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How far can smart machines, or carebots, go in performing the profoundly intimate human work of patient caregivers? How will mechanization alter how we understand the essential features of the human task of caregiving and the role of the caregiver? It is these complex questions, with real world implications, that this article discusses in reviewing "Caregiving, Carebots, and Contagion" by philosopher and bioethicist Michael Brannagan.

We describe a virtue ethics approach and its application in a four-year, integrated, longitudinal, and required undergraduate medical education course that attempts to address some of the challenges of the hidden curriculum and minimize some of its adverse effects on learners. We discuss how a curriculum grounded in virtue ethics strives to have the practical effect of allowing students to focus on their professional identity as physicians in training rather than merely on knowledge and skills acquisition. This orientation, combined with a student-generated curriculum, is designed to prepare students to identify and face challenges during their clinical years, further nurturing their professional growth. In short, a four-year integrated ethics and professionalism curriculum intentionally centered on cultivating virtuous physicians may alleviate, and even counteract, the effects of the hidden curriculum in the clinical years of medical training.

This is a patient in the relatively early stages of a serious chronic disease requiring ongoing vigilant management if acute complications are to be minimized. In today's healthcare system, we see ...

Since Oregon implemented its Death with Dignity Act, many additional states have followed suit demonstrating a growing understanding and acceptance of aid in dying (AID) processes. Traditionally, the patient has been the one to request and seek this option out. However, as Death with Dignity acts continue to expand, it will impact the role of physicians and bring up questions over whether physicians have the ethical obligation to facilitate a conversation about AID with patients during end of life discussions. Patients have the right to make informed decisions about their health, which implies that physicians have an obligation to discuss with and inform patients of the options that will accomplish the patients’ goals of care. We will argue that physicians have an ethical obligation to inform certain patients about AID (in qualifying states) during end of life care discussions. We will also address what this obligation encompasses and explore guidelines of when and how these conversations should occur and proceed. Earlier guidelines, presented by various palliative care and ethics experts, for proceeding with such conversations have mostly agreed that the discussion of hospice and end of life care with patients should be initiated early and that the individual goals of a patient during the remaining duration of life should be thoroughly examined before discussion of appropriate options. In discussing AID, physicians should never recommend but inform patients about the basics so that they can make an informed decision. If patients express further interest in AID, the physician should open up the dialogue to address the reasoning behind this decision versus other possible treatments to ensure that patients clearly comprehend the process and implications of their decision. Ultimately, any end of life choice should be made by patients with the full capacity to express what they envision for the remaining duration of life and to comprehend the advantages and disadvantages of all the possible options.

"Clinical ethics consultants" have been practicing in the United States for about 50 years. Most of the earliest consultants-the "pioneers"-were "outsiders" when they first appeared at patients' bedsides and in the clinic. However, if they were outsiders initially, they acclimated to the clinical setting and became "insiders" very quickly. Moreover, there was some tension between traditional academics and those doing applied ethics about whether there was sufficient "critical distance" for appropriate reflection about the complex medical ethics dilemmas of the day if one were involved in the decision making. Again, the pioneers deflected concerns by identifying and instituting safeguards to assure professional objectivity in clinical ethics consultation services. One might suggest that in moving inside and establishing normative practices, the pioneer clinical ethics consultants anticipated adoption of their routines and professionalization of the field.

Patients with Alzheimer’s disease and other types of dementia with acute medical problems, who have lost capacity and are without advance directives, are at risk of being over treated inhospitals. To deal with this growing demographic and ethical crisis, patients with dementia need to plan for their future medical care while they have capacity to do so. This article will examine the role of each member of the dementia care triad and how to empower the patient to participate in planning future medical care. A case will be made that physicians have the same professional disclosure obligations to dementia patients as they do to all other capable patients with terminal illnesses. Because there is little consensus about what facts should be included in a diagnostic disclosure, this article will offer a proposal to empower newly diagnosed patients with dementia with capacity to plan for their future medical care.

