Δευτέρα, 10 Ιουνίου 2019

HEC Forum is an international, peer-reviewed publication featuring original contributions of interest to practicing physicians, nurses, social workers, risk managers, attorneys, ethicists, and other HEC committee members. Contributions from all pertinent sources are included, written in a style written appealing to HEC members and lay readers. HEC Forum publishes essays and research papers, and includes such sections as Essays on Substantive Bioethical/Health Law Issues; Analyses of Procedural and Operational Committee Issues; Document Exchange; Special Articles; International Perspectives; Mt./St. Anonymous: Cases and Institutional Policies; Point/Counterpoint Argumentation; Case Reviews, Analyses, and Resolutions; Chairperson's Section; `Tough Spot'; Critical Annotations; Health Law Alert; Network News and Letters to the Editors. HEC Forum is an official partner journal of the American Society for Humanities + Bioethics: http://www.asbh.org/

The Clinical Ethics Consultant: What Role is There for Religious Beliefs?


Religions often operate as comprehensive worldviews, attempting to answer the deepest existential questions that human beings can ask: Who am I? Where do I come from? Where am I going after I die? How should I live? Often ethical systems are embedded and justified within these broader narratives. Inevitably, the clinical ethics consultant will encounter and engage with religiously based ethical systems. In this issue, the authors reflect seriously and deeply on the implications of such engagement.

The Appropriate Role of a Clinical Ethics Consultant's Religious Worldview in Consultative Work: Nearly None


Ethical reasoning is an integral part of the work of a clinical ethics consultant (CEC). Ethical reasoning has a close relationship with an individual's beliefs and values, which, for religious adherents, are likely to be tightly connected with their spiritual perspectives. As a result, for individuals who identify with a religious tradition, the process of thinking through ethical questions is likely to be influenced by their religious worldview. The connection between ethical reasoning and one's spiritual perspective raises questions about the role that CECs' personal religious worldviews should play in their professional lives and their consultative work. This paper offers numerous arguments critiquing the inclusion of a consultant's own spiritual perspective in her work and has identified only limited circumstances under which such inclusion might be permissible. In particular, these arguments lead to the conclusion that a CEC's personal beliefs should never influence her ethical analysis or development of a recommendation. Further, religious appeals should not be used in communication during decision-making conversations other than to describe the patient or surrogate's stated perspective. There may be limited cases in which a CEC may share her spiritual worldview with a patient with the intent of building a collaborative relationship, but such situations should be approached with extreme caution.

Moral Conflicts and Religious Convictions: What Role for Clinical Ethics Consultants?


Moral conflicts over medical treatment that are the result of differences in fundamental moral commitments of the stakeholders, including religiously grounded commitments, can present difficult challenges for clinical ethics consultants. This article begins with a case example that poses such a conflict, then examines how consultants might use different approaches to clinical ethics consultation in an effort to facilitate the resolution of conflicts of this kind. Among the approaches considered are the authoritarian approach, the pure consensus approach, and the ethics facilitation approach described in the Core Competencies for Healthcare Ethics Consultationreport of the American Society for Bioethics and Humanities, as well as a patient advocate approach, a clinician advocate approach, and an institutional advocate approach. The article identifies clear limitations to each of these approaches. An analysis of the introductory case illustrates those limitations, and the article concludes that deep-seated conflicts of this kind may reveal inescapable limits of current approaches to clinical ethics consultation.

Religion, Authenticity, and Clinical Ethics Consultation


A clinical ethics consultant (CEC) may, at times, be called upon to make independent substantive moral judgments and then offer justifications for those judgments. A CEC does not act unprofessionally by utilizing background beliefs that are religious in nature to justify those judgments. It is important, however, for a CEC to make such judgments authentically and, when asked, to offer up one's reasons for why one believes the judgment is true in a transparent fashion.

When Religion and Medicine Clash: Non-beneficial Treatments and Hope for a Miracle


Patient and family demands for the initiation or continuation of life-sustaining medically non-beneficial treatments continues to be a major issue. This is especially relevant in intensive care units, but is also a challenge in other settings, most notably with cardiopulmonary resuscitation. Differences of opinion between physicians and patients/families about what are appropriate interventions in specific clinical situations are often fraught with highly strained emotions, and perhaps none more so when the family bases their desires on religious belief. In this essay, I discuss non-beneficial treatments in light of these sorts of disputes, when there is a clash between the nominally secular world of fact- and evidence-based medicine and the faith-based world of hope for a miraculous cure. I ask the question whether religious belief can justify providing treatment that has either no or a vanishly small chance of restoring meaningful function. I conclude that non-beneficial therapy by its very definition cannot be helpful, and indeed is often harmful, to patients and hence cannot be justified no matter what the source or kind of reasons used to support its use. Therefore, doctors may legitimately refuse to provide such treatments, so long as they do so for acceptable clinical reasons. They must also offer alternatives, including second (and third) opinions, as well the option of transferring the care of the patient to a more accommodating physician or institution.

