Jeffrey Spike

Professional identity formation: creating a longitudinal framework through TIME (Transformation in Medical Education).

The University of Texas System established the Transformation in Medical Education (TIME) initiative to reconfigure and shorten medical education from college matriculation through medical school graduation. One of the key changes proposed as part of the TIME initiative was to begin emphasizing professional identity formation (PIF) at the premedical level. The TIME Steering Committee appointed an interdisciplinary task force to explore the fundamentals of PIF and to formulate strategies that would help students develop their professional identity as they transform into physicians. In this article, the authors describe the task force’s process for defining PIF and developing a framework, which includes 10 key aspects, 6 domains, and 30 subdomains to characterize the complexity of physician identity. The task force mapped this framework onto three developmental phases of medical education typified by the undergraduate student, the clerkship-level medical student, and the graduating medical student. The task force provided strategies for the promotion and assessment of PIF for each subdomain at each of the three phases, in addition to references and resources. Assessments were suggested for student feedback, curriculum evaluation, and theoretical development. The authors emphasize the importance of longitudinal, formative assessment using a combination of existing assessment methods. Though not unique to the medical profession, PIF is critical to the practice of exemplary medicine and the well-being of patients and physicians.

Ethics consultation: High ideals or unrealistic expectations?

Ethics consultation evolved out of the field of bioethics, which was itself largely a product of the 1970s. Thus, when the American Society for Bioethics and Humanities report Core Competencies for Health Care Ethics Consultation was commissioned 4 years ago (1), the oldest ethics services had been in existence for barely 20 years and were in the adolescent stage of developmentwith high ideals and unrealistic expectations. The report represented the opportunity to evaluate the progress of and set future agendas for ethics consultation. The report makes an informative starting point for someone interested in learning about ethics consultation. However, because it is the work of a consensus panel, the report softens or avoids some points of disagreement. This commentary tackles four such points and highlights the critical weaknesses of some of the approaches that the consensus panel presents as viable options. The four issues that we find problematic concern committees versus individual consultants, interdisciplinary competency, practical wisdom versus character, and financial support for ethics services. Committees versus Consultants The committee approach to ethics consultation may be effective in long-term care settings. However, it becomes unwieldy in acute care settings because it is difficult to convene a quorum of a 12- to 15-member committee in less than 72 hours. A second problem with committees performing consultations concerns the common practice of appointing members because of their job descriptions rather than because of their interest or experience in ethics. A third problem is the danger of groupthink. One member, such as the most politically powerful person (a member of the hospital administration or the hospital attorney, for example), can easily and sometimes inadvertently dominate the decision-making process. But in our view, the greatest problem with the committee approach is that ethics consultation must allow patients, family members, and staff the opportunity to tell their personal perspectives of the case. Attempts by a committee to conduct a personal, private discussion become impersonal interviews at best or inquisitions at worst. An alternative model would cast the ethics committee as a source of colleagues with whom individual ethics consultants can discuss a case as it unfolds. In addition, the committee would provide a forum for review of consultations after the fact as part of quality control. Each ethics consultant at the facility should be a member of the ethics committee, although not every member of the committee needs (or ought) to be a consultant. Interdisciplinary Training The real problem with certification of ethics consultants, especially in bioethics, is the difficulty in establishing consensus about training requirements in an interdisciplinary field. Training programs in health care law are located in law schools, and some clinical ethics programs at medical schools are open only to physicians. Yet philosophy is the academic home of ethics, and most of the theorists whose texts are taught in these programs are trained in philosophy. Bioethics requires contributions from law, medicine, and philosophy, in addition to input from such disciplines as theology, cultural anthropology, health care economics, and policy. One person cannot satisfy all of the required competencies in all of these fields. A national accrediting body such as the Joint Commission for the Accreditation of Healthcare Organizations might assess consultation services as groups to see whether its members possess expertise in at least the three basic professional fields. In our opinion, every ethics consultation service should have at least three members: one who holds an MD, one who holds a JD (and who should not be employed by the institutions administration or malpractice office), and one who holds a PhD in an academic field of ethics or bioethics. Each member should also have some specific training in bioethics, whether from a degree program, from a certificate program, or as part of a fellowship program. Although one consultant could well have two or more of these professional backgrounds, we believe that an ethics consultation service should include a minimum of three persons to help balance the group dynamics of problem solving and to prevent domination of any one discipline. The standards that we propose are much higher than those proposed by the consensus panel, which require only access to medical and legal expertise for the consultant or committee. The report recommendations would condone a nurse with a masters degree in bioethics, for example, as an individual consultant reporting to a committee. Such a policy would allow much more rapid expansion of ethics consultation at less cost to institutions, but at great cost to the credibility of the field. Practical Wisdom versus Character The panel recognizes that some cases are common and straightforward and some are complex. In our experience, these occur in roughly equal numbers. Most clinicians do not need an ethics consultation when the situation is straightforward, and in complex cases, they often request a consultation late, when the case has become complicated and opinions are polarized. An ethics consultation team therefore needs advanced skills and advanced knowledge on a regular basis. Although character is closely associated with ethics in the minds of many and is the essence of ethics in the Aristotelian tradition of virtue ethics, good character is arguably immeasurable. Certainly the three professional fields of law, medicine, and philosophy do not rank it highly among their entrance requirements, and their curricula do little to promote it. We suggest using another Aristotelian concept to designate this sought-after quality: practical wisdom (phronesis). Ethics consultants may not have character that is superior to that of the practitioners, but they should have more experience in analyzing ethically complex cases. This accumulated experience and the refinement of judgment that it produces is an advantage that they bring to the consultation process as specialists in addition to their disciplinary knowledge. Financial Support for Ethics Consultation Services Perhaps the greatest threat to integrity and good character in the popular mind is the profit motive. Thus, financial support for an ethics consultation service is an issue in which conflicts of interest are of grave importance. An institution must support ethics consultation, but in a way that will not compromise the consultants. Any form of payment that is provided on a unit basis has the potential to cause conflict of interest, or at least the appearance of one. The institution should estimate the amount of time that the ethics service will require, convert it into a percentage of the full-time salaries of the consultants, and reimburse their departments for that part of their salaries. For an average tertiary care teaching hospital, this figure may amount to 25% to 50% of each consultants salary. For a smaller hospital with fewer critically ill patients, it may amount to 10% of their salaries. Annual reviews should be a time to evaluate whether the reimbursed time was a reasonable approximation of the time used. This system is similar to that already in place in many institutions to support chaplaincy services. Conclusions Our ethics consultation service at the University of Rochester is now 10 years old, placing it in the second generation of programs. As a result, we were able to identify and address these four problems before we established our service. The hospital provides 25% of the salaries of two members, a physician and a lawyer, and 50% of the salary of the ethicist (who is also chair of the Ethics Committee). In return, the hospital has 24-hour consult coverage, provides substantial ethics teaching for 26 residency programs, and has monthly rounds in 6 intensive care units. Our procedure for case consultation is for one consultant to respond to the initial consultation request and gather information, including talking with members of the health care team, the patient, and the family. This lead consultant then confers with at least one other consultant to define the issues and frame an approach. The lead consultant drafts the consultation note and reviews it with at least one other consultant before it goes into the patients chart. Because many family members and specialists are often involved, the process is deliberate rather than rushed, as seems appropriate to promoting careful reflection on a serious problem. Those who have no experience of ethics consultation or who are skeptical of it will learn a great deal from reading the American Society for Bioethics and Humanities report. Most readers will agree with the reports nine conclusions. Yet, because ethics consultation is still unavailable at many hospitals, the report should also be useful to those who are deciding whether and how to implement ethics consultation at their own institutions.

