Rosoff and Schneiderman's essay “Irrational Exuberance: Cardiopulmonary Resuscitation as Fetish” (2017) raises an issue first posed by the then Chairman of the Federal Reserve Board, Alan Greenspan...

In “Deception and the Clinical Ethicist,” Christopher Meyers defends that view that deception practiced by clinical ethicists is legitimate if it satisfies a series of justifying conditions (Meyers...

Lying to one’s patients is wrong. So obvious as to border on a platitude, this truism is one that bioethicists have heartily endorsed for several decades. Deception, the standard line holds, underc...

This paper focuses on the practice of injecting patients who are dying with a relatively high dose of sedatives in response to a catastrophic event that will shortly precipitate death, something that we term ‘crisis sedation.’ We first present a confabulated case that illustrates the kind of events we have in mind, before offering a more detailed account of the practice. We then comment on some of the ethical issues that crisis sedation might raise. We identify the primary value of (...) crisis sedation as allowing healthcare professionals to provide some degree of reassurance to patients, their families and the professionals who are caring for them. Next we focus on the issue of informed consent. Finally, we ask whether continuous deep sedation might be preferable to crisis sedation in scenarios where potential catastrophic events can be anticipated. (shrink)

The opening sentence of Christopher Meyers’ Target Article is “Lying to one’s patient is wrong”. The author continues, “This truism is one that bioethicists have heartedly endorsed fo...

Some health care organizations allow physicians to withhold cardiopulmonary resuscitation from a patient, despite patient or surrogate requests that it be provided, when they believe it will be more harmful than beneficial. Such cases usually involve patients with terminal diagnoses whose medical teams argue that aggressive treatments are medically inappropriate or likely to be harmful. Although there is state-to-state variability and a considerable judicial gray area about the conditions and mechanisms for refusals to perform CPR, medical teams typically follow a (...) set of clearly defined procedures for these decisions. The procedures are based on the principle of nonmaleficence and typically include consultation with hospital ethics committees, reflecting the guidelines of relevant professional associations. Ethical debates about when CPR can and should be limited tend to rely more on discussions of theory, principles, and case studies than systematic empirical study of the situations in which such limitations are applied. Sociologists of bioethics call for empirical study, arguing that what ethicists and health professionals believe they are doing when they draft policies or invoke principles does not always mirror what is happening on the ground. In this article, we begin the task of modeling the empirical analyses sociologists call for, focusing on a cohort at Massachusetts General Hospital. We inductively analyzed ethics committee notes and medical records of nineteen patients whose surrogates did not accept the decision to withhold CPR. (shrink)

In Abram Brummett and Erica K. Salter's excellent paper, “Mapping the Moral Terrain of Clinical Deception,” they rightly note that it is sometimes ethically appropriate for health care professionals to deceive patients and families. However, they also note that because doing so violates a prima facie duty of honesty, the ethical burden of proof falls upon the deceiver. Hence, they also provide a sophisticated framework for determining whether any given case is warranted. I applaud their overall approach but also critique (...) some of their claims, in particular, their conclusion that lies of commission require greater justification than those of omission and their conflation of the principles of beneficence and nonmaleficence. I also urge them to give greater attention to how power asymmetries should be accounted for and to the impact such deceptive choices might have on the clinician's character. (shrink)

The American Journal of Bioethics, Volume 11, Issue 11, Page 22-23, November 2011.

The American Journal of Bioethics, Volume 11, Issue 11, Page 15-16, November 2011.

Legal precedent, professional‐society statements, and even many medical ethicists agree that some situations may call for a clinician to engage in an act of lying or nonlying deception of a patient or patient's family member. Still, the moral terrain of clinical deception is largely uncharted, and when it comes to practical guidance for clinicians, many might think that ethicists offer nothing more than the rule never to deceive. This guidance is insufficient to meet the real‐world demands of clinical practice, and (...) this article endeavors to articulate a framework to help clinicians better navigate the ethics of clinical deceit. The framework articulates four morally relevant dimensions of a potential deceptive act that should be examined to better determine the moral justification that might be required: the target of the act, the nature of the information, the nature of the act, and the context of the act. (shrink)

The American Journal of Bioethics, Volume 11, Issue 11, Page 18-20, November 2011.

The American Journal of Bioethics, Volume 11, Issue 11, Page 27-29, November 2011.

The American Journal of Bioethics, Volume 11, Issue 11, Page 13-14, November 2011.

I trust my lawyer more than I trust my doctor.—Shana Alexander, 1992 [The audience laughed.]1The Hippocratic Oath makes the physician invoke external supervision of her adherence to what she affirm...

The American Journal of Bioethics, Volume 11, Issue 11, Page 17-18, November 2011.

