Journal of Clinical Ethics最新文献

AbstractIn this piece I discuss optimal approaches that providers may take when pursuing surrogate decision-making. A potential critical problem here is some providers' approach differing from that of others. To the extent that this occurs, the results may be arbitrary, and the harm from this may be profound since this may affect, of course, even whether some of these patients will live or die. One factor possibly resulting in these differences is the moral weight providers place on what family members want when these outcomes differ from what they think patients would want. Providers now most commonly place greatest moral weight on following what patients would want to maximally respect their autonomy, but this view may clash with the view of others who see autonomy as more relational and thus based on prior and present social relations with others. Giving family members' wants more moral weight is a radical departure from what providers do now and may increase these differences. I discuss here the rationales for and against these competing choices.

AbstractOrgan procurement organization (OPO) staff play an essential role in the facilitation of organ donation as they guide family members and loved ones of dying patients through the donation process. Throughout the donation process, OPO staff must assume the role of a dual advocate, considering both the interests of the donor (which often include the wishes of the donor's family) and the interests of potential recipient(s). The benefits of this role are well established; however, minimal literature exists on the ways this role can cause moral distress in OPO staff, who frequently face scenarios in which adhering to the wishes of a donor family may compromise donation potential but failing to honor donor family requests may result in further emotional burden for the family. Given the frequency with which these ethically complex situations exist during donation, OPO staff are at heightened risk for experiencing moral distress and burnout, yet they are seldom acknowledged in the existing moral distress literature. As a result, it is unclear whether the current practices available to mitigate moral distress are beneficial for this population.

AbstractThe contingency phase is a transition period between usual healthcare delivery and the activation of formalized rationing protocols under crisis standards of care. The contingency phase is defined by two simultaneous goals: avert or forestall critical scarcity of healthcare resources, and provide patient-centered care that is functionally equivalent to usual care when dynamic changes to healthcare operations are necessary to prevent hospital surge overload. Contingency measures modify the allocation of hospital space, staff, and supplies in service of these two goals. Although functionally equivalent care is theoretically possible, hospitals often cannot know a priori which alterations to space, staff, or supplies will lead to downstream effects on patient outcomes, raising ethical questions about how hospitals should institute equitable contingency measures when safety and efficacy data is limited. The current ethics literature has not sufficiently addressed these questions.

AbstractThis piece discusses several ways in which providers may advocate for patients and their families that go beyond what providers usually do to help their patients. A much more expanded view of advocacy is suggested. Real cases illustrating all interventions suggested are presented, and each is paradigmatic of numerous others. Categories of possible options suggested for expanded advocacy include (1) providers enhancing patients' outcomes when standard treatments have failed, (2) providers taking measures outside those they usually take to benefit patients to a greater extent, and (3) providers sacrificing their own needs more than they customarily do to help their patients still further. The suggested interventions are practical and can be implemented immediately. Taken together, the interventions proposed are also aspirational.

AbstractThe field of surgery has relied on innovation and creativity to improve patient care and propel the field forward. Historically, regulatory oversight of innovative approaches to surgery has been largely inconsistent, rendering surgeons relatively unrestricted creative latitude in the operating room; whether this has proven to be more beneficial or harmful is subject to debate. While innovation plays a crucial role in the advancement of surgical techniques, the potential drawbacks of unregulated innovation must be seriously considered, especially when treating vulnerable populations such as infants and children. This article provides an overview of the ethical aspects surrounding innovation in pediatric surgery, including discussion of relevant considerations, controversies, and pitfalls. The following includes a review of the current and past literature surrounding the topic. The purpose of this review is to heighten awareness of the ethical challenges that surgeons face when considering novel operative techniques on pediatric patients.

AbstractPsychiatric treatment options, such as electroconvulsive therapy (ECT), can be lifesaving for individuals suffering from severe mental illness. For individuals who are unable to make or communicate their own medical decisions, this decision may fall on a legal guardian, who will make decisions on the patient's behalf. Here we discuss the considerations of end-of-life planning in a patient with severe mental illness under guardianship when treatment modalities, in this case ECT, are no longer effective.

