Ethics Consultation Research Articles

Advocacy and Bioethics: Aspiration, Obligation, and Negotiation.

AbstractA long-standing tenet of healthcare clinical ethics consultation has involved the neutrality of the ethicist. However, recent pressing societal issues have challenged this viewpoint. Perhaps now more than ever before, ethicists are being called upon to take up roles in public health, policy, and other community-oriented endeavors. In this article, I first review the concept of professional advocacy and contrast this conceptualization with the role of patient advocate, utilizing the profession of nursing as an exemplar. Then, I explore the status of advocacy in clinical ethics and how this conversation intersects with the existing professional obligations of the bioethicist, arguing that the goals of ethics consultation and ethical obligations of the clinical ethicist are compatible with the role of professional advocate. Finally, I explore potential barriers to professional advocacy and offer suggestions for a path forward.

What Factors Contribute to Ethical Problems in Patient Care? A Scoping Review and Case Series of Clinical Ethics Consultations.

A scoping review of ethical risk factors in patient care and a CEC case series were conducted, analyzing the documentation (consultation reports, feedback forms, electronic medical records) of 204 CECs from 2012 to 2020 at a somatic and a psychiatric university hospital in Basel, Switzerland. Ninety-nine ethical risk factors were identified in nine articles, related to four risk areas: patient (41), family (12), healthcare team (29), and system (17). Eighty-seven of these risk factors were documented at least once in the CEC case series. The most prevalent risk factors in the consultations studied were patient vulnerability (100%), missing or unclear hospital ethics policy (97.1%), shift work (83.3%), lack of understanding between patient and HCP (73.5%), poor communication (66.2%), disagreement between patient and HCP about care (58.8%), and multiple care teams (53.4%). The prevalence differed significantly by medical specialty. There are highly prevalent ethical risk factors at all levels of clinical care that may be used to prevent ethical problems. Further empirical research is needed to analyze risk ratios and to develop specific risk profiles for different medical specialties.

When Parents Request Nondisclosure: Rights of Adolescents to Access Their Health Information and Implications of the 21st Century Cures Act Final Rule.

AbstractDespite broad ethical consensus supporting developmentally appropriate disclosure of health information to older children and adolescents, cases in which parents and caregivers request nondisclosure continue to pose moral dilemmas for clinicians. State laws vary considerably regarding adolescents' rights to autonomy, privacy, and confidentiality, with many states not specifically addressing adolescents' right to their own healthcare information. The requirements of the 21st Century Cures Act have raised important ethical concerns for pediatricians and adolescent healthcare professionals regarding the protection of adolescent privacy and confidentiality, given requirements that chart notes and results be made readily available to patients via electronic portals. Less addressed have been the implications of the act for adolescents' access to their health information, since many healthcare systems' electronic portals are available to patients beginning at age 12, sometimes requiring that the patients themselves authorize their parents' access to the same information. In this article, we present a challenging case of protracted disagreement about an adolescent's right to honest information regarding his devastating prognosis. We then review the legal framework governing adolescents' rights to their own healthcare information, the limitations of ethics consultation to resolve such disputes, and the potential for the Cures Act's impact on electronic medical record systems to provide one form of resolution. We conclude that although parents in cases like the one presented here have the legal right to consent to medical treatment on their children's behalf, they do not have a corresponding right to direct the withholding of medical information from the patient.

On What Grounds? A Pilot Study of References Used in Clinical Ethics Consultation and Education.

In accordance with standards published by the American Society for Bioethics and Humanities (ASBH), ethics consultants are expected to provide recommendations that align with scholarly literature, professional society statements, law, and policy. However, there are no studies to date that characterize the specific references that ethics consultants and educators use to inform their work. To address this gap, a convenience sample of clinical ethics consultants and educators was surveyed online through two major listservs for clinical ethics, the ASBH Clinical Ethics Consultation Affinity Group (CECAG) and the Association of Bioethics Program Directors (ABPD). Ninety-five ethics consultants and/or educators with diverse educational background, credentials, and experience provided responses. In total, 451 references, 315 of which were unique, were reported. These references were broken into 6 categories after analysis: bioethics literature (divided into articles and books), professional society documents (divided into professional society statements and codes of ethics), federal/state/uniform/case law, hospital/health system policies, official religious teachings, and other. We found extensive variation and minimal overlap in the references respondents used for ethics consultation and education, even when referring to the same topics. Future research directions should include conducting more systematic efforts to characterize the references used by ethics consultants across the US; determining whether demographic characteristics of consultants influence the references used; and ascertaining whether the variation in references used reflects genuine disagreements in consultants' and educators' bioethical analysis or recommendations.

