Journal of Clinical Ethics最新文献

AbstractCommunity-based "free" clinics can be a key site of primary and preventive care, especially for underserved members of the community. Ethical issues arise in community clinics. Despite this-and the fact that ethics consultation is a well-established practice within hospitals-ethics support is rarely integrated within community clinics, and the clinical ethicist's role in community care settings remains unexplored. In this article I explore what community-engaged practice might look like for the clinical ethicist. I share my experience of being invited into a local community clinic where a team of volunteers, in partnership with a local church, provide care to persons experiencing housing and food security in our county. First, I outline some of the key ethical issues we encounter in our clinic, including how to promote the agency of community members, develop shared standards for clinic volunteers, and balance different values and priorities within the partnership. Second, I explore how the ethicist's knowledge and skills translate into this setting. I argue that, given the range of ethical issues that arise in community clinics and the need for ongoing dialogue, education, and critical reflection within such partnerships, there is a role for the clinical ethicist in this space. I discuss how clinical ethicists might begin to develop community-based partnerships and practices.

AbstractObjective: We performed this study to examine patients' choices to permit or refuse medical student pelvic examinations under anesthesia (EUAs) during planned gynecologic procedures.

Design: We conducted an exploratory retrospective chart review of electronic consent forms at a single academic medical center using contingency tables, logistic regression, and nonparametric tests to explore relationships between patient and physician characteristics and consent.

Results: We identified and downloaded electronic consent forms for a census of 4,000 patients undergoing gynecologic surgery from September 2020 through calendar year 2022. Forms were linked to anonymized medical record information. Of the 4,000 patients, 142 (3.6%) were removed from analysis because consent forms were incomplete. Of 3,858 patients, 308 (8.0%) were asked for EUA consent more than once, 46 of whom were not consistent. Overall, 3,308 (85.7%) patients consented every time asked, and 550 (14.2%) refused or limited EUA consent at least once. Nine patients limited their consent to female students, and two patients refused medical student participation at all. We performed exploratory multiple logistic regression analyses exploring differences in rates of consent across patient and physician demographic groups.

Conclusions: We find that some patients are more likely than others to refuse a pelvic EUA, magnifying the dignitary harm from a nonconsensual invasion of intimate bodily integrity and perpetuating historic wrongs visited upon vulnerable people of color and religious minorities. Patients' rights to respect and control over their bodies require that physicians take seriously the ethical obligation to inform their patients and ask them for permission.

AbstractUnbefriended patients are those with decisional impairments who lack family or friends to serve as healthcare surrogates. When such patients cannot make decisions, the court typically appoints a professional guardian to make choices aligned with the patient's values and preferences. However, this case report illustrates ethical challenges that can arise when professional guardians disregard the patient's authentic wishes. In this case study, the 38-year-old unbefriended African American male patient expressed fears about traumatic resuscitation efforts and ultimately desired de-escalation of care, which the guardian was hesitant to honor despite confirmed decision-making capacity. The guardian quickly reversed a new do-not-resuscitate order when the patient later changed his mind. Decisions about aggressive interventions like a colostomy were significantly delayed while awaiting final judgments involving the guardian's supervisors and the judicial system. The case highlights pitfalls with guardians defaulting to treatment escalation without sufficiently engaging with ethical standards or eliciting the patient's narrative identity, leading to inconsistent surrogate decisions. We propose that more robust reforms are needed, including enhanced training of guardians in ethical decision-making, and we present other means to facilitate best practices in proxy decision-making.

AbstractBackground: Little is known about U.S. healthcare provider views and practices regarding evidence, counseling, and shared decision-making about in-hospital versus out-of-hospital birth settings.

Methods: We conducted 19 in-depth, semistructured, qualitative interviews of eight obstetricians, eight midwives, and three pediatricians from across the United States. Interviews explored healthcare providers' interpretation of the current evidence and their personal and professional experiences with childbirth within the existing medical, ethical, and legal context in the United States.

Results: Themes emerged concerning risks and benefits, decision-making, and patient-provider power dynamics. Collectively, the narratives illuminated fundamental ideological tensions between in- and out-of-hospital providers arising from divergent assignment of value to described risks and benefits. The majority of physicians focused on U.S.-specific data demonstrating increased neonatal morbidity and mortality associated with delayed access to hospital-based interventions, thereby justifying hospital birth as the standard of care. By contrast, midwives emphasized data demonstrating fewer interventions and superior maternal and neonatal outcomes in high-income European countries, where out-of-hospital birth is more common for low-risk birthing people. A key gap in counseling was revealed, as no interviewees offered anticipatory counseling regarding birth setting options. Providers directly and indirectly illustrated the propensity for asymmetric power relations between birth providers and pregnant people, especially in hospital settings.

Conclusions: The narratives highlight the common goal of optimizing maternal and neonatal outcomes despite tensions arising from divergent prioritization of specific maternal and neonatal risks. Our findings suggest opportunities to foster collaboration and optimize outcomes via mutual respect and improved integration of care.

AbstractThe opioid crisis has greatly increased the number of patients who are illegally injecting drugs while hospitalized for other conditions. Physicians face a difficult decision in these circumstances: when is it appropriate to involuntarily discharge or "fire" a patient with opioid use disorder for their continued nonmedical use of opioids? This commentary on a case analyzes physicians' responsibilities to their patients and argues that physicians should fire nonadherent patients only when every other option has been exhausted and the expected benefits of firing the patient outweigh the expected harms.

