Joseph Fins

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.

Extracorporeal membrane oxygenation (ECMO) provides continuous circulation and/or oxygenation to adults with cardiac failure, pulmonary dysfunction, or both. The technology is similar to the traditional heart-lung bypass machines used during surgical procedures, however ECMO may be used outside the confines of the operating room and for extended periods of time. This paper explores the complexities, both clinical and ethical, of a donot-resuscitate (DNR) order for patients with cardiopulmonary failure on veno-arterial (VA-ECMO), a type of ECMO that provides resuscitation superior to the chest compressions that DNR is intended to prevent. Clinically, a DNR order has limited utility for patients on VA-ECMO and its presence can serve to create confusion. Symbolically, however, the designation may serve as a stepping-stone for surrogates facing difficult end-of-life decisions. The paper concludes by suggesting that it is prudent to avoid DNR discussions in the context of VA-ECMO.

When addressing cultural and religious differences in the clinical setting we need to be realists. Despite our public homage to pluralism and good intentions, it is just not possible to overcome all the differences that might exist and achieve perfect understanding of others. Try as we may, we will never be able to see perfectly the world through another's eyes. Instead of reaching for such perfection, we should instead reach for an approximation of shared understanding that will promote discourse and civility when peoples of different races, genders, cultures, religions, and sexual preferences interact in the clinic

What's not to like about shared decision‐making? These programs employ specially crafted decision aids to educate patients about their treatment options and then merge the newly informed patient preferences, both general and treatment‐specific, with guidance from physicians to optimize medical decisions. Sounds great, right? Even better, recent evidence indicates that shared decision‐making programs may also help bend the proverbial cost curve by reducing the use of medical interventions that patients, now properly educated about their options, often say they do not want. The notion that programs to inform and elicit patient choice might also help to align health care delivery with patient preferences for less invasive and therefore less costly treatment options seems the rarest of mutual wins in health care, in which what is best for the individual might also benefit the whole. Yet there has been scant attention to how the goals of patient care and cost‐containment, and perhaps even profitability, coincide or conflict.

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.