For Lack of a Better Plan: A Framework for Ethical, Legal, and Clinical Challenges in Complex Inpatient Discharge Planning Content Type Journal Article Pages 311-326 DOI 10.1007/s10730-009-9117-6 Authors Jane Jankowski, Albany Medical Center Albany NY 12208 USA Terese Seastrum, Northeast Health 2212 Burdett Ave. Troy NY 12180 USA Robert N. Swidler, Northeast Health 2212 Burdett Ave. Troy NY 12180 USA Wayne Shelton, Alden March Bioethics Institute, Albany Medical College 47 New Scotland Avenue, MC 153 Albany NY (...) 12208-3478 USA Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737 Journal Volume Volume 21 Journal Issue Volume 21, Number 4. (shrink)

This paper discusses the ethical issues related to hemicorporectomy surgery, a radical procedure that removes the lower half of the body in order to prolong life. The literature on hemicorporectomy (HC), also called translumbar amputation, has been nearly silent on the ethical considerations relevant to this rare procedure. We explore five aspects of the complex landscape of hemicorporectomy to illustrate the broader ethical questions related to this extraordinary procedure: benefits, risks, informed consent, resource allocation and justice, and loss and the (...) lived body. (shrink)

Our aim in this article is to define the difficulties that clinical ethics services encounter when they are asked to demonstrate the value a clinical ethics service (CES) could and should have for an institution and those it serves. The topic emerged out of numerous related presentations at the Un- Conference hosted by the Cleveland Clinic in August 2018 that identified challenges of articulating the value of clinical ethics work for hospital administrators. After a review these talks, it was apparent (...) that the field of clinical ethics may be at a crisis of sorts due to increased pressure to provide explicit measures to healthcare institutions to concretely demonstrate that CESs make a valuable difference in healthcare delivery. In this article, we grapple with how to satisfy the need for demonstrable value in a field in which metrics alone may not capture the scope of clinical ethics practice. We suggest that capturing the value of a CES has been difficult because the benefits of ethics consultation may be overt or attributable to the CES, but are often hidden due to the systems-level and process-oriented nature of clinical ethics work. Part of the difficulty in demonstrating the value of CESs is capturing and conveying all of the ways the integration of a CES throughout an institution positively affects patients, families, visitors, healthcare professionals, administrators, and the institution itself. Our aim is to (1) elucidate the multifaceted value added by a CES, including value that tends to be hidden and (2) suggest how to demonstrate value to others in a way that is not simplistic or reductionistic. (shrink)

Clinical ethics consultants (CECs) often face some of the most difficult communication and interpersonal challenges that occur in hospitals, involving stressed stakeholders who express, with strong emotions, their preferences and concerns in situations of personal crisis and loss. In this article we will give examples of how much of the important work that ethics consultants perform in addressing clinical ethics conflicts is incompletely conceived and explained in the American Society of Bioethics and Humanities Core Competencies for Healthcare Ethics Consultation and (...) the clinical ethics literature. The work to which we refer is best conceptualized as a specialized type of interviewing, in which the emotional barriers of patients and their families or surrogates can be identified and addressed in light of relevant ethical obligations and values within the context of ethics facilitation. (shrink)

As clinical ethics consultants move toward professionalization, the process of certifying individual consultants or accrediting programs will be discussed and debated. With certification, some entity must be established or ordained to oversee the standards and procedures. If the process evolves like other professions, it seems plausible that it will eventually include a written examination to evaluate the core knowledge competencies that individual practitioners should possess to meet peer practice standards. The American Society for Bioethics and Humanities has published core knowledge (...) competencies for many years that are accepted by experts as the prevailing standard. Probably any written examination will be based upon the ASBH core knowledge competencies. However, much remains to be done before any examination may be offered. In particular, it seems likely that a recognized examining board must create and validate examination questions and structure the examination so as to establish meaningful, defensible parameters after dealing with such challenging questions as: Should the certifying examination be multiple choice or short-answer essay? How should the test be graded? What should the pass rate be? How may the examination be best administered? To advance the field of health care ethics consultation, thought leaders should start to focus on the written examination possibilities, to date unaddressed carefully in the literature. Examination models—both objective and written—must be explored as a viable strategy about how the field of health care ethics consultations can grow toward professionalization. (shrink)