Resolving the Vexing Question of Credentialing: Finding the Aristotelian Mean

_____________________________________________________________________________________ Jeffrey P. Spike, Ph.D., Professor in the John P. McGovern, M.D., Center for Health, Humanities, and the Human Spirit, Director of the Campus Wide Ethics Program, University of Texas Health Science Center at Houston, 6431 Fannin, JJL 400, Houston, Texas 77030; email: jeffrey.spike@uth.tmc.edu. Resolving the Vexing Question of Credentialing: Finding the Aristotelian Mean

The Brewsters: A new resource for interprofessional ethics education

Background: One of the barriers to interprofessional ethics education is a lack of resources that actively engage students in reflection on living an ethical professional life. This project implemented and evaluated an innovative resource for interprofessional ethics education. Objectives: The objective of this project was to create and evaluate an interprofessional learning activity on professionalism, clinical ethics, and research ethics. Design: The Brewsters is a choose-your-own-adventure novel that addresses professionalism, clinical ethics, and research ethics. For the pilot of the book, a pre-test/post-test design was used. Once implemented across campus, a post-test was used to evaluate student learning in addition to a student satisfaction survey. Participants and research context: A total of 755 students in six academic schools in a health science center completed the activity as part of orientation or in coursework. Ethical considerations: The project was approved as exempt by the university’s Committee for the Protection of Human Subjects. Findings: The pilot study with 112 students demonstrated a significant increase in student knowledge. The 755 students who participated in the project had relatively high knowledge scores on the post-test and evaluated the activity positively. Discussion: Students who read The Brewsters scored well on the post-test and had the highest scores on clinical ethics. Clinical ethics scores may indicate issues encountered in mass media. Conclusion: The Brewsters is an innovative resource for teaching interprofessional ethics and professionalism. Further work is needed to determine whether actual and long-term behavior is affected by the activity.

Ethics Consultation: Persistent Brain Death and Religion: Must a Person Believe in Death to Die?

