Patients who experience difficulty making medical decisions are often referred to as “ambivalent.” However, the current lack of attention to the nuances between a cluster of phenomena that resemble...

Questions about when to limit unhelpful treatments are often raised in general medicine but are less commonly considered in psychiatry. Here we describe a survey of U.S. psychiatrists intended to characterize their attitudes about the management of suicidal ideation in patients with severely treatment-refractory illness. Respondents (n = 212) received one of two cases describing a patient with suicidal ideation due to either borderline personality disorder or major depressive disorder. Both patients were described as receiving all guideline-based and plausible emerging (...) treatments. Respondents rated the expected helpfulness and likelihood of recommending each of four types of intervention: hospitalization, additional medication changes, additional neurostimulation, and additional psychotherapy. Across both cases, most respondents said they were likely to provide each intervention, except for additional neurostimulation in borderline personality disorder, while fewer thought each intervention would be helpful. Substantial minorities of respondents indicated that they would provide an intervention they did not think was likely to be helpful. Our results suggest that while most psychiatrists recognize the possibility that some patients are unlikely to be helped by available treatments, many would continue to offer such treatments. (shrink)

Bioethicists often draw sharp distinctions between hope and states like denial, self-deception, and unrealistic optimism. But what, exactly, is the difference between hope and its more suspect cousins? One common way of drawing the distinction focuses on accuracy of belief about the desired outcome: Hope, though perhaps sometimes misplaced, does not involve inaccuracy in the way that these other states do. Because inaccurate beliefs are thought to compromise informed decision making, bioethicists have considered these states to be ones where intervention (...) is needed either to correct the person’s mental state or to persuade the person to behave differently, or even to deny the person certain options. In this article, we argue that it is difficult to determine whether a patient is really in denial, self-deceived, or unrealistically optimistic. Moreover, even when we are confident that beliefs are unrealistic, they are not always as harmful as critics contend. As a result, we need to be more permissive in our approach to patients who we believe are unrealistically optimistic, in denial, or self-deceived—that is, unless patients significantly misunderstand their situation and thus make decisions that are clearly bad for them, we should not intervene by trying to change their mental states or persuade them to behave differently, or by paternalistically denying them certain options. (shrink)

Many health care decisions depend not only upon medical facts, but also on value judgments—patient goals and preferences. Until recent decades, patients relied on doctors to tell them what to do. Then ethicists and others convinced clinicians to adopt a paradigm shift in medical practice, to recognize patient autonomy, by orienting decision making toward the unique goals of individual patients. Unfortunately, current medical practice often falls short of empowering patients. In this article, we reflect on whether the current state of (...) medical decision making effectively promotes patients' health care goals. We base our reflections, in part, on research in which we observed physicians making earnest efforts to partner with patients in making treatment decisions, but still struggling to empower patients—failing to communicate clearly to patients about decision-relevant information, overwhelming patients with irrelevant information, overlooking when patients' emotions made it hard to engage in choices, and making recommendations before discussing patients' goals. (shrink)

This study examines the public's and physicians' willingness to support deception of insurance companies in order to obtain necessary healthcare services and how this support varies based on perceptions of physicians' time pressures. Based on surveys of 700 prospective jurors and 1617 physicians, the public was more than twice as likely as physicians to sanction deception (26% versus 11%) and half as likely to believe that physicians have adequate time to appeal coverage decisions (22% versus 59%). The odds of public (...) support for deception compared to that of physicians rose from 2.48 to 4.64 after controlling for differences in time perception. These findings highlight the ethical challenge facing physicians and patients in balancing patient advocacy with honesty in the setting of limited societal resources. (shrink)

In the last few years, the U.S. health care system has seemingly been gripped by “back to the nineties” fever. But there is a notable change in professional debates about how to better control health care costs. Discussion of health care rationing, which was hotly debated in the nineties, has become much more muted.Is health care rationing passé? I contend that debates about health care rationing have waned not because the need to ration has dwindled nor because ethical debates about (...) how or whether to ration have been resolved. They have declined because the word “rationing,” and unrelated concepts such as cost‐effectiveness analysis, have been replaced by terms—“parsimony,” “value,” and “CER”—that are not burdened by emotional and historical baggage.Sometimes the best way to promote healthy moral debate is to turn to new words that don't carry the burden of past debates. (shrink)

