This book is about the ethical issues that clinicians encounter as they care for patients and is written to assist those who serve on hospital ethics committees as they deliberate about appropriate action in difficult ethical cases.

Book reviewed in this article: Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. By Albert R. Jonsen, Mark Siegler, and William J. Winslade.

This book is about the ethical issues that clinicians encounter as they care for patients and is written to assist those who serve on hospital ethics committees as they deliberate about appropriate action in difficult ethical cases.

The model of clinical ethics consultation (CEC) defended in the ASBH Core Competencies report has gained significant traction among scholars and healthcare providers. On this model, the aim of CEC is to facilitate deliberative reflection and thereby resolve conflicts and clarify value uncertainty by invoking and pursuing a process of consensus building. It is central to the model that the facilitated consensus falls within a range of allowable options, defined by societal values: prevailing legal requirements, widely endorsed organizational policies, and (...) professional standards of practice and codes of conduct. Moreover, the model stipulates that ethics consultants must refrain from giving substantive recommendations regarding how parties to a moral disagreement in the clinic should evaluate their options. We argue that this model of CEC is incomplete, because it wrongly assumes that what counts as the proper set of allowable options among which the parties are to deliberate will itself always be clearly discernible. We illustrate this problem with a recent case on which one of us consulted—a neonate born with trisomy 18 (T18). We try to show that law, policy, and standards of practice reveal no clear answer to the question posed by the case: namely, whether forgoing gastrostomy tube feedings for a baby with T18 is allowable. We suggest there may be other kinds of cases in which it may simply be unsettled whether a given choice falls within the set of allowable options within which consensus is to be facilitated. What should an ethicist do when confronting such unsettled cases? We agree with the facilitation model that an ethicist should remain neutral among the allowable options, when it is clear what the allowable options are. But, in unsettled cases, the role of a consultant should be expanded to include a process of moral inquiry into what the allowable options should be. We end by raising the issue of whether this means an ethicist should share his or her own conclusions or views about the allowability of a given clinical option. (shrink)

In terms of medical science and legal responsibility, the sleep disorder category of parasomnias, chiefly REM sleep behavior disorder and somnambulism, pose an enigmatic dilemma. During an episode of parasomnia, individuals are neither awake nor aware, but their actions appear conscious. As these actions move beyond the innocuous, such as eating and blurting out embarrassing information, and enter the realm of rape and homicide, their degree of importance and relevance increases exponentially. Parasomnias that result in illegal activity, particularly violence, are (...) puzzling phenomena for medicine and the law. Via a review of the pertinent medical literature, a general overview of the current scientific knowledge of parasomnias will be provided. Though this knowledge is far from complete, it can provide some neurobiological information about the nature of parasomnia, including conclusions about a sleepwalker’s level of intention as well as factors that predispose one to such episodes. Although a parasomniac’s complete lack of consciousness warrants acquittal from criminal liability, it does not exclude responsibility for subjecting oneself to exacerbating factors that result in these violent parasomnias. Individuals should be held accountable if they could be expected to control these factors. In addition, they should undergo appropriate treatment and management in order to prevent future parasomnia behaviors. Establishing a legal defense for parasomnia will prove difficult due to the strong potential for malingering, so specific criteria will be outlined in order to distinguish between true and fraudulent claims of crimes committed during parasomniac states. (shrink)

In this comment I discuss the role of an ethics case consultant in an institutional setting, in contrast to situations when an ethics consultant serves an individual client. In the former situation, I believe the case consultant should articulate ethical issues, options, and arguments, but not recommend a particular course of conduct. In the latter situation, the role of the ethics consultant can be defined and determined in negotiations with the client.

