It is not the outpatient setting, per se, that is presenting new challenges and opportunities to ethics consultants and ethics committees. Rather, it is the underlying reason for shifting more and more patient care from the inpatient to the outpatient setting-namely, calculations of cost-effectiveness.

We describe the legal practice of using civil court orders to mandate outpatient mental health treatment for adults with serious mental illness. After briefly placing the practice in historical context, we discuss the traditional clinical rationale and assumptions underlying outpatient commitment and its legal variants, as well as how the predominant and controversial preventive form of outpatient commitment emerged in the U.S. to address limitations of earlier versions of these laws, such as "conditional release." We then consider (...) whether, and under what conditions, outpatient commitment may be ethical, and we provide a conceptual framework for deciding such questions at the policy and individual-case levels. (shrink)

Studies link involuntary outpatient commitment with improved patient outcomes, fueling debate on its ethical justification. This study compares inpatient utilization for committed outpatients in the 1990s with those who were not under outpatient civil commitment orders. Findings reveal committed outpatients had higher utilization of inpatient services and restraint episodes prior to their commitment compared with a control group. Committed outpatients also were more likely to have been on discharge status at the time of admission, have been admitted involuntarily (...) under emergency legal procedures, and have had a greater number of admissions and hospital days prior to their commitment. Following commitment, patients had fewer hospitalizations, shorter lengths of stay, fewer seclusion episodes and hours, and fewer restraint episodes and hours. Findings are discussed within the context of parens patriae and therapeutic jurisprudence, and support medical and public policy justifications for ethical uses of outpatient civil commitment laws for seriously mentally ill patients. (shrink)

The norms and practices of clinical ethics took form relative to the environment and relationships of hospital care. These practices do not easily translate into the outpatient context because the environment and relational dynamics differ. Yet, as outpatient care becomes the center of health care delivery, the experiences of ethical tension for outpatient clinicians warrant greater responses. Although a substantial body of literature on the nature of the doctor–physician relationship has been developed and could provide theoretical (...) groundwork for an outpatient ethics, this literature is not sufficient to support outpatient caregivers in practical dilemmas. For physicians who are employed by or affiliated with a larger organization, a stronger alliance between clinical ethics and organizational ethics, identity, and mission will promote expansion of ethics resources in outpatient settings and address structural constraints in outpatient clinical care. (shrink)

Background: Midwives are required to make ethical decisions with the support of respective codes of professional ethics which provide a framework for decision making in clinical practice. While each midwife should be ethically aware and sensitive to the ever-changing issues within reproduction, few empirical studies have examined the views of student midwives in relation to reproductive ethical dilemmas. Objective: The aim of this study was to explore midwifery students’ reactions to a number of ethical dilemmas relating to women’s experiences (...) of reproductive decision making. Design: A series of focus groups were conducted with midwifery students who were asked to discuss five culturally significant scenarios including issues of knowledge acquisition regarding methods of family planning, removal or insertion of an intrauterine device, and abortion. Setting: A University in Turkey was the setting for this study. Participants: Purposeful sampling was adopted which resulted in five focus groups with a total of 57 midwifery students. Ethical considerations: The study was reviewed and granted formal ethical approval by an ethical committee at the Faculty of Health Science in Atatürk University. The head of the Faculty of Health Science approved the investigation. The participants received both oral and written information about the study and they gave their consent. Results: Five themes were identified from the analysis of the focus group data related to all five scenarios. These themes were ‘the right to information’, ‘choice and protection’, ‘parental rights and welfare of the women’, ‘make a decision’ and ‘women rights and sexual abuse’. Conclusion: This study has shown that while students respected women’s choice, they also expressed great ambivalence in some situations when personal values conflict with dominant societal beliefs and professional ethics. A focus on ethics education to include human rights is suggested as a means to enable students to explore their own social-value judgements, and as a means to limit the possible development of ethical confusion and moral distress. (shrink)

Studies link involuntary outpatient commitment with improved patient outcomes, fueling debate on its ethical justification. This study compares inpatient utilization for committed outpatients in the 1990s with those who were not under outpatient civil commitment orders. Findings reveal committed outpatients had higher utilization of inpatient services and restraint episodes prior to their commitment compared with a control group. Committed outpatients also were more likely to have been on discharge status at the time of admission, have been admitted involuntarily (...) under emergency legal procedures, and have had a greater number of admissions and hospital days prior to their commitment. Following commitment, patients had fewer hospitalizations, shorter lengths of stay, fewer seclusion episodes and hours, and fewer restraint episodes and hours. Findings are discussed within the context of parens patriae and therapeutic jurisprudence, and support medical and public policy justifications for ethical uses of outpatient civil commitment laws for seriously mentally ill patients. (shrink)

