The relevance of context has been acknowledged also recently as a fundamental element for the correct evaluation of argumentative moves within institutional fields of interaction. Indeed, not considering the larger culture-specific and social features of the context within which the interactions take place poses problems of interpretation of the data and comparability of results. Starting from these considerations, the paper aims at discussing a model for the description of the social context of interaction that may allow for a better interpretation (...) and evaluation of argumentative moves within medical consultations. The efficacy of the model is shown by applying it to the description and analysis of examples of real-life consultations recorded in the Italian region of Lombardy. In the first section, the model for the description of the social context of interaction is presented and discussed. In the second section, examples of argumentative passages from a selection of consultations are presented and commented on by relying on the model. Some concluding remarks and further developments of the research are proposed in the final section Keywords: communication context, argumentation in context, situated discourse, medical consultation. (shrink)

Medical argumentation in non-Western societies has attracted little attention. In line with the pragma-dialectical approach to the study of argumentation, this article identifies a prototypical argumentative pattern in Chinese medical consultations. In addition to institutional preconditions, whose relevance to the argumentative pattern has been well cited, a factor that may be equally important has remained unnoticed: the preference for certain drugs, treatments or therapeutic measurements on the basis of folk interpretations of medical phenomena in individual ethnic groups. (...) These preferences may be seen as cultural preferences in the medical domain. In this paper, a prototypical argumentative pattern of Chinese medical consultations is provided. Two levels of the pattern are distinguished and discussed: a basic argumentative pattern as presented in the pragmatic-dialectical approach and its extensions due to cultural preferences as well as institutional constraints. Illustrated by an exemplary analysis on the basis of empirical data collected from Chinese consulting rooms, the impact of cultural preferences on physicians’ strategic maneuvering in argumentation is identified and recognized. It is argued that the existence and impact of cultural preferences require attention in medical argumentation. (shrink)

In this article I use conceptual frames drawn from autobiography studies and feminist theory to examine the relationships between bodily experience and the social construction of sex, gender and class as they play themselves out in a selection of womens medical consultation letters written to the eminent Swiss physician, Samuel-Auguste Tissot, during the second half of the eighteenth century. My analysis of a selection of consultation letters - all of which are situated and read in the context (...) of a rich archival collection of some 1,200 letters - considers the role that bodily experience plays in the construction of self and suggests that not only the experience, but also the textual articulation of the body, were imagined both through and against accepted understandings of sex, gender and class during this period. (shrink)

While online medical consultations have become increasingly popular, not least in times when epidemics make access to medical facilities difficult, research exploring the interactive value of OMC is still in its infancy. This study examines patients’ disalignment with speculative diagnosis and its management by doctors in OMC interactions, which to my best knowledge are not examined. From a discourse analytic perspective, this study adopts Du Bois’s notion of stance-taking to approach text-based interactions collected from a widely used OMC (...) website in China. This study finds that patients’ disalignment is often based on hard evidence, which is different from the major findings of previous studies. When addressing such disalignment, doctors adopt varied discursive strategies, which are hardly mentioned in prior studies, in particular, strategies that address the affective aspect of patients’ disalignment. This study thus provides a different perspective on disalignment and its management in the clinical context. (shrink)

When physicians take readings of health indices such as temperature or blood pressure, the practices that physicians and patients employ in discussing the readings both reflect and propose a set of expectations regarding the level of technical medical information the patients should acquire and understand. In this article we demonstrate how physicians’ reporting practices reflect and propose the roles of paternalism or independent expertise and how patients’ responding practices either ratify or contest the roles cast by the physicians’ practices. (...) In contrast to the usual assumption that roles are relatively stable for individuals over the course of encounters, we treat role enactments as matters that are negotiated turn by turn in interaction. Physicians’ practices for reporting test results implicate various sets of expectations about the knowledge, interest, and responsibility state of each participant; patients employ responding practices that ratify or contest the expectations implicated by the physicians’ prior report. In each subsequent turn within the information exchange sequence, a speaker indicates whether the level and kind of information being exchanged is appropriate/inappropriate and sufficient/insufficient for the participants. (shrink)