External care quality assessment in residential care facilities for the elderly: ethical challenges and needs for clarification with a focus on ethics consultation

External care quality assessment in residential care facilities for the elderly: ethical challenges and needs for clarification with a focus on ethics consultation

Intersectionality as a tool for clinical ethics consultation in mental healthcare

Bioethics increasingly recognizes the impact of discriminatory practices based on social categories such as race, gender, sexual orientation or ability on clinical practice. Accordingly, major bioethics associations have stressed that identifying and countering structural discrimination in clinical ethics consultations is a professional obligation of clinical ethics consultants. Yet, it is still unclear how clinical ethics consultants can fulfill this obligation. More specifically, clinical ethics needs both theoretical tools to analyze and practical strategies to address structural discrimination within clinical ethics consultations. Intersectionality, a concept developed in Black feminist scholarship, is increasingly considered in bioethical theory. It stresses how social structures and practices determine social positions of privilege and disadvantage in multiple, mutually co-constitutive systems of oppression. This article aims to investigate how intersectionality can contribute to addressing structural discrimination in clinical ethics consultations with a particular focus on mental healthcare. To this end, we critically review existing approaches for clinical ethics consultants to address structural racism in clinical ethics consultations and extend them by intersectional considerations. We argue that intersectionality is a suitable tool to address structural discrimination within clinical ethics consultations and show that it can be practically implemented in two complementary ways: 1) as an analytic approach and 2) as a critical practice.

Professionalization of Clinical Ethics Consultants: A Need for Liability Protection?

Clinical Ethics Consultation (CEC) has grown significantly in the last decade, and efforts are being made to professionalize the practice. The American Society for Bioethics and Humanities (ASBH) has been instrumental in this process, having published the Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants and founded and endorsed the creation of the Healthcare Ethics Consultant Certified (HCEC) Certification Commission. The ASBH also published "core competencies" for healthcare ethics consultants and has delineated a clear identity and role of such consultants distinct from that other healthcare professionals. In addition, more enter the field armed with advanced degrees (MA and PhD) or certification in clinical ethics consultation. While some have questioned the trend toward professionalization, the momentum is clearly in its favor. This paper explores three questions: Does the professionalization of healthcare ethics consultation expose those engaged in the field to the types of liability claims faced by professionals in other fields? What specific liabilities could affect a healthcare ethics consultant? And finally, what should healthcare ethics consultants do to protect themselves against liability claims? We conclude that while the risk of liability remains low, those engaged in the field should accept that risk just as part of their status as professionals and, like those in allied professions, seek appropriate protection in the form of liability insurance.

Ethisch overleg op regionaal niveau: ervaringen van het forum voor ethische reflectie van de regio Île-de-France

Ethics consultation at a regional level: the experience of the forum for ethical reflection of the Île-de-France region Referring to experiences in healthcare ethics, we seek to better understand and assume our moral and political responsibilities in a democratic society. One of the reference points is ‘Espace éthique AP-PH’, the ethics forum of the public hospital network in Paris. Its creation in 1995 dovetailed with the upheavals of the ‘AIDS years’, in which the patient’s voice increasingly penetrated public life and spurred political mobilisation. In 2014, it was expanded into the Île-de-France region’s forum for ethical reflection. The forum for ethical reflection is a place where the art of dialogue and discussion is elevated to a normative level, which is indispensable for understanding, deliberation and joint endorsement of an ethical approach that implies responsibility. France now has 15 regional forums for ethical reflection that contribute to the development of a genuine ethical culture among healthcare providers and the general public in their region.

Availability and use of institutional support programs for emergency department healthcare personnel during the COVID-19 pandemic.

The COVID-19 pandemic placed health care personnel (HCP) at risk for stress, anxiety, burnout, and post-traumatic stress disorder (PTSD). To address this, hospitals developed programs to mitigate risk. The objectives of the current study were to measure the availability and use of these programs in a cohort of academic emergency departments (EDs) in the United States early in the pandemic and identify factors associated with program use. Cross-sectional survey of ED HCP in 21 academic EDs in 15 states between June and September 2020. Site investigators provided data on the availability of 28 programs grouped into 9 categories. Individual support programs included: financial, workload mitigation, individual COVID-19 testing, emotional (e.g., mental health hotline), and instrumental (e.g., childcare) Clinical work support programs included: COVID-19 team communication (e.g., debriefing critical incident), patient-family communication facilitation, patient services (e.g., social work, ethics consultation), and system-level exposure reduction. Participants provided corresponding data on whether they used the programs. We used generalized linear mixed models clustered on site to measure the association between demographic and facility characteristics and program use. We received 1,541 survey responses (96% response rate) from emergency physicians or advanced practice providers, nurses, and nonclinical staff. Program availability in each of the 9 categories was high (>95% of hospitals). Program use was variable, with clinical work support programs used more frequently (28-50% of eligible HCP across categories) than individual employee support programs (6-13% of eligible HCP across categories). Fifty-seven percent of respondents reported that the COVID-19 pandemic had affected their stress and anxiety, and 12% were at elevated risk for PTSD. Program use did not significantly differ for HCP who reported symptoms of anxiety and/or stress compared to those who did not. Early in the pandemic, support programs were widely available to ED HCP, but program use was low. Future work will focus on identifying barriers and facilitators to use and specific programs most likely to be effective during periods of highest occupational stress.

