A caregiver from the dominant U.S. culture and a patient from a very different culture can resolve cross‐cultural disputes about treatment, not by compromising important values, but by focusing on the patient's goals.

A caregiver from the dominant U.S. culture and a patient from a very different culture can resolve cross‐cultural disputes about treatment, not by compromising important values, but by focusing on the patient's goals.

Although ethics consultation is offered as a clinical service in most hospitals in the United States, few valid and practical tools are available to evaluate, ensure, and improve ethics consultation quality. The quality of ethics consultation is important because poor quality ethics consultation can result in ethically inappropriate outcomes for patients, other stakeholders, or the health care system. To promote accountability for the quality of ethics consultation, we developed the Ethics Consultation Quality Assessment Tool. ECQAT enables raters to assess the (...) quality of ethics consultations based on the written record. Through rigorous development and preliminary testing, we identified key elements of a quality ethics consultation, established scoring criteria, developed training guidelines, and designed a holistic assessment process. This article describes the development of the ECQAT,.. (shrink)

Context: Although ethics consultation is commonplace in United States (U.S.) hospitals, descriptive data about this health service are lacking. Objective: To describe the prevalence, practitioners, and processes of ethics consultation in U.S. hospitals. Design: A 56-item phone or questionnaire survey of the "best informant" within each hospital. Participants: Random sample of 600 U.S. general hospitals, stratified by bed size. Results: The response rate was 87.4%. Ethics consultation services (ECSs) were found in 81% of all general hospitals in the U.S., and (...) in 100% of hospitals with more than 400 beds. The median number of consults performed by ECSs in the year prior to survey was 3. Most individuals performing ethics consultation were physicians (34%), nurses (31%), social workers (11%), or chaplains (10%). Only 41% had formal supervised training in ethics consultation. Consultation practices varied widely both within and between ECSs. For example, 65% of ECSs always made recommendations, whereas 6% never did. These findings highlight a need to clarify standards for ethics consultation practices. (shrink)

The Ethics Consultation Quality Assessment Tool (ECQAT) establishes standards by which the quality of ethics consultation records (ECRs) can be assessed. These standards relate to the ethics question, consultation-specific information, ethical analysis, and recommendations and/or conclusions, and result in a score associated with one of four levels of ethics consultation quality. For the ECQAT to be useful in assessing and improving the quality of healthcare ethics consultations, individuals who rate the quality of ECRs need to be able to reliably use (...) the tool.We developed a short course to train ethics consultants in using the ECQAT, and evaluated whether the participants (1) achieved an acceptable level of calibration in matching expert-established quality scores for a set of ethics consultations, and (2) were satisfied with the course. We recruited 28 ethics consultants to participate in a virtual, six-session course. At each session participants and faculty reviewed, rated, and discussed one to two ECRs. The participants’ calibration in matching expert-established quality scores improved with repeated exposure at all levels of ethics consultation quality. Participants were generally more accurate when assessing consultation quality at the dichotomous level of “acceptable” (scores of three or four) versus “unacceptable” (scores of one or two) than they were with a more specific score. Participants had higher rates of accuracy with the extreme ratings of “strong” (level four) or “poor” (level one). Although participants were highly satisfied with the course, only a minority of participants achieved the prespecified acceptable level of calibration (that is, 80 percent or greater accuracy between their score and expert-established scores). These results suggest that ECQAT training may require more sessions or need modification in the protocol to achieve higher reliability in scoring. Such trainings are an important next step in ensuring that the ECQAT is a tool that can be used to promote improvement in ethics consultation quality. (shrink)

Empirical research pertaining to cardiopulmonary resuscitation (CPR), clinician behaviors related to do-not-resuscitate (DNR) orders and substituted judgment suggests potential contributions to medical ethics. Research quantifying the likelihood of surviving CPR points to the need for further philosophical analysis of the limitations of the patient autonomy in decision making, the nature and definition of medical futility, and the relationship between futility and professional standards. Research on DNR orders has identified barriers to the goal of patient involvement in these life and death (...) discussions. The initial data on surrogate decision making also points to the need for a reexamination of the moral basis for substituted judgment, the moral authority of proxy decision making and the second-order status of the best interests standard. These examples of empirical research suggest that an interplay between empirical research, ethical analysis and policy development may represent a new form of interdisciplinary scholarship to improve clinical medicine. (shrink)

