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Ableist attitudes and structures are increasingly recognized across all sectors of health care delivery. After Dobbs, novel questions arose in the United States concerning how to protect reproductive autonomy while avoiding discrimination against and devaluation of disabled persons. In this essay, we examine the Louisiana Department of Health's emergency declaration, "List of Conditions That Shall Deem an Unborn Child 'Medically Futile,'" issued August 1, 2022. We raise a number of medical, ethical, and public health concerns that lead us to argue that the declaration should be rescinded. Analysis of this ethically objectionable declaration provides valuable lessons about how to uphold both reproductive and disability justice in a post-Dobbs landscape.

Robert Veatch argues that physician oaths should not be valued as substantive moral commitments, transformational rituals, or symbolic acts. Further, he insists that oath recitation in medical schools is immoral. I respond to Veatch's criticisms and argue that, with alterations to their content and practice, oaths can have value for articulating moral commitments and building a sense of moral community within the profession. I break down Veatch's multitude of objections to oaths over his career, and I suggest how medical schools can avoid the pitfalls identified by Veatch. A promising and innovative path forward is to integrate a commitment to diversity, equity, and inclusion-though with an understanding that a few lines in an oath are far from sufficient for institutional culture, faculty accountability, or students' education.

The OpenNotes (ON) mandate in the 21st Century Cures Act requires that patients or their legally authorized representatives be able to access their medical information in their electronic medical record (EMR) in real time. Ethics notes fall under the domain of this policy. We argue that ethics notes are unique from other clinical documentation in a number of ways: they lack best-practice guidelines, are written in the context of common misconceptions surrounding the purpose of ethics consultation, and often answer questions of a different nature than other documentation. Thus, we believe the clinical ethics community would benefit from clarification on when the withholding of ethics notes is justified. We provide recommendations for excluding information from ethics documentation based on the likelihood and magnitude of harm that may occur with particular disclosures and suggest approaches to decrease the potential harms that may occur. We define and explain six types of reasons to exclude information from ethics notes based on significant harms that are not addressed in the ON policy: (1) harmful revelations from a protected chart note; (2) negative emotional effects on patients or families; (3) the purpose of the consultation is undermined by harmful consequences; (4) avoidable negative impact on interpersonal dynamics; (5) inappropriate labeling or disclosure of medical, social, or financial information; and (6) inclusion of biasing or otherwise unfair information. We also suggest approaches to mitigate harm when excluding, including, reframing, or delaying release of information that is perceived to be relevant to an ethics case. Overall, we hope our analysis and recommendations will initiate a much-needed discussion about the impact of the ON mandate on clinical ethics documentation.

In this essay, we suggest practical ways to shift the framing of crisis standards of care toward disability justice. We elaborate on the vision statement provided in the 2010 Institute of Medicine (National Academy of Medicine) "Summary of Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations," which emphasizes fairness; equitable processes; community and provider engagement, education, and communication; and the rule of law. We argue that interpreting these elements through disability justice entails a commitment to both distributive and recognitive justice. The disability rights movement's demand "Nothing about us, without us" requires substantive inclusion of disabled people in decision-making related to their interests, including in crisis planning before, during, and after a pandemic like Covid-19.

Shared decision making (SDM) is difficult to implement in mental health practice, but it remains an ethical ideal for motivating therapeutic capacity in patient-clinician relationships; this discrepancy warrants attention from clinical and ethical perspectives. This article explores what some clinicians see as obstacles to even attempting SDM with patients with psychiatric disabilities. In particular, this article identifies 4 such obstacles: a patient's lack of decision-making capacity, a patient's poor insight, a health care professional's therapeutic pessimism or personal dislike, and a patient's or health care professional's conflicting recovery orientations or goals of care. This article argues that each obstacle could be overcome in many cases and that health care professionals, patients, and their caregivers should remain dedicated to attempting SDM in mental health practice.

Robert Veatch's The Foundations of Justice: Why the Retarded and the Rest of Us Have Claims to Equality (1986) delves into deep questions of justice through the case of a child with disabilities. I describe what is basically right about this vision, as well as what is problematic from the standpoint of contemporary disability bioethics. From there, I dive into the notion of vulnerability that is at play in his work. He describes disability as necessarily a condition of weakness, lesser-than existence, and neediness. When disability is viewed in this way as an inherently vulnerable state of being, the essential sociopolitical dimensions of disability receive inadequate attention, which, in turn, makes it impossible to identify injustices correctly. I connect these points to concrete challenges faced by disability communities during the COVID-19 pandemic, which have raised profound questions about the just use of scarce critical care resources. Any case drawn from the pandemic is a very different kind of case than that of the child in Veatch's book, but a commonality is the question of who should get what limited resources when needs and urgency vary.