AbstractBackground: Healthcare professionals (HCPs) are frequently exposed to ethical problems in patient care that can affect the quality of care. Understanding risk factors for ethical problems may help practitioners to address these problems at an early stage. This study aims to provide an overview of ethical risk factors in patient care. Risk factors known from the literature and those found in clinical ethics consultation (CEC) cases are reviewed.

Methods: A scoping review of ethical risk factors in patient care and a CEC case series were conducted, analyzing the documentation (consultation reports, feedback forms, electronic medical records) of 204 CECs from 2012 to 2020 at a somatic and a psychiatric university hospital in Basel, Switzerland.

Results: Ninety-nine ethical risk factors were identified in nine articles, related to four risk areas: patient (41), family (12), healthcare team (29), and system (17). Eighty-seven of these risk factors were documented at least once in the CEC case series. The most prevalent risk factors in the consultations studied were patient vulnerability (100%), missing or unclear hospital ethics policy (97.1%), shift work (83.3%), lack of understanding between patient and HCP (73.5%), poor communication (66.2%), disagreement between patient and HCP about care (58.8%), and multiple care teams (53.4%). The prevalence differed significantly by medical specialty.

Conclusions: There are highly prevalent ethical risk factors at all levels of clinical care that may be used to prevent ethical problems. Further empirical research is needed to analyze risk ratios and to develop specific risk profiles for different medical specialties.

AbstractMoral distress is traditionally defined as situations where one knows the right thing to do but external constraints make it nearly impossible to pursue the right course of action. Many interventions to mitigate moral distress focus on making healthcare workers more resilient or courageous in the face of adverse circumstances. While these "virtue cultivation" responses might be valuable traits for individuals, I want to argue that cultivating virtue is at best an incomplete strategy for dealing with moral distress in an organizational setting. The individualistic character of these approaches ignores how an organization's policies may be contributing to many morally distressing situations. I will argue that resources from the virtue tradition can still play a valuable theoretical role in addressing moral distress in healthcare settings if we transpose them to the organizational level. The policies of a hospital or healthcare institution can be seen as virtuous to the degree that they further the organization's goals of medicine. Organizational virtue ethics can then illuminate the issue of moral distress in healthcare organizations. If an organization's policies contribute to its members suffering from moral distress, then that policy may well inhibit the organization from carrying out its mission of providing excellent healthcare. Organizations should respond to moral distress and seek ways to mitigate if not eliminate it.

AbstractMany family members are wary of asking whether they can be present in the intensive care unit (ICU) while patients are receiving care. However, the opportunity to be present can be profoundly beneficial, especially to family members as they approach the grieving process. In the long run, this may decrease emotional complications such as post-traumatic stress disorder (PTSD) and complex grief. Family presence may also be profoundly important to patients, who may find comfort in the presence of their loved ones. Optimizing the needs of distressed families remains a controversial topic because it may distract physicians from providing needed medical care. Both parties may benefit maximally, however, through proactive training and early education during medical school, as this article will outline. Family members who may want to visit but are unable to be present in person may also benefit through virtual telehealth visits. Finally, we acknowledge specific cases that may pose ethically difficult dilemmas for ICU providers. Solutions that may be optimal in these situations will be suggested.

AbstractClinical ethicists are routinely consulted in cases that involve conflicts and uncertainties related to surrogate decision-making for incapacitated patients. To navigate these cases, we invoke a canonical ethical-legal hierarchy of decision-making standards: the patient's known wishes, substituted judgment, and best interest. Despite the routine application of this hierarchy, however, critical scholarly literature alleges that these standards fail to capture patients' preferences and surrogates' behaviors. Moreover, the extent to which these critiques are incorporated into consultant practices is unclear. In this article I thus explore whether, and how, existing critiques of the hierarchy affect the application of these standards during ethics consults. After discussing four critiques of the hierarchy, I examine how two prominent published ethics consultation methodologies-bioethics mediation and CASES-incorporate these critiques differently. I then argue that while both methodologies explicitly endorse the same hierarchy, the varying degrees to which these four criticisms are incorporated into the prescribed consultation process could produce different applications of the same standard. I demonstrate with a case study how an ethics consultant following either methodology might produce two substantively different recommendations despite using the same substituted judgment standard. I conclude that while this heterogeneity of application should not dismantle the hierarchy's status as field-wide canon, it complicates projects of professional ethics consultation consensus building.

AbstractDisruptive mood dysregulation disorder (DMDD), a relatively new diagnosis in child and adolescent psychiatry that remains without medications approved for its indication, warrants a renewed consideration of the ethics surrounding the off-label use of medications. In the absence of empirical studies, clinicians must work with the best available information regarding treatment, such as case reports demonstrating the success of off-label interventions. Although subject to ethical limitations and the risk-benefit profile of each medication, increased use of this approach in the treatment of DMDD is warranted. A review of the literature was undertaken to identify studies for inclusion in this article. A case history of a 12-year-old girl with DMDD who was treated with amantadine with good response illustrates these ethical considerations within a clinical context. There are significant benefits of off-label uses of medications in the treatment of DMDD. The promising potential of amantadine as an agent for off-label use for pediatric populations with DMDD illustrates this approach. In the absence of approved medications for DMDD, further attempts to use off-label treatments for this disorder are warranted despite ethical constraints and varying risk-benefit profiles for each medication.