This article was downloaded by: [Northwestern University] On: 08 February 2015, At: 03:22 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Clinical Ethics: Case Reports, Consults, and Commentaries Jeffrey P. Spike
a
a
University of Texas , Houston Published online: 14 Jan 2014.
Click for updates To cite this article: Jeffrey P. Spike (2014) Clinical Ethics: Case Reports, Consults, and Commentaries, The American Journal of Bioethics, 14:1, 36-37, DOI: 10.1080/15265161.2014.862404 To link to this article: http://dx.doi.org/10.1080/15265161.2014.862404
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
The American Journal of Bioethics, 14(1): 36–37, 2014 c Taylor & Francis Group, LLC Copyright ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265161.2014.862404
Introduction
Clinical Ethics: Case Reports, Consults, and Commentaries
Downloaded by [Northwestern University] at 03:22 08 February 2015
Jeffrey P. Spike, University of Texas, Houston AJOB is pleased to introduce a new series of cases and commentaries chosen for their interest to professionals in clinical ethics and clinical ethics consultation. Clinical ethics may be almost as old as bioethics itself, but its recognition as an independent profession is just now beginning to emerge, with a new proposed code of ethics, as well as vigorous discussion of accreditation for training programs and credentialing for individual consultants. Cases for this series will be chosen so as to represent the diversity of our experiences in clinical ethics. We seek to include a balance of cases from pediatrics to adult medicine, surgery, and anesthesiology, and from issues that arise every day in primary care practice to leading-edge innovations in medicine. Each case will be followed by commentaries by clinicians and clinical ethicists. As befits the clinical practice of ethics, our goal is to help educate and prepare others who might encounter similar challenges. For those who might wonder how this differs from what AJOB already offers, I would suggest, as the editor of this new series, the following explanation. Bioethics is a very large field, an umbrella with diverse audiences and topics. At the very least, it includes clinical ethics, research ethics, and empirical and theoretical bioethics. Clinical ethics may be of interest to all bioethicists, but it is essential for those of us who are involved in seeing patients as part of our job duties. Research ethics, similarly, may be of interest to almost all of us, but is essential to those of us involved in research or institutional review boards (IRBs) rather than clinical care. Theoretical bioethics is probably the best term to identify the material most often taught in philosophy department courses, whether to undergraduate college students or to graduate students. Nor are these four areas exhaustive of bioethics. For example, environmental ethics is at least as important a topic as the others, but probably constitutes a fifth domain of knowledge and expertise. Public health ethics, with a focus on populations rather than individuals, and including more economics and policy, might well be a sixth domain of bioethics. Besides having different audiences for whom each ought to be considered necessary, another way to add clarity
to the claim of separate identities for these major branches of bioethics is that each now has its own journals and full-time professionals. A bit more about the parameters of clinical ethics might be useful. This subject is taught in medical schools around the English-speaking world, as well as in nursing and dental schools. It typically includes at least the following core subjects: informed consent, patient autonomy, decision-making capacity, risk–benefit analysis and the best interest standard, rationing and the just allocation of resources, professionalism topics such as duty to treat, accepting gifts, boundary issues, and confidentiality and its limits, plus the many issues concerning the end of life: the right to refuse treatment, withdrawing life-sustaining treatment, pain control, spiritual or existential suffering, and physician-assisted suicide and euthanasia. Clinical and legal knowledge are just as important as ethical knowledge when it comes to clinical ethics. Analysis of the case and justifications of recommendations must always reflect current clinical and legal realities. Readers should be able to take away lessons that will be useful in their own practices. Cases may present clear ethical issues, or (as so often happens) part of the task of the ethical analysis might be to determine the ethical issues. It is standard, when someone asks for a consult, to ask them what they see as the ethical issues. But clinical ethicists are also expected to add or subtract from the list. It would often be a grievous error if an ethicist said “That’s not an ethics question” when consulted on a case, and didn’t reflect on why the consult was called, and whether there is an ethics question that simply wasn’t well identified. After all, the person who called is not an ethicist, but is asking us for help from an ethicist—that help might include correctly identifying or clarifying the ethics question. Each case will be introduced with a brief description. Often this might seem too brief, an inadequate description. But that is part of the task. In real life, the first thing clinical ethicists do is ask follow-up questions. What more do we need to know before we can be comfortable making a recommendation? We will then do some research, looking up medical information, such as, for one of our cases,
