Journal of Clinical Ethics最新文献

AbstractClinical ethics support services (CESS) are advisory bodies that deal with ethical conflict arising in healthcare. Patient involvement with CESS remains a contentious issue, without uniform practice regarding whether, how, and when patients should be involved. The overall objective of the study was to understand key stakeholders' viewpoints about CESS and urgent decision-making. Patient involvement and clinical ethics emerged as a key area of discussion. Three stakeholder groups were recruited: doctors in England, CESS members in England, and CESS members in the United States. Recruitment occurred via dissemination of the study online and via email. This resulted in a sample size of 13 participants. The focus group transcripts were analyzed using reflexive thematic analysis. The study found that there was uniform acceptance of the importance of patient representation by all stakeholders. However, the ways in which their involvement was facilitated varied. CESS members in the United States routinely involved the family directly by discussion with the clinical ethicist. However, CESS members and doctors in England viewed patient presence in committee meetings as a barrier to open discussion. Instead, CESS in England would seek ways in which involvement could occur, such as a written statement or advocation by the clinical team. The clinical ethicist model, adopted in the United States, appears to support direct patient involvement in the consultation process, in comparison to the clinical ethics committee model adopted in England. However, these results are limited by the small sample size and small number of viewpoints represented.

AbstractAs one of the core tenets of bioethics, autonomy describes the ability of patients to make informed decisions about their medical care. Over the past decade, however, research in behavioral economics has called into question just how much liberty or agency individuals have when making decisions. Patients sometimes harbor irrational decision-making biases and are impacted by their surrounding environments. In particular, purposely or inadvertently, physicians can operate as choice architects: they may use "nudges" to exert their influence and guide their patients' decisions. Although such nudges occur without limiting the patients' rights to either refuse or request alternative options, the use of nudges stands in stark contrast to conventional definitions of autonomy, which assume that all actors can function independently.

AbstractPatients without capacity or a surrogate decision maker are known as unrepresented. These patients are highly vulnerable and frequently encountered in healthcare settings, though there is little consensus regarding how medical decisions should be made on these patients' behalf. Several states now require a second nontreating physician (SNTP) to evaluate nonemergent medical decisions for unrepresented patients. This article examines the legal and ethical challenges faced by SNTPs in the dual-physician authorization process, including biases in SNTP selection, time constraints, power dynamics, and accountability concerns. We propose a checklist to guide SNTPs in the care of unrepresented patients while minimizing biases and conducting rigorous risk-benefit assessments. Institutional strategies to address the challenges faced by SNTPs include systematic SNTP selection processes, protected time for evaluations, peer review panels, training to mitigate implicit bias, and iterative review for quality improvement. By providing an ethical framework for dual-physician authorization and actionable processes for minimizing bias, we seek to promote fair and thoughtful decision-making on behalf of unrepresented patients.

AbstractScholars have challenged Jameton's original conceptualization of moral distress on the basis that it is too narrow and discounts significant moral experiences. Further inconsistencies about the necessary and sufficient conditions required for moral distress to occur have heightened conceptual ambiguities. The aims of this research were to examine nurses' experiences of moral distress and to utilize these findings to critically examine a previous model of moral distress developed from data gathered in the United Kingdom. This article presents findings from a feminist interpretive phenomenological study in which nurses in the United States were interviewed about their experiences of moral distress. Nurse participants in this study described experiencing strong negative emotions in response to five distinct morally challenging situations. These situations were categorized into the same five moral events as identified in the original study, reinforcing the five subcategories identified from interviews with nurses in the United Kingdom. The most significant change to the moral distress model was centering the interpretive and evaluative component of moral distress. Understanding moral distress as subcategories enables a more precise analysis of moral distress, while retaining the power of the term "moral distress." The revised moral distress model can guide our responses to moral distress and interventions to mitigate its negative effects.

AbstractNancy Dubler's influence on the field of bioethics was both wide and deep; this article focuses on her impact on bioethics education. Dubler's work stresses the importance of three key themes: the level playing field, multiple perspectives, and mediation as a path to creating a just resolution. We explore all three of these themes in Dubler's work in bioethics education.

AbstractNancy Dubler pioneered "bioethics mediation" as a method of clinical ethics consultation (CEC), arguing that "bioethics consultation is largely, although not entirely, a matter of conflict resolution." By the time she published the second edition of Bioethics Mediation in 2011, she had garnered significant support for the idea that mediation had an important role to play in CEC. But in the intervening decade and a half, a new generation of CEC thought leaders have emerged, and there is clear evidence that, for them, conflict management has very little to do with the practice of CEC. Today, there are not only just a small proportion of ethics consultants (ECs) trained in mediation skills but also only a small proportion of ECs who view such skills as essential to the practice of CEC. Yet conflict among patients, families, and healthcare providers remains a significant problem in U.S. healthcare institutions. The new trends in CEC make it unlikely that ethics will be the locus for the conflict management services hospitals need; therefore, I will argue that it is time to transfer the mediator role from ethics to the newly emerging Patient and Guest Relations departments. I believe that this offers the best prospects for defending Dubler's legacy.

AbstractIn the past 15 years, trauma-informed care (TIC) has evolved as a new paradigm in healthcare that recognizes the impact of past traumas on patients' and families' healthcare experience while seeking to avoid inducing new trauma during clinical care. A recent paper by Lanphier and Anani extends TIC principles to healthcare ethics consultation (HEC) in what they label "trauma-informed ethics consultation" (TIEC), which calls for the "addition of trauma informed awareness, training, and skill in clinical ethics consultation." While Lanphier and Anani claim that TIEC is "novel, but not radical" because it builds on the approach to HEC endorsed by the American Society for Bioethics and Humanities, I believe that TIEC has radical implications, particularly regarding ethical obligations to surrogate decision makers (SDMs). Given what I call the SDM's "trauma capacity," I argue that TIEC accords moral priority to SDMs over patients in certain types of end-of-life cases, particularly futility disputes, which is a radical departure from the conventional HEC approach to SDMs.

AbstractIn this introduction I discuss several ethical issues pertaining to the question other authors raise regarding whether we should permit minors to donate an organ-such as part of their liver or a kidney-to a sibling. I discuss particularly limits of what ethical analysis can accomplish; overriding, disproportionate effects of what might appear to be no more than minor nuances; exceptional expertise "ethics experts" can and can't offer; how patients' and family members' feelings may prevail over rational arguments; the importance of recognizing and respecting patients' felt relationships with others; and our global obligations to people worse off. A core feeling considered is a child's feeling of guilt if the child doesn't donate and this sibling dies. A nuance considered is a sibling wanting to donate to an identical twin. I consider some providers' bias that an intervention is death prolonging rather than life prolonging. When providers arrive at an impasse and continue to reasonably differ, switching the question to how an ethical resolution should be reached and by whom is recommended. Practical applications such as this that can be implemented by providers now are offered in regard to each of the ethical issues addressed.

AbstractIn this article we focus on Nancy Neveloff Dubler's role on the New York State Task Force on Life and the Law as means to illustrate her public policy contributions as a bioethicist. We review the historical origins of the Task Force, its impact on and contributions to bioethics, and the law. We then make metaobservations about Dubler's commitment to social justice as a governing principle in her deliberative stance on the Task Force. To that end, we specifically highlight Dubler's contributions to the Task Force regarding the extension of the Family Health Care Decisions Act, New York's surrogate decision-making law, to people with disabilities; gestational surrogacy; and the need for crisis standards of care during the COVID-19 pandemic. We maintain that Dubler's contributions to public bioethics were as significant as her work at the bedside in clinical ethics consultation.