Management of ethical issues related to care of seriously ill dialysis patients in free-standing facilities

CONTEXT

There are few data on the frequency and current management of clinical ethical issues related to care of seriously ill dialysis patients in free-standing dialysis facilities.

OBJECTIVES

To examine the extent of clinical ethical challenges experienced by care providers in free-standing facilities and their perceptions about how those issues are managed.

METHODS

A total of 183 care providers recruited from 15 facilities in North Carolina completed a survey regarding the occurrence and management of ethical issues in the past year. Care plan meetings were observed at four of the facilities for three consecutive months. Also, current policies and procedures at each of the facilities were reviewed.

RESULTS

The two most frequently experienced challenges involved dialyzing frail patients with multiple comorbidities and caring for disruptive/difficult patients. The most common ways of managing ethical issues were discussions in care plan meetings (n = 47) or discussions with the clinic manager (n = 47). Although policies were in place to guide management of some of the challenges, respondents were often not aware of those policies. Also, although participants reported that ethical issues related to dialyzing undocumented immigrants were fairly common, no facility had a policy for managing this challenge. Participants suggested that all staff obtain training in clinical ethics and communication skills, facilities develop ethics teams, and there be clear policies to guide management of ethical challenges.

CONCLUSION

The scope of ethical challenges was extensive, how these challenges were managed varied widely, and there were limited resources for assistance. Multifaceted efforts, encompassing endeavors at the individual, facility, organization, and national levels, are needed to support staff in improving the management of ethical challenges in dialysis facilities.

[Ethics in aesthetic surgery]

The use of aesthetic medicine and surgery is increasingly popular, and becomes a true phenomenon of society. Many women and men are asking for such treatments. A large proportion of the population carry the idea that this branch of medicine is a true consumer product. The acts of aesthetic medicine and surgery are not without consequences. They produce important changes in the human body, and carry risks of complications that must be taken into account. The overrated media interest of this subject produce commercial drifts that act against the general health of the patients. The invasive acts of medical aesthetics must be placed in a precise legal and ethical framework to protect the patients. A project of a new Belgian law is on the way, awaiting for publication in "Le Moniteur": this law (proposed by Senator Dominique Tilmans) clarifies the competences required for performing non-surgical aesthetic treatments and specific aesthetic invasive treatments. Other projects of law are being studied, and will concern publicity, information of the public, and rules of private clinics where aesthetic invasive acts are performed. Recent international news have shown, with the PIP breast prosthesis scandal, that surveillance of the medical aesthetic field is mandatory. To provide a better protection of patients, the legislator has decided legislate over the subject.

Informing egg donors of the potential for embryonic research: a survey of consent forms from U.S. in vitro fertilization clinics

OBJECTIVE

To understand whether and to what extent U.S. IVF clinics inform egg donors that resultant embryos initially intended to be implanted for reproductive purposes may in fact be used for research instead.

DESIGN

Four hundred seventy U.S. IVF clinics were asked to respond to a questionnaire and provide a copy of the egg donor consent form(s) used at the clinic.

SETTING

Four hundred seventy U.S. IVF clinics listed in a Centers for Disease Control and Prevention database; only forms from clinics that both accepted donor eggs and provided excess embryos for research were analyzed for content.

PATIENT(S)

Not applicable.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Responses to the questionnaire, demographic data from a Centers for Disease Control and Prevention database, and the content of egg donor consent forms.

RESULT(S)

Of 222 U.S. IVF clinics that responded to our query, 100 clinics both accepted donor eggs and provided some excess embryos for research. We received 66 consent forms from these 100 clinics, which showed that although most egg donor consent forms inform donors that they will not have control over embryos resulting from their eggs, 30% inform them that some embryos may be used for research, and even fewer mention stem cell research.

CONCLUSION(S)

Egg donors in the United States, including some who may have a moral objection to research and stem cell research, are not being informed that embryos created with their donated eggs may in fact be used for these purposes. This can be corrected with the inclusion of succinct, nontechnical language in egg donor consent forms.

Using fieldwork in analyzing ethical issues related to IT in health care

This paper describes how an understanding of everyday conflicts that have ethical implications - what we call 'situated ethics'- can be explored through ethnographic field techniques in healthcare settings. Our approach to ethics is followed by findings from two ethnographic case studies focussing on issues arising as information technologies such as electronic patient records and automatic drug dispensing machines are introduced into varied health sector workplaces. By close and careful observation of these technologies in use and by incorporating narrative accounts from different perspectives the complexity and entangledness of real life occurrences are revealed. Our data suggest that several types of ethical issues (e.g., issues related to intellectual property, literacy, standardization, transparency, work ethics, and equitable allocation of resources) can be identified through fieldwork, and can have an impact on identification of everyday ethics in healthcare.

"The Civil Rights Movement of the 1990s?": The anti-abortion movement and the struggle for racial justice

In 1964, Claude and Jeanne Nolen, who were white, joined an interracial NAACP team intent on desegregating local restaurants in Austin, Texas as a test of the recently passed Civil Rights ACt. Twenty-five years later, the Nolens pleaded "no contest" in a courtroom for their continued social activism. This time the issue was not racial segregation, but rather criminal trespassing for blockading abortion clinics with Operation Rescue. The Nolens served prison sentences for direct action protests that they believe stemmed from the same commitment to Christianity and social justice as the civil rights movements. Despite its relationship to political and cultural conservatism, the anti-abortion movement since Roe v. Wade (1973) was also a product of the progressive social movements of the turbulent sixties. Utilizing oral history interviews and organizational literature, the article explores the historical context of the anti-abortion movement, specifically how the lengthy struggle for racial justice shaped the rhetoric, tactics, and ideology of the anti-abortion activists. Even after political conservatives dominated the movement in the 1980s, the successes and failures of the sixties provided a cultural lens through which grassroots anti-abortion activists forged what was arguably the largest movement of civil disobedience in American history.

Should health professionals allow reporters inside hospitals and clinics at times of natural disasters?

Journalists and health workers need to carefully consider whether it is ethical to show images of patients in medical settings, or of dead bodies in morgues.

Joining the Team: Ethics Consultation at the Cleveland Clinic

In this paper, I describe the development of ethics consultation services and their operation at the Cleveland Clinic; my own educational experiences and background and how I came to see the importance of setting and collaboration for successfully doing clinical ethics; the unique culture of the Cleveland Clinic and its influence on the ethics consultation services provided there; and, finally, the place of personal commitments and values on the conduct of ethics consultations. I stress the point that although philosophers (and perhaps other bioethicists without health professions training) are socialized and educated to do solitary work, successfully conducting ethics consultations requires relatively high levels of collaboration and cooperation that have not been sufficiently discussed. Although this paper is more a description than an analysis of the influence of institutional setting on ethics consultation, I would claim that attention to setting, either as the local scene of the consultation or the institutional and social framework, deserves more attention by bioethicists intent on understanding ethics consultation.