Address correspondence to Jeffrey P. Spike, PhD, Samuel E. Karff Professor, McGovern Center for Humanities and Ethics, University of Texas, Houston, 6431 Fannin, JJL Suite 410, Houston, TX 77030, USA. E-mail: [email protected]
36 ajob
Clinical Ethics
readers will have the grounds needed for comparing recommendations and judging which conclusion has the best support. I hope many readers of these cases will thus find that the cases provide them a chance to exercise their own clinical ethics skills. We are soliciting new cases. Cases themselves may be published anonymously, as a further guarantee of confidentiality. Even so, any contingencies that do not affect the discussion should be masked, to further protect confidentiality. Cases should be 500–600 words (or longer if the case requires it). Each case will be followed by commentaries. Authors of cases may write a commentary if they like, or they may suggest others to write commentaries, though this is not required. Commentaries should be 1000–2000 words. Please send cases directly to the series editor at the e-mail address that follows: [email protected]
Downloaded by [Northwestern University] at 03:22 08 February 2015
this issue: How often do children identify with a gender other than their genetic sexual identity? How often do they change their mind some time later? Is there an age after which they never change their mind? We also will ask for more social information, such as, for the other case in this issue: What did the patient say about organ donation? Did he ever address donation after cardiac death (DCD), also known as non-heart beating donor protocols (NHBD), or just donation after death as declared by neurological criteria? Unlike thoroughly researched commentaries for target articles typical of AJOB, the clinical case commentaries are modeled on consult notes, which are expected (within very constrained time limits) to recommend a resolution or course of action with strong ethical justifications. While two commentators might still arrive at different conclusions,
January, Volume 14, Number 1, 2014
ajob 37
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Clinical Ethics: Case Reports, Consults, and Commentaries Jeffrey P. Spike
a
a
University of Texas , Houston Published online: 14 Jan 2014.
Click for updates To cite this article: Jeffrey P. Spike (2014) Clinical Ethics: Case Reports, Consults, and Commentaries, The American Journal of Bioethics, 14:1, 36-37, DOI: 10.1080/15265161.2014.862404 To link to this article: http://dx.doi.org/10.1080/15265161.2014.862404
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
The American Journal of Bioethics, 14(1): 36–37, 2014 c Taylor & Francis Group, LLC Copyright ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265161.2014.862404
Introduction
Clinical Ethics: Case Reports, Consults, and Commentaries
Downloaded by [Northwestern University] at 03:22 08 February 2015
Jeffrey P. Spike, University of Texas, Houston AJOB is pleased to introduce a new series of cases and commentaries chosen for their interest to professionals in clinical ethics and clinical ethics consultation. Clinical ethics may be almost as old as bioethics itself, but its recognition as an independent profession is just now beginning to emerge, with a new proposed code of ethics, as well as vigorous discussion of accreditation for training programs and credentialing for individual consultants. Cases for this series will be chosen so as to represent the diversity of our experiences in clinical ethics. We seek to include a balance of cases from pediatrics to adult medicine, surgery, and anesthesiology, and from issues that arise every day in primary care practice to leading-edge innovations in medicine. Each case will be followed by commentaries by clinicians and clinical ethicists. As befits the clinical practice of ethics, our goal is to help educate and prepare others who might encounter similar challenges. For those who might wonder how this differs from what AJOB already offers, I would suggest, as the editor of this new series, the following explanation. Bioethics is a very large field, an umbrella with diverse audiences and topics. At the very least, it includes clinical ethics, research ethics, and empirical and theoretical bioethics. Clinical ethics may be of interest to all bioethicists, but it is essential for those of us who are involved in seeing patients as part of our job duties. Research ethics, similarly, may be of interest to almost all of us, but is essential to those of us involved in research or institutional review boards (IRBs) rather than clinical care. Theoretical bioethics is probably the best term to identify the material most often taught in philosophy department courses, whether to undergraduate college students or to graduate students. Nor are these four areas exhaustive of bioethics. For example, environmental ethics is at least as important a topic as the others, but probably constitutes a fifth domain of knowledge and expertise. Public health ethics, with a focus on populations rather than individuals, and including more economics and policy, might well be a sixth domain of bioethics. Besides having different audiences for whom each ought to be considered necessary, another way to add clarity