An individual’s right to refuse life-sustaining treatment is a fundamental expression of patient autonomy; however, supporting this right poses ethical dilemmas for healthcare providers when the patient has attempted suicide. Emergency physicians encounter patients who have attempted suicide and are likely among the first medical providers to face the dilemma of honoring the patient’s DNR or intervening to reverse the effects of potentially fatal actions. We illustrate this issue by introducing a case example in which the DNR of a terminally (...) ill woman was not honored because the cause of her cardiac arrest was suicide. We argue that although a terminal diagnosis should change the way health care providers respond to a suicide attempt, many of the theoretical underpinnings for how one should treat suicide attempts—especially the criterion of external reasonability, that is the action to withhold or withdraw life-sustaining measures is reasonable independent of the precipitating event—are common to all situations :3–12, 2013). The presumption that patients who attempt suicide lack capacity due to acute mental illness is flawed because it fails to account for a competent individual’s reasonable preference to not be forced to live in an unbearable, terminal condition. In states without legislation allowing physician aid in dying, patients and providers must grapple with these limitations on a case-by-case basis. In cases where the patient has a limited life expectancy and there is not concern for psychiatric illness as the primary cause of the suicidal action, we argue that the negative right to refuse life-sustaining treatment should prevail. (shrink)

Benchmarks against which healthcare ethics consultation (HCEC) services can assess their performance are needed. As first-generation benchmarks continue to be developed, it is the obligation of the field to continually evaluate how these measures reflect the performance of any single HCEC service. This will be possible only with widespread reporting of standardized data points. In their article in this issue of The Journal of Clinical Ethics, Glover and colleagues provide a valuable preliminary approach for assessing appropriate consult volumes for a (...) HCEC service. The limitations of their study read as a call to action for the field of clinical ethics to expand and standardize data reporting so that more robust metrics can be developed. In response to this call by Glover and colleagues, the Cleveland Clinic HCEC service provides consult data from 2015 through 2019 for one of its medical centers, and offers an additional volumebased metric, consult-to-ICU-to-bed ratio (CiBR), that may add nuance to any normative assessment of HCEC service consult volume. Given that volume-based metrics are the native language of the clinical environment, efforts to improve such metrics in the field through transparency and standardization are warranted. However, the expositive power of volume-based metrics is limited; additional domains related to quality and outcomes are needed. (shrink)

This article presents the case of a mother who is planning a home birth with a midwife with the shared knowledge that the fetus would have congenital anomalies of unknown severity. We discuss the right of women to choose home birth, the caregivers’ duty to the infant, and the careproviders’ dilemma about how to respond to this request. The ethical duties of concerned careproviders are explored and reframed as professional obligations to the mother, infant, and their profession at large. Recommendations (...) are offered based on this case in order to clarify the considerations surrounding not only home birth of a fetus with anticipated anomalies, but also to address the ethical obligations of caregivers who must navigate the unique tension between respecting the mother’s wishes and the duty of the careproviders to deliver optimal care. (shrink)

The nurse asks the ethics consultant what can be done to stop the patient’s blogging. R.J.’s messages on the public forum are taking their toll on the care environment and the health care providers...

Volume 20, Issue 3, March 2020, Page 21-24.

The authors of this article are previous or current members of the Clinical Ethics Consultation Affairs (CECA) Committee, a standing committee of the American Society for Bioethics and Humanities (ASBH). The committee is composed of seasoned healthcare ethics consultants (HCECs), and it is charged with developing and disseminating education materials for HCECs and ethics committees. The purpose of this article is to describe the educational research and development processes behind our teaching materials, which culminated in a case studies book called (...) A Case-Based Study Guide for Addressing Patient-Centered Ethical Issues in Health Care (hereafter, the Study Guide). In this article, we also enumerate how the Study Guide could be used in teaching and learning, and we identify areas that are ripe for future work. (shrink)

Volume 20, Issue 6, June 2020, Page 75-77.

