How do we respond to the patient who no longer needs inpatient care but refuses to leave the hospital? Complex hospital discharges commonly involve consideration of legal, financial, clinical, and practical issues. Yet, the ethical and contextual issues embedded in complex inpatient discharges are of concern and have not received adequate attention by medical ethicists. The aim of this work is to encourage clinicians and administrators to incorporate a justice rubric when approaching inpatient discharge dilemmas. This paper presents justice as (...) the ethical principle most neglected in situations involving complex discharges and suggests that a justice focused lens allows clinicians and administrators to move beyond notions of patient autonomy in crafting morally responsible hospital discharge decisions that reflect efficient stewardship of an appropriate share of medically indicated services. This issue deserves additional attention from medical ethicists in the future. (shrink)

In this paper, I argue that the doctrine of double effect is disposed toward abuse. I try to identify two distinct sources of abuse of double effect: the conditions associated with standard formulations of double effect and the difficulty of fully understanding one’s own intentions in action. Both of these sources of abuse are exacerbated in complex circumstances, where double effect is most often employed. I raise this concern about abuse not as a criticism of double effect but rather as (...) a problem that defenders should observe and try to prevent. I go on to suggest certain methods for avoiding the abuse of double effect such as hesitating to use it, applying it only with other agents, and selectively and carefully propagating it. (shrink)

As policy makers place great hope in health information technology as a means to lower costs and achieve improvements in health care quality, safety, and efficiency, organizations at the forefront of building health information exchange networks attempt to weave the concept and function of informed consent into an evolving information-driven health care system. The vast amount of information that will become available to both health professionals and patients in the new HIT-driven environment can reasonably be expected to affect the relationship (...) between them in many ways, particularly in the area of informed consent. During this early stage of HIT adoption, it is critical that we engage in discussions regarding informed consent’s proper role in a heretofore unknown health care environment — one in which electronic information sharing holds primary importance. The central and largely unexamined question of whether and how the legal and ethical underpinnings of informed consent will fit into the context of HITenabled treatment is critical to both public policy and clinical practice. (shrink)

Efforts to reform medical education have emphasized the need to formalize instruction in medical ethics. However, the discipline of medical ethics education is still searching for an acceptable identity among North American medical schools; in these schools, no real consensus exists on its definition. Medical educators are grappling with not only what to teach (content) in this regard, but also with how to teach (process) ethics to the physicians of tomorrow. A literature review focused on medical ethics education among North (...) American medical schools reveals that instruction in ethics is considered to be vitally important for medical students. Agreement by medical educators on a possible core curriculum in ethics should be explored. To develop such a curriculum, deliberative curriculum inquiry by means of a targeted Delphi technique may be a useful methodology. However, the literature reveals that medical curricular change is notoriously slow. General implications for medical ethics education as a discipline are discussed. (shrink)

Objective: To evaluate moral development as an indicator of the capacity to consent among two groups of patients from the Hospital de Clínicas in Porto Alegre, RS, Brazil.Method: Fifty-nine adolescents and 60 patients over 60 years of age participated in a cross-sectional study to assess moral development using Loevinger’s model of ego stages.Results: Age and moral development showed no association, with most participants in the two groups being in the conscientious phase.Conclusions: Age is probably not an adequate variable to measure (...) decision-making capacity, because questions of medical consent relate to participants’ own personal health. Decision-making capacity should be viewed as a continuous function. While the age of the person whose consent is needed should be considered, age alone, from a moral perspective, is not the main determinant of this capacity. (shrink)

This survey describes in detail ethics committees (ECs) at acute care hospitals in Upstate New York. It finds that in just two years (1984 and 1985), following the Baby Doe controversy and the Report of the President’s Commission, 40% of urban ECs and 37% of university ECs were formed. One half of rural ECs formed in 1992–1995, following the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirement of access to ethics consultation. Generally, ECs are committees of the powerful within (...) the hospital; the administration or the medical staff is the organizational parent of 73% of ECs. These groups appoint 80% of EC chairs and 79% of members; they constitute 45% of the membership. Most EC members (81%) lack even rudimentary formal training in bioethics, yet only 18% of ECs consider member education a major role. Many ECs are rather inactive: 53% meet less than every other month and 61% have fewer than six case consultations in the prior year. On the basis of this survey’s findings, suggestions are offered to improve the credibility of these ubiquitous committees as stewards of bioethics, rather than of the powerful within the hospital. (shrink)

The lack of consensus in American society regarding the permissibility of assisted suicide and euthanasia is due in large part to a failure to address the nature of the human person involved in the ethical act itself. For Karol Wojtyla, philosopher and Pope, ethical action finds meaning only in an authentic understanding of the person; but it is through acting ( actus humanus ) alone that the human person reveals himself. Knowing what the person ought to be cannot be divorced (...) from what he ought to do; forWojtyla, the structure of the ethical “do” – the act itself – comes first. The current paper will focus on four arguments used to justify assisted suicide and euthanasia: (1) the argument from autonomy, (2) the argument from compassion, (3) the argument from the evil of suffering, and (4) the argument from the loss of dignity. It will seek to answer each claim from the perspective of Karol Wojtyla's philosophical anthropology. Much of this will come from his defining work in pure philosophy, The Acting Person (1969). The final part of the paper will suggest some positive solutions to the stalemate over the euthanasia debate, again drawn from Wojtyla's idea of human fulfillment through participation with the other, and with the community itself. (shrink)