57 found
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  1.  16
    Capacity Reconceptualized: From Assessment Tool to Clinical Intervention.Omar F. Mirza & Jacob M. Appel - 2024 - Cambridge Quarterly of Healthcare Ethics 33 (1):35-39.
    Capacity evaluation has become a widely used assessment device in clinical practice to determine whether patients have the cognitive ability to render their own medical decisions. Such evaluations, which might be better thought of as “capacity challenges,” are generally thought of as benign tools used to facilitate care. This paper proposes that such challenges should be reconceptualized as significant medical interventions with their own set of risks, side effects, and potentially deleterious consequences. As a result, a cost–benefit analysis should be (...)
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  2.  19
    Trial by Triad: substituted judgment, mental illness and the right to die.Jacob M. Appel - 2022 - Journal of Medical Ethics 48 (6):358-361.
    Substituted judgment has increasingly become the accepted standard for rendering decisions for incapacitated adults in the USA. A broad exception exists with regard to patients with diminished capacity secondary to depressive disorders, as such patients’ previous wishes are generally not honoured when seeking to turn down life-preserving care or pursue aid-in-dying. The result is that physicians often force involuntary treatment on patients with poor medical prognoses and/or low quality of life as a result of their depressive symptoms when similarly situated (...)
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  3. Sex rights for the disabled?Jacob M. Appel - 2010 - Journal of Medical Ethics 36 (3):152-154.
    The public discourse surrounding sex and severe disability over the past 40 years has largely focused on protecting vulnerable populations from abuse. However, health professionals and activists are increasingly recognising the inherent sexuality of disabled persons and attempting to find ways to accommodate their intimacy needs. This essay explores several ethical issues arising from such efforts.
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  4.  15
    Personal responsibility and transplant revisited: A case for assigning lower priority to American vaccine refusers.Jacob M. Appel - 2022 - Bioethics 36 (4):461-468.
    Priority for solid organ transplant generally does not consider the underlying cause of the need for transplantation. This paper argues that a distinctive set of factors justify assigning lower priority to willfully unvaccinated individuals who require transplant as a result of suffering from COVID‐19. These factors include the personal responsibility of the patients for their own condition and the public outrage likely to ensue if willfully unvaccinated patients receive organs at the expense of vaccinated ones. The paper then proposes a (...)
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  5.  15
    Is there a right to a fully vaccinated care team?Jordan L. Schwartzberg, Jeremy Levenson & Jacob M. Appel - 2022 - Clinical Ethics 17 (3):235-240.
    Although COVID-19 vaccines are free and readily available in the United States, many healthcare workers remain unvaccinated, potentially exposing their patients to a life-threatening pathogen. This paper reviews the ethical and legal factors surrounding patient requests to limit their care teams exclusively to vaccinated providers. Key factors that shape policy in this area include patient autonomy, the rights of healthcare workers, and the duties of healthcare institutions. Hospitals must also balance the rights of interested parties in the context of logistical (...)
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  6.  31
    If it ducks like a quack: balancing physician freedom of expression and the public interest.Jacob M. Appel - 2022 - Journal of Medical Ethics 48 (7):430-433.
    Physicians expressing opinions on medical matters that run contrary to the consensus of experts pose a challenge to licensing bodies and regulatory authorities. While the right to express contrarian views feeds a robust marketplace of ideas that is essential for scientific progress, physicians advocating ineffective or dangerous cures, or actively opposing public health measures, pose a grave threat to societal welfare. Increasingly, a distinction has been made between professional speech that occurs during the physician-patient encounter and public speech that transpires (...)
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  7.  11
    Engagement without entanglement: a framework for non-sexual patient–physician boundaries.Jacob M. Appel - 2023 - Journal of Medical Ethics 49 (6):383-388.