Despite an abundance of academic conferences, clinical ethicists lacked a forum to share innovative practices with peers and to generate solutions to common challenges. Organizers of the first Clinical Ethics Un-Conference developed a working event centered on active participation and problem solving through peer learning, with the goal of improving realworld practice. Registrants included 95 individuals from 64 institutions. Attendees were surveyed immediately after the Un-Conference, and again eight months later. After eight months, 85 percent (n = 33/39) of the (...) survey respondents reported that they found the event “highly impactful” or “some-what impactful” to their clinical practice, and 23 attendees reported that they had implemented ideas or projects inspired by the event. Three sets of best practice guidelines and four white papers were published from the event. As the field of clinical ethics continues to advance and evolve, this working event format offers an innovative, disruptive alternative to a traditional conference format and may serve as a model for future efforts aimed at improving real-world clinical ethics practice. (shrink)

Abstract In this paper I undertake an in-depth examination of an oft mentioned but rarely expounded upon state: suspended judgment. While traditional epistemology is sometimes characterized as presenting a “yes or no” picture of its central attitudes, in fact many of these epistemologists want to say that there is a third option: subjects can also suspend judgment. Discussions of suspension are mostly brief and have been less than clear on a number of issues, in particular whether this third option should (...) be thought of as an attitude or not. In this paper I argue that suspended judgment is (or at least involves) a genuine attitude. Content Type Journal Article Pages 1-17 DOI 10.1007/s11098-011-9753-y Authors Jane Friedman, St Catherine’s College, University of Oxford, Oxford, OX1 3UJ UK Journal Philosophical Studies Online ISSN 1573-0883 Print ISSN 0031-8116. (shrink)

In this paper we investigate the locus of believability effects in syllogistic reasoning. We identify three points in the reasoning process at which such effects could occur: the initial interpretation of premises, the examination of alternative representations of them (in all of which any valid conclusion must be true), and the “filtering” of putative conclusions. The effect of beliefs at the first of these loci is well established. In this paper we report three experiments that examine whether beliefs have an (...) effect at the other two loci. In experiments 1 and 2 subjects drew their own conclusions from syllogisms that suggested believable or unbelievable ones. In the third experiment they evaluated conclusions that were presented to them. The data show that beliefs both affect the examination of alternative models and act as a filter on putative conclusions. We conclude by showing how some types of problem and some problem contents make the existence of alternative models more obvious than others. (shrink)

In this paper I argue that there is a class of attitudes that have questions (rather than propositions or something else) as contents.

A century ago, John Dewey remarked that when home changes radically, school must change as well. With home, family, and gender roles dramatically altered in recent years, we are faced with a difficult problem: in the lives of more and more American children, no one is home. The Schoolhome proposes a solution. Drawing selectively from reform movements of the past and relating them to the unique needs of today's parents and children, Jane Martin presents a philosophy of education that (...) is responsive to America's changed and changing realities. As more and more parents enter the workforce, the historic role of the domestic sphere in the education and development of children is drastically reduced. Consequently, Martin advocates removing the barriers between the school and the home--making school a metaphorical "home," a safe and nuturant environment that provides children with the experience of affection and connection otherwise missing or inconsistent in their lives. In this proposition, the traditional schoolhouse where children are drilled in the three Rs is transformed into a "schoolhome" where learning is animated by an ethic of social awareness. At a time when many school reformers are calling for a return to basics and lobbying for skills education and quick-fix initiatives, Martin urges us to reconsider the distinctive legacies of Dewey and Montessori and to conceive of a school that integrates the values of the home with those of social responsibility. With cultural diversity and gender equality among its explicit goals, the schoolhome expands upon Dewey's edict to educate the "whole child," seeking instead to educate all children in the culture's whole heritage. Martin eloquently challenges reformers to reclaim the founding fathers' vision of the nation as a domestic realm, and to imagine a learning environment whose curriculum and classroom practice reflect not merely an economic but a moral investment in the future of our children. More than a summons to action, this remarkable book is a call to rethink the assumptions we bring to the educational enterprise, and so, to act wisely. (shrink)

