Journal of Clinical Ethics最新文献

AbstractTransplant psychiatry is a rapidly growing field all across the nation. There are no clear biopsychosocial criteria for transplantation, but similarities among the different leading rating scales do exist. At least at this time, there is no unified electronic medical record (EMR) across all transplant centers, making it possible for information gained at one center to be lost when a patient is transferred or presented to a new center and does not disclose their prior evaluation history. A national database covering a patient's personal history of prior biopsychosocial evaluations would be a helpful unifying tool, helping to ensure that appropriate knowledge is obtained from each candidate. There are some important factors that should be considered before a tool like this can be implemented. These include establishment of the database itself, the presentation of the data, and its impact on equity and justice. We do believe that a database, in the long run, may help bring about fairness in the organ allocation system.

AbstractAs artificial intelligence (AI) becomes increasingly incorporated into the workflow of clinical practice, it will raise numerous ethical issues and lead to related clinical ethics consultations to address those issues. However, many of the ethical issues associated with AI feature fundamental distinctions from those currently encountered in clinical ethics consultations. Despite potential differences in the types of ethical issues precipitated by AI, little attention has been given to how to approach these issues when they need to be addressed in clinical ethics consultations. In this article, we provide a walkthrough on adapting clinical ethics consultations to look at these issues through an AI lens, which will allow us to recognize essential information and develop targeted questions that guide consultations toward appropriate decisions. We then provide three case studies exploring hypothetical scenarios based on real AI systems and how a clinical ethicist might guide the discussion of ethical issues presented by AI in each scenario. Following the case studies, we further discuss clinical AI in the context of clinical ethics consultations and conclude with a call for more attention to this area of increasing importance.

AbstractIntroduction: The practice of automatic suspension of "do not attempt resuscitation" (DNAR) orders has been abandoned in favor of more nuanced discussions. We sought to assess the practical implementation of DNAR orders at our institution during surgery.

Methods: This study conducted a retrospective review of DNAR practices, examining the records of 100 random patients with preexisting DNAR orders prior to surgery. The review documented any changes in DNAR status relative to surgery and then assessed whether the changes in DNAR status were carried forward into the electronic health record (EHR) as updated orders.

Results: The DNAR status of patients with an existing DNAR order was documented as having been rediscussed in 85 percent of cases prior to surgical procedures or interventions requiring general anesthesia. That noted, there was no update in the EHR to the DNAR orders in 88 percent of these cases, suggesting a potential gap in desired care were an event requiring resuscitation to happen while under anesthesia.

Conclusion: Our review indicates that while alterations in the DNAR wishes were often documented relative to anesthesia and surgery, the code status order was not consistently updated, leading to potential gaps in care. The findings underscore the need to standardize processes for updating DNAR status with order sets to ensure that the patient's wishes are accurately reflected during and after anesthesia or surgery.

AbstractEven in countries with a defined legal framework for advance directives (AD), the rates of completion are low. The goal of the present study was to assess whether intervention by means of a lecture by a family physician (FP) is effective for the facilitation of completion of AD by patients. A secondary aim was to assess the knowledge and attitudes of adults on AD. The intervention included an interactive lecture on AD by an FP in two villages in southern Israel. The success of the intervention was measured as completion of AD at primary care clinics over a three-month period after the intervention. Sixty-seven patients 17 years of age and older attended the lecture (1.0% vs. 19.0% for the religious and secular villages, respectively, p < .001). Ten participants (14.9%) completed AD within three months after the intervention (p = .002). Patients from both the secular and religious villages expected that their FP (74%) and/or an outpatient nurse (33%) would initiate the discussion on AD and commented that they would like the topic to be more prominent in the media. Intervention by means of an interactive lecture delivered by an FP in the community is an effective way to motivate patients to complete AD.

AbstractIn recent years, more attention has been paid to living donation as a means to reduce the suffering of individuals with end-stage kidney or liver disease. Implicated ethical issues include medical risk and risk of coercion, counterbalanced by improved medical outcomes and the benefits of saving a life. Living donation becomes particularly ethically complicated with the prospect of child donation, given the child's developing autonomy and uniquely dependent status. We outline four broad ethical considerations pertinent to living child organ donation: (1) beneficence, (2) respect for the family as a moral unit, (3) respect for the child as a person, and (4) justice. We conclude that it can be ethical for a healthy child to donate a kidney or liver lobe to a close relative who has exhausted other options provided that certain protections are put into place. Ideally, these donations will be rare. Lastly, we construct a model transplant center donation policy.

