Joseph Fins

The COVID-19 Pandemic a stress test for clinical medicine and medical ethics, with a confluence over questions of the proportionality of resuscitation. Drawing upon his experience as a clinical ethicist during the surge in New York City during the Spring of 2020, the author considers how attitudes regarding resuscitation have evolved since the inception of do-not-resuscitate orders decades ago. Sharing a personal narrative about a DNR quandry he encountered as a medical intern, the author considers the balance of patient rights versus clinical discretion, warning about the risk of resurgent physician paternalism dressed up in the guise of a public health crisis.

Multiple studies have been performed to identify the most common ethical dilemmas encountered by ethics consultation services. However, limited data exists comparing the content of ethics consultations requested by specific hospital specialties. It remains unclear whether the scope of ethical dilemmas prompting an ethics consultation differ between specialties and if there are types of ethics consultations that are more or less frequently called based on the specialty initiating the ethics consult. This study retrospectively assessed the incidence and content of ethics consultations called by surgical vs. non-surgical specialties between January 1, 2013 to December 31, 2018 using our RedCap Database and information collected through the EMR via our Clinical and Translational Science Center. 548 total ethics consultations were analyzed. Our results demonstrate that more surgical consults originated from the ICU, as opposed to lower acuity units, and surgical patients were more likely to have a DNR in place. Surgical specialties were more likely to call about issues relating to withholding/withdrawing life-sustaining treatment, while non-surgical specialties were more likely to call about issues related to discharge planning. There appear to be morally relevant differences between consults classified as the “same” that are not entirely captured by the usual ethics consultations classification system. In conclusion, this study highlights the unique ethical issues experienced by surgical vs. non-surgical specialties. Ultimately, our data can help ethics consultation services determine how best to educate various hospital specialties to approach ethical issues commonly experienced within their field.

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.

On January 5, 2019, the Associated Press reported that a woman thought to have been in the vegetative state for over a decade gave birth at a Hacienda HealthCare facility. Until she delivered, the staff at the Phoenix center had not noticed that their patient was pregnant. The patient was also misdiagnosed.Misdiagnosis of patients with disorders of consciousness in institutional settings is more the norm than the exception. Misdiagnosis is also connected to a broad and extremely significant change in the understanding of the vegetative state—a change that the field of bioethics has not yet fully taken into account. In September 2018, the American Academy of Neurology, the American College of Rehabilitation Medicine, and the National Institute on Disability, Independent Living, and Rehabilitation Research issued a comprehensive evidence‐based review on disorders of consciousness and an associated practice guideline on the care of these patients. These landmark publications update the 1994 Multi‐Society Task Force Report on the Vegetative State, which subcategorized the persistent vegetative state as either persistent (once the vegetative state lasted one month) or permanent (once the vegetative state lasted three months after anoxic injury or twelve months after traumatic injury). Noting that 20 percent of patients thought to be permanently unconscious might regain some level of consciousness, the new guideline has eliminated the permanent vegetative state as a diagnostic category, replacing it with the chronic vegetative state.

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...

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

Cultural historians and historians of medicine are a rarity in bioethics. Even those who write histories of bioethics are philosophers, sociologists, or theologians. Where have all the historians gone? If bioethics is to contribute to the urgent work of addressing social justice, structural racism, and health inequity, we bioethicists need to embrace history as a fully constituent part of our field. Historians can help us apprehend the ideas that shaped bioethics, and health policy more broadly, and discover the dissenting arguments that might inspire us now. Given our annus horribilis, history has become an instrumental necessity. It is only through the study of history that we can understand the past so as to reimagine how bioethics can influence health policy and work toward health equity.

Undocumented and undomiciled, Gustavo Jiménez had been in the United States for several years. He knew his leg wasn’t right when it began to swell and redden. After the cellulitis spread to his bloodstream, he was found unconscious on the street and admitted to the intensive care unit. He improved quickly and was soon able to tell a social worker his name and that he had family in Quito. Then his health took a turn for the worse, and he developed multisystem organ failure. His doctors believed his prognosis grave and further care futile. They wanted to invoke a provision under their state’s law that allows, at the discretion of at least two physicians, for the withdrawal of life‐sustaining therapy for isolated and decisionally incapacitated patients, but the social worker had ethical concerns about the doctors’ desire to make such a momentous decision without family input. She asked for a “time‐out to locate his family,” but one of the doctors asserted, “His family isn’t here, and you’ll never find them. Besides we need the bed. The ER is full of patients we can help.” What is owed a patient and family in such a situation?

