Sufficiency of care in disasters: ventilation, ventilator triage, and the misconception of guideline-driven treatment

This essay examines the management of ventilatory failure in disaster settings where clinical needs overwhelm available resources. An ethically defensible approach in such settings will adopt a "sufficiency of care" perspective that is: (1) adaptive, (2) resource-driven, and (3) responsive to the values of populations being served. Detailed, generic, antecedently written guidelines for "ventilator triage" or other management issues typically are of limited value, and may even impede ethical disaster response if they result in rescuers' clumsily interpreting events through the lens of the guideline, rather than customizing tactics to the actual context. Especially concerning is the tendency of some expert planners to mistakenly assume that medical treatment of respiratory failure: (1) always requires full-feature mechanical ventilators, (2) will always occur in hospitals, and (3) can be planned in advance without sophisticated public consultation about likely ethical dilemmas.     

An ethical framework for the responsible management of pregnant patients in a medical disaster

The ethics of managing obstetric patients in medical disasters poses ethical challenges that are unique in comparison to other disaster patients, because the medical needs of two patients--the pregnant patient and the fetal patient--must be considered. We provide an ethical framework for doing so. We base the framework on the justice-based prevention of exploitation of populations of patients, both obstetric and non-obstetric, in medical disasters. We use the concept of exploitation to identify a spectrum from ethically acceptable, to ethically challenging, to ethically unacceptable, management of obstetric patients in medical disasters. We also address the ethics of the care of obstetric and neonatal patients when the resources of a hospital are completely overwhelmed in a large-scale medical disaster.     

The personal is the organizational in the ethics of hospital social workers

Understanding the social context of clinical ethics is vital for making ethical discourse central in professional practice and for preventing harm. In this paper, we present findings about clinical ethics from in-depth interviews and consultation with 7 members of a hospital social work department. Workers gave different accounts of ethical dilemmas and resources for ethical decision making than did their managers, whereas workers and managers agreed on core-guiding ethical principles and on ideal situations for ethical discourse. We discuss the research team's initial interpretations, the relevance of the extant ethics literature to organizational structures and dynamics, and alternative perspectives on clinical ethics.     

Taking seriously the "what then?" question: an ethical framework for the responsible management of medical disasters

When healthcare resources become overwhelmed in medical disasters, as they inevitably will, we have to ask, in an unflinching fashion, the question: "What then?" or more precisely, "What should we do when we run out of resources?" In a mass casualty event worthy of the designation, we will indeed run out of resources, perhaps quite quickly. This article provides an ethical framework for the responsible management of medical disasters in which the "What then?" question must be asked. The framework begins with a critique of existing guidance from professional associations of physicians and then argues for an alternative approach that qualifies the obligation to preserve life, takes seriously the ethical challenges of overwhelmed healthcare resources, and countenances physician-assisted suicide as a last resort.     

The Personal Is the Organizational in the Ethics of Hospital Social Workers

Understanding the social context of clinical ethics is vital for making ethical discourse central in professional practice and for preventing harm. In this paper we present findings about clinical ethics from in depth interviews and consultation with 7 members of a hospital social work department. Workers gave different accounts of ethical dilemmas and resources for ethical decision making than did their managers, whereas workers and managers agreed on core-guiding ethical principles and on ideal situations for ethical discourse. We discuss the research team's initial interpretations, the relevance of the extant ethics literature to organizational structures and dynamics, and alternative perspectives on clinical ethics.     

Complexity of ethical decision making in psychiatry

Psychiatric residents and psychiatrists have little difficulty in making judgments about a clinical course of action to take with patients. However, making ethical clinical decisions is more challenging, because psychiatric residents are usually provided little formal training in ethics. Further, many ethical dilemmas are complex, requiring knowledge of the psychiatric profession's ethics code, moral principles, law, and practice standards and of how they should be weighed in the decision-making process. The purpose of this article is to demonstrate this complexity in regard to the identification of potential ethical dilemmas, understanding the issues that these dilemmas raise, and formulating potential solutions to them. Two common but important areas of treatment in which ethical dilemmas arise (informed consent and competence of care) are used as examples for our presentation. The article demonstrates that to successfully engage in ethical analysis in psychiatry is impossible without substantial formal training in the process.     

