Certifying clinical ethics consultants: who pays?

The movement advocating the formal certification of clinical ethics consultants may result in major changes to the field of clinical ethics consultation by creating a new standard of care. The actual certification process is still in the development phase, but unanswered questions include: What will certification cost, and, Who will pay? Currently there is little salary support for ethics consultants and no regulation requiring healthcare institutions to offer clinical ethics consultation. Without the support of healthcare administrators and accreditation bodies, this may remain unchanged. Healthcare administrators may be unwilling to pay for certification or professional services if accreditation bodies do not require healthcare institutions to provide certified ethics consultants' services. If consultants will not be reimbursed or paid, they may not seek certification. If certified consultants are required, healthcare administrators may look for ways to cover the costs for providing this service, including insurance or third-party reimbursement and direct billing of patients for consultations, which may affect who performs and who participates in ethics consultation. However, this is less than ideal, as bioethicists believe ethics consultation should be available to all as part of providing safe, quality ethical care and support and guidance for patients, families, and healthcare staff. Going forward, bioethicists should study quality improvement, patient safety, and cost-savings resulting from certification-eligible clinical ethics consultants' activities. Administrators and financial personnel can be surveyed regarding their support for the certification process. Bioethicists should enlist the help of patient rights and safety advocacy groups, professional medical associations, and healthcare administrators. Bioethicists should invite accreditation bodies, healthcare administrators, and financial personnel to collaborate in the development of the certification process. Without their support, certification may be of value only to the bioethics community, and may have little standing in actual clinical healthcare institution settings.     

Selective appropriation, medical ethics, and health politics: the complementarity of Baker, McCullough, and me

Baker and McCullough (2007) criticize a 1979 article by this author for insufficiently appreciating how physicians have appropriated ideas from moral philosophy. This rejoinder argues that the two articles are complementary. The 1979 article summarized evidence that leading physicians in the nineteenth and twentieth centuries appropriated ideas from moral philosophy and related disciplines that reinforced their political goals of self-regulation and dominance of the allocation of resources for health. In retrospect the 1979 article also urged bioethicists to appropriate ideas from other disciplines, including moral philosophy, which would contribute to improving the health of populations.     

A Code of Ethics for Health Care Ethics Consultants: Journey to the Present and Implications for the Field

For decades a debate has played out in the literature about who bioethicists are, what they do, whether they can be considered professionals qua bioethicists, and, if so, what professional responsibilities they are called to uphold. Health care ethics consultants are bioethicists who work in health care settings. They have been seeking guidance documents that speak to their special relationships/duties toward those they serve. By approving a Code of Ethics and Professional Responsibilities for Health Care Ethics Consultants, the American Society for Bioethics and Humanities (ASBH) has moved the professionalization debate forward in a significant way. This first code of ethics focuses on individuals who provide health care ethics consultation (HCEC) in clinical settings. The evolution of the code's development, implications for the field of HCEC and bioethics, and considerations for future directions are presented here.     

Gene Doping and the Responsibility of Bioethicists

In this paper we will argue: (1) that scholars, regardless of their normative stand against or for genetic enhancement indeed have a moral/professional obligation to hold on to a realistic and up-to-date conception of genetic enhancement; (2) that there is an unwarranted hype surrounding the issue of genetic enhancement in general, and gene doping in particular; and (3) that this hype is, at least partly, created due to a simplistic and reductionist conception of genetics often adopted by bioethicists.     

A Legacy of Silence: Bioethics and the Culture of Pain

For over 20 years the medical literature has carefully documented the undertreatment of all types of pain by physicians. During this same period, as the field of bioethics came of age, the phenomenon of undertreated pain received almost no attention from the bioethics literature. This article takes bioethicists to task for failing to recognize the undertreatment of pain as a major ethical, and not merely a clinical, failing of the medical profession. The nature and extent of the problem of undertreated pain is examined, as well as possible reasons for its disregard by bioethicists. The factors contributing to undertreated pain in the clinical setting are considered, as well as the hazards posed by recent failures to address ethically questionable clinical practices. Finally, suggestions are offered for refocusing the attention of bioethicists to this significant problem.     

Prisoners’ competence to die: hunger strike and cognitive competence

Several bioethicists have recently advocated the force-feeding of prisoners, based on the assumption that prisoners have reduced or no autonomy. This assumed lack of autonomy follows from a decrease in cognitive competence, which, in turn, supposedly derives from imprisonment and/or being on hunger strike. In brief, causal links are made between imprisonment or voluntary total fasting (VTF) and mental disorders and between mental disorders and lack of cognitive competence. I engage the bioethicists that support force-feeding by severing both of these causal links. Specifically, I refute the claims that VTF automatically and necessarily causes mental disorders such as depression, and that these mental disorders necessarily or commonly entail cognitive impairment. Instead, I critically review more nuanced approaches to assessing mental competence in hunger strikes, urging that a diagnosis of incompetence be made on a case-by-case basis—a position that is widely shared by the medical community.     

