The COVID-19 pandemic has raised a host of ethical challenges, but key among these has been the possibility that health care systems might need to ration scarce critical care resources. Rationing p...

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)

This paper argues that the type of conscience claims made in last decade’s spate of cases involving pharmacists’ objections to filling birth control prescriptions and cases such as Ms. Means and Mercy Health Partners of Michigan, and even the Affordable Care Act and the Little Sisters of the Poor, as different as they appear to be from each other, share a common element that ties them together and makes them fundamentally different in kind from traditional claims of conscience about which (...) a practical consensus emerged in the 1980s and 1990s. This difference in kind is profoundly significant; so much so, we contend, that it puts them at odds with the normative basis for protecting conscience claims in United States health care settings in the first place, making them illegitimate. Finally, we argue that, given the illegitimacy of these contemporary claims of conscience, physicians and other health professionals must honor their well-established standing obligations to provide informed consent and refer or transfer care even if the service requested or needed is at odds with their own core moral beliefs—a requirement that is in line with the aforementioned practical consensus on traditional claims of conscience. (shrink)

There is a gap in the clinical bioethics literature concerning the approach to assessment of medical decision-making capacity of adolescents or young adults who demonstrate diminished maturity due to longstanding reliance on caregiver support, despite having reached the age of majority. This paper attempts to address this question via the examination of a particular case involving assessment of the decision-making capacity of a young adult pregnant patient who also had a physically disabling neurological condition. Drawing on concepts from adolescent bioethics (...) and feminist critiques of bioethical theory, we argue that limited life experience, secondary to a disabling neurological condition, can result in a lack of adult-like capacity even in a patient who is legally an adult. In such cases, it may be that autonomy, to the extent that it is to be relevant and meaningful, must be viewed through a relational lens. Furthermore, clinicians may avoid unjustifiably paternalistic practices by working with the patient help her gain a better appreciation of the consequences of her decision, thereby calling forward her capacity rather than resorting to being directive in counseling. We conclude that lessons from this case can be used to approach ethically complex instances of medical decision-making in adult patients with normal cognition but diminished experiential maturity. (shrink)

Volume 19, Issue 11, November 2019, Page 73-75.

In “Consensus, Clinical Decision Making, and Unsettled Cases,” David M. Adams and William J. Winslade make multiple references to both editions of the American Society of Bioethics and Humanities (ASBH) Core Competencies for Healthcare Ethics Consultation in their discussion of two assumptions that are supposed to be at the heart of the facilitated consensus model’s inability to handle unsettled cases; that is, that:1. Consultants “should maintain a kind of moral impartiality or neutrality throughout the process,” “explicitly condemn[ing] anything resembling a (...) substantive ‘ethics’ recommendation,” and2. “What counts as the proper set of allowable options among which the parties are to deliberate will itself always be clearly discernible.”Herein, I argue that neither of these assumptions is required by ASBH’s ethics facilitation approach. I then conclude by suggesting that, despite their fundamentally mistaken interpretation of the ASBH approach—perhaps even because of it—Adams and Winslade have made two important contributions to the ethics consultation literature. (shrink)

BackgroundFew comparative studies of clinical ethics consultation practices have been reported. The objective of this study was to explore how American and Japanese experts analyze an Alzheimer's case regarding ethics consultation.MethodsWe presented the case to physicians and ethicists from the US and Japan (one expert from each field from both countries; total = 4) and obtained their responses through a questionnaire and in-depth interviews.ResultsEstablishing a consensus was a common goal among American and Japanese participants. In attempting to achieve consensus, the (...) most significant similarity between Japanese and American ethics consultants was that they both appeared to adopt an "ethics facilitation" approach. Differences were found in recommendation and assessment between the American and Japanese participants. In selecting a surrogate, the American participants chose to contact the grandson before designating the daughter-in-law as the surrogate decision-maker. Conversely the Japanese experts assumed that the daughter-in-law was the surrogate.ConclusionOur findings suggest that consensus building through an "ethics facilitation" approach may be a commonality to the practice of ethics consultation in the US and Japan, while differences emerged in terms of recommendations, surrogate assessment, and assessing treatments. Further research is needed to appreciate differences not only among different nations including, but not limited to, countries in Europe, Asia and the Americas, but also within each country. (shrink)