The objective of this article is to explore the identity construction by students with invisible disabilities as disclosed in medical consultations at a university health center. In particular, I work on the assumption that analysing the discursive processes through which students with invisible disabilities construct, negotiate and resist their roles and identities may contribute to a better understanding of living and studying with an invisible condition. Taking a discourse analytic approach, I consider identity as a dynamic and negotiable process (...) that takes place in specific interactional occasions. The findings have shown that these students sometimes construct contested identities as patients, students, or experts during medical consultations, responding to conflicting expectations of others and their own. (shrink)

While previous studies highlight the dynamic nature of identity co-construction, how and especially why speakers construct and shift their own multiple identities still remains understudied. The present study argues that identity is part of speaker communicative resources as evidenced by radio program hosts’ strategic employment and shift among their different identities to facilitate their interactional purposes. Based on data drawn from radio medical consultations, this article attempts to reveal the dynamic adaptability of hosts’ identity construction. It is found that (...) in general, hosts of medical consultation programs construct three identities for themselves, namely an authoritative expert identity, a caring friend identity and a sales representative identity; the three identities constructed are respectively adaptable to power relationships, solidarity and role relationships between hosts and callers in conversation; the three identities shift in conversations to facilitate callers’ purchasing acts. (shrink)

In recent years, the opioid crisis in the United States has sparked significant discussion on doctor–patient interactions concerning chronic pain treatments, but little to no attention has been given to investigating the vocal aspects of patient talk. This exploratory sociolinguistic study intends to fill this knowledge gap by employing prosodic discourse analysis to examine context-specific linguistic features used by the interlocutors of two distinct medical interactions. We found that patients employed both low pitch and creak as linguistic resources when (...) describing chronic pain, narrating symptoms and requesting opioids. The situational use of both features informs us about the linguistic ways in which patients frame fraught issues like chronic pain in light of the current opioid crisis. This study expands the breadth of phonetic analysis within the domain of discourse analysis, serving to illuminate discussions surrounding the illocutionary role of the lower vocal tract in expressing emotions. (shrink)

Libertarian paternalism is a concept derived from cognitive psychology and behavioural science. It is behind policies that frame information in such a way as to encourage individuals to make choices which are in their best interests, while maintaining their freedom of choice. Clinicians may view their clinical consultations as far removed from the realms of cognitive psychology but on closer examination there are a number of striking similarities.

BackgroundEthics consult services are well established, but often remain underutilized. Our aim was to identify the barriers and perceptions of the Ethics consult service for physicians, advance practice providers (APPs), and nurses at our urban academic medical center which might contribute to underutilization.MethodsThis was a cross-sectional single-health system, anonymous written online survey, which was developed by the UCSD Health Clinical Ethics Committee and distributed by Survey Monkey. We compare responses between physicians, APPs, and nurses using standard parametric and non-parametric (...) statistical methods. Satisfaction with ethics consult and likelihood of calling Ethics service again were assessed using a 0–100 scale using a 5-likert response structured (0 being “not helpful at all” to 100 being “extremely helpful”) and results presented using box plots and interquartile ranges (IQR).ResultsFrom January to July 2019, approximately 3800 surveys were sent to all physicians, APPs and nurses with a return rate of 5.5—10%. Although the majority of respondents had encountered an ethical dilemma (85–92.1%) only approximately half had ever requested an Ethics consult. The primary reason for physicians never having requested a consult was that they never felt the need for help (41%). For APPs the primary reasons were not knowing an Ethics consult service was available (33.3%) or not knowing how to contact Ethics (27.8%). For nurses, it was not knowing how to contact the Ethics consult service (30.8%) or not feeling the need for help (26.2%). The median satisfaction score (IQR) for Ethics consult services rated on a 0–100 scale, from physicians was 76 (29), for AAPs 89 (49), and nurses 70 (40) (p = 0.62). The median (IQR) of likelihood of consulting Ethics in the future also on a 0–100 scale was 71 (47) for physicians, 69 (45) for APPs, and 61 (45) for nurses (p = 0.79). APP’s and nurses were significantly more likely than physicians to believe that the team did not act on the Ethics consult’s recommendations.ConclusionsBased on the results presented, we were able to identify actionable steps to better engage healthcare providers—and in particular APPs and nurses—and scale up institutional educational efforts to increase awareness of the role of the Ethics consult service at our institution. Actionable steps included implementing a system of ongoing feedback that is critical for the sustainability of the Ethics service role. We hope this project can serve as a blueprint for other hospital-based Ethics consult services to improve the quality of their programs. (shrink)