Clinical Ethics Consultation for Patients Impacted by Incarceration: A Single Center Retrospective Review.

Health care professionals and patients impacted by incarceration face unique medical, legal, and ethical issues. The frequency and nature of ethics consultations for these patients are underexplored. This study aimed to characterize the primary ethical issue and contextual features of ethics consultations involving patients impacted by incarceration. We conducted a qualitative concept content analysis of ethics consultations involving patients impacted by incarceration and calculated descriptive statistics of demographics to compare these patients with the broader population of patients impacted by incarceration at a single institution from January 1, 2015, through June 30, 2022. We identified 37,184 patients impacted by incarceration (people currently or formerly incarcerated or whose surrogate decision-maker is incarcerated) at our institution. Most were White (70%) and non-Hispanic (88%); 51% were male, 49% female. Individuals impacted by incarceration comprised 3% (n = 38) of ethics consults. Most were White (58%), male (79%), and hospitalized (92%). The primary ethical issues were surrogate decision-making (34%) and fiduciary duties (beneficence/nonmaleficence/best interest; 16%). The primary contextual feature was intra-family communication challenges (37%). Incarceration status impacts access to decision-makers and the provision of medically necessary care. Ethics consultation for women and individuals in outpatient and emergency settings could be underutilized. More education about ethics consultation services and coordination with correctional officials is recommended.

Characterization of patients requiring inpatient hospital ethics consults- A single center study.

Ethics consultations are often needed at difficult junctures of medical care. However, data on the nature of how patient characteristics, including race/ethnicity, language, and diagnosis, affect ethics consult outcomes are lacking. We performed a retrospective cohort study of all patients who were seen by the Ethics Consult Service between 2017 and 2021 at a large tertiary academic center with the aim of determining whether patient demographic and clinical factors were associated with the timing of ethics consult requests and recommendations of the ethics team. We found that patients admitted for COVID-19 had significantly longer median times to consult from admission compared with other primary diagnoses (19 vs 8 days respectively, p = 0.015). Spanish-speaking patients had longer median times to consult from admission compared to English speaking patients (20 vs 7 days respectively, p = 0.008), indicating that language barriers may play a role in the timing of ethics consultation. This study demonstrates the need to consider clinical and demographic features when planning and prioritizing ethics consultations at large institutions to enhance consult efficiency, resource utilization, and patient experience and autonomy.

‘Sit down and thrash it out’: opportunities for expanding ethics consultation during conflict resolution in long-term care

Objective: To identify the frequency and nature of care conflict dilemmas that United States long-term care providers encounter, response strategies, and use of ethics resources to assist with dispute resolution. Design: An online cross-sectional survey was distributed to the Society for Post-Acute and Long-Term Care Medicine (AMDA). Results: Two-thirds of participants, primarily medical directors, have rejected surrogate instructions and 71% have managed family conflict. Conflict over treatment decisions and issues interpreting advance directives were frequently reported. Half of facilities lack a formal dispute mediation policy. Only five respondents have called an ethics consult for assistance. Conclusion: Ethically tense care conflicts commonly arise in long-term and post-acute care facilities. Few facility procedures incorporate ethics resources into actual practice. Recommendations are made to create actionable policy, increase access to ethics services, and support staff skill development in order to improve the end-of-life care experiences for patients, families, and care facility staff.