Clinical ethics committees, with their typical threefold function of education, policy formation, and consultation, are present in nearly all U.S. hospitals today, and they are increasingly common in other healthcare settings such as long-term care and even home care. Ethics committees are at least as prevalent in Canadian hospitals as they are in U.S. hospitals, and their presence is growing in Europe, much of Asia, and Central and South America. Although ethics committees serve a variety of needs, their ultimate goal (...) ought to be to promote ethical practices or, in other words, to engender the integration of ethics into the life of the medical center. Of the three primary functions of ethics committees, ethics consultation has historically been the most controversial and problematic, and consult services in many healthcare institutions have struggled to thrive. (shrink)

Volume 20, Issue 7, July 2020, Page 125-128.

Volume 20, Issue 7, July 2020, Page 139-141.

Clinicians' fear of malpractice litigation is the most significant obstacle to the open reporting of medical mistakes. Without open reporting of medical mistakes, however, root cause analysis of mistakes cannot be done, thus undermining efforts to implement safeguards to minimize the occurrence of future mistakes. Efforts to prevent medical mistakes, therefore, must first directly address cliniciansÕ fear of malpractice litigation. In this paper, we explore the relationship between the current malpractice system and cliniciansÕ fear of litigation. Ultimately, we argue that (...) both the prevention of medical mistakes and the goals of malpractice litigation itself will be better served if substantial malpractice reform is undertaken. (shrink)

Health care workers have not gone along with President Bush's request that they be vaccinated against smallpox in order to prepare the nation's health care system for a terrorist attack using the virus. But there is no professional moral obligation to receive the vaccination—either as a matter of public health or as a matter of national security.

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 11.2 (2001) 115-116 [Access article in PDF] The Ethics of Medical Mistakes: Historical, Legal, and Institutional Perspectives Introduction In late 1999, the Institute of Medicine (IOM) released its report on medical errors, To Err is Human: Building a Safer Health System. The report estimated almost 50,000 deaths per year nationally due to medical mistakes, making it a leading cause of death. IOM speculated that (...) more than half of the deaths related to medical error are preventable. The IOM report shocked the public and medical professionals alike, sparking a national discussion of how to make the health care system safer. This multifaceted issue has profound implications for all aspects of health care, from the very personal--e.g., the relationship of caregiver and patient--to the societal--e.g., a nation's responsibility to its citizens.On 15 May 2000, the University of Pittsburgh Medical Center hosted an ethics conference devoted to the topic of medical mistakes. The goal was to bring together experts from various disciplines, before an audience of both providers and patients, to discuss medical mistakes and their implications. In this issue of the Kennedy Institute of Ethics Journal, we present selected papers resulting from that conference. These papers reflect not only the original oral presentations, but also much of the discussion those presentations generated. Three key perspectives on the ethics of medical mistakes are offered: historical, legal, and institutional.Rosa Lynn Pinkus offers a revealing historical perspective on the ethics of medical mistakes. In analyzing the history of mistake reporting in neurosurgery, she shows how the notion of a mistake developed only as the notion of a standard of practice emerged. Although much of managed care is directed toward systematically fostering a standard of care, this pursuit is relatively new in health care. One might speculate that as more standards are created, mistakes--defined as deviations from standard practice--must increase. If deviation from standard practice is overly castigated, however, then needed innovation in practice may be stifled. Interestingly, as Pinkus discusses, medical malpractice suits quickly followed the emergence of practice standards, driving the initial open reporting of mistakes underground. [End Page 115]Taking up the issue of medical malpractice, Thomas May and Mark Aulisio consider the ramifications of the current malpractice system for mistake prevention. The current system, they argue, while failing to adequately achieve its purported goals of deterring medical mistakes and compensating victims, itself creates a climate that deters the open reporting of mistakes by engendering fear and shame in clinicians. According to May and Aulisio, this failure to report medical mistakes openly has serious ramifications. Chief among these is the inability to do root cause analysis of mistakes, and then, where possible, to implement safeguards to minimize the occurrence of future mistakes. Ultimately, both the prevention of medical mistakes and the goals of malpractice litigation itself will be better served if substantial malpractice reform is undertaken.Andy Thurman argues that even in the current climate institutions ought to have a policy (and practice) of admitting to and openly reporting medical mistakes. Thurman argues that doing so not only is the right thing to do, but is also in the interest of institutions. Interestingly, he contends that failing to admit and openly report mistakes is both at odds with the mission of health care institutions and puts them at higher risk of litigation, and liability. In light of this, Thurman then suggests an institutional process for handling medical mistakes.Michael DeVita concedes that disclosing mistakes is widely supported by the health professionals' principles of ethics, but argues that there are a number of factors that conspire to make doing so a very difficult task. In analyzing an index case, DeVita contends that platitudes about being honest are not nearly enough to foster honest behavior and that policies that offer specific guidance on handling unfavorable events are needed in health care institutions.Finally, we conclude with the policy on disclosure of unfavorable events (this terminology is chosen because it includes both iatrogenic and natural diseases and conditions) that resulted from... (shrink)

