Medical ethics need review

How decisions are made and communication is handled are essential to ensuring a good outcome.In the case of Scardoni v Hawryluck,1 Mrs H was an 81-year-old woman with advanced Alzheimer disease, cardiovascular illness, and septic shock whose family and physician could not agree on goals for care, requiring that a legal decision be made regarding the level of care to be provided. Over time and after much discussion, the multidisciplinary team on the intensive care unit (ICU) reached a consensus that intensive care for Mrs H would not improve her condition. So it was decided that after Mrs H was stepped down to a general medical unit, should an infection or respiratory distress develop, she would not be returned to the ICU. The attending ICU physician informed the family that instead of ICU care, “the hospital would offer her palliative care: painkillers and sedatives to keep her comfortable while her afflictions took their course.”2 In this particular case, the patient’s family challenged the health care team’s recommendations and insisted that their mother be readmitted to the ICU so that aggressive life-sustaining treatment would continue.This case, although Canadian, is relevant to ICU settings throughout North America. The purpose of this discussion is not to provide an in-depth ethical analysis, but rather to use the case of Mrs H to characterize one type of health care situation that clinical ethicists could help facilitate. Medical recommendations such as those involved in the care of Mrs H are made to prevent the “revolving door” patient, who according to ICU teams will receive no medical benefit if returned to the ICU. Decisions not to readmit are euphemistically referred to by some ICU staff as the “one-way ticket out of ICU” or “celestial transfer.” Such language shared between colleagues reflects a coping strategy, a “gallows humor,” intended to manage difficult feelings like sadness, anger, grief, sympathy, or moral distress. Cases like that of Mrs H are of particular concern to critical care nursing. Research has indicated that moral distress, a significant contributing factor to burnout, is encountered by ICU nurses when the care they are providing to a patient is regarded as futile.3It is not uncommon for hospital-based clinical ethicists to receive a request for consultation when disputes regarding similar recommendations for care arise between substitute decision makers and the ICU treatment team. These cases can lead to moral distress because of commonly held opinions among team members that futile treatment is being provided. Although staff can provide many life-sustaining treatments to such a patient, ethical questions often arise during the patient’s stay in the ICU. What ought to happen when an ICU team decides that a patient should be transferred to a general medical unit to receive comfort measures only, with no readmission to the ICU? Although teams discuss the practical questions about what can be done, the ethical questions about what ought to be done are sometimes not as clear. The following discussion explores how clinical ethicists can provide valuable assistance with the kinds of ethical challenges these situations customarily present. Particular emphasis will be placed on working within a process-driven, interdisciplinary framework that maintains a communication-oriented approach to ethical decision making.Clinical ethics is a relatively new field, and the role and purpose of clinical ethicists can vary somewhat according to the particular health care setting. For the purpose of this discussion, the authors describe the knowledge, skills, and activities of clinical ethicists through their review of relevant literature as well as their own training and experiences as staff clinical ethicists at 2 acute care settings in Ontario, Canada.Greater legal clarity or legislative measures to specifically address conflicts that arise over withdrawal or withholding of treatment for terminally ill patients are required, according to at least one legal expert. Current Canadian law, according to this same scholar, leaves doctors, patients and their families in a “grey zone” as to who should have ultimate authority on such decisions.4 The daily reality in most North American ICUs is that this gray zone persists—for better or worse. Although hospitals attempt to provide guidelines for addressing conflicts such as the one involving Mrs H, it is the quality of communication and relationship within the interdisciplinary team and between the treating team and the patient’s family that has a marked influence on decision making.5–7 In most cases similar to this one, consensus about level of care is first achieved by the interdisciplinary team, and a subsequent agreement is reached between the treatment team and the patient’s substitute decision maker and family. However, when agreement cannot be reached because of irreconcilable notions pertaining to what constitutes benefit to the patient and what constitutes harm, the results can be uncertain, stressful, and most unsatisfactory for both the health professionals involved and the patient’s family. This combination of an unfortunate turn of events for the patient, sharing of bad news with family members, and the recommendation for care outside of the ICU is a juncture of decision making at which conflict can occur and ethical challenges are most apparent to members of the interdisciplinary team.8,9Much has been written about the difficulties in communication within the ICU and how this affects patient care. Considerable evidence indicates that communication between the ICU team, patients, and patients’ families can be inadequate, leading to conflict and a possible long-term effect on the patient’s family.6,8,10,11 In one study,8 46% of families who had a loved one die in the ICU reported conflict over decisions to withdraw or withhold life-support measures. These family members also reported conflict over the manner in which staff communicated with or behaved toward them. The authors of that study8 cited family members who felt pressured by staff to “hasten their loved one’s death because they placed a burden on valued resources.” The importance of communication between treatment teams and patients and patients’ families cannot be overstated. In addressing the difficulties and deficiencies that have been identified, 2 experts concluded, “communication with caregivers is consistently identified as the most important and least achieved factor in patient/family satisfaction surveys.”12Intensive care is primarily intended to provide maximum benefit to those patients who are likely to recover from their infirmity or trauma.13 When the interdisciplinary team is not clearly communicating ethical considerations as well as the criteria they are using to determine the effectiveness or success of the treatment plan, patients’ families may develop erroneous expectations that life-sustaining interventions will continue to be offered.6 At the same time as a loved one is receiving ICU care with a grim prognosis, families are struggling to come to terms with impending loss. Family functioning or experience in coping with loss,14 unrealistic expectations regarding health outcome, within a societal context of diverse religious or cultural beliefs, can markedly influence families’ decision making about end-of-life care. Such formidable contributing factors further emphasize that effective communication strategies, as well as an appropriate level of sensitivity, ought to be used in ICUs when dealing with patients’ families.11Team communication, in particular communication between disciplines, also has proven problematic in decisions about end-of-life care in the ICU. Critical care nurses have cited difficulties