Erin A. Egan

The clinical response to brain death : A policy proposal

ABSTRACT The ethical and scientific literature reflects a certain amount of controversy and confusion surrounding the concept of death by neurological criteria, or brain death. The issues surrounding brain death occur with limited frequency for those working in acute critical care settings. Even so, the literature and our own experiences evidence the discomfort of caregivers and policymakers when dealing with brain-dead patients and their family and loved ones. One particular area in which there seems to be significant diversity of opinion is what should occur when death by neurological criteria is pronounced. At some hospitals, when the patient is pronounced dead by neurological criteria, the support equipment is removed from the body immediately and the body is prepared for visitation by family or is transported to the morgue. In other hospitals, support equipment is maintained for a certain limited period to allow the family to be present when the equipment is ultimately removed. In general, however, it appears that institutional guidelines and policy are vague, at best, or often silent about the issue of when, how, and, to some extent, who decides what is done with the body. This policy paper discusses the confusion of care providers as well as lay persons related to the general concepts of death by neurological criteria. In addition, alternative approaches to the withdrawal of support equipment are examined. This article may also allow nursing administrators to better understand the importance of establishing specific clinical guidelines for their staff related to patients declared dead by neurological criteria. Our conclusion is that a universal policy should be adopted whereby all institutions develop the same guidelines concerning when and how treatment modalities should be withdrawn on their brain-dead patients. Such policy guidelines may not extinguish the misconceptions, misunderstandings, and discomforts that are present with a diagnosis of brain death, but it would certainly allow for more consistent actions on the part of the caregivers. Consistency would substantially benefit caregivers, families, and society alike.

Ethics Training in Graduate Medical Education

highly accessible and oexible. I sought out the web-based program from Loyola University Chicago. A high-quality web-based program like the one at Loyola can make the traditional commuter graduate program seem cumbersome and inefacient by comparison. Using e-mail and online “classroom” environments, students can plan their activities and interact at times convenient to them, the faculty, and other students. Multiple teaching methods such as lectures, journal articles available by electronic reserve, CD-ROM and DVD recordings, real-time chats, and group assignments keep the program from becoming too routine. (I might add that online learning could become monotonous if the instructors are not motivated to be creative regarding formats and assignments. Fortunately, I have not found this to be an issue in Loyola’s program.) I believe the development of on-line programs can lead to a much wider dispersal of knowledge and expertise among professionals working in healthcare settings and can eventually lead to an improvement in the ethical care of patients and staff at healthcare facilities around the country and the world.

Clinical Ethics and Patient Safety

Patient safety and ethics are interrelated concepts. Clinical ethics is similar to other clinical practices and can be evaluated and improved using basic quality improvement principles. Distilling ethical issues clinically can be facilitated by identifying specific elements of safety and how they are affected by the ethical concerns. In addition, promoting patient safety rests on core ethical principles ubiquitous in medicine—the professional duties to provide benefit and prevent harm. Tying these ethical principles to quality and safety analysis has been a strong motivator in quality and safety improvement. Further, describing safety issues in terms of ethical responsibilities has the potential to motivate individual providers to improve quality and safety within their personal practice.

Organizational ethics in residency training: moral conflict with supervising physicians.

It is inevitable that physicians in training will be exposed to behavior by supervising physicians that the trainees find unethical. By nature these events are rare. It is imperative within any residency training program that resident physicians have immediate access to a meaningful review process in cases of moral conflict with supervising physicians. Here, I discuss the reasons why this issue must be recognized and what it entails. Most important, I discuss the procedural steps that are essential for the training program to make this a meaningful safety mechanism in residency training. This issue is central to promoting conscious development of professionalism in clinical training. Physicians in training, especially resident physicians, need to be taught to value and protect their own professional integrity. The responsibility for fulfilling this ethical duty falls on the individual residency programs as well as the administrative organizations that regulate residency training. Thus, ensuring this process of review is an organizational ethical imperative. Availability of this process is fundamental to promoting and ensuring ethical behavior by all participants in residency training.

