Clinical Ethics最新文献_第5页

Your patient is a person: A narrative medical approach to weight discrimination in medicine 你的病人是一个人:医学中体重歧视的叙事医学方法

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2023-04-11 DOI: 10.1177/14777509231168335

Anna E. Ulrey

Several studies have established the prevalence of discrimination upon the basis of weight in healthcare; however, these studies lack the element of human experience that makes addressing the issue vital to both individual and public health. Narrative medicine is an interdisciplinary field that utilizes powerful narrative skills and creativity to address the needs of those who seek and deliver healthcare, promoting healing, and self-reflection for both patients and physicians. This paper seeks to re-evaluate key studies regarding the issue of weight discrimination in healthcare through the lens of narrative medicine. In doing so, it further integrates the aspect of human experience into the study of medical ethics in order to improve the lived experience of overweight individuals in medicine.

几项研究已经证实，在医疗保健中，基于体重的歧视普遍存在;然而，这些研究缺乏使解决这一问题对个人和公共卫生都至关重要的人类经验因素。叙事医学是一个跨学科的领域，它利用强大的叙事技巧和创造力来满足那些寻求和提供医疗保健的人的需求，促进治疗，以及病人和医生的自我反思。本文试图通过叙事医学的镜头重新评估关于医疗保健体重歧视问题的关键研究。在这样做的过程中，它进一步将人类经验方面纳入医学伦理研究，以改善超重个体在医学中的生活经验。

引用次数: 0

Using legal doctrine and feminist theory to move beyond shared decision making for the practice of consent 运用法律原则和女权主义理论，超越共同决策，实现同意的实践

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2023-04-09 DOI: 10.1177/14777509231168329

A. Sarela

The necessity of consent is widely justified on the basis of the principle of respect for autonomy. Also, it is widely believed that shared decision making (SDM) is the practical device to seek patients’ consent for medical treatment. In this essay, I argue that SDM, while necessary, is insufficient for consent; because, in the paradigm of evidence-based medicine, SDM is contingent upon other practices to identify appropriate treatments that form the subjects of SDM. Indeed, case law emphasises normative decision-making practices that precede SDM. Furthermore, case law supplies a nuanced understanding of SDM, which includes not only exchange of information but also attention to human vulnerability that persists despite formal retention of decision-making capacity. In addition, the law marks out a space in which people with capacity are absolutely entitled to self-determination. Thus, a four-step framework of decision making can be induced from legal doctrine. This legal framework corresponds to a construct of respect for autonomy that draws upon feminist theory. Feminist scholars have objected to the focus on individuals in traditional theories of autonomy; instead, they insist that people have to be considered in the context of their social influences and relationships. Feminists separate out four ideas of autonomy, and these ideas can be used to construct a four-layered model of respect for autonomy, in which each layer corresponds sequentially to a step in the legal framework of decision making. This model of respect for autonomy provides both conceptual clarity and theoretically robust justification for doctors’ various obligations in decision-making practices for consent.

根据尊重自主权的原则，同意的必要性得到了广泛的证明。此外，人们普遍认为共同决策(shared decision making, SDM)是寻求患者医疗同意的实用手段。在本文中，我认为SDM虽然必要，但不足以达成共识;因为，在循证医学范式中，SDM取决于其他实践，以确定构成SDM主题的适当治疗。事实上，判例法强调在SDM之前的规范性决策实践。此外，判例法提供了对SDM的细致理解，其中不仅包括信息交换，还包括对尽管正式保留决策能力但仍然存在的人类脆弱性的关注。此外，法律划定了一个空间，使有能力的人绝对有权自决。因此，可以从法律理论中归纳出一个四步决策框架。这一法律框架与基于女权主义理论的尊重自主权的概念相对应。女权主义学者反对传统自治理论中对个体的关注;相反，他们坚持认为，人们必须在他们的社会影响和关系的背景下考虑。女权主义者分离出四种自治观念，这些观念可以用来构建一个尊重自治的四层模型，其中每一层依次对应于决策法律框架中的一个步骤。这种尊重自主权的模式为医生在同意决策实践中的各种义务提供了概念上的清晰度和理论上的有力理由。

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引用次数: 2

Tackling the COVID elective surgical backlog: Prioritising need, benefit or equality? 解决新冠肺炎择期手术积压：优先考虑需求、利益还是平等？

