Informed consent is the single most important concept for understanding decision-making capacity. There is a steady pull in the clinical world to transform capacity into a technical concept that can be tested objectively, usually by calling for a psychiatric consult. This is a classic example of medicalization. In this article I argue that is a mistake, not just unnecessary but wrong, and explain how to normalize capacity assessment.Returning the locus of capacity assessment to the attending, the primary care doctor, and (...) even to ethics consultation in today's environment will require a substantial effort to undo a strong but illusory impression of capacity assessment. Hospital attorneys as well as clinical ethicists with a sophisticated understanding of health law can be in the vanguard of this reorientation. (shrink)

The American Journal of Bioethics, Volume 12, Issue 8, Page 13-15, August 2012.

The year 2013 may someday be seen as the year a new profession was born. Clinical ethics consultation has been practiced in different ways for roughly 30 years, originally initiated by a group of h...

A fourteen year old is diagnosed with aplastic anemia. The teen and his parents are Jehovah’s Witnesses. An ethics consult is called on the day of admission by an ethically sophisticated social worker and attending. The patient and his parents see this diagnosis as “a test of their faith.” The ethical analysis focuses on the mature minor doctrine, i.e. whether the teen has the capacity to make this decision. The hospital chooses to take the case to court, with a result (...) that is at odds with the ethics consultation recommendations. Ethics was never deposed or otherwise invited to be involved with the hearing. Thus the larger question of the relation of ethics and law was brought into stark relief. (shrink)

How can one be trained to enter the evolving field of clinical ethics consultation? The classroom is not the proper place to teach clinical ethics consultation; it is best done in a clinical setting. The author maps the elements that might be included in an apprenticeship, and sets out propositions for debate regarding the training needed for clinical ethics consultants and directors of clinical ethics consultation services.

In lieu of an abstract, here is a brief excerpt of the content:The Philosophy of George Engel and the Philosophy of MedicineJeffrey P. Spike (bio)KeywordsGeorge Engel, psychosocial medicine, medical education, medical humanities, interviewing skills, philosophy of medicine, scientific methodDoctor Brad Lewis has encouraged us to consider George Engel’s philosophy with his excellent essay on Engel and Pragmatism. As a philosopher teaching full time in a medical school, it is refreshing to have an opportunity to analyze the work of two physicians (...) at this level of reflection and abstraction. It is even more of a pleasure because I knew Dr. Engel personally while I was teaching at the University of Rochester School of Medicine. I will make some observations of the philosophy behind Dr. Engel’s work, both published and practical, that is, as reflected in his writing but also in his influence in the medical curriculum at the institution that he called home for some thirty years (as seems appropriate when considering someone’s bona fides as a pragmatist).Engel’s Philosophy and Medicine’s PhilosophyGeorge Engel’s primary philosophical concern was to fight the powerful belief (or perhaps delusion) that medicine was evolving into a pure physical science, an extension of biochemistry and cell biology, or as we would now call them, proteomics and genomics. There is little evidence that he espoused any one methodology for basic science, so much as he opposed any one methodology for medicine. So to say he was a pragmatist seems underdetermined by his words, if that is taken to mean he advocated for changing the methodological model for scientific research. Rather the question is whether his preferred medical methodology is best characterized as pragmatic, or by some other description. On that score I agree with Lewis wholeheartedly.Of course, it might be that the claim of pragmatism is not meant to suggest a change in method for basic science, but to advocate for retaining an appreciation for the whole range of approaches to knowledge, from experimental science to epidemiology, and from epidemiology to acculturation. By that definition of pragmatism, Engel was indeed a pragmatist. Interpreted this way, he wanted medicine to stop worshipping the scientific method and appreciate that there are many paths to knowledge besides through the wet lab.It might be said that there are different scientific methods for different sciences, and Engel wanted us to appreciate that the reductionist methods [End Page 315] appropriate to the sciences of the small are not necessarily methods that can be applied to all sizes of objects we study, or all levels of reality (like the psychological and social). This is the truth about the world, although I am not sure that this is what Engel meant. As Lewis notes, Engel’s writing does sometimes sound as if he worshipped at the alter of science, as if all subjects of importance can be studied scientifically. But if he believed that, he was not correct. It might be, if all the subjects of the university that Lewis mentions are important, that some will turn out to be able to be studied in academically rigorous methods that are not scientific in any of the usual meanings of the word. Consider philosophy itself, for example.To the degree that it may stretch the evidence to say that Engel would have advocated for a pragmatic scientific method, it is still the case that pragmatism as outlined by Lewis and Engel’s biopsychosocial model can both be used to help medicine understand itself and overcome the temptation to idolize science. Medicine is not a science, or at least it is not just a science; in fact, I would suggest that it never was a science, and it will never be a science. Medicine is about health and illness, and uses whatever science it can to promote health and to treat (ameliorate or cure) illness.None of this should necessarily lead us to idolize pragmatism either. If each subject has its own ideal methodology for study, then it may be that pragmatism is the preferred method for, say, clinical judgment, whereas the scientific method is the best for the ‘hard’ sciences, and logic for philosophy. Or perhaps pragmatism and inductive logic are competing models for clinical... (shrink)

Fifteen years ago I was the ethicist involved in a case of a 20-year-old woman who had a stroke, and who was discovered in the emergency room to be 16 weeks pregnant on the same day she was declare...