A 47-year-old woman with a history of anxiety disorder is admitted to the hospital for shortness of breath. On the third day of hospitalization, she asks her physician for a copy of all documents pertaining to her care. What expectation should she have for full disclosure? Are there limits on her access to her medical records and do her physician's concerns about professional privilege matter?The virtues of transparency in medicine have been well described. As proponents of transparency, we favor patient access to their medical records, but we are increasingly troubled by the ease and extent of disclosure in current practice as technology advances and...

It is generally agreed that physicians should not provide futile interventions, for the obvious reason that an intervention without utility causes harm without benefit. However, despite efforts to standardize a definition, there is a lack of universal consensus as to what constitutes “futility.” Two recent policy statements object to the terminology of futility based on the lack of a universal definition. Schneiderman, Jecker, and Jonsen object to the proposed alternative terminology of “inappropriate.” These differing opinions about the most apt terminology raise the question of whether definitions are helpful or counterproductive in addressing disputes that...

Abstract:In the 2015 David Kopf Lecture on Neuroethics of the Society for Neuroscience, Dr. Joseph Fins presents his work on neuroethics and disorders of consciousness through the experience of Maggie and Nancy Worthen, a young woman who sustained a severe brain injury and her mother who cared for her. The central protagonists in his book,Rights Come to Mind: Brain Injury, Ethics and the Struggle for Consciousness(Cambridge University Press, 2015), their experience is emblematic of the challenges faced by families touched by severe brain injury and the possibility for improved diagnosis and treatment offered by progress in neuroscience. By telling their story, and those of other families interviewed as part of the research forRights Come to Mind,Fins calls for improved care for this population arguing that this is both an access to care issue and a civil and disability rights issue worthy of greater societal attention.

Sometimes one’s greatest academic disappointments can have unexpected outcomes. This is especially true when one is trying to change career trajectories or do something that others did not take seriously. My path into neuroethics was an unexpected journey catalyzed in part by constructive disappointment and the disbelief of colleagues who thought that the work I was pursuing nearly two decades prior was a fool’s errand. After all, could anyone—in his or her right mind—ever conceive of waking up a person unconscious from brain injury and getting him to speak?1.

Naloxone, which reverses the effects of opioids, was synthesized in 1960, though the hunt for opioid antagonists began a half-century earlier. The history of this quest reveals how cultural and medical attitudes toward opioids have been marked by a polarization of discourse that belies a keen ambivalence. From 1915 to 1960, researchers were stymied in seeking a “pure” antidote to opioids, discovering instead numerous opioid molecules of mixed or paradoxical properties. At the same time, the quest for a dominant explanatory and therapeutic model for addiction was likewise unsettled. After naloxone’s discovery, new dichotomizing language arose in the “War on Drugs,” in increasingly divergent views between addiction medicine and palliative care, and in public debates about layperson naloxone access. Naloxone, one of the emblematic drugs of our time, highlights the ambivalence latent in public and biomedical discussions of opioids as agents of risk and relief.

A thirty-year-old single mother with recurrent, metastatic, treatment-refractory cancer presents to the emergency room with severe difficulty breathing due to an obstructive tumor in her neck, compounded by progressive disease in her lungs and a new pulmonary embolism. She cannot be safely intubated and would require an emergent awake tracheotomy. Even if the airway can be successfully secured surgically, the likelihood that she will be able to be weaned from mechanical ventilation is very low. The surgeon, a young mother too, appreciates the patient's desire for more time with her toddler. But the surgeon knows the significant risk of surgery, the massive responsibility she would accept in trying to get the patient through it, and the emotional toll of an intraoperative death on surgical staff. And she can imagine the second-guessing that will come during the inevitable morbidity and mortality conference if the patient should die in the perioperative window. Yet the surgeon does not want to take the “easy” way out; after all, critically ill patients undergo aggressive resuscitation all the time. What should she do?