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J Clin Ethics [journal]
- How Do We Choose? [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(4):308-310.
The Hearts and Minds of Ghana project improves the lives of those who are less fortunate and have few resources. Providing clear goals for the mission, devising prior guidelines for patient selection and treatment, achieving a better understanding of local culture and expectations, and good team work, facilitate making better ethical decisions, but doesn't make them less difficult.
- Epilogue: Ethical Goals for the Future. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(4):323-332.
Based on the experiences of the Hearts and Minds of Ghana authors, I present possible approaches to the ethical questions that clinicians who participate in health missions and disaster relief programs often face.
- Pediatric Heart Surgery in Ghana: Three Ethical Questions. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(4):317-323.
When a group of doctors and nurses from Boston, Massachusetts, provided evaluation and heart surgery to children in Ghana, they encountered three rationing dilemmas: (1) What portion of surgery slots should they reserve for the simplest, most cost-effective surgeries? (2) How much time should be reserved for especially simple, nonsurgical interventions? (3) How much time should be reserved to training local staff to perform such surgeries? This article investigates these three dilemmas.
- Ethical Aspects of Arranging Local Medical Collaboration and Care. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(4):314-316.
Yearly pediatric cardiac surgery missions to Ghana are of tremendous benefit to local children, but may create thorny ethical dilemmas for local clinicians who refer and screen children for the mission and who provide care to the children after the mission concludes for the year. This article presents the experiences and concerns of a pediatrician who is a local member of the Hearts and Minds of Ghana project.
- Great Need, Scarce Resources, and Choice: Reflections on Ethical Issues Following a Medical Mission. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(4):311-313.
Medical missions to provide cardiac surgical procedures in developing and technologically less advanced countries is a great challenge. It is also immensely gratifying, personally and professionally. Such missions typically present significant ethical dilemmas, especially making difficult choices, given limited time and resources, and the inability to help all children in need of cardiac surgery. We describe some of these issues from our perspective as visiting cardiologists.
- Medical Missions to Ghana: The Ethics of Choosing Children for Cardiac Surgery. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(4):307.
The Hearts and Minds of Ghana project travels from Boston Children's Hospital for two weeks each year to provide cardiac surgery to children in Ghana. Of the hundreds of children in need, how to choose who will receive lifesaving surgery?
- Identifying Challenges to Communicating with Patients about Their Imminent Death. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(4):296-306.
The research literature suggests that physicians' attitudes regarding disclosing a diagnosis of cancer have changed, from nondisclosure to full disclosure. Physicians' attitudes towards disclosing a patient's prognosis are likewise said to have changed, although not to the same degree. The aim of this study was to identify inherent challenges in communicating information about imminent death. It included one set of interviews with patients and another set with doctors, and subsequent discussions of ways to overcome obstacles to patients' understanding their situation. Patients were diagnosed with leukemia, myeloma, or lung cancer; the doctors were hematologists and lung oncologists. The two sets of interviews were analyzed separately using a content analysis model developed by Graneheim and Lundman. For each set of interviews, eight content areas were defined as belonging to an area of interest and scrutinized for the information they included regarding communicating prognoses to patients. The main finding was a discrepancy between patients' desire to be fully informed regarding their prognosis and physicians' reluctance to offer a prognosis until a patient had overt signs of approaching death. We conclude that existing guidelines for disclosure of bad news should be modified to encourage disclosure and discussion of uncertain prognostic information, unless a patient is clearly opposed to receiving such information or otherwise not a suitable partner for dialogue.
- Surrogate Decision Making and Intellectual Virtue. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(4):291-295.
Patients can be harmed by a religiously motivated surrogate decision maker whose decisions are contrary to the standard of care; therefore, surrogate decision making should be held to a high standard. Stewart Eskew and Christopher Meyers proposed a two-part rule for deciding which religiously based decisions to honor: (1) a secular reason condition and (2) a rationality condition. The second condition is based on a coherence theory of rationality, which they claim is accessible, generous, and culturally sensitive. In this article, I will propose strengthening the rationality condition by grounding it in a theory of intellectual virtue, which is both rigorous and culturally sensitive.
- Developing and Testing a Checklist to Enhance Quality in Clinical Ethics Consultation. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(4):281-290.
Checklists have been used to improve quality in many industries, including healthcare. The use of checklists, however, has not been extensively evaluated in clinical ethics consultation. This article seeks to fill this gap by exploring the efficacy of using a checklist in ethics consultation, as tested by an empirical investigation of the use of the checklist at a large academic medical system (Cleveland Clinic). The specific aims of this project are as follows: (1) to improve the quality of ethics consultations by providing reminders to ethics consultants about process steps that are important for most patient-centered ethics consultations, (2) to create consistency in the ethics consultation process across the medical system, and (3) to establish an effective educational tool for trainers and trainees in clinical ethics consultation. The checklist was developed after a thorough literature review and an iterative process of revising and testing by a group of experienced ethics consultants. To pilot test the checklist, it was distributed to 46 ethics consultants. After a six-month pilot period in which ethics professionals used the checklist during their clinical activities, a survey was distributed to all of those who used the checklist. The 10-item survey examined consultants' perceptions regarding the three aims listed above. Of the 25 survey respondents, 11 self-reported as experts in ethics consultation, nine perceived themselves to have mid-level expertise, and five self-reported as novices. The majority (68 percent) of all respondents, regardless of expertise, believed that the checklist could be a "helpful" or "very helpful" tool in the consultation process generally. Novices were more likely than experts to believe that the checklist would be useful in conducting consultations. The limitations of this study include: reduced generalizability given that this project was conducted at one medical system, utilized a small sample size, and used self-reported quality outcome measures. Despite these limitations, to the authors' knowledge this is the first investigation of the use of a checklist systematically to improve quality in ethics consultation. Importantly, our findings shed light on ways this checklist can be used to improve ethics consultation, including its use as an educational tool. The authors hope to test the checklist with consultants in other healthcare systems to explore its usefulness in different healthcare environments.
- Who's at the Table? Moral Obligations to Equal-Priority Surrogates in Clinical Ethics Consultations. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(4):273-280.
Existing state surrogate decision-maker laws are fragmented and inconsistent and fail to ensure that all eligible decision makers of the same surrogate priority class are included in the healthcare decisions made for an incapacitated loved one. In this article, we explore three categories of harm that result from failing to include all surrogates of equal priority in a patient's healthcare decision, namely harms to the patient, harms to the excluded surrogate, and harms to the family. Given these harms, we argue that clinical ethicists have a moral obligation to take reasonable steps to include all surrogate decision makers of equal priority in the healthcare decision-making process for patients without a designated healthcare proxy.