Stephen R. Latham

Medical professionalism in society.

Today, at the dawn of a new century, genuine medical professionalism is in peril. Increasing-ly, physicians encounter perverse financial incentives, fierce market competition, and the erosion of pa...

Optimal use of orders not to intervene and advance directives

More rigorous efforts in advance care planning are required in order to tailor end-of-life care to the preferences of patients so that they can experience a satisfactory last chapter of their lives. There is need for better availability and tracking of advance directives, and more uniform adoption of form documents that can be honored in every state. The discouraging evidence of inadequate end-of-life decision making indicates the necessity of several improvement strategies. In response to this need, the Council on Ethical and Judicial Affairs of the American Medical Association has examined this issue again and presents the following report and recommendations.

U.S. Law and Animal Experimentation: A Critical Primer

Every countrys law permits medical experimentation on animals. While some countries protect particular kinds of animals from being subject to experimentation—notably great apes and endangered species—very few place concrete limitations on what researchers may cause animals to suffer, given sufficient scientific justification. What laws do, instead, is establish standards for the humane treatment and housing of animals in labs, and they encourage researchers to limit or seek alternatives to the use of animals, when doing that is consistent with the scientific goals of their research. The system that has evolved in the United States combines elements of sometimes competing regulatory philosophies. The result is a complex, multilayered system that addresses the most important concerns, but, partly because of historical accident, also leaves some gaps. Even proponents of medical research on animals can see obvious ways in which the regulatory structure could be changed to benefit animals. Perhaps more important, though, is the fact that the existing regulatory structure, imperfect though it may be, is elastic enough to accommodate substantial changes that could reduce unnecessary animal suffering.

Moral Distress and Cooperation With Wrongdoing

I confess to being fully persuaded by the case made by Campbell, Ulrich, and Grady (2016) for expanding our collective understanding of the bioethical term of art “moral distress.” It seems to me c...

Professionalization of Clinical Ethics Consultation: Defining (Down) the Code

to manage conflicts of interest and obligation, to respect privacy and confidentiality, and to communicate responsibly— and, importantly, recommending procedural options for exercising these responsibilities. As with any professional code, its ultimate success or failure depends upon its embrace by the field’s members and the diligence with which its professional organizations endorse, disseminate, and continually update the code to keep it responsive to the needs of the profession and of those whom it serves. &

Whither the Affordable Care Act

The U.S. Supreme Court has likely already decided how much, if any, of President Obamas signature Affordable Care Act it is going to strike down as unconstitutional; its holding will be published this summer. No matter what the Court decides, though, it will send state and federal legislators scrambling—either to implement the law or to deal with the consequences of its alteration. There are various decisions the Court might make, but it is still most apt either to leave the ACA standing, or to selectively invalidate some of its mandate-related provisions. In either case, there will be exchanges to design and manage, subsidies to allocate, transparency standards to design and enforce. The Courts decision will thus mark the beginning, not the end, of health reform.

Expert bioethics testimony.

Stephen R. Latham he question of whether the normative testimony of ethics experts should be admissible under the T rules of evidence has been the subject of much debate. Professor Imwinkelried’s paper’ is an effort to get us, for a moment, to change that subject. He seeks to turn our attention, instead, to a means by which bioethics experts’ normative analyses might come before the court without regard to the rules of evidence a means lying formally outside those rules’jurisdiction. The court, he argues, may freely consider evidence from expert bioethicists so long as it is performing a legislative rather than an adjudicative function. The rules of evidence apply to the court’s efforts to find the facts of a particular case, Imwinkelried argues, but they do not constrain the court’s investigations relative to its creative law-making efforts. A judge should thus be free to solicit and rely upon a bioethics expert’s normative analyses and conclusions when she is framing a new common-law rule regardless of whether the analyses and conclusions would have been admissible as expert testimony and opinion under Iiederal Rule of Evidence 702, which governs testimony by experts. Part I of my response briefly notes some of my suspicions about Imwinkelried’s admittedly ingenious argument; it concludes that his effort to change the subject is misguided, and that we need to return to consideration of the admissibility of normative bioethics testimony under the rules of evidence. Part I1 briefly addresses two considerations under the evidence rules: the reliability of expert bioethics testimony, and the ways in which such testimony might be helpful. This consideration of the expert’s helpfulness leads to Part 111, which seeks to defuse some of the debate about ethics expert witnessing by denying that the bioethicist, as expert witness, in any way acts as a moral authority.