There has been much discussion about whether traditional epistemology's doxastic attitudes are reducible to degrees of belief. In this paper I argue that what I call the Straightforward Reduction - the reduction of all three of believing p, disbelieving p, and suspending judgment about p, not-p to precise degrees of belief for p and not-p that ought to obey the standard axioms of the probability calculus - cannot succeed. By focusing on suspension of judgment (agnosticism) rather than belief, we can (...) see why the Straightforward Reduction is bound to fail. I argue that, in general, suspending about p is not just a matter of having some specified standard credence for p, and in the end I suggest some ways to extend the arguments that will put pressure on other credence-theoretic accounts of belief and suspension of judgment as well. (shrink)

“Basic research” is often used in science policy. It is commonly thought to refer to research that is directed solely toward acquiring new knowledge rather than any more practical objective. Recently, there has been considerable concern about the future of basic research because of purported changes in the nature of knowledge production and increasing pressures on scientists to demonstrate the social and economic benefits of their work. But is there really something special about basic research? The author argues here that (...) “basic research” is a flexible and ambiguous concept that is drawn on by scientists to acquire prestige and resources. She shows that it is used for boundary work and gives examples of the work it does in different situations by drawing on interviews with scientists and policy makers on the category of basic research and the changes they have seen in it over time. (shrink)

There are modes of presentation of a person in thought corresponding to the first and third person pronouns. This paper proposes that there is also thought involving a second person mode of presentation of another, which might be expressed by an utterance involving ‘you’, but need not be expressed linguistically. It suggests that co-operative activity is the locus for such thought. First person thought is distinctive in how it supplies reasons for the subject to act. In co-operative action there is (...) first person plural intending and judging. So there is a way of thinking of another, when openly co-operating with him or her, which plays the distinctive role of giving reason for contribution to the co-operative activity. In slogan form, ‘you’ is ‘we minus I’. The way children learn to use second and third person pronouns is naturally explained on this view. Contrasting less sophisticated kinds of co-operative activity with more sophisticated forms, and considering some issues about common knowledge and commo.. (shrink)

_Strange Wonder_ confronts Western philosophy's ambivalent relationship to the Platonic "wonder" that reveals the strangeness of the everyday. On the one hand, this wonder is said to be the origin of all philosophy. On the other hand, it is associated with a kind of ignorance that ought to be extinguished as swiftly as possible. By endeavoring to resolve wonder's indeterminacy into certainty and calculability, philosophy paradoxically secures itself at the expense of its own condition of possibility. _Strange Wonder_ locates a (...) reopening of wonder's primordial uncertainty in the work of Martin Heidegger, for whom wonder is first experienced as the shock at the groundlessness of things and then as an astonishment that things nevertheless _are_. Mary-Jane Rubenstein traces this double movement through the thought of Emmanuel Levinas, Jean-Luc Nancy, and Jacques Derrida, ultimately thematizing wonder as the awesome, awful opening that exposes thinking to devastation as well as transformation. Rubenstein's study shows that wonder reveals the extraordinary in and through the ordinary, and is therefore crucial to the task of reimagining political, religious, and ethical terrain. (shrink)

_Strange Wonder_ confronts Western philosophy's ambivalent relationship to the Platonic "wonder" that reveals the strangeness of the everyday. On the one hand, this wonder is said to be the origin of all philosophy. On the other hand, it is associated with a kind of ignorance that ought to be extinguished as swiftly as possible. By endeavoring to resolve wonder's indeterminacy into certainty and calculability, philosophy paradoxically secures itself at the expense of its own condition of possibility. _Strange Wonder_ locates a (...) reopening of wonder's primordial uncertainty in the work of Martin Heidegger, for whom wonder is first experienced as the shock at the groundlessness of things and then as an astonishment that things nevertheless _are_. Mary-Jane Rubenstein traces this double movement through the thought of Emmanuel Levinas, Jean-Luc Nancy, and Jacques Derrida, ultimately thematizing wonder as the awesome, awful opening that exposes thinking to devastation as well as transformation. Rubenstein's study shows that wonder reveals the extraordinary in and through the ordinary, and is therefore crucial to the task of reimagining political, religious, and ethical terrain. (shrink)