Background Compulsory treatments represent a legal means of imposing treatment on an individual, usually with a mental illness, who refuses therapeutic intervention and poses a risk of self-harm or harm to others. Compulsory outpatient treatment in psychiatry, also known as community treatment order, is a modality of involuntary treatment that broadens the therapeutic imposition beyond hospitalization and into the community. Despite its existence in over 75 jurisdictions worldwide, COT is currently one of the most controversial topics in psychiatry, and (...) it presents significant ethical challenges. Nonetheless, the ethical debate regarding compulsory treatment almost always stops at a preclinical level, with the different ethical positions arguing for or against its use, and there is little guidance to support for the individual clinicians to act ethically when making the decision to implement COT. Main body The current body of evidence is not clear about the efficacy of COT. Therefore, despite its application in several countries, evidence favouring the use of COT is controversial and mixed at best. In these unclear circumstances, ethical guidance becomes paramount. This paper provides an ethical analysis of use of COT, considering the principlist framework established by Ross Upshur in 2002 to justify public health interventions during the 2002–2004 severe acute respiratory syndrome outbreak. This paper thoroughly examines the pertinence of using the principles of harm, proportionality, reciprocity, and transparency when considering the initiation of COT. Conclusion Ross Upshur’s principlist model provides a useful reflection tool for justifying the application of COT. This framework may help to inform sounder ethical decisions in clinical psychiatric practice. (shrink)

In the context of long waiting time to access rehabilitation services, a large majority of settings use referral prioritization to help manage waiting lists. Prioritization practices vary greatly between settings and there is little consensus on how best to prioritize referrals. This paper describes the prioritization processes for physiotherapy services in Québec and its potential implications in terms of equity in access to services. This is a secondary analysis of a survey of outpatient physiotherapy departments (n=98; proportion of participation (...) was 99%) conducted in 2015 across publicly funded hospitals in Québec. In many settings, persons with acute orthopaedic conditions were prioritized while chronic conditions were given a lower priority. There were 72 different combinations of prioritization criteria used in outpatient physiotherapy departments. Variability was also observed in the type of personnel involved in the prioritization process, the number of priority levels used to rank the referrals and the source of information used to prioritize referrals. These results highlight potential issues regarding equity in access to physiotherapy services: the prioritization of persons with acute conditions to the detriment of those with chronic conditions, the lack of consensus on a fair prioritization process and the importance to adequately assess patients’ needs for treatment. Further research and interventions on prioritization criteria and processes are needed to ensure equitable access to physiotherapy services, especially in the public sector. (shrink)

In the context of long waiting time to access rehabilitation services, a large majority of settings use referral prioritization to help manage waiting lists. Prioritization practices vary greatly between settings and there is little consensus on how best to prioritize referrals. This paper describes the prioritization processes for physiotherapy services in Québec and its potential implications in terms of equity in access to services. This is a secondary analysis of a survey of outpatient physiotherapy departments conducted in 2015 across (...) publicly funded hospitals in Québec. In many settings, persons with acute orthopaedic conditions were prioritized while chronic conditions were given a lower priority. There were 72 different combinations of prioritization criteria used in outpatient physiotherapy departments. Variability was also observed in the type of personnel involved in the prioritization process, the number of priority levels used to rank the referrals and the source of information used to prioritize referrals. These results highlight potential issues regarding equity in access to physiotherapy services: the prioritization of persons with acute conditions to the detriment of those with chronic conditions, the lack of consensus on a fair prioritization process and the importance to adequately assess patients’ needs for treatment. Further research and interventions on prioritization criteria and processes are needed to ensure equitable access to physiotherapy services, especially in the public sector. (shrink)

In mental health policy, a central ethical dilemma concerns involuntary outpatient commitment (OPC), which aims to treat vulnerable individuals with serious mental illness who decline services. The first concern regards whether coercive services undermine the quality of clinical interactions within treatment, particularly as it relates to psychiatric medication use. The second concern is the unexamined role that OPC, and coercive psychiatric programs more broadly, play in the broader landscape of social welfare policy. To examine these concerns, the purpose of (...) this dissertation is to analyze how the management of psychiatric medications in involuntary outpatient services is undergirded by (a) provider and client interpretations of psychiatric medication effects and (b) moral discourses related to coercion and client autonomy. To achieve this aim, I examined data from a team-based ethnography that consisted of 1000 hours of participant observations and 56 semi-structured interviews with 20 clients, 21 providers, and 12 client family members with diverse backgrounds. I analyzed how medication compliance was discussed, monitored, and enforced in an involuntary outpatient program. My analysis demonstrates that medications were interpreted as a technology to control clinical symptoms (clinical control) though, particularly among clients, were also viewed as a method to control client mental experiences, behavioral expression, and autonomy (social control). Providers believed that medications were a necessary component of services (compulsory compliance) and could reduce client vulnerability to violence victimization and perpetration related to clinical symptoms (medicating vulnerability). To address client noncompliance, providers employed several strategies that I categorized as client manipulation. These strategies included providers, family members, and court officials strategizing ways to undermine client autonomy without clients’ knowledge (concealed collusion), deceiving clients into believing that medications were mandated when they were not (performing coercion), and minimizing the role of client consent and preferences in decision-making processes (circumventing consent). These findings demonstrate the pervasive role of manipulation to gain client medication compliance in OPC, which I named institutional coercion. They also highlight that the broader moral justifications for manipulating clients relate to their status as structurally vulnerable in their community settings and a growing relationship between the erosion of the welfare state and psychiatric coercion. (shrink)

