The combination of money and intimacy, particularly in the context of paid caring, can be difficult, given the tendency to view them as belonging to separate spheres. This research studied paid caring within the context of breastfeeding and labor support, using 72 interviews with lactation consultants, doulas, clients, and health care professionals, as well as 150 hours of ethnographic observation. Building upon the work of Viviana Zelizer, I examined the relational work of lactation consultants, doulas, and their clients, (...) finding that this process is highly influenced by the way gender is mapped onto the separate spheres dichotomy. Lactation consultants, doulas, and their clients drew boundaries around their social relations to construct them as different from family care in order to legitimate the combination of money and intimacy. Lactation consultants and doulas both experienced tension in determining appropriate transactions and media for their care work, which illustrates how the separate spheres ideology can perpetuate the relative low pay of care work. (shrink)

BackgroundProfessional health care practice should be based on ethical decisions and actions. When there are competing ethical standards or principles, one must choose between two or more competing options. This study explores ethical dilemmas experienced by International Board Certified Lactation Consultants.MethodsThe investigator interviewed seven International Board Certified Lactation Consultants and analyzed the interviews using qualitative research methods.Results"Staying Mother-Centred" emerged as the overall theme. It encompassed six categories that emerged as steps in managing ethical dilemmas: 1) recognizing the dilemma; (...) 2) identifying context; 3) determining choices; 4) strategies used; 5) results and choices the mother made; and 6) follow-up. The category, "Strategies used", was further analyzed and six sub-themes emerged: building trust; diffusing situations; empowering mothers; finding balance; providing information; and setting priorities.ConclusionsThis study provides a framework for understanding how International Board Certified Lactation Consultants manage ethical dilemmas. Although the details of their stories changed, the essence of the experience remained quite constant with the participants making choices and acting to support the mothers. The framework could be the used for further research or to develop tools to support IBCLCs as they manage ethical dilemmas and to strengthen the profession with a firm ethics foundation. (shrink)

For decades a debate has played out in the literature about who bioethicists are, what they do, whether they can be considered professionals qua bioethicists, and, if so, what professional responsibilities they are called to uphold. Health care ethics consultants are bioethicists who work in health care settings. They have been seeking guidance documents that speak to their special relationships/duties toward those they serve. By approving a Code of Ethics and Professional Responsibilities for Health Care Ethics Consultants, the American Society (...) for Bioethics and Humanities (ASBH) has moved the professionalization debate forward in a significant way. This first code of ethics focuses on individuals who provide health care ethics consultation (HCEC) in clinical settings. The evolution of the code's development, implications for the field of HCEC and bioethics, and considerations for future directions are presented here. (shrink)

This chapter contains sections titled: Lactational Burkas, Lactational Burdens Breastfeeding as Obscene The Intimacy of Breastfeeding “Breast is Best” Milkmen Conclusion Notes.

The mammalian blastocyst exhibits a high capacity for aerobic glycolysis, a metabolic characteristic of tumours. It has been considered that aerobic glycolysis is a means to ensure a high carbon flux to fulfil biosynthetic demands. Here, alternative explanations for this pattern of metabolism are considered. Lactate creates a microenvironment of low pH around the embryo to assist the disaggregation of uterine tissues to facilitate trophoblast invasion. Further it is proposed that lactate acts as a signalling molecule (especially at the reduced (...) oxygen tension present at implantation) to elicit bioactive VEGF recruitment from uterine cells, to promote angiogenesis. Finally it is suggested that the region of high lactate/low pH created by the blastocyst modulates the activity of the local immune response, helping to create immune tolerance. Consequently, the mammalian blastocyst offers a model to study the role of microenvironments, and how metabolites and pH are used in signalling. (shrink)

Usage of psychotropics during pregnancy and lactation has always been a topic of debate and controversy. The debate stems from the potential adverse effects on the growing fetus or infants due to the transfer of psychotropic drugs through placenta or breast milk of mothers receiving them; and the problem of discontinuing psychotropics in lactating mother considering chances of relapse. However, most of the psychotropics are found to be relatively safe when used cautiously during the lactation phase. This article (...) describes available data on the use of psychotropics in lactating mothers, in particular, in relation to the safety profile of infants. (shrink)