The COVID-19 pandemic swept through New York City swiftly and with devastating effect. The crisis put enormous pressure on all hospital services, including the clinical ethics consultation team. This report describes the recent experience of the ethics consultants and Columbia University Irving Medical Center during the COVID-19 surge and compares the case load and characteristics to the corresponding period in 2019. By reporting this experience, we hope to supplement the growing body of COVID-19 scientific literature and provide details (...) of the human toll the virus took on our hospitals and communities. We also aim to highlight the role of the clinical ethics consultant as well as areas of policy and law that may need to be addressed in order to be better prepared for a future public health crisis. (shrink)

The complexity of cognitive emulation of human diagnostic reasoning is the major challenge in the implementation of computer-based programs for diagnostic advice in medicine. We here present an epistemological model of diagnosis with the ultimate goal of defining a high-level language for cognitive and computational primitives. The diagnostic task proceeds through three different phases: hypotheses generation, hypotheses testing and hypotheses closure. Hypotheses generation has the inferential form of abduction (from findings to hypotheses) constrained under the criterion of plausibility. Hypotheses testing (...) is achieved by a deductive inference (from generated hypotheses to expected findings), followed by an eliminative induction, constrained under the criterion of covering, which matches expected findings against patient''s findings to select the best explanation. Hypotheses closure is a deductive-inductive type of inference very similar to the inferences operating in hypotheses testing. In this case induction matches the consequences of the generated hypotheses against the patient''s characteristics or preferences under the criterion of utility. By using the language exploited in this epistemological model, it is possible to describe the cognitive tasks underlying the most influential knowledge-based diagnostic systems. (shrink)

Growing evidence suggests that nurses and other clinicians often feel insufficiently equipped to manage ethical issues that arise in their practice (Truog et al. 2015; Woods 2005; Darmon et al. 201...

In order to maximize human performance, defence forces continue to explore, develop, and apply human performance enhancement (HPE) methods, ranging from pharmaceuticals to (bio)technological enhancement. This raises ethical, legal, and societal concerns and requires organizing a careful reflection and deliberation process, with relevant stakeholders. We discuss a range of ethical, legal, and societal aspects (ELSA), which people involved in the development and deployment of HPE can use for such reflection and deliberation. A realistic military scenario with proposed HPE application can (...) serve as a starting point for such an iterative and participatory process. Stakeholders can discuss this application, modify its features, and design appropriate processes around it – for instance, procedures for informed consent. We propose that organizing aspects into these three categories – ethical, legal, and societal – can help involve appropriate interlocutors at different moments: legal aspects with people in strategy or management roles, from the start of a project; ethical aspects with people in operations and medical roles, during development; and societal aspects with people in communication and personnel roles, during deployment. Notably, we developed and discussed this framework and the three aspects in close collaboration with personnel from the military. (shrink)

Ethics consults at a university medical center share many qualitites with those in other settings. What makes them different, if at all, is a difference of degree, not kind. All consult services share the tasks of exploring cases for possible recommendation, contributing to the development of institutional and public policy, and educating colleagues and patients about medical ethics dimensions. Nonetheless, the university setting, devoted as it is to teaching, research, and public service, brings a slightly different focus to (...) these tasks and adds other, peripheral ones. (shrink)