At 41 weeks, the patient had been delivered by Cesarean section for failure to progress at Hospital A in the same city. Three days after birth she suffered a respiratory arrest. Resuscitation and ventilator support were initiated promptly but the child did poorly, and shortly after this first arrest, the parents were told by the child's physician that she had no chance of recovery. Nevertheless, the mother continued to insist that the child be kept on a respirator and aggressive support (...) be maintained. (shrink)

Background:Ethics rounds are one way to support healthcare personnel in handling ethically difficult situations. A previous study in the present project showed that ethics rounds did not result in significant changes in perceptions of how ethical issues were handled, that is, in the ethical climate. However, there was anecdotal evidence that the ethics rounds were viewed as a positive experience and that they stimulated ethical reflection.Aim:The aim of this study was to gain a deeper understanding of how (...) the ethics rounds were experienced and why the intervention in the form of ethics rounds did not succeed in improving the ethical climate for the staff.Research design:An exploratory and descriptive design with a qualitative approach was adopted, using individual interviews.Participants and research context:A total of 11 healthcare personnel, working in two different psychiatry outpatient clinics and with experience of participating in ethics rounds, were interviewed.Ethical considerations:The study was based on informed consent and was approved by one of the Swedish Regional Ethical Review Boards.Findings:The participants were generally positive about the ethics rounds. They had experienced changes by participating in the ethics rounds in the form of being able to see things from different perspectives as well as by gaining insight into ethical issues. However, these changes had not affected daily work.Discussion:A crucial question is whether or not increased reflection ability among the participants is a good enough outcome of ethics rounds and whether this result could have been measured in patient-related outcomes. Ethics rounds might foster cooperation among the staff and this, in turn, could influence patient care.Conclusion:By listening to others during ethics rounds, a person can learn to see things from a new angle. Participation in ethics rounds can also lead to better insight concerning ethical issues. (shrink)

This book is a resource for providers and students, integrating germane basic science information with clinical-medicine insights. The goal is to improve primary-care outpatient interactions for physicians, APRNs, and PAs. It is unique, integrating germane basic-science information with clinical-medicine. Unlike other resources that introduce these concepts more distinctly, this book bridges the gap and provides insights for providers and students. Also, there are succinct, yet comprehensive, presentations on managing the more common out-patient problems. The book is designed for primary (...) care providers and students, e.g., physicians, APRNs, and PAs, who desire to improve their patient-education, diagnostic, and treatment skills. The PEARLS are instruments to embellish and emphasize important concepts. The focus of the book is to improve outpatient medicine delivery, and better informed and confident providers are keys to the process. (shrink)

BackgroundThe principles of informed consent, confidentiality and privacy are often neglected during patient care in developing countries. We assessed the degree to which doctors in Lahore adhere to these principles during outpatient consultations.Material & MethodThe study was conducted at medical out-patient departments (OPDs) of two tertiary care hospitals (one public and one private hospital) of Lahore, selected using multi-stage sampling. 93 patients were selected from each hospital. Doctors' adherence to the principles of informed consent, privacy and confidentiality was observed (...) through client flow analysis performed by trained personnel. Overall patient perception was also assessed regarding these practices and was compared with the assessment made by our data collectors.ResultsSome degree of informed consent was obtained from only 9.7% patients in the public hospital and 47.8% in the private hospital. 81.4% of patients in the public hospital and 88.4% in the private hospital were accorded at least some degree of privacy. Complete informational confidentiality was maintained only in 10.8% and 35.5% of cases in public & private hospitals respectively. Informed consent and confidentiality were better practiced in the private compared to the public hospital (two-sample t-test > 2, p value < 0.05). There was marked disparity between the patients' perspective of these ethical practices and the assessment of our trained data collectors.ConclusionObservance of medical ethics is inadequate in hospitals of Lahore. Doctors should be imparted formal training in medical ethics and national legislation on medical ethics is needed. Patients should be made aware of their rights to medical ethics. (shrink)

Ethical Considerations at the Intersection of Psychiatry and Religion aims to give mental health professionals a conceptual framework for understanding the role of R/S in ethical decision-making and serve as practical guidance for approaching challenging cases. Part I addresses general considerations, including the basis of therapeutic values in a pluralistic context, the nature of theological and psychiatric ethics, spiritual issues arising in diagnosis and treatment, unhealthy and harmful uses of religion, and practical implications of personal spirituality. Part II examines (...) how these considerations apply in specific contexts: inpatient and outpatient, consultation-liaison, child and adolescent, geriatric, disability, forensic, community, international, addiction and disaster and emergency psychiatry, as well as in the work of religious professionals, ethics committees, psychiatric education, and research. Thick descriptions of case examples analyzed using the framework of Jonson and Winslow show the clinical relevance of understanding the contributions of religion and spirituality to patient preferences, quality of life, decision making, and effective treatment. (shrink)