The evolutionary origin of human pair-bonds is uncertain. One hypothesis, supported by data from forgers, suggests that pair-bonds function to provision mothers and dependent offspring during lactation. Similarly, public health data from large-scale industrial societies indicate that single mothers tend to wean their children earlier than do women living with a mate. Here we examine relations between pair-bond stability, alloparenting, and cross-cultural trends in breastfeeding using data from 58 “traditional” societies in the Standard Cross-Cultural Sample (SCCS). Analyses show that (...) stable conjugal relationships were associated with significantly later weaning among the societies in the SCCS. The relationship between pair-bond stability and age at weaning was not mediated by women’s ability to provision themselves or women’s kin support. Availability of alloparental care was also inversely related to age at weaning, and the association was not significantly reduced after controlling for frequency of divorce. This study indicates that among a woman’s kin relationships, a pair-bond with a child’s father is especially supportive of breastfeeding. These cross-cultural findings are further evidence that human pair-bonds may have evolved to support lactation. (shrink)

l‐Lactate is emerging as a crucial regulatory nexus for energy metabolism in the brain and signaling transduction in synaptic plasticity, memory processes, and drug addiction instead of being merely a waste by‐product of anaerobic glycolysis. In this review, the role of lactate in various memory processes, synapse plasticity and drug addiction on the basis of recent studies is summarized and discussed. To this end, three main parts are presented: first, lactate as an energy substrate in energy metabolism of the brain (...) is described; second, lactate as a novel signaling molecule in synaptic plasticity, neural circuits, memory, and drug addiction is described; and third, in light of the above descriptions, it is plausible to speculate that lactate is predominantly a signaling molecule in specific memory processes and partly acts as an energy substrate. The future perspective in lactate signaling involving microglia and associated precise signaling pathways in the brain is highlighted. (shrink)

SummaryThe effects of infant suckling patterns on the post-partum resumption of ovulation and on birth-spacing are investigated among the Gainj of highland New Guinea. Based on hormonal evidence, the median duration of lactational anovulation is 20·4 months, accounting for about 75% of the median interval between live birth and next successful conception. Throughout lactation, suckling episodes are short and frequent, the interval changing slowly over time, from 24 minutes in newborns to 80 minutes in 3-year olds. Maternal serum prolactin (...) concentrations decline in parallel with the changes in suckling patterns, approaching the level observed in non-nursing women by about 24 months post-partum. A path analysis indicates that the interval between suckling episodes is the principal determinant of maternal prolactin concentration, with time since parturition affecting prolactin secretion only in so far as it affects suckling frequency. The extremely prolonged contraceptive effect of breast-feeding in this population thus appears to be due to a slow decline in suckling frequency with time since parturition and absence of a decline over time in hypothalamic–pituitary responsiveness to the suckling stimulus. (shrink)

The identification of neural substrates underlying the long lasting debilitating impact of drug cues is critical for developing novel therapeutic tools. Metabolic coupling has long been considered a key mechanism through which astrocytes and neurons actively interact in response of neuronal activity, but recent findings suggested that disrupting metabolic coupling may represent an innovative approach to prevent memory formation, in particular drug‐related memories. Here, we review converging evidence illustrating how memory and addiction share neural circuitry and molecular mechanisms implicating lactate‐mediated (...) metabolic coupling between astrocytes and neurons. With several aspects of addiction depending on mnemonic processes elicited by drug experience, disrupting lactate transport involved in the formation of a pathological learning, linking the incentive, and motivational effects of drugs with drug‐conditioned stimuli represent a promising approach to encourage abstinence. (shrink)

