Journal of Clinical Ethics最新文献

AbstractSurgeons face numerous perioperative challenges when caring for patients with life-threatening or chronic diseases. Although palliative care teams are uniquely poised to aid in the supportive approach to such holistic needs, they are underutilized by surgical services. Palliative care has been associated with an average reduction of $3,237 per admission, as well as reduction in emergency department visits, hospital admissions, and hospital length of stay. For patients within the intensive care setting, palliative interventions have shown a 26 percent relative risk reduction in intensive care unit length of stay and overall alignment of patients' and families' goals of care. However, there is a paucity of data surrounding outcomes associated with palliative care in surgery. It remains pervasive in surgical culture that operative intervention and palliation are mutually exclusive and occur sequentially, rather than concurrently. The majority (76.1%) of surgeons have no formal education in palliative care and feel burdened with the unrealistic expectations for patient outcomes after surgical intervention (61.8%). These cultural and knowledge barriers have significant impact on surgical palliative care referrals and team-based care. Preoperative palliative care consultations in surgical patients occur less than 1 percent of the time. Preoperative palliative care may serve to help explore, clarify, and document quality-of-life values and preferences, in hopes of better promoting goal-concordant care. We recommend implementing frailty-score-based risk assessments to refer surgical patients to palliative care consultation preoperatively. Normalizing referral to palliative care can help surgeons embrace its potential benefit in patient care and improve utilization.

AbstractThe Liaison Committee on Medical Education recently adopted structural competency, an approach to understanding and responding to social factors in health and healthcare, as a required part of medical training. We have found that structural competency education shows promise for graduate and continuing bioethics education as well. In postgraduate bioethics education, structural competency focuses on the practical skills of identifying where social forces impact specific patients and how clinicians can respond. This can support clinical ethicists in their attempts to help clinicians identify, understand, and respond to ethical dilemmas caused by social forces, for example, the ways in which resource availability may influence a patient's opportunities and health options, and the impact of the built environment on the health hazards people encounter. We describe how one clinical ethics program integrated structural competency into bioethics education for medical residents and other clinicians. This structural competency education pilot received extremely positive feedback from participating clinicians. Ninety-seven percent of those who responded to evaluation surveys identified structural competency as "valuable" or "very valuable" to their clinical practice. When providing feedback on this education, clinicians described immediately incorporating structural competency strategies in ethically difficult patient care situations. We present a case study shared and developed by clinicians using these strategies to improve patient care. This practical use of structural competency education suggests that there may be benefits to integrating this approach into bioethics education. We suggest next steps for bioethics educators to further examine these educational strategies following our promising pilot.

AbstractWhen patients are unable to make decisions for themselves, medical teams often turn to surrogate decision makers to help identify what the patient would have wanted. Unless a patient has designated a surrogate, teams must rely on statutory hierarchies that often prioritize legal and biological ties. When cases arise in which patients do not want their legal surrogate to be their medical decision maker, they must take steps to exclude that person. Unfortunately, people often are not aware of this until they are unable to make complex medical decisions for themselves. While much has been said about the capacity to appoint surrogates, comparatively little has been said about excluding surrogates. In current practice, a patient's decision to exclude a surrogate would not be respected when they do not have capacity. It is our view that this blanket inclusion of surrogates can be seriously harmful and potentially violating. Our goals in this article are twofold. First, we aim to carve out the decision to exclude a surrogate as distinct from the decision to appoint one. Second, we argue that respecting an incapacitated patient's exclusion to some degree is morally appropriate. We will conclude by offering suggestions about how to respect the preference to exclude while considering the risks that may come with exclusion.

AbstractThe evaluation of decisional capacity is essential in clinical care, but limited guidance exists regarding when such assessments are necessary. Established models, such as Appelbaum and Grisso's "four skills" framework, provide guidance on how to assess capacity but do not address when and whether such evaluations should be conducted. This article proposes a three-step rubric to help clinicians determine whether a formal capacity assessment is justified. The first step emphasizes assuming capacity without evaluation unless reasonable uncertainty exists. The second step involves ascertaining whether the results of the evaluation would impact patient care. The third step requires weighing the potential benefits of the assessment against its costs vis-à-vis patient well-being. This rubric aims to reduce unnecessary evaluations, mitigate bias, and preserve patient autonomy by ensuring that capacity evaluations are conducted only when truly indicated.