We believe that clinical ethics consultants (CECs) should offer advice, options, and recommendations to attending physicians and their teams. In their article in this issue of The Journal of Clinical Ethics, however, Kornfeld and Prager give CECs a somewhat different role. The CEC they describe may at times be more aptly understood as a medical interventionist who appropriates the roles of the attending physician and the medical team than as a traditional CEC. In these remarks, we distinguish the role of (...) the CEC from that of the physician, in contrast to some of these authors’ recommendations, which confuse the two roles. (shrink)

John H. Evans’s views on the multiple roles of healthcare ethics consultants are based on his claim that bioethics is a “distinct profession” that has a “system of abstract knowledge.” This response to Professor Evans disputes both of his claims. It is argued that clinical ethicists are consultants but not professionals. Their roles as consultants require more than one abstract form of knowledge (principlism). Instead, clinical ethicists rely upon a variety of ethical perspectives and other skills to help resolve conflicts (...) and facilitate healthcare decisions and policy making, whether it is in clinical, research, policy, or organizational contexts. The credibility and effectiveness of clinical ethicists depend upon their knowledge of ethics, their practical experience, and personal abilities, not one form of abstract knowledge. (shrink)

Persons who commit crimes involving sexual abuse of children exploit their victims in several ways. Sex offenders use their power and authority over vulnerable children to whom they have easy access. Teachers, coaches, clergy, family members and childcare workers have been exposed as sex offenders. The Pennsylvania State University football coach, Jerry Sandusky, is now in prison for his many crimes. The widespread cover up of sexual abuse by Catholic priests in the USA and other countries is a horrendous scandal. (...) It is not surprising that law enforcement, mental health professionals, victims and their families are outraged. It is no surprise that radical interventions such as chemical or surgical castration are a response to the public pressure to protect children from molestation.I agree with Professor John McMillan's thoughtful discussion and nuanced analysis of surgical castration.1i He concludes that surgical castration of sex offenders is ethically permissible if these conditions are met: Castration should be requested by the sex offender. Informed consent from a competent sex offender is required. Consent to castration must not be coerced via threats or inducements.He also says that “castration might be useful for the reconfiguring of a life that has gone badly awry.”To supplement his discussion I will describe a state law in Texas2 that permits voluntary surgical castration for repeat child molesters while they are incarcerated as …. (shrink)

We argued in our joint article that the facilitated consensus model of clinical ethics consultation is incomplete because it does not address the problem of what we have called “unsettled cases.” Sabrina Derrington and April Dworetz, Mark Aulisio, and Al Jonsen have each usefully challenged our claims and conclusions. In this brief article we respond to some of their arguments.

ABSTRACT There is a fierce debate about nonsmokers-only hiring policies, also referred to as no-nicotine hiring policies and “tobacco free” hiring policies. The favorable outcomes of no-nicotine hiring policies include reduced health costs, improved worker productivity, enhanced organizational image, and symbolic messaging. The unfavorable consequences of such policies include violating personal liberty, risking a “slippery slope” to other health-compromising behaviors, exacerbating socio-economic disparities, and discriminating against smokers. No-nicotine hiring policies have not been adequately evaluated and a new approach is warranted. (...) The new conditional employment policy for smokers is described with stipulations for the probationary period. Autonomy and fairness are frequently cited as ethical principles to analyze no-nicotine hiring policies. An analysis of ethical principles is presented for no-nicotine hiring policies and the new conditional employment policy. The ethical principle of fairness is rooted in the effectiveness of any policy. Therefore, an evaluation plan is described for the conditional employment policy to assess effectiveness and efficiency. The proposed policy provides a powerful incentive to overcome smoking addictions, preserve the ethical principles of autonomy and fairness, as well as bridge the divide between personal liberty and personal responsibility. (shrink)

Persons who experience severe brain injury often suffer significant disorders of consciousness. Anoxic injuries from cardiac arrest or strokes and traumatic injuries from falls, vehicular crashes, or assaults can result in several conditions in which patients lose or have diminished consciousness for an extended period of time. Two such conditions that create considerable public confusion and controversy are the vegetative state and the minimally conscious state. Although these conditions have generated significant medical and academic research, the general public and policymakers (...) are often confused about the nature of VS and MCS. The most recent evidence for this confusion is the acrimonious public debate, the extensive media coverage, the prolonged litigation, and the attempts of various governmental officials to intervene in dealing with the plight of Terri Schiavo. (shrink)

Book reviewed in this article: Sex, Drugs, Death and the Law: An Essay on Human Rights and Overcriminalization. By David A. J. Richards. Totowa, NJ: Rowman and Littlefield, 1982. xii + 316 pp. $26.95.