In the clinical setting, questions of medical ethics raise a host of perplexing problems, often complicated by conflicting perspectives and the need to make immediate decisions. In this volume, bioethicists and physicians provide a nuanced, in-depth approach to the difficult issues involved in bioethics consultation. Addressing the needs of researchers, clinicians, and other health professionals on the front lines of bioethics practice, the contributors focus primarily on practical concerns -- whether ethics consultation is best done by individuals, teams, or committees (...) how an ethics consult service should be structured the need for institutional support and techniques and programs for educating and training staff -- without neglecting more theoretical considerations, such as the importance of character or the viability of organizational ethics. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:94 Feminist Studies 47, no. 1. © 2021 by Feminist Studies, Inc. Jennifer C. Nash Black Lactation Aesthetics: Remaking the Natural in Lakisha Cohill’s Photographs In her 1992 essay “Selling Hot Pussy,” bell hooks recounts entering a “late night dessert place” with a group of colleagues who all began to laugh at a shelf of “gigantic chocolate breasts complete with nipples— huge edible tits.”1 For hooks, the chocolate (...) Black breasts are mammy imagery, a “displaced longing for a racist past when the bodies of black women were a commodity, available to anyone white who could pay the price.”2 For her white colleagues, the chocolate breasts are simply comical. Her colleagues’ response—their willingness to consume, laugh, and ignore racial, gendered, sexual violence—constitutes the racialized visual marketplace that hooks’s essay seeks to both describe and dismantle. The chocolate breasts become a rhetorical point of entry into hooks’s critical engagement with a visual marketplace where Black female bodies are delectable and disposable objects. hooks’s analysis has become part of a canon of Black feminist work exploring how Black breasts get taken up as signs of pathology, “excess flesh,” sexual deviance, hypersexuality, and alterity.3 From histories of the so-called Hottentot Venus and the preoccupation with her breasts, buttocks, and genitalia—including 1. bell hooks, “Selling Hot Pussy,” Black Looks: Race and Representation (Boston: South End Press, 1992), 61. 2. hooks, 61–62. 3. See Nicole R. Fleetwood, Troubling Vision: Performance, Visuality, and Blackness (Chicago: University of Chicago Press, 2010). Jennifer C. Nash 95 signature works by Zine Magubane, Janell Hobson, Samantha Pinto, and T. Denean Sharpley-Whiting4 —to scholarship on the construction of black women’s imagined corporeality as “social dead weight” by Sabrina Strings, Black feminists have given critical attention to the construction of Black breasts as the location of Black women’s imagined racial and sexual difference.5 If Black breasts have been culturally and scientifically constructed as deviant, excessive, pornographic, and desirous, they have largely been uncoupled from an identification with nutrition—from the capacity to sustain and feed babies—except their connection with wet nursing and their conscription into maternal labor for white children. In this imaginary, Black breasts provide nutrition only when recruited as white property, with their nurturance capacity oriented toward white health and futurity. We might understand the cultural inability to interpret Black breasts as nurturing Black life as part of what Andrea Freeman describes as the “unmothering” of Black women, the unseeing of Black maternity except to elevate it as a symbol of brokenness or pathology.6 But in recent years, as I argue in my forthcoming book Birthing Black Mothers, Black breasts have entered the US cultural imagination anew. Black breasts are increasingly viewed as in need of support through seemingly benign state interventions to encourage Black breastfeeding. Indeed, Black breasts are recruited by an array of actors who often find themselves strangely aligned to champion Black breastfeeding —including NGOs, public health campaigns, and reproductive justice efforts spearheaded by Black feminists—precisely because Black breastfeeding is thought to perform urgent political, emotional, and 4. See Zine Magubane, “Which Bodies Matter? Feminism, Poststructuralism, Race, and the Curious Theoretical Odyssey of the ‘Hottentot Venus,’” Gender & Society 15, no. 6 (2001): 816–834; Janell Hobson, Venus in the Dark: Blackness and Beauty in Popular Culture (New York: Routledge, 2005); Samantha Pinto, Infamous Bodies: Early Black Women’s Celebrity and the Afterlives of Rights (Durham, NC: Duke University Press, 2020); and T. Denean Sharpley-Whiting, Black Venus: Sexualized Savages, Primal Fears, and Primitive Narratives in French (Durham, NC: Duke University Press, 1999). 5. See Sabrina Strings, Fearing the Black Body: The Racial Origins of Fat Phobia (New York: NYU Press, 2019). 6. Andrea Freeman, “Unmothering Black Women: Formula Feeding as an Incident of Slavery,” Hastings Law Journal 69, no 1545 (2018): 1545–1606. 96 Jennifer C. Nash public health work. Black breastmilk is increasingly described as a crucial technology of Black life, one that supports Black infant life and inoculates it physically, psychically, and even spiritually against the array of anti-Black forces that wound and violate. The work that Black breast milk is thought to perform includes its posited... (shrink)