As everybody knows, advances in medicine and medical technology have brought enormous benefits to, and created vexing choices for, us all – choices that can, and occasionally do, test the very limits of thinking itself. As everyone also knows, we live in the age of consultants, i.e., of professional experts who are ready, willing, and able to give us advice on any and every conceivable question. One such consultant is the medical ethics consultant, or the medical ethicist (...) who consults.Medical ethics consultants involve themselves in just about every aspect of health care decision making. They help legislators and judges determine law, hospitals formulate policies, medical schools develop curricula, etc. In addition to educating physicians, nurses, and lawyers, amongst others, including medical, nursing, and law students, they participate in clinical decision making at the bedside. (shrink)

In response to national trends calling for increasing accountability and an emerging dialogue within bioethics, we describe an effort to credential clinical ethicists at a major academic medical center. This effort is placed within the historical context of prior calls for credentialing and certification and efforts currently underway within organized bioethics to engage this issue. The specific details, and conceptual rationale, behind the New York-Presbyterian Hospital’s graduated credentialing plan are shared as is their evolution and ratification within the context (...) of institutional policy. While other programs will design their credentialing schema consistent with their local context and demographics, the description of one such effort is offered to be instructive to others who want to bring additional standardization to the assessment of the readiness and credentials of those who will engage in the practice of clinical ethics case consultation. (shrink)

Background and aimsFew Polish hospitals have Hospital Ethics Committee (HECs) and the services are not always adequate. In this situation, the role of HECs, in providing, among others, ethical advice on the discontinuation of persistent therapies, may be taken over by other entities. The aim of our research was to investigate, how often and on what issues hospital chaplains are asked for ethical advice in reaching difficult medical decisions.MethodsA survey of 100 Roman Catholic chaplains was conducted, that is, at (...) least 10% of all chaplains currently working in Polish hospitals.ResultsOf the participants, 29% confirmed receiving requests for advice in making a morally difficult medical decision. Receiving this type of request was not conditional on the place of their service, duration of their pastoral mission or HEC membership. The largest group of chaplains (21%) encounter questions concerning the ethical dilemmas associated with discontinuing persistent therapy. Patients and their families most often raise issues related to the methods of birth control, and the medical staff raise the issue of termination of pregnancy—as reported by 9% and 15% of chaplains, respectively. Most of the chaplains asked for help (79%) experience a deficit of specialist knowledge in the area of medicine or ethics.ConclusionsIn order to improve the quality of ethical consultations in Polish hospitals, in addition to further development of HECs, it is postulated to develop a system for bioethical education of chaplains. (shrink)

An evaluation of mental capacity is critical to a clinician's judgment about whether or not persons can make medical treatment decisions on their own behalf, and uncertainty about their ability to meaningfully participate in that process is one of the more common reasons an ethics consult is requested. The care of decisionally incapable patients—particularly those who lack advance care documents and no living relative who can speak for them—presents a quandary to healthcare personnel attempting to plan care in their (...) best interest, especially when options are multiple but none are ideal. These situations can be further complicated if involving a patient with a dual diagnosis of mental retardation and mental illness living in a community group home. (shrink)

Laacke et al. investigate the ethical implications of possible artificial intelligence systems that automatically detect signs of depression by analyzing data from social media. The art...

We present the perspective of a Bioethics Consultation Service operating in an urban hospital in Dayton, Ohio, USA, as it adapted to treating Sars-CoV-2 patients throughout 2020. Since the first case of COVID-19 was reported in Ohio on 9 March 2020, until 1 January 2021, the Bioethics Consultation Service was consulted 60 times, a 22.5% increase from the same period of 2019. The most common diagnoses requiring consultation included end-stage renal disease requiring dialysis, out-of-hospital cardiac arrest, and (...) sepsis. Only 10% of consultations were for patients hospitalized with COVID-19. This is a qualitative analysis of the cases we saw and a discussion of factors that affected our service while adapting to COVID-19 standards of care. (shrink)

In most U.S. jurisdictions, clinicians providing informal “curbside” consults are protected from medical malpractice liability due to the absence of a doctor-patient relationship. A recent Minnesota Supreme Court case, Warren v. Dinter, offers the opportunity to reassess whether the majority rule is truly serving the best interests of patients.

