D. Micah Hester

The OHRP and SUPPORT

A group of medical ethicists and pediatricians asks for reconsideration of the recent Office for Human Research Protections decision about informed consent in SUPPORT.

The Great Debates

This CQ department is dedicated to bringing noted bioethicists together in order to debate some of the most perplexing contemporary bioethics issues. You are encouraged to contact “The Great Debates” department editor, D. Micah Hester ( hesterdm@uams.ed ), UAMS/Humanities, 4301 W. Markham St., #646, Little Rock, AR 72205, with any suggestions for debate topics and interlocutors you would like to see published herein.

Why We Must Leave Our Organs to Others

Organ procurement presents several ethical concerns (from what constitutes acceptable criteria for death to issues involved in specifically designating to whom an organ can be given), but none is more central than the concern for what are appropriate means for acquiring organs. The following discussion attempts a different perspective on the issue of organ procurement by arguing that, rather than appealing to our charitable consciences or our pocketbooks, relinquishing our organs after death in this day and age is, in fact, obligatory for most people. Each of us is pressed by the growing demand for our organs should we die “rightly,” and that desperate need has risen to such a level that not to release our organs for transplantation would constitute a serious moral wrong.

A Conceptual Model for the Translation of Bioethics Research and Scholarship.

While the bioethics literature demonstrates that the field has spent substantial time and thought over the last four decades on the goals, methods, and desired outcomes for service and training in bioethics, there has been less progress defining the nature and goals of bioethics research and scholarship. This gap makes it difficult both to describe the breadth and depth of these areas of bioethics and, importantly, to gauge their success. However, the gap also presents us with an opportunity to define this scope of work for ourselves and to help shape the broader conversation about the impact of academic research. Because of growing constraints on academic funding, researchers and scholars in many fields are being asked to demonstrate and also forecast the value and impact of their work. To do that, and also to satisfy ourselves that our work has meaningful effect, we must understand how our work can motivate change and how that change can be meaningfully measured. In a field as diverse as bioethics, the pathways to and metrics of change will likewise be diverse. It is therefore critical that any assessment of the impact of bioethics research and scholarship be informed by an understanding of the nature of the work, its goals, and how those goals can and ought to be furthered. In this paper, we propose a conceptual model that connects individual bioethics projects to the broader goals of scholarship, describing the translation of research and scholarly output into changes in thinking, practice, and policy. One of the key implications of the model is that impact in bioethics is generally the result of a collection of projects rather than of any single piece of research or scholarship. Our goal is to lay the groundwork for a thoroughgoing conversation about bioethics research and scholarship that will advance and shape the important conversation about their impact.

Guidance for healthcare ethics committees

Preface Part I. The Context of Healthcare Ethics Committee Work: 1. Introduction to healthcare ethics committees D. Micah Hester and Toby Schonfeld 2. Brief introduction to ethics and ethical theory D. Micah Hester and Toby Schonfeld 3. Ethics committees and the law Stephen Latham 4. Cultural and religious issues in health care Alissa Swota Part II. Consultation: 5. Mission, vision, goals: defining the parameters of the ethics consultation Marty Smith 6. Ethics consultation process Jeffrey Spike 7. Informed consent, shared decision making, and the ethics committee Randall Horton and Howard Brody 8. Decision-making capacity Art Derse 9. Family dynamics and surrogate decision making Lisa Soleymani Lehmann 10. Confidentiality Toby Schonfeld 11. Advance care planning and end-of-life decision making Nancy M. P. King and John Moskop 12. Medical futility Thaddeus Mason Pope 13. Ethical issues in reproduction Anne Drapkin Lyerly 14. Ethical issues in neonatology John Lantos 15. Ethical issues in pediatrics D. Micah Hester Part III. Policy Development and Organizational Issues: 16. Ethics committees and distributive justice Nancy Jecker 17. Developing effective ethics policy Anne Lederman Flamm 18. Implementing policy to the wider community Mary Faith Marshall and Joan Liaschenko 19. Ethics in and for the organization Mary Rorty Part IV. Educating Others: 20. The healthcare ethics committee as educator Kathy Kinlaw 21. Education as prevention Kayhan Parsi 22. Understanding ethics pedagogy Felicia Cohn Index.

