of Bioethics: Vol. 10, No. 1, pp. 68-70.

Background: Previous studies have found lapses in ethical safeguards for subjects of critical-care research. Objective: To assess recently published empiric critical-care research conducted in the United States for the reporting of research protections as they relate to informed consent and surrogate decision-making. Methods: Systematic review of a sample of empiric critical-care research studies published between 2000 and 2004. Results: Of 51 studies reviewed, consent was reported as having been obtained in 44. Assessment of subjects' decision-making capacity was noted in 35% (...) of studies. Assessments of subjects' capacity was less likely to be reported in studies in which researchers accepted consent from either subjects or from third parties, compared to studies with only subjects' consent. Five studies did not report securing Institutional Review Board approval. Conclusion: Lapses in the reporting of critical-care research are prevalent. (shrink)

The American Journal of Bioethics, Volume 11, Issue 11, Page 20-21, November 2011.

Preparations for large-scale disasters have tended to focus on triage schema, stockpiling of materials, and other logistical concerns. Less attention has been given to the myriad of distressing and almost unthinkable ethically charged dilemmas that will emerge at the bedside during a catastrophe, and how they may be best managed. Yet, it is these bedside issues that may limit or thwart the effectiveness of disaster planning, and, therefore, they ought to be carefully considered.