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J Clin Ethics [journal]
- Letter: Improving Patient-Doctor Communication about Risk and Choice in Obstetrics and Gynecology through Medical Education: A Call for Action. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(2):176.
The authors suggest that three articles published in the Fall 2013 issue of The Journal of Clinical Ethics could be used in graduate medical education to help students be more prepared to address differences in professional opinion and improve their skills in patient-doctor communication.
- Legal Briefing: Informed Consent in the Clinical Context. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(2):152-175.
This issue's "Legal Briefing" column covers recent legal developments involving informed consent.1 We covered this topic in previous articles in The Journal of Clinical Ethics.2 But an updated discussion is warranted. First, informed consent remains a central and critically important issue in clinical ethics. Second, there have been numerous significant legal changes over the past year. We categorize recent legal developments into the following 13 categories: (1) Medical Malpractice Liability, (2) Medical Malpractice Liability in Wisconsin, (3) Medical Malpractice Liability in Novel Situations, (4) Enforcement by Criminal Prosecutors, (5) Enforcement by State Medical Boards, (6) Enforcement through Anti-Discrimination Laws, (7) Statutorily Mandated Disclosures Related to End-of-Life Counseling, (8) Statutorily Mandated Disclosures Related to Aid in Dying, (9) Statutorily Mandated Disclosures Related to Abortion, (10) Statutorily Mandated Disclosures Related to Telemedicine, (11) Statutorily Mandated Disclosures Related to Other Interventions, (12) Statutorily Mandated Gag and Censorship Laws, (13) Informed Consent in the Research Context.
- Ethics Pocket Cards: An Educational Tool for Busy Clinicians. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(2):148-151.
The adage "an ounce of prevention is worth a pound of cure" is widely used in healthcare settings and can be applied to the work of institutional clinical ethics committees. The model of clinical ethics consultation, however, is inherently reactive: a crisis or question emerges, and ethics experts are called to help. In an effort to employ a proactive component to the model of clinical ethics consultation (as well as to standardize our educational interventions), we developed ethics pocket cards. The purpose of this article is to: (1) describe the rationale for using ethics pocket cards, (2) provide examples of our cards, and (3) begin a dialogue about the potential uses of ethics pocket cards. In doing so, we hope to explore how such portable, economical devices can advance the goals of ethics consultation as well as the educational aims of ethics committees.
- Chinese Physicians' Attitudes toward and Understanding of Medical Professionalism: Results of a National Survey. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(2):135-147.
Medical professionalism has been developing in the Peoples' Republic of China as one way to better address perennial and new challenges in healthcare in an ever-changing society. Among many recent developments in this area is promotion by the national Chinese Medical Doctor Association of the principles and values contained in the international document, "Medical Professionalism in the New Millennium: A Physician Charter."To discover Chinese physicians' attitudes toward and understanding of medical professionalism.The authors distributed a self-reporting questionnaire that included 34 statements and four case scenarios concerning the general principles of medical professionalism: the primacy of patients' welfare, respect for patients' autonomy, promotion of social justice, and professional self-regulation. The questionnaire included controversial issues such as the role of the family in decision making and reporting medical errors. A total of 2,966 practicing physicians, randomly selected from the Chinese Medical Association database, were surveyed, and 1,198 valid questionnaires were returned. Our sample covered 23 provinces and 51 cities throughout the Peoples' Republic of China.More than 80 percent of the physicians who responded agreed that the physician-patient relationship should be a relationship of trust founded on professional altruism, and that informed consent is necessary. More than 95 percent agreed that physicians should promote professional self-regulation as well as social justice. More than half agreed with the principle of the primacy of patients' welfare (62.8 percent), and that physicians have a responsibility to report medical errors and incompetent colleagues (51.0 percent). In certain cases, a great majority of Chinese physicians favored familism and paternalism.The study does not include data on how Chinese physicians practice medical professionalism, or the perspectives of physicians working in smaller cities and in rural areas.Based on responses to the survey, Chinese physicians strongly support the majority of the fundamental principles and responsibilities of medical professionalism, including dedication, altruism, social justice, self-regulation, and informed consent. However, their support for the primacy of patients' welfare as a general principle, and the physician's responsibility to report medical errors and incompetent colleagues, is relatively low. To help advance medical professionalism in the People's Republic of China, professional development programs and medical ethics education should not only emphasize the general principles involved, but also formulate guidelines on how these principles can be carried out in practice.
