AbstractCommunity-based \"free\" clinics can be a key site of primary and preventive care, especially for underserved members of the community. Ethical issues arise in community clinics. Despite this-and the fact that ethics consultation is a well-established practice within hospitals-ethics support is rarely integrated within community clinics, and the clinical ethicist\'s role in community care settings remains unexplored. In this article I explore what community-engaged practice might look like for the clinical ethicist. I share my experience of being invited into a local community clinic where a team of volunteers, in partnership with a local church, provide care to persons experiencing housing and food security in our county. First, I outline some of the key ethical issues we encounter in our clinic, including how to promote the agency of community members, develop shared standards for clinic volunteers, and balance different values and priorities within the partnership. Second, I explore how the ethicist\'s knowledge and skills translate into this setting. I argue that, given the range of ethical issues that arise in community clinics and the need for ongoing dialogue, education, and critical reflection within such partnerships, there is a role for the clinical ethicist in this space. I discuss how clinical ethicists might begin to develop community-based partnerships and practices.

AbstractClinical ethicists are routinely consulted in cases that involve conflicts and uncertainties related to surrogate decision-making for incapacitated patients. To navigate these cases, we invoke a canonical ethical-legal hierarchy of decision-making standards: the patient\'s known wishes, substituted judgment, and best interest. Despite the routine application of this hierarchy, however, critical scholarly literature alleges that these standards fail to capture patients\' preferences and surrogates\' behaviors. Moreover, the extent to which these critiques are incorporated into consultant practices is unclear. In this article I thus explore whether, and how, existing critiques of the hierarchy affect the application of these standards during ethics consults. After discussing four critiques of the hierarchy, I examine how two prominent published ethics consultation methodologies-bioethics mediation and CASES-incorporate these critiques differently. I then argue that while both methodologies explicitly endorse the same hierarchy, the varying degrees to which these four criticisms are incorporated into the prescribed consultation process could produce different applications of the same standard. I demonstrate with a case study how an ethics consultant following either methodology might produce two substantively different recommendations despite using the same substituted judgment standard. I conclude that while this heterogeneity of application should not dismantle the hierarchy\'s status as field-wide canon, it complicates projects of professional ethics consultation consensus building.

During a clinical ethics fellow\'s first week of independent supervised service, two unhoused patients on the same floor were resisting the medical team\'s recommendations to discharge. In the team\'s view, both were medically stable and no longer required hospitalization in an acute setting. The medical team suspected malingering for both. The social worker and case manager had employed their usual means of gentle persuasion and eliminating psychosocial barriers to no avail. Rather than call the police, the attending physician, social worker, and case manager decided to call ethics. These cases lead the fledgling fellow to consider the appropriate role for ethicists in difficult discharge cases. The article analyzes each case, evaluates their similarities and differences in the context of suspected malingering, and comments on ethical issues surrounding cases of suspected malingering. Finally, the authors reflect on the value and importance of developing and maintaining epistemic and professional independence.

This symposium collection of twelve narratives from individuals who experienced clinical ethics consultations provides perspectives from a group that has not been adequately explored in the bioethics literature. The authors represent a variety of stakeholders who received ethics consultations: healthcare providers and family members. This commentary will focus on three themes addressed in the different narrative accounts: the reasons for requesting an ethics consultation; the expectations of the narrators from the consultation; and the conclusions the authors drew from their experience of the ethics consultation.

This commentary discusses 12 stories about receiving ethics consultation in hospitals. Five stories are by physicians, three by nurses, and four by family members; three of the writers have training in bioethics. Some writers requested the consultation, others experienced the consultation as an imposition forced upon them, and in two cases, the story is about the absence of any consultation service. Three types of narrative are found to structure the stories: the genuine dilemma narrative, the institutional intransigence narrative, and the relational care narrative. Throughout, the question is what makes for a valuable consultation, and the general answer is whether consultation enables the development of mutually supportive relationships.

This commentary reflects on twelve stories of participants in clinical ethics consultations from the perspective of family members, some of whom are ethics consultants, and healthcare professionals. Together they reveal expectations of ethics consultations and suggest descriptions of the service. Some common themes emerge, including the role of the clinical ethics consultant in navigating complex situations, assuring all stake-holder voices are heard, attending to moral distress, addressing issues that seem beyond medical practice, and being accessible. They are almost uniformly positive about the experience, with criticism primarily about lack of access to the service.

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An ethicist advocates a moral framework for technology.

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This commentary takes up a challenge posed by Franklin Miller in a 2022 essay in Bioethics Forum. Dr. Miller queried whether bioethicists could be useful in public health policy contexts and while he refrained from issuing an ultimate opinion, did identify several challenges to such utility. The current piece responds to the challenges Dr. Miller identifies and argues that with appropriate training, public health ethicists can be of service in virtually any context in which public health policies are deliberated and decided.