For Lack of a Better Plan: A Framework for Ethical, Legal, and Clinical Challenges in Complex Inpatient Discharge Planning Content Type Journal Article Pages 311-326 DOI 10.1007/s10730-009-9117-6 Authors Jane Jankowski, Albany Medical Center Albany NY 12208 USA Terese Seastrum, Northeast Health 2212 Burdett Ave. Troy NY 12180 USA Robert N. Swidler, Northeast Health 2212 Burdett Ave. Troy NY 12180 USA Wayne Shelton, Alden March Bioethics Institute, Albany Medical College 47 New Scotland Avenue, MC 153 Albany NY (...) 12208-3478 USA Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737 Journal Volume Volume 21 Journal Issue Volume 21, Number 4. (shrink)

Our aim in this article is to define the difficulties that clinical ethics services encounter when they are asked to demonstrate the value a clinical ethics service (CES) could and should have for an institution and those it serves. The topic emerged out of numerous related presentations at the Un- Conference hosted by the Cleveland Clinic in August 2018 that identified challenges of articulating the value of clinical ethics work for hospital administrators. After a review these talks, it was apparent (...) that the field of clinical ethics may be at a crisis of sorts due to increased pressure to provide explicit measures to healthcare institutions to concretely demonstrate that CESs make a valuable difference in healthcare delivery. In this article, we grapple with how to satisfy the need for demonstrable value in a field in which metrics alone may not capture the scope of clinical ethics practice. We suggest that capturing the value of a CES has been difficult because the benefits of ethics consultation may be overt or attributable to the CES, but are often hidden due to the systems-level and process-oriented nature of clinical ethics work. Part of the difficulty in demonstrating the value of CESs is capturing and conveying all of the ways the integration of a CES throughout an institution positively affects patients, families, visitors, healthcare professionals, administrators, and the institution itself. Our aim is to (1) elucidate the multifaceted value added by a CES, including value that tends to be hidden and (2) suggest how to demonstrate value to others in a way that is not simplistic or reductionistic. (shrink)

Clinical ethics consultants (CECs) often face some of the most difficult communication and interpersonal challenges that occur in hospitals, involving stressed stakeholders who express, with strong emotions, their preferences and concerns in situations of personal crisis and loss. In this article we will give examples of how much of the important work that ethics consultants perform in addressing clinical ethics conflicts is incompletely conceived and explained in the American Society of Bioethics and Humanities Core Competencies for Healthcare Ethics Consultation and (...) the clinical ethics literature. The work to which we refer is best conceptualized as a specialized type of interviewing, in which the emotional barriers of patients and their families or surrogates can be identified and addressed in light of relevant ethical obligations and values within the context of ethics facilitation. (shrink)

As clinical ethics consultants move toward professionalization, the process of certifying individual consultants or accrediting programs will be discussed and debated. With certification, some entity must be established or ordained to oversee the standards and procedures. If the process evolves like other professions, it seems plausible that it will eventually include a written examination to evaluate the core knowledge competencies that individual practitioners should possess to meet peer practice standards. The American Society for Bioethics and Humanities has published core knowledge (...) competencies for many years that are accepted by experts as the prevailing standard. Probably any written examination will be based upon the ASBH core knowledge competencies. However, much remains to be done before any examination may be offered. In particular, it seems likely that a recognized examining board must create and validate examination questions and structure the examination so as to establish meaningful, defensible parameters after dealing with such challenging questions as: Should the certifying examination be multiple choice or short-answer essay? How should the test be graded? What should the pass rate be? How may the examination be best administered? To advance the field of health care ethics consultation, thought leaders should start to focus on the written examination possibilities, to date unaddressed carefully in the literature. Examination models—both objective and written—must be explored as a viable strategy about how the field of health care ethics consultations can grow toward professionalization. (shrink)

This paper discusses the ethical issues related to hemicorporectomy surgery, a radical procedure that removes the lower half of the body in order to prolong life. The literature on hemicorporectomy (HC), also called translumbar amputation, has been nearly silent on the ethical considerations relevant to this rare procedure. We explore five aspects of the complex landscape of hemicorporectomy to illustrate the broader ethical questions related to this extraordinary procedure: benefits, risks, informed consent, resource allocation and justice, and loss and the (...) lived body. (shrink)

