Center for Biomedical Ethics

NEXT EVENT

ETHICAL ISSUES IN "RETAINER-FEE" OR "CONCIERGE" MEDICAL PRACTICE

THURSDAY, JUNE 8, 2006
5:30-7:30 PM


Email CBME@Brown.edu for further information.

Note new location!! “Crystal Room, Alumnae Hall, 194 Meeting Street, Providence (on the Brown campus)

From downtown Providence, take College Street up the hill to the Van Wickle Gates. Take a left onto Prospect Street and then a right at the light onto Waterman Street. Take the 1st left onto Brown St. Look for parking on Brown or neighboring streets. Alumnae Hall will be a short walk down the hill onto Meeting Street, #194 on the north side of the street. The Crystal Room is on the second floor.

PAST EVENTS

"Court-Appointed Guardians: Strangers at the Bedside?"
"Time to Pull the Plug on Substituted Judgment?"
"Suffering & Justice: Topics from the ASBH Meeting"
"Dissent on Informed Consent"
"No Place Left To Go...Ethical Dilemmas in RI Free Clinic"
"Does DNR Disqualify You From an ICU Bed?"
"Medicine in the Marketplace: Commerce or Compassion?"
"Living with Grief: Ethical Dilemmas at the End of Life"
"Flu Vaccine Triage: Who Really Needs It? Who Gets It? How to Decide?"
"Testing the Limits: Ethics in the Hospice Unit"
"Limitations of Surrogate Decision-Making – A Modern Day Dax?"
"Negotiating Moral Differences: When Doctors and Nurses Disagree"
"Dead or Dead Enough"
"Medical Futility: Clarity or Confusion?"
"Ethics Consultation: Nuts and Bolts"
"Ethics Committee Benchmarking Project"
"Barriers to Advance Directives"


APRIL 6 , 2006– "Court-Appointed Guardians: Strangers at the Bedside?"

TIME: 5:30 pm - 7:30 pm

A panel discussion moderated by Jay Baruch, MD

PANELISTS:
Kathleen Heren: Clinical Director, Alliance for Better Long Term Care
Lynn McNicoll, MD: Geriatrician, Assistant Professor of Medicine, Brown University
Valerie Pauley, MEd: Director, Volunteer Guardian Program

CASE FOR DISCUSSION:
A 76 year old man with impaired judgment didn’t have family willing or able to make decisions for him regarding his affairs or medical issues.  During a long hospital admission, hospital social workers and a local attorney arranged for a court appointed guardian. The patient was then transferred to a nursing home for further care, where the guardian met him for the first time.  About 6 weeks later, the guardian received a phone call from the emergency department at the VA Medical Center.  The patient had an implantable cardiac device (a defibrillator) that “keeps going off” and “this is very painful.” The physician asked the guardian for permission to turn the device off (and allow the patient to die).  The guardian was unsure of the limits of her decision-making authority and the best medical decision to make in this situation. The guardian didn’t understand what the cardiac device was, how it worked, and whether other treatment options existed.

OBJECTIVES:
1) Develop a greater understanding of the types of medical decisions guardians are called upon to make on behalf of incapacitated patients (wards), and the process by which such decisions are made.
2) Analyze the ethical foundations for surrogate decision-making in general, and how decision-making by guardians compares to these standards.
3) Examine the relationship between guardians and their wards.
4) Discuss alternatives to guardianship for patients lacking decision-making capacity.

FEBRUARY 10 , 2006 – Dr. John Lantos: "Time to Pull the Plug on Substituted Judgment?"


Dr. John Lantos

Professor of Pediatrics and Medicine
The University of Chicago
Pritzker School of Medicine
Associate Director
MacLean Center for Clinical Medical Ethics



Dr. Lantos is the author of numerous articles on medicine and ethics, as well as the books:

The Lazarus Case: Life and Death Issues in Neonatal Intensive Care
The Last Physician: Walker Percy and the Moral Life of Medicine
Do We Still Need Doctors?


Click here for Dr. Lantos' Powerpoint presentation on substituted judgment.

DECEMBER 1, 2005 – "Suffering and Justice" – Selected topics from the American Society for Bioethics and Humanities meeting

Presented by:
Jay Baruch, MD, Director, Ocean State Ethics Network
Thomas Bledsoe, MD, Interim Director, Center for Biomedical Ethics

Topics
• Abu Ghraib and Guantanamo: Medical Professionalism, Dual Loyalty and Human Rights
• Conceptions of Justice: International Considerations Related to Basic Rights to Healthcare/National Considerations Related to Investment in Public Health
• Justice and Quality of Life – A New Model of Caring About and Caring for Patients with Dementia
• Just Responses to Sterilization Requests by Guardians of the Cognitively Disabled

Objectives of this session:
1) Provide background education on emerging issues in bioethics
2) Discuss emerging issues in bioethics and practical implications on a local level
3) Continue the dialogue within OSEN relating to fairness and justice in healthcare

Click here for Dr. Tom Bledsoe's Powerpoint presentation.