Many academic medical centers are seeking to attract patients from outside their historical catchment areas for economic and programmatic reasons, and patients are traveling for treatment that is unavailable, of poorer quality, or more expensive at home. Treatment of these patients raises a number of ethical issues including whether they may be given priority in scheduling outpatient follow-up appointments in order to reduce the period of time they are away from home. Granting them priority is potentially unjust because medical (...) treatment is generally allocated based on medical need and resource utilization, and then on a first-come, first-served basis. While it is difficult to compare the opportunity cost of waiting for an appointment to different patients, nonresident patients incur higher expenditures for travel, room, and board than resident patients. Giving them priority in scheduling to reduce these costs may be justifiable. Preferentially scheduling nonresident patients may also indirectly benefit resident patients consistent with Rawls’s difference principle. This potential justification, however, rests on several empirical claims that should be demonstrated. In addition to reducing resident patients’ waiting times, medical centers should not prioritize nonresident patients over resident patients with more urgent medical needs. There is, therefore, a limited and circumscribed justification for prioritizing nonresident patients in scheduling follow-up appointments. (shrink)

With a focus on end-of-life discussion in aging and chronically ill populations, this book offers insight into the skill of communicating in complex and emotionally charged discussions. This text is written for all clinicians and professionals in the fields of healthcare and public health who are faced with questions of ethical deliberation when a patient's illness turns from chronic to terminal. This skill is required to manage care well in an age of advanced technology, and numerous autonomous choices. With a (...) palliative care and ethics focus, the manuscript provides case studies illustrating issues which occur in the acuity and chronicity of end of life. Clear tools for clinicians, such as scripting and "the advance care planning video library" are included. The book focuses on the unique concept of outpatient ethics, including readmission prevention and shortened length of stay through good communication for clinicians who will be required to conduct this discussion with patients. The ethical undertone in this text provides a perfect opening for application in healthcare ethics classes, both in fields of public health and healthcare. Medical scholars and physicians, nurse practitioners and physician's assistants, as well as social workers, both in practice and training, will benefit from this text. (shrink)

Background:Clinical investigation is a growing field employing increasing numbers of nurses. This has created a new specialty practice defined by aspects unique to nursing in a clinical research context: the objectives, setting, and nature of the nurse–participant relationship. The clinical research nurse role may give rise to feelings of ethical conflict between aspects of protocol implementation and the duty of patient advocacy, a primary nursing responsibility. Little is known about whether research nurses experience unique ethical challenges distinct from those experienced (...) by nurses in traditional patient-care settings.Research objectives:The purpose of the study was to describe the nature of ethical challenges experienced by clinical research nurses within the context of their practice.Research design:The study utilized a qualitative descriptive design with individual interviews.Participants and research context:Participating nurses self-identified as having experienced ethical challenges during screening. The majority were Caucasian, female, and worked in outpatient settings. Approximately 50% had > 10 years of research experience.Ethical considerations:The human subjects review board approved the study. Written informed consent was obtained.Findings:Predominant themes were revealed: the inability to provide a probable good, or/do no harm, and dual obligations. The following patterns and subthemes emerged: conflicted allegiances between protocol implementation, needs of the participant, desire to advance science, and tension between the nurse–patient therapeutic relationship versus the research relationship.Discussion:Participants described ethical challenges specific to the research role. The issues are central to the nurse–participant relationship, patient advocacy, the nurse’s role in implementing protocols, and/or advancing science.Conclusion:Ethical challenges related to the specialized role of clinical research nurses were identified. More research is warranted to fully understand their nature and frequency and to identify support systems for resolution. (shrink)

Introduction: Consultation methods differ between medical practitioners depending on the individual setting. However, the central tenet to the doctor–patient relationship is the issue of confidentiality. This prospective survey highlights patient attitudes towards consultation methods in the setting of an ophthalmic outpatient department. Method: Questionnaires were completed by 100 consecutive patients, who had been seen by an ophthalmologist in a single room, which had a joint doctor–patient consultation occurring simultaneously. Results: Each question of all 100 questionnaires was completed. 58% of (...) patients were not concerned about sharing a consultation room with another patient or doctor. However, this did not equate to the 49% of patients who were indifferent to discussing issues in the joint consultation room. The most common factor was the general issue of confidentiality. Discussion: Ensuring total patient confidentiality may be deemed more necessary for certain medical specialties than for others, as seen in the practice of separate medical records in genitourinary medicine, for instance. However, with regard to patient consultations, the same level of confidentiality should be afforded across all specialties, and such factors should be borne in mind when planning outpatient clinics. (shrink)