A Survey of Ethical and Professional Challenges Experienced by Spanish Health-Care Professionals that Provide Genetic Counseling Services

Genetic testing is increasingly applied for diagnosis and clinical treatment. In some countries, genetic counseling services are provided by professionals with specific training in this discipline, whereas other countries have no teaching programs and counseling is offered by physicians, nurses, pharmacists or biochemists. This counseling raises more and more ethical dilemmas for health professionals at their clinics. The purpose of this study was to analyze the characteristics of Spanish professionals devoted to providing genetic counseling services and to investigate the frequency of the ethical dilemmas they face. Results from 72 survey respondents revealed this counseling is provided by an almost even number of male and female professionals, mostly physicians with many years of professional experience. The overall frequency of the ethical dilemmas encountered was not high. The most frequent dilemmas corresponded to emotional responses by patients, informed consent, uncertainty about test results, and limitations on health-care resources. The frequency of dilemmas involving discrimination and provider directiveness was very low. Additional findings, practice implications, and research recommendations are presented.     

面对临床无效治疗:思考与抉择

对于没有临床救治意义的病人 ,要不要继续治疗 ?这既是临床医疗问题 ,又是一个涉及社会、伦理、法规的问题。在社会多元化发展的今天 ,对于临床无效治疗无论放弃与否 ,都应当把维护病人的利益作为医疗活动的出发点。在此基础上 ,知情同意和尊重病人自主权是医务人员必须遵循的基本道德原则 ,同时也应当考虑卫生资源的有效分配和社会公众的健康利益     

The senior therapist's grandiosity: Clinical and ethical consequences of merging multiple roles

Grandiose senior therapists who knowingly foster treatment relationships that run counter to the wisdom and ethics of the field of psychotherapy can do harm to their patients. When practitioners merge the boundaries of treatment they simultaneously violate professional ethical codes and violate the frame of the analysis. Multiple role relationships often exploit patients' dependency while gratifying the narcissism of the senior therapist. The focus of this paper will be to explore the motivation and personality of senior therapists who are socially involved with their patients. The convergence of ethical and clinical problems related to multiple role relationships will be addressed also. Professionals may be able to resolve the problem through group process.     

Family participation in the care of patients in public health disasters

The ethical implications of disaster planning garner increasing scrutiny. The role of families in disaster efforts is a topic that requires additional ethical examination. This article reviews the potential roles for families before and during disasters, with particular attention to the impact on children and vulnerable elderly patients. The potential positive and negative impact of family participation in different aspects of healthcare and disaster efforts is assessed.     

Ethical considerations of integrating spiritual direction into psychotherapy

Integrating spirituality and religion into clinical practice or psychotherapy has become a significant area of interest in the mental health field today. This article focuses more specifically on integrating spiritual direction into psychotherapy, discusses ethical issues involved, and suggests ethical guidelines for the appropriate and helpful use of spiritual direction in the context of psychotherapy and counseling.     

‘Radical Interpretation’ and the Assessment of Decision‐Making Capacity

The assessment of patients' decision‐making capacity (DMC) has become an important area of clinical practice, and since it provides the gateway for a consideration of non‐consensual treatment, has major ethical implications. Tests of DMC such as under the Mental Capacity Act (2005) for England and Wales aim at supporting autonomy and reducing unwarranted paternalism by being ‘procedural’, focusing on how the person arrived at a treatment decision. In practice, it is difficult, especially in problematic or borderline cases, to avoid a consideration of beliefs and values; that is, of the substantive content of ideas rather than simple ‘cognitive’ or procedural abilities. However, little attention has been paid to how beliefs and values might be assessed in the clinical context and what kind of ‘objectivity’ is possible. We argue that key aspects of Donald Davidson's ideas of ‘Radical Interpretation’ and the ‘Principle of Charity’ provide useful guidance as to how clinicians might approach the question of whether an apparent disturbance in a person's thinking about beliefs or values undermines their DMC. A case example is provided, and a number of implications for clinical practice are discussed.     

An ethically justified framework for clinical investigation to benefit pregnant and fetal patients

Research to improve the health of pregnant and fetal patients presents ethical challenges to clinical investigators, institutional review boards, funding agencies, and data safety and monitoring boards. The Common Rule sets out requirements that such research must satisfy but no ethical framework to guide their application. We provide such an ethical framework, based on the ethical concept of the fetus as a patient. We offer criteria for innovation and for Phase I and II and then for Phase III clinical trials to improve the health of pregnant patients and of fetal patients and also criteria to responsibly manage the transition from investigation to clinical practice. Basing ethical criteria for research involving pregnant women on the ethical concept of the fetus as a patient insulates the proposed ethical framework and therefore research on pregnant women from the divisive and politicized concepts and discourses of personhood, fetal rights, and unborn child.     

