Journal of Clinical Ethics最新文献

AbstractThis analysis of professional organizational policies regarding potentially inappropriate life-sustaining medical treatment (LSMT) focuses on the specific threshold criteria that policies apply for limiting LSMT, as well as when (if ever) override of patient/surrogate preferences may be reasonable. Our article offers a critical analysis of one influential approach, proffered by the Society of Critical Care Medicine, that applies a prognosis-based definition of nonbeneficial/inappropriate treatment to determine that ethical threshold. We observe that this prognosis-based threshold resembles rationing in important ways, though it pertains to settings where resources may not be limited. In doing so, the approach raises concerns similar to those that have been raised about rationing, including the potential for strong institutional or individual practitioner biases and for discrimination against those with severe neurological impairments and/or indefinite technological dependence. We conclude that such concerns are valid and may never be entirely unavoidable. They may, however, be ameliorated with policies that incorporate various conceptions of harm within the calculus of cogent "competing ethical considerations" that define potentially inappropriate LSMT.

AbstractThis introduction to The Journal of Clinical Ethics highlights and expands four articles within this issue that propose somewhat new and radical innovations to help and further the interests of patients and families worst off. One article urges us to enable historically marginalized groups to participate more than they have in research; a second urges us to allocate limited resources that can be divided, such as vaccines and even ventilators, in a different way; a third urges us to help families find greater meaning when their loved ones are dying; and a fourth urges us to treat patients who illegally use drugs as caringly as is possible, though there may be limits to what providers can do. This piece also addresses the importance of providers bonding with patients, recognizing that some providers may be better at eliciting patients' trust than others, and thus the importance of connecting these patients with these providers since this may be the sole way these patients can optimally respond and do well. Finally, providers taking time away from their patients to oppose and reduce social stigma is considered.

AbstractA long-standing tenet of healthcare clinical ethics consultation has involved the neutrality of the ethicist. However, recent pressing societal issues have challenged this viewpoint. Perhaps now more than ever before, ethicists are being called upon to take up roles in public health, policy, and other community-oriented endeavors. In this article, I first review the concept of professional advocacy and contrast this conceptualization with the role of patient advocate, utilizing the profession of nursing as an exemplar. Then, I explore the status of advocacy in clinical ethics and how this conversation intersects with the existing professional obligations of the bioethicist, arguing that the goals of ethics consultation and ethical obligations of the clinical ethicist are compatible with the role of professional advocate. Finally, I explore potential barriers to professional advocacy and offer suggestions for a path forward.

AbstractPregnant research participants have long been excluded from early-stage clinical trials. This stance has been considered ethically justifiable because it upholds the principle of nonmaleficence by avoiding potential harm, using the fetus(es) as the point of reference. However, there are unintended consequences with this default approach. To illustrate these consequences, this article will review the inclusion and exclusion criteria of the Phase II and Phase III SARS-CoV-2 vaccine trials, demonstrating a downstream delay of vaccine recommendations, which hindered public health efforts. Incorporating ethical principles in addition to nonmaleficence, the authors propose an intentional effort to include pregnant participants in Phase II and Phase III designs. We consider the goals of Phase II and Phase III research of demonstrating safety and efficacy and propose that pregnant participants can potentially support these goals. Rather than reflexive exclusion, the gestational age of the participant or the pharmacology of the trial intervention may be considered as part of inclusion for pregnant participants. Expanding the principles beyond nonmaleficence, pregnancy may become a demographic variable rather than an exclusion criterion.

AbstractObjective: Thorough informed consent requires decision-making capacity, adequate information, lack of coercion, and an appropriate environment. Consent obtained in the preoperative area is hurried, limiting the quality of informed consent and the opportunity for patient reflection, characteristics inconsistent with patient-centered practice. The incidence of obtaining consent immediately prior to surgery is unknown.

Methods: Consecutive patients undergoing surgery at a single center between 1 June 2021 and 14 June 2021 were identified. Time between consent signature and operating room arrival time was measured. Three surgeons reviewed cases and categorized them as major or not major operations.

Results: 78.7 percent (199/253) of patients arriving to the preoperative area the day of surgery signed written consent that day. 99.6 percent (248/249) of anesthesia consents were signed the day of surgery. Spanish as a primary language corelated significantly with consent signing on the day of surgery (p = .04). Race and distance traveled for surgery were not significantly associated with consent signing in the preoperative area. 79.3 percent (157/198) had consent signed within 90 minutes of arrival to the operating room. Among major outpatient cases, 77.8 percent (182/234) had consent signing in the preoperative area.

