Incapacitated adult patients are commonly divided into two groups for purposes of decision making; those with a surrogate and those without. Respectively, these groups are often referred to as represented and unrepresented, and the relative ethics of decision making between them raises two particular issues. The first issue involves the differential application of the best interests standard between groups. Second is the prevailing notion that representedness and unrepresentedness are categorical phenomena, though it is more aptly understood as a multidimensional and (...) continuous variable based on relational moral authority. This paper examines the nature of representedness as it relates to ethical norms of surrogate decision making. (shrink)

Volume 20, Issue 7, July 2020, Page 112-114.

Current guidelines treat palliative sedation to unconsciousness as an effective medical treatment for terminally ill patients who need relief from severe symptoms, yet also restrict its use in ways that are extraordinary for medical treatments. A closer look at the kinds of cases in which palliative sedation is used suggests a way of adjusting the guidelines to resolve this seeming contradiction.

Although ethics is increasingly integrated in the curriculum of U.S. medical schools, it remains not well integrated with system issues, and social and structural contexts of illness. Moreover, ethical analysis is not often taught as a clinical skill. To address these issues, an outcomes driven course in Social Sciences, Humanities, Ethics and Professionalism (SHEP) was created. Within the course, a web-based concept mapping device, SHEP Case Analysis Tool (SCAT), was created which schematizes the structure and flow of clinical cases from (...) diagnosis to treatment options, to shared decision making to outcome, and includes key stakeholders, influences, and structural features of the health system. In the course, each student analyzes a case in which they were directly involved using SCAT and presents their analysis to faculty and peers. This exercise 1) reinforces knowledge-based portions of the course pedagogy, 2) supports meta-cognition and critical thinking through concept mapping, 3) applies multidimensional analysis to identify ethical, social, and system issues that impact patient-care. 4) develops problem solving skills, 5) counters the hidden curriculum/support professional identity formation, and 6) develops skills in reflective discourse. This paper outlines the development and use of this concept mapping case analysis tool in an undergraduate medical education curriculum. (shrink)

The ‘best interests’ decision making standard is used in clinical care to make necessary health decisions for non-capacitated individuals for whom neither explicit nor inferred wishes are known. It has been also widely acknowledged as a basis for enrolling some non-capacitated adults into clinical research such as emergency, critical care, and dementia research. However, the best interests standard requires that choices provide the highest net benefit of available options, and clinical research rarely meets this criterion. In the context of modern (...) norms of bioethics, the best interests standard rarely supports surrogate consent for research and should not be accepted as a routine provision. (shrink)

Since the path-breaking work of Karl Deutsch on security communities and Ernst Haas on European integration, it has been clear that international institutions may create senses of community and belonging beyond the nation state. Put differently, they can socialize. Yet the mechanisms underlying such dynamics have been unclear. This volume explores these mechanisms of international community building, from a resolutely eclectic stand point. Rationalism is thus the social theory of choice for some contributors, while others are more comfortable with social (...) constructivism. This problem-driven perspective and the theoretical bridge building it are the cutting edge in international relations theory. By providing more fined-grained arguments on precisely how international institutions matter, such an approach sheds crucial light on the complex relationship between states and institutions, between rational choice and social constructivism, and, in our case, between Europe and the nation state. (shrink)

The American Journal of Bioethics, Volume 11, Issue 6, Page 46-47, June 2011.

Health disparities are primarily driven by structural inequality including systemic racism. Medical educators, led by the AAMC, have tended to minimize these core drivers of health disparities. Ins...

A powerful new examination of the performative that asks "what's next?" for this well-worn concept.

The authors are national school resource experts and have teamed up to write a comprehensive book on ethics and politics. It covers everything you need to know about ethical leadership and dealing with politics in schools. The book starts with an ethical framework and moves on to politics with unions, administrators, and School Boards with suggested strategies for effective conflict resolution. There are realistic cases in every chapter of the book with the final chapter focused on comprehensive ethical and political (...) cases to test the reader in addressing such issues in the educational or related settings. Benefits and Features of Book:.A comprehensive book covering all aspects of ethics and school politics..Each chapter objectives are aligned with the ELCC, InTASC, ISLCC, and TLEC standards used for accreditation and alignment in program content..Many federal and various state data sources are included..Each chapter contains a comprehensive case study and exercises for practical application..Provides a blend of academic, theoretical, and practical perspectives in handling and dealing in ethical and political situations..Several handy resources are included in the appendices.". (shrink)

Background: Previous studies have found lapses in ethical safeguards for subjects of critical-care research. Objective: To assess recently published empiric critical-care research conducted in the United States for the reporting of research protections as they relate to informed consent and surrogate decision-making. Methods: Systematic review of a sample of empiric critical-care research studies published between 2000 and 2004. Results: Of 51 studies reviewed, consent was reported as having been obtained in 44. Assessment of subjects' decision-making capacity was noted in 35% (...) of studies. Assessments of subjects' capacity was less likely to be reported in studies in which researchers accepted consent from either subjects or from third parties, compared to studies with only subjects' consent (P=0.042). Five studies did not report securing Institutional Review Board approval. Conclusion: Lapses in the reporting of critical-care research are prevalent. (shrink)

Just as noncapacitated decision making will forever be a feature of clinical medicine, so will the quest for effective advance care planning and serviceable documentation of these preferences. “Re-...