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2023-04-06 DOI: 10.1177/14777509231166532

J. Pugh, Matthew Seah, A. Carr, J. Savulescu

The National Health Service (NHS) in the UK is currently facing a significant waiting list backlog following the disruption of the COVID-19 pandemic, with millions of patients waiting for elective surgical procedures. Effective treatment prioritisation has been identified as a key element of addressing this backlog, with NHS England's delivery plan highlighting the importance of ensuring that those with ‘the clinically most urgent conditions are diagnosed and treated most rapidly’. Indeed, we describe how the current clinical guidance on prioritisation issued by The Federation of Surgical Specialty Associations serves this aim. However, whilst there are strong reasons to prioritise elective surgery in accordance with clinical need, we argue that it would be a mistake to assume that prioritisation in accordance with clinical need requires only a clinical or scientific judgement. The understanding of clinical need that we choose to employ in a prioritisation system will be grounded by some key ethical judgements. Moreover, we may also have to make trade-offs between addressing clinical need, safeguarding equality, and achieving other benefits. As the UK faces up to the backlog, it is important that surgical prioritisation guidelines enshrine a broad range of values that we believe ought to determine access to care in non-emergency circumstances. Our analysis suggests that the current approach to prioritisation is not a sufficiently nuanced way of balancing the different moral values that are operative in this context.

在新冠肺炎疫情中断后，英国国家医疗服务体系（NHS）目前面临着大量的等待名单积压，数百万患者正在等待选择性手术。有效的治疗优先顺序已被确定为解决这一积压问题的关键因素，英国国家医疗服务体系的交付计划强调了确保“临床上最紧急的患者得到最快速的诊断和治疗”的重要性。事实上，我们描述了外科专业协会联合会发布的当前关于优先顺序的临床指南是如何实现这一目标的。然而，尽管有充分的理由根据临床需要优先考虑择期手术，但我们认为，认为根据临床需求优先考虑只需要临床或科学判断是错误的。我们选择在优先顺序系统中使用的对临床需求的理解将以一些关键的伦理判断为基础。此外，我们可能还必须在满足临床需求、保障平等和实现其他利益之间进行权衡。在英国面临积压工作之际，重要的是，手术优先顺序指南包含了广泛的价值观，我们认为这些价值观应该决定在非紧急情况下获得护理的机会。我们的分析表明，目前的优先顺序方法并不是一种足够微妙的方式来平衡在这种情况下运作的不同道德价值观。

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引用次数: 0

All abortions are medically necessary 所有堕胎在医学上都是必要的

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2023-04-02 DOI: 10.1177/14777509231166530

E. Kendal

When restrictive abortion policies are presented there are often two questions posed: will there be an exception to save the life of the ‘mother’ and will there be an exception in the case of rape or incest. This article will demonstrate that there are no distinctive elements to the first ‘exception’, that do not also apply to all abortions on demand. Through consideration of the potentially lethal impacts of pregnancy on physical and mental health, the case will be made that all requested abortions fit the criteria of ‘medically necessary’.

当提出限制性堕胎政策时，通常会提出两个问题：是否会有例外来挽救“母亲”的生命，以及强奸或乱伦的情况是否会例外。这篇文章将证明，第一个“例外”没有什么独特的元素，也不适用于所有按需堕胎。通过考虑怀孕对身心健康的潜在致命影响，将证明所有要求的堕胎都符合“医学必要”的标准。

引用次数: 1

Recovery without normalisation: It's not necessary to be normal, not even in psychiatry 没有正常化的康复：没有必要是正常的，即使在精神病学中也是如此

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2023-03-28 DOI: 10.1177/14777509231165880

Zsuzsanna Chappell, Sofia M. I. Jeppsson

In this paper, we argue that there are reasons to believe that an implicit bias for normalcy influences what are considered medically necessary treatments in psychiatry. First, we outline two prima facie reasons to suspect that this is the case. A bias for ‘the normal’ is already documented in disability studies; it is reasonable to suspect that it affects psychiatry too, since psychiatric patients, like disabled people, are often perceived as ‘weird’ by others. Secondly, psychiatry's explicitly endorsed values of well-being and function are hard to measure directly, which is why we see simpler box-ticking conceptions of recovery used in large research studies. This need not be problematic, but might lead to researchers and clinicians focusing too much on treatments that promote easy-to-measure proxies for recovery, instead of what actually matters to psychiatric patients themselves. Next, we provide examples of treatments and treatment decisions within two areas – self-injury and psychosis – which are hard to explain unless we assume that an implicit and harmful normalcy bias is at work. We conclude with some suggestions for clinicians and future research.