An experimental breast-feeding education programme conducted at the Philippine General Hospital in Manila demonstrated that women could be motivated to improve their breast-feeding practices and lengthen their period of lactational amenorrhoea in comparison to a control group. Mothers who participated in the programme breast-fed their babies more frequently, delayed the introduction of regular supplements, used fewer bottles and pacifiers and maintained night feeding longer than mothers who were not exposed to the positive breast-feeding messages. The programme was successful in lengthening (...) the period of amenorrhoea among women with elementary, high school, or technical school education, but not among college-educated women. Different educational approaches may be necessary for women of different education levels. (shrink)

Context: Although ethics consultation is commonplace in United States (U.S.) hospitals, descriptive data about this health service are lacking. Objective: To describe the prevalence, practitioners, and processes of ethics consultation in U.S. hospitals. Design: A 56-item phone or questionnaire survey of the "best informant" within each hospital. Participants: Random sample of 600 U.S. general hospitals, stratified by bed size. Results: The response rate was 87.4%. Ethics consultation services (ECSs) were found in 81% of all general hospitals in the U.S., and (...) in 100% of hospitals with more than 400 beds. The median number of consults performed by ECSs in the year prior to survey was 3. Most individuals performing ethics consultation were physicians (34%), nurses (31%), social workers (11%), or chaplains (10%). Only 41% had formal supervised training in ethics consultation. Consultation practices varied widely both within and between ECSs. For example, 65% of ECSs always made recommendations, whereas 6% never did. These findings highlight a need to clarify standards for ethics consultation practices. (shrink)

Metabolic dysfunction is a ubiquitous underlying feature of many neurological conditions including acute traumatic brain injuries and chronic neurodegenerative conditions. A central problem in neurological patients, in particular those with traumatic brain injuries, is an impairment in the utilization of glucose, which is the predominant metabolic substrate in a normally functioning brain. In such patients, alternative substrates including ketone bodies and lactate become important metabolic candidates for maintaining brain function. While the potential neuroprotective benefits of ketosis have been recognized for (...) up to almost a century, the majority of work has focused on the use of ketogenic diets to induce such a state, which is inappropriate in cases of acute disease due to the prolonged periods of time (i.e., weeks to months) required for the effects of a ketogenic diet to be seen. The following review seeks to explore the neuroprotective effects of exogenous ketone and lactate preparations, which have more recently become commercially available and are able to induce a deep ketogenic response in a fraction of the time. The rapid response of exogenous preparations makes their use as a therapeutic adjunct more feasible from a clinical perspective in both acute and chronic neurological conditions. Potentially, their ability to globally moderate long-term, occult brain dysfunction may also be relevant in reducing lifetime risks of certain neurodegenerative conditions. In particular, this review explores the association between traumatic brain injury and contusion-related dementia, assessing metabolic parallels and highlighting the potential role of exogenous ketone and lactate therapies. (shrink)

There is little information about the content of ethics consultations in pediatrics. We sought to describe the reasons for consultation and ethical principles addressed during EC in pediatrics through retrospective review and directed content analysis of EC records at St. Jude Children's Research Hospital. Patient-based EC were highly complex and often involved evaluation of parental decision making, particularly consideration of the risks and benefits of a proposed medical intervention, and the physician's fiduciary responsibility to the patient. Nonpatient consultations provided guidance (...) in the development of institutional policies that would broadly affect patients and families. This is one of the few existing reviews of the content of pediatric EC and indicates that the distribution of ethical issues and reasons for moral distress are different than with adults. Pediatric EC often facilitates complex decision making among multiple stakeholders, and further prospective research is need.. (shrink)