in communication and decision making within interdisciplinary ICU teams. Ferrand et al15 reported that 75% of the nursing staff who participated believed that “collaboration was inadequate during decision making” despite general agreement that such team collaboration is necessary and desired. In another study,16 about one-third of the ICU nurses who participated felt “excluded by physicians from patient care decisions and felt their exclusion to be a detriment to patient care.”In terms of the burdens carried in making decisions about end-of-life care, some evidence suggests that physicians and nurses experience equal burdens. Physicians experience the burdens associated with having to make these decisions, and nurses feel the burden of having to carry out care decisions made by someone else.17 Given the shared burdens that members of the interdisciplinary team face, as well as the reported difficulties in end-of-life care decision making in the ICU, ensuring effective communication is a key feature of high-quality patient care.7 The following discussion is intended to demonstrate how clinical ethicists can be supportive of such strategies for effective communication and decision making.Medical recommendations like those pertaining to the care of patients such as Mrs H are based on best-practice standards of care and are informed by ethical principles like beneficence, nonmaleficence, and autonomy. Continued life-sustaining support in situations where benefit is in question can be regarded as futile, a concept with inherent ethical challenges. As Weijer et al18 point out, the values inherent in medical futility arguments often confuse treatment considered ineffective and treatment that will be effective but will ultimately result in a controversial outcome such as permanent unconsciousness. A team’s decision to not readmit a patient for ICU care can be an attempt to address futility based on controversial outcomes that the team may perceive as causing more harm for the patient than good. Poignantly stated, “if the welfare of the patient is the whole purpose of providing treatment and if that treatment brings needless suffering, then the whole purpose of medicine is defeated.”19 Although the concept of futility in ICU care is a subject worthy of ethical debate, it will not be the focus of this discussion. Rather, the subject of this discussion is the role of clinical ethicists in helping decision makers address ethical considerations such as futility.The results of inadequate communication, misunderstandings, or disagreements arising from divergent views about what is beneficent and the institutional realities surrounding resource allocation can be seen in the moral distress and subsequent moral residue experienced by both the patient’s family members and the health care staff involved. Moral distress occurs when a person can identify the ethically appropriate course of action, but does not feel able to carry this action forward because of barriers that may include lack of resources, legal limits, institutional obstacles, or imbalances in power, for example. Effects of moral distress on an individual can include feelings of anger, frustration, anxiety, or depression.20 Moral residue can be encountered when “deeply held beliefs, values and principles” are set aside at the expense of one’s personal sense of integrity.21 For families of patients, moral residue can manifest in lifelong memories about difficult health care experiences.The experience of moral distress and moral residue are of particular importance to critical care nursing. Some evidence indicates a relationship between an ICU care nurse’s perception of providing futile care, inadequate communication about the care plan within the interdisciplinary team, and the incidence of moral distress, emotional exhaustion, and burnout.3,16,22 Cases like that of Mrs H can present these kinds of challenges to nurses providing care at the bedside. The discussion also highlights how clinical ethicists can assist interdisciplinary teams in addressing ethical challenges that can lead to moral distress.Finally, the ethical climate within our health care settings is shaped by the organizational values inherent in hospital policies, approaches to handling conflict, allocation of human and material resources, the daily-lived experience of staff providing care, and those to whom care is provided.23,24 Economic constraints, resource allocation difficulties, and staffing shortages contribute to the moral climate of health settings, the moral distress of staff, and burnout among health care providers.25,26In cases such as that of Mrs H, the ethical challenges are not just about treatment requests considered inadvisable but also about scarce resources like ventilator-equipped beds in ICU settings. In the minds of some families, the need for an ICU bed is the primary reason that palliative measures are now being recommended. When conflict surrounds decisions about level of care, it is the bedside ICU nurse who fields the questions, concerns, and emotions expressed by patients’ families.It is through such challenging decision making, in which no agreement is reached, that the moral climate is regrettably defined for all persons with a stake in the decision. However oppressive these disagreements feel to both health care professionals and patients’ family members, most often the disagreements, ironically, do not result from a lack of good intentions on either side of the debate. Rather, these circumstances reflect the complex ethical challenges that are inherent in contemporary health care settings. Clinical ethicists can be an important resource to health care teams, patients, and patients’ families in addressing these difficult challenges.Clinical ethicists who provide consultative services may be requested by the ICU team when conflicts such as the one surrounding the planning of Mrs H’s level of care arise. What are the characteristics, skills, and knowledge that make clinical ethicists a useful resource in helping to address conflict over decisions about level of care for stable but critically ill ICU patients?Clinical ethicists come from a diverse background of training: clinical and academic experiences that include but are not limited to medicine, nursing, social work, theology, philosophy, and anthropology. Most clinical ethicists have advanced academic degrees and/or training in clinical ethics. Despite this diversity in background, clinical ethicists engage in common functions: consultative services, research, education and the development of policies pertaining to patient care and organizational ethics.27–29Clinical ethicists are trained to view ethical problems within an interdisciplinary health care environment whose primary commitment should always be to provide the best patient care possible. Patient care and goals for care are best understood through the wishes, beliefs, and values of the patient and the patient’s family. The approach taken by clinical ethicists in providing consultation is to model interdisciplinary collaboration and effective communication with patients and their families, with the objective of enhancing ethical decision making.28–30In effect, clinical ethicists in cases such as the one involving Mrs H act as facilitators of communication and decision making about goals for care, while directing attention to the ethical considerations underlying such decisions. Generally, clinical ethicists can help clarify differences in the way ethical considerations such as sanctity or quality of life are valued on the basis of religious, personal, or cultural values. Some evidence suggests that ethics consultation generally has been useful in preventing or resolving conflicts, and in reducing the incidence of prolonged