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The ethics of involving persons with cognitive impairments and/or mental illness in research continues to gain academic and public attention. Concerns about the ability of such persons to provide ethically and legally valid consent and about the appropriateness of their research involvement in certain categories of studies have resulted in publication of guidelines, position papers, standards, and court decisions. These analyses address not only when and from whom informed consent may be obtained but also under what conditions it is ethically permissible to involve persons in research who are too decisionally impaired to provide their own consent.
It is an advance in research ethics that there is heightened appreciation of the need for greater protections for, and possibly research participation limitations on, persons unable to give their own consent. In our zeal to protect potentially vulnerable subjects, however, we must craft new protections carefully. Prudence is required in shaping and implementing any new protections.
This article provides practical ethical guidance for clinicians making decisions after a nuclear detonation, in advance of the full establishment of a coordinated response. We argue that the utilitarian maxim of the greatest good for the greatest number, interpreted only as “the most lives saved,” needs refinement. We take the philosophical position that utilitarian efficiency should be tempered by the principle of fairness in making decisions about providing lifesaving interventions and palliation. The most practical way to achieve these goals is to mirror the ethical precepts of routine clinical practice, in which 3 factors govern resource allocation: order of presentation, patient's medical need, and effectiveness of an intervention. Although these basic ethical standards do not change, priority is given in a crisis to those at highest need in whom interventions are expected to be effective. If available resources will not be effective in meeting the need, then it is unfair to expend them and they should be allocated to another patient with high need and greater expectation for survival if treated. As shortage becomes critical, thresholds for intervention become more stringent. Although the focus of providers will be on the victims of the event, the needs of patients already receiving care before the detonation also must be considered. Those not allocated intervention must still be provided as much appropriate comfort, assistance, relief of symptoms, and explanations as possible, given the available resources. Reassessment of patients' clinical status and priority for intervention also should be conducted with regularity.
(Disaster Med Public Health Preparedness. 2011;5:S46-S53)
Ethics rounds in clinical ethics have already taken hold in multiple
venues. There are “sit-down rounds,” which usually consist of
a bioethicist setting a specific, prescheduled time aside for residents
and/or others to bring a case or two for discussion with the
bioethicist. Another kind of rounds that occurs on an ad hoc or infrequent
basis is to have either a staff or outside bioethicist give hospital-wide
and/or departmental “grand rounds.” Grand rounds is a
traditional educational format in medicine and adding bioethics to the
topics covered in grand rounds is an important means of elevating ethical
awareness within a department or throughout a healthcare organization.
Newer is the rounding practice of adding a bioethicist to other
established rounding processes, such as case management and utilization
review rounds. All of these kinds of ethics rounds are important
opportunities to elevate the level of moral discourse within a healthcare
setting and are becoming part and parcel of any full-service hospital
bioethics program.Some of the content of
this paper was delivered by DeRenzo in her talk, “Having a
Bioethicist Round Weekly in the Intensive Care Unit: Benefits to Patients
and Staff of Upstream Preventive Ethics versus Conflicted Downstream
Consultations,” presented at the Second International Conference on
Clinical Ethics Consultation, Basel, Switzerland, March 2005.