Ethics expert testimony: against the skeptics.

There is great skepticism about the admittance of expert normative ethics testimony into evidence. However, a practical analysis of the way ethics testimony has been used in courts of law reveals that the skeptical position is itself based on assumptions that are controversial. We argue for an alternative way to understand such expert testimony. This alternative understanding is based on the practice of clinical ethics.

Discussing organ donations with patients.

BACKGROUND: The gap between the demand and supply of organs has prompted examination of health care professionals' roles in organ retrieval. This study examines Illinois family physicians' advisory roles as reflected in their beliefs and conversations with patients about cadaveric organ donation. METHODS: A 50-item questionnaire was mailed to a random sample of 500 members of the Illinois Academy of Family Physicians. A total of 272 usable surveys were returned. RESULTS: The majority (67%) of the respondents believe that individuals' wishes to donate should prevail even when patients' families prefer not to donate. Yet, in conversations with patients, most of these physicians recommend only that patients sign driver's license donor cards (81%) and have discussions with family members (57%), methods that do not ensure that individuals' donative wishes will be carried out. Few physicians encourage completion of a health care power of attorney, the method most likely to ensure respect for patient wishes when an individual's desire to donate is specified. DISCUSSION: Family physicians could more effectively help patients implement their desires to donate if they would become more familiar with and include in their discussions the potential role of health care powers of attorney.

Beyond Pittsburgh: protocols for controlled non-heart-beating cadaver organ recovery.

Much of the ethical debate about controlled non-heart-beating cadaver (NHBC) organ recovery has focused on the University of Pittsburgh Medical Center (UPMC) protocol. Some commentators have voiced serious reservations about the ethical acceptability of that protocol; others have argued that the protocol contains sufficiently stringent ethical safeguards to warrant a limited and carefully monitored trial at UPMC. UPMC is not the only organization pursuing controlled NHBC organ procurement, however. The study of organ procurement organizations described in this article suggests that controlled NHBC organ procurement is a practice that, if not yet widespread, is certainly no longer isolated to a few organizations in which it is carefully monitored. Rather, it is being carried out under a variety of circumstances, many of which are less carefully constrained ethically than at the University of Pittsburgh Medical Center. The next stage of the ethical debate should focus on issues that are arising in a variety of settings as the practice spreads.

Certainty and agnosticism about lethal injection in late abortion.

PIP: This article was written in support of a claim forwarded by Joan Callahan that fetal intracardiac potassium chloride injection (KCl injection) should be offered to women undergoing second-trimester abortion. Callahan provides three positive arguments for use of the technique: maternal safety, the short-term interests of fetuses, and the longterm interests of fetuses who survive the abortion. The author of this article notes that the fact that KCl injection is currently the safest procedure for the mother is argument enough in favor of offering the procedure. Even physicians who object to the procedure are obligated to inform their patients about it and should be encouraged to help their patients locate a physician willing to perform KCl injection. Callahan's argument about fetal pain is sound but unnecessary as long as KCl injection remains the safest procedure for the mother. The argument about preventing longterm suffering for fetuses who survive late abortion is the weakest because it is impossible to determine whether the fetuses would be better off dead or alive. Hospitals can resolve some of the dilemmas which are associated with KCl injection by having a well thought out and clearly communicated policy about resuscitation of an aborted fetus. Callahan argues that the policy should be a blanket "do not resuscitate." The author is less sure that a blanket policy in either direction would be correct. Since it is impossible to know in advance what is best for the child, other factors must determine whether one policy is preferable to another. These include legal considerations such as the Americans with Disabilities Act which prohibits discrimination against disabled individuals in hospitals.^ieng

Expanding the boundaries of informed consent: disclosing alcoholism and HIV status to patients.

Since informed consent became legally required in the therapeutic setting, the risks physicians were to disclose have been limited to the risks of particular procedures. Two recent court decisions in which disclosure of surgeons' alcoholism and positive human immunodeficiency virus status was required may begin to erode that limit. The grounds for this expansion of disclosure requirements were inherent in the 20-year-old "materiality" standard for disclosure; nevertheless, the change they signal is profound. These cases may signal a trend that, in the long term, could result in a shift in physician-patient communication and a significant loss of privacy for physicians.

On developing a geriatric ethic: personhood in the thought of Stanley Hauerwas.

Those who provide health care for the elderly are being confronted by a variety of ethical problems, including paternalism, withdrawal of life-support systems, and allocation of scarce resources. Discussion surrounding these issues lacks persuasive power because it lacks an appropriate theoretical grounding. This paper grounds geriatric ethics in the theory of the person described by Stanley Hauerwas. It shows that Hauerwas' emphasis on the attributes of temporality, sociality, and limitation is both consistent with the conclusions of gerontologists, and fruitful for developing specific ethical guidelines. Three ethical principles--continuity, interdependence, and normality--provide a framework from which to begin to resolve ethical problems in geriatrics.

Financially motivated transfers and discharges: administrators' ethics and public expectations.

In response to a competitive environment, hospital administrators are pressuring physicians to discharge Medicare patients "sicker and quicker" and to transfer indigent patients from their emergency rooms. This paper compares health administrators' ethics to public expectations regarding financially motivated hospital transfers and discharges. Health administrators use balancing strategies: code morality, survivalism, mission dependency, and tithing. Public expectations, exemplified in P.L. 99-272, P.L. 99-509, and recent case law, are based on norms of potential for patient harm and patient occupancy. These norms are morally preferable to those of health administrators; they reinforce the value of identified lives and the reliability of the health care system.

Rethinking paradigms in geriatric ethics.

This paper calls for a shift away from autonomy as the central value in geriatric ethics. In treatment and experimental settings, differences between older and younger adults are easily attributed to deficiencies on the part of the elderly when autonomy is the central value. Overemphasis on the concept of autonomy skews our understanding of human relationships toward excessively rational models, distracts attention from important physical and social characteristics of aged persons, and results in ethics by default. This paper describes several principles that would be more useful starting points than autonomy in developing a geriatric ethic.