controversial treatment.31,32 Current trends in the training and education of clinical ethicists have emphasized skills, knowledge, and expertise better suited to provide ethics support in real time as dilemmas and conflict around decisions related to patient care unfold.28What is particularly important about the approach used by most clinical ethicists is the emphasis placed on fair and just processes for decisions of such importance and consequence in an ICU environment.In cases such as the one involving Mrs H, it is not just what decision ought to be made that is of interest to clinical ethicists, but if and why a particular decision is ethically defensible. If so, to whom is it ethically defensible? How ought discussions and conflicts be managed? These questions raise ethical concerns about justice, fairness, and a reasoned approach to decisions of such consequence. Ethical consideration must also be given to the moral climate, how people feel treated, and the concerns and opinions of key persons with a stake in the decision making, with overarching consideration given to trust in the process used to make such important decisions. Therefore clinical ethicists are as concerned with procedural fairness as they are with outcome when assisting with ethically challenging situations in health care settings.Principal aspects of procedural fairness are as follows: that the process for decision making be as transparent as possible to all involved; that concerns of key persons with a stake in the decision making be considered; that the reasons or rationale behind decisions can be understood and defended; that people responsible for decisions be held accountable; and that in the event disagreement occurs, decisions can be reviewed, taking into account the concerns of those who disagree.33 Process-driven approaches to decision making or to resolving conflict used by clinical ethicists are dependent on using frameworks to guide communication. Such frameworks for communication are not just ethically defensible; they have been shown empirically to be part of good practice standards in ICU settings.6,11,34 Lilly et al35(pS398) found that using a standardized framework for communication resulted in health care providers seeing decision making as a “process rather than as an event”—an attribute consistent with principles for ethical decision making.An example of such a framework to guide communication is described by Lautrette et al,34 who identify such attributes as timeliness, opportunities for the patient’s family to speak, use of appropriate and sensitive language, and ensuring that the setting is private and comfortable. In addition to these attributes, clinical ethicists would include discussion of the values in conflict and ethical obligations that underscore decision making.Frameworks for communication appear well supported in the literature anyway, so what makes the involvement of clinical ethicists of added benefit?Despite advances in implementing communication strategies in many settings, improvement in general is needed in managing communication, enhancing understanding, and meeting needs of ICU patients and their families.6,8,10,11 Furthermore, Sherwin36 believes that communication frameworks and hospital policies can be used coercively, to enforce a particular outcome, if those who lead these discussions or who adhere to policies are not reflecting on personal biases, institutional pressures, and ethical considerations.Clinical ethicists act as facilitators, helping to raise important ethical questions, model effective communication, and model ethical decision making by using teachable moments to heighten the awareness and understanding of the ethical considerations in each case. Within most health care settings, necessary and unavoidable imbalances in power are present between various persons who have a stake in the decision making. Clinical ethicists assist in discussing the values that underlie decisions of such importance, making these transparent to and understood by key involved parties. They model the principles of procedural fairness. Inherently challenging decisions about level of care, as in the case of Mrs H, are often met with challenging feelings and opinions, making fairness and ethical reflection more important than less to involved parties.Clinical ethicists advocate for policies and practices that reduce coercive consequences that can arise when members of the ICU treatment team, patients, or patients’ family members feel overruled or dismissed. In conducting an ethics consultation, the clinical ethicist leads discussions with the interdisciplinary team members about ethical considerations that contribute to moral distress, for example, the conflict in the way benefit and harm associated with a particular therapy or level of care are understood. In most instances, the clinical ethicist must ensure that concerns raised by members of the interdisciplinary team and concerns expressed by patients’ family members are shared and considered. This process is handled in an open and transparent manner. In creating an opportunity through the consultative process for the interdisciplinary team to address concerns, related to both areas of conflict and moral distress, clinical ethicists are also capitalizing on valuable teachable moments in which knowledge about ethics and decision making can be enhanced. As Kälvemark Sporrong et al37(p835) concluded, “Ethical competence is a key factor in preventing or reducing moral distress.”We have found that consultation on an individual case often helps treatment teams identify preventative strategies to reduce or avoid conflict and to engage in more timely discussion about ethics the next time a complex care situation arises. Such measures are necessary in creating a moral climate in which discussion about ethics in daily practice can be supported and thus reducing the effects or incidence of moral distress. The potential exists for all members of the interdisciplinary ICU team, including the most responsible physician, to be so engaged in ethical reflection and decision making on challenging cases. Clinical ethicists model skills of effective communication, ethical reflection, and decision making as well as principles of procedural fairness within the consultative process that they facilitate.We are not suggesting that effective communication, procedural fairness, ethical reflection, and decision making are deficient whenever clinical ethicists are not involved in such cases. In reality, complex and ethically challenging cases occur routinely in ICU settings, most often without the involvement of clinical ethicists. What is being proposed is that clinical ethicists should be seen as a valuable resource for addressing challenging cases in the ICU. Better understanding is needed about the role of clinical ethicists and the kinds of assistance they can provide.In most cases, the ICU team and patient’s family agree on recommendations that comfort measures be provided on a medical intermediate care unit or a palliative care unit for a stable but critically ill patient. However, as in the case of Mrs H, these decisions may be met with considerable emotion from the patient’s family and with differences of opinion about benefit and the appropriate level of care. We think that clinical ethicists can be a valuable resource when challenging cases arise. By providing consultation, clinical ethicists can model effective communication, ethical reflection, and decision making, while following principles of procedural fairness, all of which are key elements to upholding ethics in daily practice and are of particular importance when conflict occurs about level of care in the ICU.The following are practical considerations for critical care nurses:

John Gregory (1724–73) wrote the first modern, professional medical ethics in the English language, appearing as Lectures on the Duties and Qualifications of a Physician in 1772. This paper examines Gregory’s medical ethics as a blend of modern methods of medical science and ethics with premodern ideas. The paper begins by situating Gregory’s medical ethics in the context of both private medical practice and the care of patients at the Royal Infirmary of Edinburgh, focusing on the crisis of intellectual and moral trust that prompted Gregory to lecture and write on medical ethics. Drawing on the modern methods of Francis Bacon’s philosophy of medicine, and David Hume’s science of morals, Gregory bases his medical ethics on the complementary capacities of openness to conviction and sympathy. His moral exemplars of the virtues of candour, steadiness, and tenderness were women of learning and virtue, reflecting the premodern idea of chivalry in the life of service to the sick.

Medical law and ethics are frequently referred to in conjunction, and appear together in many textbooks. But do they combine to form a cohesive unit, and do they benefit each other? It may be argued that they do not, but rather suffer a symbiotic relationship, clashing rather than cooperating. This book examines this relationship, and how the law sees medical ethics. It then considers whether medical ethics functions in the way that the law thinks that it does. After providing a historical perspective that identifies medical ethics discourse as disjointed and fragmented, the book continues by examining key medico-legal case law and reports that have an inherent ethical content for clues as to how they define medical ethics and its role. It also considers how medical ethics sees the law, concluding that a misapprehension by each party as to what the other does creates a mutually harmful relationship between them.

The University of Chicago Pritzker School of Medicine has developed and evaluated an extensive teaching program in clinical ethics coordinated primarily through the Center for Clinical Medical Ethics. The program provides medical students with a foundation in medical ethics during the four years of medical school and augments the clinical ethics knowledge and teaching skills of the housestaff and clinical faculty at the University of Chicago. Together, medical student teaching and clinical faculty development have made clinical ethics an integral part of medical education at the University of Chicago. Through these efforts, the teaching program aims to incorporate clinical ethics considerations into medical decisions and in this way contribute to improving patient care. (A detailed overview of all clinical ethics instruction at the school is provided.)

The evolution of Islamic medical ethics codes and treatises began with the akhlāq and adab treatises, followed by the codes developed by the Islamic Organization for Medical Sciences (IOMS). Akhlāq and adab approximate the meaning of ethics. Akhlāq refers to one’s character, while adab literally means civility or etiquette and refers to norms of right conduct, which are often understood as “one’s disposition as formed by habit.” Though an official code of ethics was absent in the early years of Islam, a small group of conscientious physicians, concerned with the quality of medical care and the reputation of their profession, provided guidelines for individual physicians’ professional behavior. These include Adab–al Ţabīb (The Practical Ethics of the Physician), the Akhlāq -al-Ţabīb (Medical Ethics), and al-Qānūn Fi’l-Tibb (Canon of Medicine). Other important ethics codes include the Islamic Code of Medical Ethics, the International Islamic Code for Medical and Health Ethics, and the Islamic Code of Medical and Health Ethics.