Accountability and Community on the Internet: A Plea for Restorative Justice

In this article, I analyze norm enforcement on social media, specifically cases where an agent has committed a moral transgression online and is brought to account by an Internet mob with incongruously injurious results in their offline life. I argue that users problematically imagine that they are members of a particular kind of moral community where shaming behaviors are not only acceptable, but morally required to ‘take down’ those who appear to violate community norms. I then demonstrate the costs that are associated with this strategy; the most worrisome being those that distort the nature of moral dialog and the purpose and effectiveness of accountability practices online, creating a vitriolic and polarising online environment. Because of these negative consequences, I suggest that we ought to hold others accountable for restorative ends. I argue that restorative accountability practices can help us cultivate new norms online that rely less for their enforcement upon negative acts such as shame, and more upon positive acts that focus upon the most appropriate way to make amends to the victim(s) and the community. In this sense, restorative accountability incorporates important elements from the ethics of care, a relational ethics that values creating, promoting, and restoring good social and personal relationships. I conclude by arguing that accountability practices premised on the ethics of care produce better outcomes for the victim(s) of a moral violation, the transgressor, and the community.     

African American women—education for what?

The article examines the long commitment of the black community to the education of its women as a tool toward liberation and the resulting emergence of a new genre of American intellectualism. The article explores the role of women as carriers and creditors of African American culture in the community, while distinguishing between intellect workers (those who distribute and apply culture) and intellectuals (those who create culture). In addition, the article explores how African American women, while providing a perspective of their own, have been uniquely able to bridge the concerns of black men and white women. It is the emergence of this new American radical intellectualism, as represented by African American women, that potentially comprises a significant and critical force within the American ideology. This new intelligentsia, the article surmises, is only limited by the prejudices and discrimination present in a racist, sexist, and classist society.     

Responding to Those Who Hope for a Miracle: Practices for Clinical Bioethicists

Significant challenges arise for clinical care teams when a patient or surrogate decision-maker hopes a miracle will occur. This article answers the question, “How should clinical bioethicists respond when a medical decision-maker uses the hope for a miracle to orient her medical decisions?” We argue the ethicist must first understand the complexity of the miracle-invocation. To this end, we provide a taxonomy of miracle-invocations that assist the ethicist in analyzing the invocator's conceptions of God, community, and self. After the ethicist appreciates how these concepts influence the invocator's worldview, she can begin responding to this hope with specific practices. We discuss these practices in detail and offer concrete recommendations for a justified response to the hope for a miracle.     

The young women's network: a case study in community development

While young women have been found to be at additional risk for psychological morbidity after a breast cancer diagnosis, their specific needs in relation to support are not well described. A community development approach was utilized to develop the Young Women's Network, a peer support programme for young women who have been diagnosed with breast cancer that addresses their specific psychological and social needs. Central to this approach was the key role of the target group in both the definition of the problem and the generation of the solutions. This article describes the steps involved in developing this programme and guidelines for health professionals and community members who may wish to replicate either the Young Women's Network or this particular approach to programme development. Copyright © 2001 John Wiley & Sons, Ltd.     

Taking Representation Seriously: Rethinking Bioethics Through Clint Eastwood��s Million Dollar Baby

In this article, I propose a new model for understanding the function of representation in bioethics. Bioethicists have traditionally judged representations according to a mimetic paradigm, in which representations of bioethical dilemmas are assessed based on their correspondence to the "reality" of bioethics itself. In this article, I argue that this mimetic paradigm obscures the interaction between representation and reality and diverts bioethicists from analyzing the tensions in the representational object itself. I propose an anti-mimetic model of representation that is attuned to how representations can both maintain and potentially subvert dominant conceptions of bioethics. I illustrate this model through a case study of Clint Eastwood's film Million Dollar Baby. By focusing attention on the film's lack of adherence bioethical procedures and medical science, critics missed how an analysis of its representational logic provides a means of reimagining both bioethics and medical practice. In my conclusion, I build off this case study to assess how an incorporation of representational studies can deepen-and be deepened by-recent calls for interdisciplinarity in bioethics.     

The Role of Religious Leaders in Promoting Healthy Habits in Religious Institutions

The growing obesity epidemic in the West, in general, and the USA, in particular, is resulting in deteriorating health, premature and avoidable onset of disease, and excessive health care costs. The religious community is not immune to these societal conditions. Changing health behavior in the community requires both input from individuals who possess knowledge and credibility and a receptive audience. One group of individuals who may be uniquely positioned to promote community change but have been virtually ignored in the applied health and consulting psychology literature is religious leaders. These individuals possess extraordinary credibility and influence in promoting healthy behaviors by virtue of their association with time-honored religious traditions and the status which this affords them—as well as their communication skills, powers of persuasion, a weekly (captive) audience, mastery over religious texts that espouse the virtues of healthy living, and the ability to anchor health-related actions and rituals in a person’s values and spirituality. This article focuses on ways in which religious leaders might promote healthy habits among their congregants. By addressing matters of health, nutrition, and fitness from the pulpit and in congregational programs, as well as by visibly adopting the tenets of a healthier lifestyle, clergy can deliver an important message regarding the need for healthy living. Through such actions, religious leaders can be effective agents in promoting critical change in these areas.     