Through an analysis of policy texts, population statistics and a targeted sample from the popular press, this paper both furthers knowledge about changing meanings of working motherhood in the contemporary US, and proposes a refinement to existing conceptual work relating to how wage-work and care-work are combined. I focus analysis on recent US social policy which grants new rights and protections for women seeking to combine lactation and wage-work (the Patient Protection and Affordable Care Act of 2011). I critique (...) this policy through Bernise Hausman’s work on the politics of motherhood, arguing that it represents a form of work-life integration that is particularly burdensome for working mothers. I further argue that maternal practice as well as well as expectations of working motherhood in the contemporary US are being reshaped around the demands of neoliberalism, producing what I term ‘neoliberal motherhood’. I assert that this policy represents a way of combining wage-work and care-work that is not captured within existing feminist theory, and suggest that a re-working of theory in this area is needed in order to address cases in which embodied care-work is enfolded within the time and space of wage-work. (shrink)

Genome Canada has funded a research project to evaluate the usefulness of different forms of ethical analysis for assessing the moral weight of public opinion in the governance of genomics. This paper will describe a role of public consultation for ethical analysis and a contribution of ethical analysis to public consultation and the governance of genomics/biotechnology. Public consultation increases the robustness of ethical analysis with a more diverse and rich accounts experiences. Consultation must be carefully and respectfully designed to generate (...) sufficiently diverse and rich accounts of moral experiences. Since dominant groupstend to define ethical or policy issues in a manner that excludes some interests or perspectives, it is important to identify the range of interests that diverse publics hold before defining the issue and scope of a consultation. Similarly, a heavy policy focus and pressures to commercialize products risk oversimplification of the discussion and the premature foreclosure of ethical dialogue. Consequently, a significant contribution of ethical dialogue strengthened by social analysis is to consider the context and non-policy use of power to govern genomics and to sustain social debate on enduring ethical issues. (shrink)

Over the past few decades, Indigenous communities have successfully campaigned for greater inclusion in decision-making processes that directly affect their lands and livelihoods. As a result, two important participatory rights for Indigenous peoples have now been widely recognized: the right to consultation and the right to free, prior and informed consent (FPIC). Although these participatory rights are meant to empower the speech of these communities—to give them a proper say in the decisions that most affect them—we argue that the way (...) these rights have been implemented and interpreted sometimes has the opposite effect, of denying them a say or ‘silencing’ them. In support of this conclusion we draw on feminist speech act theory to identify practices of locutionary, illocutionary, and perlocutionary group silencing that arise in the context of consultation with Indigenous communities. (shrink)

In this issue, Ellen Fox and colleagues report on their national study on ethics consultation in U.S. hospitals, following up on the previous 1999–2000 landmark study. Th...

Although ethics consultation is offered as a clinical service in most hospitals in the United States, few valid and practical tools are available to evaluate, ensure, and improve ethics consultation quality. The quality of ethics consultation is important because poor quality ethics consultation can result in ethically inappropriate outcomes for patients, other stakeholders, or the health care system. To promote accountability for the quality of ethics consultation, we developed the Ethics Consultation Quality Assessment Tool. ECQAT enables raters to assess the (...) quality of ethics consultations based on the written record. Through rigorous development and preliminary testing, we identified key elements of a quality ethics consultation, established scoring criteria, developed training guidelines, and designed a holistic assessment process. This article describes the development of the ECQAT,.. (shrink)

A 1999–2000 national study of U.S. hospitals raised concerns about ethics consultation (EC) practices and catalyzed improvement efforts. To assess how practices have changed since 2000, we administered a 105-item survey to “best informants” in a stratified random sample of 600 U.S. general hospitals. This primary article details the methods for the entire study, then focuses on the 16 items from the prior study. Compared with 2000, the estimated number of case consultations performed annually rose by 94% to 68,000. The (...) median number of consults per hospital was unchanged at 3, but more than doubled for hospitals with 400+ beds. The level of education of EC practitioners was unchanged, while the percentage of hospitals formally evaluating their ECS decreased from 28.0% to 19.1%. The gap between large, teaching hospitals and small, nonteaching hospitals widened since the prior study. We suggest targeting future improvement efforts to hospitals where needs are not being met by current approaches to EC. (shrink)