Dear Editor, Medical ethics is an interdisciplinary concept, which deals with ethical issues in medical sciences. Medical ethics can be defined as “Respecting principles and values in medical decisions concerning public health”.1 Dramatic changes have been made in medical ethics after development in medicine, technology, and ethical issues. Currently, the evaluation of science production is very important because it can create a scientific competition in different fields at the international level. Scientometrics can present a clear image of growth and development in different sciences. Continuous evaluation of science production in medical ethics and utilizing the results, would ultimately lead to its improvement. Many studies have shown that despite the importance of medical ethics, the results obtained through scientometric studies have not been applied in this field.2-5 Therefore, the main objective of the present study was to evaluate the status of science production in the field of medical ethics. Thomson Reuters database was searched to find any scientific product related to medical ethics published during 1990-2010. Various document types such as Articles, Editorials, Book Reviews, Proceeding papers, and Review Articles in which the subject of “medical ethics” was reflected in the title, abstract, or keywords were selected. The data were analyzed using HistCite software, version 12.03.17 (developed by Eugene Garfield at Thomson Reuters Institute, USA). The most (6.95%) and the least (0.86%) number of articles in medical ethics was published in 2009 and 1992, respectively. The average growth rate of publications during 1990-2010 was 65.98%. Total Local Citation Score (TLCS) and Total Global Citation Score (TGCS) indicated that most of the documents were related to fields other than medical ethics. This means that journals related to medical ethics had fewer numbers of articles on medical ethics in comparison with other journals. McCullough was the top producer who had written 31 (1.02%) articles in medical ethics. Totally, researchers from 82 countries had published articles related to medical ethics. The United States, England, and Germany were ranked first to third. The United States and England had produced 51.3% of all publications. An evaluation of the publications showed that they were presented in 14 different types. Most of the publications were produced in Article format with high TGCS and TLCS rates. The Editorials and Book Reviews were ranked second and third. The publications were written in 15 languages. English, German, and French were ranked first to third, respectively. A comparison between TLCS and TGCS revealed that most of the citations were related to other fields. A few citations were devoted to medical ethics which was not unexpected because of the limited number of documents (3035 documents). The general impact factor illustrated that the articles of this field had a high average citation, which indicated that there was a close relationship between the articles related to this field and the other fields. The most productive authors had a high local impact factor and according to their records, their local impact factor was higher than total local impact factor. All of the documents were published in 901 journals among which “Journal of Medical Ethics” had published 290 articles (9.55%) and it was ranked first. The existence of different journals with different scopes indicates that medical ethics is an interdisciplinary subject and the researchers of other fields are interested in this specialized field. Articles of this field have an increasing growth rate and the present study indicates greater participation of the science community in medical ethics publishing. However, the number of citations does not have a uniform growth rate. This could be due to the small size of this field and its association with other small fields. The global distribution of the papers and their language variations signify the global concerns for medical ethics. Moreover, linguistic, geographic, and publication type diversity of the published articles indicate a sustainable development in this field.

University of Chicago, Chicago, Illinois. pangelos@surgery.bsd.uchicago.eduEdited by Gail A. Van Norman, M.D., Stephen Jackson, M.D., Stanley H. Rosenbaum, M.A., M.D., and Susan K. Palmer, M.D. New York, Cambridge University Press, 2011. Pages: 318. Price: $66.00.When one thinks of the ethical issues in the care of patients today, the issues specific to anesthesiology may not immediately rise to the top of the list. Nevertheless, Clinical Ethics in Anesthesiology: A Case-based Textbook is an important book that deserves a place on the shelf of both practicing anesthesiologists and those with a scholarly interest in ethics. This is a multi-authored text edited by four well-respected anesthesiologists.The book is divided into six sections that address both important topics for medical ethics (considered broadly) and specific topics of particular relevance to the specialty of anesthesiology: consent and refusal; end-of-life issues; pain management; research and publication; practice issues; and anesthesiologists, the state, and society. Each chapter begins with a specific case that focuses the issue squarely in the context of anesthesiology. The chapters are well-organized, with helpful subheadings of important concepts as well as a table of “key points” at the end of every chapter and a series of references for further reading.Although one might initially question the need for another text devoted to the ethical issues of a particular specialty, I believe this book fills an important niche. No one would argue that the issues raised in the book are unique to anesthesiologists alone. However, I would argue that a volume such as this is critical for anesthesiologists to understand the ethical implications of some of these topics for their specialty. For example, although it might not be evident to all why the topic “informed consent for preoperative testing” should be included in such a text, Van Norman clearly makes the case in her chapter on this subject that this is a central issue for an anesthesiologist to consider. In the case provided, a 15-yr-old girl is about to undergo an elective diagnostic arthroscopy for pain and swelling. The patient, accompanied by her mother, denies being sexually active. However, the anesthesiology group that covers this hospital requires pregnancy testing before elective surgery in female patients. Once the pregnancy test comes back positive, the anesthesiologist is faced with a series of difficult issues. For example, state law forbids disclosing that information to anyone other than the patient, but the mother will likely suspect the finding if the case is canceled. In addition, state law requires reporting this finding to Child Protective Services as evidence of sex with a minor. Van Norman thoughtfully considers these topics along with others, such as assessing the evidence to support any routine preoperative testing.This is just one example of the manner in which the authors of the chapters are able to bring important ethical considerations into case contexts that are familiar to anesthesiologists. There is ample suggestion in the text that ethical decisions in anesthesiology cannot and should not be made in isolation from other medical and surgical disciplines. However, the overarching theme is that the anesthesiologist must also be aware of, and integrally involved in, the ethical decision-making around many important clinical topics.Although scholars of clinical medical ethics will not find new and groundbreaking information in this text, it is nevertheless an important book for this group as well. In order to make the case that ethical discussion is important for all medical disciplines, there must be examples that resonate with many different practitioners. As a surgeon, I see significant overlap between the ethical issues in anesthesiology and in surgery, yet when I present ethics cases to residents and fellows, I invariably focus on the ethical issues for the surgeon. The focus and perspective taken on any topic in ethics will alter the extent to which a particular specialist might see the case and the topic as relevant.Although there is room for discussion and disagreement about how truly distinct the ethics of anesthesiology should be from, for example, the ethics of surgery, there should be no disagreement over the importance of addressing ethical issues from the perspective of specific disciplines. Such focused considerations make clear that the field of clinical medical ethics requires attention from all specialties in medical practice.