Ethical viewpoints for and against the use of supervised community treatment (SCT), also known as outpatient commitment and community treatment orders, are examined. The perspectives of writers on civil liberties are considered. This paper argues that while civil liberties are an important concern SCT is ethically justifiable in the circumscribed population of ‘revolving door’ patients it applies to. This is on the grounds that it enables individuals to actualise their positive liberty. The issue of insight into mental illness is (...) also considered and it is concluded that a further argument in favour of SCT comes from evidence that insight relates to neurobiological deficits. Limits to the ethical justifiability of SCT are considered with reference to individuals with substance dependency. The paper concludes that SCT is ethically permissible only in those with severe mental illness who have a history of losing capacity to consent to treatment and/or admission. (shrink)

The aim of the present investigation was to describe and to classify significant ethical problems encountered by the members of the staff during the daily clinical work at a hospital medical department. A set of definitions was prepared for the purpose, including the definition of a 'significant ethical problem'. During a three month period 426 inpatients and 173 outpatients were admitted. Significant ethical problems were encountered during the management of 106 in-patients (25 per cent) and 9 out-patients (5 per cent). (...) No significant difference was found between the frequency of ethical problems in female and male patients, but a positive correlation was noted between the number of problems and the patients' age. The problem types were classified according to a problem list. The results of this investigation suggest that greater attention must be paid to discussions about ethical problems among doctors and other categories of health personnel and that, among others, medical students ought to be taught the analysis of ethical problems. (shrink)

I am in the process of trying to organize an ethics committee at a large community mental health center in Central Massachusetts and am seeking advice from anyone with experience in this or a similar milieu. The agency is a large (almost 700 employees), nonprofit, community-based program that operates under the auspices of a broad, academically affiliated, behavioral health system. An independent board of trustees, responsible to the parent organization governs the agency. The agency primarily provides outpatient care (...) and treatment to adults and children with mental health, substance abuse, developmental disabilities, and homelessness issues. It does not provide any psychiatric emergency or acute in-patient mental health services but does operate an inpatient detoxification unit for substance abuse treatment and DUI program. Additionally, the agency has a vast network of residential programs and transitional facilities for individuals with a history of chronic mental illness and substance abuse problems. Outpatient medical care is also provided to homeless clients who reside in area shelters (including a shelter for men and women) and a large number of clients who have HIV/AIDS and/or who have been dually diagnosed (substance abuse and mental illness), and are part of a scattered-site supportive housing program. (shrink)

Ethical codes help guide the methods of research that involves samples gathered from ?at-risk? populations. The current article reviews general as well as specific ethical principles related to gathering informed consent from partner violent offenders mandated to outpatient treatment, a group that may be at increased risk of unintentional coercion in behavioral sciences research due to court mandates that require outpatient treatment without the ethical protections imbued upon prison populations. Recommendations are advanced to improve the process of informed (...) consent within this special population and data supporting the utility of the recommendations in a sample 70 partner violent offenders are provided. Data demonstrate that participants were capable of comprehending all essential elements of consent. (shrink)

Community treatment orders are a legal mechanism to extend powers of compulsion into outpatient mental health settings in certain circumstances. Previous ethical analyses of these powers have explored a perceived tension between a duty to respect personal freedoms and autonomy and a duty to ensure that patients with the most complex needs are able to receive beneficial care and support that maximises their welfare in the longer-term. This empirical ethics paper presents an analysis of 75 interviews with psychiatrists, (...) patients and family carers to show how these ethical considerations map onto the different ways that community treatment orders are used and experienced in practice. A complex and nuanced account of how the requirements to respect patients’ autonomy, to respect patients’ liberty and to act beneficently should be interpreted in order to make judgements about the ethics of community treatment orders is presented. The article argues that, due to such complexity, no general ethical justification for community treatment orders can be provided, but a justification on the basis of the promotion of patients’ autonomy could provide an ethical reason for community mental health practitioners to make use of a community treatment order in some limited circumstances. (shrink)

Community treatment orders are a legal mechanism to extend powers of compulsion into outpatient mental health settings in certain circumstances. Previous ethical analyses of these powers have explored a perceived tension between a duty to respect personal freedoms and autonomy and a duty to ensure that patients with the most complex needs are able to receive beneficial care and support that maximises their welfare in the longer-term. This empirical ethics paper presents an analysis of 75 interviews with psychiatrists, (...) patients and family carers to show how these ethical considerations map onto the different ways that community treatment orders are used and experienced in practice. A complex and nuanced account of how the requirements to respect patients’ autonomy, to respect patients’ liberty and to act beneficently should be interpreted in order to make judgements about the ethics of community treatment orders is presented. The article argues that, due to such complexity, no general ethical justification for community treatment orders can be provided, but a justification on the basis of the promotion of patients’ autonomy could provide an ethical reason for community mental health practitioners to make use of a community treatment order in some limited circumstances. (shrink)