AbstractThis article examines Nancy Dubler's pioneering work in bioethics mediation and its enduring impact on the Bioethics Consultation Service for Montefiore Medical Center. In its early formulations, Dubler's application of the techniques and skills of alternate dispute resolution arose directly from her attempt to procedurally grapple with the emotional, psychological, and interpersonal realities uncovered through direct encounters with patients, families, and medical providers in situ. In this article, we argue that the resulting emphasis on dialogic engagement and the firsthand identification of values within the methodology of bioethics mediation fundamentally alters the substance and process of ethics facilitation by changing how we communicate with stakeholders and the way in which we subsequently reason about and derive normative claims. In contrast to committee-based and non-bedside models of case consultation, we maintain that this shift toward an inclusive and deliberative approach to ethics consultation introduces important insights into what it means to be an epistemically responsible interlocuter at the bedside. After examining this question in relation to an adapted case study, we offer the claim that the discursive norms of bioethics mediation-grounded in the concept of speaking with rather than for others-underscore the transformative potential of dialogue, which remains Nancy Dubler's most enduring legacy.

AbstractAmong her many scholarly contributions to the field of bioethics, Nancy Neveloff Dubler's exploration of the ethical, legal, and procedural dimensions of surrogate decision-making on behalf of persons who cannot make their own medical decisions has been the most impactful. In their 1999 publication "The Doctor-Proxy Relationship: An Untapped Resource," Dubler and coauthors Linda Farber Post and Jeffrey Blustein examined the decision-making paradigm of patients, their physicians, and trusted family and friends of patients.¹ The authors examined the historic dynamics supporting these collaborations and identified themes from focus groups with physicians and patient proxies. Recommendations put forth at the time to support patient proxies are reflected in well-established best practices and standards today. It is notable that there was no distinction made by the authors between those proxies related through kinship and those bonded through intimate relationships and friendships. Despite their appropriately inclusive recognition, many of the state guidelines establishing surrogate hierarchies systematically deprioritize friendships in favor of biological kinship or go so far as to exclude such individuals from being eligible to serve in these roles on behalf of patients, with whom they may have long-standing and well-established relationships defined by choice. Relying solely on traditional nuclear family structures denies the ethical legitimacy of chosen families and persons who may be best suited to make decisions for the patient.

AbstractWithout question, Professors Nancy Dubler and Carol Liebman provided a service of immeasurable value to clinical bioethics, by bringing mediation to the clinical setting. As clinical ethics consultants learned long ago, the great majority of consults stem not from genuine moral puzzlement, in which everyone is truly uncertain about what decision(s) may be best, but from conflict. Sometimes that conflict can be resolved by clearing up miscommunications or securing missing information. But sometimes conflict is real and entrenched. It is here that mediation offers great worth, and in this tribute issue of the Journal of Clinical Ethics we acknowledge an enormous debt of gratitude to Dubler and Liebman for bringing this shining light into healthcare's clinical setting. That said, by attempting to merge mediation with traditional ethics consultation, Dubler/Liebman's adapted version of mediation revises all three cornerstone tenets of ethics and process in mediation: neutrality, self-determination, and privacy. The result is often not bona fide mediation but a process quite different from it.

AbstractBackground: We combined simulation-based learning and ethics education for a unique, educational experience for nursing students. We aimed to assess students' feelings of confidence, efficacy, and moral distress before and after a simulation session focused primarily on handling an ethical dilemma.

Methods: A simulation session featuring an ethical dilemma was enacted as an in-class activity for a nursing ethics course. Optional pre- and post-surveys were made available to nursing students ($n=13$) to collect both quantitative (five-point Likert) and qualitative data, including a modified version of the Measure of Moral Distress-Healthcare Professionals tool.

Results: Students reported significantly increased levels of confidence in handling real-life ethical dilemmas, knowledge of working with a physician in real-life ethical dilemmas, and competence in selecting appropriate actions in ethical dilemmas. Overall moral distress was not found to be significantly increased in participants.

Conclusions: Nursing students describe ethics simulation as a valuable, innovative tool for preparing them to handle eventual ethical challenges in their career and anticipating moral distress.

AbstractDespite the prevailing norm of patient autonomy, a patient's direct participation in clinical ethics remains quite infrequent given that most often the patient is incapacitated. Often, clinical ethics consultants deal with someone representing the patient-either family members or a legal surrogate (DPA) who has decision-making authority. This stands in sharp contrast to most European countries, where an incapacitated patient typically falls under medical jurisdiction. Despite recent legal trends in Europe recognizing the role of advance directives and the possibility of a surrogate representing the patient (such as a "trusted person"), these persons are only "consulted" by the healthcare team; most often, they have no decision-making authority. This article explores these contrasting cultural differences regarding who (a legally recognized surrogate in the United States vs. mostly the physician in Europe) has the legitimacy to speak on behalf of the incapacitated patient who can no longer voice his/her preferences. Surrogates (often families) are in the United States given a voice for their incapacitated loved one because they are often those bearing the burden of any decisions; in many European countries, however, society (the state) at large will bear much of such cost. By looking into the broader contrasting framework of autonomy-focused bioethics, such as in the United States, versus public health ethics, which entails commitment to the common good before the individual, much of the differences of patients' role in clinical ethics and even the format of clinical ethics support services here and abroad can be better understood.