- Aetna's Compassionate Care Program and End-of-Life Decisions. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(2):131-134.
In this article we describe the successes of Aetna's Compassionate Care Program in providing case management services for people with advanced illnesses.
- Uncharted Terrain: Preference Construction at the End of Life. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(2):120-130.
Respect for patients' self-determination has long been considered central to efforts to improve end-of-life care, yet efforts to promote advance directives or engage patients in end-of-life discussions are often unsuccessful. In this article, I contend that this is because the shared decision-making approach typically used in healthcare assumes patients' capacity to make rational choices, which is not always possible in end-of-life decisions. Drawing on decision theory, behavioral psychology, and related studies of end-of-life care, I present a growing body of evidence that suggests the novelty, complexity, and uncertainty of end-of-life circumstances make rational and stable preferences difficult to establish. I argue that an effective decision-making approach for the terminally ill must recognize and respond to the unique characteristics of end-of-life choices, including their nonrational dimensions. I conclude with a description of an initiative that appears to do so, resulting in increased patients' satisfaction.
- Detoxifying the Concept of Rationing. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(2):116-119.
Andrew Hantel's proposal for dealing with cancer drug shortages exemplifies the kind of clinician-led discussion of rationing the U.S. political process requires. I argue that the U.S. will not get a grip on healthcare cost escalation until we set true budgets for healthcare. We will not be able to do that until the public accepts that rationing, done right, is an ethical necessity, not an ethical abomination. Because endorsing rationing is a third rail for politicians, "top down" leadership is currently impossible. As a result, health professionals must lead a "bottom up" educational process. Hantel shows how this can be done.
- A Protocol and Ethical Framework for the Distribution of Rationed Chemotherapy. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(2):102-115.
Shortages of generic, injectable chemotherapeutics have been increasing in prevalence since 2006. Due to the lack of access to first-line, lifesaving treatments, physicians have been forced to ration chemotherapy between patients. Although the scarcity has been managed with good intentions, it has been done in an ad hoc manner, without the benefit of an ethically grounded and standardized schema. Using an approach based on the "accountability for reasonableness" method by Daniel and Sabin, I establish a framework and protocol for rationing that is specific to chemotherapy. Prior to the state of true shortage, I present guidelines for the use of an adequate supply of chemotherapy with knowledge of upcoming scarcity. Within the rationing framework itself, I first prioritize emergency use of chemotherapeutics and those already receiving treatment at the time of shortage. I advocate for stratifying patients based on the prognostic indicators of their cancer type, using a combination of clinical-trial-based initial response and longer term survival, followed by the patients' line of treatment. All patients who are not able to receive their "best" treatment must receive a sequent, next-best treatment, and their treatment team must have the ability to appeal to a rationing committee in special circumstances. I reject the ideas of stratification based on the intention of the treatment, perceived quality of life, pre-existing condition not impacting performance status, the classical "sickest first" argument, and giving preference to pediatric cases. Lastly, I advocate for any system of rationing to be transparent to those it affects and acknowledge the difficulties it presents to patients and physicians alike.
- Stumbled, Fumbled, Bumbled, Grumbled, and Humbled: Looking Back at the Future History of Clinical Ethics. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(2):96-101.
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.
- How to Help Patients and Families Make Better End-of-Life Decisions. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(2):83-95.
How can clinical ethics consultants best assist patients and their family members when patients may be dying? In this introduction, I consider this concern in light of four articles that appear in this issue of The Journal of Clinical Ethics, by Jeffrey T. Berger; Mary T. White; Linying Hu, Xiuyun Yin, Xiaolei Bao, and Jin-Bao Nie; and Thaddeus Mason Pope and Melinda Hexum. Patients and family members experience extreme stress at the end of life, a high-stakes situation in which few of us have extensive experience. This stress can make us less able to process new information, cripple decision making, and even lead to long-term harm. I provide a number of practical approaches that clinical ethics consultants can use to help patients and family members in these situations, so that their decisions may reflect more what they really want and so that, after this stress has diminished, they may then do better.