An individual’s right to refuse life-sustaining treatment is a fundamental expression of patient autonomy; however, supporting this right poses ethical dilemmas for healthcare providers when the patient has attempted suicide. Emergency physicians encounter patients who have attempted suicide and are likely among the first medical providers to face the dilemma of honoring the patient’s DNR or intervening to reverse the effects of potentially fatal actions. We illustrate this issue by introducing a case example in which the DNR of a terminally (...) ill woman was not honored because the cause of her cardiac arrest was suicide. We argue that although a terminal diagnosis should change the way health care providers respond to a suicide attempt, many of the theoretical underpinnings for how one should treat suicide attempts—especially the criterion of external reasonability, that is the action to withhold or withdraw life-sustaining measures is reasonable independent of the precipitating event—are common to all situations :3–12, 2013). The presumption that patients who attempt suicide lack capacity due to acute mental illness is flawed because it fails to account for a competent individual’s reasonable preference to not be forced to live in an unbearable, terminal condition. In states without legislation allowing physician aid in dying, patients and providers must grapple with these limitations on a case-by-case basis. In cases where the patient has a limited life expectancy and there is not concern for psychiatric illness as the primary cause of the suicidal action, we argue that the negative right to refuse life-sustaining treatment should prevail. (shrink)

Benchmarks against which healthcare ethics consultation (HCEC) services can assess their performance are needed. As first-generation benchmarks continue to be developed, it is the obligation of the field to continually evaluate how these measures reflect the performance of any single HCEC service. This will be possible only with widespread reporting of standardized data points. In their article in this issue of The Journal of Clinical Ethics, Glover and colleagues provide a valuable preliminary approach for assessing appropriate consult volumes for a (...) HCEC service. The limitations of their study read as a call to action for the field of clinical ethics to expand and standardize data reporting so that more robust metrics can be developed. In response to this call by Glover and colleagues, the Cleveland Clinic HCEC service provides consult data from 2015 through 2019 for one of its medical centers, and offers an additional volumebased metric, consult-to-ICU-to-bed ratio (CiBR), that may add nuance to any normative assessment of HCEC service consult volume. Given that volume-based metrics are the native language of the clinical environment, efforts to improve such metrics in the field through transparency and standardization are warranted. However, the expositive power of volume-based metrics is limited; additional domains related to quality and outcomes are needed. (shrink)

This article presents the case of a mother who is planning a home birth with a midwife with the shared knowledge that the fetus would have congenital anomalies of unknown severity. We discuss the right of women to choose home birth, the caregivers’ duty to the infant, and the careproviders’ dilemma about how to respond to this request. The ethical duties of concerned careproviders are explored and reframed as professional obligations to the mother, infant, and their profession at large. Recommendations (...) are offered based on this case in order to clarify the considerations surrounding not only home birth of a fetus with anticipated anomalies, but also to address the ethical obligations of caregivers who must navigate the unique tension between respecting the mother’s wishes and the duty of the careproviders to deliver optimal care. (shrink)

The nurse asks the ethics consultant what can be done to stop the patient’s blogging. R.J.’s messages on the public forum are taking their toll on the care environment and the health care providers...

Volume 20, Issue 6, June 2020, Page 75-77.

Volume 20, Issue 3, March 2020, Page 21-24.

The authors of this article are previous or current members of the Clinical Ethics Consultation Affairs (CECA) Committee, a standing committee of the American Society for Bioethics and Humanities (ASBH). The committee is composed of seasoned healthcare ethics consultants (HCECs), and it is charged with developing and disseminating education materials for HCECs and ethics committees. The purpose of this article is to describe the educational research and development processes behind our teaching materials, which culminated in a case studies book called (...) A Case-Based Study Guide for Addressing Patient-Centered Ethical Issues in Health Care (hereafter, the Study Guide). In this article, we also enumerate how the Study Guide could be used in teaching and learning, and we identify areas that are ripe for future work. (shrink)