In 1972, I created the new field of clinical medical ethics (CME) in the Department of Medicine at the University of Chicago. In my view, CME is an intrinsic part of medicine and is not a branch of bioethics or philosophical ethics or legal ethics. The relationship of patients with medically trained and licensed clinicians is at the very heart of CME. CME must be practiced and applied not by nonclinical bioethicists, but rather by licensed clinicians in (...) their routine, daily encounters with inpatients and outpatients. CME addresses many clinical issues such as truth-telling, informed consent, confidentiality, surrogate decision making, and end-of-life care, while also encouraging personal, humane, and compassionate interactions between experienced clinicians and patients.The goals of CME are to improve patient care and outcomes by helping physicians and other health professionals Clinical Medical Ethics: Its History and Contributions to American Medicine Mark Siegler, Guest Editor identify and respond to clinical-ethical challenges that arise in the ordinary care of patients. As Edmund Pellegrino, Peter A. Singer, and I wrote in the first issue of The Journal of Clinical Ethics, 30 years ago: “The central goal of CME is to improve the quality of patient care by identifying, analyzing, and contributing to the resolution of ethical problems that arise in the routine practice of clinical medicine.” Similar to cardiology and oncology consultations, ethics consultations are a small component of a much larger field, and the process of consultations is certainly not at the core of cardiology or oncology or CME.In this article, I intend to discuss the origins of the field of CME, its goals and methods, the relationship between the broad field of CME and the much narrower practice of ethics consultation, the contributions of the MacLean Center at the University of Chicago in developing the field of CME, and, finally, how CME has improved the practice of medicine in the United States. (shrink)

This case consultation offers three cases that illustrate a collaborative consultation model for psychiatric ethics that we have developed in outpatient clinic and in emergency psychiatry over the last 10 years. After we present these cases, we discuss three points of interest: 1) the characteristics we found to be important to our collaborative project, 2) the benefits of an integrative approach, and 3) ways that our collaborative moral reasoning developed our awareness of and sensitivity to ethical issues. We (...) end by raising some topics on which commentators could engage.Potter began working with El-Mallakh more than 10 years ago. Her impetus was that she was writing a critique of the criteria used in borderline... (shrink)

The current Medicare prospective payment system has many positive incentives for hospitals to control costs. Hospitals are increasing outpatient surgery, decreasing admissions, decreasing length of stay, and decreasing use of ancillary services. These are just the effects that Congress and the Health Care Financing Administration hoped for to save the Medicare trust fund. However, there has been evidence of some adverse outcomes including premature discharge, “dumping” sicker patients and patients without insurance, and adverse impact on hospitals with specialty centers. (...) We examine these issues and present a possible solution based on a new Computerized Severity Index. (shrink)

An estimated 6,500 undocumented immigrants in the United States have been diagnosed with end-stage renal disease. These individuals are ineligible for the federal insurance program that covers dialysis and/or transplantation for citizens, and consequently are subject to local or state policies regarding the provision of healthcare. In 76% of states, undocumented immigrants are ineligible to receive scheduled outpatient dialysis treatments, and typically receive dialysis only when presenting to the emergency center with severe life-threatening symptoms. ‘Emergency-only hemodialysis’ is associated with (...) higher healthcare costs, higher mortality, and longer hospitalizations. In this paper, we present an ethical critique of existing federal policy. We argue that EOHD represents a failure of fiduciary and professional obligations, contributes to moral distress, and undermines physician obligations to be good stewards of medical resources. We then explore potential avenues for reform based upon policies introduced at the state level. We argue that, while reform at the federal level would ultimately be a more sustainable longterm solution, state-based policy reforms can help mitigate the ethical shortcomings of EOHD. (shrink)

Ethical clinical practice requires cultural competency. In the United States, Hispanics report stronger attitudinal barriers to drug abuse treatment than any other racial/ethnic group. Hispanics report feeling that drug abuse treatment providers do not understand their unique cultural needs and are unfamiliar with their experiences of discrimination and immigration. Using this case study to explore broader ethical and policy issues, this study investigates the extent to which US universities train counselors to address the culturally specific needs of Hispanic patients and (...) how this is reflected in practice in Los Angeles County. Based on a content analysis of the required courses, syllabi, and course descriptions at 30 universities related to culture/race/racism/ethnicity/diversity at the undergraduate and graduate levels on the addiction therapist track, and thematic analysis of eight in-depth interviews with counselors working in outpatient rehabilitation centers in Los Angeles, I argue that cultural competency education for drug abuse counselors is too surface level and infrequent to adequately prepare students for a career in addiction counseling for Hispanic clients. Significant changes must be made to how cultural diversity is valued and prioritized in the field of psychology to provide better care for Hispanic people with a substance use disorder and fulfill the moral obligation to eliminate this health disparity. Although this study focuses on counselors in Los Angeles, these findings are relevant for professionals and healthcare systems across the United States and beyond who seek to provide equitable and effective care for Hispanic patients. (shrink)