While a significant literature has appeared discussing theoretical ethical concerns regarding COVID-19, particularly regarding resource prioritization, as well as a number of personal reflections on providing patient care during the early stages of the pandemic, systematic analysis of the actual ethical issues involving patient care during this time is limited. This single-center retrospective cohort mixed methods study of ethics consultations during the first surge of the COVID 19 pandemic in Massachusetts between March 15, 2020 through June 15, 2020 aim to (...) fill this gap. Results indicate that there was no significant difference in the median number of monthly consultation cases during the first COVID-19 surge compared to the same period the year prior and that the characteristics of the ethics consults during the COVID-19 surge and same period the year prior were also similar. Through inductive analysis, we identified four themes related to ethics consults during the first COVID-19 surge including (1) prognostic difficulty for COVID-19 positive patients, (2) challenges related to visitor restrictions, (3) end of life scenarios, and (4) family members who were also positive for COVID-19. Cases were complex and often aligned with multiple themes. These patient case-related sources of ethical issues were managed against the backdrop of intense systemic ethical issues and a near lockdown of daily life. Healthcare ethics consultants can learn from this experience to enhance training to be ready for future disasters. (shrink)

In the clinical setting, questions of medical ethics raise a host of perplexing problems, often complicated by conflicting perspectives and the need to make immediate decisions. In this volume, bioethicists and physicians provide a nuanced, in-depth approach to the difficult issues involved in bioethics consultation. Addressing the needs of researchers, clinicians, and other health professionals on the front lines of bioethics practice, the contributors focus primarily on practical concerns -- whether ethics consultation is best done by individuals, (...) teams, or committees how an ethics consult service should be structured the need for institutional support and techniques and programs for educating and training staff -- without neglecting more theoretical considerations, such as the importance of character or the viability of organizational ethics. (shrink)

As the field of clinical ethics consultation sets standards and moves forward with the Quality Attestation process, questions should be raised about what ethical issues really do arise in practice. There is limited data on the type and number of ethics consultations conducted across different settings. At Loyola University Medical Center, we conducted a retrospective review of our ethics consultations from 2008 through 2013. One hundred fifty-six cases met the eligibility criteria. We analyzed demographic data on these patients (...) and conducted a content analysis of the ethics consultation write-ups coding both the frequency of ethical issues and most significant, or key, ethical issue per case. Patients for whom ethics consultation was requested were typically male, white, between 50 and 69 years old, of non-Hispanic origin, and of Roman Catholic faith. Nearly half were in the intensive care unit and 44.2 % died in the hospital. The most frequent broad ethical categories were decision-making, goals of care/treatment, and end-of-life. More specifically, capacity, patient’s wishes/autonomy, and surrogate decision maker were the most frequent particular ethical issues. The most common key ethical issues were withdrawing/withholding treatment, patient wishes/autonomy, and capacity. Our findings provide additional data to inform the training of clinical ethics consultants regarding the ethical issues that arise in practice. A wider research agenda should be formed to collect and compare data across institutions to improve education and training in our field. (shrink)

(2001). The History of Medical Ethics Is Crucial for a Critical Perspective in the Continuing Development of Ethics Consultation. The American Journal of Bioethics: Vol. 1, No. 4, pp. 55-57.

In France, the practice of clinical ethics, and more specifically of clinical ethics consultation (CEC), is marked both by a heritage of practices from across the Atlantic and by a desire to adapt to the needs of the national context, which is increasingly giving a voice to patients. While the practice remained marginal in France for a long time, a number of structures developed in the wake of the Covid-19 health crisis. The aim of this article is to take (...) an initial national look at the practice of CEC in France, from its origins to its prospects. An exploratory questionnaire was drawn up by 5 teams offering CEC and linked by a historic partnership. It consisted of 4 parts: presentation of the structure, form taken by the CEC, whether or not they agreed with the fundamental proposals, and whether or not they wanted to form a national CEC collective. The results cover 38 organizations, 26 of which say they practice CEC. Although the practices of these 26 organizations varied, they all agreed on the objective of offering case-by-case medical decision support, with the majority adhering to the basic principles identified and wishing to participate in a CEC collective. This initial exploration provides an opportunity to put the practice of CEC in France into perspective in the international context and opens up prospects for collective work on the practical and methodological fundamentals, both by drawing on the similarities and the differences between different countries. (shrink)

