Original Contribution

Edmund G. Howe

The Journal of Clinical Ethics 21, no. 1 (Spring 2010): 3-13.

Abstract

    The author suggests that a "first generation" task in bioethics is to give patients the information they need; a "second generation" task is to do this in the most effective way; and a "third generation" task is to avoid harming patients by imposing value biases. The author discusses ways to pursue this third generation task.

Original Contribution

Martin L. Smith, Richard R. Sharp, Kathryn L. Weise, and Eric Kodish

The Journal of Clinical Ethics 21, no. 1 (Spring 2010): 14-22.

Abstract

    While consensus exists among many practitioners of ethics consultation about the need for and identification of core competencies and standards, there has been virtually no attempt to determine how these competencies and standards are best taught and assessed. We believe that clinical ethics consultation has reached a state of sufficient maturity that expert practitioners can evaluate those who are new to the field. We will outline several steps that can facilitate the creation of a certification process for clinical ethics consultants, assuring the competency and quality of consultation for the patients, families, and healthcare professionals who utilize ECSs.

Original Contribution

Chris Kaposy

The Journal of Clinical Ethics 21, no. 1 (Spring 2010):23-9.

    In a pandemic situation, resources in intensive care units may be stretched to the breaking point, and critical care triage may become necessary. In such a situation, I argue that a patient’s combined vulnerability to illness and social disadvantage should be a justification for giving that patient some priority for critical care. In this article I present an example of a critical care triage protocol that recognizes the moral relevance of vulnerability to illness and social disadvantage, from the Canadian province of Newfoundland and Labrador.

Original Contribution

Daniel Kim, Kristin Schleiter, Bette-Jane Crigger, John W. McMahon, Regina M. Benjamin, and Sharon P. Douglas, for the Council on Ethical and Judicial Affairs, American Medical Association

The Journal of Clinical Ethics 21, no. 1 (Spring 2010): 30-5.

Abstract

    The Council on Ethical and Judicial Affairs of the American Medical Association examines physicians’ professional ethical responsibility in the event that the security of patients’ electronic records is breached.

    A physician’s obligation to respect confidentiality and guard a patient’s privacy is a well-established principle of professional ethics that dates back to the Hippocratic Oath.1 The American Medical Association (AMA) Code of Medical Ethics, in Opinion E-5.07, "Confidentiality: Computers," sets out precautionary steps to protect the confidentiality of electronically stored health information.2 Current AMA policies do not address, however, physicians’ ethical responsibilities in the event that the security of electronic records is breached and patients’ data are inappropriately accessed. This report examines physicians’ professional ethical responsibility in this area.

Original Contribution

Valerie Satkoske and Lisa S. Parker

The Journal of Clinical Ethics 21, no. 1 (Spring 2010): 36-8.

Abstract

    Implementation of guidelines regarding breaches of electronic health information requires an anticipatory stance and physician and patient education regarding security and monitoring measures and methods of redress. Adopting a preventive ethics, rather than a crisis management, model may also increase physician awareness of how the information they choose to include and privilege within the health record may expose patients to added harms if not done mindfully.

Original Contribution

Robert M. Sade

The Journal of Clinical Ethics 21, no. 1 (Spring 2010): 39-41.

Abstract

    Breaches of electronic medical records constitute a type of healthcare error, but should be considered separately from other types of errors because the national focus on the security of electronic data justifies special treatment of medical information breaches. Guidelines for protecting electronic medical records should be applied equally to paper medical records.

    The American Medical Association (AMA) Council on Ethical and Judicial Affairs (CEJA) provides guidelines for the first time on how physicians should respond to a breach in the security of an electronic medical record (EMR). In their report, "A Physician’s Role Following a Breach of Electronic Health Information," CEJA recommends that physicians do what they can to ensure that a breach of an EMR is reported to the patient promptly, along with a description of how the breach occurred, what information was disclosed, the potential consequences of the breach, any corrective actions that have been undertaken by responsible individuals or agencies, and how the patient might help to minimize adverse consequences. At all times, the report emphasizes, the physician should hold the patient’s interests above those of the physician and any group or institution.

    The recommendations that appear at the end of CEJA reports become an opinion in the Code of Medical Ethics (the Code), a body of ethical guidelines that is widely used by state medical licensing boards and by courts at various levels of jurisdiction in adjudicating allegations of physicians’ ethical transgressions. Therefore, this report is important and is worthy of close scrutiny.