When Religious Language Blocks Discussion About Health Care Decision Making


There is a curious asymmetry in cases where the use of religious language involves a breakdown in communication and leads to a seemingly intractable dispute. Why does the use of religious language in such cases almost always arise on the side of patients and their families, rather than on the side of clinicians or others who work in healthcare settings? I suggest that the intractable disputes arise when patients and their families use religious language to frame their problem and the possibilities of solution. Unlike clinicians, they are not bilingual and thus lack the capacity to understand and negotiate differences in terms that are responsive to those who work in healthcare settings. After considering a representative case, I explore whether an ethics consultant or chaplain can function as a translator and suggest that, at best, such efforts at mediation depend on contingent aspects of a case and will only be partially successful. To appreciate limits on the role for bilingual translators, I consider a futility dispute where a parent using religious language demands that everything be done for a permanently unconscious child. I challenge the traditional interpretation that says the parent values "mere duration of biological life irrespective of quality." From a religious perspective, human life is never "merely biological." This effort to slot the dispute into standard philosophical schemas misses what is crucial in the dispute. I suggest that a better interpretation views the dispute at a meta-level as one about whether withholding and withdrawing care is morally distinguishable from killing. Curiously, this interpretation makes the advocate of futile care into an ally of those "quality of life" advocates who also challenge this distinction. The crux of their dispute now rests on the normative ethics of killing. While I think my interpretation comes much closer to the views of many who demand 'futile care,' I suggest that it still falls short because of the way it reconstructs the religious concerns in nonreligious terms. I close by considering an analogy between the language of suffering and the language of faith, suggesting that both require a much richer understanding of the narratives that orient the lives of patients and their families.

Integrative Clinical Ethics Support in Gender Affirmative Care: Lessons Learned


Clinical ethics support (CES) for health care professionals and patients is increasingly seen as part of good health care. However, there is a key drawback to the way CES services are currently offered. They are often performed as isolated and one-off services whose ownership and impact are unclear. This paper describes the development of an integrative approach to CES at the Center of Expertise and Care for Gender Dysphoria (CEGD) at Amsterdam University Medical Center. We specifically aimed to integrate CES into daily work processes at the CEGD. In this paper, we describe the CES services offered there in detail and elaborate on the 16 lessons we learned from the process of developing an integrative approach to CES. These learning points can inform and inspire CES professionals, who wish to bring about greater integration of CES services into clinical practice.

Talking the Talk: Enhancing Clinical Ethics with Health Literacy Best Practices


A significant proportion of the U.S. population exhibits low health literacy. Evidence suggests that low health literacy is correlated with higher medical costs and poorer health outcomes. Even more concerning, evidence suggests that low health literacy threatens patients' and families' autonomy and exacerbates injustices in patients who are already vulnerable to difficulties navigating the health care system. There is also, however, increasing evidence that health literacy interventions—including initiatives such as plain language practices and teach-back—improve comprehension and usefulness of health care information. I show how health literacy best practices can enhance the work of clinical ethicists in their primary roles of policy, consultation, and education. In the final section, I suggest ways health literacy initiatives may be enhanced with insights from clinical ethicists.

Professionalism: An Archaeology


For more than two decades, classes on "professionalism" have been the dominant platform for the non-technical socialization of medical students. It thus subsumes elements of previous foundation courses in bioethics and "medicine and society" in defining the appropriate relation between practitioners, patients, and society-at-large. Despite its importance, there is, however, no clear definition of what "professionalism" entails or the manner in which it serves various purported goals. This essay reviews, first, the historical role of the vocational practitioner in society, and second, the introduction of "professionalism" as a newly constituted, core value in teaching. The structure of the paper is as an archaeology, a Foucauldian term for an investigation of seemingly separate but related antecedent contexts and ideas whose result is a perspective or point of view. The goal thus is an attempt to precisely locate "professionalism" within the greater history of medicine and its contemporary role in medical socialization.

Parental Decision Making: The Best Interest Principle, Child Autonomy, and Reasonableness


On what basis should we judge whether a parent's medical decision for their child is morally acceptable? In a recent article, Johan Bester attempts to answer this question by defending a version of the Best Interest Standard (BIS) for parental decision making. The purpose of this paper is to identify a number of problems faced by Bester's version of BIS and to suggest ways to redress these problems. Accordingly, we intend to advance the project of formulating a method for guiding parents' medical decision making for their children. We argue that Bester's standard fails to accommodate the autonomy of the child and that his criteria for assessing the reasonableness of the parents' argument for their decision is too weak. We conclude that properly addressing these worries renders his test otiose and that it ought to be replaced with the three commonly held principles of bioethics—the principles of autonomy, beneficence, non-maleficence—and a standard of reasonableness.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos

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