To promote ethical practices, healthcare managers must understand the ethical challenges encountered by key stakeholders. To characterize ethical challenges in Veterans Administration (VA) facilities from the perspectives of managers, clinicians, patients, and ethics consultants. We conducted focus groups with patients (n = 32) and managers (n = 38); semi-structured interviews with managers (n = 31), clinicians (n = 55), and ethics committee chairpersons (n = 21). Data were analyzed using content analysis. Managers reported that the greatest ethical challenge was fairly (...) distributing resources across programs and services, whereas clinicians identified the effect of resource constraints on patient care. Ethics committee chairpersons identified end-of-life care as the greatest ethical challenge, whereas patients identified obtaining fair, respectful, and caring treatment. Perspectives on ethical challenges varied depending on the respondent's role. Understanding these differences can help managers take practical steps to address these challenges. Further, ethics committees seemingly, are not addressing the range of ethical challenges within their institutions. (shrink)

This paper proposes an ethical framework for rationing publicly financed health care. We begin by classifying alternative rationing criteria according to their ethical basis. We then examine the ethical arguments for four rationing criteria. These alternatives include rationing high technology services, non-basic services, services to patients who receive the least medical benefit, and services that are not equally available to all. We submit that a just health care system will not limit basic health care to persons unable to pay for (...) it. Furthermore, justice in health care requires limiting publicly-financed non-basic health care, striving for equality in access to basic health care, and relying on medical benefit to ration non-basic health care. (shrink)

Context: Although ethics consultation is commonplace in United States hospitals, descriptive data about this health service are lacking. Objective: To describe the prevalence, practitioners, and processes of ethics consultation in U.S. hospitals. Design: A 56-item phone or questionnaire survey of the “best informant” within each hospital. Participants: Random sample of 600 U.S. general hospitals, stratified by bed size. Results: The response rate was 87.4%. Ethics consultation services were found in 81% of all general hospitals in the U.S., and in 100% (...) of hospitals with more than 400 beds. The median number of consults performed by ECSs in the year prior to survey was 3. Most individuals performing ethics consultation were physicians, nurses, social workers, or chaplains. Only 41% had formal supervised training in ethics consultation. Consultation practices varied widely both within and between ECSs. For example, 65% of ECSs always made recommendations, whereas 6% never did. These findings highlight a need to clarify standards for ethics consultation practices. (shrink)

Clinical ethics consultation is largely outside the scope of regulation and oversight, despite its importance. For decades, the bioethics community has been unable to reach a consensus on whether there should be accountability in this work, as there is for other clinical activities that influence the care of patients. The American Society for Bioethics and Humanities, the primary society of bioethicists and scholars in the medical humanities and the organizational home for individuals who perform CEC in the United States, has (...) initiated a two‐step quality attestation process as a means to assess clinical ethics consultants and help identify individuals who are qualified to perform this role. This article describes the process. (shrink)

To promote ethical practices, healthcare managers must understand the ethical challenges encountered by key stakeholders. To characterize ethical challenges in Veterans Administration facilities from the perspectives of managers, clinicians, patients, and ethics consultants. We conducted focus groups with patients and managers ; semi-structured interviews with managers, clinicians, and ethics committee chairpersons. Data were analyzed using content analysis. Managers reported that the greatest ethical challenge was fairly distributing resources across programs and services, whereas clinicians identified the effect of resource constraints on (...) patient care. Ethics committee chairpersons identified end-of-life care as the greatest ethical challenge, whereas patients identified obtaining fair, respectful, and caring treatment. Perspectives on ethical challenges varied depending on the respondent's role. Understanding these differences can help managers take practical steps to address these challenges. Further, ethics committees seemingly, are not addressing the range of ethical challenges within their institutions. (shrink)