Original Contribution

Sharona Hoffman

The Journal of Clinical Ethics 21, no. 1 (Spring 2010): 42-43.

Abstract

The American Medical Association Council on Ethical and Judicial Affairs (CEJA) has written a position paper on physicians’ ethical responsibilities in the event that the security of patients’ electronic health information has been breached. The report offers compelling ethical and practical justifications for notification requirements and articulates guidelines for clinicians. This commentary addresses a gap in the report. It outlines the new legal duty to disclose security breaches, established by the 2009 HITECH Act, which is only briefly mentioned in the report. The commentary also analyzes the CEJA recommendations in light of the legal mandate and suggests that the guidance would benefit from further clarification.

Original Contribution

S. Van McCrary

The Journal of Clinical Ethics 21, no. 1 (Spring 2010): 44.

    An original poem.

Original Contribution

Rebecca L. Volpe

The Journal of Clinical Ethics 21, no. 1 (Spring 2010): 45-57.

Abstract

    Informed consent is the practical application of the principle of autonomy, and two of the five core features of informed consent are related to information. Researchers have reported on patients’ expressed needs for information, such as their stated desires for the quantity of and the source of information. A separate body of research has examined patients’ unexpressed needs for information from the perspective of cognitive psychology, such as the emotional tone and order of information. This article suggests that the autonomy of patients is best served by meeting their expressed and unexpressed information needs in tandem.

Original Contribution

Michele J. Karel, Ronald J. Gurrera, Bret Hicken, and Jennifer Moye

The Journal of Clinical Ethics 21, no. 1 (Spring 2010): 58-71.

Abstract

    Purpose. To examine the contribution of "values-based reasoning" in evaluating older adults’ capacity to make medical decisions.

    Design and Methods. Older men with schizophrenia (n=20) or dementia (n=20), and a primary care comparison group (n=19), completed cognitive and psychiatric screening and an interview to determine their capacity to make medical decisions, which included a component on values. All of the participants were receiving treatment at Veterans Administration (VA) outpatient clinics.

    Results. Participants varied widely in the activities and relationships they most valued, the extent to which religious beliefs would influence healthcare decisions, and in ratings of the importance of preserving quality versus length of life. Most participants preferred shared decision making with doctor, family, or both. Individuals with schizophrenia or dementia performed worse than a primary care comparison group in reasoning measured by the ability to list risks and benefits and compare choices. Individuals with dementia performed comparably to the primary care group in reasoning measured by the ability to justify choices in terms of valued abilities or activities, whereas individuals with schizophrenia performed relatively worse compared to the other two groups. Compared to primary care patients, participants with schizophrenia and with dementia were impaired on the ability to explain treatment choices in terms of valued relationships.

    Conclusion. Medical decision making may be influenced by strongly held values and beliefs, emotions, and long life experience. To date, these issues have not been explicitly included in structured evaluations of medical decision-making capacity. This study demonstrated that it is possible to inquire of and elicit a range of healthcare related values and preferences from older adults with dementia or schizophrenia, and individuals with mild to moderate dementia may be able to discuss healthcare options in relation to their values. However, how best to incorporate a values assessment into a structured capacity evaluation deserves further research attention.

Original Contribution

Thaddeus Mason Pope

The Journal of Clinical Ethics 21, no. 1 (Spring 2010): 72-82.

Abstract

    This issue’s "Legal Briefing" column covers legal developments pertaining to informed consent. Not only has this topic been the subject of recent articles in this journal, but it also been the subject of numerous public and professional discussions over the past several months.

    Legal developments concerning informed consent can be usefully grouped into nine categories:

Original Contribution

Thaddeus Mason Pope

The Journal of Clinical Ethics 21, no. 1 (Spring 2010): 83-5.

Abstract

    This column concisely reviews: significant legal developments concerning medical futility and assisted suicide; three late-2009, early 2010 court cases involving neonatal medical futility disputes; and a number of cases involving the criminal enforcement of assisted suicide laws, as well as recent court cases and legislation aimed to legalize assisted suicide.

    "Legal Briefing" provides a more comprehensive summary of legal developments on one or two issues, while "Legal Update" more concisely reviews significant recent legal developments that affect clinical bioethics. In the past several months, there have been notable developments concerning medical futility and assisted suicide.

Correspondence

John V. Geisheker

The Journal of Clinical Ethics 21, no. 1 (Spring 2010): 86-8.

    A letter to the editor.