Case summary We first heard about this case from nurses in one of our intensive care units (ICUs) while we were conducting an inservice. When the session was over, we discussed it between ourselves, and decided that it must have been misrepresented. The case had been presented as one of a teenager who was brain dead, had been so for six months, yet had been brought into the ICU for treatment. We have run into this before, we thought: medical professionals confusing brain death with persistent vegetative state (PVS). But, of course, we reasoned, no one can be brain dead for six months. To us, as it would to many, the case sounded like a clinical and ethical impossibility. A week later, we were called by an attending physician from another ICU, at the urging of that unit’s nursing staff. They had a patient who was brain dead, whose presence was causing distress among the staff. Ronald Chamberlain, a fifteen-year-old boy, had been a patient at a nearby longterm rehabilitation facility that is equipped to care for ventilator-dependent patients. Ronald had undergone a cardiac arrest with electromechanical dissociation, and was brought to the hospital emergency room as part of a full resuscitative effort. It took twenty minutes of cardiopulmonary resuscitation to recover a pulse. With his cardiopulmonary status stabilized, Ronald was admitted to the ICU. Ronald was the patient we had heard about. The ICU attending doctor who called us accepted the admission because he believed it appropriate to evaluate the validity of the diagnosis of brain death, which reportedly had been made six months earlier at another facility. (We later learned that the staff of the ICU from which the patient had been discharged two weeks earlier believed that

Do Clinical Ethics Consultants Have a Fiduciary Responsibility to the Patient

interests of a particular category of participant. The substantial risk of advocacy is denying legitimate moral disagreement or uncertainty. Advocacy for a particular position may also undermine the consultant’s neutrality and ability to facilitate a resolution of the conflict. If the consultant must become a party to the conflict, he/she should acknowledge this change and contribute to collaborative, rather than adversarial, environment.

When Ethics Consultation and Courts Collide: A Case of Compelled Treatment of a Mature Minor

A fourteen year old is diagnosed with aplastic anemia. The teen and his parents are Jehovah’s Witnesses. An ethics consult is called on the day of admission by an ethically sophisticated social worker and attending. The patient and his parents see this diagnosis as “a test of their faith.” The ethical analysis focuses on the mature minor doctrine, i.e. whether the teen has the capacity to make this decision. The hospital chooses to take the case to court, with a result that is at odds with the ethics consultation recommendations. Ethics was never deposed or otherwise invited to be involved with the hearing. Thus the larger question of the relation of ethics and law was brought into stark relief.

Patients' competence to consent to treatment.

n engl j med 358;6 www.nejm.org february 7, 2008 644 The editorialist replies: Although we may one day use HPV testing for primary screening, we are not ready to do so at this time. Before we can accept HPV testing for primary screening, we will need to develop a rapid, simple, accurate, and affordable HPV DNA test. New algorithms, including a triage for HPV DNA tests, will need to be developed and tested. The duration of protection afforded by a negative HPV DNA test will require further long-term follow-up of studies like the one reported by Mayrand and colleagues. As noted in my editorial, the ultimate goal of cervical screening has to be to reduce the incidence of and mortality from invasive cervical cancer worldwide with the use of a cost-effective and readily available test. The optimal approach will depend on the prevalence of disease, access to screening, and available resources. We are not there yet.

Responding to requests for dialysis for severely demented and brain injured patients.

Nephrologists, like all physicians, need to offer their patients all reasonable treatment options, but only the reasonable options. When dialysis is (or is not) a reasonable option is an important ethical issue. The justification for dialysis, like any life‐sustaining treatment, is that it prolongs life for a patient who either wishes to live or, if cognitively impaired, would (in the opinion of others) likely benefit from extending their life. This article focuses on patients with advanced dementia or severe and irreversible brain injury who are no longer capable of enjoying life, and hence gain no benefit from dialysis. I present guidelines for withholding and withdrawing dialysis and offer suggestions designed to help nephrologists avoid causing harm when the patient’s family demands that dialysis be performed.

Putting the "ethics" into "research ethics".

Assuming that Rhodes would accept this revised definition (and I have no reason to think that she would not), we could then ask whether non-participants in research ethics are free-riders. And I think the answer, so long as participants are adequately remunerated, is that they fairly clearly are not. There are, of course, substantive questions as to what “adequate” remuneration would consist in, but the general conceptual framework should be clear. As a first attempt, we might say that A is adequately remunerated for φ’ing if and only if A autonomously chooses the remuneration given full information regarding possible consequences of φ’ing. To allay fears of coercion, we might go on to say that an autonomous will is absent if the moral agent has no meaningful alternatives from which to choose.1 So, given current research practices, I think it is plausible to claim that non-participants are not free-riding upon participants of research studies. If this is true (and presuming no other moral failings on the part of nonparticipants), then they are not doing anything morally wrong and Rhodes would be unable to ascribe a duty to participate upon these individuals. Of course, the whole argument is predicated upon the current structure of research programs and the presumption of adequate remuneration. There are numerous arguments for socialized medicine and against its privatization (most of which I would not support), and I suspect that Rhodes would endorse some of