Despite an abundance of academic conferences, clinical ethicists lacked a forum to share innovative practices with peers and to generate solutions to common challenges. Organizers of the first Clinical Ethics Un-Conference developed a working event centered on active participation and problem solving through peer learning, with the goal of improving realworld practice. Registrants included 95 individuals from 64 institutions. Attendees were surveyed immediately after the Un-Conference, and again eight months later. After eight months, 85 percent (n = 33/39) of the (...) survey respondents reported that they found the event “highly impactful” or “some-what impactful” to their clinical practice, and 23 attendees reported that they had implemented ideas or projects inspired by the event. Three sets of best practice guidelines and four white papers were published from the event. As the field of clinical ethics continues to advance and evolve, this working event format offers an innovative, disruptive alternative to a traditional conference format and may serve as a model for future efforts aimed at improving real-world clinical ethics practice. (shrink)

The role of culture in shaping folk psychology and mindreading has been neglected in the philosophical literature. This paper shows that there are significant cultural differences in how psychological states are understood and used by drawing on Spaulding’s recent distinction between the ‘goals’ and ‘methods’ of mindreading to argue that the relations between these methods vary across cultures; and arguing that differences in folk psychology cannot be dismissed as irrelevant to the cognitive architecture that facilitates our understanding of psychological states. (...) The paper concludes that any good account of social cognition must have the conceptual resources to explain how culture affects our understanding of psychological states, and that this explanandum should not be an after-thought but instead a guiding feature for those accounts. (shrink)

Recent philosophy of mind has had a mistaken conception of the nature of psychological concepts. It has assumed too much similarity between psychological judgments and those of natural science and has thus overlooked the fact that other people are not just objects whose thoughts we may try to predict and control but fellow creatures with whom we talk and co-operate. In this collection of essays, Jane Heal argues that central to our ability to arrive at views about others' thoughts (...) is not knowledge of some theory of the mind but rather an ability to imagine alternative worlds and how things appear from another person's point of view. She then applies this view to questions of how we represent others' thoughts, the shape of psychological concepts, the nature of rationality and the possibility of first person authority. This book should appeal to students and professionals in philosophy of mind and language. (shrink)

While it is widely acknowledged that psychology is in the throes of a replication ‘crisis’, relatively little attention has been paid to the role theory plays in our evaluation of replications as ‘failed’ or ‘successful’. This paper applies well-known arguments in philosophy of science about the interplay between theory and experiment to a contemporary case study of infants’ understanding of false belief (Onishi and Baillargeon [2005]), and attempts to replicate it. It argues that the lack of consensus about over-arching theories (...) informing both the concepts under study and the methodologies used to track them means that researchers disagree over which experiments constitute replications of the original. The second part of the paper places this specific debate within a broader discussion of the replication crisis as a crisis of ‘theory’, developing work by Muthukrishna and Henrich ([2018]) and Bird ([2018]). Bird argues that the lack of agreed over-arching theories in psychology means that a high rate of replication failure is to be expected; this paper agrees with his diagnosis but challenges his proposal that more replication will resolve the problem. (shrink)

Can a business be said to demonstrate moral virtues, and does being virtuous mean that it is more likely to behave ethically?

“Basic research” is often used in science policy. It is commonly thought to refer to research that is directed solely toward acquiring new knowledge rather than any more practical objective. Recently, there has been considerable concern about the future of basic research because of purported changes in the nature of knowledge production and increasing pressures on scientists to demonstrate the social and economic benefits of their work. But is there really something special about basic research? The author argues here that (...) “basic research” is a flexible and ambiguous concept that is drawn on by scientists to acquire prestige and resources. She shows that it is used for boundary work and gives examples of the work it does in different situations by drawing on interviews with scientists and policy makers on the category of basic research and the changes they have seen in it over time. (shrink)