As clinical ethics consultants move toward professionalization, the process of certifying individual consultants or accrediting programs will be discussed and debated. With certification, some entity must be established or ordained to oversee the standards and procedures. If the process evolves like other professions, it seems plausible that it will eventually include a written examination to evaluate the core knowledge competencies that individual practitioners should possess to meet peer practice standards. The American Society for Bioethics and Humanities (ASBH) has published core knowledge competencies for many years that are accepted by experts as the prevailing standard. Probably any written examination will be based upon the ASBH core knowledge competencies. However, much remains to be done before any examination may be offered. In particular, it seems likely that a recognized examining board must create and validate examination questions and structure the examination so as to establish meaningful, defensible parameters after dealing with such challenging questions as: Should the certifying examination be multiple choice or short-answer essay? How should the test be graded? What should the pass rate be? How may the examination be best administered? To advance the field of health care ethics consultation, thought leaders should start to focus on the written examination possibilities, to date unaddressed carefully in the literature. Examination models-both objective and written-must be explored as a viable strategy about how the field of health care ethics consultations can grow toward professionalization.

I shall do less whenever I shall believe what I am doing hurts the cause, and I shall do more whenever I shall believe doing more will help the cause. I shall try to correct errors when shown to be...

The article by Professor Fiester (2015) expresses concern about the long-term moral distress or negative moral emotions, both aspects of moral residue, that linger in some stakeholders’ experiences...

This article discusses how the paradigm of Cartesian mind-body dualism has shaped the cultural and institutional life of modern science and medicine. John Dewey (1859-1952) made this case in a speech to the New York Academy of Medicine in 1927, "Preoccupation with the Disconnected," an expanded version of which was published as "Body and Mind" in the Bulletin of the New York Academy of Medicine in January 1928. From the perspective of Dewey's broader philosophy, the most urgent aspect of mind-body dualism is of a practical, not theoretical, nature. Medicine at present has an opportunity in both education and practice to reconcile internally disparate trends that result from mind-body dualism and to renew its mission.

Health care ethics committees may fail in their role as mediators if their members lack impartiality, independence, or expertise in policy formation.

Clinical ethics consultants (CECs) often face some of the most difficult communication and interpersonal challenges that occur in hospitals, involving stressed stakeholders who express, with strong emotions, their preferences and concerns in situations of personal crisis and loss. In this article we will give examples of how much of the important work that ethics consultants perform in addressing clinical ethics conflicts is incompletely conceived and explained in the American Society of Bioethics and Humanities Core Competencies for Healthcare Ethics Consultation and the clinical ethics literature. The work to which we refer is best conceptualized as a specialized type of interviewing, in which the emotional barriers of patients and their families or surrogates can be identified and addressed in light of relevant ethical obligations and values within the context of ethics facilitation.

Many patients in the intensive care unit (ICU) have predictable medical and discharge outcomes, but some trajectories are marked with medical uncertainty. Stressed family-surrogates receive multiple medical updates from a variety of personnel. These circumstances can lead to confusion, which may result in conflicts and dissatisfaction with care. This study examined the effects of adding a family support coordinator to the surgical, neurological, and medical ICUs on family, physician, and nurse satisfaction with communication and care. A quasi-experimental design was conducted in 2 sequential phases (baseline and intervention). The data sources were 2 surveys: (1) Family Satisfaction Survey and (2) Nurse and Physician Perception and Satisfaction Survey. Family Satisfaction Survey data, a combined data set, were collected in the 3 ICUs. Nurse and Physician Perception and Satisfaction Survey data were collected from the attending physicians and critical care nurses in the medical and neurological ICUs. Results show that family ratings of satisfaction with ICU team communication and care generally increased as a result of the intervention. Overall, physician and nurse perceptions of communication and care did not change as a result of the intervention.

Despite the emergence of clinical ethics consultation as a clinical service in recent years, little is known about how clinical ethics consultation differs from, or is the same as, other medical consultations. A critical assessment of the similarities and differences between these 2 types of consultations is important to help the medical community appreciate ethics consultation as a vital service in today's health care setting. Therefore, this Special Article presents a comparison of medical and clinical ethics consultations in terms of fundamental goals of consultation, roles of consultants, and methodologic approaches to consultation, concluding with reflections on important lessons about the physician-patient relationship and medical education that may benefit practicing internists. Our aim is to examine ethics consultation as a clinical service integral to the medical care of patients. Studies for this analysis were obtained through the PubMed database using the keywords ethics consultation, medical consultation, ethics consults, medical consults, ethics consultants, and medical consultants. All English-language articles published from 1970 through August 2011 that pertained to the structure and process of medical and ethics consultation were reviewed.