The Metaphysical Foundations of Reproductive Ethics

Many bioethicists working in reproductive ethics tacitly assume some theory of diachronic personal identity. For example, Peter Singer argues that there is no identity relation between a foetus and a future individual because the former shares no robust mental connections with the latter. Consequently, abortion prevents the existence of an individual; it does not destroy an already existing individual.
Singer's argument implicitly appeals to the psychological account of personal identity, which, although endorsed by many philosophers such as Derek Parfit, is contentious. Singer does not attempt to defend the psychological account before applying it to the moral permissibility of abortion. Indeed, with some notable exceptions, very few bioethicists attempt antecedently to defend their chosen theory of personal identity before applying it to their ethical arguments. In this paper, I look at the issues of abortion, embryonic stem cell research, and human reproductive cloning in order to illustrate how many of the arguments made by bioethicists on these topics are, at least partly, based upon veiled metaphysical assumptions. My objective is to illustrate that progress can be made on these topics by attending to their fundamental metaphysical claims.     

Coconstructing Mother–Infant Distress: The Microsynchrony of Maternal Impingement and Infant Avoidance in the Face-to-Face Encounter

This article takes a new look at the self-experience of creative artists. A five-step model of the creative process is put forth: preparation, inspiration, realization, completion, and objectification. The vicissitudes the creative self undergoes in each step are described, as well as the selfobject experiences needed to sustain the self through each phase. Of particular interest in this regard are the roles of the “muse” and of the artistic community. The article then describes three pathologies that the creative self is particularly prone to: addictions, vertical splits, and depression/isolation. The article concludes with a case example of a female patient who brought her paintings and stories into therapy.     

Feminist bioethics: toward developing a "feminist" answer to the surrogate motherhood question.

Although a wide variety of feminist approaches to bioethics presently share a common feminist methodology (sometimes referred to as "raising the woman question"), they do not all share the same feminist politics, ontology, epistemology, and ethics. As a result of their philosophical differences, feminist bioethicists do not always agree on which biomedical principles, practices, and policies are best suited to serving women's interests. In other words, some feminist bioethicists insist that so-called "assisted reproduction" enhances women's procreative liberty, while others claim that it does nothing of the sort. Although such disagreement among feminist bioethicists reassures the general public that the feminist "program" for bioethics is not ideologically monolithic, it also confuses the public, especially women. In order to overcome this confusion, feminist bioethicists should work toward developing the kind of shared theoretical base that will foster frequent consensus on the biomedical principles, practices, and policies most likely to serve the interests of most women in the U.S. today.     

Truly intensive clinical ethics immersion at the Washington Hospital Center

Opportunities for practical, hospital-based training in those skills demanded by clinical ethics consultation (CEC) have been limited. Given the number of individuals who provide part-time CEC, greater access to condensed, practical training such as the clinical ethics immersion course offered by the Washington Hospital Center, is necessary. Two participants in the initial cohort evaluate their CE training at a busy, urban referral center, exploring prior expectations, perceptions of its utility and suggestions for improvement. Such training will prove valuable not only for bioethicists who lack practical CEC experience "at the bedside" but also for ethics consultants whose ethics services have a low consult volume who wish to sharpen their skills.     

The Uses and Abuses of Moral Theory in Bioethics

Moral theory is an important guide to bioethical decision-making, but it can confuse and mislead those who offer ethical advice to clinicians and researchers, delaying decisions that must be made in a timely fashion. In this paper I examine the ways moral theory can lead bioethicists astray. Absent a sensitivity to the empirical realities of ethical problems, moral theory 1) contributes to the disappearance of the persons caught in an ethical quandary, 2) focuses on the puzzle-solving rather than examining the conditions that generate moral problems, and 3) universalizes ethical dilemmas, overlooking local processes for resolving moral questions. Taken together, empirically informed moral theory and theoretically informed empirical research can help bioethicists transcend the is/ought problem in ethical work.     

Attempting science: the creation and early development of the Institut métapsychique international in Paris, 1919-1931

In 1919, the Institut métapsychique international (IMI) held its first meeting in Paris. With their choice of a name, the founders made their intentions clear. By using the term métapsychique rather than the more common sciences psychiques, they indicated a departure from previous enterprises of such kind in France. By attaching the label international to it, they signified that this orientation was to affect not just French research on psychical phenomena, but that of the whole community. This article tells the story of the first 12 years of the IMI in its attempts to impose a program of research and to incorporate psychical phenomena into the scientific corpus in particular ways. The article ends in 1931 with a spectacular attempt by members of the IMI to dominate the international psychical research community. The failures of the IMI, both with psychical researchers and the scientific community in general, are explained here in terms of characteristics of the institute and the field itself.