Joseph Fins

Incapacitated adults with a legally appointed guardian or conservator may be recruited for or involved with medical, behavioral, or social science research. Much of the research in which such persons participate is aimed at evaluating medical interventions for them, or contributing to general knowledge about disorders from which they may suffer. In this paper we will consider how the appointment of guardians for patients with disorders of consciousness —severe brain injuries that affect a patient’s level of arousal and ability to interact —impacts such patients’ access to research.Such persons may be under guardianship because they have lost decisional capacity (i.e., those in a coma or...

Edmund Pellegrino noted that contemporary medicine is to a large extent a North American product, and so too is the ethics that accompanies it. This was an accurate observation back in the 1980s when he said it. Even today bioethics is to a considerable extent informed by the seminal works of the Anglo-American model, at least seen from the United States. The dissemination of ideas from the Spanish-speaking world has been nearly invisible to the English-speaking world of bioethics, isolated by language and culture from intellectual currents abroad

The application of neuroimaging technology to the study of the injured brain has transformed how neuroscientists understand disorders of consciousness, such as the vegetative and minimally conscious states, and deepened our understanding of mechanisms of recovery. This scientific progress, and its potential clinical translation, provides an opportunity for ethical reflection. It was against this scientific backdrop that we convened a conference of leading investigators in neuroimaging, disorders of consciousness and neuroethics. Our goal was to develop an ethical frame to move these investigative techniques into mature clinical tools. This paper presents the recommendations and analysis of a Working Meeting on Ethics, Neuroimaging and Limited States of Consciousness held at Stanford University during June 2007. It represents an interdisciplinary approach to the challenges posed by the emerging use of neuroimaging technologies to describe and characterize disorders of consciousness.

The restructuring of the healthcare marketplace has exerted pressure directly and indirectly on clinical ethics programs. The fiscal orientation and emphasis on efficiency, outcome measures, and cost control have made it increasingly difficult to communicate arguments in support of the existence or growth of ethics programs. In the current marketplace, arguments that rely on the claim that ethics programs protect patient rights or assist in the professional formation of practitioners often result in minimal levels of funding and preclude program growth. Where ethics programs could once sustain themselves on goodwill alone and values arguments in an expanding healthcare market they are now encountering—at least by anecdotal reports—cutbacks and even elimination. To respond to these challenges, we offer an economic model that can be used to demonstrate the “value” of an institutionally based ethics program

I am honored to pay tribute to Dr. Pellegrino and a bit humbled as there are so many others who would want to have this opportunity and who knew Dr. Pellegrino better than I. Tom Beauchamp suggested that I might place Dr. Pellegrino into the broader context of the history of medicine. He wrote Thaddeus Pope:Without being disrespectful of the many celebrated figures from Hippocrates to Percival, my view is that no physician has been more productive in the field or made a greater contribution than Ed. I would like to see someone address this question.1And then he suggested my name. So here I am, an improbable choice because I wasn’t from the Kennedy Institute. I am a Hastings Center guy, two perennial teams, always ..

A forty-year-old man is brought to the emergency room by his wife at five in the morning, two hours after he fell down the stairs at home, hitting his head and injuring his arm. He tells the ER physician that he got up to get a drink of water and tripped in the dark. His speech is slurred, and he smells strongly of alcohol. Lab results reveal elevated liver enzymes, and his blood alcohol level is 0.1. His medical history is unremarkable. When asked about his alcohol consumption, he says he usually has one or two drinks a night with dinner but that he drinks more on holidays and special occasions. He admits he had more to drink than usual last night because it had been a stressful day at work, but he is vague about how much he drank. His wife takes the ER physician aside and describes a very different situation. She says that her husband regularly has three or four drinks a night. She always goes to bed before he does and thinks he stays up later so he can continue to drink. She says that he often has no memory of conversations they had the night before and is concerned because he makes work-related calls at night. When asked what he does for a living, she hesitates, and then answers that he is an internist. He does not work at this hospital but works at one of its affiliated clinics. The ER doctor is concerned that his patient is an impaired physician. Yet when the admitting hospitalist, to whom he explains the situation, asks if he really wants to “go there,” he shrugs his shoulders. “I suppose,” she replies, “you might as well call an ethics consult.”