This article proposes a new theoretical framework for analyzing complex inpatient hospital discharge dilemmas. Each component of the framework is defined, illustrated with a hypothetical case, and discussed from legal,ethical and practical problem solving viewpoints. Patients who lack reasonable and safe discharge plans invariably challenge existing interpretations of autonomy, capacity, and justice. Such cases often require legal advice and sometimes intervention from the judicial system when alternatives are exhausted. As an extension of previous work on discharge planning (Swidler et al., 2007), this work strives to provide medical professionals with an organized way of approaching inpatient discharge barriers and to encourage new ways of considering and designing healthcare policy both to reduce discharge delays and also better to serve patients.

The costs associated with Intensive Care Units (ICUs) are high and at times invasive ICU care may not be beneficial, particularly for those patients admitted to ICUs who have little hope of recovery. The process of clarifying medical goals for these patients is often facilitated by addressing psychosocial factors. Social workers in the ICU are uniquely qualified to assess and address many of the complex psychosocial circumstances and can clarify potential misperceptions, enhancing communication among patients (if capacitated), their families, and the medical team members. This can not only help improve quality of life for very sick and dying patients in the ICU and their families, but may also reduce the likelihood of decision-making conflicts from arising. Further studies need to be done to investigate the effectiveness of social work interventions in reducing family distress, avoiding care that is unwanted by patients, and demonstrating cost-saving benefits.

• Background Long stays in the intensive care unit are associated with high costs and burdens on patients and patients’ families and in turn affect society at large. Although factors that affect length of stay and outcomes of care in the intensive care unit have been studied extensively, the conclusions reached have not been reviewed to determine whether they reveal an organizational pattern that might be of practical use in reducing length of stay in the unit. • Objective To identify and categorize the factors associated with prolonged stays in the intensive care unit and to describe briefly the nonmedical interventions to date designed to reduce length of stay. • Methods Articles published between January 1990 and March 2005 in English-language journals indexed by MEDLINE were searched for studies on outcomes and costs of care in the intensive care unit and on care at the end of life. • Results The emerging consensus is that length of stay in the intensive care unit is exacerbated by several increasingly discernible medical, social, psychological, and institutional factors. At the same time, several nonmedical, experimental interventions have been designed to reduce length of stay. • Conclusions Interventions involving palliative care, ethics consultations, and other methods to increase communication between healthcare personnel, patients, and patients’ families may be helpful in decreasing length of stay in the intensive care unit. Further studies are needed to provide a strategy for targeting specific risk factors indicated by the literature review.

Recent debate on whether physicians should discuss gun ownership with their patients has centered on determining whether gun injuries are an issue of health or safety, and on protecting patient privacy. Yet, physicians’ duties span personal health, public health, and safety spheres, and they often must address private patient matters. To prioritize gun safety and reduce gun injuries, the primary policy-driving question should be: will physician counseling on gun ownership effectively reduce gun-related injuries without interfering with the physician’s other treatment obligations or compromising the physician–patient relationship? Existing data on physician-initiated conversations with patients about guns support a positive prevention effect. However, it is critical that physician-initiated discussions of safe gun practices are not motivated by, nor convey, disapproval of gun ownership. To be ethical, respectful, and efficient, the conversation should be standard between primary care providers and all of their patients (not limited to patient subsets); questions and education should be limited to topics of gun-ownership risks and storage practices; and the conversation must be framed without bias against gun ownership.

The risk of a newborn having critical congenital heart disease (CCHD) is about 1 out of 100 babies, making it the most common birth defect. If this condition goes undetected, the consequences for t...