    The integrity of the patient–physician relationship depends on maintaining professional boundaries. While ethicists and professional organisations have devoted significant consideration to the subject of sexual boundary transgressions, the subject of non-sexual boundaries, especially outside the mental health setting, has been largely neglected. While professional organisations may offer guidance on specific subjects, such as accepting gifts or treating relatives, as well as general guidance on transparency and conflict of interest, what is missing is a principle-based method that providers can use to (...)
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  8. A suicide right for the mentally ill? A swiss case opens a new debate.Jacob M. Appel - 2007 - Hastings Center Report 37 (3):21-23.
  9.  6
    Goldwater After Trump.Jacob M. Appel & Akaela Michels-Gualtieri - 2021 - Cambridge Quarterly of Healthcare Ethics 30 (4):651-661.
    The “Goldwater rule,” a policy adopted by the American Psychiatry Association in 1973, prohibits organization members from diagnosing or offering professional opinions regarding the mental health of public figures without both first-hand evaluation and authorization. Initially developed in response to a controversial survey of APA members during the 1964 Presidential election campaign, the ethics rule faced few large scale challenges until the election of Donald Trump in 2016. Since that time, a significant number of psychiatrists have either violated or criticized (...)
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  10.  18
    Substituted judgment for the never‐capacitated: Crossing Storar's bridge too far.Jacob M. Appel - 2021 - Bioethics 36 (2):225-231.
    Since several landmark legal decisions in the 1970s and 1980s, substituted judgment has become widely accepted as an approach to decision‐making for incapacitated patients that incorporates their autonomy and interests. Two notable exceptions have been cases involving minors and those involving cognitively or psychiatrically impaired individuals who never previously possessed the ability to contemplate the medical decisions involved in their care. While a best interest standard may have universal merit in pediatric cases, this paper argues that substituted judgement has been (...)
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  11.  72
    The Importance of Patient–Provider Communication in End-of-Life Care.Timothy R. Rice, Yuriy Dobry, Vladan Novakovic & Jacob M. Appel - 2012 - Journal of Bioethical Inquiry 9 (4):439-441.
    Successful formulation and implementation of end-of-life care requires ongoing communication with the patient. When patients, for reasons of general medical or psychiatric illness, fail to verbally communicate, providers must be receptive to messages conveyed through alternate avenues of communication. We present the narrative of a man with schizophrenia who wished to forgo hemodialysis as a study in the ethical importance of attention to nonverbal communication. A multilayered understanding of the patient, as may be provided by both behavioral and motivational models, (...)
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  12.  45
    Safeguarding Confidentiality in Electronic Health Records.Akhil Shenoy & Jacob M. Appel - 2017 - Cambridge Quarterly of Healthcare Ethics 26 (2):337-341.
    Abstract:Electronic health records (EHRs) offer significant advantages over paper charts, such as ease of portability, facilitated communication, and a decreased risk of medical errors; however, important ethical concerns related to patient confidentiality remain. Although legal protections have been implemented, in practice, EHRs may be still prone to breaches that threaten patient privacy. Potential safeguards are essential, and have been implemented especially in sensitive areas such as mental illness, substance abuse, and sexual health. Features of one institutional model are described that (...)
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  13.  12
    Artificial intelligence in medicine and the negative outcome penalty paradox.Jacob M. Appel - forthcoming - Journal of Medical Ethics.
    Artificial intelligence (AI) holds considerable promise for transforming clinical diagnostics. While much has been written both about public attitudes toward the use of AI tools in medicine and about uncertainty regarding legal liability that may be delaying its adoption, the interface of these two issues has so far drawn less attention. However, understanding this interface is essential to determining how jury behaviour is likely to influence adoption of AI by physicians. One distinctive concern identified in this paper is a ‘negative (...)
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  14.  62
    “How Hard It Is That We Have to Die”.Jacob M. Appel - 2012 - Cambridge Quarterly of Healthcare Ethics 21 (4):527-536.
  15.  36
    Medical Repatriation Does Not Justify Hospital Entanglement in Nonmedical Matters.Jacob M. Appel - 2012 - American Journal of Bioethics 12 (9):9-11.
