Attitudes of Oregon psychologists toward physician-assisted suicide and the Oregon Death With Dignity Act

Since the passage of the Oregon Death With Dignity Act (ODDA), psychologists have been grappling with how to fulfill their legally specified role in the process of physician-assisted suicide. We surveyed Oregon psychologists to elicit their views on assisted suicide and the process of assessing patients who request such assistance. There was a high degree of support for assisted suicide and the ODDA, but also a minority who were highly opposed. Most survey respondents raised ethical or practical concerns with their role as assessors. Many important questions about how evaluations in the complex area should be conducted remain unanswered.     

Death with Dignity: Fifty Years of Soul-Searching

The thesis of this paper is that there has been a gradual liberalization of thinking in the U.S. since the 1950's about what is morally allowable in how individuals control their own dying. The degree of liberalization will be plotted based on changes in public and professional opinion, landmark court cases, publication of books about dying, key players in the public eye, and the emergence of more organizations promoting death with dignity. More recent developments show a growing interest in finding better ways to respond to the needs of the dying. A final section speculates on the future of death with dignity.     

Psychological autopsies: methods and ethics

Essential knowledge on suicide is derived from studies that include interviews with survivors. In this paper, we discuss methodological and ethical issues pertaining to the interview method known as "psychological autopsy"; the discussion is based on our application of the method to three studies of suicides in Sweden and on a review of other investigations. Interviewing a survivor is a delicate matter, and the integrity of the deceased, the integrity and health of the informant, and the psychological strain on the interviewer must all be taken into consideration. The interviewer should have clinical experience in order to be prepared to deal with interviewees in grief. Contact by telephone, followed by an introductory letter, provides an opportunity to meet survivors in an empathic manner and has a low rejection rate. A 2- to 6-month interval between suicide and interview is recommended. The survivor's reactions to the interview should be evaluated in order to expand the empirical base for ethical considerations. Studies on the validity and reliability of the method are necessary.     

Strangers at the benchside: research ethics consultation

Institutional ethics consultation services for biomedical scientists have begun to proliferate, especially for clinical researchers. We discuss several models of ethics consultation and describe a team-based approach used at Stanford University in the context of these models. As research ethics consultation services expand, there are many unresolved questions that need to be addressed, including what the scope, composition, and purpose of such services should be, whether core competencies for consultants can and should be defined, and how conflicts of interest should be mitigated. We make preliminary recommendations for the structure and process of research ethics consultation, based on our initial experiences in a pilot program.     

Cultivating ethics consultation: commentary on "The development of a clinical ethics consultation service in a community hospital

Conclusion: Simpson's article [in this issue, p. 124-130] provides us with needed data about the development and utilization of an ethics consultation service in a community hospital. It makes clear, however, how much further we have to go in developing guiding standards for practitioners and institutions. We need to learn much more about the effectiveness of ethics consultation in meeting well-defined goals and producing desired processes and outcomes before standards for credentials and accountability have a sound empirical basis.     

Political and interpersonal aspects of ethics consultation

Previous papers on ethics consultation in medicine have taken a positivistic approach and lack critical scrutiny of the psychosocial, political, and moral contexts in which consultations occur. This paper discusses some of the contextual factors that require more careful research. We need to know more about what prompts and inhibits consultation, especially what factors effectively prevent house officers and nonphysicians from requesting consultation despite perceived moral conflict in cases. The attitudes and institutional power of attending medical staff seem important, especially where innovative interventions raise ethical questions. Ethics consultants also need to address the thorny problems of the origin(s) of the consultant's authority, whistleblowing, conflicts of interest that affect the consultant, persistently poor communications in hospitals, systemic inequity in the availability or quality of services for some, and the standing of the consultant's recommendations, including their appearance in the patient's medical record.     

Negotiating the moral order: paradoxes of ethics consultation

Ethics consultation at the bedside has been hailed as a better way than courts and ethics committees to empower patients and make explicit the value components of treatment decisions. But close examination of the practice of ethics consultation reveals that it in fact risks subverting those ends by interpolating a third (expert) party into the doctor-patient encounter. In addition, the practice of bioethics through consultation does the broader cultural work of fashioning a shared moral order in the face of manifestly plural individual commitments. In doing so, however, bioethics furthers medicine's position as a privileged domain of public moral discourse in contemporary American society.     

Credentialing and certification in ethics consultation: lessons from palliative care

In response to an article by Acres and colleagues, "Credentialing the Clinical Ethics Consultant: An Academic Medical Center Affirms Professionalism and Practice:" the authors urge continued action for the credentialing and certification of clinical ethics consultants. They also promote a vigorous and engaged model for ethics consultation.     

Inside baseball and ethics consultation: a comment on "ethics been very good to us"

In response to the article by Scofield, I consider the that, how, and why of ethics consultation, moral expertise, and the rules of the game. The question still to be engaged is, how does all of this work out for patients and families?     

Training in clinical ethics consultation: the Washington Hospital Center course

How can one be trained to enter the evolving field of clinical ethics consultation? The classroom is not the proper place to teach clinical ethics consultation; it is best done in a clinical setting. The author maps the elements that might be included in an apprenticeship, and sets out propositions for debate regarding the training needed for clinical ethics consultants and directors of clinical ethics consultation services. I was invited to be an observer of the first Intensive Course in Clinical Ethics at the Washington Hospital Center (WHC). I had no input into the planning. Having been present at a meeting of the Clinical Ethics Consultation Affinity Group of the American Society of Bioethics and Humanities (ASBH) when the issue of a lack of training programs was discussed, I was acutely aware of the need. Knowing how popular the various four-day intensive courses in bioethics have been, held at Georgetown University first, and then in Seattle and locations in the Midwest, it seemed time to have a four-day intensive course that was devoted to clinical ethics. The differences between bioethics and clinical ethics is substantial and largely unappreciated by those in bioethics. So when the WHC team agreed to take on the task of offering an intensive in clinical ethics, it was an important step for the field.