The concept of vulnerability is widely used in bioethics, particularly in research ethics and public health ethics. The traditional approach construes vulnerability as inherent in individuals or the groups to which they belong and views vulnerability as requiring special protections. Florencia Luna and other bioethicists continue to challenge traditional ways of conceptualizing and applying the term. Luna began proposing a layered approach to this concept and recently extended this proposal to offer two new concepts to analyze the concept of vulnerability, namely understanding external conditions that trigger vulnerability and layers of vulnerability with cascading effects. Luna’s conception of vulnerability is useful, which we demonstrate by applying her layered view and the new analyses in multiple contexts. We begin by outlining Luna’s view and we use vignettes from healthcare involving transgender patients, the care of patients in psychiatric contexts, and research involving prisoners to illustrate how each part of Luna’s concept elucidates important moral issues.

Baby A1 was born prematurely with severe encephalopathy, injured brainstem, and a potentially injured spinal cord. He had no response to pain or other external stimuli. The neonatal team unanimousl...

Rights Come to Mind: Brain Injury, Ethics, and the Struggle for Consciousness (2015) by Joseph J. Fins offers rich narratives of families and patients who experience disorders of consciousness in flawed health-care systems that are not clinically, structurally, financially, or ethically prepared to respond to the inherent complexities of these conditions. In 2018, only a few years after the publication of this book, the medical guidelines for these disorders officially changed with key publications in Neurology. Fins has called on bioethicists to respond to these significant developments, and this paper serves as a response to that call. This article offers a critical analysis of a couple of Fins's arguments. But it also emphasizes the importance of these developments and Fins's work for thinking through bedside and organizational ethics issues that arise in advocating for patients with disorders of consciousness.

Ask any clinical ethics consultant, and they can tell you about their transformative cases. Some stick with us because all roads led nowhere. Cassandra Lee had a history of pulling out lines and tubes and a distaste of warming blankets. Her admission marked her thirtieth over the past year. Many of the challenges facing the hospital caring for her were not unique: significant psychiatric issues, prolonged nonadherence to medical advice, and end-of-life decision-making combined to create an ethically dense and vexing situation. Ms. Lee, like so many patients, was suffering because of system failures.

At its core, nonideal theory is an attempt not only to address issues of justice, but it also provides us a lens through which we can articulate our limitations as knowers and reasoners, the ways in which we are relational in our autonomy needs, and the ways in which we are deeply dependent upon institutions and social supports for our agency and identities. Bringing this lens into bioethics means shifting our orientation in our scholarship and our practice. This shift will have implications in how bioethical evaluations are taken up and played out in policies, institutional structures that inform the clinical encounter, and avenues for protection and redress for marginalized and vulnerable populations. It will also allow theorists and researchers to interrogate the status quo, revealing how many standard policies and practices are embedded in social and institutional arrangements that privilege the few or are built on exclusionary norms. The path forward, and the aim of this volume, is to extend the scholarship of nonideal approaches to bioethics. The volume is divided into two main parts. The first is focused on philosophically unpacking nonideal theory as an approach in bioethics. The second offers applications of nonideal theory in environmental ethics, healthcare ethics, public heath ethics, and genetic ethics. Our collective aim is to expand what has been considered nonideal bioethics. The history of nonideal theory has as its point of reference a turn away from Rawlsian justice, but the future of nonideal theory is ripe with possibilities.

The COVID-19 (Coronavirus disease of 2019) pandemic has led to intense conversations about ventilator allocation and reallocation during a crisis standard of care. Multiple voices in the media and multiple state guidelines mention reallocation as a possibility. Drawing upon a range of neuroscientific, phenomenological, ethical, and sociopolitical considerations, the authors argue that taking away someone’s personal ventilator is a direct assault on their bodily and social integrity. They conclude that personal ventilators should not be part of reallocation pools and that triage protocols should be immediately clarified to explicitly state that personal ventilators will be protected in all cases.

