Thorny Issues in Clinical Ethics Consultation : North American and European Perspectives

This book addresses new and evolving thorny issues in clinical ethics consultation. It is a book for our time. The contributors provide essential critical reflection on the standards and methods of training clinical ethics consultants as the field seeks to professionalize. This collection incorporates both North American and European experts, offering different perspectives on issues such as marginalized populations, the opioid epidemic, complex discharge, micro-managing families, and continually challenging issues at the end-of-life, such as determinations of brain death, physician-assisted death, and futility. The authors engage the complexities of choosing for others when making decisions for incapacitated adults and pediatric patients. This volume engages with the growing literature in these debates and offers new perspectives from both academics and practitioners. The readings are of particular interest to bioethicists, clinicians, ethics committees, and students in bioethics and beyond. These new essays advance discussions in the professionalization and certification of ethics consultants and offer crucial insights on new and evolving thorny issues in the practice of clinical ethics consultation. [Editeur] Preface Contents Acronyms Part I: Introduction to Part I: History and Development of the Formation and Training of Clinical Ethics Consultants Chapter 1: A Brief Introduction to the History of Clinical Ethics 1.1 Objectives 1.2 The Birth of Clinical Ethics 1.3 The Professionalization of Clinical Ethics 1.4 1970s: Patients ́ Rights Affirmed, But Ignored! 1.5 1980s: HECs and Ethics Consultation Spread 1.6 1990s: A Crisis of Confidence in Clinical Ethics Consultation 1.7 2000s: A Crisis of Confidence 1.8 2010-2020: Clinical Ethics Consultation Professionalizes 1.9 The Past as Prologue References Chapter 2: Clinical Ethics Consultation: Current Standards in the Field 2.1 Objectives 2.2 Case 2.3 Defining Standards 2.4 CEC & Ethics Committees: Historical Milestones 2.5 CEC Standards in the U.S.: One Size Fits All? 2.6 Evaluating CEC Quality & Its Impact on Evolving Standards References Chapter 3: What Does Competency Have to Do with It? Ethics Fellowship Training and the Experience of a Hospital-Based Program ... 3.1 Objectives 3.2 Case One 3.3 Introduction: A Look at Training in Clinical Ethics 3.4 The Apprenticeship Model 3.5 The History of Competency-Based Education in Medicine 3.6 CBE in Clinical Ethics 3.7 Specifics, Concerns, and Next Steps References Chapter 4: Models of Training for Clinical Ethics Consultants and Approaches to Quality Assessment and Improvement 4.1 Objectives 4.2 Introduction 4.3 Classic Pathways into Clinical Ethics Consultation 4.4 The Need for Systematic Training of Clinical Ethics Consultants 4.5 The Ideal Training Models for Clinical Ethics Consultants 4.6 Specific Models of Training and Assessment 4.7 Relation to Quality Assessment and Quality Improvement References Chapter 5: New Approaches for Advancing Ethics Quality: Assessment of the Ethics Consultation Record 5.1 Objectives 5.2 Case One 5.3 Conclusion References Chapter 6: Historical Development of Clinical Ethics Consultation in Europe 6.1 Objectives 6.2 Case Example (From the Late 1990s) 6.3 How It All Began in Europe 6.4 Pioneers ́ Work and Influence 6.5 Variety and Commonalities of European Approaches 6.6 Conclusions References Chapter 7: Clinical Ethics Consultation in Germany: History, Current Status and Models of Training 7.1 Objective 7.2 Case Study 7.3 Development of Clinical Ethics Consultation