Tom Tomlinson

Ethics and communication in do-not-resuscitate orders.

Despite the extensive literature devoted to do-not-resuscitate (DNR) orders, they continue to raise vexing problems for physicians, house staff, nurses, and policy makers. The difficulties include ...

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.

Moral Concerns and the Willingness to Donate to a Research Biobank

Research biobanks are increasing in number and importance, with great potential for advancing knowledge of human health, disease, and treatment. Recruitment of donors is vital to their success and relies largely on blanket consent, in which donors give one-time permission for any future research uses of their coded specimen. This approach to consent has been endorsed recently in proposed changes to federal regulations. Previous studies suggest that donors may have moral, religious, and cultural concerns about the use to which their specimens are put, which may affect their willingness to give blanket consent.These earlier studies, however, used convenience samples unrepresentative of the US population.

Respecting Donors to Biobank Research

The most common way for people to consent to research with their banked biological material is through signing a blanket consent, which allows any future use, giving the donor no information or control. This does not respect the donor or the philosophy if donation.

Casuistry in medical ethics: Rehabilitated, or repeat offender?

For a number of reasons, casuistry has come into vogue in medical ethics. Despite the frequency with which it is avowed, the application of casuistry to issues in medical ethics has been given virtually no systematic defense in the ethics literature. That may be for good reason, since a close examination reveals that casuistry delivers much less than its advocates suppose, and that it shares some of the same weaknesses as the principle-based methods it would hope to supplant.

Futile care in oncology: when to stop trying

The idea that some medical interventions may be ‘futile’, and so should not to be attempted by the responsible physician, is a traditional one. However, in the late 1960s, our increasing recognition of principles that respected patient autonomy and authority over treatment, eclipsed this ‘paternalistic’ perspective for some time. Only in the past decade has the concept of futile treatment, and the physician authority that this implies, seen a resurgence as a legitimate ethical perspective. Nearly all of the more recent discussions have focused on the use of cardiopulmonary resuscitation (CPR). This is understandable, since CPR is the only intervention requiring an order not to provide. Until very recently, this was a decision which always required the patient’s or surrogate’s consent, at least in the USA. Physicians had to obtain consent not to use CPR, even when they were sure of its uselessness. This lead to conflicts between the demands of patients or families for CPR, and the physician’s (or other medical staff’s) reluctance to provide it. Two sorts of arguments support the physician’s authority to say “no” to such demands by patients and their families. The first, and most central, rests on the claim that patients’ ‘rights of autonomy’, which are by now well established in law and ethics, are negative rights, not positive ones. They include the right to refuse a recommended treatment, or to choose among the treatment options on offer. However, there can be no general right to demand whatever intervention the patient might choose, since this would make it impossible for health professionals to practise with integrity. They could be forced to provide interventions which would violate the most fundamental duties defining the character of the profession – in particular, the duty to help rather than hurt. This right to professional integrity is reflected in everyday medical practice; it is not the cardiac patient, for example, who decides whether he or she is a candidate for a bypass. It is the surgeons who must consider the moral weight of the possibility that the patient’s death might be by their hand. The second argument concerns how to properly enable the exercise of patient autonomy. Making choices is important to us when real alternatives are at stake – ie when what we choose will significantly affect our interests. The ‘autonomy’ that is offered to patients or their surrogates is a

The moral concerns of biobank donors: the effect of non-welfare interests on willingness to donate

Donors to biobanks are typically asked to give blanket consent, allowing their donation to be used in any research authorized by the biobank. This type of consent ignores the evidence that some donors have moral, religious, or cultural concerns about the future uses of their donations – concerns we call “non-welfare interests”. The nature of non-welfare interests and their effect on willingness to donate to a biobank is not well understood.In order to better undersand the influence of non-welfare interests, we surveyed a national sample of the US population (in June 2014) using a probability-based internet panel. Logistic regression models assessed the demographic and attitudinal characteristics associated with participants’ willingness to give consent for unspecified future uses of their donation when presented with 7 research scenarios that raised possible non-welfare interest concerns.Most people had non-welfare interests that significantly affect their willingness to donate to a biobank using blanket consent. Some non-welfare interests are associated with subgroups but others are not. A positive attitude toward biomedical research in general was associated with increased willingness to donate, while concerns about privacy and being African American were associated with decreased willingness.Non-welfare interests matter and can diminish willingness to donate to a biobank. Our data suggest that trust in research promotes willingness to donate. Ignoring non-welfare interests could erode this trust. Donors’ non-welfare interests could be accommodated through greater transparency and easier access to information about the uses of donations.

Ethics, professionalism, and humanities at Michigan State University College of Human Medicine

This article describes the variety of approaches used at Michigan State University’s College of Human Medicine for teaching ethics, professionalism, and humanities to undergraduate medical students: courses in ethics and health policy; mentoring programs; selectives in history, literature, and spirituality; structured patient care experiences; and discussions with students in their clinical years on the ethical and professional challenges confronting them in their clinical experiences. Some of these approaches, such as the structured patient-care experience, may be unique to Michigan State. The authors place special emphasis on discussing the challenges that confront this curriculum, including struggles to keep up with the pace of change in the health care system, preserving and highlighting the linkages between the “ethics” and the “professionalism” strands of the curriculum, making optimal use of Web technologies, successfully communicating to students the ultimately practical importance of the medical humanities other than ethics, and solving the problems of geography created by a widely dispersed community campus system.

The physician's influence on patients' choices

Although the traditional physician ethic sees nothing objectionable about the doctors influence over patients, superficial conceptions of the patients right to self-determination imply that this influence may be manipulative. On the contrary, there are several different lines of argument which can reconcile self-determination with the physicians influence. Nevertheless, drawing the boundaries between legitimate methods of persuasion, and manipulation or coercion sometimes proves difficult.

Understanding the Public's Reservations about Broad Consent and Study-By-Study Consent for Donations to a Biobank: Results of a National Survey.

Researchers and policymakers do not agree about the most appropriate way to get consent for the use of donations to a biobank. The most commonly used method is blanket—or broad—consent where donors allow their donation to be used for any future research approved by the biobank. This approach does not account for the fact that some donors may have moral concerns about the uses of their biospecimens. This problem can be avoided using “real-time”—or study-by-study—consent, but this policy places a significant burden on biobanks. In order to better understand the public’s preferences regarding biobank consent policy, we surveyed a sample that was representative of the population of the United States. Respondents were presented with 5 biobank consent policies and were asked to indicate which policies were acceptable/unacceptable and to identify the best/worst policies. They were also given 7 research scenarios that could create moral concern (e.g. research intending to make abortions safer and more effective) and asked how likely they would be to provide broad consent knowing that their donation might be used in that research. Substantial minorities found both broad and study-by-study consent to be unacceptable and identified those two options as the worst policies. Furthermore, while the type of moral concern (e.g., regarding abortion, the commercial use of donations, or stem cell research) had no effect on policy preferences, an increase in the number of research scenarios generating moral concerns was related to an increased likelihood of finding broad consent to be the worst policy. The rejection of these ethically problematic and costly extremes is good news for biobanks. The challenge now is to design a policy that combines consent with access to information in a way that assures potential donors that their interests and moral concerns are being respected.