A commentary on “Must We Be Courageous?,” by Ann Hamric, John Arras, and Margaret Mohrmann, and on “Patient-Satisfaction Surveys on a Scale of 0 to 10: Improving Health Care, or Leading It Astray?,” by Alexandra Junewicz and Stuart J. Youngner, bothin the May-June 2015 issue.

A number of influential reports on influenza pandemic preparedness include recommendations for extra-autonomous decisions to withdraw mechanical ventilation from some patients, who might still benefit from this technology, when demand for ventilators exceeds supply. An unintended implication of recommendations for nonvoluntary and involuntary termination of life support is that it make pandemic preparedness plans vulnerable to patients’ claims for assisted suicide and active euthanasia. Supporters of nonvoluntary passive euthanasia need to articulate why it is both morally different and morally superior (...) to voluntary active euthanasia if they do not wish to invite expansion of end-of-life options during health system catastrophe. (shrink)

Discussions about resource allocation commonly invoke concerns of unfair and variable decisions when physicians ration at the bedside. This concern is no less germane in disaster medicine, in which physicians make triage and allocation decisions under duress, and patients and their families may be challenged to self-advocate. Unfortunately, a real-time mechanism to support a process for ethical decision making may not be available to medical relief workers. Yet, resources for ethics decision support can be important for the moral well-being of (...) the clinician, the ethical integrity of the relief effort, and to bolster the trust and confidence of the population receiving medical services. The need for clinical ethical support should be anticipated in disaster preparedness planning. (shrink)

This retrospective of the last quarter century of clinical ethics offers an examination of some of the areas in which it should focus, and refocus, attention in the next.

Binding theory (e.g., Chomsky, 1981) has played a central role in both syntactic theory and models of language processing. Its constraints are designed to predict that the referential domains of pronouns and reflexives are nonoverlapping, that is, are complementary; these constraints are also thought to play a role in online reference resolution. The predictions of binding theory and its role in sentence processing were tested in four experiments that monitored participants' eye movements as they followed spoken instructions to have a (...) doll touch a picture belonging to another doll. The instructions used pronouns and reflexives embedded in picture noun phrases (PNPs) containing possessor phrases (e.g., Pick up Ken. Have Ken touch Harry's picture of himself). Although the interpretations assigned to pronouns were generally consistent with binding theory, reflexives were frequently assigned interpretations that violated binding theory. In addition, the timing and pattern of eye movements were inconsistent with models of language processing that assume that binding theory acts as an early filter to restrict the referential domain. The interpretations assigned to reflexives in PNPs with possessors suggest that they are binding‐theory‐exempt logophors, a conclusion that unifies the treatment of reflexives in PNPs. (shrink)

During a catastrophe that disables the health system, ethically charged situations will undoubtedly emerge that will challenge patients, relatives, clinicians, and others involved in health delivery. This second of two special sections of The Journal of Clinical Ethics includes discussions of the implications of a system collapse on particularly vulnerable member of society, children, pregnant women, and those who are socio-economically, culturally, and linguistically disempowered. Additionally, it offers insights into the processes used by committees to plan for catastrophic care.

The American Journal of Bioethics, Volume 11, Issue 11, Page 20-21, November 2011.

Preparations for large-scale disasters have tended to focus on triage schema, stockpiling of materials, and other logistical concerns. Less attention has been given to the myriad of distressing and almost unthinkable ethically charged dilemmas that will emerge at the bedside during a catastrophe, and how they may be best managed. Yet, it is these bedside issues that may limit or thwart the effectiveness of disaster planning, and, therefore, they ought to be carefully considered.

With narrow exception, physicians’ treatment of incapacitated patients requires the consent of health surrogates. Although the decision-making authority of surrogates is appropriately broad, their moral authority is not without limits. Discerning these bounds is particularly germane to ethically complex treatments and has important implications for the welfare of patients, for the professional integrity of clinicians, and, in fact, for the welfare of surrogates. Palliative sedation is one such complex treatment; as such, it provides a valuable model for analyzing the scope (...) of surrogates’ moral authority. Guidelines for palliative sedation that present it as a “last-resort” treatment for severe and intractable suffering yet require surrogate consent in order to offer it are ethically untenable, precisely because the moral limits of surrogate authority have not been considered. (shrink)