    The American Journal of Bioethics, Volume 12, Issue 9, Page 9-11, September 2012.
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  16.  12
    Tainted Largess: A Moral Framework For Medical School Donations.Charles Sanky & Jacob M. Appel - 2020 - Cambridge Quarterly of Healthcare Ethics 29 (3):437-445.
    Rather than being a neutral phenomenon, the authors propose that medical school donations should be viewed as a social good for advancing education and improving healthcare. Seen in this light, they aim to offer a framework for analysis that will be useful to medical institutions and their stakeholders in addressing proposed donations from contentious or divisive sources, and in managing those donations that subsequently appear controversial.
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  17.  7
    The Pandemic of Invisible Victims in American Mental Health.Jacob M. Appel - 2024 - Hastings Center Report 54 (2):3-7.
    Although considerable attention has been devoted to the concepts of “visible” and “invisible” victims in general medical practice, especially in relation to resource allocation, far less consideration has been devoted to these concepts in behavioral health. Distinctive features of mental health care in the United States help explain this gap. This essay explores three specific ways in which the American mental health care system protects potentially “visible” individuals at the expense of “invisible victims” and otherwise fails to meet the needs (...)
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  18.  99
    May Doctors Refuse Infertility Treatments to Gay Patients?Jacob M. Appel - 2006 - Hastings Center Report 36 (4):20-21.
  19.  55
    Toward an Ethical Eugenics.Jacob M. Appel - 2012 - Jona’s Healthcare Law, Ethics, and Regulation 14 (1):7-13.
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  20.  33
    Smoke and Mirrors: One Case for Ethical Obligations of the Physician as Public Role Model.Jacob M. Appel - 2009 - Cambridge Quarterly of Healthcare Ethics 18 (1):95.
    As a result of workplace clean air regulations and strict guidelines imposed by the Joint Commission on Accreditation of Healthcare Organizations in 1993, most hospitals in the United States are now virtually smoke free. Although evidence suggests that these restrictions both cause smoking employees to consume fewer cigarettes per day and induce some employees to quit smoking entirely, the policies have also driven many healthcare providers—including physicians—onto the public sidewalks for their cigarette breaks. Patients entering many hospitals pass white-coated medical (...)
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  21.  35
    Unconventional harm reduction interventions for Minor-attracted persons.Jacob M. Appel - 2023 - Clinical Ethics 18 (2):183-191.
    Minor-attracted persons raise multiple ethical and legal challenges. Sexual contact between adults and children is justly prohibited on child welfare grounds. Advances in technology raise the prospect of interventions for minor-attracted persons that have the potential to reduce harm to children by diverting would-be offenders to other endeavors that nonetheless may generate moral disgust This essay examines three of these potential harm reduction technologies (sex robots, haptic devices and synthetic child pornography) and raises the possibility that their use can be (...)
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  22.  17
    Refusal of transplant organs for non-medical reasons including COVID-19 status.Sai Kaushik Yeturu, Susan M. Lerner & Jacob M. Appel - 2023 - Clinical Ethics 18 (2):172-176.
    Transplant centers and physicians in the United States have limited guidance on the information which they can and cannot provide to transplant candidates regarding donors of potential organs. Patients may refuse organs for a variety of reasons ranging from pernicious requests including racism to misinformation about emerging medicine as with the COVID-19 vaccine and infection. Patient autonomy, organ stewardship, and equity are often at odds in these cases, but precedent indeed exists to help address these challenges. This work uses such (...)
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  23.  21
    Toxic: The Challenge of Involuntary Contraception in Incompetent Psychiatric Patients Treated with Teratogenic Medications.Jacob M. Appel, Bridget King & Jordan L. Schwartzberg - 2022 - Journal of Clinical Ethics 33 (1):29-35.
