Journal of Clinical Ethics最新文献

AbstractThis piece describes two patients whose external circumstances caused harm to them. One had poor health insurance and lacked financial resources. The other lacked access to optimal healthcare because he was not a U.S. citizen. These external factors are commonly now referred to as "structural" and "intersectional" when they are single and multiple, respectively. This piece initially discusses how providers may better come to identify these external sources of harm to patients and then, hopefully, seek to alleviate them. It then discusses how providers, too, may cause external harm. They may make erroneous presuppositions about their patients based on their having certain impairments or symptoms, not know this, and as a result cause these patients iatrogenic harm. Means to avoid this, drawn largely from The Anti-Ableist Manifesto, a recently published, authoritative text on this subject written by Tiffany Yu, are outlined. Finally, the life of a young man, Mats Steen, is presented. His life most profoundly poses the questions of how we make inferences regarding people based only on how they look and what (little) we may know about them and how this may then affect how we can relate with them. Steen's life story is viewable on Netflix.

AbstractContext: As advance directives (ADs) become more frequently utilized, opportunities increase for conflict between a patient's designated healthcare power of attorney (POA) and the treatment preferences outlined in their living will (LW). Little is known about patient preferences regarding how to resolve these conflicts.

Objectives: To assess patient preferences regarding whether their POA or LW should have authority in times of conflict.

Methods: In this mixed methods study, we completed a retrospective chart review to analyze patient selections in their AD, including selections in a novel section of the AD called the "Binding Guidance" section that gives patients the ability to designate whether their POA or LW should have authority when there is conflict between the two. Additionally, willing patient participants were asked two interview questions about their selections to further elucidate their perspectives.

Results: Out of 143 patients, 48.3 percent (n = 69) chose to have their LW followed over their POA and 51.7 percent (n = 74) chose to have their POA followed over their LW. Several statistically significant associations were identified regarding binding guidance selections. Seventy-four (51.75%) of these patients also answered the additional interview questions, with the participants evenly distributed (n = 37 each) in their binding guidance selections.

Conclusion: Patients have varying preferences regarding whether their POA or LW should have authority in times of conflict. ADs should reflect this variation in preferences and allow patients the ability to designate whether they prefer their POA or LW to have ultimate authority when in conflict.

AbstractNew York City Health + Hospitals (NYC H+H), our nation's largest municipal healthcare system, with 10 acute care hospitals and five long-term care facilities, asserts in its mission statement that healthcare workers should join with communities to promote and protect the total physical, mental, and social well-being of the people. Such is reflective of the communitarian viewpoint, focusing on the importance of the community and advocating for their common good, which is in keeping with the concept of communitarian ethics espoused by Nancy Dubler when she assumed the role of ethics advisor to NYC H+H in 2009. From the onset she implemented key changes, beginning with the creation of a system-wide Bioethics Council, in which all 10 ethics committee chairpersons met regularly with her. During these meetings, groundwork was laid for (1) creation of standardized clinical ethics chart notes, with inclusion of key ethical principles; (2) establishment of a Clinical Ethics Consultation Program for continuous evaluation of performance and education of clinical ethics consultants; (3) development of mechanisms to qualify consultants, including a year-long bioethics certificate course, supervised training, and participation in an annual ethics symposium; (4) formation of clinical ethics algorithms; and (5) publication of journal articles to highlight the work of the Bioethics Council to the broader bioethics community. This article will focus on how Nancy transformed the nation's largest municipal healthcare system from an enterprise lacking an integrated approach to clinical ethics to one with a robust clinical ethics infrastructure and vibrant ethics community.

AbstractMedical deportation, or the forced removal of severely injured and chronically ill, low-income, uninsured migrants to their countries of origin, remains a practice implemented by hospitals throughout the United States. This practice has been rightfully highly criticized by immigration advocates and human rights organizations. In 2019, the U.S. government eliminated a deferred action program allowing migrants without documentation to avoid deportation while they or their relatives were undergoing lifesaving medical treatment, forcing patients with highly complex medical needs to give up specialized healthcare allowing them to survive and thrive. When meaningful recovery from severe disease and injury is possible, medical deportation is unquestionably abhorrent, often rooted in media-driven, racialized criminalization of U.S. residents without documentation. However, extreme circumstances call into question whether there is ever an appropriate implementation of this practice. This commentary on a case seeks to highlight that in circumstances where patients face no chance of meaningful recovery, medical deportation may serve as an avenue through which to alleviate suffering.

AbstractClinical ethicists ought to account for stakeholder traumas while finding an acceptable balance between competing obligations and responsibilities. Among these is the ethical responsibility to avoid unnecessary suffering that can occur if the decision-making process is prolonged when accounting for the past and present traumas of patients, healthcare team members, and surrogate decision makers (SDMs). Autumn Fiester makes a radical proposal to prioritize avoidance of SDM retraumatization, suggesting that current ethics consultation best practices fall short of standards in trauma-informed approaches. We respond to Fiester and argue that current best practices in ethics consultation already support creating space to identify stakeholder traumas and integrate them into the decision-making process, which sufficiently fulfills an ethics consultant's responsibility to implement trauma-informed practices. Fiester's proposal of prioritizing SDMs, even when this risks violating a patient's bodily dignity, falls back on a traditional view of prioritizing a power structure of those who are related to a patient by genetics or by law. Ethics consultants should flexibly negotiate all stakeholder perspectives to avoid unnecessary retraumatization and to prioritize stakeholders, depending on the specific ethical issues and context.

AbstractTreating two patients who either are closely related or are members of the same household can raise a distinct set of ethical challenges. These challenges, which differ depending on whether or not the overlapping patients are aware of the common provider, may include ethics issues related to confidentiality, entanglement, objectivity, expectations, and potential manipulation. This article examines each of these issues and offers general guidance on how to manage such cases. While the focus is on psychiatric care, where these issues are often more pronounced, the reasoning applies to other medical subfields, including those in which overlapping care is either tolerated or sanctioned. The goal is to generate awareness about an underappreciated challenge that has not yet received significant consideration in either the medical or ethics literature.

AbstractIn their article "Attending to Trauma, Balancing Power, and Prioritizing Stakeholders in Ethics Consultation," Ford, Morley, and Sankary respond to my argument about surrogate trauma and prioritization. They offer the most challenging set of arguments against my thesis. They also offer the sharpest critique of Lanphier and Anani's original TIEC proposal. Ford, Morley, and Sankary likely represent the reaction that most professional clinical ethicists will have to my proposal, and their voice is essential in this debate, both for their own philosophical insights and for the representation of the views of many in the field.

AbstractThis piece builds on research conducted and reported in this issue in which nursing students underwent simulation training to increase their confidence when discussing ethical conflicts with physicians. I discuss here the general importance of nurses and physicians finding ways to work optimally together, especially when they face difficult ethical dilemmas involving patients. These providers reducing any emotional conflict they might have with each other is critically important for several reasons. Chief among these reasons are the direct harm this will cause these patients, due to their feeling increased tension, and also, as a result of this increased tension, their thinking less clearly regarding their utmost medical needs and wants. I discuss why this need is increased when ethics decisions are at stake, and I suggest three specific practical approaches that providers in both groups can use to enhance their ability to interact more harmoniously and synergistically with each other. They can immediately adopt these suggestions in their clinical practices. Their ability to use these suggestions most effectively will, however, continue to increase if and as they continue to use and practice them over time. The positive outcomes for providers using these approaches, even for just a few minutes, may surprise them. Though brief, the difference these approaches can make may be disproportionately substantial. Encounters they dreaded, instead of being confrontational, may become caring, rewarding, and productive.