NOVEMBER 3 , 2005 – "Dissent on Informed Consent: Socio-Philosophical Aspects of Japanese Efforts to Forge an Alternative Path in Bioethics"

The Center for Biomedical Ethics and the Ocean State Ethics Network welcomed Professor William LaFleur, a Senior Fellow and Professor of Japanese Culture and Bioethics in the Center for Bioethics at UPenn. Professor LaFleur has extensively written and researched the Japanese approach to medical ethics, which often contrasts strongly with our own. Resistant to the American insistence that patient autonomy requires that medical decisions be made by individuals, some Japanese bioethicists are trying to articulate a "family based" approach. How this plays out in decisions about therapy selection, organ transplantation, and the use of stored tissue was analyzed at this early evening lecture.

SEPTEMBER 22 , 2005 "No Place Left To Go...Ethical Dilemmas in R.I. Free Clinic"

A panel discussion moderated by Jay Baruch, MD

Guest panelists:
Judith Koegler, RN – Nurse Clinic Coordinator, R.I. Free Clinic
Lisa Smolski – Executive Director, R.I. Free Clinic
Caroline Troise, MD – Volunteer Medical Director, R.I. Free Clinic


Judith Koegler, Jay Baruch, Lisa Smolski, Caroline Troise

Objectives of this session:
1) Understand how R.I. Free Clinic is different than community health centers.
2) Analyze how lacking health insurance can have non-health related consequences.
3) Understand the challenges faced by caregivers who offer free care.
4) Discuss strategies to ensure access and high-quality care to the community of uninsured persons when resources are limited.

Consider that free access doesn't imply open access. Can we identify justifiable criteria relevant to the decision of who gets the appointment? What is meant by "medical need"? Can a fair decision be made in the face of overwhelming need?

Click here for RIFC FAQs
Click here for RIFC Fact Sheet

MAY 19 , 2005 "Does DNR Disqualify You From an ICU Bed?"

A panel discussion moderated by William J. Kirkpatrick, LICSW. Case presentation by Vadim Fayngersh, MD. Guest panelists: Thomas Bledsoe, MD; Achal Dhupa, MD; Michael Felder, DO; and Mitchell M. Levy, MD.

Objectives of this session:

1) Discuss how code status impacts one's "right" to ICU admission.
2) Analyze how advance directives may be interpreted differently by health care providers.
3) Discuss strategies to help resolve dilemmas between treatment teams.

MAY 5 , 2005 "Medicine in the Marketplace: Commerce or Compassion?"

Dr. Barbara Bridgman Perkins, author of The Medical Delivery Business: Health Reform, Childbirth and the Economic Order, led a provocative discussion to examine where and how the profession of medicine fits into the business of medicine.

APRIL 20, 2005 "Living with Grief: Ethical Dilemmas at the End of Life "

Co-sponsored by the Center for Biomedical Ethics, the Lifespan Comprehensive Cancer Center, and the Rhode Island Hospital Ethics Committee

Satellite teleconference & local panel discussion
Location: Rhode Island Hospital, George Auditorium

DECEMBER 2 , 2004 —"Flu Vaccine Triage: Who Really Needs It? Who Gets It? How to Decide?"

A panel discussion, moderated by Dr. Jay Baruch

Guest panelists:
Dr. Marguerite A. Neill, infectious disease specialist
Ms. Helen Drew, Health Legislative and Community Liaison with the RI Department of Health

Consider: Presently, the current flu vaccine shortage is a serious health issue on a national and statewide level. There will not be enough vaccine to cover those population groups considered to be highest priority and most in need. For certain high-risk populations, the flu can be potentially lethal. For others, the flu can lead to a serious illness that results in lost time from work and school, and compromises vital family routines.

The shortage of flu vaccine has raised many important issues concerning the uncomfortable topic of bedside rationing. This symposium will provide an open forum for the discussion of this sensitive topic.  What is the role of the flu vaccine? How are we defining burdens and benefits when it comes to the disease and the vaccine? What criteria should be considered relevant when deciding whether a patient does or does not get vaccinated and why? Who should make these decisions? How can we make this allocation process fair, justifiable, consistent, and transparent?

Objectives of the session:

  • Address the scope of the flu vaccine shortage on a statewide level.
  • Develop a better understanding of how the present vaccine shortage impacts different communities of patients and health care providers.
  • Discuss bedside rationing and principles of distributive justice as it applies to the flu vaccine shortage.

Click here for Dr. Marguerite Neill's Powerpoint presentation on the flu vaccine shortage.


SEPTEMBER 23, 2004 —"Testing the Limits: Ethics in the Hospice Unit"

An open case discussion, moderated by Dr. Jay Baruch and Dr. Thomas Bledsoe.

Case for consideration: A middle age male is admitted to Hospice with a primary diagnosis of ALS. He lives with his wife and minor child, who is extremely close to the patient. The patient has expressed suicidal ideations since he came on to the hospice service. The hospice team in this case is primarily the RN, MSW, and CNA. The patient verbalized to the MSW that he would tolerate the disease progression to a certain point before taking his own life. This was communicated to the interdisciplinary team on several occasions at their weekly meetings. A psychiatric evaluation was performed, clearing him of any type of clinical depression. The patient's family is aware of his wishes. The patient's wife sought counseling and supports her husband's decision.