The ArgumentThis paper argues that different epistemic styles exist in science, and that these make up an important unit of analysis for studying science. On occasion these different sets of commitments to ways of doing and knowing about the world may fall along national boundaries. The case presented here examines German and American embryology around 1900 and shows that differences in goals and approaches make up different epistemic styles.In particular, the Germans sought causal mechanical explanations of as many phenomena as (...) possible, guided by strong theories which achieved confirmation when they fit with as much of the available data as possible. The Americans, in contrast, sought definitive facts, as many as possible, which might be quite specific or narrowly based. These facts could lead to empirical generalizations which, in turn, could guide the generation of new knowledge in the form of new facts. Thus, the two epistemic styles emphasized different goals, processes of investigation, and standards of evidence. (shrink)

There are modes of presentation of a person in thought corresponding to the first and third person pronouns. This paper proposes that there is also thought involving a second person mode of presentation of another, which might be expressed by an utterance involving ‘you’, but need not be expressed linguistically. It suggests that co-operative activity is the locus for such thought. First person thought is distinctive in how it supplies reasons for the subject to act. In co-operative action there is (...) first person plural intending and judging. So there is a way of thinking of another, when openly co-operating with him or her, which plays the distinctive role of giving reason for contribution to the co-operative activity. In slogan form, ‘you’ is ‘we minus I’. The way children learn to use second and third person pronouns is naturally explained on this view. Contrasting less sophisticated kinds of co-operative activity with more sophisticated forms, and considering some issues about common knowledge and commo.. (shrink)

Responsible Research and Innovation (‘RRI’) is a cross-cutting priority for scientific research in the European Union and beyond. This paper considers whether the way such research is organised and delivered lends itself to the aims of RRI. We focus particularly on international consortia, which have emerged as a common model to organise large-scale, multi-disciplinary research in contemporary biomedical science. Typically, these consortia operate through fixed-term contracts, and employ governance frameworks consisting of reasonably standard, modular components such as management committees, advisory (...) boards, and data access committees, to co-ordinate the activities of partner institutions and align them with funding agency priorities. These have advantages for organisation and management of the research, but can actively inhibit researchers seeking to implement RRI activities. Conventional consortia governance structures pose specific problems for meaningful public and participant involvement, data sharing, transparency, and ‘legacy’ planning to deal with societal commitments that persist beyond the duration of the original project. In particular, the ‘upstream’ negotiation of contractual terms between funders and the institutions employing researchers can undermine the ability for those researchers to subsequently make decisions about data, or participant remuneration, or indeed what happens to consortia outputs after the project is finished, and can inhibit attempts to make project activities and goals responsive to input from ongoing dialogue with various stakeholders. Having explored these challenges, we make some recommendations for alternative consortia governance structures to better support RRI in future. (shrink)

This paper offers one explanation for the institutional basis of food insecurity in Australia, and argues that while alternative food networks and the food sovereignty movement perform a valuable function in building forms of social solidarity between urban consumers and rural producers, they currently make only a minor contribution to Australia’s food and nutrition security. The paper begins by identifying two key drivers of food security: household incomes (on the demand side) and nutrition-sensitive, ‘fair food’ agriculture (on the supply side). (...) We focus on this second driver and argue that healthy populations require an agricultural sector that delivers dietary diversity via a fair and sustainable food system. In order to understand why nutrition-sensitive, fair food agriculture is not flourishing in Australia we introduce the development economics theory of urban bias. According to this theory, governments support capital intensive rather than labour intensive agriculture in order to deliver cheap food alongside the transfer of public revenues gained from rural agriculture to urban infrastructure, where the majority of the voting public resides. We chart the unfolding of the Urban Bias across the twentieth century and its consolidation through neo-liberal orthodoxy, and argue that agricultural policies do little to sustain, let alone revitalize, rural and regional Australia. We conclude that by observing food system dynamics through a re-spatialized lens, Urban Bias Theory is valuable in highlighting rural–urban socio-economic and political economy tensions, particularly regarding food system sustainability. It also sheds light on the cultural economy tensions for alternative food networks as they move beyond niche markets to simultaneously support urban food security and sustainable rural livelihoods. (shrink)