Historically nurses have lacked significant input in end-of-life decision-making, despite being an integral part of care. Nurses experience negative feelings and moral conflict when forced to aggressively deliver care to patients at the EOL. As a result, nurses participate in slow codes, described as a limited resuscitation effort with no intended benefit of patient survival. The purpose of this study was to explore and understand the process nurses followed when making decisions about participation in limited resuscitation. Five core categories emerged (...) that describe this theory: (1) recognition of patient and family values at the EOL; (2) stretching time and reluctance in decision-making; (3) harm and suffering caused by the physical components of CPR; (4) nurse’s emotional and moral response to delivering aggressive care, and; (5) choosing limited resuscitation with or without a physician order. Several factors in end-of-life disputes contribute to negative feelings and moral distress driving some nurses to perform slow codes in order to preserve their own moral conflict, while other nurses refrain unless specifically ordered by physicians to provide limited care through tailored orders. (shrink)

Background: Cardio-pulmonary resuscitation is the default procedure during cardio-pulmonary arrest. If a patient does not want cardio-pulmonary resuscitation, then a do not attempt resuscitation order must be documented. Often, this order is not given; even if thought to be appropriate. This situation can lead to a slow code, defined as an ineffective resuscitation, where all resuscitation procedures are not performed or done slowly. Research objectives: To describe the perceptions of nurses working on internal medicine wards of slow codes, including the (...) factors associated with its implementation. Research design: This was a cross-sectional, descriptive study. Participants completed a personal characteristics questionnaire and the Perceptions and Factors of Slow Codes questionnaire designed for this study. Participants and research context: The sample was a convenience sample of nurses working on internal medicine wards in two Israeli hospitals. Ethical considerations: The study received ethical approval from both institutions, where data were collected and stored according to institutional policy. Findings: Most reported that resuscitations were conducted according to protocol (n = 90, 76.2%). Some took their time calling the code (n = 22, 18.3%), or waited by the bedside and did not perform cardio-pulmonary resuscitation (n = 45, 37.5%). Factors most associated with slow codes were poor patient prognosis (mean = 3.52/5, standard deviation = 1.27) and a low chance of patient survival (mean = 3.37/5, standard deviation = 1.21). Two-thirds (n = 76, 66.8%) reported that slow codes were done on their unit and the majority (n = 80, 69%) perceived slow codes as ethical. Discussion: This study confirms that slow codes are part of medical care on internal medicine wards, where most nurses perceive them as an ethical alternative. These perceptions are in contrast to most legal and ethical opinions expressed in the literature. Conclusion: Nurses should be educated about the legal and ethical implications of slow codes, and qualitative and quantitative studies should be conducted that further investigate its implementation. (shrink)

This article addresses whether cardiopulmonary resuscitation and sustained physiological support should ever be permitted in individuals who are diagnosed as brain dead and who had held previously expressed moral or religious objections to the currently accepted criteria for such a determination. It contrasts how requests for care would normally be treated in cases involving a brain-dead individual with previously expressed wishes to donate and a similarly diagnosed individual with previously expressed beliefs that did not conform to a brain-based conception of (...) death. The paper first focuses narrowly on requests for CPR and then expands its scope to address extended physiological support. It describes how refusing the brain-dead non-donor's requests for either CPR or extended support would represent enduring harm to the antemortem or previously autonomous individual by negating their beliefs and self-identity. The paper subsequently discusses potential implications of policy that would allow greater accommodations to those with conscientious objections to currently accepted brain-based death criteria, such as for cost, insurance, higher brain formulations and bedside communication. The conclusion is that granting wider latitude to personal conceptions around the definition of death, rather than forcing a contested definition on those with valid moral and religious objections, would benefit both individuals and society. (shrink)

The American Journal of Bioethics, Volume 11, Issue 11, Page 24-25, November 2011.

We argue against Christopher Meyers’s call for clinical ethicists to participate in deceiving patients, surrogate decision-makers, or family members. While we acknowledge that some forms of deception may be ethically appropriate in highly circumscribed situations, the type of case Meyers describes as involving justifiable deception differs in at least two important ways. First, Meyers fails to distinguish acts of deception based on the critical feature of who is being deceived—patient, surrogate, or family member—and the overarching duty to respect the autonomy (...) of relevant decision-makers to make rationally-informed decisions. Second, Meyers’s analysis relies on an assessment of harm, a value-laden concept which health care professionals and ethicists should not presumptively assess without considering how the patient, surrogate, or family might assess specific harms. (shrink)

The American Journal of Bioethics, Volume 11, Issue 11, Page 20-21, November 2011.

Each time patients and their families are asked to make a decision about resuscitation, they are also asked to engage the political, social, and cultural concerns that have shaped its history. That history is exemplified in the career of Claude S. Beck, arguably the most influential researcher and teacher of resuscitation in the twentieth century. Careful review of Beck’s work discloses that the development and popularization of the techniques of resuscitation proceeded through a multiplication of definitions of death. CPR consequently (...) remains unique among medical treatments, because it is indicated precisely when a person dies, depending always on how each event of death becomes defined practically by patients, families, and medical professionals present at the time. It is therefore as an occasion to manage a surplus of definitions of death, and not as an occasion to determine the physiological efficacy of resuscitation, that one should approach analysis of contemporary challenges in decision-making about resuscitation. (shrink)

The American Journal of Bioethics, Volume 11, Issue 11, Page 29-30, November 2011.