Objectives of the session:

  • Discuss what is meant by good palliative care at the end of life: What do we mean when we say respect for life and relief of suffering in this context?
  • Consider the role of aggressive symptom management and its relationship to the principle of double effect.
  • Discuss how health care providers consider confidentiality in a case such as this.
  • Analyze whether the mission of hospice care is further illuminated or compromised by cases such as this.

JUNE 3, 2004 —"Limitations of Surrogate Decision-Making– A Modern Day Dax?"

A brief clip of the film "Dax's Case" was shown. Several members of the Ocean State Ethics Network board then addressed ethical questions raised by the film and the actual burn case presented. Presenters included William Kirkpatrick, LICSW; Mary Brunell, EdD, RN; Dr. Michael Felder; Dr. Stephen Mernoff, and Dr. Jay Baruch.

Click here for a copy of the case handout and questions discussed.
Click here for Bill Kirkpatrick's Powerpoint presentation on surrogate decision making.
Click here for Dr. Stephen Mernoff's Powerpoint presentation on surrogate decision making.

Objectives of the session:

  • Understand substituted judgement and best interest standards when making decisions for patients unable to do so.
  • Discuss what counts as due diligence in information gathering.
  • Analyze whether substituted judgment standards should always trump best interest, or can providers ever over-rule a good faith attempt at substituted judgment?
  • Discuss how certain elements in the patient's history can prejudice decision makers or caregivers.

MARCH 4, 2004 — "Negotiating Moral Differences: When Doctors and Nurses Disagree"

The panel included Cynthia Padula, PhD, RN, CS; Lynn Pasquerella, PhD, and Sheri Smith, PhD. This public forum explored the complex dynamic between doctors and nurses, how their roles inform their perception and reaction to ethical problems, and strategies to address and hopefully improve this infrequently talked about issue.
Click here for a summary
of the discussion.

DECEMBER 4, 2003 — "Dead or Dead Enough"

A panel on organ donation, in conjunction with the New England Organ Bank, who wanted to promote non-heart-beat cadaver donation (NHBCD) in Rhode Island. Cardiac death may appear straight forward, but when tied to organ donation poses many areas for ethical inquiry. For example, after what minimal interval from the moment the heart stops can death be declared? Does that equal death of brain tissue? Can end-of-life care, withdrawal of medical treatment, and respect for the dying be separated from the organ procurement process? What constitutes valid consent? What is the role of ethics committees in hospital NHBCD protocols? Dr. Stephen Mernoff, Medical Director, Neurorehabilitation Program, Rehabilitation Hospital of Rhode Island gave a thorough review of brain death criteria. Then, Paul E. Morrissey, MD, Assistant Medical Director, New England Organ Bank, and chief of transplantation surgery at Rhode Island Hospital spoke on organ transplantation in R.I.

Click here for Dr. Jay Baruch's Powerpoint presentation.
Click here for Dr. Stephen Mernoff's Powerpoint presentation.
Click here for Dr. Paul Morrissey's Powerpoint presentation.

OCTOBER 2, 2003 — "Medical Futility: Clarity or Confusion?"

The term "futility" is difficult to define, yet evokes strong emotional responses from clinicians and their families. Futility often doesn't represent differences in medical judgment, but differences in values.
Click here for Dr. Jay Baruch's Powerpoint presentation

JUNE 26, 2003 —"Ethics Consultation: Nuts and Bolts"

Dr. Jay Baruch gave a talk which provided a brief, general overview on the process of ethics consultation. Issues discussed included the aim of clinical ethics consultation, the nature of "ethics expertise," the essential elements of ethics consultations, the different models of ethics consultation, and potential pitfalls that can undermind an ethics consult. Following the talk, representatives from three ethics committees presented cases that came before their respective HECs. We discussed why a consultation went well and why it may have gone poorly.
Click here for Dr. Jay Baruch's Powerpoint presentation

MAY 6, 2003 — "Ethics Committee Benchmarking Project"

Bill Kirkpatrick, Director of Clinical Social Work for Lifespan Academic Medical Center, presented preliminary results from his "Ethics Committee Benchmarking Project." This project surveyed HECs of fourteen hospitals in Rhode Island and Massachusetts. His work provided information about particular strengths and needs of HECs in the region, and gave the evolving ethics network a cogent approach to curriculum development that would most benefit network members.
Click here for Bill Kirkpatrick's Powerpoint presentation.

MARCH 31, 2003 — "Barriers to Advance Directives"

The lack or inadequacy of advanced directives seemed to be a common problem across the state. The panelists drew three different perspectives on this rich issue. They included Maureen Glynn, Assistant Attorney General, Dr. Joan Teno, Professor of Community Health and Medicine and a principal investigator in the SUPPORT trial, and Mary Callahan-Cimini, Executive Director, Aging 2000.
Click here for Dr. Joan Teno's Powerpoint presentation.