Fourteen Important Concepts Regarding Moral Distress

I suggest that we may want to strive, over time, to change our present professional-cultural view, from one that sees an expression of moral distress as a threat, to a professional-cultural view that welcomes these challenges. Such an effort to better medicine would not only include dissenting clinicians, but patients (and their loved ones) as well.

Nine Lessons from Ashley and Her Parents

Parents' love for their child, even a child who has severe impairments, may give them much joy and quality in their life. This is also the case for caregivers of adults with severe cognitive impairments, such as end-stage dementia. How can clinicians work with these parents and caregivers and help them?

New Ways to Cut through Ethical Gordian Knots

Clinicians and ethicists routinely encounter complex ethical dilemmas that seem intractable, which have been described as ethical Gordian knots. How can they best assist patients and surrogate decision makers who are entangled in struggles around the capacity to make life-or-death treatment decisions? In this article I describe unconventional and unorthodox approaches to help slice through these dilemmas.

Going from What Is, to What Should Be, to Care Better for Our Patients and Families

This piece discusses ways in which clinicians may go beyond their usual practices. These include exploring the limits of old laws, consulting with colleagues and ethics committees earlier and more often, and giving patients' family members new choices they didn't have previously. This could include asking patients and family members whether clinicians should prioritize staying in the single, unconflicted role of serving patients and families, even when this might preclude simultaneously serving another interest, for example, that of a hospital.

New Paradigms in Medical Ethics

As new technologies develop, new ethical paradigms may be needed. This article considers several examples, such as stopping venoarterial extracorporeal membrane oxygenation (VA-ECMO), treating patients who are in a locked-in-like state who have awareness, purposefully deceiving patients who have dementia, meeting the needs of transgender persons, showing loved ones patients' wounds, and doing research on controlled substances. I suggest that clinicians should identify the practices underlying their value assumptions so they can alter their assumptions when this might improve the care they offer to their patients.

Harmful Emotional Responses that Patients and Physicians May Have When their Values Conflict

One of the most difficult decisions a clinician may face is when, if ever, to decline what a patient wants, based on the clinician's own moral conscience. Regardless of what the clinician decides, the outcome may be deeply emotionally painful for both parties, and the pain may last. I will discuss this pain, how it occurs, and what we can do to try to reduce it before, during, and after a conflict arises. Approaches include explaining how we are like the patient or doctor, that no one is perfect, and that what we do is not who we are.

How Clinicians Can Reduce "Bullied Acquiescence"

Clinicians and patients and their families may disagree about a course of treatment, and the ensuing conflict may seem intractable. The parties may request mediation, or use mediation-based approaches, to help resolve the conflict. In the process of mediation, and at other times, parties in conflict may feel so pressured to accept a resolution that they acquiesce unwillingly--and such resolutions often unravel. In this article I investigate how "bullied acquiescence" might happen, and how to avoid it.

What Do We Owe Medical Students and Medical Colleagues Who Are Impaired?

Physicians who are impaired, engage in unprofessional behavior, or violate laws may be barred from further practice. Likewise, medical students may be dismissed from medical school for many infractions, large and small. The welfare of patients and the general public must be our first priority, but when we assess physicians and students who have erred, we should seek to respond as caringly and fairly as possible. This piece will explore how we may do this at all stages of the proceedings physicians and students may encounter. This may include helping them to resume their medical careers if and when this would be sufficiently safe and beneficial for patients.

Professionalism: one size does not fit all

When a child is born with or acquires special needs, the parents may find some parental tasks more difficult. They may not know how to make their tasks easier, or that some parents find it exceptionally rewarding and meaningful to raise their children with special needs. This piece explores how clinicians might share this potentially life-altering information. It also explores when and why clinicians might want to make one-of-a-kind exceptions to their usual professional practices.

How to Help Parents, Couples, and Clinicians When an Extremely Premature Infant Is Born

Parents may experience profound stress when their infant is extremely premature or has exceptionally low birth weight. This article presents several approaches that clinicians and ethics consultants can use to reduce this stress when a parent is single and alone, as well as when both parents are present. Offering parents additional options, taking preventative measures, and using approaches based on recent innovations in psychotherapies are emphasized. Since the clinicians who care for these neonates may find it exceptionally stressful and may experience "burn out," especially over time, this article also addresses what may work best for them. Finally it will discuss clinicians, who, despite their best efforts, find that caring for these infants is simply too painful to bear.

Mediation Approaches at the Beginning or End of Life

The approaches used in mediation may help ethics consultants, especially in difficult cases. In this piece, I primarily discuss these techniques. I also discuss how clinicians may be of the most help to parents of infants with severe genetic conditions, to research participants, and to patients who may be at risk for Alzheimer's disease and their surrogate decision makers.