Power and clinical psychology: a model for resolving power-related ethical dilemmas

This article considers power in clinical psychology. It is argued that power is present at every level of clinical psychologists' practice and can be used positively and negatively. Drawing on organizational, ethical, psychological, and personal influences, a heuristic problem-solving model for the process of understanding and resolving power-related ethical dilemmas is proposed. It is contended that such a model provides a humane and systematic process of understanding and working through power-related ethical dilemmas. It is argued that resolving power-related ethical issues cannot be achieved through the statement of absolute values but rather requires a process of understanding, action, and review. The model is used to draw out implications for promoting ethical practice and preventing the abuse of power in clinical psychology.     

When Psychotherapy Is Not Working: Ethical Considerations

Evidence-based practice (EBP) models have been developed, in part, to enhance the likelihood that the outcome of health care treatment, including psychotherapy, leads to positive improvement. However, two additional outcomes can occur: no change and poor outcome (e.g., harm, worsening of symptoms). What does the clinician do when psychotherapy is not working? When faced with various treatment decisions, such as this, the EBP model posits that therapists should apply their clinical expertise in considering the “best available research” within the context of various patient characteristics. In part because of various limitations of this approach, I suggest that another important set of principles are important to consider in tandem when faced with this clinical dilemma—that is, ethical concerns. Borrowing from the American Psychological Association’s (2017a) Ethics Code, I discuss how the following issues exist when clinicians wrestle with this question: avoidance of harm, competence, conflicts of interest, and informed consent. I conclude this paper with a list of suggestions that can potentially foster the application of ethical principles when making treatment decisions.     

Placebo effect and randomized clinical trials

The achievement of optimal therapeutic results presupposes the use of appropriate treatment combined with maximal utilization of placebo effects. These aims may sometimes be difficult to satisfy in randomized clinical trials (RCTs). The question thus arises whether there is a conflict between the goals of therapy and those of experimental research; and if so, to what extent, and how is it handled in practice by clinicians and researchers. Various ethical problems have been discussed in several reports connected with RCTs. But we have found no discussion concerning the conflict between obtaining informed consent and promoting optimal placebo effects. Information about RCTs can be given in various ways. Sometimes appropriate information about RCTs to patients involves non-optimal utilization of placebo effects. This gives rise to ethical and methodological problems, which are discussed in this article.     

辅助生殖技术引发的案例伦理分析

辅助生殖技术虽然给无数个不育夫妇带来了福音,但同时也给人类传统的伦理观念带来了冲击和挑战,同时它的滥用还可能给人类造成灾难。通过对由辅助生殖技术引发的7个典型案例的伦理分析和研究,来进一步探讨辅助生殖技术中伦理问题及其对策。     

Addressing the dual relationship problem in forensic and correctional practice

The dual relationship problem in forensic and correctional practice emerges from conflict between two sets of ethical norms: those associated with community protection and justice versus norms related to offender/defendant well-being and autonomy. The problem occurs because forensic practitioners typically have their professional roots in mental health or allied disciplines such as psychiatry, clinical psychology, social work, or law, and as such, often struggle to ethically justify aspects of forensic and/or correctional work. First, the problem of dual relationships will be described and its nuances explored. As will become apparent, the problem extends beyond the straightforward conflict of roles and resides at the very heart of professional practice. It is a core normative conflict created by practitioners varying ethical allegiances. Second, contemporary ways of resolving the dual relationship problem will be briefly outlined, that is, approaches that assert the primary of one set of codes over the other or involve the construction of hybrid ethical codes. Third, after briefly reviewing the shortcomings of these approaches I present a possible way forward drawing from relational ethics and the concept of moral acquaintances.     

Questionnement éthique dans la clinique de l’éveil de coma : un cheminement nécessaire au processus de subjectivation du patient et… du soignant

For the last six years, our clinical practice of patients in coma arousal care has led us to wonder about the subjective precariousness. In this clinical care, we must think about the ethical question of patient's subjective existence continuity. We wonder how the patient can be considered as a subject. On the one hand, it is based on the clinical and neuropsychological coma arousal care and on the other hand on particular patient–caregiver relationship, illustrated by a clinical situation. It seems that it depends on the ethical behaviour of the caregiver in front of a patient in an important subjective precariourness while the caregiver is powerful.     

How certain boundaries and ethics diminish therapeutic effectiveness

When taken too far, certain well-intentioned ethical guidelines can become transformed into artificial boundaries that serve as destructive prohibitions and thereby undermine clinical effectiveness. Rigid roles and strict codified rules of conduct between therapist and client can obstruct a clinician's artistry. Those anxious conformists who go entirely by the book, and who live in constant fear of malpractice suits, are unlikely to prove significantly helpful to a broad array of clients. It is my contention that one of the worst professional/ethical violations is to permit current risk-management principles to take precedence over humane interventions.