This article discusses the triage response to the COVID-19 delta variant surge of 2021. One issue that distinguishes the delta wave from earlier surges is that by the time it became the predominant strain in the USA in July 2021, safe and effective vaccines against COVID-19 had been available for all US adults for several months. We consider whether healthcare professionals and triage committees would have been justified in prioritising patients with COVID-19 who are vaccinated above those who are unvaccinated (...) in first-order or second-order triage. Given that lack of evidence for a correlation between short-term survival and vaccination, we argue that using vaccination status during first-order triage would be inconsistent with accepted triage standards. We then turn to notions of procedural fairness, equity and desert to argue that that there is also a lack of justification for using vaccination status in second-order triage. In planning for future surges, we recommend that medical institutions base their triage decisions on principles meant to save the most lives, minimise inequity and protect the public’s trust, which for the time being would not be served by the inclusion of vaccination status. (shrink)

Significant challenges arise for clinical care teams when a patient or surrogate decision-maker hopes a miracle will occur. This article answers the question, “How should clinical bioethicists respond when a medical decision-maker uses the hope for a miracle to orient her medical decisions?” We argue the ethicist must first understand the complexity of the miracle-invocation. To this end, we provide a taxonomy of miracle-invocations that assist the ethicist in analyzing the invocator's conceptions of God, community, and self. After the ethicist (...) appreciates how these concepts influence the invocator's worldview, she can begin responding to this hope with specific practices. We discuss these practices in detail and offer concrete recommendations for a justified response to the hope for a miracle. (shrink)

Volume 20, Issue 7, July 2020, Page 202-204.

How should clinical ethicists be trained? Scholars have stated that clinical ethics fellowships create well-trained, competent ethicists. While this appears intuitive, few features of fellowship programs have been publicly discussed, let alone debated. In this paper, we examine how fellowships can foster effective mentoring relationships. These relationships provide the foundation for the fellow’s transition from novice to competent professional. In this essay, we begin by discussing our pedagogical commitments. Next, we describe the structures our program has created to assist our (...) fellows in becoming competent ethicists. We then outline the kinds of knowledge, skills, and professional attributes mentors should possess. Following this, we focus on the knowledge, skills, and professional attributes that fellows develop as they co-create effective mentoring relationships. We will not prescribe a single approach to fellowship training; instead, our perspective will, we hope, become a catalyst for further conversation on training and mentoring clinical ethics fellows. (shrink)

Mrs. Duong had coronary artery disease, ischemic cardiomyopathy, and mildly altered mental status when her case was presented before an advanced heart therapy medical review board. She was accepted for left ventricular assist device placement pending additional insight into her cognitive state. Before the LVAD could be implanted, however, Mrs. Duong went into cardiogenic shock, and her heart failure team placed an intra‐aortic balloon pump in her subclavian artery. Within two weeks, Mrs. Duong became IABP dependent and deconditioned. The attending (...) deemed her as lacking capacity to make complex medical decisions, and the medical review board officially declined her for LVAD placement. The heart failure and CICU teams feel that Mrs. Duong is not being helped by the care they are giving her. They recommend terminal weaning of the IABP and initiation of comfort care. Her family disagrees, pointing to activities like continued eating and interacting with family. At an impasse after yet another family meeting, the attending for the heart failure team asks the clinical ethics consultant, “Do we have to replace the balloon pump when it fails?”. (shrink)

Every clinical ethics consultant, no matter their own spirituality, will meet patients, families, and healthcare professionals whose spiritualities anchor their moral worldviews. How might ethicists respond to those who rely on spirituality when making medical decisions? And further, should ethicists incorporate their own spiritual commitments into their clinical analyses and recommendations? These questions prompt reflection on foundational issues in the philosophy of medicine, political and moral theory, and methods of proper clinical ethics consultation. Rather than attempting to offer definitive answers (...) to these questions, this essay prompts readers to consider their own answers to these questions. Specifically, it offers a taxonomic analysis of six (6) distinct responses: assessment, delegation, examination, translation, incorporation, and assertion. Furthermore, this essay describes the role of the ethicist’s own spiritual commitments during the responses. Each section also names several strengths and weaknesses that ethicists ought to consider when evaluating the purpose and scope of each response. This paper prompts readers to consider circumstances under which they might promote, critique, or incorporate spiritual worldviews—their own and those of their patients—when offering clinical analyses and recommendations. (shrink)

Despite the interpersonal nature of family meetings and the frequency in which they occur, the clinical ethics literature is devoid of any rich descriptions of what clinical ethicists should actually be doing during family meetings. Here, we propose a framework for describing and understanding “transitioning” facilitation skills based on a retrospective review of our internal documentation of 100 consecutive cases wherein a clinical ethicist facilitated at least one family meeting. The internal documents were analyzed using qualitative methodologies, i.e., “codes”, to (...) identify emergent themes. We identified four different transitioning strategies clinical ethicists use to reach a meaningful resolution. These transitioning strategies serve as a jumping-off point for additional analyses, future research, evaluating clinical ethics consultation, and overall performance improvement of a consultation service. (shrink)