End-of-Life Care and Pragmatic Decision Making: A Bioethical Perspective

1. Crito revised 2. Blindness, narrative, and meaning: moral living 3. Radical experience and tragic duty: moral dying 4. Needing assistance to die well: PAS and beyond 5. Experiencing lost voices: dying without capacity 6. Dying young: what interests do children have? 7. Caring for patients: cure, palliation, comfort, and aid in the process of dying.

Physician Deception and Patient Autonomy

Bennett Foddy (2009) argues in favor of the use of placebos when no (other) effective treatments exist. This is a controversial position that we challenge. We begin with a logical point. Foddy (2009) notes “a strong and growing consensus” on the efficacy of placebos “as treatments for. . . unpleasant psychological symptoms” (4). Later he claims that “[P]lacebos are not, strictly speaking, a treatment” because they “perform no action on a person’s body” (4). But if placebos are not a treatment, then it is difficult to make sense of Foddy’s repeated claim that they are, under certain conditions, the best treatment option. An equivocation runs throughout the target article. On the one hand, Foddy states that placebos are not treatment because they are physiologically inert; on the other hand, he champions the use of placebos as treatment on the grounds that they are efficacious psychologically. The equivocation may seem harmless enough; however, it plays a pivotal role in covering over presuppositions and confusions in Foddy’s overall argument. It is important to note that Foddy’s (2009) argument is not about placebos per se, but deception by health care professionals—specifically physicians. In fact, though Foddy notes that placebos (as pills) trade off a “conditioned association between treatment and benefit” (4), one could run his argument, mutatis mutandis, for any physiologically inert item or practice; on Foddy’s view, given the right circumstances, physicians may have a duty to prescribe chanting, crystals, séances, or even donating large sums of money to a guru. The crucial datum for Foddy is that deception, when appropriately executed, can have beneficial medical consequences. He argues that, for some conditions, no (other) effective treatments exist, and deception has at least some chance of creating a positive/beneficial outcome. Therefore, he concludes, deception is warranted. The view that under certain circumstances physicians should deceive their patients raises worries concerning patient autonomy. Foddy (2009) is understandably eager to allay these concerns. He argues that there are two reasons why the use of placebos when (other) treatments are not available cannot be seen as an act of limiting or coercing choice. First, choice is not limited by deception because no other alternatives exist. Second, deception is not coercive because placebos are not, in fact, a treatment and coercion implies forced treatment. So while a patient might refuse to a round of chemotherapy because it has toxic side effects,

Professing Public Health: Practicing Ethics and Ethics as Practice

This essay attempts to bring ethical and public health practices together in order to show that good, ethical deliberation is, by nature of the profession, good public health practice. I attempt to reconstruct some of the ethical tensions between individuals and communities by undermining the classical Enlightenment liberal notion of the self with a concept of self as social product. Such an understanding of the self does justice to the ethical character of public health practices and gives a different, more effective perspective on how to approach deliberation of public health concerns.

What Is a Parent to Do?: The Case of Baby G.

Born at 24 weeks gestation, Baby G now lies in a neonatal intensive care unit two months post-birth. He has pulmonary hypoplasia, congenital scoliosis, and swallowing issues that will require placement of a feeding tube, and bowel dystonia that interferes with his ability to absorb feedings. Shortly after birth, he experienced a cardiopulmonary arrest and now has obvious neurological impairments. As a result of incomplete development of his lungs and severe chronic lung disease, he cannot breathe on his own. Because of his chronic respiratory failure, tracheostomy and long-term assisted ventilation was offered as an option that would allow him to be discharged from the acute care setting. However, his congenital scoliosis and severe neurocognitive impairments mean that he has little potential for eventual weaning from assisted ventilation. While there are surgeries available to correct his scoliosis, the outcome of such surgeries is uncertain; they could not be performed before two to three years of age, and the risks are increased due to his pulmonary co-morbidities.

What Constitutes a Just Match?: A Reply to Murphy

In April of 2001 I published a brief commentary in the journal Academic Medicine questioning the current character and functioning of the National Residency Matching Program (or “the match,” as it is known in medical schools and teaching centers). The purpose of the article was to stimulate a rethinking of process. At 50 years old, the environment through which the match operates (and has helped to create) has changed, and as such I thought it time to ask ourselves whether or not the match, its algorithm, and, more important, the values it manifests might well need an overhaul.