Journal of Clinical Ethics最新文献

AbstractAutumn Fiester suggests that trauma-informed ethics consultation (TIEC) should focus on surrogate decision makers (SDMs) in preference over patients when (a) the patient is comatose or neurologically devastated, and hence beyond the capacity for suffering or further trauma; (b) the patient is thus incapable of asserting preferences; and (c) the patient's wishes are not known, for example, in the absence of an advance directive. Therefore, (d) in these instances the moral obligation to prevent trauma for SDMs overrides obligations to patients. Perhaps Fiester might countenance other instances, but, as presented, Fiester's TIEC placing others' trauma above patients' is thus construed fairly narrowly. This commentary first offers a few brief observations regarding each tenet of Fiester's argument and then offers broader reflections on ethics consultation and on TIEC in particular. As discussed below, when the issue sparking the request for an ethics consultant (EC) is a bona fide question of values rather than, for example, clearing up miscommunication or identifying a need for further information, ECs aim primarily to gather information and then offer their recommendation(s). This mission, I suggest, stands on thinner ice than we may recognize. Moreover, I will argue that if ECs disclose that mission to patients and SDMs with full clarity and truth, genuine TIEC becomes virtually impossible.

AbstractComplex ethical considerations arise when providing medical care for unrepresented patients. Additionally, case reports on navigating ethical challenges when caring for unrepresented patients are sparse. Here we report a clinical case of a patient who has intellectual disability, is unrepresented, and has aortic valve stenosis. We demonstrate a detailed application of capacity assessments, as well as the standards of proxy consent. We also pose a successful implementation of two-physician consent as an effective procedure to help navigate medical care for unrepresented patients. Finally, we discuss the need to streamline the provision of medical care for unrepresented patients. Through this case report, we aim to contribute to the ongoing discussion of how to best provide medical care for unrepresented patients.

AbstractIn this issue Autumn Fiester and several other experts explore optimal ethical approaches to surrogate decision-making and trauma-informed ethics consultation (TIEC). Trauma-informed care is currently recommended in many clinical contexts in which the risks of patients being traumatized by their illness and its treatment are present. This care gives priority to patients feeling safe, an asymptotic goal that prescribes no one standard practice for all patients, but one that prescribes individualized treatment tailored to each patient's idiosyncratic needs. Core points Fiester makes are how patients are especially prone to feeling traumatized when others, as is always the case with their providers, have greater power over them and the rarely considered conclusion that although providers have exceptional medical expertise and experience, this does not necessarily provide them with greater ethical expertise than their patients or others. Fiester's most radical contention may be that providers, including ethics consultants, give priority to patients' and surrogate decision makers' feelings. I discuss here these contentions and Fiester's main aim of first creating and then maintaining trust and caring feelings between all parties, no matter how much initially they may disagree. I discuss, too, how legally her suggestions may be implemented immediately.

AbstractIn this issue of The Journal of Clinical Ethics, persons who knew bioethicist and lawyer Nancy Dubler celebrate her and the most important contributions she made to the practice of clinical ethics consultation (CEC). Her insights and the many discussions here include the unmet needs of prisoners, optimal approaches to bioethics mediation that prioritize the feelings of and relations between people, ethics consultants asking families of patients who can't speak for themselves what the patient was like as a person before they discuss ethics, allocating resources consistently and fairly, learning CEC by role-playing in disempowered roles, distinguishing what is ethical from what is legal, increasing contributions from nonmedical people, increasing interconnections between health systems and the broader bioethics community, replacing oral feedings with tube feedings, fostering substitute decision makers whom patients most want, and appreciating root causes of patients' and families' mistrust. All these topics are likely to be optimal CEC practices, if not already implemented.

AbstractPhysicians are responsible for declaring patients dead. Although this decision may appear straightforward, physicians often encounter complex cases in which the decision is ambiguous. Using an extraordinary yet illustrative case, this article examines the labor-intensive tasks such cases require in order for the physician to reach a diagnosis of death. We explore three subjects: (1) definitions of death as defined in the Uniform Declaration of Death Act, (2) practical challenges for meeting those definitions of death, and (3) the detrimental impact of a delayed or ambiguous death diagnosis on caregivers, the healthcare system, and organ recipients.

AbstractIntroduction: Hospital ethics committees guide healthcare workers and patients through complex consent issues. Prior research highlights gaps in consent forms and information delivery, but little is known about real-world ethics consults on consent. This study examines common challenges in consent discussions and compares patient and consult characteristics of consent-related versus other consults.

Methods: De-identified ethics consult notes and patient data from Vanderbilt University Medical Center, a quaternary care academic medical center (2014-24), were analyzed. Consults were classified as consent or nonconsent related. Chi-square, Fisher's exact, and Wilcoxon rank-sum tests compared characteristics, while logistic regression assessed associations between consent themes.

