George Agich

In March 1997, 60 Minutes, a nationally syndicated news magazine program, featured a story in which it was claimed that The Cleveland Clinic Foundation had in place a non-heart-beating donor protocol that involved killing patients for their organs. These charges were brought by a philosopher from a local university. A student who worked at LifeBanc, the northeastern Ohio organ procurement agency where the organ donation protocol originated, was given the protocol by LifeBanc with the understanding that it was to be used in class; the student and professor charged that the protocol involved killing patients for their organs. These claims were advanced without noting that the protocol was a draft that was being reviewed and revised and had not been implemented.

The bioethics literature on managed care has devoted significant attention to a broad range of conflicts that managed care is perceived to have introduced into the practice of medicine. In the first part of this paper we discuss three kinds of conflict of interest: conflicts of economic incentives, conflicts with patient and physician autonomy, and conflicts with the fiduciary character of the physician–patient relationship. We argue that the conflicts are either not as serious as they are often alleged to be or not unique to managed care. In part two we argue that managed care represents a new paradigm for medical care that features a new concept of management. We discuss three types or levels of management that managed care highlights, namely, administrative, clinical, and resource, which together offer a more sophisticated vantage point from which to assess patient care. We do not endorse managed care, but attempt to highlight some of the positive changes brought by managed care that were difficult to attain under traditional reimbursement systems

Background: In the USA, the Food and Drug Administration waiver of informed consent permits certain emergency research only if community consultation occurs. However, uncertainty exists regarding how to define the community or their representatives.Objective: To collect data on the actual preferences and values of a group—those at risk for stroke—most directly affected by the waiver of informed consent for emergency research.Design: Face to face focused interviews were conducted with 12 patients who were hospitalised with a stroke diagnosis in the previous year. The interviews were audiotaped and a transcript based method was used for their analysis.Results: All 12 participants felt “that it was important that new treatments for stroke be developed”, but they were initially confused about the distinction between “research for stroke” and “emergency research for stroke”. However, after explanation, most expressed willingness to participate in the latter. In the absence of a surrogate to give informed consent in a stroke emergency situation, the majority said they would want the physician to “go ahead and enrol them in the trial”.Conclusions: This study is the first to identify the values and concerns of individuals most directly affected by stroke emergency research. Further interviews and focus groups are needed to develop and test a validated questionnaire on the preferences and values surrounding emergency research for stroke.

Free and informed consent is generally acknowledged as the legal andethical basis for living organ donation, but assessments of livingdonors are not always an easy matter. Sometimes it is necessary toinvolve psychosomatics or ethics consultation to evaluate a prospectivedonor to make certain that the requirements for a voluntary andautonomous decision are met. The paper focuses on the conceptualquestions underlying this evaluation process. In order to illustrate howdifferent views of autonomy influence the decision if a donor's offer isethically acceptable, three cases are presented – from Germany, theUnited States, and India. Each case features a person with questionabledecision-making capacity who offered to donate a kidney for a siblingwith severe renal insufficiency. Although the normative framework issimilar in the three countries, different or sometimes even contraryarguments for and against accepting the offer were brought forward. Thesubsequent analysis offers two explanations for the differences inargumentation and outcome in spite of the shared reference to autonomyas the guiding principle: (1) Decisions on the acceptability of a livingdonor cannot simply be deducted from the principle of autonomy but needto integrate contextual information; (2) understandings of the wayautonomy should be contextualized have an important influence on theevaluation of individual cases. Conclusion: Analyzing the conceptualassumptions about autonomy and its relationship to contextual factorscan help in working towards more transparent and better justifieddecisions in the assessment of living organ donors.

This article is an attempt to clarify a confusion in the brain death literature between logical sufficiency/necessity and natural sufficiency/necessity. We focus on arguments that draw conclusions regarding empirical matters of fact from conceptual or ontological definitions. Specifically, we critically analyze arguments by Tom Tomlinson and Michael B. Green and Daniel Wikler. which, respectively, confuse logical and natural sufficiency and logical and natural necessity. Our own conclusion is that it is especially important in discussing the brain death issue to observe the distinction between logical and natural sufficiency/necessity in a strict fashion.

This paper discusses the importance of Richard M. Zaner’s work on clinical ethics for answering the question: what kind of doing is ethics consultation? The paper argues first, that four common approaches to clinical ethics – applied ethics, casuistry, principlism, and conflict resolution – cannot adequately address the nature of the activity that makes up clinical ethics; second, that understanding the practical character of clinical ethics is critically important for the field; and third, that the practice of clinical ethics is bound up with the normative commitments of medicine as a therapeutic enterprise.

Dr Agich takes up a previous difficult case related by Dr Kottow in an earlier issue of the Journal. He analyses the three ethical problems as presented in the case and offers his own opinion of it as well as his own conclusions with regard to the medical ethical aspects of it. Unlike Dr Kottow, Dr Agich's reading of the case indicates that the application of the principle of informed consent does not rule out ethical decisions for the physician, but emphasizes the relevance of ethical analysis beyond the issue of informed consent.