There has been growing concern about the effects on the patient-physician relationship of the increasing demands on physicians to balance their fiduciary and stewardship responsibilities, what has been called "double agency." Various authors have proposed ways to restore patient centeredness to the patient-physician interaction. We have previously discussed the need to establish a patient-physician alliance to achieve this aim and to facilitate achieving this balance in mutual understanding. In this essay, we examine six concepts derived by Michael Balint from research seminars with primary care physicians. These six concepts are (a) the basic fault; (b) the physician's apostolic function; (c) the mutual investment company; (d) the drug "doctor"; (e) the deeper diagnosis; and (f) the conspiracy of anonymity. We believe these six concepts describe basic forces that shape the patient-physician relationship and allow for the development of an alliance between patients and physicians that can help preserve the essentials of the relationship.

To provide preliminary evidence of the types and amount of involvement by healthcare industry representatives (HCIRs) in surgery, as well as the ethical concerns of those representatives.A link to an anonymous, web-based survey was posted on several medical device boards of the website http://www. cafepharma.com. Additionally, members of two different medical device groups on LinkedIn were asked to participate. Respondents were self-identified HCIRs in the fields of orthopedics, cardiology, endoscopic devices, lasers, general surgery, ophthalmic surgery, oral surgery, anesthesia products, and urologic surgery.A total of 43 HCIRs replied to the survey over a period of one year: 35 men and eight women. Respondents reported attending an average of 184 surgeries in the prior year and had an average of 17 years as an HCIR and six years with their current employer. Of the respondents, 21 percent (nine of 43) had direct physical contact with a surgical team or patient during a surgery, and 88 percent (38 of 43) provided verbal instruction to a surgical team during a surgery. Additionally, 37 percent (16 of 43) had participated in a surgery in which they felt that their involvement was excessive, and 40 percent (17 of 43) had attended a surgery in which they questioned the competence of the surgeon.HCIRs play a significant role in surgery. Involvement that exceeds their defined role, however, can raise serious ethical and legal questions for surgeons and surgical teams. Surgical teams may at times be substituting the knowledge of the HCIR for their own competence with a medical device or instrument. In some cases, contact with the surgical team or patient may violate the guidelines not only of hospitals and medical device companies, but the law as well. Further study is required to determine if the patients involved have any knowledge or understanding of the role that an HCIR played in their surgery.

This paper attempts to provide a descriptive theoretical overview of the medical futility debate. I will first argue that quantitative data cannot alone resolve the medical futility debate. I will then examine two aspects of medical futility, which I call the prospective and immediate, respectively. The first involves making prospective factual and value judgments about the efficacy of proposed medical interventions, while the latter involves making value judgments about ongoing medical conditions where the clinical data are clear. At stake is the nature and scope of individual rights. Thus, I maintain there is an undeveloped aspect to the medical futility debate and, briefly, analyze two political perspectives which give rise to different understandings of medical futility. The view that I will defend is that only a system with defined collective goals can accommodate a normative concept of medical futility. These larger questions are the value options which, if unaddressed, may be settled by default of economic grounds.

Dealing as we do with poor suffering humanity, we see the man unmasked, exposed to all the frailities and weaknesses, and you have to keep your heart soft and tender lest you have too great a contempt for your fellow creatures. Sir William Osler

The patient-physician relationship has undergone major and increasingly rapid changes in the past 40 years. It has moved from a relationship based on physician paternalism, through one of patient autonomy, to one where the patient and the physician's authority and control over the patient's care are facing significant threats from outside sources. In this article, we examine the historical and social forces that have contributed to these changes and the effects these forces have had on the traditional models of the patient-physician relationship. We present arguments to support our proposal for a patient-physician alliance in the community based on mutual education of physician and patient about health and illness, values and persons, social responsibility, beneficence, trust, and a degree of paternalism. We believe such an alliance offers the best hope for patients and their physicians to regain the initiative in guiding the evolution of health care in a way that preserves the essentials of the therapeutic relationship. (JAMA. 1996;275:887-891)

Members of the Clinical Ethics Consultation Affairs Standing Committee of the American Society for Bioethics and Humanities present a collection of insights and recommendations developed from their collective experience, intended for those engaged in the work of healthcare ethics consultation.