Results: Among 4,127 ethics consults, 137 (3.3%) were consent related. Compared to nonconsent consults, consent consults involved more adult (96.4% vs. 84.2%, p = .005) and female (58.4% vs. 19.0%, p = .001) patients and were more often low in complexity (36.5% vs. 22.8%, p < .001). Common issues included capacity (65.0%), surrogate decision-making (46.0%), communication barriers (38.0%), treatment timing (29.2%), goals of care (20.4%), patient refusal (19.7%), and sensitivity/invasiveness concerns (13.1%). Capacity concerns increased the odds of surrogate decision-making issues (OR = 2.97, 95% CI: 1.51-6.30). Advance directive completion was linked to older age (p = .031) and goals-of-care discussions (50.0% vs. 17.5%, p = .018).

Conclusion: Consent-related consults differ in patient demographics and complexity, with capacity, surrogate decision-making, and communication barriers as key concerns. This study provides actionable insights to improve consent protocols, patient-clinician interactions, and ethical decision-making.

AbstractNancy Dubler founded the Montefiore Bioethics Consultation Service in the late 1970s on the cusp of two epidemics: AIDS and mass incarceration. In New York these two phenomena intersected with devastating consequences. By the late 1980s, the HIV infection rate among incarcerated people in New York State was the highest in the nation. Hospitals across the state built locked units staffed by correctional officers to manage the influx of incarcerated patients dying from AIDS-units that persist to this day. Dubler's earliest scholarship reflects this ethically fraught context. In this article we will first retrace Dubler's work on carceral medicine, in which she advocated for quality, compassionate healthcare for incarcerated patients even as she foregrounded the impossibility of delivering truly equitable care in a carceral setting. We will then show how healthcare providers in prisons, jails, and hospitals continue to struggle with the ethical dilemmas of caring for patients in what Dubler called "non-health-care spaces." In exploring these issues, we draw from our own experiences as ethics consultants and educators working with providers caring for incarcerated patients in New York State. In particular, we focus on how the carceral context may impact medical decision-making and how clinical ethicists (and providers) should respond. Nearly 50 years after Estelle v. Gamble established the right to healthcare in prisons and jails, we observe that providers continue to struggle with many of the ethical challenges Dubler identified decades ago.

AbstractBenevolent deception-the practice of intentionally withholding or distorting information to protect patients from harm-raises significant ethical concerns, particularly in multicultural healthcare settings, where cultural norms may endorse deception as an act of care. Nancy Neveloff Dubler strongly opposes deception, arguing that it compromises the integrity of clinical ethics consultants (CECs), erodes trust, and distorts the role of ethical mediation. This article explores the ethical tensions surrounding benevolent deception, particularly in cases where families request that physicians deceive patients based on cultural expectations. Drawing from Dubler's vision of CECs as mediators rather than enforcers, I propose a trust-oriented approach that enables CECs to facilitate shared ethical deliberation, foster open dialogue, and respect cultural differences while upholding core bioethical principles. Ultimately, this approach reaffirms Dubler's legacy by advocating for clinical ethics consultation as a transparent, patient-centered process that prioritizes trust, integrity, and informed decision-making over deception.

AbstractMedical distrust is often the result of social injustices, discrimination, systemic racism, and the repeated experience of epistemic injustices. Signaling medical trustworthiness in this context requires not only demonstrating competence and caring but grappling with the source of distrust rooted in experience. While we should be wary of framing every unmediatable conflict as an issue of distrust, which may simplify a complex human experience to an identity-based response, we argue that a community-engaged intersectional approach to mediation can address conflicts rooted in distrust and is fundamentally aligned with Nancy Dubler's legacy of addressing power differentials. We present a case where traditional tools of mediation-including addressing informational and emotional gaps-were insufficient at reaching a "principled resolution." In this case, the distance between the family member's and the medical team's understanding of the facts was so profound that it could not be overcome. Far from being irrational or unreasonable, this outcome was a direct response to the perpetual unequal access to epistemic authority experienced by this Black family. Mediators often belong to social groups with more power, and this bias can impact mediation practices, communication norms, and assumptions about conflict. Inclusive mediation models rooted in conflict theory can build on Nancy Dubler's classical work. We argue that bioethicists must engage in risky conversations with local communities to "collaboratively imagine what a more trustworthy system might look like." We describe the inclusive mediation model and how it expands on Nancy Dubler's foundational work and honors her tremendous legacy.

AbstractIn their article "Defining and Refining Trauma-Informed Ethics Consultation," Lanphier and Anani respond to my argument about surrogate trauma and prioritization. I show that there is a great deal of overlap between my view and the views of Lanphier and Anani, the architects of TIEC, with potentially some differences. Lanphier and Anani's commentary is structured by three discussion points: (1) the degree to which their articulation of TIEC challenges the HEC status quo, (2) their distinction between HEC "process" and "method," and (3) the legitimacy of "ethically acceptable options."