Although clinical ethics consultation is a high-stakes endeavor with an increasing prominence in health care systems, progress in developing standards for quality is challenging. In this article, we describe the results of a pilot project utilizing portfolios as an evaluation tool. We found that this approach is feasible and resulted in a reasonably wide distribution of scores among the 23 submitted portfolios that we evaluated. We discuss limitations and implications of these results, and suggest that this is a significant step (...) on the pathway to an eventual certification process for clinical ethics consultants. (shrink)

Effective Altruism is a popular social movement that encourages individuals to donate to organizations that effectively address humanity’s most severe poverty. However, because Effective Altruists are committed to doing the most good in the most effective ways, they often argue that it is wrong to help those nearest to you. In this paper, I target a major subset of Effective Altruists who consider it a moral obligation to do the most good possible. Call these Obligation-Oriented Effective Altruists (OOEAs), and their (...) movement Obligation-Oriented Effective Altruism (OOEA). I argue that insofar as this variety of OOEA seems to commit us to refrain from helping the people right in front of us, there is something intuitively wrong about it. In response, I introduce an alternative model that embraces partiality: Mutual Aid. Mutual Aid is a network of community members, usually from the same geographical region, who share a commitment to offer, receive, and exchange material goods, wealth, and social support. I recommend Mutual Aid as a liberatory model, which—through empathy, solidarity, and care—mobilizes community building and provides a catalyst for community advocacy. As such, we should resist the claims of OOEAs that partially distributing our funds to people or causes we care about is morally wrong or even less than ideal. We do not have a moral obligation to use our funds “effectively;” rather, we have a broader obligation to address human suffering, and Mutual Aid is one moral alternative for discharging this duty. (shrink)

Proposed here is that an overriding principle of nature governs all population behavior; that a single tenet drives the many regimes observed in nature—exponential-like growth, saturated growth, population decline, population extinction, and oscillatory behavior. The signature of such an all embracing principle is a differential equation which, in a single statement, embraces the entire panoply of observations. In current orthodox theory, this diverse range of population behaviors is described by many different equations—each with its own specific justification. Here, a single (...) equation governing all the regimes is proposed together with the principle from which it derives. The principle is: The effect on the environment of a population’s success is to alter that environment in a way that opposes the success. Experiments are suggested which could validate or refute the theory. Predictions are made about population behaviors. (shrink)

The use of deception in medical care is highly suspect in this country. Yet there is one condition for which deception is often used as a diagnostic tool. Nonepileptic seizures, a psychiatric condition in which emotional or psychological conflicts manifest themselves unconsciously through bodily symptoms, are currently diagnosed by a procedure called “provocative saline infusion.” The test is fundamentally deceptive, requiring the physician to intentionally and directly lie to the patient, causing the patient to believe that the administered solution caused (...) his seizures. Without such deception, the test might be useless. (shrink)

The rise of networked social movements contesting neo-liberal globalization and protesting the summits of global finance and governance organizations has posed an analytical challenge to social movement theorists and called into question the applicability to this global milieu of the familiar concepts and heuristics utilized in social movement studies. In this article, we argue that the self-defining alter-globalization movement(s) might instead be engaged with as an expression and effect of global complexity, and we draw upon a ‘minor’ literature in social (...) movement studies that includes Gregory Bateson, Gilles Deleuze and Alberto Melucci to illustrate our claims. This article uses a Deleuzian reading of complexity to describe the phase space of the ‘movement of movements’, and its perturbation of global civil society through the iteration of sense-making processes (reflexive framing) and the exploration of singularities inhering in social movement ‘plateaux’. Those transnational gatherings, protests and social forums facilitated by computer-mediated communications and the advent of unprecedented mobility which constitute a ‘shadow realm’ that remains largely invisible to political exchange theories operating within the conceptual confines of the nation-state. (shrink)