在这篇论文中，我们认为有理由相信，对正常状态的隐性偏见会影响精神病学中医学上必要的治疗方法。首先，我们概述了怀疑情况确实如此的两个初步理由。残疾研究中已经记录了对“正常人”的偏见；有理由怀疑它也会影响精神病学，因为精神病患者和残疾人一样，经常被其他人认为是“奇怪的”。其次，精神病学明确认可的幸福感和功能价值观很难直接衡量，这就是为什么我们在大型研究中看到了更简单的康复概念。这不一定是有问题的，但可能会导致研究人员和临床医生过于关注促进易于测量的康复指标的治疗，而不是对精神病患者本身真正重要的治疗。接下来，我们提供了两个领域的治疗和治疗决策的例子——自伤和精神病——除非我们假设隐性和有害的常态偏见在起作用，否则很难解释。最后，我们对临床医生和未来的研究提出了一些建议。

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引用次数: 3

Is “terminally ill self-killing” suicide? “绝症自杀”是自杀吗？

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2023-03-16 DOI: 10.1177/14777509231164002

Ivars Neiders, V. Dranseika

When a terminally ill patient kills herself, using a drug prescribed by a physician for this purpose, in bioethical literature this would be described as a case of physician-assisted suicide. This would also be a case of suicide according to the standard account of suicide in the philosophical literature. However, in recent years, some authors have argued that terminally ill self-killing in fact should not be considered suicide. In this paper, we don’t try to address the philosophical merits of such arguments. Instead, we ask whether these considerations align with the way non-philosophers think about suicide. We present empirical evidence from four studies that address different concerns raised about terminally ill self-killing being a suicide. We conclude that the raised concerns cannot be supported by the folk understanding of suicide.

当一名绝症患者使用医生为此开具的药物自杀时，在生物伦理文献中，这将被描述为医生协助自杀的情况。根据哲学文献中对自杀的标准描述，这也是一个自杀案例。然而，近年来，一些作者认为，事实上，绝症自杀不应被视为自杀。在这篇论文中，我们不试图讨论这些论点的哲学价值。相反，我们问这些考虑是否与非哲学家看待自杀的方式一致。我们提供了四项研究的经验证据，这些研究解决了人们对绝症自杀的不同担忧。我们得出的结论是，人们对自杀的理解不能支持人们提出的担忧。

引用次数: 0

Ethics consultation in patients with behavioral and psychological symptoms of dementia 痴呆行为和心理症状患者的伦理咨询

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2023-03-07 DOI: 10.1177/14777509231160056

M. Makhinson, Juliana Gomez-Makhinson, Catherine Jennings, S. Huerta

The increasing age of the patient population around the globe and in the United States has resulted in a growing number of patients with dementia. In this manuscript, we examined the role of the ethics consultation service in patients who have dementia and associated cognitive and neuropsychiatric sequelae. We addressed a particularly challenging case presenting with behavioral and psychological symptoms of dementia. We discussed the ethical questions and challenges considered by the ethics consultation service and compared these with current suggestions and expectations from the research literature regarding the role of ethics consultation service in dementia management. We demonstrated two potentially useful approaches of clinical ethical analysis, the principalist theorem and Jonsen's four quadrants approach. While the number of consults in patients with behavioral and psychological symptoms of dementia is likely to increase in clinical ethics, the role of the ethics consultation service in this cohort of patients still remains to be determined. There are significant gaps in understanding of the ethics consultation service role in dementia management, and much work remains to be undertaken on the part of regulatory and healthcare systems in clarifying their roles, expectations, and competencies.