The consumer/survivor/ex-patient movement contends that individuals diagnosed with mental health conditions are routinely doubted or dismissed when they make claims about their needs, values, and interests. Too many therapists, the claim goes, take a parentalist stance toward their patients. Recent work on expertise shows how some patients can acquire competence with their medical condition sufficient for sophisticated participation in management of their care; that is, they can become “patient experts.” This chapter argues that many psychotherapy patients can become patient experts and, thereby, benefit from robust shared decision making (SDM). In these cases, attitudes of distrust and protectionism can lead to the moral failure of epistemic injustice, thereby harming both the patient and the therapeutic relationship. Drawing on recent literature on epistemic injustice, SDM, and expertise from epistemology, the authors contend that the success of SDM relies largely on the therapist’s appreciation of the varying types and degrees of expertise and epistemic advantage involved in decision making.

Our aim in this article is to define the difficulties that clinical ethics services encounter when they are asked to demonstrate the value a clinical ethics service (CES) could and should have for an institution and those it serves. The topic emerged out of numerous related presentations at the Un-Conference hosted by the Cleveland Clinic in August 2018 that identified challenges of articulating the value of clinical ethics work for hospital administrators. After a review these talks, it was apparent that the field of clinical ethics may be at a crisis of sorts due to increased pressure to provide explicit measures to healthcare institutions to concretely demonstrate that CESs make a valuable difference in healthcare delivery. In this article we grapple with how to satisfy the need for demonstrable value in a field in which metrics alone may not capture the scope of clinical ethics practice. We suggest that capturing the value of a CES has been difficult because the benefits of ethics consultation may be overt or attributable to the CES, but are often hidden due to the systems-level and process-oriented nature of clinical ethics work. Part of the difficulty in demonstrating the value of CESs is capturing and conveying all of the ways the integration of a CES throughout an institution positively affects patients, families, visitors, healthcare professionals, administrators, and the institution itself. Our aim is to (1) elucidate the multifaceted value added by a CES, including value that tends to be hidden and (2) suggest how to demonstrate value to others in a way that is not simplistic or reductionistic.

The covert administration of medication occurs with incapacitated patients without their knowledge, involving some form of deliberate deception in disguising or hiding the medication. Covert medication in food is a relatively common practice globally, including in institutional and homecare contexts. Until recently, it has received little attention in the bioethics literature, and there are few laws or rules governing the practice. In this paper, we discuss significant, but often overlooked, ethical issues related to covert medication in food. We emphasise the variety of ways in which eating has ethical importance, highlighting what is at risk if covert administration of medication in food is discovered. For example, losing trust in feeders and food due to covert medication may risk important opportunities for identity maintenance in contexts where identity is already unstable. Since therapeutic relationships may be jeopardised by a patient’s discovery that caregivers had secretly put medications in their food, this practice can result in an ongoing deception loop. While there may be circumstances in which covert medication is ethically justified, given a lack of suitable alternatives, we argue that in any particular case this practice should be continually re-evaluated in light of the building moral costs to the relational agent over time.

In an effort to address healthcare disparities in lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations, many hospitals and clinics institute diversity training meant to increase providers' awareness of and sensitivity to this patient population. Despite these efforts, many healthcare spaces remain inhospitable to LGBTQ patients and their loved ones. Even in the absence of overt forms of discrimination, LGBTQ patients report feeling anxious, unwelcome, ashamed, and distrustful in healthcare encounters. We argue that these negative experiences are produced by a variety of subtle, ostensibly insignificant features of healthcare spaces and interpersonal interactions called microaggressions. Healthcare spaces and providers often convey heteronormative microaggressions, which communicate to LGBTQ-and, we suggest, intersex and asexual (IA)-people that their identities, experiences, and relationships are abnormal, pathological, unexpected, unwelcome, or shameful. We identify heteronormative microaggressions common to healthcare settings and specify how they negatively impact LGBTQIA patients. We argue that standard diversity training cannot sufficiently address heteronormative microaggressions. Despite these challenges, healthcare institutions and providers must take responsibility for heteronormative microaggressions and take steps to reduce their frequency and mitigate their effects on LGBTQIA care. We conclude by offering strategies for problem-solving at the level of medical education, institutional culture and policy, and individual awareness.

The COVID-19 (Coronavirus disease of 2019) pandemic has led to intense conversations about ventilator allocation and reallocation during a crisis standard of care. Multiple voices in the media and multiple state guidelines mention reallocation as a possibility. Drawing upon a range of neuroscientific, phenomenological, ethical, and sociopolitical considerations, the authors argue that taking away someone’s personal ventilator is a direct assault on their bodily and social integrity. They conclude that personal ventilators should not be part of reallocation pools and that triage protocols should be immediately clarified to explicitly state that personal ventilators will be protected in all cases.