Background: Some members of the general public feel that patients who cause their own organ failure through smoking, alcohol use, or drug use should not receive equal priority for scarce transplantable organs. This may reflect a belief that these patients (1) cause their own illness, (2) have poor transplant prognoses or, (3) are simply unworthy. We explore the role that social acceptability, personal responsibility, and prognosis play in people's judgments about transplant allocation. Methods: By random allocation, we presented 283 prospective (...) jurors in Philadelphia county with one of five questionnaire versions. In all questionnaires, subjects were asked to distribute transplantable hearts between patients with and without a history of three controversial behaviors (eating high fat diets against doctors’ advice, cigarette smoking, or intravenous drug use). Across the five questionnaire versions, we varied the relative prognosis of the transplant candidates and whether their behavior caused their primary organ Results: Subjects were significantly less willing to distribute organs to intravenous drug users than to cigarette smokers or people eating high fat diets (p le; 0.0005), even when intravenous drug users had better transplant outcomes than other patients. Subjects’ allocation decisions were influenced by transplant prognosis, but not by whether the behavior in question was causally responsible for the patients’ organ failure. Conclusion: People's unwillingness to give scarce transplantable organs to patients with controversial behaviors cannot be explained totally on the basis of those behaviors either causing their primary organ failure or making them have worse transplant prognoses. Instead, many people believe that such patients are simply less worthy of scarce transplantable organs. (shrink)

Randomized trials depend on clinicians feeling that they are morally justified in allowing their patients to be randomized across treatment arms. Typically such justification rides on what has been called “clinical equipoise”—when there is disagreement of opinion among the community of experts about whether one treatment is better than another, then physicians can ethically enter their patients into a clinical trial, even if individual physicians are not at equipoise. Recent debates over prominent studies, however, illustrate that controversy can be easily (...) created rather than dispelled by trials, with many clinicians choosing not to use the proven therapy until they receive more convincing evidence of its superiority. In such situations, we propose that a new standard of equipoise be used to guide decisions about the ethical justifications for research trials—a standard of behavioral equipoise. Under behavioral equipoise, a trial is potentially justifiable if it addresses behavioral resistance to prior scientific evidence. (shrink)

In their article, “Supported Decision Making with People at the Margins of Autonomy,” Peterson, Karlawish, and Largent point to the fact that the concept of ‘supported decision-making’ has recently...

> ‘The fact about himself that the bullshitter hides, on the other hand, is that the truth-values of his statements are of no central interest to him; what we are not to understand is that his intention is neither to report the truth nor conceal it. It is just this lack of connection to a concern with truth—this indifference to how things really are—that is the essence of bullshit.’1 > —Harry Frankfurt In his paper, Nudging, informed consent, and bullshit, William (...) Simkulet accuses doctors of being bullshitters when they knowingly influence patient decision making through means other than argument and reasoning, that is, through ‘nudges.’ In these instances, he contends that they care little about patient understanding or communicating the truth about the options and, instead, care only about presenting alternatives in ways that cause patients to do what the physicians think they should do.2 However, doctors can intend to enhance patient understanding at the same time that they try to influence patients’ choices. Consider a physician who wants her patient to get a vaccine. …. (shrink)

Sometimes doing what’s right depends on anticipating how people will react when you do the right thing. Consider two aspects of challenge trial payments discussed by Lynch and colleagues. Th...

Ms. P. is in the ICU with respiratory failure and sepsis. She has been on a ventilator for almost a week, and now has impending kidney failure. Her children, who have been taking turns at the bedsi...

Volume 19, Issue 5, May 2019, Page 62-63.

