Journal of Clinical Ethics最新文献

Clinical ethics consultants provide a range of services in hospital settings and in teaching environments. Training to achieve the skills needed to meet the expectations of employers comes in various forms, ranging from on-the-job training to formal fellowship training programs. We surveyed graduates of clinical ethics fellowships to evaluate their self-reported preparedness for their first job after fellowship training. The results indicated several areas of need, including greater exposure to program-building skills, quality improvement skills, and approaches to working with members of higher administration. These data will be of use to educators as well as to fellows who advocate for elements of training in preparation for their first position.

The author, editor-in-chief of The Journal of Clinical Ethics, recalls the contributions of Albert R. Jonsen, PhD, one of the founding members of the editorial board of the journal.

Some of the most difficult clinical ethics consultations involve patients who have both medical and mental health needs, as these cases can result in considerable moral distress on the part of the bedside staff. In this article we examine the issues that such consults raise through the illustrative example of a particular case: several years ago our ethics consultation service received a request from a critical care attending physician who was considering a rarely performed psychosurgical intervention to address intractable and life-threatening agitation and aggression in an adolescent patient for whom standard treatments had proven unsuccessful. We consider strategies that may be useful in addressing not only the ethical dilemmas or the clinical problems, but also the emotional, social, and moral distress that arise in delivering care in such complex cases, in which standard routine practices of care have been exhausted. In addition, we explore the processes that led to this situation and suggest ways to promote early recognition and intervention for similar cases in the future.

In February 2016, the Cleveland Clinic initiated the first attempt at cadaveric uterine transplantation (UTx) in the United States. The transplantation was ultimately unsuccessful, but it opened doors for further research on both live and cadaveric UTx. While initial strides toward successful transplantation have been made, questions persist on the ethics of UTx: whether the uterus is a vital organ, whether we should prioritize live or cadaveric options, and how the procedure should be covered by health insurance. If we agree that the goal of the medical profession is both to treat and improve quality of life, then the question of whether or not infertility is considered a disease becomes inconsequential in the discussion. As such, the medical enterprise should move forward with research in UTx. In doing so, considering the ethical implications of UTx remains essential-and we must remember to pair innovation with regulation.

In this article I argue that the biological processes that make us human have error rates that distribute illness on a no-fault basis. I propose this as an ethical foundation for universal healthcare.

The controversy over the so-called Ashley Treatment (AT), a series of medical procedures that inhibited both growth and sexual development in the body of a profoundly intellectually impaired girl, usually centers either on Ashley's rights, including a right to an intact, unaltered body, or on Ashley's parents' rights to make decisions for her. The claim made by her parents, that the procedure would improve their ability to care for her, is often dismissed as inappropriate or, at best, irrelevant. We argue, however, that caregiving is a central issue in the controversy, as Ashley's need for caregiving is a defining characteristic of her life. In this article, we analyze the ethics of the Ashley Treatment within the context of family caregiving. Through the physical and emotional work of caregiving, families participate in the formation and maintenance of personal identity, a process that Hilde Lindemann recently called "holding." We argue that, in an intellectually disabled person such as Ashley, who depends on her family for every aspect of her care, the family's contribution to identity is an essential source of personhood. We believe that the treatment can be justified if it is indeed an instance of appropriate family "holding" for Ashley.

Medical decision making on behalf of unrepresented patients is one of the most challenging ethical issues faced in clinical practice. The legal environment surrounding these patients is equally complex. This article describes the efforts of a small coalition of interested healthcare professionals to address the issue in Colorado. A brief history of the effort is presented, along with discussion of the legal, ethical, practical, and political dimensions that arose in Colorado's effort to address decision making for unrepresented patients through an extension of the existing Colorado Medical Treatment Decision Act (CRS 15-18). A discussion of lessons learned in the process is included.

Refusing treatment for potentially curable childhood cancers engenders much discussion and debate. I present a case in which the competent parents of a young Amish child with acute myeloid leukemia deferred authority for decision making to the child's maternal grandfather, who was vocal in his opposition to treatment. I analyze three related concerns that distinguish this case from other accounts of refused treatment. First, I place deference to grandparents as decision makers in the context of surrogate decision making more generally. Second, the maternal grandfather's ardent refusal of treatment and his rationale appeared to be inconsistent with the beliefs expressed by other family members and by members of the same Amish community, leading members of the medical team to question whether refusal of treatment should be treated differently when it appears to be based on the idiosyncratic beliefs of an individual rather than on community-wide values. Third, the medical team perceived tension and dissension between the nonverbal behavior of some family members and the verbal statements made by the maternal grandfather, leading the team to question the parents' true wishes and debate how to weigh nonverbal and indirect forms of communication. Finally, building upon the conclusions of these queries, I explore whether, if the child's prognosis was less favorable or if he were to relapse later, the maternal grandfather should have been permitted to drive a decision to refuse further treatment.

Crosscultural encounters are common in the delivery of healthcare, and cultural differences may contribute to misunderstandings and ethical conflict. Encounters between members of the Amish ethno-religious group and modern, science-based healthcare providers hold a high potential for misunderstanding and conflict because the Amish stridently maintain a countercultural outlook and they approach such encounters with suspicion and anxiety. This commentary on the case presented by Amy E. Caruso Brown, MD,1 involving a grandfather's resistance to treating a child with leukemia commends this physician for successfully managing the case and deriving important insights from reflection upon it. It argues, however, that the level of conflict most likely would have been reduced if the care team had made more of an effort to listen to the grandfather and acknowledge the emotional trauma he had suffered.

Lisa Freitag and Joan Liaschenko's thoughtful and important article goes directly to the under-examined heart of Ashley's case, namely to what sustains her in a habitable and intelligible identity. Though quite sympathetic with their conclusion and line of argument, I try to trouble their proceedings a bit, largely by wondering how having a specific such identity, out of several that may be in-principle available, matters to someone with Ashley's cognitive scope. I do this not simply to be contrary, but because their article also seems to me to raise issues in the ethics of bioethics-in particular, what I call the dilemma of ethical endeavor: How ought one publicly pursue deeply important and complex issues, the very raising of which may offend interlocutors who indeed have grounds for resentment. Making a habit of second guessing oneself may be part of the answer.