In “Bioethics and the Whole: Pluralism, Consensus, and the Transmutation of Bioethical Methods into Gold,” Patricia Martin identifies themes common to three emerging approaches to clinical bioethics--clinical pragmatism, ethics facilitation, and mediation-in order to develop an “ethical consensus method” that can serve as a “practical, step-by-step guide” for decision making She is to be applauded both for her identification of themes common to these three approaches and for her contribution to what we hope will be a growing literature on practical (...) methods for problem solving in clinical bioethics that take seriously the ideal of consensus. After a few preliminary remarks concerning Martin's working model, we focus the majority of our commentary on the notion of “consensus,” which is at the heart of her “ethical consensus method,” and the three approaches from which it is drawn. (shrink)

In “Bioethics and the Whole: Pluralism, Consensus, and the Transmutation of Bioethical Methods into Gold,” Patricia Martin identifies themes common to three emerging approaches to clinical bioethics--clinical pragmatism, ethics facilitation, and mediation-in order to develop an “ethical consensus method” that can serve as a “practical, step-by-step guide” for decision making She is to be applauded both for her identification of themes common to these three approaches and for her contribution to what we hope will be a growing literature on practical (...) methods for problem solving in clinical bioethics that take seriously the ideal of consensus. After a few preliminary remarks concerning Martin's working model, we focus the majority of our commentary on the notion of “consensus,” which is at the heart of her “ethical consensus method,” and the three approaches from which it is drawn. (shrink)

In “Bioethics and the Whole: Pluralism, Consensus, and the Transmutation of Bioethical Methods into Gold,” Patricia Martin identifies themes common to three emerging approaches to clinical bioethics--clinical pragmatism, ethics facilitation, and mediation-in order to develop an “ethical consensus method” that can serve as a “practical, step-by-step guide” for decision making She is to be applauded both for her identification of themes common to these three approaches and for her contribution to what we hope will be a growing literature on practical (...) methods for problem solving in clinical bioethics that take seriously the ideal of consensus. After a few preliminary remarks concerning Martin's working model, we focus the majority of our commentary on the notion of “consensus,” which is at the heart of her “ethical consensus method,” and the three approaches from which it is drawn. (shrink)

La aplicación de la versión tradicional –estructurada en cuatro partes– de la doctrina católica del doble efecto a dos casos de conflicto materno-fetal –la histerectomía en el caso de cáncer de útero, y la craneotomía en el caso de parto obstruido–, ha originado cierta confusión entre los partidarios de las versiones –estructuradas en dos partes contemporáneas– del doble efecto. Aunque la craneotomía, no la histerectomía, fue prohibida de acuerdo a la DDE tradicional, pocos partidarios de las versiones contemporáneas de la (...) DDE consideran que estos casos sean significativamente diferentes. ¿La aplicación tradicional de la DDE a estos dos casos puede entenderse? Si así es, ¿esta aplicación sorprendente puede arrojar luz a los debates contemporáneos sobre el doble efecto? Este artículo trata estas dos preguntas. Se divide en tres apartados: en el apartado I se ofrece una panorámica sobre la génesis histórica –en la casuística católica romana– de las versiones de la DDE articuladas en cuatro partes; en el apartado II se discute las aplicaciones habituales de la DDE tradicional en cuatro partes a una serie de casos, y se presta una atención particular al análisis ortodoxo de los dos procedimientos de aborto terapéutico mencionados, la histerectomía y la craneotomía. Tras exponer tres concepciones de la acción intencional, la tomista, la davidsoniana y la goldmaniana, se muestra que desde ninguna de ellas esos casos pueden distinguirse en virtud de la intención; en el apartado III se lleva a cabo un análisis de lo que se denomina el principio de prioridad causal, que da sentido a la aplicación tradicional de la DDE a estos y otros casos. El artículo concluye explicando por qué se pensó que las tres primeras condiciones de la DDE tradicional, que se reducen a una en las versiones modernas del doble efecto, estaban relacionadas pese a ser diferentes. Por último, sugiero que los desafíos que propiciaron el desarrollo del principio de prioridad causal aclaran otros desafíos similares que deben ser afrontados por cualquier versión moderna adecuada del doble efecto. (shrink)