The sudden onset of severe traumatic brain injury (sTBI) is an event suffered by millions of individuals each year. Regardless of this frequency in occurrence, accurate prognostication remains difficult to achieve among physicians. There are many variables that affect this prognosis. Physicians are expected to assess the clinical indications of the brain injury while considering other factors such as patient quality of life, patient preferences, and environmental context. However, this lack of certainty in prognosis can ultimately affect treatment recommendations and (...) prompt clinical ethical issues at the bedside, as it leaves room for physician bias and interpretation. In this article, we introduce data on neurosurgeon values that may shed light on the process physicians and patients involved in sTBI undergo. In doing so, we highlight the many nuances in decision-making for patients suffering from sTBI and discuss potential solutions to better patient-physician or surrogate-physician interactions. (shrink)

: The move from a notion that community values ought to play a role in health care decision making to the creation of health care policies that in some way reflect such values is a challenging one. No single method will adequately measure community values in a way appropriate for setting health care priorities. Consequently, multiple methods to measure community values should be employed, thereby allowing the strengths and weaknesses of the various methods to complement each other. A preliminary research (...) agenda to bring together empirical research on community values with more traditional research on health care ethics is outlined, with the goal of identifying and measuring acceptable community values that are relatively consistent across measurement methods and, ultimately, developing ways to incorporate these values into health care priority decision making. (shrink)

Background Some have hypothesized that talk about suffering can be used by clinicians to motivate difficult decisions, especially to argue for reducing treatment at the end of life. We examined how talk about suffering is related to decision-making for critically ill patients, by evaluating transcripts of conversations between clinicians and patients’ families.Methods We conducted a secondary qualitative content analysis of audio-recorded family meetings from a multicenter trial conducted in the adult intensive care units of five hospitals from 2012–2017 to look (...) at how the term “suffering” and its variants were used. A coding guide was developed by consensus-oriented discussion by four members of the research team. Two coders independently evaluated each transcript. We followed an inductive approach to data analysis in reviewing transcripts; findings were iteratively discussed among study authors until consensus on key themes was reached.Results Of 146 available transcripts, 34 (23%) contained the word “suffer” or “suffering” at least once, with 58 distinct uses. Clinicians contributed 62% of first uses. Among uses describing the suffering of persons, 57% (n = 24) were related to a decision, but only 42% (n = 10) of decision-relevant uses accompanied a proposal to limit treatment, and only half of treatment-limiting uses (n = 5) were initiated by clinicians. The target terms had a variety of implicit meanings, including poor prognosis, reduced functioning, pain, discomfort, low quality of life, and emotional distress. Suffering was frequently attributed to persons who were unconscious.Conclusions Our results did not support the claim that the term “suffering” and its variants are used primarily by clinicians to justify limiting treatment, and the terms were not commonly used in our sample when decisions were requested. Still, when these terms were used, they were often used in a decision-relevant fashion. (shrink)

: Samia Hurst and Marion Danis provide a thoughtful framework for how to judge the morality of bedside rationing decisions. In this commentary, I applaud Hurst and Danis for advancing the level of debate about bedside rationing. But when I attempt to apply the framework to my own clinical practice, I conclude that the framework comes up short.

Randomized trials depend on clinicians feeling that they are morally justified in allowing their patients to be randomized across treatment arms. Typically such justification rides on what has been called “clinical equipoise”—when there is disagreement of opinion among the community of experts about whether one treatment is better than another, then physicians can ethically enter their patients into a clinical trial, even if individual physicians are not at equipoise. Recent debates over prominent studies, however, illustrate that controversy can be easily (...) created rather than dispelled by trials, with many clinicians choosing not to use the proven therapy until they receive more convincing evidence of its superiority. In such situations, we propose that a new standard of equipoise be used to guide decisions about the ethical justifications for research trials—a standard of behavioral equipoise. Under behavioral equipoise, a trial is potentially justifiable if it addresses behavioral resistance to prior scientific evidence. (shrink)

A response to “Rationing Is Still Rationing,” by Robert J. Wells.

As Jonathan Haidt explains in The Righteous Mind, it is often our moral intuitions that come first, rapidly or even automatically, with ethical reasoning coming later. Haidt's book is one of many that have come out in recent years highlighting the relevance of psychology (and its close cousin, neuroscience) for understanding human morality. As a behavioral scientist, I have devoured many of these books. I am fascinated by human nature and love trying to understand why all of us behave and (...) think the way we do. But as a physician ethicist, I often find myself reading these books with a parallel agenda: not just to understand human nature, but also to see whether this line of research has relevance for my work as an ethicist. My bottom line: Understanding moral psychology ought to be a required component of ethics training, not because the science will help us to differentiate between right and wrong, but because it will better equip us to teach ethics in a way that promotes moral behavior in our students. (shrink)