in Germany 7.4 National Standards for Ethics Committees 7.5 Recommendations and Guidelines for Ethics Consultation Services 7.6 Curriculum for Ethics Consultation in Healthcare 7.7 National Training Programs for Ethics Consultation 7.8 Certification of Ethics Consultants 7.9 Ethics Consultation in Out-Patient Facilities and Nursing Homes 7.10 Conclusion References Chapter 8: Innovation or Stagnation? The State of Art of Clinical Ethics Support in Switzerland 8.1 Objectives 8.2 Introduction 8.3 The Swiss Context - Europe but Not European Union 8.4 `Swiss ́ Values - Responsibility, Self-Determination and Consensus 8.5 Development of Clinical Ethics Support in Switzerland - An Overview 8.5.1 Prevalence of Clinical Ethics Support Services 8.5.2 Key Topics of Clinical Ethics 8.5.3 Structural Challenges Over the Years 8.6 National Recommendations for Clinical Ethics - From `Consulting ́ to `Support ́ 8.7 Current Challenges - Professionalization, Innovation or Stagnation 8.7.1 The Meaning of `Clinical Ethics ́ Is Still Unclear 8.7.2 Concepts Are Still Unclear References Part II: Introduction to Part II: Emerging and Thorny Clinical Ethical Issues Chapter 9: Ethics Consultation and Marginalized Populations 9.1 Objectives 9.2 Case 1 9.3 Case 2 9.4 Introduction 9.5 Marginalized Populations 9.6 Advocacy and Activism 9.7 Advocating for Marginalized Populations 9.8 Goals of Clinical Ethics Consultation 9.9 Feasibility and Cautions References Chapter 10: Vulnerable Populations, the Inverse Care Law, and the Role of Clinical Ethicists: Experiences from Switzerland 10.1 Objectives 10.2 Case: Dr. Hope and the Patient on the ``Blacklist ́ ́ 10.3 The Swiss Context: Opportunities and Vulnerabilities 10.4 The Idea of Universal Health Coverage as a Positive Right to Serve the ``Worst Off ́ ́ and the Dynamic of the Inverse Care ... 10.5 Clinical Ethicists as Witnesses of Epistemic Injustice and the Advocacy Role 10.6 The Personal Is Political: Why Individual Approaches Are Necessary But Not Sufficient to Deal with Vulnerability in Clini... 10.7 Assessing and Addressing Vulnerability in the Clinical Setting References Chapter 11: Clinical Ethics Consultations Regarding Patients with Opioid Use Disorders 11.1 Objectives 11.2 Case 11.2.1 Ethical Framework: Choice and Moral Responsibility in Substance Use Disorders 11.3 Ethical Issues in the Inpatient Setting 11.4 Goals of Care: Harm Reduction or ``Clean and Sober ́ ́? 11.5 Conclusion References Chapter 12: The Opioid Crisis: A European Perspective 12.1 Objectives 12.2 Case 1 12.3 Case 2 12.4 Case 3 12.5 Introduction 12.6 Opioid Overuse in Europe 12.7 Opioid Underuse 12.8 Ethical Synthesis References Chapter 13: Ethical Issues in Complex Discharge Cases 13.1 Objectives 13.2 Case 13.3 Introduction 13.4 Unsafe Discharge 13.5 Lack of Insurance 13.6 Patients Who Are Undocumented Immigrants 13.7 The Patient or the Patient ́s Surrogate Refuses a Safe Discharge Plan 13.8 Responses to Complex Discharge Cases 13.9 Relevant Ethical Issues References Chapter 14: How Clinical Ethics Consultants Navigate Complex Acute Care Discharge Cases in Ontario 14.1 Objectives 14.2 Case 14.3 Application to Clinical Ethics Consultation 14.4 Conclusion References Chapter 15: Thorny Issues in Clinical Ethics Consultation: When Surrogates Refuse Basic Care 15.1 Objectives 15.2 Case 1 15.3 Case 2 15.4 Introduction 15.5 The Role of the Surrogate 15.6 Shared Decision Making and Refusal 15.7 Is Surrogate Refusal Also Neglect? 