Michele A. Carter

Cultural engagement in clinical ethics: a model for ethics consultation.

In the rapidly evolving healthcare environment, perhaps no role is in greater flux and redefinition than that of the clinical bioethicist. The discussion of ethics consultation in the bioethics literature has moved from an ambiguous concern regarding its proper place in the clinical milieu to the more provocative question of which methods and theories should best characterize the intellectual and practical work it claims to do. The American Society for Bioethics and Humanities addressed these concerns in its 1998 report, Core Competencies for Health Care Ethics Consultation . The report tries to answer the question as to what disciplinary training, background experience, and levels of knowledge in ethics the clinical ethics consultant should have, and what specific skills and character traits the clinical ethics consultant should cultivate. In addition to acquiring knowledge of common bioethical issues, theoretical concepts in ethical theory and moral reasoning, and health-related law and policy, the report also recommends that ethics consultants demonstrate knowledge of the health beliefs and perspectives of patients and healthcare providers. In our opinion, this recommendation underscores a crucial aspect of the practice of ethics consultation in the increasingly multicultural settings of healthcare institutions. Clearly, the dynamic of American life and culture is permeated with diversity and variety as new groups suffuse their own beliefs and faith perspectives into the health sector. New immigrant groups force society to question traditional healthcare practices and to accommodate changing medical needs.

Ethical aspects of genetic testing.

This article explores ethical concerns and emerging dilemmas associated with the proliferation of information resulting fromthe extraordinary advances in molecular genetics. It provides an overviewof the ethical and legal challenges associated with predictive testing for inherited disease currently being addressed in the literature. Finally, it offers a framework of ethical principles that can be used to guide nurses and other practitioners in the appropriate application of research findings to the clinical practice setting. The ethical guidelines of self-determination, benefit-burden ratio, and justice promulgated in The Belmont Report are interpreted in the new context of predictive genetic testing. The author concludes by discussing how to balance the technical imperative to advance genetic knowledge for the sake of human health with the ethical imperative to preserve the fundamental rights and liberties of both individuals and communities who are its recipients.

A synthetic approach to bioethical inquiry

This paper attempts to sort out some of the current tensions and ambiguities inherent in the field of bioethics as it continues to mature. In particular it focuses on the question of the methodological relevance of theory or ethical principles to the domain of clinical ethics. I offer an approach to reasoning about moral conflict that combines the insights of contemporary moral theorists, the philosophy of American pragmatism, and the skills of rhetorical deliberation. This synthetic approach locates a proper role for moral theory in the practice of clinical ethics, thus linking abstract philosophical ideas about morality, humanity, suffering, and health to specific deeds, actions, and decisions in the concrete lives of particular individuals. The aim of this synthetic approach of bioethical inquiry is a rapprochement between theoretical knowledge in moral philosophy and the contextualized, relational, and practical understanding of what morality demands of us in our daily lives. I argue for a conception of bioethical inquiry that takes morality to be a study of certain practical, socially embedded concerns about matters of right and wrong, good and evil, as well as a study of the moral theories by which these actual concerns can be explored and critically evaluated.

Management of the Jehovah's witness in obstetrics and gynecology: A comprehensive medical, ethical, and legal approach

Importance Obstetricians and gynecologists frequently deal with hemorrhage so they should be familiar with management of patients who refuse blood transfusion. Although there are some reports in the literature about management of Jehovahs Witness patients in obstetrics and gynecology, most of them are case reports, and a comprehensive review about these patients including ethicolegal perspective is lacking. Objective This review outlines the medical, ethical, and legal implications of management of Jehovahs Witness patients in obstetrical and gynecological settings. Evidence Acquisition A search of published literature using PubMed, Ovid Medline, EMBASE, and Cochrane databases was conducted about physiology of oxygen delivery and response to tissue hypoxia, mortality rates at certain hemoglobin levels, medical management options for anemic patients who refuse blood transfusion, and ethical/legal considerations in Jehovahs Witness patients. Results Early diagnosis of anemia and immediate initiation of therapy are essential in patients who refuse blood transfusion. Medical management options include iron supplementation and erythropoietin. There are also some promising therapies that are in development such as antihepcidin antibodies and hemoglobin-based oxygen carriers. Options to decrease blood loss include antifibrinolytics, desmopressin, recombinant factor VII, and factor concentrates. When surgery is the only option, every effort should be made to pursue minimally invasive approaches. Conclusion and Relevance All obstetricians and gynecologists should be familiar with alternatives and “less invasive” options for patients who refuse blood transfusions. Target Audience Obstetricians and gynecologists, family physicians Learning Objectives After completing this activity, the learner should be better able to explain the oxygen delivery systems and response to tissue hypoxia mechanisms in humans, recognize options to correct anemia in Jehovahs Witness patients, recognize agents that are used in certain clinical scenarios in obstetrics and gynecology setting to reduce blood loss in patients who are refusing blood transfusion, and identify ethical/legal considerations for Jehovahs Witness patients.

A Narrative Approach to the Clinical Reasoning Process in Pediatric Intensive Care: The Story of Matthew

This paper offers a narrative approach to understanding the process of clinical reasoning in complex cases involving medical uncertainty, moral ambiguity, and futility. We describe a clinical encounter in which the pediatric health care team experienced a great deal of conflict and distrust as a result of an ineffective process of interpretation and communication. We propose a systematic method for analyzing the technical, ethical, behavioral, and existential dimensions of the clinical reasoning process, and introduce the Clinical Reasoning Discussion Tool—a dialogical and interpretive device aimed at improving communication, understanding, empathy, and moral deliberation in the clinical setting.