Identification of Patients Expected to Benefit from Electronic Alerts for Acute Kidney Injury

BACKGROUND AND OBJECTIVES Electronic alerts for heterogenous conditions such as AKI may not provide benefit for all eligible patients and can lead to alert fatigue, suggesting that personalized alert targeting may be useful. Uplift-based alert targeting may be superior to purely prognostic-targeting of interventions because uplift models assess marginal treatment effect rather than likelihood of outcome. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This is a secondary analysis of a clinical trial of 2278 adult patients with AKI randomized to an automated, electronic alert system versus usual care. We used three uplift algorithms and one purely prognostic algorithm, trained in 70% of the data, and evaluated the effect of targeting alerts to patients with higher scores in the held-out 30% of the data. The performance of the targeting strategy was assessed as the interaction between the model prediction of likelihood to benefit from alerts and randomization status. The outcome of interest was maximum relative change in creatinine from the time of randomization to 3 days after randomization. RESULTS The three uplift score algorithms all gave rise to a significant interaction term, suggesting that a strategy of targeting individuals with higher uplift scores would lead to a beneficial effect of AKI alerting, in contrast to the null effect seen in the overall study. The prognostic model did not successfully stratify patients with regards to benefit of the intervention. Among individuals in the high uplift group, alerting was associated with a median reduction in change in creatinine of -5.3% (P=0.03). In the low uplift group, alerting was associated with a median increase in change in creatinine of +5.3% (P=0.005). Older individuals, women, and those with a lower randomization creatinine were more likely to receive high uplift scores, suggesting that alerts may benefit those with more slowly developing AKI. CONCLUSIONS Uplift modeling, which accounts for treatment effect, can successfully target electronic alerts for AKI to those most likely to benefit, whereas purely prognostic targeting cannot.

Facilitated discussion: good and good for you.

I entirely agree with Autumn Fiester (2015) that in clinical ethics cases rooted in disagreements among or between stakeholders, clinical ethics consultation ought to aim not primarily at recommendation making but at facilitation of communication between the disputing parties. The mediator’s core skill—that of encouraging parties to focus not on their short-term positions but on their broader interests— is of great value in such circumstances, both because it can help parties discover and articulate the interests they hold in common (and thus help prevent them frommischaracterizing and misunderstanding one another’s motives), and because it can help parties understand that their bottomline positional differences flow from reasonable convictions, sincerely held. There is no doubt that every clinical ethics consultation has to issue in resolution. The dialysis must be done or not; the vent comes off or it does not. We have to decide, and then do, something. But Fiester is right to point out that a clinical ethics consultation procedure that is designed to aim merely at resolution, without paying adequate attention to the process by which resolution is reached, is seriously misguided. This is importantly true even where adequate attention to process fails to result in agreement on the proper resolution. As Fiester briefly notes, “closure” can flow not only from agreement, but also from the parties’ sense that even if they do not, finally, agree on the same course of action, they have spoken and been heard: that they have made their reasoning understandable to one another. Indeed, on some accounts, the whole of morality flows from our desire to make our actions understandable to others, via the articulation of rules governing our actions that others cannot reasonably reject (I have in mind Scanlon 2000). “Closure” may be not just a psychological, but also a moral, concept. But most of what I want to say is rather more lowbrow, and centers not on ethics but on institutional interests. The fact is that any deliberative procedure that results either in moral distress or in the outbreak of “moral emotions” is a hospital administrator’s nightmare. It is a recipe for employee dissatisfaction, reputational damage, and even litigation. From a purely prudential point of view, these things are costly—in terms of time, of money, of effort, of attention—and for that reason alone, even if one is not particularly concerned with the psychological goods of “closure,” they are to be avoided. Many clinical ethics consultations, including the case Fiester outlines, are “medical futility” problems: cases in which family members are demanding care that the treatment team deems inappropriate. Generally, the team’s view that the care is inappropriate is not straightforwardly objective or scientific (“No point giving an enema for an earache”), but is value laden: “This procedure would be painful and stressful for the patient, and stands very little chance of restoring her health” or “This burdensome intervention would relieve the patient’s condition, but would not restore him to any decent quality of life.” Families may straightforwardly reject the value judgments: “Even one minute of additional life is worth any burden.” Or they may feel guilty about being complicit with a medical team that seeks their permission to “give up” on their loved one. Or they may feel that, as a religious matter, they cannot decide when their loved one should die, because that decision belongs to God. Or they may feel that, given the very real history of racism and classism in American medicine, it is their job always to demand everything from a medical team that, they are convinced, is only too willing to give up on their loved one. For whatever reason, such “futility” disputes are the regular fare of clinical ethics consultations. Many facilities have developed “futility” or “inappropriate care” policies to respond to such conflicts (Mercurio 2005). These policies have the general shape of the “due process” futility policy adopted by the American Medical Association Council on Ethical and Judicial Affairs (1997), and of the well-known “Texas Futility Statute” (Ch. 166.046 Texas Health and Safety Code; for an argument in favor of the Texas “due process” approach over state-law approaches that attempt to define medical futility substantively, see Pope 2007). Roughly speaking,

Between Public Opinion and Public Policy: Human Embryonic Stem‐Cell Research and Path‐Dependency

In bioethics as in other areas of health policy, historical institutional factors can shape policy independently of interests or public opinion. This article finds policy divergence among countries with similar national moral views of stem cell research, and explains that divergence as the product of path-dependency.