全球和美国患者年龄的增长导致痴呆症患者的数量不断增加。在这份手稿中，我们研究了道德咨询服务在痴呆症和相关认知和神经精神后遗症患者中的作用。我们处理了一个特别具有挑战性的案例，表现为痴呆症的行为和心理症状。我们讨论了伦理咨询服务所考虑的伦理问题和挑战，并将其与研究文献中关于伦理咨询服务在痴呆症管理中作用的当前建议和期望进行了比较。我们展示了两种潜在有用的临床伦理分析方法，原理定理和Jonsen的四象限方法。尽管在临床伦理方面，有痴呆行为和心理症状的患者的咨询数量可能会增加，但伦理咨询服务在这群患者中的作用仍有待确定。在理解道德咨询服务在痴呆症管理中的作用方面存在重大差距，监管和医疗保健系统在澄清其作用、期望和能力方面仍有许多工作要做。

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引用次数: 0

Body integrity dysphoria and medical necessity: Amputation as a step towards health 身体完整性焦虑和医疗必要性：截肢是迈向健康的一步

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2023-03-05 DOI: 10.1177/14777509231160398

R. Gibson

Interventions are medically necessary when they are vital in achieving the goal of medicine. However, with varying perspectives comes varying views on what interventions are (un)necessary and, thus, what potential treatment options are available for those suffering from the myriad of conditions, pathologies and disorders afflicting humanity. Medical necessity's teleological nature is perhaps best illustrated in cases where there is debate over using contentious medical interventions as a last resort. For example, whether it is appropriate for those suffering from body integrity dysphoria to receive healthy limb amputations. This paper explores how one's perception of medicine's goal underpins whether interventions are necessary or unnecessary, using the controversial topic of therapeutic amputation as an example. By contrasting ‘classical’ amputations with their more contentious counterparts, it highlights how the idea of medical necessity influences and restrains clinical decision-making. The paper starts by giving an account of body integrity dysphoria, focusing on the debate concerning elective amputation's justifiability. It then introduces Georges Canguilhem's vitalist theory of health, paying particular attention to his emphasis on adaptability. Then, this paper uses his theory as a lens through which to evaluate the appropriateness of therapeutic amputation as a medically necessary procedure. Ultimately, the paper highlights how the label of medical necessity is withheld from potential therapeutic interventions because they fail to conform to pre-established ideas of medicine's purpose and that by doing so, potential harm befalls those who are left with no effective treatments and must look for solutions in the non-clinical world.

当干预措施对实现医学目标至关重要时，它们在医学上是必要的。然而，从不同的角度来看，对哪些干预措施是（不）必要的，以及对那些患有困扰人类的各种疾病、病理和病症的人有哪些潜在的治疗选择，人们的看法也各不相同。医疗必要性的目的论性质可能最好地体现在关于将有争议的医疗干预作为最后手段的争论中。例如，对于那些患有身体完整性焦虑症的人来说，接受健康的截肢手术是否合适。本文以治疗性截肢这一有争议的话题为例，探讨了人们对医学目标的看法如何支撑干预措施是必要的还是不必要的。通过将“经典”截肢术与更有争议的截肢术进行对比，它强调了医疗必要性的概念如何影响和限制临床决策。本文首先介绍了身体完整性焦虑症，重点讨论了选择性截肢的正当性问题。然后介绍了乔治·坎吉勒姆的生命主义健康理论，特别是他对适应性的重视。然后，本文将他的理论作为一个镜头，通过它来评估治疗性截肢作为一种医学必要程序的适当性。最终，这篇论文强调了医疗必要性的标签是如何在潜在的治疗干预措施中被保留的，因为它们不符合预先确立的医学目的，这样做会对那些没有有效治疗方法的人造成潜在的伤害，他们必须在非临床世界寻找解决方案。

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引用次数: 1

Rethinking systemic ableism: A response to Zagouras, Ellick, and Aulisio. 重新思考系统性残疾歧视:对扎古拉斯、埃利克和奥利西奥的回应。

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2023-03-01 DOI: 10.1177/14777509221094472

Erin E Andrews, Kara B Ayers, Joseph A Stramondo, Robyn M Powell

Introduction: This article is a response to Zagouras, Ellick, and Aulisio who presented a case study justifying the questioning of the capacity and autonomy of a young woman with a physical disability who was pregnant and facing coercive pressure to terminate.

Case description: Julia is described as a 26-year-old woman with a neurological disability that requires her to receive assistance with activities of daily living. She was described as living with her parents who provided her with personal care assistance. Julia became pregnant and her parents wished her to terminate because they did not want to care for her child in addition to her. In fact, Julia's parents threatened her with institutionalization if she did not elect to terminate the pregnancy. Her health care team questioned her decision-making capacity based on her alleged "mental age" and experiences of being sheltered and excluded. The health care team used directive tactics to convince Julia to terminate the pregnancy, which describe as both an ethical and feminist intervention.