Conclusions: This demonstrates routine consent signing in the hurried preoperative setting, suggesting a potential source for improved informed consent. Additionally, language-based consenting disparities, specifically in Spanish, offer opportunity for improvement. The majority of consents were signed the day of surgery, in the preoperative area, and within 90 minutes prior to operating room start time. This offers an opportunity for improved patient-centered care.

AbstractCochlear implants can restore hearing in people with severe hearing loss and have a significant impact on communication, social integration, self-esteem, and quality of life. However, whether and how much clinical benefit is derived from cochlear implants varies significantly by patient and is influenced by the etiology and extent of hearing loss, medical comorbidities, and preexisting behavioral and psychosocial issues. In patients with underlying psychosis, concerns have been raised that the introduction of auditory stimuli could trigger hallucinations, worsen existing delusions, or exacerbate erratic behavior. This concern has made psychosis a relative contraindication to cochlear implant surgery. This is problematic because there is a lack of data describing this phenomenon and because the psychosocial benefits derived from improvement in auditory function may be a critical intervention for treating psychosis in some patients. The objective of this report is to provide an ethical framework for guiding clinical decision-making on cochlear implant surgery in the hearing impaired with psychosis.

AbstractTo examine the ethical duty to patients and families in the setting of the resuscitation bay, we address a case with a focus on providing optimal care and communication to family members. We present a case of nonsurvivable traumatic injury in a minor, focusing on how allowing family more time at the bedside impacts the quality of death and what duty exists to maintain an emotionally optimal environment for family grieving and acceptance. Our analysis proposes tenets for patient and family-centric care that, in alignment with trauma-informed care principles, optimize the long-term well-being of the family, namely valuing family desires and sensitivity to location.

AbstractThe assumption in current U.S. mainstream medicine is that birthing requires hospitalization. In fact, while the American College of Obstetricians and Gynecologists supports the right of every birthing person to make a medically informed decision about their delivery, they do not recommend home birth owing to data indicating greater neonatal morbidity and mortality. In this article, we examine the evidence surrounding home birth in the United States and its current limitations, as well as the ethical considerations around birth setting.

AbstractThere is societal consensus that cancer clinical trial participation is unjust because some sociodemographic groups have been systematically underrepresented. Despite this, neither a definition nor an ethical explication for the justice norm of equity has been clearly articulated in this setting, leading to confusion over its application and goals. Herein we define equity as acknowledging sociodemographic circumstances and apportioning resource and opportunity allocation to eliminate disparities in outcomes, and we explore the issues and tensions this norm generates through practical examples. We assess how equality-based enrollment structures in clinical cancer research have perpetuated historical disparities and what equity-based alternatives are necessary to achieve representativeness and an expansive conception of participatory justice in clinical cancer research. This framework addresses the breadth from normative to applied by defining the justice norm of equity and translating it into practical strategies for addressing participation disparities in clinical cancer research.

AbstractA 29-year-old female East African refugee with no formal psychiatric history and a medical history significant for HIV was admitted for failure to thrive and concern for bizarre behavior in the context of abandonment by her husband and separation from her child. After psychiatric evaluation, it was determined that she did not have the capacity to care for herself independently; adult protective services then pursued and was awarded guardianship. While admitted, the patient repeatedly refused medical treatment, had a feeding tube placed for forced nutrition and medications (though she did at one point remove this tube herself), and received two electroconvulsive therapy (ECT) treatments. Soon thereafter, the patient's court-appointed guardian met with the primary medical, psychiatric, and ethics teams to discuss goals of care in the setting of complex social and cultural needs. It was collectively determined that the patient's choices to refuse care (including nutrition, lab work, medications, and ECT) and some repeated behaviors (e.g., denial of divorce, denial of HIV, denial of need for care) could be considered culturally appropriate in the context of the acute stressors leading up to hospitalizations. All teams concluded, therefore, that the patient had the capacity to refuse these interventions and that further forced intervention would pose a greater chance of exacerbating her already-significant trauma history than improving her outcomes. Ultimately, the patient was able to be discharged into the care of her guardian, who would assist her in receiving support from members of her community who share her language and culture.