This paper inquiries into the complex issue of informed consent applying artificial intelligence in medical diagnostic consultations. The aim is to expose the main ethical and legal concerns of the New Health phenomenon, powered by intelligent machines. To achieve this objective, the first part of the paper analyzes ethical aspects of the alleged right to explanation, privacy, and informed consent, applying artificial intelligence in medical diagnostic consultations. This analysis is followed by a legal analysis of the limits and (...) requirements for the explainability of artificial intelligence. Followed by this analysis, recommendations for action are given in the concluding remarks of the paper. (shrink)

Background Few studies have been conducted to assess the quality of orientation practices for ethics advisory committees that conduct ethics consultation. This survey study focused on several Harvard teaching hospitals, exploring orientation quality and committee members’ self-evaluation in the American Society of Bioethics and Humanities ethics consultation competencies. Methods We conducted a survey study that involved 116 members and 16 chairs of ethics advisory committees, respectively. Predictor variables included professional demographics, duration on committees and level of training. Outcome (...) variables included familiarity with and preparedness in the ASBH competencies and satisfaction with orientations. We hypothesised that responses would be associated with both the aforementioned predictors and whether or not participants had encountered the ASBH competencies in training. Results A majority of respondents found their orientation curricula to be helpful, although a significant portion of respondents did not receive any orientation or were unsatisfied with their orientation. Familiarity with ASBH competencies was a statistically significant predictor of respondents’ self-evaluation in particular categories. Standard educational materials were reported as offered during orientation, such as readings and case studies ; different medium resources were less evidenced such as videos on ethics consultation. Conclusions Institutions should re-evaluate orientation practices for ethics committee members that perform ethics consultation. Integrating ASBH competencies and useful methods into a resourceful pedagogy will help improve both member satisfaction with orientation and preparation in consultation. (shrink)

There is little information about the content of ethics consultations in pediatrics. We sought to describe the reasons for consultation and ethical principles addressed during EC in pediatrics through retrospective review and directed content analysis of EC records at St. Jude Children's Research Hospital. Patient-based EC were highly complex and often involved evaluation of parental decision making, particularly consideration of the risks and benefits of a proposed medical intervention, and the physician's fiduciary responsibility to the patient. Nonpatient consultations (...) provided guidance in the development of institutional policies that would broadly affect patients and families. This is one of the few existing reviews of the content of pediatric EC and indicates that the distribution of ethical issues and reasons for moral distress are different than with adults. Pediatric EC often facilitates complex decision making among multiple stakeholders, and further prospective research is need.. (shrink)

Clinical ethicists encounter the most emotionally eviscerating medical cases possible. They struggle to facilitate resolutions founded on good reasoning embedded in compassionate care. This book fills the considerable gap between current texts and the continuing educational needs of those actually facing complex ethics consultations in hospital settings. 28 richly detailed cases explore the ethical reasoning, professional issues, and the emotional aspects of these impossibly difficult consultations. The cases are grouped together by theme to aid teaching, discussion and professional growth. (...) The cases inform any reader who has a keen interest in the choices made in real-life medical dilemmas as well as the emotional cost to those who work to improve the situations. On a more advanced level, this book should be read by ethics committee members who participate in ethics consultations, individual ethics consultants, clinicians who seek education about complex clinical ethics cases, and bioethics students. (shrink)

Doctor-patient interaction has gained increasing attention among sociologists and linguists during the last few decades. The problem with the studies performed so far, however, has been a lack of a theoretical framework which could bring together the various phenomena observed within medical consultations. Mikhail Bakhtin's philosophy of language offers us tools for studying medical practice as socio-cultural semiotic phenomenon. Applying Bakhtin's ideas of polyphonic, context-dependent and open-ended nature of human communication opens the possibilities to develop prevailing theoretical and (...) empirical approaches to the study of medical consultations. (shrink)