15.8 Response of the Clinician 15.9 Fear of Conflict 15.10 Fear of Interrupting the Surrogate ́s Relationship to the Patient 15.11 Ethical Resolution of Clinical Cases 15.12 Conclusion References Chapter 16: Families Who Micromanage: ``Please Come Help Us with This Family - They Are Micromanaging Everything! ́ ́ 16.1 Objectives 16.2 Case 1 16.3 Case 2 16.4 Ethical Issues 16.5 Homework First 16.6 Identification of the Involved Parties 16.7 Determining the Influence of the Micromanager 16.8 Team Meeting 16.9 Reaching Team Decisions 16.10 Approaching the Micromanager 16.11 Conducting a Formal Meeting 16.12 Specific Agreements 16.13 Boundaries 16.14 ``Nuclear Options ́ ́ 16.15 What Happened in Our Vignettes? References Part III: Introduction to Part III: Persistent and Thorny Clinical Ethical Issues Chapter 17: Neuroethics in the Clinic: Amplifying Patient Perspectives Through Enhanced Decision-Making Frameworks 17.1 Objectives 17.2 Case One 17.3 Case Two 17.4 Introducing Clinical Neuroethics 17.5 Case One: An Attempt to Liberate ``Locked-In Capacity ́ ́ 17.6 Case Two: Challenging Neuroessentialism 17.7 Takeaways for the Clinical Ethicist References Chapter 18: Brain Death/Death by Neurological Criteria in the United States: What Every Clinical Ethics Consultant Should Know 18.1 Objectives 18.2 Case 18.3 Medical History of BD/DNC 18.4 Legal History of BD/DNC 18.5 Reasons for Families to Object to BD/DNC 18.6 Consequences of Objections from Families to BD/DNC 18.7 Ways to Address Objections from Families to BD/DNC 18.8 Ways to Prevent Controversy Due to Objections from Families to BD/DNC 18.9 Objections from Healthcare Professionals to BD/DNC 18.10 The Need for Consent Prior to Determination of BD/DNC 18.11 Conclusion References Chapter 19: When Patients Still Hope, But Doctors See No More Therapeutic Options: Ethical Debates on Futility and Potentially... 19.1 Objectives 19.2 Case 19.3 Why Patients and Surrogates Demand Non-indicated Treatments 19.4 Why Doctors Reject Patients ́ or Surrogates ́ Potentially Inappropriate Treatment Requests 19.5 Medical Futility in the Discussion 19.6 A Process Model for Dealing with Requests for Potentially Inappropriate Treatment in a Clinical Context 19.7 Outlook References Chapter 20: Physician Aid in Dying in the United States: A Prescription for Death or Control? 20.1 Objectives 20.2 Case 20.3 Physician-Aid-In-Dying Laws: An Ongoing Ethical Debate 20.4 Legal Requirements: Qualified Patients and Reporting 20.5 Rational Suicide and the Role of the Psychiatrist 20.6 Opting In or Out: Healthcare Professional Conscience 20.7 A Timely Process? 20.8 Role of the Clinical Ethics Consultant 20.9 Conclusion References Chapter 21: Medical Aid in Dying in Canada: Undertaking Clinical Ethics Consultations in a Rapidly Evolving Regulatory Landsca... 21.1 Objectives 21.2 Case one - Quadriplegia, Treatment Refusal, and ``Natural ́ ́ Death 21.3 Introduction 21.4 Applying Eligibility Criteria 21.5 Case Two - Julia Lamb and Reasonable Foreseeability 21.6 Clinical Ethics Consultants and Conscientious Disagreements 21.7 Conclusion References Chapter 22: Physician Assisted Suicide and Euthanasia in the European Context 22.1 Objectives 22.2 Case Study: Dealing with a Suicidal Patient ́s Reported ``Wish to Die ́ ́ 22.3 Europe: A Continent with a Wide Range of Frameworks 22.4 Recent Development in Germany: Back to Tolerance? 22.5 The Very Particular Situation in Switzerland - Controversy About Guidelines 22.6 Ethics Consultation and Policies for Orientation 22.7 Outlook: Thorny Issues Persisting References Chapter 23: Pediatric Ethics Issues and Clinical Ethics Consultation in the United States 23.1 Objectives 23.2 Case One 23.3 Introduction 23.4 The Responsibility of Parents 23.5 Deciding for Children: Two Moral Concerns 23.5.1 Who Decides? 