    Limitations on reproductive decision making, including forced sterilization and involuntary birth control, raise significant ethical challenges. In the United States, these issues are further complicated by a disturbing history of the abuse and victimization of vulnerable populations. One particularly fraught challenge is the risk of teratogenicity posed by moodstabilizing psychiatric medications in patients who are incapable of appreciating such dangers. Long-acting reversible contraception (LARC) offers an intervention to prevent pregnancy among individuals who receive such treatments, but at a cost to (...)
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  24.  13
    Decisional Capacity After Dark: Is Autonomy Delayed Truly Autonomy Denied?Jacob M. Appel - 2024 - Cambridge Quarterly of Healthcare Ethics 33 (2):260-266.
    The model for capacity assessment in the United States and much of the Western world relies upon the demonstration of four skills including the ability to communicate a clear, consistent choice. Yet such assessments often occur at only one moment in time, which may result in the patient expressing a choice to the evaluator that is highly inconsistent with the patient’s underlying values and goals, especially if a short-term factor (such as frustration with the hospital staff) distorts the patient’s preferences (...)
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  25.  17
    Social Support: From Exclusion Criteria to Medical Service.Jacob M. Appel - 2024 - Cambridge Quarterly of Healthcare Ethics 33 (1):17-22.
    One of the criteria used by many transplant centers in assessing psychosocial eligibility for solid organ transplantation is social support. Yet, social support is a highly controversial requirement that has generated ongoing debate between ethicists and clinicians who favor its consideration (i.e., utility maximizers) and those who object to its use on equity grounds (i.e., equity maximizers). The assumption underlying both of these approaches is that social support is not a commodity that can be purchased in the marketplace. This essay (...)
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  26.  12
    Rethinking Second Chances: When Rejected Liver Transplant Candidates Seek Reevaluation Elsewhere.Jacob M. Appel & Akhil Shenoy - 2023 - Journal of Clinical Ethics 34 (2):196-203.
    Liver transplantation offers a lifesaving treatment for patients suffering from end-stage liver failure, but not all candidates in the United States are eligible owing to center-specific criteria. When a patient is rejected at a transplantation center for medical, surgical, or psychosocial issues, they are often referred to other centers. We focus on this practice of reevaluation at a second center when the candidate was rejected for psychosocial reasons. We review the criteria used by health professionals to determine psychosocial eligibility and (...)
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  27.  22
    A Philosophy for Choosing Doctors.Jacob M. Appel - 2022 - Cambridge Quarterly of Healthcare Ethics 31 (3):407-410.
    This essay advocates for the wholesale reevaluation of the process used by American medical schools for selecting physicians, examining fundamental questions such as the purpose of physicians and the nature of meritocracy. It raises questions about the size of medical school classes, the specific academic requirements, and the inadequacy of current efforts to increase diversity. Ultimately, the essay argues for consideration of a range of reforms that will focus on the community-empowering aspects of medical admissions decisions.
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  28.  12
    Against Intelligence: Rethinking Criteria for Medical School Admissions.Jacob M. Appel - forthcoming - Cambridge Quarterly of Healthcare Ethics:1-6.
    Intelligence, as measured by grades and/or standardized test scores, plays a principal role in the medical school admissions process in most nations. Yet while sufficient intelligence is necessary to practice medicine effectively, no evidence suggests that surplus intelligence beyond that threshold is correlated with providing higher quality medical care. This paper argues that using perceived measures of intelligence to distinguish between applicants, at levels that exceed the level of intelligence required to practice medicine, is both unfair to applicants and fails (...)
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  29.  58
    Castration Anxiety: Physicians, “Do No Harm,” and Chemical Sterilization Laws.Jacob M. Appel - 2012 - Journal of Bioethical Inquiry 9 (1):85-91.