Abstract:While the medical ethics literature has well explored the harm to patients, families, and the integrity of the profession in failing to disclose medical errors once they occur, less often addressed are the moral and professional obligations to take all available steps to prevent errors and harm in the first instance. As an expanding body of scholarship further elucidates the causes of medical error, including the considerable extent to which medical errors, particularly in diagnostics, may be attributable to cognitive sources, insufficient progress in systematically evaluating and implementing suggested strategies for improving critical thinking skills and medical judgment is of mounting concern. Continued failure to address pervasive thinking errors in medical decisionmaking imperils patient safety and professionalism, as well as beneficence and nonmaleficence, fairness and justice. We maintain that self-reflective and metacognitive refinement of critical thinking should not be construed as optional but rather should be considered an integral part of medical education, a codified tenet of professionalism, and by extension, a moral and professional duty.

Sometimes, researchers play by the rules yet their research still generates misgivings. Is it always enough, then, to abide by the rules and regulations for human subjects research? Or, in fact, might too close a focus on the rules blind both investigator and regulator to larger, overarching concerns? Or put more bluntly, could an emphasis on regulatory compliance lead to a misconstrual of the ethics of a research study?These questions are raised by the Bucharest Early Intervention Project, a study conducted on Romanian children who lived in orphanages in the aftermath of the notorious regime of Nicolae Ceaucescu.

There is a palpable malaise in American medicine as clinical practice veers off its moorings, swept along by a new commercialism that is displacing medical professionalism and its attendant moral obligations. Although the sociology of this phenomenon is complex and multifactorial, I argue that this move toward medical commercialism was accelerated by the abortive efforts of the Clinton Administration's Health Security Act. Through an analysis of performative speech I show that, although the Clinton plan drew on many strands of speech about healthcare, it favored the discourse of health policy and health economics over that of clinical practice and professionalism. Though the Clinton plan failed, this new vocabulary of health economics has led us to imagine a new descriptive framework, which has commodified healthcare and commercialized the clinic

: This paper presents a method of moral problem solving in clinical practice that is inspired by the philosophy of John Dewey. This method, called "clinical pragmatism," integrates clinical and ethical decision making. Clinical pragmatism focuses on the interpersonal processes of assessment and consensus formation as well as the ethical analysis of relevant moral considerations. The steps in this method are delineated and then illustrated through a detailed case study. The implications of clinical pragmatism for the use of principles in moral problem solving are discussed.

Although clinical ethics consultation is a high-stakes endeavor with an increasing prominence in health care systems, progress in developing standards for quality is challenging. In this article, we describe the results of a pilot project utilizing portfolios as an evaluation tool. We found that this approach is feasible and resulted in a reasonably wide distribution of scores among the 23 submitted portfolios that we evaluated. We discuss limitations and implications of these results, and suggest that this is a significant step on the pathway to an eventual certification process for clinical ethics consultants

Without exaggeration, it could be said that we are entering a golden age of neuroscience. Informed by recent developments in neuroimaging that allow us to peer into the working brain at both a structural and functional level, neuroscientists are beginning to untangle mechanisms of recovery after brain injury and grapple with age-old questions about brain and mind and their correlates neural mechanisms and consciousness. Neuroimaging, coupled with new diagnostic categories and assessment scales are helping us develop a new diagnostic nosology about disorders of consciousness which will likely improve prognostication and suggest therapeutic advances. Historically such diagnostic refinement has yield therapeutic advances in medicine and there is no reason to doubt that this will be the case for disorders of consciousness, perhaps bringing relief to a marginalized population now on the periphery of the therapeutic agenda. In spite of this promise, the translation of research findings into the clinical context will be difficult. As we move from descriptive categories about disorders of consciousness, like the vegetative or minimally conscious states, to ones further specified by integrating behavioral and neuroimaging findings, humility not hubris should be the virtue that guides the ethical conduct of research and practice.

A 28-year-old female-to-male transgender patient presents to the emergency room with one day of pleuritic chest pain and shortness of breath. The patient is found to have an acute pulmonary embolus and is admitted is to the academic hospitalist teaching service for further management.The transgender population is diverse in gender identity, expression, and sexual orientation. Although estimates vary, one study suggests that 0.3% of adults identify as transgender. The U.S. National Transgender Discrimination Survey revealed that 28% of transgender adults have experienced harassment in medical settings, 19% reported being refused care, and 28% postponed care because of discrimination...