Burns, C. R. Introduction.--Antiquity: Margalith, D. The ideal doctor as depicted in ancient Hebrew writings. Edelstein, L. The Hippocratic oath. Edelstein, L. The professional ethics of the Greek physician. Michler, M. Medical ethics in Hippocratic bone surgery. Maas, P. L., Oliver, J. H. An ancient poem on the duties of a physician.--The medieval era: Levey, M. Medical deontology in ninth century Islam. Bar-Sela, A., Hoff, H. E. Isaac Israeli's fifty admonitions of the physicians. Rosner, F. The physician's prayer attributed to (...) Moses Maimonides. MacKinney, L. C. Medical ethics and etiquette in the early middle ages, the persistence of Hippocratic ideals. Welborn, M. C. The long tradition, a study in fourteenth-century medical deontology.--The modern period: Larkey, S. V. The Hippocratic oath in Elizabethan England. Pleadwell, F. L. Samuel Sorbiere and his Advice to a young physician. Clark, G. Bernard Mandeville, M.D., and eighteenth-century ethics. Burns, C. R. Thomas Percival, medical ethics or medical jurisprudence? Burns, C. R. Reciprocity in the development of Anglo-American medical ethics, 1765-1865. Williams, T. F. Cabot, Peabody, and the care of the patient. (shrink)

The evolution of humans required performing increasingly hierarchically complex tasks within multiple domains. Hierarchical complexity increases task by task. Tasks occur within, and differ by, determinable domains, their stages of performance measurable using the Model of Hierarchical Complexity. How well one performs within single and multiple domains is considered to indicate intelligence. Original task-initiation is more difficult than imitational learning and can create new domains. Levels of support reduce task difficulty, increasing performance. Task-performance may be generalized to other domains. Stages (...) of developing tools and empathy are presented to demonstrate domains' roles in the evolution of human intelligence. (shrink)

Social media and Internet technologies present several emerging and ill-explored issues for a modern healthcare workforce. One issue is patient-targeted Googling, which involves a healthcare professional using a social networking site or publicly available search engine to find patient information online. The study’s aim was to address a deficit in data and knowledge regarding PTG, and to investigate medical student use of SNSs due to a close association with PTG. The authors surveyed final year medical students at the Otago Medical (...) School, University of Otago in January 2016. A subset completed focus groups that were analysed using thematic analysis to identify key themes relating to students’ attitudes towards PTG, and reasons why they might engage in PTG. Fifty-four students completed the survey, which showed that PTG was uncommon. Attitudes were varied and context dependent. Most participants saw problems with PTG and favoured more explicit guidance on the issue. SNS usage was high ; participants were concerned by the content of their SNS profiles and who they were connecting with online. Participants showing high SNS use were 1.83 times more likely to have conducted PTG than lower use groups. The diverse attitudes uncovered in this study indicated that teaching or guidelines could be useful to healthcare professionals considering PTG. Though ethically problematic, PTG may be important to patient care and safety. The decision to conduct PTG should be made with consideration of ethical principles and the intended use of the information. (shrink)

Background Social media and Internet technologies present several emerging and ill-explored issues for a modern healthcare workforce. One issue is patient-targeted Googling, which involves a healthcare professional using a social networking site or publicly available search engine to find patient information online. The study’s aim was to address a deficit in data and knowledge regarding PTG, and to investigate medical student use of SNSs due to a close association with PTG. Method The authors surveyed final year medical students at the (...) Otago Medical School, University of Otago in January 2016. A subset completed focus groups that were analysed using thematic analysis to identify key themes relating to students’ attitudes towards PTG, and reasons why they might engage in PTG. Results Fifty-four students completed the survey, which showed that PTG was uncommon. Attitudes were varied and context dependent. Most participants saw problems with PTG and favoured more explicit guidance on the issue. SNS usage was high ; participants were concerned by the content of their SNS profiles and who they were connecting with online. Participants showing high SNS use were 1.83 times more likely to have conducted PTG than lower use groups. Conclusions The diverse attitudes uncovered in this study indicated that teaching or guidelines could be useful to healthcare professionals considering PTG. Though ethically problematic, PTG may be important to patient care and safety. The decision to conduct PTG should be made with consideration of ethical principles and the intended use of the information. (shrink)