Patents: The Public Interest versus the Private Privilege

Pharmaceutical companies have become a favorite whipping boy of physician groups, consumer activists, and certain politicians. These companies spend a great deal on the advertising and marketing of their products, but they also make a lot of money and have one of the highest proat margins of any industry. Yet, as David Resnik and Kenneth De Ville (2002) carefully argue, making a lot of money is no crime.1 In fact, this strong anancial incentive is what drives drug makers to spend millions of dollars in research and development, looking for that breakthrough drug that will give their investors impressive returns. Why should the government ever have the moral authority to abrogate a pharmaceutical company’s patent, thereby jeopardizing this implicit incentive scheme? Resnik and De Ville provide a useful analytical framework in determining whether the federal government should ever have the moral authority to override the intellectual property rights of pharmaceutical companies. They offer a utilitarian justiacation for deferring to these property rights. They concede, however, “that these rights are not absolute and can be violated to promote social values or state interests under certain conditions.” Their argument is carefully constructed in that they are not just defending the intellectual property rights of pharmaceutical companies but are also concerned about the potential fruits of pharmaceutical research and development that can potentially help the public. This prompts us to ask a few questions: what is the nature of a patent right? Are pharmaceutical products different from other patented products? Does existing law already provide adequate compensation for governmental takings? Considering that even civil liberties may be curtailed during times of national emergency, do property rights merit more protection? Patents are complex legal entities. Black’s Law Dictionary deanes a patent as “[t]he exclusive right to make, use, or sell an invention for a speciaed period (usu. 17 years), granted by the federal government to the inventor if the device or process is novel, useful, and nonobvious” (Garner 1999). As Resnik and De Ville discuss, the rationale behind granting a patent is not primarily to reward the inventor, but rather to encourage public disclosure of an invention so that when the patent expires, the public can have free access to the invention (Kintner and Lahr 1975). The ultimate goal of the patent process is to serve the public interest. One commentator has dubbed the tension here as the “incentives-access paradigm” that is at the heart of the intellectual property debate (Lunney 1996). A tension arises between the goal of incentivizing people to create useful products for the public while assuring that the public has access to these products. This balancing act becomes even more controversial and political when the products are not just luxury consumer goods but pharmaceutical products that can potentially save lives. This brings us to our second question: are pharmaceuticals in a different moral category from the majority of patented products? Resnik and De Ville lump pharmaceuticals with other “vital” products, such as computer software, computer hardware, research databases, and automobiles. One would be hard-pressed, however, to equate a potentially life-saving drug with a car or even a computer. The fact that pharmaceutical products may have an inherent and immediate impact upon the health and safety of the public puts them in a different moral category. If anything, the onus should be placed upon the patent holder of a potentially life-saving product to show why the product’s patent should not be overridden if the government wishes to override the patent during a public emergency. Aside from the overriding importance of public health and safety, current patent law and remedies adequately protect intellectual property interests when the government chooses to override a patent. First, a patent is not an absolute right but a privilege granted by the government. The government can therefore reasonably limit the scope of the privilege in the interest of the public. In addition, the existing law already provides adequate compensation for governmental takings. Finally, considering that some commentators have defended the curtailment of certain civil liberties during times of national emergency, property rights should not merit even more protection (Posner 2001). The current law adequately protects companies in the event of compulsory licensure. As Resnik and De Ville point out, compulsory licensure is a “taking” by the gov-

Patient safety and medical error: a constant focus in medical ethics.

The theme editor introduces a special issue that examines patient safety and medical errors. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

An impaired resident.

Physicians and physicians-in-training have a responsibility to speak up if they feel a medical colleagues impairment puts patients at risk. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

An impaired resident: case for commentary.

Physicians and physicians-in-training have a responsibility to speak up if they feel a medical colleagues impairment puts patients at risk. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

Right to discontinue treatment: case for commentary.

An ethical case explores a 70-year-old man diagnosed with pancreatic cancer who wants to have his pacemaker turned off in order to hasten what he fears may be an unpleasant death. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.