to the claim of separate identities for these major branches of bioethics is that each now has its own journals and full-time professionals. A bit more about the parameters of clinical ethics might be useful. This subject is taught in medical schools around the English-speaking world, as well as in nursing and dental schools. It typically includes at least the following core subjects: informed consent, patient autonomy, decision-making capacity, risk–benefit analysis and the best interest standard, rationing and the just allocation of resources, professionalism topics such as duty to treat, accepting gifts, boundary issues, and confidentiality and its limits, plus the many issues concerning the end of life: the right to refuse treatment, withdrawing life-sustaining treatment, pain control, spiritual or existential suffering, and physician-assisted suicide and euthanasia. Clinical and legal knowledge are just as important as ethical knowledge when it comes to clinical ethics. Analysis of the case and justifications of recommendations must always reflect current clinical and legal realities. Readers should be able to take away lessons that will be useful in their own practices. Cases may present clear ethical issues, or (as so often happens) part of the task of the ethical analysis might be to determine the ethical issues. It is standard, when someone asks for a consult, to ask them what they see as the ethical issues. But clinical ethicists are also expected to add or subtract from the list. It would often be a grievous error if an ethicist said “That’s not an ethics question” when consulted on a case, and didn’t reflect on why the consult was called, and whether there is an ethics question that simply wasn’t well identified. After all, the person who called is not an ethicist, but is asking us for help from an ethicist—that help might include correctly identifying or clarifying the ethics question. Each case will be introduced with a brief description. Often this might seem too brief, an inadequate description. But that is part of the task. In real life, the first thing clinical ethicists do is ask follow-up questions. What more do we need to know before we can be comfortable making a recommendation? We will then do some research, looking up medical information, such as, for one of our cases,
Address correspondence to Jeffrey P. Spike, PhD, Samuel E. Karff Professor, McGovern Center for Humanities and Ethics, University of Texas, Houston, 6431 Fannin, JJL Suite 410, Houston, TX 77030, USA. E-mail: [email protected]
36 ajob
Clinical Ethics
readers will have the grounds needed for comparing recommendations and judging which conclusion has the best support. I hope many readers of these cases will thus find that the cases provide them a chance to exercise their own clinical ethics skills. We are soliciting new cases. Cases themselves may be published anonymously, as a further guarantee of confidentiality. Even so, any contingencies that do not affect the discussion should be masked, to further protect confidentiality. Cases should be 500–600 words (or longer if the case requires it). Each case will be followed by commentaries. Authors of cases may write a commentary if they like, or they may suggest others to write commentaries, though this is not required. Commentaries should be 1000–2000 words. Please send cases directly to the series editor at the e-mail address that follows: [email protected]
Downloaded by [Northwestern University] at 03:22 08 February 2015
this issue: How often do children identify with a gender other than their genetic sexual identity? How often do they change their mind some time later? Is there an age after which they never change their mind? We also will ask for more social information, such as, for the other case in this issue: What did the patient say about organ donation? Did he ever address donation after cardiac death (DCD), also known as non-heart beating donor protocols (NHBD), or just donation after death as declared by neurological criteria? Unlike thoroughly researched commentaries for target articles typical of AJOB, the clinical case commentaries are modeled on consult notes, which are expected (within very constrained time limits) to recommend a resolution or course of action with strong ethical justifications. While two commentators might still arrive at different conclusions,
January, Volume 14, Number 1, 2014
ajob 37