There is no doubt that emotions have an important effect on practices of moral reasoning such as clinical ethics consultation. Empathy is not only a basic human emotion but also an important and learnable skill for health care professionals. A basic amount of empathy is essential both in patient care and in clinical ethics consultation. This article debates the “adequate dose” of empathy in ethics consultations in clinical settings and tries to identify possible situations within the process of consultation in (...) which this crucial feeling is at risk. (shrink)

With the rapid development of genetic research and applications in health care there is some agreement among funding and regulatory bodies that the public(s) need to be equipped to deal with the choices that the new technologies will offer them, although this does not necessarily include a role for the public in influencing their development and regulation. This paper considers the methods and purpose of public consultations in the area of genetics including large-scale surveys of opinion, consensus conferences and focus (...) groups. Consultation has been undertaken to enable the researchers/policy makers to see what the public do not know and plan more public education to make up the deficiency, to check on areas of concern so that public education can be used to address them or to gain a public mandate for a planned policy. An alternative and more recent approach is to find out what the public(s) do know and understand and to see how experts can learn from them in order to get a fuller view of technology in use. (shrink)

BackgroundAdherence to widely accepted practice standards is a frequently used measure of healthcare quality. In the U.S., the most widely recognized authoritative source of practice standards for ethics consultation (EC) is the second edition of the American Society for Bioethics and Humanities’ Core Competencies for Healthcare Ethics Consultation report.MethodsTo determine the extent to which EC practices in U.S. hospitals adhere to these practice standards, we developed and analyzed 12 evaluative measures from a national survey.ResultsOnly three of the 12 standards achieved (...) over 75% adherence with reported EC practices: allowing anyone involved in a case to request an EC (100%), not requiring an attending physician’s permission to conduct an EC (97.6%), and having at least one person on the ethics consultation service (ECS) with advanced level EC proficiency (79.3%).ConclusionsImplications are discussed for achieving consensus on EC standards as they continue to evolve. (shrink)

To design effective strategies to improve ethics consultation (EC) practices, it is important to understand the views of ethics practitioners. Previous U.S. studies of ethics practitioners have overrepresented the views of academic bioethicists. To help inform EC improvement efforts, we surveyed a random stratified sample of U.S. hospitals, examining ethics practitioners’ opinions on EC in general, on their own EC service, on strategies to improve EC, and on ASBH practice standards. Respondents across all categories of hospitals had very positive perceptions (...) of their own ethics consultation service (ECS) and few concerns about quality. Our findings suggest that the ethics-related needs of small, rural, non-teaching hospitals may be very different from those of academic medical centers, and therefore, different approaches to addressing ethical issues might be warranted. (shrink)

BackgroundWhile previous research has examined various aspects of ethics consultation (EC) in U.S. hospitals, certain EC practices have never been systematically studied.MethodsTo address this gap, we surveyed a random stratified sample of 600 hospitals about aspects of EC that had not been previously explored.ResultsNew findings include: in 26.0% of hospitals, the EC service performs EC for more than one hospital; 72.4% of hospitals performed at least one non-case consultation; in 56% of hospitals, ECs are never requested by patients or families; (...) 59.0% of case consultations involve conflict; the usual practice is to visit the patient in all formal EC cases in 32.5% of hospitals; 56.6% of hospitals do not include a formal meeting in most EC cases; 61.1% of hospitals do not routinely assess ethics consultants’ competencies; and 31.6% of hospitals belong to a bioethics network. We estimate the total number of non-case consultations performed in U.S. hospitals to be approximately one half the number of case consultations; we estimate the total number of ECs performed in U.S. hospitals, including both case and non-case consultations, to be just over 100,000 per year.ConclusionsThese findings expand our current understanding of EC in U.S. hospitals, and raise several concerns that suggest a need for further research. (shrink)