The study examined the effect of adding a full-time family support coordinator to the surgical intensive care unit team on family satisfaction, length-of-stay, and cost in the surgical intensive care unit.A quasi-experimental design was conducted in two phases: baseline (8 mos) and intervention (10 mos) phases. Data on family satisfaction, length-of-stay, and costs from both phases were collected.The intervention added a new role, the family support coordinator, to the surgical intensive care unit team. The family support coordinator functioned as a liaison between the patient's family and the health care team.The results revealed that generally the intervention was associated with increases in family satisfaction with communication for all surgical intensive care unit team members, with physicians, social workers, and respiratory care therapists showing increases in significance. The largest increase was for physician communication (p = .0034). Families also rated their perceptions of the quality of care provided to their family members by various members of the surgical intensive care unit team. Mean ratings increased for all areas of care, with respiratory and nursing care showing the largest increases. Families' perceptions of the care and treatment they received during the stay of their family member showed increases in all areas of satisfaction between baseline and intervention, particularly those areas most related to the intervention.The implementation of the family support coordinator intervention increased family satisfaction across a range of parameters. Although there were decreases in length-of-stay and costs, they were not statistically significant. Further research is needed to determine whether intervention refinement could produce lower length-of-stay and costs.

Every day, in every hospital, hospital staff members, patients, and families wrestle with critically important discharge decisions. Those decisions can raise complex issues with significant ethical...

How many textbooks or introductory articles in bioethics begin with a section on ethical theory? Of the many that do, the relevance of basic theories of utilitarianism, deontology, virtue ethics, feminist ethics, casuistry and so on, is assumed. These theories are also considered in light of the well-accepted principles of medical ethics: (1) respect for patient autonomy, (2) beneficence, (3) non-maleficence and (4) justice. Those of us trained in philosophy find these sections on theory terse summations of complex philosophical views. Physicians and nurses, and others not trained in philosophy, sometimes struggle to get their gist, and end up with an ability to make a basic analysis and formulate arguments about ethical problems from each of these perspectives, and to write and discuss the issues that arise with fellow ethicists. But how essential are these theoretical perspectives to the real work of clinical ethics consultants? It is important that we do not forget just how applied and practical that work is.

Long stays in the intensive care unit are associated with high costs and burdens on patients and patients' families and in turn affect society at large. Although factors that affect length of stay and outcomes of care in the intensive care unit have been studied extensively, the conclusions reached have not been reviewed to determine whether they reveal an organizational pattern that might be of practical use in reducing length of stay in the unit.To identify and categorize the factors associated with prolonged stays in the intensive care unit and to describe briefly the nonmedical interventions to date designed to reduce length of stay.Articles published between January 1990 and March 2005 in English-language journals indexed by MEDLINE were searched for studies on outcomes and costs of care in the intensive care unit and on care at the end of life.The emerging consensus is that length of stay in the intensive care unit is exacerbated by several increasingly discernible medical, social, psychological, and institutional factors. At the same time, several nonmedical, experimental interventions have been designed to reduce length of stay.Interventions involving palliative care, ethics consultations, and other methods to increase communication between healthcare personnel, patients, and patients' families may be helpful in decreasing length of stay in the intensive care unit. Further studies are needed to provide a strategy for targeting specific risk factors indicated by the literature review.

No topic in medical education has received more attention and generated more discussion in recent years than that of “professionalism”. In many ways, this should come as no surprise in light of the dramatic technical and scientific advances in medicine, the changing, and often confounding, roles of physicians in complex health care systems, and the growing expectation throughout society that physicians should provide more effective, patient-centered care. Any of these factors alone is sufficient to create anxiety and confusion about basic duties and responsibilities of physicians to patients, the medical profession and to society. In this complex, demanding, commercialized and yet, values-laden, world of health care it is an understatement to say that there are fundamental challenges to what it means to be a medical professional in today's society.