At the outset of this chapter, I want to echo the praise offered by all of the contributors to this volume for Finder’s outstanding, thoughtful and self-critical narrative of the case of 83 year old Mrs. Hamadani and her fiercely devoted children. The brocade account is carefully woven, like a fine Persian tapestry, to convey the rich complexity of an actual ethics consultation as it transpires not over hours, but rather over days, weeks, months and even, as in this case, (...) years. Mrs. Hamadani’s narrative so told is replete with questions worthy of critical reflection. What is an appropriate role for ethics consultation in healthcare? How can an autonomy-centric culture accommodate community-centric cultural difference? How can or should the voice of the patient be heard when she cannot speak for herself and the much louder and anguished voices of others demand to be heard? What are the bounds of acceptable medical treatment and how should care teams respond when patient or family demands threaten to push care givers to cross those bounds? What is an appropriate response for ethics consultants when they are asked to take over a case or prevent a colleague from interacting with an unwilling family? Do the motivations of patients, family, or members of the care team in calling ethics consultants necessarily shape the consultant’s role? And so the list goes on, as the variety of commentaries which comprise the majority of this volume, as well as the multitude of discussions that you, the readers, will inevitably have with colleagues, students, and friends make abundantly clear. (shrink)

In this essay, I proceed by, first, laying out H. Tristram Engelhardt's argument for the principle of permission as the proper foundation for a secular bioethic. After considering how a number of commentators have tried to undermine this argument, I show why it is immune to some of these advances. I then offer my own critique of Engelhardt's project. This critique is two pronged. First, I argue that Engelhardt is unable to establish his own foundation for a secular bioethic. This (...) inability leaves him with only contingent points of departure for a secular bioethic, some of the more salient of which he has ignored. Second, I argue that even if Engelhardt's project succeeds, it is in danger of being irrelevant in a practical sense because it ignores important contextual dimensions of the peculiar enterprise we call bioethics. Ultimately, the proper foundations for a relevant secular bioethic, I argue, must appeal to certain contingent features of the context that gives rise to the need for it. (shrink)

The crisis in donor organ and tissue supply is one of the most difficult challenges for transplant today. New policy initiatives, such as the driver's license option and requiredrequest, have been implemented in many states, with other initiatives, such as mandatedchoice and presumedconsent, proposed in the hopes of ameliorating this crisis. At the same time, traditional acquisition of organs from human cadavers has been augmented by living human donors, and nonheartbeating human donors, as well as experimental animal and artificial sources. (...) Despite these efforts, the crisis persists and is perhaps most tragic when it threatens the lives of children, driving parents to sometimes desperate measures. Herein, we address one very controversial step some parents have taken to obtain matching tissue or organs for their needy children—that is, having a child, in part, for the purpose of organ or tissue procurement. (shrink)

The first reported successful kidney transplantation occurred in 1954, between twins. Since then, organ donation and transplantation has become less a medical marvel than a common expectation of patients with a variety of diseases resulting in organ failure. Those expectations have caused demand for organs to skyrocket far beyond available supply, fueling an organ shortage and resulting in over 60,000 patients on transplant waiting lists. In this special issue, our contributors attempt to shed new light on some of the many (...) old ethical questions raised by transplant in the contemporary context of extreme scarcity. (shrink)