The conflicts of interest that may arise in relationships between academic researchers and industry continue to prompt controversy. The bulk of attention has focused on financial aspects of these relationships, but conflicts may also arise in the legal obligations that faculty acquire through consulting contracts. However, oversight of faculty members' consulting agreements is far less vigorous than for financial conflicts, creating the potential for faculty to knowingly or unwittingly contract away important rights and freedoms. Increased regulation could prevent this, but (...) it is unclear what forms of oversight universities view as feasible and effective. In this article, we report on a Delphi study to evaluate several approaches for oversight of consulting agreements by medical schools. The panel was comprised of 11 senior administrators with responsibility for oversight of faculty consulting relationships. We found broad agreement among panelists regarding the importance of institutional oversight to protect universities' interests. There was strong support for two specific approaches: providing educational resources to faculty and submitting consulting agreements for institutional review. Notwithstanding the complexities of asserting authority to regulate private consulting agreements between faculty members and companies, medical school administrators reached consensus that several approaches to improving institutional oversight are feasible and useful. (shrink)

The goal of this paper is to review and describe the characteristics and outcomes of ethics consultations on a gastrointestinal oncology service and to identify areas for systems improvement and staff education. This is a retrospective case series derived from a prospectively-maintained database of the ethics consultation service at Memorial Sloan Kettering Cancer Center. The study analyzed all ethics consultations requested for patients on the gastrointestinal medical oncology service from September 2007 to January 2016. A total of 64 (...) patients were identified. The most common primary ethical issue was the DNR order, followed by medical futility. The most common contextual issues were dispute/conflict between staff and family, dispute/conflict intra-family, and cultural/ethnic/religious issues. The majority of ethical issues leading to consultation were resolved ; i.e., the patient, surrogate, and/or healthcare team followed the recommendation of the ethics consultant. 22% had a DNR order prior to the ethics consult and 69% had a DNR order after the consult. In this population of patients on a gastrointestinal oncology service, ethics consultations are most often called regarding patients with advanced cancers and the most common ethical conflicts arose between families and the health care team over goals of care at the end of life, specifically related to the DNR order and perceived futility of continued/escalation of treatment. Ethics consultations assisted with conflict resolution. Conflicts might be reduced with improved communication about prognosis and earlier end of life care planning. (shrink)

In recent years, the model of shared decision-making has become increasingly promoted as the preferred standard in doctor-patient communication. As the model considers doctor and patient as coe-qual partners that negotiate their preferred treatment options in order to reach a shared decision, shared de-cision-making notably leaves room for the usage of argumentation in the context of medical consultation. A paradigm example of argumentative conflict in consultation is the discussion that emerges between doctors and their patients concerning antibiotics (...) as a method of treatment for what is presumed to be a viral infec-tion. In this paper, a case of such argumentative conflict is studied, using the extended pragma-dialectical theory to argumentation. It is examined how a patient and her physician manoeuvre strategically in order to maintain a balance between dialectical reasonableness and rhetorical effectiveness, as well as an equilibri-um between patient participation and evidence-based medication, while arguing their case for and against antibiotics respectively. (shrink)

To design effective strategies to improve ethics consultation (EC) practices, it is important to understand the views of ethics practitioners. Previous U.S. studies of ethics practitioners have overrepresented the views of academic bioethicists. To help inform EC improvement efforts, we surveyed a random stratified sample of U.S. hospitals, examining ethics practitioners’ opinions on EC in general, on their own EC service, on strategies to improve EC, and on ASBH practice standards. Respondents across all categories of hospitals had very positive (...) perceptions of their own ethics consultation service (ECS) and few concerns about quality. Our findings suggest that the ethics-related needs of small, rural, non-teaching hospitals may be very different from those of academic medical centers, and therefore, different approaches to addressing ethical issues might be warranted. (shrink)