Ethicians, ethicists and the goals of clinical ethics consultation.

We believe that clinical ethics consultation (CEC) has as its goal the delivery of healthcare in a manner consistent with the moral rules and the moral ideals. Towards this end, CEC pursues the instrumental ends of clarifying the limits of acceptable ethical disagreement and facilitating a choice among ethically acceptable alternatives. In pursuing these ends, healthcare ethics consultation (HEC) and CEC services confront three broad categories of questions: (1) questions of professional duty; (2) questions of law; and (3) questions of general morality. Professional duty questions concern what has been referred to as the "internal morality of medicine", and include questions such as the medical legitimacy of the goal(s) being pursued, or the acceptability of the means being employed. Questions of law concern themselves with what the law requires, permits or prohibits. Questions of general morality include all those not falling within the scope of the above categories. We submit that this has implications for the organization and structure of consultation services and HEC and for the methodology and processes employed in CEC. Thus: (1) questions of professional duty should be addressed only by physician members (whom we would distinguish by employing the term "ethicians") of the HEC or CEC service. The only role for non-ethicians under these circumstances would be in helping to resolve disagreements between/among professionals; (2) questions of law, in contrast, should be addressed only by the attorney member(s) of the HEC or CEC service; (3) questions of general morality may be addressed by the entire membership of the HEC or CEC service.

Beyond medical futility: a proposed taxonomy of ultra vires acts in medicine.

When is a physician's act non-medical, and how might such non-medical acts be classified? One approach, analogous to the substantive due process inquiry employed by American courts weighing the constitutionality of legislative acts, would involve consideration of the following questions: 1) Is a legitimate medical goal being pursued? 2) Are the means being employed legitimately medical? 3) Are the goals and means appropriately related? Accordingly, a physician acts medically when employing legitimate and appropriate medical means in pursuit of a legitimate medical goal. In contrast, when the goals pursued or means employed are not legitimately medical, or when the two are not appropriately related, the act is medically ultra vires ("beyond the powers")--that is, an act beyond the physician's power or authority--and consequently non-medical. Medically ultra vires acts may be further sub-classified depending upon which prong of the above trident is defective. Where the goal of the act, though achievable, is not legitimately medical, the act is medically ultra vires because of goal illegitimacy, or medically ultra fines ("beyond the ends"). Where the means employed are not legitimately medical, the act is medically ultra vires because of means illegitimacy, or medically ultra modos ("beyond the means"). Where the means and goals are not appropriately related, the act is medically ultra vires because of means-goals disjunction, or medically ultra nexus ("beyond the connection"). Medical futility (where the medical goal in question, albeit legitimate, cannot be achieved by the act under consideration) represents the paradigmatic example of the latter.

Acupuncture and spinal cord medicine.

BACKGROUND: The National Institutes of Health has concluded that the potential value of acupuncture justifies expanding its use into conventional medicine and studying it further. METHODS: Literature review of acupuncture as it pertains to spinal cord medicine. RESULTS: Acupuncture has been used to treat a number of spinal cord injury (SCI)-related conditions, including motor deficits, pain, spasticity, and syringomyelia. CONCLUSION: Acupuncture shows promise as an intervention in the treatment of SCI-related conditions. Further research, carried out in careful and systematic fashion by qualified practitioners of acupuncture in concert with spinal cord medicine specialists, is needed.

Phenazopyridine in the management of autonomic dysreflexia associated with urinary tract infection.

OBJECTIVE: Documentation of possible usefulness of phenazopyridine in the management of autonomic dysreflexia (AD) associated with urinary tract infection. SETTING: Veterans Administration Spinal Cord Injury Center. RESULTS: A 36-year-old man with tetraplegia and AD triggered by cystitis improved both subjectively and objectively following the institution of a 2-day course of phenazopyridine. CONCLUSION: Phenazopyridine may be useful in the management of AD associated with cystitis.