Purpose This study aims to diagnose the transformation of ethics into procedural compliance within institutional contexts and to propose a practice-oriented reconstruction termed “Real Ethics,” which preserves moral deliberation while maintaining essential safeguards, using clinical and AI ethics as emblematic cases within a broader institutional analysis. Design/methodology/approach The research employs a conceptual analysis informed by the works of Weber, Habermas, MacIntyre, Taylor, Tronto and Foucault, in conjunction with selected literature from clinical ethics, Institutional Review Boards, public health and artificial intelligence (AI) governance. Findings The findings indicate that institutional ethics frequently transitions from reasoned judgment to a focus on auditability and risk management, resulting in moral outsourcing, epistemic exclusion and moral distress. While procedural tools are crucial, they must serve as adaptable scaffolds firmly rooted in deliberative processes. Originality/value This study offers a unified institutional diagnosis of the proceduralization of ethics across multiple professional fields drawing on clinical and AI ethics as paradigmatic cases and presents actionable design principles for sustaining ethical agency across diverse institutional contexts.

For fifteen years no national ethics committee has matched the quality and value of the work of the U.S. President's Commission. Its analyses and guidance remain some of the most useful in bioethics. The need to continue to produce such work is widely recognized. In Europe various countries have set up various types of committee, but none has yet had the same impact. The closest is probably the French national committee, which has produced nearly forty guidance notes (Avis) in the last decade. Within France they have had a considerable impact and, in some cases, have led to changes in the law. But any wider influence that the committee might have is prevented by the French language law, which requires that all official documents only be published in French. There are other national committees--in Denmark and Italy, for instance. The Danish Council of Ethics has taken the need for public consultation very seriously and reaches a large portion of the Danish population, particularly school children. But the council's analyses of ethical dilemmas have not so far attracted much attention outside the country. Those of the Italian committee have had even less influence, probably because the government appointed so many committee members to represent every possible sectarian interest that the committee cannot function. The need for a committee in the United Kingdom--indeed for two committees, one for medical ethics generally, and one for medical research ethics--has long been recognized. The creation of either has, however, been effectively stymied by the medical officers at the Department of Health who advise ministers. For some curious reason--perhaps because they think it helps to keep discussion of medical ethics centered within the medical profession--they have ensured for two decades that British governments do the least possible about medical ethics dilemmas. Research ethics committees (the U.K. equivalent of IRBs), for instance, struggle to function because the Department of Health refuses to mandate any support for them, either funding or training. On average they review eighty research proposals each year, yet some have to do so without any budget. Other bioethics issues are dealt with in an ad hoc fashion, as late in the day as possible. Bob Edwards, the driving force behind the development of in vitro fertilization, asked for consideration of the law and ethics of assisted reproduction as early as 1969. Yet the Human Fertilization and Embryology Act only came into force in 1990, twelve years after the first test tube baby was born. This September afforded another splendid example of last-minute ad hockery. …

In 1972, soon after I started the first medical intensive care unit (MICU) at the University of Chicago, a unit whose patients raised multiple, serious ethical issues, I created the new field of Clinical Medical Ethics (CME) in the Department of Medicine at the university. In my view, both in 1972 and today, CME is an intrinsic part of medicine, surgery and all medical disciplines, and is not a branch of bioethics or philosophical ethics or legal ethics or theoretical ethics. Rather, it is a central component of clinical care that must be practiced and applied by licensed clinicians in their routine, daily encounters with patients. Although bioethicists may provide theoretical insights to clinicians, bioethicists cannot practice medicine or examine patients or provide care to patients. During the past 49 years, CME has become a transformative field in medicine and surgery that aims to improve both the clinical and ethical quality of care and outcomes that clinicians provide their patients (Singer et al., BMC Med Ethics 2:1, 2001). In ordinary clinical practice, CME addresses many clinical ethical issues, including truth-telling, informed consent, confidentiality, surrogate decision-making, the risks, benefits and alternatives to surgical or medical procedures, end-of-life care, and also encourages personal, humane, compassionate, and fair interactions between doctor and patient.The goals of CME are to improve patient care and outcomes by helping physicians, surgeons and other health professionals identify and respond to clinical-ethical challenges that arise in the ordinary care of patients. As Edmund Pellegrino, Peter A. Singer and I wrote 30 years ago: “The central goal of CME is to improve the quality of patient care by identifying, analyzing and contributing to the resolution of ethical problems that arise in the routine practice of clinical medicine” (Siegler et al., J Clin Ethics 1:5–9, 1990). Similar to cardiology and oncology consultations, ethics consultations are a small component of a much larger field, just as the consultations in cardiology and oncology or CME are certainly not at the core of cardiology, oncology or Clinical Medical Ethic.This article will discuss the following five topics: the origins of the field of CME; the goals and methods of CME; the relationship between the larger field of CME and the narrower practice of ethics consultations; the contributions of the MacLean Center at the University of Chicago in developing the fields of Clinical Medical Ethics; and how CME has improved the practice of medicine and surgery (Siegler, J Clin Ethics 30:17–26, 2019).KeywordsClinical Medical EthicsMacLean Center for Clinical Medical EthicsDoctor-patient accommodationShared decision-makingTruth-tellingInformed consentConfidentialitySurrogate decision-making