Ethics Consult: Using Hospice as "Treatment" for Behavioral Problems of Dementia

Patients with Behavioral and Psychological Symptoms of Dementia (BPSD) are among the most challenging patients to treat; these behaviors are estimated to occur in up to 90% of patients with dementia (Aigbogun 2019); of these, one in 5 patients displays aggression (Eastley 1997). The usual treatments have only modest efficacy at best and at times are ineffective in some individuals. Some behaviors such as physical aggression make it difficult, if not impossible, to find placement for these patients. Placement in nursing homes on a hospice status have traditionally required evidence of a 6 month life expectancy; placement in an inpatient hospice setting is usually reserved for patients with even shorter life expectancies such as 2 weeks. Prognosticating life expectancy in patients with dementia is challenging and often inaccurate (Jayes 2004). Furthermore the use of terminal palliative sedation is supposed to be confined to the last 2 weeks of life and/or extreme physical suffering (Schuman-Oliver 2008, AMA Opinion 2013).This session will present 2 cases of individuals with advanced dementia who did not meet the traditional Medicare criteria for hospice, as both were ambulatory and did not have significant co-morbid medical issues. Both had significant aggressive behaviors that responded poorly to extensive trials of various medications during extended stays on a geriatric psychiatry inpatient unit. Both were referred to a local inpatient hospice where the staff use “suffering" as a hospice criteria and were “treated” with the usual hospice medications and expired in less than 3 weeks.This session will use the two clinical cases to address the following: review the issue of prognostication of advanced dementia and the challenges of defining the end of life; review efforts to define “suffering” in advanced dementia in both the medical and ethics literature; review issues concerning palliative sedation; define how this differs from medical aid in dying and euthanasia. The experience of Dutch geriatricians addressing these issues will be presented (Veldwijck-Rouenhorst 2021). A geriatric psychiatrist will present the 2 cases and set up the questions and ethical issues that these cases pose. An ethics professor-scholar from Emory University will review the ethics literature and teachings that address these issues and help lead a discussion with the audience. The overall goal is to provide a framework of steps the audience members can take if confronted with similar cases.

374 Operationalization of a Translational Ethics Program

OBJECTIVES/GOALS: Within our CTSA hub, greater emphasis is on understanding innovation and human health impact of translational science writ large rather than focus on translational research projects. Our program is restructured to reflect distinguishing ethical features of translational science which are complimentary to traditional research ethics issues. METHODS/STUDY POPULATION: This descriptive analysis depicts the development of our ethics program as an exemplar of how to integrate into the research enterprise of an academic health science center that engages in translational research. Our relational approach is predicated on the embodiment of ethical values by all who are involved in research committed to proactive dialog, team building, and collaboration. This translational research culture is facilitated by a multidisciplinary ethics team who are embedded throughout the translational research enterprise. RESULTS/ANTICIPATED RESULTS: Our program is integrated into a translational science enterprise within a CTSA hub in four areas: relational structure (from leadership team to community engagement), education (from trainees to the research community to the public), support (through ethics consultation with multiple touchpoints in the translational science pathway), and team science (from team on-boarding and communication to D&I research of team science interventions). We have developed a research agenda examining research ethics topics that increase quality, applicability and downstream social impact of research; understanding translational science through historical and science & technologies studies lenses, and ethnographic and mixed-method approaches to understanding team science and the science of team science. DISCUSSION/SIGNIFICANCE: The integration of a translational ethics program provides attention to traditional research ethics issues regarding study conduct and integrity but also transcends those concerns to focus on the translational science enterprise itself through relationships, cultivating trust, team science, DEIA, and social responsibility.

A case of testicular cancer in a long‐term hydranencephaly survivor with undescended testes

IntroductionThe development of malignant tumors in patients with hydranencephaly is extremely rare. We describe the first case of testicular cancer that developed in the undescended testes of a long‐term survivor of hydranencephaly.Case presentationA 32‐year‐old man with severe cerebral palsy due to hydranencephaly was referred to our department for the evaluation of a subcutaneous lump in the lower right abdomen. He was a long‐term survivor of hydranencephaly. After confirming the diagnosis of right testicular cancer originating in his undescended testes, surgical resection was performed. Pathological examination revealed a mixed‐type germ cell tumor.ConclusionThe decision‐making process for treating malignant tumors, like testicular cancer, in adults with severe cerebral palsy can be challenging. Clinical ethics consultation could be helpful in avoiding treatment delays.

Comparative Analysis of Professional Ethics in Legal Practice and Medical Practice

This research investigates the comparison of professional ethics between legal practice and medical practice and how practitioners in both fields face ethical dilemmas and resolve moral conflicts. Through comparative analysis, we clarify the similarities and differences in the ethical codes and moral principles governing the practice of law and medicine and their implementation in practical situations. We found that both professions have a focus on individual interests, integrity, and fairness, although there are differences in the emphasis and application of these values. Legal practitioners and physicians face complex ethical dilemmas daily, and they rely on the guidance of ethical codes, moral principles, and consultation with colleagues or ethics committees to resolve moral conflicts that arise. Continued research could deepen understanding of the factors that influence ethical decision making and develop more effective strategies for dealing with moral challenges in the workplace