The annual volume of ethics consultations (ECs) has been a topic of interest in the bioethics literature, in part because of its presumed relationship to quality. To better understand factors associated with EC volume, we used multiple linear regression to model the number of case consultations performed in the last year based on a national survey. We found that hospital bed size, academic affiliation, and urban/rural location were all associated with EC volume, but were not the primary drivers. Instead, these (...) variables affected EC volume through three other variables, all of which relate to ethics staffing: the percentage of case consultations performed by a single individual; whether the survey respondent’s main role at the hospital contained the word “ethics”; and especially, the number of full-time ethics program staff. We conclude that EC is an example of supply-sensitive care, and further research is needed to determine the optimal level of EC activity. (shrink)

The primary objective of The Health Care Ethics Con sultant is to focus attention on an immediate practical problem: the role and responsibilities, the education and training, and the certification and accreditation of health care ethics consultants. The principal questions addressed in this book include: Who should be considered health care ethics consultants? Whom should they advise? What should be their responsi bilities and what kind of training should they have? Should there be some kind of accreditation or certification program (...) to ensure that those who call themselves ethics consultants are in fact qualified to advise, consult, research, and write in health care ethics? The distinguished authors ofthese articles are persons with diverse backgrounds, interests, presumptions, and val ues. Not surprisingly, therefore, diverse responses have emerged to the questions posed. Though the book's chapters are individually authored, they are informed by the group discussions that went on during active workshop sessions, and by knowledge of the contributions of others. All of the chapters meaningfully represent their consensus. This is not to say that there were no disagreements regarding specific details, but rather that there were no fundamental objections on the book's basic content among a panel of authors who share basic premises regarding the role, responsibilities, education, and certifica tion of health care ethics consultants. (shrink)

Systematic study of the intersection of ethics consultation services and solid organ transplants and recipients can identify and illustrate ethical issues that arise in the clinical care of these patients, including challenges beyond resource allocation. This was a single-centre, retrospective cohort study of all adult ethics consultations between January 1, 2007, and December 31, 2017, at a large academic medical centre in the north-eastern United States. Of the 880 ethics consultations, sixty (6.8 per cent ) involved solid organ transplant, thirty-nine (...) (65.0 per cent) for candidates and twenty-one (35.0 per cent ) for recipients. Ethics consultations were requested for 4.3 per cent of heart, 4.9 per cent of lung, 0.3 per cent of liver, and 0.3 per cent of kidney transplant recipients over the study period. Nurses were more likely to request ethics consultations for recipients than physicians (80.0 per cent vs 20.0 per cent, p = 0.006). The most common reason for consultation among transplant candidates was discussion about intensity of treatment or goals of care after the patient was not or was no longer a transplant candidate. The most common reason for ethics consultation among transplant recipients was disagreement between transplant providers and patients/families/non-transplant healthcare professionals over the appropriate intensity of treatment for recipients. Very few consultations involved questions about appropriate resource allocation. Ethics consultants involved in these cases most often navigated communication challenges between transplant and non-transplant healthcare professionals and patients and families. (shrink)

In spite of an intensive discussion of ethical subjects, psychiatric departments rarely request clinical ethics support. However, during regular psychological supervisions subjects with an underlying ethical conflict are increasingly encountered. Based on the case study of a 39-year-old female patient suffering from personality disorder and her newborn child, the role of ethical consultation in psychiatric treatment and the decision making regarding health and welfare of child and mother will be presented. While discussing opportunities and limitations of psychological supervision as a (...) possible vehicle for clinical ethics support, it becomes obvious that during psychological supervision, ethical conflicts can also be reflected and treatment alternatives be evaluated. Psychological supervision finds its limits because of its more intuitive processes when the conflict escalates, when the patient cannot be involved and when institutional interests dominate. In these cases, the more structured and formalised process of clinical ethics consultation clearly offers advantages. (shrink)