INTRODUCTION: As the COVID19 pandemic persists across the globe, health care professionals and institutions continue to face ethical challenges and often are uncertain about their responses to those challenges While some of these ethical issues have been experienced before, e g , ventilator allocation during H1N1, refusing CPR during Ebola outbreak, similar and other unique ethical issues have developed during the COVID19 pandemic To better understand individual and institutional perspectives, we designed and distributed a survey to capture those working health care and others perceive issues surrounding institutional responses to COVID-19 Given the nature of COVID-19, and our interim analysis, it is likely that many of these issues will arise in the critical care setting METHODS: We sent a survey out weekly to two large bioethics listservs starting in April 2020 Members of the listserv were asked to complete the survey each week and to forward the survey to interdisciplinary colleagues who may not be members of these listservs At this point in our analysis we have completed basic descriptive statistics, including X-tabs and Fischer's exact test RESULTS: Using only 6 months of data for participants who complete the survey for the first time, we received 446 respondents since April 2020 The average age of participants was 47 6 and over 71% of participants identified as female 95% of the respondents work primarily in the US with 62% working in critical care setting at least part-time Overall, when asked about the extent to which it is ethically reasonable to limit CPR (during crisis standards of care) for patients with COVID-19, for the sake of conserving scarce resource, nearly 50% of respondents choose the response, ?Can be reasonable, but generally one should not limit CPR ? Relatedly, 64% of respondents believed it was always reasonable to require providers to don all PPE before initiating CPR on a patient with COVID This is especially relevant in light of the finding that over 78% of participants replied that their institution does not or that they were unsure whether or not their institution has a policy that limits CPR for COVID19 patients when there is insufficient PPE CONCLUSIONS: The survey identified the need for broadly collaborative efforts to resolve ethical issues during COVID-19

The question of whether a patient has insight is among the first to be considered in psychiatric contexts. There are several competing conceptions of clinical insight, which broadly refers to a patient’s awareness of their mental illness. When a patient is described as lacking insight, there are significant implications for patient care and to what extent the patient is trusted as a knower. Insight is currently viewed as a multidimensional and continuous construct, but competing conceptions of insight still lack consensus on the specifics. Studies also give contradictory evidence regarding the frequency and consequences of poor insight. A number of crucial questions remain unanswered. After outlining some of the key theoretical disagreements about what insight means, I highlight ethical issues that have not received much attention in the literature. Given the conceptual ambiguities and the absence of standardised bedside tools, there are significant ethical concerns about insight assessments. I highlight two main ethical concerns, specifically that these assessments risk: (1) marginalising patients by setting unattainable ideals for self-knowledge and (2) minimising the patient’s own perspective on their mental health. I close with recommendations for documenting and responding to concerns about poor insight, so patients who are vulnerable to losing epistemic trust are better supported in their therapeutic relationships.

In this issue of the Hastings Center Report, Jason Wasserman and Mark Navin argue that patients without decisional capacity can still have relatively stable wishes or inclinations toward one treatment option over another and that these preferences are "not devoid of moral weight and might therefore guide or at least influence treatment decisions when they cannot be defeated by other considerations." This position is not controversial among most bioethicists. The hard work comes in sussing out the details of this position. How much moral weight do these preferences have? When should preferences be defeated by other considerations? How should we identify actual preferences, and how should preferences be differentiated and weighed against one another?

Although there has been significant attention in clinical ethics to when physicians should follow a parent's wishes, there has been much less discussion of the obligation to solicit viewpoints and decisions from all caregivers who have equal moral and legal standing in relation to a pediatric patient. How should healthcare professionals respond when one caregiver dominates decision making? We present a case that highlights how these problems played out in an ethical bargain. Ethical bargaining occurs when the parties involved choose not to pursue a morally preferable option for the sake of coming to a resolution. This case is not one of parental disagreement; rather, the medical team agreed to exclude the patient's mother from decision making if the patient's father promised to bring their son back to the hospital for necessary medical tests. We argue that there is an obligation to notice and acknowledge power asymmetries in the family unit, which, in this case, was manifested as the marginalization of the female decision maker by the male decision maker. In these scenarios, clinicians should be careful to avoid treating parents as one homogenous unit, and they should take action to enable caregivers' autonomy and voice. While there are moral and practical limits to how and when physicians should intervene in family dynamics, we discuss the steps that the medical team should have taken in this case to avoid undermining the parental authority of the mother. We conclude by offering recommendations to address and enable caregivers' autonomy at an institutional level, and we discuss the importance of tracking and responding to damaging family dynamics to prevent ethically impermissible bargaining.

