Adam Peña

An Embedded Model for Ethics Consultation: Characteristics, Outcomes, and Challenges

Background: Little has been written about models for clinical ethics consultation. By “model” we mean the way in which the engagement between the clinical ethics consultant, hospital staff, and other stakeholders is structured, with a key variable being the degree of integration with stakeholders within the institution or segments of the institution. We describe an innovative model of clinical ethics consultation, which we term “embedded ethics,” involving embedding clinical ethics consultants within clinical specialties and subspecialties based on institutional needs and areas of clinical ethicists’ expertise. Methods: The overarching methodology for this article is a case study, reporting our experience with an intervention that we evaluated using mixed methods. Results: Our results underscore the positive impact that an embedded ethics intervention can have on consultation volume and intensity, as well as clinical staff perceptions of an ethics consultation service (ECS). Conclusions: Our experience with the embedded ethics model supports several intuitions about the benefits of adopting such a model for increasing awareness (and use) of the ECS as a resource for clinicians, patients, and families and of improving clinicians’ satisfaction.

“Systematizing” Ethics Consultation Services

While valuable work has been done addressing clinical ethics within established healthcare systems, we anticipate that the projected growth in acquisitions of community hospitals and facilities by large tertiary hospitals will impact the field of clinical ethics and the day-to-day responsibilities of clinical ethicists in ways that have yet to be explored. Toward the goal of providing clinical ethicists guidance on a range of issues that they may encounter in the systematization process, we discuss key considerations and potential challenges in implementing system-wide ethics consultation services. Specifically, we identify four models for organizing, developing, and enhancing ethics consultation activities within a system created through acquisitions: (1) train-the-trainer, (2) local capacity-building, (3) circuit-riding, and (4) consolidated accountability. We note each model’s benefits and challenges. To our knowledge, this is the first paper to consider the broader landscape of issues affected by consolidation. We anticipate that clinical ethicists, volunteer consultants, and hospital administrators will benefit from our recommendations.

Misinformed users: improving informed decision-making on social media.

Dear Editors, High-profile transplantation cases like Roel Marien continue to be the focus of international public debate on social networking sites (SNS) (e.g., Facebook) [1]. There has been little, if any, guidance from professional societies or agencies (e.g., UNOS, ESOT) about how to ensure the quality and reliability of information about organ donation and transplantation generally on SNS. Current regulatory frameworks do not address the potential impact of social media upon transplantation processes. This is problematic given that SNS is increasingly used as a vehicle for organ donation registration, via, for example, Facebook’s “Organ Donor” feature [2]. If users are exposed to misinformation about organ donation and transplantation, a significant ethical concern regarding informed consent and refusal is raised. The modest goal of this commentary is to briefly suggest strategies for the use of SNS as a mechanism for registration in a way that could foster informed decision-making. While the use of SNS can have a positive impact on organ donation initiatives (e.g., increased awareness of organ donation), SNS may also provide misinformation on a large scale [3]. For example, the Facebook forum, “Discussing Lung Transplantation and Sarah Murnaghan,” provides heavily biased information about the controversial decision to allocate adult lungs into a pediatric patient. One user commented, “Everyone is. . .horrified at Sarah’s outcome and no other child has gotten adult lungs (probably cause no one else wants to risk their child for an experiment) [4].” Given the efficiency and expediency of SNS, misinformation available to the general public is hard to control and can create confusion about transplant processes. Under the current model in the USA, individuals who want to become an organ donor can designate their status by means of a donor card or a driver’s license [3]. Recognizing the shortcomings of this approach, other authors argue in favor of improving existing mechanisms of registration [3]. With the pervasive use of social media, SNS have begun to serve as “more modern” mechanisms for consenting to be an organ donor [3,5]. A recent study concluded that one application generated a 21-fold increase in registrations over the baseline registration rate, proposing that SNS can increase donation rates [2]. Using SNS as mechanism of consent may promote uninformed decision-making, which could undermine autonomy-based principles [6]. National transplant societies and local health departments could collaboratively develop mechanisms to promote informed decision-making in the context of SNS: 1 National transplant societies could develop relevant criteria [7] for health departments to evaluate the credibility and quality of information on SNS within their respective countries (e.g., authorship). 2 National transplant societies could partner with SNS to create informational videos that automatically start once a user clicks on an SNS function as a mandatory step before a user can register online. 3 Built-in features on SNS could direct users to websites where information related to organ donation is subject to quality control (e.g., health department website). These strategies would help protect the integrity of transplant medicine while utilizing SNS to buttress informed decision-making about organ donation and transplantation for users of SNS.

Preventing the Predictable

Clinical ethicists should not agree to take this type of consultation because it could violate their professional obligations and professional integrity. The time constraints and communication barriers make it nearly impossible for the clinical ethicist to conduct a rich analysis that is well founded in information-gathering details. However, we recognize that the clinical ethicist in this case did agree to take the consultation, and that it would be counterproductive for us to argue the facts. Thus, we suggest that, based on the facts given, it may be ethically appropriate for the clinical ethicist to recommend a blood transfusion, assuming the surrogate is able to distinguish her husband’s preferences rather than her own interests. The ethicist can justify this recommendation by appealing to the surrogate’s intimate knowledge of her husband’s theological commitments and therapeutic preferences over the categorical SRF. On the other hand, if the ethicist has reservations about Mrs. N’s ability to make a substituted judgment, then he may promote the SRF over Mrs. N’s testimony. Whatever the ethicist’s conclusion—be it affirming, denying, or recusing—the ethicist should (1) help alleviate feelings of guilt Mrs. N may experience, (2) address the surgical team’s moral distress, and, looking forward, (3) work to prevent similar situation from occurring in the future (see Varisco and Scheinin [2015] and Pena [2015]). &

Same Goal, Different Path

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