AbstractReproductive autonomy is a fundamental ethical principle in healthcare, yet insurance denials of care often undermine patient decision-making. This article examines a case in which a 35-year-old patient with stage 4 endometriosis sought a total hysterectomy and bilateral salpingo-oophorectomy to manage severe, refractory pelvic pain. Despite the patient's informed and autonomous decision, her insurer denied authorization based on a paternalistic concern for her future fertility. Through an ethical analysis, this article critiques the role of insurers in reproductive decision-making, highlighting the inherent conflict of interest, lack of clinical nuance, and burdens imposed on clinicians. The disproportionate scrutiny of sterilization procedures, rooted in a history of reproductive injustice, further complicates the ethical landscape. To address these challenges, we propose integrating interinstitutional ethics consultations into prior authorization processes, ensuring that patient autonomy is respected while maintaining oversight for medical necessity. This case underscores the need to balance oversight with respect for reproductive autonomy to optimize patient care and equitable access to necessary procedures.

AbstractThis article responds to Autumn Fiester's "TIEC, Trauma Capacity, and the Moral Priority of Surrogate Decision Makers in Futility Disputes," in which Fiester argues for a vision of trauma-informed ethics consultation that systematically prioritizes the preferences of surrogate decision makers in cases of disagreement between surrogates and clinical teams over continued life-sustaining therapies for severely neurologically impaired patients. We identify three issues arising from Fiester's article that allow us to clarify our account of trauma-informed ethics consultation on which she builds and that illustrate the need for further research on trauma-informed ethics consultation in both theory and practice. The first issue responds to her charge that ours was an overly "modest" proposal. The second issue is to suggest closer attention to distinctions between ethics consultation process, methods, and content that we argue would enhance Fiester's account. The third is to better evaluate the appropriate role of "ethically acceptable options" in trauma-informed ethics consultation. In conclusion, we raise several global points regarding the further development of trauma-informed ethics consultation and conceptualizations of trauma-informed care relevant to it.

AbstractSolid organ transplants save lives, but demand for transplantable organs outpaces supply. Traditionally, organs from patients infected with the Hepatitis C virus (HCV) were ineligible for donation to recipients without HCV (HCV D+/R- transplants) owing to concerns about intentionally transmitting HCV to organ recipients. New direct-acting antivirals against HCV and increased HCV+ organs from the opioid epidemic promised to solve the organ shortage. In 2017, the American Society of Transplantation argued that HCV D+/R- transplants are ethically permissible to maximize transplantable organs. This utilitarian argument suffers from flaws inherent to utilitarianism and could be made obsolete by resolving the organ supply/demand mismatch. A better argument for ethical HCV D+/R- transplants arises from the principle of double effect (PDE). The good effect of prolonging a life through transplantation outweighs the evil effect of infecting recipients with HCV. The PDE provides ethical grounding for HCV D+/R- transplants and creates better informed consent discussions.

AbstractIn her article "A Deeper Look at Ethics Consultation" Haavi Morreim responds to my argument about surrogate trauma and prioritization. Morreim and I both have significant reservations about conventional healthcare ethics consultation (HEC) practice, and those general concerns about HEC are the focus of much of Morreim's commentary. I will first respond to important issues Morreim raises about my prioritization of surrogate decision makers' trauma in certain end-of-life ethics disputes, and then I will turn my attention to her general arguments about the practice of clinical ethics that bear directly on my stance.

AbstractCommunity-based "free" clinics can be a key site of primary and preventive care, especially for underserved members of the community. Ethical issues arise in community clinics. Despite this-and the fact that ethics consultation is a well-established practice within hospitals-ethics support is rarely integrated within community clinics, and the clinical ethicist's role in community care settings remains unexplored. In this article I explore what community-engaged practice might look like for the clinical ethicist. I share my experience of being invited into a local community clinic where a team of volunteers, in partnership with a local church, provide care to persons experiencing housing and food security in our county. First, I outline some of the key ethical issues we encounter in our clinic, including how to promote the agency of community members, develop shared standards for clinic volunteers, and balance different values and priorities within the partnership. Second, I explore how the ethicist's knowledge and skills translate into this setting. I argue that, given the range of ethical issues that arise in community clinics and the need for ongoing dialogue, education, and critical reflection within such partnerships, there is a role for the clinical ethicist in this space. I discuss how clinical ethicists might begin to develop community-based partnerships and practices.