Rationale, aims and objectives There has been inadequate philosophical attention to the claims of psychiatric user/survivor activist groups, although these groups represent a significant social justice movement. Many of the core concerns and claims emerging from this activism can be found in disability activism. A first step that must be taken is to question how mental illnesses are modelled. Biomedical modelling is heavily criticized by psychiatric users/survivors for being reductionistic and for perpetuating damaging presumptions about decline and pathology. Social constructionist modelling, on the other hand, tends to be overly dismissive of biological factors that are often at play with these sorts of impairments. A middle-ground approach, interactionist modelling, promises to be responsive to demands for recognition from psychiatric users/survivors. Method I will first outline the core commitments of psychiatric users/survivors. Next, I will evaluate different models for mental illness by bringing together insights from user/survivor and disability activism. Conclusions I conclude that interactionist modelling holds the best hope for supporting shared decision making. This type of model braids together the expertise of patients and medical professionals.

We argue that we have obligations to future people that are similar in kind to obligations we have to current people. Modifying Michael Bratman’s account, we argue that as planning agents we must plan for the future to act practically in the present. Because our autonomy and selfhood are relational by nature, those plans will involve building affiliative bonds and caring for others. We conclude by grounding responsibility to future others by the way we plan through our social institutions. Our account fills out the story of responsibility to future generations by referring only to ourselves, our practical identities, and practical reason.

This case raises a number of ethical flags related to the meaning of left ventricular assistance device (LVAD) deactivation, the quality of the consent and physician–patient relationship, how to re...

The MedStar Washington Hospital Center clinical ethics team became involved in a case when the family requested the posthumous removal of a patient's ovaries for future reproductive use. This case presents a novel question for clinical ethicists, since the technology for posthumous female reproduction is still in development. In the bioethics literature, the standard position is to refuse to comply with such a request, unless there is explicit consent or evidence of explicit conversations that demonstrate the deceased would have wanted this option pursued. Ms D's case, we suggest, offers an exception to this default position; complying with the family's request could have been ethically permissible in this case, had it been medically feasible.

How can social institutions complicate and worsen vulnerabilities of particular individuals or groups? We begin by explicating how certain diagnoses within mental health and medicine operate as interactive kinds of labels and how such labels can create institutional barriers that hinder one’s capacity to achieve wellbeing. Interactive-kind modeling is a conceptual tool that elucidates the ways in which labeling can signal to others how the labeled person ought to be treated, how such labeling comes about and is perceived, and how it compounds vulnerabilities. We argue that this shift in standpoint helps us recognize and mitigate compounded vulnerabilities.

There has been inadequate philosophical attention to the claims of psychiatric user/survivor activist groups, although these groups represent a significant social justice movement. Many of the core concerns and claims emerging from this activism can be found in disability activism. A first step that must be taken is to question how mental illnesses are modelled. Biomedical modelling is heavily criticized by psychiatric users/survivors for being reductionistic and for perpetuating damaging presumptions about decline and pathology. Social constructionist modelling, on the other hand, tends to be overly dismissive of biological factors that are often at play with these sorts of impairments. A middle-ground approach, interactionist modelling, promises to be responsive to demands for recognition from psychiatric users/survivors.I will first outline the core commitments of psychiatric users/survivors. Next, I will evaluate different models for mental illness by bringing together insights from user/survivor and disability activism.I conclude that interactionist modelling holds the best hope for supporting shared decision making. This type of model braids together the expertise of patients and medical professionals.

Scientists, clinicians, and bioethicists are worried about how so-called personhood measures would limit access to certain types of contraception, research involving stem cells, and access to fertility treatments. While these measures have been struck down in Colorado, South Dakota, California, and Mississippi, the bill signed into law in Oklahoma in February deserves critical scrutiny, particularly into the ways these legal measures influence eligibility for clinical research. Oklahoma's bill states that the laws of the state “shall be interpreted and construed to acknowledge on behalf of the unborn child at every stage of development all the rights, privileges, and immunities available to other persons, citizens, and residents of this state.”