A multi-country mixed-method study identifying the association between perceived ethical work climate and problems among critical care nurses

BackgroundGiven the grave ethical tension and dilemmas posed continuously which are aggravated in the intensive care unit context and its related caregiving provision, combined with their impact on critical care nurses’ job satisfaction and work-related risks, exploring and analyzing these tensions and conflicts is crucial. This study was conducted to examine the relationship between perceived ethical work climate and problems among critical care nurses in addition to exploring their perspectives on the ethical work climates while caring for patients with infectious diseases.Design and methodA mixed-method research design was used to conduct this study among 635 participants, comprising 170 from Egypt, 144 from Jordan, 161 from Saudi Arabia, and 160 from the United Arab Emirates. Online or paper-based survey forms were distributed to all eligible critical care nurses who agreed to take part in the study. The survey contained both quantitative and qualitative data that were analyzed separately and integrated during the discussion. The study was reported following the STROBE guidelines.FindingsThe overall ethical work climate was fairly good and was significantly associated with ICU nurses’ personal and professional characteristics. The findings also identified three main themes: (1) an ethical sense of failure, (2) environmental condemnation, and (3) an instant action plan for resolving ethical conflicts.ConclusionsICU nurses perceived that ICU ethical climate was fairly good. The results indicated that ICU nurses generally had a relatively fair perception of the ethical work climate, with implications for addressing ethical issues and conflicts in various settings.ImpactMentorship and/or close supervision concerning ethical resilience, consultation, and decision-making is crucial in the ICU milieu. Metacognitive strategies to reinforce problem-solving and decision-making ICU nurses’ skills could help them overcome the different ethical challenges. Adequate resources, teamwork, and organizational support are promising tactics to improve ICU nurses’ ethical skills.Trial registrationNot applicable.

Specific Trends in Pediatric Ethical Decision-Making: An 18-Year Review of Ethics Consultation Cases in a Pediatric Hospital.

This is a qualitative examination of ethics consultation requests, outcomes, and ethics committee recommendations at a tertiary/quaternary pediatric hospital in the U.S. The purpose of this review of consults over an 18-year period is to identify specific trends in the types of ethical dilemmas presented in our pediatric setting, the impact of consultation and committee development on the number and type of consults provided, and any clinical features and/or challenges that emerged and contributed to the nature of ethical situations and dilemmas. Furthermore, in reviewing clinical ethics consultation trends for nearly two decades, we can identify topic areas for further ethics education and training for ethics consultants, ethics committee members, and pediatric healthcare teams and professionals based on our experiences. Our study with nearly two decades of data prior to the COVID-19 pandemic can serve as groundwork for future comparisons of consultation requests and ethics support for pediatric hospitals prior to, during, and following a pandemic.

ChatGPT: aid to medical ethics decision making?

Physicians have to make countless decisions every day. The medical, ethical and legal aspects are often intertwined and subject to change over time. Involving an ethics committee or arranging an ethical consultation are examples of potential aids to decision making. Whether and how artificial intelligence (AI) and the large language model (LLM) of the company OpenAI (San Francisco, CA, USA), known under the name ChatGPT, can also help and support ethical decision making is increasingly becoming amatter of controversial debate. Based on acase example, in which afemale physician is confronted with ethical and legal issues and presents these to ChatGPT to come up with answers, the first indications of the strengths and weaknesses are ascertained. Due to the rapid technical development and access to ever increasing quantities of data, the utilization should be closely observed and evaluated.

The Impact of Clinical Ethics Consultations on Physicians in aLatin American Context.

Clinical bioethics plays a significant role in hospital settings through bioethics consultations, which focus on providing ongoing assistance in complex situations within the doctor-patient dynamic. These consultations entail regular interaction between physicians and clinical bioethicists. This situation prompts an exploration into how bioethics consultations affect physicians. The current research aims to understand the influence of bioethics consultations on physicians' bioethical knowledge by analyzing the lexical content in their patients' medical records. Medical records are a synthesis carried out by physicians, often reflecting collaborative efforts, and capturing verbal statements indicative of thought processes suggestive of learning. The study is a sequential mixed-methods design with a retrospective descriptive approach, comparing medical records from the early years of the Department of Humanism and Bioethics' operation (2013-2015) to the more recent ones (2019). Technical bioethical terminology such as "therapeutic effort limitation," "futility," "beneficence," and "respect for autonomy" is more prevalent in recent medical records. This trend may stem from the positive impact of bioethics consultations conducted by the Department, with haptic communication serving as a particularly effective form of interaction with others during experiences of moral distress. This appears to be characteristic of cultures like those in Latin America.