Perceptions of Medical Providers on Morality and Decision-Making Capacity in Withholding and Withdrawing Life-Sustaining Treatment and Suicide.

BACKGROUND: This study attempts to understand if medical providers beliefs about the moral permissibility of honoring patient-directed refusals of life-sustaining treatment (LST) are tied to their beliefs about the patient's decision-making capacity. The study aims to answer: 1) does concern about a patient's treatment decision-making capacity relate to beliefs about whether it is morally acceptable to honor a refusal of LST, 2) are there differences between provider types in assessments of decision-making capacity and the moral permissibility to refuse LST, and 3) do provider demographics impact beliefs about decision-making capacity and the moral permissibility to refuse LST. Methods: A mixed-methods survey using Likert assessment and vignette-based questions was administered to medical providers within a single health system in the upper Midwest (N = 714) to assess their perspectives on the moral acceptance and decision-making capacity in cases of withholding and withdrawing treatment and suicide. Results: Behavioral health providers report accepting of the moral permissibility of suicide (91.2%) more than either medical providers (77.2%) or surgeons (74.4%) (n = 283). Decision-making capacity was questioned more in the vignettes of the patients refusing life-saving surgery (36%) and voluntarily starvation (40.8%) than in the vignette of the patient requesting to deactivate a pacemaker (13%) (n = 283). Behavioral health providers were more concerned about the capacity to refuse life-saving surgery (55.9%) than medical providers (33.8%) or surgeons (23.1%) (n = 283). Conclusions: Respondents endorse the moral permissibility of persons to withhold or withdraw from treatment regardless of motive. Clinical concerns about a patient's treatment decision-making capacity do not strongly correlate to views about the moral permissibility of honoring refusals of LST. Different provider types appear to have different thresholds for when to question treatment decision-making capacity. Behavioral health providers tend to question treatment decision-making capacity to refuse LST more than non-behavioral health providers.

Why Tolerate Conscientious Objections in Medicine.

Most arguments about conscientious objections in medicine fail to capture the full scope and complexity of the concept before drawing conclusions about their permissibility in practice. Arguments favoring and disfavoring the accommodation of conscientious objections in practice tend to focus too narrowly on prima facie morally contentious treatments and religious claims of conscience, while further failing to address the possibility of moral perspectives changing over time. In this paper, I argue that standard reasons against permitting conscientious objections in practice-that their permission may result in harm to patients, the idea that medical providers willingly enter into the medical field, and that conscientious objections stand contrary to medical professionalism-do not apply in all cases and that the medical field and health systems in which many physicians now practice should continue to tolerate conscientious objections in practice.

The role of palliative care in acute trauma: When is it appropriate?

INTRODUCTION: We hypothesized that trauma providers are reticent to consider palliative measures in acute trauma care. METHODS: An electronic survey based on four patient scenarios with identical vital signs and serious blunt injuries, but differing ages and frailty scores was sent to WTA and EAST members. RESULTS: 509 (24%) providers completed the survey. Providers supported early transition to comfort care in 85% old-frail, 53% old-fit, 77% young-frail, and 30% young-fit patients. Providers were more likely to transition frail vs. fit patients with (OR = 4.8 [3.8-6.3], p < 0.001) or without (OR = 16.7 [12.5-25.0], p < 0.001) an advanced directive (AD) and more likely to transition old vs. young patients with (OR = 2.0 [1.6-2.6], p < 0.001) or without (OR = 4.2 [2.8-5.0], p < 0.001) an AD. CONCLUSIONS: In specific clinical situations, there was wide acceptance among trauma providers for the early institution of palliative measures. Provider decision-making was primarily based on patient frailty and age. ADs were helpful for fit or young patients. Provider demographics did not impact decision-making.

Ethical Challenges Arising in the COVID-19 Pandemic: An Overview from the Association of Bioethics Program Directors (ABPD) Task Force.

The COVID-19 pandemic has raised a host of ethical challenges, but key among these has been the possibility that health care systems might need to ration scarce critical care resources. Rationing policies for pandemics differ by institution, health system, and applicable law. Most seem to agree that a patient's ability to benefit from treatment and to survive are first-order considerations. However, there is debate about what clinical measures should be used to make that determination and about other factors that might be ethically appropriate to consider. In this paper, we discuss resource allocation and several related ethical challenges to the healthcare system and society, including how to define benefit, how to handle informed consent, the special needs of pediatric patients, how to engage communities in these difficult decisions, and how to mitigate concerns of discrimination and the effects of structural inequities.

Toward accommodating physicians' conscientious objections: an argument for public disclosure.

This paper aims to demonstrate how public disclosure can be used to balance physicians' conscientious objections with their professional obligations to patients--specifically respect for patient autonomy and informed consent. It is argued here that physicians should be permitted to exercise conscientious objections, but that they have a professional obligation to provide advance notification to patients about those objections. It is further argued here that public disclosure is an appropriate and ethically justifiable limit to the principle of advance notification. The argument for publicly disclosing physicians' conscientious objections is made in this paper by discussing three practical benefits of public disclosure in medicine, and then addressing how publicly disclosing physicians' conscientious objections is not an undue invasion of privacy. Three additional concerns with public disclosure of physicians' conscientious objections are briefly addressed--potential harassment of physicians, workplace discrimination, and mischaracterising physicians' professional aptitude--concluding that each of these concerns requires further deliberation in the realm of business ethics.

Taking bioethics personally.

This narrative symposium examines the relationship of bioethics practice to personal experiences of illness. A call for stories was developed by Tod Chambers, the symposium editor, and editorial staff and was sent to several commonly used bioethics listservs and posted on the Narrative Inquiry in Bioethics website. The call asked authors to relate a personal story of being ill or caring for a person who is ill, and to describe how this affected how they think about bioethical questions and the practice of medicine. Eighteen individuals were invited to submit full stories based on review of their proposals. Twelve stories are published in this symposium, and six supplemental stories are published online only through Project MUSE. Authors explore themes of vulnerability, suffering, communication, voluntariness, cultural barriers, and flaws in local healthcare systems through stories about their own illnesses or about caring for children, partners, parents and grandparents. Commentary articles by Arthur Frank, Bradley Lewis, and Carol Taylor follow the collection of personal narratives.