    Chemical castration laws, such as one recently adopted in the U.S. State of Louisiana, raise challenging ethical concerns for physicians. Even if such interventions were to prove efficacious, which is far from certain, they would still raise troubling concerns regarding the degree of medical risk that may be imposed upon prisoners in the name of public safety as well as the appropriate role for physicians and other health care professionals in the administration of pharmaceuticals to competent prisoners over the inmates’ (...)
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  30.  12
    How Hard It Is That We Have to Die.Jacob M. Appel - 2012 - Cambridge Quarterly of Healthcare Ethics 21 (4):527-536.
  31.  10
    Anything You Do Not Say Can Be Used against You: Volitional Refusal to Engage in Decisional Capacity Assessment.Jacob M. Appel - 2023 - Journal of Clinical Ethics 34 (2):204-210.
    The most widely accepted model of decisional capacity assessment requires that a patient communicate a clear and consistent choice to the evaluator. This approach works effectively when patients prove unable to express a choice owing to physical, psychological, or cognitive limitations. In contrast, the approach raises ethics concerns when applied to patients who volitionally refuse to communicate a choice. This article examines the ethical issues that arise in such cases and offers a rubric for addressing decisional capacity under such circumstances.
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  32.  14
    A Realpolitik for Presidential Health: A Psychiatrist's Perspective.Jacob M. Appel - 2021 - Hastings Center Report 51 (4):12-17.
    The health and fitness of United States presidents has been a matter of concern since the Constitutional Convention. Several United States presidents, including James Madison, James Garfield, and Woodrow Wilson, were significantly impaired during portions of their tenure. Yet how to address this issue has proved both ethically and politically challenging, increasingly so during our nation's current period of elevated polarization. This essay reviews the history of presidential impairment and the range of proposals that have been offered to address it. (...)
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  33.  14
    Against Whitecoat Washing: The Need for Formal Human Rights Assessment in International Collaborations.Jacob M. Appel - 2022 - American Journal of Bioethics 22 (10):1-4.
    On February 24, 2022, Russia invaded its neighboring nation, Ukraine, in what is widely regarded in the West as a grave breach of international law. Since that time, the Russian military has been i...
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  34. Capacity, informed consent and third-party decision-making.Jacob M. Appel - 2024 - New York. NY: Cambridge University Press.
    This Element examines three related topics in the field of bioethics that arise frequently both in clinical care and in medico-legal settings: capacity, informed consent, and third-party decision-making. All three of these subjects have been shaped significantly by the shift from the paternalistic models of care that dominated medicine in the United States, Canada, and Great Britain prior to the 1960s to the present models that privilege patient autonomy. Each section traces the history of one of these topics and then (...)
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  35.  15
    Case Study: Organ Solicitation on the Internet: Every Man for Himself?Jacob M. Appel & Mark D. Fox - 2005 - Hastings Center Report 35 (3):14.
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  36.  14
    Divided Loyalties: Fire and ICE.Jacob M. Appel - 2021 - Hastings Center Report 51 (6):4-5.
    This essay explores the challenges of dual loyalty in the emergency setting. The author, an emergency room psychiatrist, finds himself caring for a patient who has been detained by U.S. Immigration and Customs Enforcement for potential deportation under circumstances that the author finds unjust. He also recognizes that the patient's reported psychiatric symptoms are likely not of the nature or severity to justify a psychiatric admission that might forestall deportation. While the author has taught the subject of dual loyalty in (...)
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  37.  34
    Ethics: English High Court Orders Separation of Conjoined Twins.Jacob M. Appel - 2000 - Journal of Law, Medicine and Ethics 28 (3):312-318.
  38.  25
    Ethics: English High Court Orders Separation of Conjoined Twins.Jacob M. Appel - 2000 - Journal of Law, Medicine and Ethics 28 (3):312-313.
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  39.  25
    In Defense of Tongue Splitting.Jacob M. Appel - 2005 - Journal of Clinical Ethics 16 (3):236-238.
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  40.  27
    Medical School: The Wrong Applicant Pool?.Jacob M. Appel - 2019 - Hastings Center Report 49 (2):6-8.