Adding to A.O. Aldridge’s 1951 list, this list of British eighteenth-century references to Shaftesbury provides further evidence that the philosophy of Shaftesbury and Hutcheson is an important rival to Lockean empiricism during the early and middle decades of the century. The peak of Shaftesbury’s influence occurs during the 1740’s and 1750’s when the deist controversy was at its height. A more conservative political and religious climate of opinion after 1759 is one reason for the decline of Shaftesbury’s reputation as a (...) philosopher. Another is Shaftesbury’s displacement by Hume as an important enemy of orthodox Christianity. During the 1760’s and later, Hume is attacked by the Scottish “common sense” philosophers, who find anticipations of Humean scepticism in Locke and Berkeley (but not in Shaftesbury), thereby unwittingly helping to provide the foundation for the eventual establishment of Locke, Berkeley, and Hume as the “big three” of eighteenth-century philosophy. (shrink)

Adding to A.O. Aldridge’s 1951 list, this list of British eighteenth-century references to Shaftesbury provides further evidence that the philosophy of Shaftesbury and Hutcheson is an important rival to Lockean empiricism during the early and middle decades of the century. The peak of Shaftesbury’s influence occurs during the 1740’s and 1750’s when the deist controversy was at its height. A more conservative political and religious climate of opinion after 1759 is one reason for the decline of Shaftesbury’s reputation as a (...) philosopher. Another is Shaftesbury’s displacement by Hume as an important enemy of orthodox Christianity. During the 1760’s and later, Hume is attacked by the Scottish “common sense” philosophers, who find anticipations of Humean scepticism in Locke and Berkeley (but not in Shaftesbury), thereby unwittingly helping to provide the foundation for the eventual establishment of Locke, Berkeley, and Hume as the “big three” of eighteenth-century philosophy. (shrink)

Adding to A.O. Aldridge’s 1951 list, this list of British eighteenth-century references to Shaftesbury provides further evidence that the philosophy of Shaftesbury and Hutcheson is an important rival to Lockean empiricism during the early and middle decades of the century. The peak of Shaftesbury’s influence occurs during the 1740’s and 1750’s when the deist controversy was at its height. A more conservative political and religious climate of opinion after 1759 is one reason for the decline of Shaftesbury’s reputation as a (...) philosopher. Another is Shaftesbury’s displacement by Hume as an important enemy of orthodox Christianity. During the 1760’s and later, Hume is attacked by the Scottish “common sense” philosophers, who find anticipations of Humean scepticism in Locke and Berkeley (but not in Shaftesbury), thereby unwittingly helping to provide the foundation for the eventual establishment of Locke, Berkeley, and Hume as the “big three” of eighteenth-century philosophy. (shrink)

In this paper we argue that moral deference is prima facie obligatory in cases in which the testifier is a member of a marginalized social group that the receiver is not and testifies about their marginalized experience. We distinguish between two types of deference: epistemic deference, which refers to believing p in virtue of trusting the testifier, and actional deference, which involves acting appropriately in response to the testimony given. The prima facie duty we propose applies to both epistemic and (...) actional deference, though defeaters may quash either or both obligations. Even if one fails to epistemically defer to the marginalized testifier, we argue that they may still be ethically obligated to act in accordance with their testimony. (shrink)

The set of procedures called variously mindreading, mentalizing, or social cognition — broadly put, the process by which we know others — is one that literature can dramatize in peculiarly intense ways. This essay describes three accounts of these procedures in current cognitive scientific debate — Theory Theory, Simulation Theory, and Interaction Theory. It is argued that each account alone struggles to capture the strange blend of immediacy and opacity that confronts me when I seek to grasp the minds of (...) others. Through close readings of two literary passages, it is further argued that literature can by contrast do exactly this. To read ‘cognitively’ is thus both to reveal and to enlist literature's power to think about thinking. (shrink)