AbstractPatients' spiritual views and, more generally, the meaning they feel in their lives is often, if not always, most important to them, especially when they have serious illness. Yet there are no standard requirements for providers to explore with patients their spiritual needs. Providers' views regarding their both taking initiatives to explore with patients needs and then to discuss with them their religious concerns if they want this vary widely. This piece explores, then, the extent to which providers should take these initiatives and, if they have this interest, whether as providers they should carry on these discussions or refer these patients, always, to clergy persons, as some providers adamantly advocate because they have expertise in this area that providers lack. This piece goes on to discuss whether providers believe they should have these discussions even when their patients' beliefs differ greatly from their own. In exploring this question, examples involving patients with Muslim, Hindu, and Christian beliefs are considered. Beliefs reported by some people from Germany and Israel regarding physician-assisted dying also are reported and compared, illustrating that patients' and people's beliefs cannot be reliably just inferred. Practical approaches, finally, are suggested.

AbstractThe ethical allocation of scarce medical resources has received significant attention, yet a key question remains unaddressed: how should scarce, divisible resources be allocated? We present a case from the COVID-19 pandemic in which scarce resources were divided among patients rather than allocated to some patients over others. We assess how widely accepted allocation principles could be applied to this case, and we show how these principles provide insufficient guidance. We then propose alternatives that may help guide decision-making in such cases, and we evaluate the possibility of treating patients equally by dividing resources equally. Resource scarcity is not limited to pandemic situations, and many healthcare resources are divisible. This question-how to allocate these divisible resources-deserves greater attention from bioethics.

AbstractThe authors describe their Ethics Program's transition from utilizing ethics committees to instead implementing a three-initiative structure consisting of Ethics Grand Rounds, an Ethics Liaison Network, and an Ethics Advisory Group. They first outline the history of ethics committees. Then, they discuss the history of their Ethics Program and the challenges that ethics committees posed. Next, they describe their approach to developing new initiatives for non-ethicist healthcare professionals to engage in ethics work and what these initiatives specifically entail. They then describe how they worked to secure buy-in for dissolving their ethics committees and, based on pre- and post-implementation surveys, how this transition has been received by former ethics committee members. Finally, the authors reflect on what has been gained and lost through these changes and offer insights and recommendations for other ethics programs thinking about discontinuing their own ethics committees in favor of more innovative models.

AbstractBackground: Clinical ethics consults are sometimes requested for patients who lack capacity and do not assent to discharge recommendations, particularly those with neurocognitive or psychiatric disorders desiring home discharge. Balancing the risks and benefits of overriding patient preferences involves considering dignity, values, clinical information, and available resources. Outcomes of such consultations lack characterization in the literature.

Methods: We examined clinical ethics consultations from December 2015 to June 2023 at a large, urban academic medical center serving a diverse community with high poverty rates. Time to readmission and proportion readmitted within 30 days were analyzed by discharge disposition.

Results: Among 1,163 ethics consults, 167 were for discharge planning. The median age was 65.4. Of these, 56.7 percent were male; 29.9 percent, Black, non-Hispanic; 26.9 percent, Hispanic; and 19.1 percent, White, non-Hispanic. More than 37 percent had a psychiatric diagnosis, with a similar percentage affected by dementia. Discharge to skilled nursing facilities (SNFs), home without nursing care, home with nursing care, subacute rehabilitation facilities, and elopement constituted 33, 26, 26, 2, and 2 percent, respectively. The discharged-to-home group showed the highest average days to readmission (243), while the average for the discharged-to-SNF group was 153. These differences were not statistically significant when controlling for age, gender, and comorbid conditions.

Conclusions: Half of the patients consulted for discharge planning were discharged home and were not at higher risk for early readmission. This higher-than-expected percentage may reflect increased attention to patient values when bioethics is involved.