BackgroundThere is continued need for enhanced medical ethics education across the United States. In an effort to guide medical ethics education reform, we report the first interprofessional survey of a cohort of graduate medical, nursing and allied health professional students that examined perceived student need for more formalized medical ethics education and assessed preferences for teaching methods in a graduate level medical ethics curriculum.MethodsIn January 2018, following the successful implementation of a peer-led, grassroots medical ethics curriculum, student leaders under faculty guidance conducted a cross-sectional survey with 562 of 1357 responses received (41% overall response rate) among students enrolled in the School of Medicine, College of Nursing, Doctor of Physical Therapy and BS/(D) MD Professional Scholars programs at The Medical College of Georgia at Augusta University. An in person or web-based questionnaire was designed to measure perceived need for a more in-depth medical ethics curriculum.ResultsThe majority of respondents were female (333, 59.3%), white (326, 58.0%) and mid-20s in age (340, 60.5%). Almost half of respondents (47%) reported no prior medical ethics exposure or training in their previous educational experience, while 60% of students across all degree programs reported an interest in more medical ethics education and 92% noted that an understanding of medical ethics was important to their future career. Over a quarter of students (28%) were interested in pursuing graduate-level training in medical ethics, with case-based discussions, small group peer settings and ethics guest lectures being the most desired teaching methods.ConclusionsThe future physician, nursing and physical therapist workforce in our medical community demonstrated an unmet need and strong interest for more formal medical ethics education within their current coursework. Grassroots student-driven curricular development and leadership in medical ethics can positively impact medical education. Subsequent integration of interprofessional training in medical ethics may serve as a vital curricular approach to improving the training of ethically competent healthcare professionals and overcoming the current hierarchical clinical silos.

BackgroundAs the practice of medicine inevitably raises both ethical and legal issues, it had been recommended since 1999 that medical ethics and human rights be taught at every medical school. Most Nigerian medical schools still lack a formal undergraduate medical ethics curriculum. Medical education remains largely focused on traditional medical science components, leaving the medical students to develop medical ethical decision-making skills and moral attitudes passively within institutions noted for relatively strong paternalistic traditions.In conducting a needs assessment for developing a curriculum germane to the Nigerian society, and by extension most of Sub-Saharan Africa, this study determined the views of Nigerian medical students on medical ethics education, ethical issues related to the doctor-patient relationship and the ethical/professional dilemmas they are confronted with.MethodsUsing self-administered 63-item structured questionnaires, a cross-sectional survey of the final year medical students of the University of Nigeria was conducted in July 2015.Using the Statistical Package for the Social Sciences software (SPSS Version 17), frequency counts and percentages were generated.ResultsThe sample included 100 males (71.4%) and 40 females (28.6%), with the respective mean (SD) age being 24.6(5.61) and 21.8 (6.38) years. Only 35.7% were satisfied with their medical ethics knowledge, and 97.9% indicated that medical ethics should be taught formally. Only 8.6% had never witnessed a medical teacher act unethically. The dilemmas of poor communication between physicians and patients, and the provision of sub-standard care were reported highest for being encountered ‘often’. A majority (60.7%) indicated that “a doctor should do his best always, irrespective of the patient’s wishes”. No significant difference in responses across gender was noted.ConclusionThere is a strong desire by the contemporary Nigerian medical student for medical ethics education. Their lack of exposure in medical ethics in an ethically challenging environment suggest a dire need for the development of an appropriate medical ethics curriculum for them and the provision of an ethically conducive learning environment.