23.5.2 What Decisions Are Allowed? 23.6 Children Continue to Develop: Teenage Decisions Making 23.7 Conclusion References Chapter 24: Ethical Issues and Decision Making for Children: A European Perspective 24.1 Objectives 24.2 Case 1 24.3 Case 2 24.4 Introduction 24.5 Best Interests of the Child 24.6 Decision Making at the End of Life 24.7 Refusals of Life Saving Treatment by Minors 24.8 Conclusion References Chapter 25: The Adolescent Transplant Candidate: Thorny Issues in Assessment and Allocation 25.1 Objectives 25.2 Case One 25.3 Introduction 25.4 Timing of Transplant and Non-adherence as a Listing Factor 25.5 Marijuana and Other Behaviors in Transplant Candidacy Decisions 25.6 Adolescent Decision Making in Transplant Listing Decisions 25.7 Conclusions References Chapter 26: Classifying the Contradiction: A Practical Approach When Surrogates Appear to Contradict a Patient ́s Wishes 26.1 Objectives 26.2 Case 1 26.3 Case 2 26.4 Surrogate Decision-Making 26.5 Identifying the Source of Contradiction 26.6 Clarifying the Patient ́s Wishes 26.7 Establishing the Ethical Framework 26.8 Supporting Stakeholders 26.9 Conclusion References Chapter 27: Thorny Issues in Clinical Ethics Consultation: A Canadian Perspective on Surrogate Decision Making Concerning Pote... 27.1 Objectives 27.2 Case One 27.3 Informed Consent and Withholding and Withdrawing Life-Sustaining Treatment in Canada 27.4 Ethical Justifications for Overriding Surrogate Decision Making 27.5 Conclusion - A Morally Distressing Situation References Part IV: Introduction to Part IV: Organizational Issues in U.S. Ethics Consultation Chapter 28: Moving Ethics Upstream: Shifting Clinical Ethics Consultation from Volume to Value 28.1 Objectives 28.2 Case 28.2.1 Reactive Clinical Ethics Consultation Model 28.2.2 Proactive Clinical Ethics Consultation Model 28.3 Nature of the Problem 28.4 Constructing a Proactive Ethics Integration Model 28.4.1 Systematic Approaches and Standardized Resources 28.4.2 Identifying and Addressing Clinical Ethics Issues 28.4.3 Integrating into Existing and Emerging Clinical and Organizational Processes 28.5 Conclusion References Chapter 29: The Tension Between ``Margin and Mission ́ ́ as an Ethical Issue in Healthcare 29.1 Objectives 29.2 Case One 29.3 Can Clinical Ethics Help in Organizational Issues? 29.4 The Competing Identities of an Organization: Discerning an Ethical Resolution References "This book addresses new and evolving thorny issues in clinical ethics consultation. It is a book for our time. The contributors provide essential critical reflection on the standards and methods o training clinical ethics consultatnts as the field seeks to professionalize. This collection incorporates both North American and European experts, offering different perspectives on issues such as marginalized populations, the opioid epidemic, complex discharge, micro-managing families, and continually challenging issues at the end-of-life, such as determination of brain death, physician-assisted death, and futility. The authors engage the complexities of choosing for others when making decisions for incapacitated adults and pediatric patients. This volume engages with the growing literature in these debates and offers new perspectives from both academics and pracitioners. The readings are of particular interest to bioethicists, clinicians, ethics committees, and students in bioethics and beyond. These new essays advance discussions in the professionalization and certification of ethics consultatns and offer crucial insights on new and evolving thorny issues in the practice of clinical ethics consultation"--Back cover