Discussion: The current authors take issue with the case analysis provided by and argue that they neglected to account for numerous instances of systemic ableism that adversely affected Julia, demonstrated prejudicial and judgmental attitudes toward pregnancy and disability, inappropriately questioned her decision-making capacity by infantilizing her, misconstrued the feminist concept of relational autonomy, and colluded with coercive interference from family members. This is a classic example of discriminatory and culturally incompetent reproductive health care for a disabled woman.

引言:这篇文章是对Zagouras, Ellick和auliisio的回应，他们提出了一个案例研究，证明了一个身体残疾的年轻女性在怀孕期间面临强制终止妊娠的能力和自主性的质疑。病例描述:Julia是一名26岁的女性，患有神经功能障碍，需要在日常生活活动中获得帮助。据描述，她和父母住在一起，父母为她提供个人护理帮助。茱莉亚怀孕了，她的父母希望她终止妊娠，因为他们不想除了她之外还要照顾她的孩子。事实上，茱莉亚的父母威胁她，如果她不选择终止妊娠，就把她送进精神病院。她的医疗团队基于她所谓的“心理年龄”以及被庇护和排斥的经历，质疑她的决策能力。医疗团队使用指导性策略说服朱莉娅终止妊娠，这被描述为一种道德和女权主义的干预。讨论:当前的作者对所提供的案例分析提出了质疑，并认为他们忽视了对朱莉娅不利的系统性残疾歧视的许多实例，对怀孕和残疾表现出偏见和评判的态度，通过将她幼稚化来不恰当地质疑她的决策能力，误解了女性主义的关系自主概念，并与家庭成员的强制干预串通在一起。这是残疾妇女获得歧视性和文化上无能的生殖保健的典型例子。

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引用次数: 1

Rationing in pediatric hospitalizations during COVID-19: A step back to move forward. 新冠肺炎期间儿科住院人数的定量配给：后退一步向前推进

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2023-03-01 DOI: 10.1177/14777509221094471

Binh Phung

The latest Omicron variant of the novel coronavirus has itself created a novel situation-bringing attention to the topic of healthcare rationing among hospitalized pediatric patients. This may be the first time that many pediatricians, nurses, parents, and public health officials have been compelled to engage in uncomfortable discussions about the allocation of medical care/resources. Simply put, finite budgets, resources, and a dwindling healthcare workforce do not permit all patients to receive unlimited medical care. Triage and bedside rationing decisions are happening in a range of difficult everyday circumstances both implicitly and explicitly, but in ways not recognized by even the best ethically framed intentions. Clinicians and hospital administrators have largely been left on their own "to flatten the rationing curve" in hopes that resources never have to be explicitly rationed at their facility. Unfortunately, the downstream result is a misinformed and distrustful public (i.e. parents, guardians, and caregivers) filled with people who are already burdened with inflammatory pseudoscience narratives and deficits in health literacy. This paper aims to elevate a more thoughtful conversation about healthcare rationing by analyzing some existing ethical principles/framework developed for rationing decision making during previous emergency responses and drawing from the day-to-day clinical perspectives of a frontline pediatric acute care/hospitalist.

最新的新型冠状病毒欧米克隆变种本身就造成了一种新的局面——引起了人们对住院儿科患者医疗配给问题的关注。这可能是许多儿科医生、护士、家长和公共卫生官员第一次被迫参与关于医疗保健/资源分配的令人不安的讨论。简单地说，有限的预算、资源和不断减少的医疗保健人员不允许所有患者获得无限的医疗服务。分诊和床边配给的决定在一系列困难的日常环境中或明或暗地发生着，但即使是最合乎道德的意图也没有意识到这一点。临床医生和医院管理人员在很大程度上只能靠自己的力量“使配给曲线变平”，希望他们的设施永远不必明确地配给资源。不幸的是，下游的结果是误导和不信任的公众(即父母、监护人和照顾者)，其中充斥着已经背负煽动性伪科学叙述和健康素养缺陷的人。本文旨在通过分析一些现有的伦理原则/框架制定配给决策在以前的应急响应和借鉴一线儿科急症护理/住院医生的日常临床观点，提升一个更深思熟虑的对话关于医疗配给。

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引用次数: 0