Reviewed by: The Cambridge Handbook of Human Dignity: Interdisciplinary Perspectives ed. by Marcus Düwell et al. Alfred I. Tauber The Cambridge Handbook of Human Dignity: Interdisciplinary Perspectives Edited by Marcus Düwell, Jens Braarvig, Roger Brownsword, and Dietmar Mieth. Cambridge: Cambridge University Press, 2014. Pp. 629. $145 (cloth). Globalization, at least for advanced societies, has resulted in what is essentially a single medical-industrial complex developed within a highly integrated collaborative bioscience. Yet one of the key differences within that complex hinges on whether or not health care is a right. Health care in the United States is dominated by an individual-based consumer model, while most European nations and Canada have adopted a communal responsibility for clinical care. This fundamental opposition is reflected in medical ethics characteristic of each system. A so-called “new bioethics” originating in Europe has been proposed to balance the autonomy-based approach dominant in the American system with a schema based on human dignity (Beyleveld and Brownsword 2001). How such a recalibration might affect American bioethics is uncertain, but such discussions reflect the ongoing evolution of American medical ethics from its original commitments to individual autonomy to more pluralistic formulations. [End Page 560] A Moral Dichotomy? Extrapolating from case law, commentators have noted how autonomy became the lynchpin of medical ethics in the United States. In the post–World War II era, the basis of informed consent underlies the doctor-patient relationship, and in the opinion of many American bioethicists, autonomy thus trumps other ethical principles (such as beneficence, justice, and non-maleficence) (Annas 1989). When placed in the wider context of American political culture, the dominance of individual choice as a guiding politico-economic principle is reflected in the consumer model of health insurance, and that ethos also stretches beyond the commodification of health care to autonomy-based models of medical decision-making. Indeed, critics assert that medical ethics in its autonomy-oriented posture has been coopted by the very institutions ethicists once sought to criticize and transform. For example, Haliburton (2015) charges that an ironic reversal has taken hold: “The mainstreaming of bioethics has resulted in its domestication: it is at home in the institutions it would once have viewed with skepticism, and a central part of practices it would once have challenged” (3). On this view, autonomy has not only been transgressed, it actually serves heteronomy. In contrast, Europe and Canada place less credence in autonomy as a governing precept, both in the domain of health-care services (universal access is a right of citizenship) and as a governing tenet of medical practice. According to the dominant European point of view, where autonomy is compromised—as in the setting of illness—patients need to be protected, and so dignity, integrity, and vulnerability become guiding, protective values (Beyleveld and Brownsword 2001). In sum, respect for patient autonomy becomes only one of several values in the calculus of care. Communal responsibilities—conceived in terms both of individual patient care and of the larger socioeconomic context of institutional and governmental accountability—take priority (Parizeau 2000). These putative differences in moral attitudes reflect deeply held cultural standards. Medical ethics was born as a formal discipline in the late 1960s, and the initial concerns of American ethicists reflected complex social factors, all of which seemed to converge on a newly activated suspicion of authority (Jonsen 1998). In parallel with the loss of trust in government, education, and business, critics identified instances of patient abuse and unwarranted physician paternalism that demanded redress. If the ancient moral philosophy governing the doctor-patient relationship had become suspect, then a defensive posture that would assure patient rights was required. Thus a newly articulated medical ethics sought to build on an assumed beneficence, but one fortified with a new demand concerning the respect of patient autonomy in the guise of informed consent (Tauber 2005). The dominant voices advocated patient autonomy, not only because it was the most easily extrapolated from a rights-based politico-judicial culture, but also because it best captured what was missing: trust. From this cultural perspective, medical ethics is one piece of the deep moral crisis Americans continue to face. Medical ethics, and patient...

Abstract. Parker M, Hope T (Institute of Health Sciences, Headington, Oxford, UK). Medical ethics in the 21st century. J Intern Med 2000; 248: 1–6.Objectives. To foresee how medical ethics may develop in the 21st century.Design. We have looked into our crystal ball to see what factors are likely to drive medical ethics over the next few decades. We have given examples of how such factors might affect specific issues.Results. Those factors that we identified as likely to shape the future of medical ethics are: Globalization. Medical ethics is likely to have to grapple increasingly with ethical issues arising from the huge discrepancies in the level of health care available in different countries. Increase in longevity. We predict that there will be, at least amongst the richer nations, a significant increase in life expectancy. This will result in issues of resource allocation becoming increasingly problematic within medicine. Child enhancement. Developments in genetics combined with control of reproduction will make it possible to select our children for a broad range of characteristics. There are optimistic and pessimistic predictions as to how such power will be used. In either case, this area will be an important focus of concern in medical ethics. The biological determination of behaviour. Genetic research will lead to an increasing sense that undesirable behaviour is genetically determined. This will lead to a re‐examination of such concepts as criminal responsibility. Therapeutic research and clinical practice. We predict that an increasing amount of clinical practice will be within the setting of clinical trials. The ethics of therapeutic research and clinical practice will need to be brought within a coherent framework.

Medical ethics is important for every medical practitioner. A doctor should acquire sound knowledge on medical ethics which is very much important in clinical practice. Medical ethics is a system of moral principles that apply values and judgments to the practice of medicine. Medical ethics derive from numerous sources. Physicians face ethical dilemmas more frequently as community relies on physicians for critical services. Ethics are a useful element for solving these dilemmas. Medical ethics based on four basic principles: autonomy, beneficence, nonmaleficence and justice. Physicians are expected to have higher standards than the law. The code of medical ethics provides a guide line in the context of doctor patient relationship and the society.
 JCMCTA 2016 ; 27 (2) : 9 - 11