This paper is based on case-study research in four English secondary schools. It explores the pressure placed on English and mathematics departments because of their results being reported in annual performance tables. It examines how English and maths departments enact policies of achievement, the additional power and extra resources the pressure to achieve brings and the possibility of resistance.

The proposal to allow assisted dying for people who are not severely ill reignited the Dutch end‐of‐life debate when it was submitted in 2016. A key criticism of this proposal is that it is too radical a departure from the safe and well‐functioning system the Netherlands already has. The goal of this article is to respond to this criticism and question whether the Dutch system really can be described as safe and well functioning. I will reconsider the usefulness of the (...) suffering criterion, and I will ultimately argue this criterion should be rejected altogether. Instead, we should consider moving towards an autonomy‐only approach to assisted dying. This would resolve some significant issues occurring under the current system of assisted dying in the Netherlands and ultimately make the process safer and better functioning. I will then consider some possible objections to adopting an autonomy‐only approach and provide some preliminary responses to these also. I will finally highlight some potential areas where further research may be necessary, namely, how to mitigate the effect of external factors such as poverty or other life aspects that may have the potential to distort the individual's ability to make autonomous decisions. I will also consider some possible international lessons that can be taken from both current as well as the proposed practice in the Netherlands. (shrink)

A paradigm for peace discovered in the cosmopolitan neighborhoods of poor urban immigrants.

The pervasive use of contracts in healthcare is a source of unease for many healthcare ethicists and patient advocates. This commentary examines the use of such contracts with individuals in rehabilitation settings who have complex medical and behavioural issues. The goals of this paper are to examine the many factors that can lead to contract use, to discuss some legal and ethical implications of contract use, and to assess contract use in light of concerns about health equity. The paper concludes (...) with some practical alternatives to the use of such contracts, and refers specifically to tools that might be borrowed from the field of behavioural therapy. (shrink)

Using the insights of evolutionary epistemology, the author develops a new naturalist realist methodology of science, and applies it to the conceptual, practical, and ethical problems of the social sciences.

Postcolonialism offers challenging and provocative ways of thinking about colonial and neocolonial power, about self and other, and about the discourses that perpetuate postcolonial inequality and violence. Much of the seminal work in postcolonialism has been shaped by currents in philosophy, notably Marxism and ethics. "Understanding Postcolonialism" examines the philosophy of postcolonialism in order to reveal the often conflicting systems of thought which underpin it. In so doing, the book presents a reappraisal of the major postcolonial thinkers of the twentieth (...) century.Ranging beyond the narrow selection of theorists to which the field is often restricted, the book explores the work of Fanon and Sartre, Gandhi, Nandy, and the Subaltern Studies Group, Foucault and Said, Derrida and Bhabha, Khatibi and Glissant, and Spivak, Mbembe and Mudimbe. A clear and accessible introduction to the subject, "Understanding Postcolonialism" reveals how, almost half a century after decolonisation, the complex relation between politics and ethics continues to shape postcolonial thought. (shrink)

This chapter contains sections titled: The Missing Women A Case Study of Cultural Loss Cultural Wealth Regained Making the Cultural Wealth Work Agenda for the Future.

This article studies the effects of social institutions on organizational corruption at the societal level by focusing on the possible interactions between the institutional pillars that have been identified in past research. Based on these three institutional aspects or pillars, this article tests the interactive effects of social institutions among societies throughout the world. The results suggest that the three institutional pillars have significant interactive effects on organizational corruption at the societal level. A discussion of the implications of the research (...) findings for researchers and practitioners is given. (shrink)