In Community as Healing , Micah Hester aspires to offer a bold alternative to the theoretical approach that has dominated bioethics since the 1970s. He begins by claiming that the concepts of individual patient autonomy portrayed in the well-known works of Tom Beauchamp and James Childress in Principles of Biomedical Ethics and H. Tristram Engelhardt in The Foundations of Bioethics are inadequate. As he states

During recent decades the doctrine of informed consent has become a standard part of medical care as an expression of patients' rights to self-determination. In situations when only one treatment alternative exists for a potential cure, the extent of a patient's self-determination is constrained. Our hypothesis is that for patients considering a life-saving procedure such as bone marrow transplant (BMT), informed consent has little meaning as a basis for their right to self-determination. A longitudinal study of BMT patients was undertaken with four self-administered questionnaires. Questions centered around expectations, knowledge, anxiety and factors contributing to their decision to undergo treatment. Although the informed consent process made patients more knowledgeable about the treatment, their decision to consent was largely based on positive outcome expectations and on trust in the physician. Informed consent relieved their anxieties and increased their hopes for survival. Our conclusion was that the greatest value of the informed consent process lay in meeting the patients' emotional rather than cognitive needs. When their survival is at stake and BMT represents their only option, the patient's vulnerability puts a moral responsibility on the physician to respect the principle of beneficence while not sacrificing the patient's right to self-determination.

More than 90 people attended a March 25–27, 2004, conference on Ethics and Epidemics. This conference was sponsored by the Albany Medical College–Graduate College of Union University Masters in Bioethics Program, the University at Albany School of Public Health, the New York State Department of Health, and the Wadsworth Laboratories. Attendees came from Australia, Africa, Asia, Europe, Canada, and the United States. Among the 24 papers and panels, presentations were made by George Annas, professor and chair of Health Law at the Boston University School of Public Health; Ezekiel Emanuel, chair of the Department of Clinical Bioethics of the Magnuson Center of the National Institutes of Health; Thomas R. Freiden, commissioner, New York City Department of Health; Matthew Wynia, director of the Institute of Ethics of the American Medical Association; Kenyan bioethicist Angela Wassuna associate for International Affairs of the Hastings Center; and 19 other bioethicists and health professionals. Presentations ranged from case studies to health policy debates. Many reviewed the history of epidemics, emphasizing their global nature and the imperative of global strategies for epidemic control. Several papers examined recent epidemics and explored new strategies for dealing with epidemic control while respecting human rights. The consensus was that the old policeman model of public health needs updating. Discussion focused on how best to balance public safety, professional responsibility, personal liberty, and human rights, while effectively containing epidemics. Emanuel and Wynia reaffirmed the responsibility of physicians and first responders to put their health and lives at risk in combating epidemics. Yet, noting the vulnerability of first responders (in the Toronto severe acute respiratory syndrome [SARS] outbreak and elsewhere), they distinguished between bravery and foolhardiness, arguing that just as professionals have a responsibility to protect the public from disease, the public, in turn, has a responsibility to provide the training, equipment, and resources to minimize the need to take risks. Virtually all conferees observed that the public health infrastructure needs substantial rebuilding to cope effectively with epidemics. Annas, however, noted that in bioterrorist assaults the control of biologic agents is a public health problem to be dealt with by public health officials, not by the U.S. Department of Defense or the U.S. Department of Homeland Security. He further stated that policies on epidemic control that involve consistent, open, and truthful communication with the public—like those used in New York and Toronto during the recent SARS outbreak—create cooperative environments that minimize conflicts between freedom and safety and limit the effects of isolation and quarantine. However, Emanuel et al. asserted that the traditional enforcement authority of public health law was essential and needed as a fallback. The result of the debate was that 21st century methods need to be developed to control infectious disease epidemics that reconcile the need to protect public health and respect human rights. The conference program is available on http://www.bioethics.union.edu under "News." For further information contact bioethics@union.edu or 518-388-8045.

(2003). Respect for Donor Autonomy and the Dead Donor Rule. The American Journal of Bioethics: Vol. 3, No. 1, pp. 20-21.

In Reply. —Dr Hensel raises several interesting points.First, he applies our patient-physician alliance in community model to the case we described in our article. We fully agree with the scenario Hensel describes. This is indeed how we would envisage the working of our model. As Hensel implies, third-party payers, especially managed care organizations, are not yet at the point of responding altruistically or indeed with enlightened self-interest to such situations. At the same time, not all physicians are ready to pursue matters as Hensel describes. We need to undertake significant educational efforts to move in the desired direction on both theme fronts.Second, Hensel is correct in stating that managed care organizations are willing to deny payment for expensive procedures, but are not willing to support the time it takes to educate the patient about the appropriate use of such tests. Again, this is an area where mutual education is needed.