Thomasma and Pellegrino's [3] focus on the healing relationship as the way to give medical ethics a philosophical foundation contains a number of difficulties. Most importantly, their approach focuses philosophical analysis on an idealized view of the healing relationship in which the ideal of health is seen as an uncontroversial norm in the individual case. medical ethics is then characterized as ‘an intrinsic part of the medical act itself’. Philosophical inquiry seems limited to a description of the practice of medicine in which ethical norms are embodied. Insufficient attention to methodology leaves unclear how this vision is to be achieved in philosophical reflection.

This paper argues that the concept of management is critically important for understanding managed care. A proper interpretation of management is needed before a positive account of the ethics of managed care can be constructed. The paper discusses three aspects of management: administrative, clinical, and resource management, and compares the central commitments of traditional medical practice with those of managed care for each of these aspects. In so doing, the distinctive conceptual features of the managed care paradigm are discussed. The paper concludes by arguing that the concept of management implicit in the managed care paradigm affords a basis for building a more adequate ethic of managed care.

Thomasma and Pellegrino''s [3] focus on the healing relationship as the way to give medical ethics a philosophical foundation contains a number of difficulties. Most importantly, their approach focuses philosophical analysis on an idealized view of the healing relationship in which the ideal of health is seen as an uncontroversial norm in the individual case. medical ethics is then characterized as an intrinsic part of the medical act itself. Philosophical inquiry seems limited to a description of the practice of medicine in which ethical norms are embodied. Insufficient attention to methodology leaves unclear how this vision is to be achieved in philosophical reflection.

This paper offers an exposition of what the question of method in ethics consultation involves under two conditions: when ethics consultation is regarded as a practice and when the question of method is treated systematically. It discusses the concept of the practice and the importance of rules in constituting the actions, cognition, and perceptions of practitioners. The main body of the paper focuses on three elements of the question of method: canon, discipline, and history, which are treated heuristically to outline what the question of method in ethics consultation fully involves.

This article discusses the approach of the Clinical Ethics Consultation Advisory Committee (CECA) in developing A Case-Based Study Guide for Addressing Patient-Centered Ethical Issues in Health Care. This article addresses the processes used by the CECA, its use of pivot questions intended to encourage critical reflection, and the target audience of this work. It first considers the salience of case studies in general education and their relevance for training ethics consultants. Second, it discusses the enfolding approach used in presenting the case material designed to engage the trainee in the details of the case while stimulating critical reflection. And, third, this article briefly comments on the target audience with the caveat that even superbly developed cases are prone to misuse, although that prospect should not deter their development.

This article accepts the proposition that old people want to be treated with dignity and that statements about dignity point to ethical duties that, if not independent of rights, at least enhance rights in ethically important ways. In contexts of policy and law, dignity can certainly have a substantive as well as rhetorical function. However, the article questions whether the concept of dignity can provide practical guidance for choosing among alternative approaches to the care of old people. The article explores the paradoxical relationship between the apparent lack of specific content in many conceptions of dignity and the broad utility that dignity appears to have as a concept expressive of shared social understandings about the status of old people.

Central to much medical ethical analysis is the concept of the role of the physician. While this concept plays an important role in medical ethics, its function is largely tacit. The present paper attempts to bring the concept of a social role to prominence by focusing on an historically recent and rather richly contextured role, namely, that of consultation liaison psychiatry. Since my intention is primarily theoretical, I largely ignore the empirical studies which purport to develop the detailed functioning of the role. My limited intent is to draw attention to the theoretical complexity of the consultation liaison role as an example of the general relevance of role concepts to medical ethics. For this reason, consultation liaison psychiatry will function as an illustration of fundamental concepts of medical ethics rather than as a subject of analysis in its own right. Similarly, the concept of the social role will be developed only as is necessary to explore the general relationship between the consultation liaison role and ethical analysis. Keywords: medical ethics, consultation liaison psychiatry, social role, autonomy, institution CiteULike Connotea Del.icio.us What's this?

Method in ethics consultation has at least three distinguishable components: a canon – that is, the rules that guide actions, cognitions, judgments, and perceptions involved in performing an ethics consultation; a discipline – that is, a mastery, or at least possession, of the specific types of actions and intentions of ethics consultation which are guided by the rules that are embodied in the actions of competent ethics consultants; and a history – that is, the narrative of, and critical reflection on, the actions, including the analyses, assessments, and communications undertaken in the course of the consultation, including the reasoning about the practical issues and the steps toward resolving the ethical question or issues that arose. As a doing, then, ethics consultation consists in actions and intentions that constitute a distinctive set of meanings in the clinical space of patient care in which the meanings brought to patient care through the actions and communications of the ethics consultation help shape, to some extent, the way that the case develops and is understood, which is further reflected in how the case is represented. In this sense, statements about ethics consultation methodology, and theories of ethics consultation, are secondary to the actual practice itself. The analysis and interpretation of actions and communications of those involved in the clinical care of the patient represents a complex process that blends the meaning of ethical concepts, principles, and theories with the constructed and uncovered clinical and value meanings of the case.