Background. Decisions to test, enrol and disclose HIV status are among the ethical challenges that may influence adherence to antiretroviral therapy (ART) and HIV care and treatment in adolescents living with HIV. In the Tanzanian setting, how parental perceptions of ethical issues affect adolescents’ adherence to HIV care and treatment is not well known.Objective. To explore parental perceptions of ethical issues in adolescent HIV care and treatment. Methods. The study employed a descriptive qualitative exploratory design and was conducted at Temeke (...) Regional Referral Hospital in Dar es Salaam Care and Treatment Centre (CTC) in the Outpatient Department (OPD). The study population were parents and non-parent caregivers of HIV-infected adolescents 10 - 19 years of age. A total of 16 persons participated in semi-structured interviews after their consent was obtained. All interviews were audiotaped, transcribed verbatim in Swahili and back-translated into English. An inductive content analysis was used, and standards of qualitative rigour applied. Results. Three qualitative themes emerged: balancing adolescents’ autonomy with parents’ desire to protect their children; parental dilemmas regarding disclosure of adolescents’ HIV status; and parental reasons for delayed disclosure.Conclusion. Participants perceived that parental authority should override adolescents’ autonomy in HIV care and treatment. Disclosure of HIV status to adolescents is a challenge to parents. Delays in disclosure often occur because parents feel guilty and because they have fears of rejection by their adolescent children. (shrink)

In November 2018 the American Society for Bioethics and Humanities (ASBH) administered the first Healthcare Ethics Consultant Certification examination to 138 candidates, 136 of whom (98.5 percent) passed and were “certified” as “healthcare ethics consultants.” I believe this certification process is both premature and inadequate.Certification for ethics consultants is premature because, as Kornfeld and Prager state repeatedly in their article in this issue of The Journal of Clinical Ethics, “The Clinician as Clinical Ethics Consultant: An (...) Empirical Method of Study,” there is a lack of “empirical data on the nature of the problems that prompt ethics consultation requests and on the functions required to address them.” These authors proceed to provide a model for the kind of empirical data collection that is needed.Even more relevant, the ASBH model that certifies clinical ethics consultants is inadequate. First, it is inappropriate for a nonclinical organization such as the ASBH to claim the right to certify a clinical process, ethics consultation, involving patients and health professionals. Second, the current certification process requires only a written examination in contrast to the two-step quality attestation process proposed in 2013 by Eric Kodish, MD, and 11 other senior members of the ASBH, including its then president.Third and most importantly, the eligibility criteria for being certified to work on hospital units and to make clinical recommendations for patients and families are minimal and insufficient. The only stated requirements are a bachelor’s degree and 400 hours of healthcare ethics consulting experience. By contrast, practicing physicians and nurses train for many years to gain clinical experience that enables them to apply clinical ethical standards in the care and management of all inpatients and outpatients, not just the small percent for whom an ethics consultation is requested. (shrink)

Objective: To determine if the medical record might overestimate the quality of care through false, and potentially unethical, documentation by physicians.Design: Prospective trial comparing two methods for measuring the quality of care for four common outpatient conditions: structured reports by standardised patients who presented unannounced to the physicians’ clinics, and abstraction of the medical records generated during these visits.Setting: The general medicine clinics of two veterans affairs medical centres.Participants: Twenty randomly selected physicians from among eligible second and third year (...) internal medicine residents and attending physicians.Main measurements: Explicit criteria were used to score the medical records of physicians and the reports of SPs generated during 160 visits . Individual scoring items were categorised into four domains of clinical performance: history, physical examination, treatment, and diagnosis. To determine the false positive rate, physician entries were classified as false positive , false negative, true positive, and true negative.Results: False positives were identified in the medical record for 6.4% of measured items. The false positive rate was higher for physical examination and diagnosis than for history and treatment . For individual physician subjects, the false positive rate ranged from 0.098 to 0.397.Conclusions: These data indicate that the medical record falsely overestimates the quality of important dimensions of care such as the physical examination. Though it is doubtful that most subjects in our study participated in regular, intentional falsification, we cannot exclude the possibility that false positives were in some instances intentional, and therefore fraudulent, misrepresentations. Further research is needed to explore the questions raised but incompletely answered by this research. (shrink)

The population of most non-dominant ethnic groups in the USA is growing dramatically. Faculty members are challenged to develop curricula that adequately prepare our future nurses. An increased focus on clinical ethics has resulted from the use of sophisticated technology, changes in health care financing, an increasing elderly population and the shift of care from inpatient to outpatient settings. Nurses frequently face situations demanding resolution of ethical dilemmas involving cultural differences. Nursing curricula must include content on both (...) class='Hi'>ethics and cultural sensitivity. Active student participation is an important element providing a foundation for ethical practice. A proposed educational format was introduced with graduating baccalaureate students. In a pilot study, curricular content on cultural sensitivity and ethical practice was taught in separate modules. Students were then asked to identify and problem solve an ethical dilemma involving patients and professional caregivers from vastly different cultures. Course faculty members provided discussion questions to guide the students' thinking. (shrink)