Diese Abhandlung untersucht die Frage, ob internationale Richtlinien für die Gentechnologie, insbesondere im Hinblick auf "genetische Verbesserungen" , wünschenswert und machbar erscheinen. Es wird die Auffassung vertreten, daß die Forderung nach solchen internationalen Richtlinien sich unüberwindlichen praktischen Hindernissen gegenübersieht. Den Hintergrund für diese Auffassung bilden die Ambivalenz des Richtlinienkonzepts, das Fehlen einer Autorität, die solche Richtlinien in Kraft setzen könnte, mangelnder Konsens über zentrale Normen oder Werte, die in die Richtlinien einbezogen werden könnten, der Widerstand sowohl von Seiten der Wissenschaft (...) als auch der privaten Wirtschaft gegen solche Richtlinien und schließlich die öffentliche Forderung nach der Einführung von Methoden "genetischer Verbesserung". Die Forschung über Methoden "genetischer Verbesserung" hat schon begonnen und wird sich ohne Zweifel fortsetzen. Es wird daher in diesem Beitrag vorgeschlagen, daß öffentliche Mittel zur Unterstützung der Forschung über "genetische Verbesserung" zur Verfügung gestellt werden, um sicher zu stellen, daß Forschung dieser Art angemessene vorhergehende Begutachtung und andauernde Überwachung erfährt. Öffentlichkeit, Vorausschau und Kritik können uns helfen, vom Mißbrauch des Menschen als Forschungsobjekt und rücksichtslosem Forscherdrang weg und hin zu akzeptablen Formen der "genetischen Verbesserung" zu kommen. This essay explores whether international guidelines in genetics, specifically regarding genetic enhancement, are desirable and feasible. It is argued that the quest for international guidelines faces insuperable practical obstacles. These include the ambiguity of the concept of guidelines, no authoritative body to issue guidelines, lack of consensus about substantive norms or values to be incorporated into guidelines, resistance from the scientific as well as the private business sector to guidelines, and public demand for genetic enhancement. Genetic enhancement research has already begun and will no doubt continue. It is proposed that public funding for genetic enhancement research be provided to ensure that such research receives adequate prior review and continual monitoring. Publicity, oversight, and critique can help steer us away from abuses of human research subjects and reckless science toward acceptable forms of genetic enhancement. (shrink)

In analyzing moral distress, perhaps greater attention should be given to the possible implicit sources of feelings of distress, as well as explicit sources.

When a health care professional contacts a health care attorney for advice about how to deal with a medical error involving a patient, what is the most ethically appropriate response? Honesty is the best policy; the ethical health lawyer should advise the client to tell the patient the truth. This advice is neither naïve nor impractical, as we will show. More importantly, it is without question the right thing to do for a number of sound reasons. It may not be (...) a natural inclination or an easy task to accomplish; several countervailing factors discourage health professionals from telling patients the truth about medical errors. However, we will argue that resistance to truthful disclosure can and should be overcome by rational arguments that also take into consideration the psychodynamics of the patient-health professional relationship. (shrink)

Volume 19, Issue 9, September 2019, Page 8-10.

Book reviewed in this article: Madness and the Criminal Law. By Norval Morris. The Insanity Plea: The Uses and Abuses of the Insanity Defense. By William J. Winslade and Judith Wilson Ross.

The American Journal of Bioethics, Volume 11, Issue 12, Page 75-77, December 2011.