Individuals who are profoundly mentally handicapped do not have the capacity to make their own decisions and also do not have a past record of decisions, from when they had capacity, to guide us in making decisions for them. They represent a difficult group, ethically, for surrogate decision making. Here I propose some guidelines, distinguishing between these patients and patients in a persistent vegetative state (PVS). As the life span of patients becomes shorter, or their level of consciousness becomes permanently (...) impaired, the presumption for comfort care should become an imperative, and the standard of evidence to justify any invasive intervention should become higher. For members of this population, who have no more ability to refuse treatment than to consent to it, protection of the vulnerable must mean allowing a peaceful death as well as a comfortable life. Reasonable legal safeguards are also proposed to allow improved end-of-life decisions to be made for this population. (shrink)

Volume 19, Issue 10, October 2019, Page W5-W8.

The first ethics casebook that integrates clinical ethics (medical, nursing, and dental) and research ethics with public health and informatics. The book opens with five chapters on ethics, the development of interprofessional ethics, and brief instructional materials for students on how to analyze ethical cases and for teachers on how to teach ethics. In today's rapidly evolving healthcare system, the cases in this book are far more realistic than previous efforts that isolate the decision-making process by professions as if each (...) is not embedded in a larger context that involves healthcare teams, hospital policies, and technology. The central claim of this book is that ethics is an important common ground for all of the health professions. Furthermore, when we recognize that our professions converge upon a common goal we will find less conflict and more pleasure in working together. (shrink)

Surgical ethics is a well-recognized field in clinical ethics, distinct from medical ethics. It includes at least a dozen important issues common to surgery that do not exist in internal medicine simply because of the differences in their practices. But until now there has been a tendency to include ethical issues of anesthesiology as a part of surgical ethics. This may mask the importance of ethical issues in anesthesiology, and even help perpetuate an unfortunate view that surgeons are “captain of (...) the ship” in the operating theater (leaving anesthesiologists in a subservient role).We will have a better ethical understanding if we see surgery and anesthesia as two equal partners, ethically as well as in terms of patient care. Informed consent is one such issue, but it is not limited to that. Even on the topic of what type of anesthesia to use, anesthesiologists have often felt subsumed to the surgeon’s preferences. This commentary takes the case study and uses it as a exemplar for this very claim: it is time to give due recognition for a new field in clinical ethics, ethics in anesthesia. (shrink)

This is the second issue of Clinical Ethics cases. Every six months we plan to present two cases, each with a few commentaries by ethical, clinical, and legal experts who include ethics consultatio...

On the face of it, this is a very simple case. But in fact it has at least two different dilemmas that make it exceedingly difficult. For that reason, I find it almost a paradigm for clinical ethic...

Many ethics faculty in medical schools do not include abortion in their required curriculum. On the face of it, this is a singular failure since abortion is certainly an important ethical issue. Th...

The author analyzes the lessons for ethics consultants presented by McCrary and colleagues in their case, “Elective Delivery Before 39 Weeks’ Gestation: Reconciling Maternal, Fetal, and Family Interests in Challenging Circumstances.” Clinical ethics cases that involve different specialists representing the best interests of different parties in a case, such as this case involving neonatologists and perinatologists, are complex and time-consuming. The author concludes that ethics must insure the interests of the fetus and future person are not subsumed to the interests (...) of those with a voice, without deliberate reflection and strong ethical justification. (shrink)

The author of “How Bioethics and Case Law Diverge in Assessments of Mental Capacity: An Argument for a Narrative Coherence Standard” (2020) arrives at a reasonable conclusion; however, it is far le...

This case is in some ways unique, and in other ways very typical of ethics consults. No matter how many consults one has been involved with, new cases always pose new questions. This case is unique...

Resolving the Vexing Question of Credentialing: Finding the Aristotelian Mean Content Type Journal Article Pages 263-273 DOI 10.1007/s10730-009-9100-2 Authors Jeffrey P. Spike, University of Texas Health Science Center at Houston Center for Health, Humanities, and the Human Spirit, Director of the Campus Wide Ethics Program 6431 Fannin, JJL 400 Houston Texas 77030 USA Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737 Journal Volume Volume 21 Journal Issue Volume 21, Number 3.