How to Retain the Trust of Patients and Families When We Will Not Provide the Treatment They Want

How might clinicians best try to retain the trust of patients and family members after clinicians oppose giving a treatment? If clinicians can maintain the trust of patients and families in these situations, this may soften what may be the greatest possible loss--the death of a loved one. I discuss what clinicians seeking to retain trust should not do--namely impose their values and reason wrongly--and introduce strategies that clinicians may use to reduce both. I present five principles that clinicians can follow to try to retain trust, with examples that illustrate each. I suggest specific interventions that clinicians can make, especially when they anticipate that a patient and/or family may, in time, want a treatment that is futile.

Epilogue: ethical goals for the future

Based on the experiences of the Hearts and Minds of Ghana authors, I present possible approaches to the ethical questions that clinicians who participate in health missions and disaster relief programs often face.

New approaches with surrogate decision makers

A first principle in ethics consultation is that reasoning is essential. A second principle is that the religious and cultural views of patients and their surrogates are usually respected. What can be done when these principles collide-when patients or surrogates have religious or cultural views and beliefs that clinicians find unreasonable or even offensive? Mediation may provide some approaches to assist us in providing the most ethically appropriate assistance.

Ethically optimal interventions with impaired patients

It may be difficult to imagine having a severe impairment such as quadriplegia or being dependent on a respirator. There is evidence that when careproviders make treatment decisions for patients who are in these situations, we imagine the patients are worse-off than they report they are -- most patients with even very severe impairments report that they greatly value being alive. This misperception may cause us to make treatment decisions for patients with impairments that we might not make for other patients. In this article I describe how to provide better care for patients who have impairments. This includes not presupposing that the patients' quality of life is decreased, considering with patients how outside factors may be limiting their functioning, and seeking to help offset these factors, if we can, when they exist, to avoid allowing patients' impairments to result in their being truly "disabled".

How to help patients and families make better end-of-life decisions

How can clinical ethics consultants best assist patients and their family members when patients may be dying? In this introduction, I consider this concern in light of four articles that appear in this issue of The Journal of Clinical Ethics, by Jeffrey T. Berger; Mary T. White; Linying Hu, Xiuyun Yin, Xiaolei Bao, and Jin-Bao Nie; and Thaddeus Mason Pope and Melinda Hexum. Patients and family members experience extreme stress at the end of life, a high-stakes situation in which few of us have extensive experience. This stress can make us less able to process new information, cripple decision making, and even lead to long-term harm. I provide a number of practical approaches that clinical ethics consultants can use to help patients and family members in these situations, so that their decisions may reflect more what they really want and so that, after this stress has diminished, they may then do better.

What should careproviders do when a patient "won't budge"?

Patients who face making a high-stakes decision--whether or not to accept a lifesaving intervention--may make a decision that their careproviders believe is deeply and dangerously mistaken. How can careproviders best help patients in such situations? If a determination of competency exam seems to be in the patients' best interests, how can careproviders refer their patients without betraying their patients' trust, given that the trust between patients and careproviders is one of the most powerful tools careproviders have in working with patients? Ethically, is it possible for careproviders to participate in determinations of competency for their own patients? I will present approaches that careproviders can adopt to help patients who "won't budge" when making what appear to be dangerously erroneous choices regarding lifesaving interventions.

The best place for bare-knuckled ethics

In the documentary Boston Med, patients, their family members, and their careproviders agree to be filmed in real medical situations. Why would they do this? The possible answers to this question may help us to make sense of the paradoxical results of a recent study, in which patients with terminal illness ranked their careproviders highly for communication, even though the patients had failed to learn that they had a fatal illness. Based on this analysis, I offer careproviders a practical approach they can use to improve communication with patients, particularly to help patients to feel less alone. This same approach can also be applied in bioethics consultation.

Families, strangers, and those most alone: insights from cultures, including our own

In this introduction to this issue of The Journal of Clinical Ethics (JCE), I will discuss the legacy of our recently departed friend and colleague, Edmund D. Pellegrino, MD. In this light, I will discuss three articles in this issue of the journal that provide insight into the cultures of China, Mexico, and the U.S., and propose alternative approaches for careproviders in the U.S. to include in their practice as they work with patients and family members at the end of life.

Why careproviders may conclude that treating a patient is futile

I shall examine one way that careproviders may come to judgments of "futility" in cases that are less than clearcut, in the hope that, if such judgment is unwarranted, it may be avoided.

When a mother wants to deliver with a midwife at home

In this special issue of The Journal of Clinical Ethics, different views on both the ethical desirability of women delivering in hospitals or at home with midwives are discussed. What careproviders, including midwives, should recommend to mothers in regard to the place of giving birth is considered. Emotional concerns likely to be of importance to mothers, fathers, midwives, and doctors are also presented. Finally, possible optimal approaches at the levels of both policy and the bedside are suggested.