The 2009 pandemic of influenza A was relatively mild, but a subsequent outbreak of pandemic influenza could be much worse. According to projections from the Department of Health and Human Services, the potential health consequences of a severe influenza pandemic in the United States could be literally overwhelming: up to 1.9 million deaths; 90 million people sick; 45 million people needing outpatient care; 9.9 million people hospitalized, of whom 1.485 million would need treatment in an intensive care unit ; (...) and 742,500 patients needing mechanical ventilators. Even a less cataclysmic, moderate pandemic would result in 209,000 deaths; 90 million people sick; 45 million people needing outpatient care; 865,000 people hospitalized, of whom 128,750 would need treatment in an ICU; and 64,875 patients needing mechanical ventilators. (shrink)

In response to the Covid‐19 pandemic, health care systems worldwide canceled or delayed elective surgeries, outpatient procedures, and clinic appointments. Although such measures may have been necessary to preserve medical resources and to prevent potential exposures early in the pandemic, moving forward, the indirect effects of such an extensive medical shutdown must not outweigh the direct harms of Covid‐19. In this essay, we argue for the reopening of evidence‐based health care with assurance provided to patients about the safety and (...) necessity of high‐value vaccinations, screenings, therapeutics, and procedures. To ensure that virtually all non‐Covid‐related services do not come to a halt again, health care systems and physician practices must preemptively increase their capacity, secure adequate personal protective equipment to safeguard health care personnel, and develop a measured approach to reclosing such routine health care, should it become necessary in the future. (shrink)

In todays’ super-diverse societies, communication and interaction in clinical encounters are increasingly shaped by linguistic, cultural, social and ethnic complexities. It is crucial to better understand the difficulties patients with migration background and healthcare professionals experience in their shared clinical encounters and to explore ethical aspects involved. We accompanied 32 migrant patients during their medical encounters at two outpatient clinics using an ethnographic approach. Overall, data of 34 interviews with patients and physicians on how they perceived their encounter and (...) which difficulties they experienced are presented. We contrasted the perspectives on the difficult aspects and explore ethical questions surrounding the involved issues. Patients and physicians describe similar problem areas, but they have diverging perspectives on them. Two main themes were identified by both patients and physicians: >patients’ behaviour in relation to doctors’ advice relationship issues<. A deeper understanding of the difficulties and challenges that can arise in cross-cultural settings could be provided by bringing together healthcare professionals’ and patients’ perspectives on how a cross- cultural clinical encounter is perceived. Ethical aspects surrounding some of the difficulties could be highlighted and should get more attention in clinical practice and research. (shrink)

BackgroundInternationally, patient access to notes is increasing. This has been driven by respect for patient autonomy, often recognised as a primary tenet of medical ethics: patients should be able to access their records to be fully engaged with their care. While research has been conducted on the impact of patient access to outpatient and primary care records and to patient portals, there is no such review looking at access to hospital medical records in real time, nor an ethical (...) analysis of the issues involved in such a change in process.MethodsThis study employed a systematic review framework in two stems, to integrate literature identified from two searches: Medline, CINAHL and Scopus databases were conducted, (for (1) hospitalised patients, patient access to records and its effects on communication and trust within the doctor-patient relationship; and (2) patient access to medical records and the ethical implications identified). The qualitative and quantitative results of both searches were integrated and critically analysed.Results3954 empirical and 4929 ethical studies were identified; 18 papers representing 16 studies were identified for review (12 empirical and 6 ethical). The review reveals a consensus that our current approach to giving information to patients – almost exclusively verbally – is insufficient; that patient access to notes is a welcome next step for patient-centred care, but that simply allowing full access, without explanation or summary, is also insufficient. Several ethical implications need to be considered: increased information could improve patient trust and knowledge but might transfer an (unwelcome) sense of responsibility to patients; doctors and patients have conflicting views on how much information should be shared and when; sharing written information might increase the already significant disparity in access to health care, and have unforeseen opportunity costs. The impact on medical practice of sharing notes in real time will also need to be evaluated.ConclusionsThe review presents encouraging data to support patient access to medical notes. However, sharing information is a critical part of clinical practice; changing how it is done could have significant empirical and ethical impacts; any changes should be carefully evaluated. (shrink)

People with dementia have commonly been excluded from research. The adverse impacts of this exclusion are now being recognized and research literature, position statements, and ethics guidelines increasingly call for inclusion of people with dementia in research. However, few published studies investigate the views of potential participants on taking part in research should they experience dementia-related cognitive impairment. This cross-sectional survey examined the views of people aged sixty and older attending hospital outpatient clinics about clinical research participation if (...) they had dementia and impaired decision-making ability. Over 90 percent of respondents were agreeable to participating in a wide range of research activities, such as cognitive testing, physical measurements, imaging procedures, and blood draws. For drug studies, however, agreement dropped to 60 percent. Altruism was a strong motivator for research participation. In regard to who should be involved in decisions about their participation in research during periods of incapacity, respondents mostly preferred the person they appoint as their substitute decision-maker for healthcare matters or a doctor or health professional on the research team. Over three-quarters expressed interest in making an advance research directive. The study findings are discussed in relation to law reforms in Australia that aim to strengthen respect and inclusion for people with impaired decision-making capacity, especially by providing frameworks for advance planning for research participation. (shrink)