Services of ethics consultants are nowadays commonly used in such various spheres of life as engineering, public administration, business, law, health care, journalism, and scientific research. It has however been maintained that use of ethics consultants is incompatible with personal autonomy; in moral matters individuals should be allowed to make their own decisions. The problem this criticism refers to can be conceived of as a conflict between the professional autonomy of ethics experts and the autonomy of the persons they serve. (...) This paper addresses this conflict and maintains that when the nature of both ethics consultation and individual autonomy is properly understood, the professional autonomy of ethics experts is compatible with the autonomy of the persons they assist. (shrink)

Despite their central role in the construction and development of the market for virtues as well as in the design, implementation, and evaluation of corporate sustainability strategies and governmental sustainability policies, sustainability consultants remain at best “hidden” corporate change agents. In this paper, we bring sustainability consultants back to the fore to account for how these actors discreetly regulate and shape contemporary sustainability transformations from the outside-in. We do so first by unpacking various roles of consultants as engineers, market builders, (...) power vehicles, boundary workers, issue translators, and soft regulators; then we conceptualize how, through these roles, they contribute to empowering, legitimizing but also potentially supplanting and undermining the activities of corporate change agents operating inside corporations. We finally propose some research orientations for studying further the role of sustainability consultants in corporate transformations toward sustainability. (shrink)

This chapter focuses on ethical governance, which speaks to the infrastructure, processes, and practices that decrease the probability of performing ethically wrong actions and ethically bad outcomes resulting from relatively innocent actions. The ethics consultant can help spot gaps or other insufficiencies in ethical infrastructure, process, and practice. Ethics consulting consists in engaging in a due diligence process for ethical risk. The goal is to identify possible sources of ethical risk both in terms of features of the product and (...) the ways it may or may not be used, and to recommend feature changes and best practices for ethical deployment and use of the product. Ethics consulting more generally can be seen as aimed at either doing a bunch of good or avoiding a bunch of bad. Ethical challenges often arise in business because of competing assumptions and commitments that create seemingly irresolvable tensions or obscure the potentially bad consequences of particular decisions. (shrink)

In most U.S. jurisdictions, clinicians providing informal “curbside” consults are protected from medical malpractice liability due to the absence of a doctor-patient relationship. A recent Minnesota Supreme Court case, Warren v. Dinter, offers the opportunity to reassess whether the majority rule is truly serving the best interests of patients.

In this paper I attempt to address what appears to be a novel theoretical and practical problem concerning physician-assisted suicide (PAS). This problem arises out of a newly created set of circumstances in which persons are hospitalized in jurisdictions where PAS, though now legally available to patients, remains morally contentious. When moral disagreements over PAS come to divide physicians, patients, and family members, it is quite likely they will today find their way to the hospital’s consulting ethicist, a member of (...) an emerging group of professionals charged with the responsibility (so we are told) of resolving moral conflict in the clinic. What can or should an ethics consultant do to fulfill this mandate in such circumstances? I argue that the now predominant conception of clinical ethics consultation is importantly deficient in that it provides no final guidance to ethicists on how they should respond in such cases. The ethicist may only recommend—or assist others to reach—solutions to moral disagreements falling within the limits of established norms. Since the normative landscape of PAS appears to be changing, whether it falls within these limits is unsettled. I conclude that the accepted goals of ethics consultation require a revised and expanded conception of the ethicist's role in cases involving PAS. I close by outlining what that revised understanding would look like and the further questions it raises. (shrink)

Background: There is growing interest in credentialing hospital ethicists. Consult volume is being incorporated into credentialing criteria, although few data supporting this approach are available...

Ethics consultation has become an integral part of the fabric of U.S. health care delivery. This article summarizes the second edition of the Core Competencies for Health Care Ethics Consultation report of the American Society for Bioethics and Humanities. The core knowledge and skills competencies identified in the first edition of Core Competencies have been adopted by various ethics consultation services and education programs, providing evidence of their endorsement as health care ethics consultation (HCEC) standards. This revised report was prompted (...) by thinking in the field that has evolved since the original report. Patients, family members, and health care providers who encounter ethical questions or concerns that ethics consultants could help address deserve access to efficient, effective, and accountable HCEC services. All individuals providing such services should be held to the standards of competence and quality described in the revised report. (shrink)