    Evidence‐based medicine has become both the mantra of clinical practice and the dominant contemporary approach to patient care. Gordon Guyatt et al. first proposed applying the concept to medical education in the early 1990s, arguing for training that “de‐emphasizes intuition, unsystematic clinical experience, and pathophysiologic rationale” in favor of “examination of evidence from clinical research”; over the following twenty‐five years, nearly every medical school and residency program in the United States incorporated these methods into its training. During this same period, (...)
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  41. Organ solicitation on the internet: Every man for himself: Commentary.Jacob M. Appel - 2005 - Hastings Center Report 35 (3):14-15.
  42.  50
    Privacy versus History.Jacob M. Appel - 2012 - Cambridge Quarterly of Healthcare Ethics 21 (1):51-63.
    One of the most fundamental tenets of medical research, enshrined in the World Medical Association’s Declaration of Helsinki, is that scientific investigation involving human beings requires the informed consent of the subjects.
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  43.  12
    Privacy versus History.Jacob M. Appel - 2012 - Cambridge Quarterly of Healthcare Ethics 21 (1):51-63.
    One of the most fundamental tenets of medical research, enshrined in the World Medical Association’s Declaration of Helsinki, is that scientific investigation involving human beings requires the informed consent of the subjects.
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  44.  10
    Reconsidering Capacity to Appoint a Healthcare Proxy.Jacob M. Appel - 2023 - Cambridge Quarterly of Healthcare Ethics 32 (1):69-75.
    Clinicians are often called upon to assess the capacity of a patient to appoint a healthcare agent. Although a consensus has emerged that the standard for such assessment should differ from that for capacity to render specific healthcare decisions, exactly what standard should be employed remains unsettled and differs by jurisdiction. The current models in use draw heavily upon analogous methods used in clinical assessment, such as the “four skills” approach. This essay proposes an alternative model that relies upon categorization (...)
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  45.  30
    Research Guidelines: Changes Urged.Jacob M. Appel - 2001 - Journal of Law, Medicine and Ethics 28 (s4):103-104.
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  46.  22
    Research Guidelines: Changes Urged.Jacob M. Appel - 2001 - Journal of Law, Medicine and Ethics 28 (4_suppl):103-104.
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  47.  4
    Research Guidelines: Changes Urged.Jacob M. Appel - 2001 - Journal of Law, Medicine and Ethics 29 (1):103-104.
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  48.  15
    Taking care of the beloved patient.Jacob M. Appel - 2023 - Clinical Ethics 18 (1):13-17.
    While the management of treating “hateful” patients has been the subject of considerable commentary, far less attention has been paid to the ethical challenges involved in the treatment of “beloved” patients. This essay offers a non-exhaustive taxonomy of “beloved” patients that includes relatable patients, inspiring patients, empathy-inducing patients, and joyful patients, and then discusses the potential pitfalls involved in the optimal care of each group. By drawing attention to these often overlooked and unwitting risks, the hope is to mitigate both (...)
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  49.  13
    The draw of the few: the challenge of crisis guidelines for extremely scarce resources.Jacob M. Appel - 2022 - Journal of Medical Ethics 48 (12):1032-1036.
    The COVID-19 pandemic has focused considerable attention on crisis standards of care (CSCs). Most public CSCs at present are effective tools for allocating scarce but not uncommon resources (like ventilators and dialysis machines). However, a different set of challenges arise with regard to extremely scarce resources (ESRs), where the number of patients in need may exceed the availability of the intervention by magnitudes of hundreds or thousands. Using the allocation of extracorporeal membrane oxygenation machines as a case study, this paper (...)
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  50.  15
    When All the PICU’s a Platform.Jacob M. Appel - 2021 - American Journal of Bioethics 21 (7):75-77.
    The Internet has vastly expanded the opportunity for patients and families to share their medical narratives with the general public. Yet blogs and social media posts can also prove a source of con...
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