Background/purpose:Research from other disciplines demonstrates that ethical position, idealism, or relativism predicts ethical decision-making. Individuals from diverse cultures ascribe to various religious beliefs and studies have found that religiosity and culture affect ethical decision-making. Moreover, little literature exists regarding undergraduate nursing students’ ethical position; no studies have been conducted in the United States on students’ ethical position, their self-identified culture, and intrinsic religiosity despite an increase in the diversity of nursing students across the United States.Participants and Research Context Objectives:The study’s (...) two aims were to determine the relationship of self-identified culture, religiosity, and ethics position of undergraduate nursing student and whether students’ level of education and past ethics courses taken related to idealism. Two hundred and twelve volunteer undergraduate students participated.Research design:A descriptive cross-sectional study was designed for participants who completed the Ethical Position Questionnaire, The intrinsic subscale of the Religious Orientation Scale, and a Demographic, Cultural, Ethnicity Form. To test the five hypotheses, analyses included t-tests, correlations, and ANOVA.Ethical Considerations:The study was approved by the Institutional Review Board at Adelphi University.Results:Idealism and intrinsic religiosity were significantly related. Differences were observed for intrinsic religiosity and idealism for cultural identity and cultural dimensions such as parents’ place of birth, and if participants were US born. Students’ level of education or participation in past courses on ethics did not influence idealism.Conclusions:The study’s findings were similar to most of the research from other disciplines on culture, ethics position, and religiosity. Generic courses on ethics taken prior to clinical work may not assist nursing students in integrating principles into complex ethical dilemmas. Self-identified culture, religion, and intrinsic religiosity related to ethics position; completing ethics courses and level of education, juniors compared with seniors, did not influence idealism. Faculty should consider integrating students’ culture, religious orientation, and ethics position into teaching ethics for all levels of nursing education. (shrink)

The work of Spinoza, Descartes and Leibniz is cited in an attempt to develop, both expositorily and critically, the philosophy of Anne Viscountess Conway. Broadly, it is contended that Conway's metaphysics, epistemology and account of the passions not only bear intriguing comparison with the work of the other well-known rationalists, but supersede them in some ways, particularly insofar as the notions of substance and ontological hierarchy are concerned. Citing the commentary of Loptson and Carolyn Merchant, and alluding to other commentary (...) on the Cambridge Platonists whose work was done in tandem with Conway's, it is contended that Conway's conception of the "monad" preceded and influenced Leibniz's, and that her monistic vitalism was in many respects a superior metaphysics to the Cartesian system. It is concluded that we owe Conway more attention and celebration than she has thus far received. (shrink)

This book explores the persistence of Pythagorean ideas in theoretical physics. It shows that the Pythagorean position is both philosophically deep and scientifically interesting. However, it does not endorse pure Pythagoreanism; rather, it defends the thesis that mind and mathematical structure are the grounds of reality. The book begins by examining Wigner's paper on the unreasonable effectiveness of mathematics in the natural sciences. It argues that, whilst many issues surrounding the applicability of mathematics disappear upon examination, there are some core (...) issues to do with the effectiveness of mathematics in fundamental physics which remain. The core issues are the existence of the laws of nature and our minds ability to fathom them, the use of formal mathematics in discovering things about the quantum world, the fact that deep mathematics is needed to describe fundamental physics, and the asymptotic nature of the quest for knowledge. These issues are the focus of the book. The author seeks to explain them within a metaphysical framework that takes mind and mathematical structure as its fundamental principles. The framework - called quantum monadology - combines ideas from Leibnizian monadology, set theory, and consistent histories quantum theory. (shrink)

Overviews -- Hildegard of Bingen -- Anne Conway -- Mary Astell -- Mary Wollstonecraft -- Harriet Taylor Mill -- Edith Stein -- Simone Weil -- Simone de Beauvoir -- Conclusions.

This article examines the work of the seventeenth-century thinker Catharine Trotter Cockburn with an eye toward explication of her trenchant empiricism, and the foundations upon which it rested. It is argued that part of the originality of Cockburn's work has to do with her consistent line of thought with regard to evidence from the senses and the process of abstract conceptualization; in this she differed strongly from some of her contemporaries. The work of Martha Brandt Bolton and Fidelis Morgan is (...) cited, and there is an auxiliary argument to the effect that Cockburn is probably better known as a playwright than she is as a philosophical thinker. (shrink)