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The model for capacity assessment in the United States and much of the Western world relies upon the demonstration of four skills including the ability to communicate a clear, consistent choice. Yet such assessments often occur at only one moment in time, which may result in the patient expressing a choice to the evaluator that is highly inconsistent with the patient’s underlying values and goals, especially if a short-term factor (such as frustration with the hospital staff) distorts the patient’s preferences momentarily. These challenges are particularly concerning in cases, which arise frequently in hospital settings, in which patients demand immediate self-discharge, often during off-hours, while faced with life-threatening risks. This paper examines the distinctive elements that shape such cases and explores their ethical implications, ultimately offering a model for such situations that can be operationalized.
Intelligence, as measured by grades and/or standardized test scores, plays a principal role in the medical school admissions process in most nations. Yet while sufficient intelligence is necessary to practice medicine effectively, no evidence suggests that surplus intelligence beyond that threshold is correlated with providing higher quality medical care. This paper argues that using perceived measures of intelligence to distinguish between applicants, at levels that exceed the level of intelligence required to practice medicine, is both unfair to applicants and fails to serve the interests of patients.
Capacity evaluation has become a widely used assessment device in clinical practice to determine whether patients have the cognitive ability to render their own medical decisions. Such evaluations, which might be better thought of as “capacity challenges,” are generally thought of as benign tools used to facilitate care. This paper proposes that such challenges should be reconceptualized as significant medical interventions with their own set of risks, side effects, and potentially deleterious consequences. As a result, a cost–benefit analysis should be implemented prior to imposing such capacity challenges, and efforts should be made to minimize such challenges in situations where they are unlikely to alter the course of treatment.
One of the criteria used by many transplant centers in assessing psychosocial eligibility for solid organ transplantation is social support. Yet, social support is a highly controversial requirement that has generated ongoing debate between ethicists and clinicians who favor its consideration (i.e., utility maximizers) and those who object to its use on equity grounds (i.e., equity maximizers). The assumption underlying both of these approaches is that social support is not a commodity that can be purchased in the marketplace. This essay argues for the reconceptualization of social support as a product that can—and should—be purchased for transplant candidates to render them eligible for transplant.
Requests by patients for providers of specific demographic backgrounds pose an ongoing challenge for hospitals, policymakers, and ethicists. These requests may stem from a wide variety of motivations; some may be consistent with broader societal values, although many others may reflect prejudices inconsistent with justice, equity, and decency. This paper proposes a taxonomy designed to assist healthcare institutions in addressing such cases in a consistent and equitable manner. The paper then reviews a range of ethical and logistical challenges raised by such requests and proposed guidance to consider when reviewing and responding to them.
Clinicians are often called upon to assess the capacity of a patient to appoint a healthcare agent. Although a consensus has emerged that the standard for such assessment should differ from that for capacity to render specific healthcare decisions, exactly what standard should be employed remains unsettled and differs by jurisdiction. The current models in use draw heavily upon analogous methods used in clinical assessment, such as the “four skills” approach. This essay proposes an alternative model that relies upon categorization and sliding scale risk assessment that can be used to determine to how much scrutiny the proxy appointment should be subjected and how much certainty of accuracy should be required in order to maximize the patient’s autonomy and ensure that her underlying wishes are met.
This essay advocates for the wholesale reevaluation of the process used by American medical schools for selecting physicians, examining fundamental questions such as the purpose of physicians and the nature of meritocracy. It raises questions about the size of medical school classes, the specific academic requirements, and the inadequacy of current efforts to increase diversity. Ultimately, the essay argues for consideration of a range of reforms that will focus on the community-empowering aspects of medical admissions decisions.
The “Goldwater rule,” a policy adopted by the American Psychiatry Association (APA) in 1973, prohibits organization members from diagnosing or offering professional opinions regarding the mental health of public figures without both first-hand evaluation and authorization. Initially developed in response to a controversial survey of APA members during the 1964 Presidential election campaign, the ethics rule faced few large scale challenges until the election of Donald Trump in 2016. Since that time, a significant number of psychiatrists have either violated or criticized the rule openly. This paper argues that whatever the initial merits of the rule, the prohibition has since been rendered obsolete by the combined lack of professional consensus supporting the policy, absence of a meaningful enforcement mechanism, and the credible statements of non-APA members in the mental health professions regarding public figures.
Rather than being a neutral phenomenon, the authors propose that medical school donations should be viewed as a social good for advancing education and improving healthcare. Seen in this light, they aim to offer a framework for analysis that will be useful to medical institutions and their stakeholders in addressing proposed donations from contentious or divisive sources, and in managing those donations that subsequently appear controversial.
Electronic health records (EHRs) offer significant advantages over paper charts, such as ease of portability, facilitated communication, and a decreased risk of medical errors; however, important ethical concerns related to patient confidentiality remain. Although legal protections have been implemented, in practice, EHRs may be still prone to breaches that threaten patient privacy. Potential safeguards are essential, and have been implemented especially in sensitive areas such as mental illness, substance abuse, and sexual health. Features of one institutional model are described that may illustrate the efforts to both ensure adequate transparency and ensure patient confidentiality. Trust and the therapeutic alliance are critical to the provider–patient relationship and quality healthcare services. All of the benefits of an EHR are only possible if patients retain confidence in the security and accuracy of their medical records.
One of the most fundamental tenets of medical research, enshrined in the World Medical Association’s Declaration of Helsinki, is that scientific investigation involving human beings requires the informed consent of the subjects.
As a result of workplace clean air regulations and strict guidelines imposed by the Joint Commission on Accreditation of Healthcare Organizations in 1993, most hospitals in the United States are now virtually smoke free. Although evidence suggests that these restrictions both cause smoking employees to consume fewer cigarettes per day and induce some employees to quit smoking entirely, the policies have also driven many healthcare providers—including physicians—onto the public sidewalks for their cigarette breaks. Patients entering many hospitals pass white-coated medical students and residents puffing away at the curbside.