The practice around informed consent in clinical medicine is both inconsistent and inadequate. Indeed, in busy, contemporary health care settings, getting informed consent looks little like the formal process developed over the past sixty years and presented in medical textbooks, journal articles, and academic lectures. In this article, members of the Society of Teachers of Family Medicine (STFM) Collaborative on Ethics and Humanities review the conventional process of informed consent and its limitations, explore complementary and alternative approaches to doctor‐patient interactions, (...) and propose a new model of consent that integrates these approaches with each other and with clinical practice. The model assigns medical interventions to a consent continuum defined by the discrete categories of traditional informed consent, assent, and nondissent. Narrative descriptions and clinical exemplars are offered for each category. The authors invite colleagues from other disciplines and from the academic ethics community to provide feedback and commentary. (shrink)

Millum and Bromwich’s excellent article provides both conceptual and practical rationale for reexamining the fundamentals of the informed consent process for research and clinical interventi...

The singular expertise of family physicians is the ability to manage complexity with pragmatism, both clinically and ethically. Telemedicine raises multiple questions about the nature of the patient‐physician relationship as manifested in clinical encounters. Some of these questions are concerning, underscoring the need to assess whether medical care is better with this new technology—or if it is just different or maybe even worse. It seems clear, however, that, regardless of its limitations, telemedicine is here to stay. The pragmatic complex ethical (...) question, then, is how all of us together—both medical professionals and society at large—will manage it. (shrink)

In this Open Peer Commentary, we draw on our clinical experience to argue that instrumental paternalism carves a pathway to competent refusal of medical intervention. Whether C successfully navigat...

PurposeTo discover where patients with advance directives (ADs) obtain them and to learn what patients’ understanding is of how ADs function.MethodsAdult patients with ADs admitted to the four acute-care hospitals in Monterey County, California, were asked to participate in a survey during the study period 1 July to 8 September 2009.ResultsOf 5,811 total admissions, 455 patients (7 percent) had an AD. Of these 455 patients, 204 (45 percent) completed our survey. Participants included 146 patients with a power of attorney for (...) healthcare (72 percent), and 21 patients who were unable to identify the type of AD they had (10 percent). Attorneys provided ADs to 99 participants (49 percent) and personal physicians provided ADs to 12 participants (6 percent). Most participants (181, or 89 percent) had spoken to their family about their AD; fewer (131, or 65 percent) to their physician. Of the 146 participants with a power of attorney, only 73 (50 percent) said they had spoken specifically to their agent. Family members (38 percent) and attorneys (35 percent) were seen as helpful in completing ADs; physicians (1 percent) were not.ConclusionsFew study participants had advance directives, and attorneys provided and discussed ADs with study participants more than physicians did. Because many patients with ADs seem not to fully understand them, new approaches to advance planning education must be developed. (shrink)

Founded upon the primacy of the principle of respect for autonomy, three methods of surrogate decision making traditionally have been promoted to help the family and friends of incapacitated patients. Unfortunately, the standards of advance directives, substituted judgment, and best interests are often inadequate in practice. Studies report that few patients have formal, written advance directives; that patients often change their minds about treatment over time; that many patients are simply not ready or willing to plan ahead—in part, because some (...) patients and families simply don’t believe in autonomy; that those patients who do plan ahead often do not communicate their plans; and that while some patients want their directives followed strictly, many prefer that their surrogates use judgment in making decisions. After reviewing articles describing a variety of alternative approaches, a new clinical standard of surrogate empowerment is proposed to reconcile and integrate these observations and concepts. The “procedure” for this clinical standard is presented. (shrink)

“Where's Dr. Tunzi?” Flor bellowed from the waiting room. “Is he here today?” Tattooed and built like a short middle linebacker, Flor is one of my favorite people. Despite schizophrenia, hepatitis C, and diabetes, she lives up to her name with a colorful and sunny personality. She and her partner, Nancy, have been my patients for about fifteen years, since I first met them at the small homeless clinic I help staff. I was away one day last year when Flor (...) and Nancy came in. It would be an understatement to say that it wasted everybody's time. But “team care” and “patient-centered medical home” are the buzzwords of the day. (shrink)

I propose that a minimum standard of public service activities be defined and required by all U.S. medical specialties in order to ma.

That's Brandenberg Concerto #3,” the Latino teenager informed me as I entered the exam room. I have a habit of whistling around the hospital. A little Bach. A little Gershwin. Disney. The Beatles. Italian folk songs. Christmas carols in December. I mix it up. As whistlers go, I'm pretty good—maybe a seven out of ten, all around—but I'm no virtuoso. In my work as a family physician, my repertoire is also quite broad, but not endlessly deep.My Latino teenager ostensibly came (...) in for evaluation of a “lump” that turned out to be a small lymph node. The real reason for his visit, however, was to discuss symptoms of depression and anxiety, a self‐described sense of “disassociation,” and his severely alcoholic father. “Tell the doctor why you are really here,” his mother told us both in Spanish as she exited the room. And I had fifteen minutes. With patients waiting. (shrink)

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...

The practice of generalist medicine differs from the practice of other clinical disciplines. We postulate that the application of ethics in generalist practice similarly differs from its application in other healthcare settings. In contrast to the problem- focused practice of ethics in other medical specialties, the practice of ethics in generalist medicine blends habits of mind with behaviors applied routinely over time—an ethical way of being. Using a graphic summary and tabular matrix, we present five “T” habits of mind (time, (...) talk, tact, touch, and trust), associate them with applicable practice characteristics, and link them to observable clinician behaviors to demonstrate how the application of ethics in generalist practice is a day-to-day endeavor and not simply a means to resolve episodic conflicts. We textually review key aspects of the matrix and present two case studies that illustrate how such habits of mind and practice behaviors inform the ethical way of being we espouse. We invite generalist practitioners to incorporate the five “T” habits and associated behaviors into their daily care of patients, and we encourage clinical ethicists and other clinical faculty members to consider using them as a model for ethics education with medical students and resident physicians. (shrink)