Clerkship Ethics: Unique Ethical Challenges for Physicians-in-Training.

Three ethical conflicts in particular are paradigmatic of what we define as "clerkship ethics." First, a distinction that differentiates the clerkship student from the practicing physician involves the student's principal role as a learner. The clerkship student must skillfully balance her commitment to her own education against her commitment to patient care in a fashion that may compromise patient care. While the practicing physician can often resolve the tension between these two goods when they come into conflict, the clerkship student is left with a more ambiguous set of choices. Second, evaluative scrutiny during clinical clerkships often forces medical students to balance doing what is morally fitting against the perceived expectations of the medical teams in which they work. Third and finally, a deeply entrenched culture of medical hierarchy presents a particular challenge to innovation and improvement in ethics education during the clerkship years. Students regard faculty as exemplars, but are not provided with the tools to assess when technical medical competence is not matched by moral competence; moreover, these faculty are unlikely to have experienced the ethics education in which students are asked to demonstrate mastery.

Duty, Empathy, and Hierarchy: Healing "Difficult Patients".

Anthony is a fourth-year medical student, currently on service during an away surgery rotation. He is rounding with a first-year intern, Dr. Lovett, and the attending, Dr. Todd. They stop outside the room of Mr. Turpin, a 54-year-old male who has recently had a toe amputation due to uncontrolled diabetes mellitus. His chart lists him as a drug-seeker managed for chronic pain. As such, his analgesics are being closely monitored. Before entering the room, Dr. Lovett mentions that the patient had been irritated the night prior, complaining of uncontrolled pain, and upset at staff for refusing increased pain medication. Dr. Todd knows this, remarking that Mr. Turpin has a history of being a "difficult patient."

Assessment of orientation practices for ethics consultation at Harvard Medical School-affiliated hospitals.

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 (ASBH) ethics consultation competencies. METHODS: We conducted a survey study that involved 116 members and 16 chairs of ethics advisory committees, respectively (52% and 62.5% response rates). 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 (62%), although a significant portion of respondents did not receive any orientation (24%) or were unsatisfied with their orientation (14%). Familiarity with ASBH competencies was a statistically significant predictor of respondents' self-evaluation in particular categories (54% had heard of the competencies). Standard educational materials were reported as offered during orientation, such as readings (50%) and case studies (41%); different medium resources were less evidenced such as videos on ethics consultation (19%). 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.

Maintaining the Punitive Element of Tort through Social Sanctions in Malpractice Reform.

In this piece, I focus on the limitations of moving medical malpractice from a tort to contracts basis, particularly in the loss of the punishment aspect of punitive damages. In doing so, I present the way in which medical malpractice is currently implemented in the United States under tort law. I then briefly review current malpractice reform efforts, focusing more so on the idea of "no-fault" administrative systems. Here, I also explore the fundamental legal differences between contracts and tort. I then discuss the ethics of blame-shielding and whether or not we are losing something by failing to blame bad actors. In doing so, I focus on the ethical implications of punishment. Operating under the assumption that the current tort-based medical malpractice system is driving up health care costs, I conclude by proposing a hybrid system that combines contract theory with noneconomic punitive sanctions: a "no-fault fault system."

Re-Evaluating the Ethics of Uterine Transplantation.

In February 2016, the Cleveland Clinic initiated the first attempt at cadaveric uterine transplantation (UTx) in the United States. The transplantation was ultimately unsuccessful, but it opened doors for further research on both live and cadaveric UTx. While initial strides toward successful transplantation have been made, questions persist on the ethics of UTx: whether the uterus is a vital organ, whether we should prioritize live or cadaveric options, and how the procedure should be covered by health insurance. If we agree that the goal of the medical profession is both to treat and improve quality of life, then the question of whether or not infertility is considered a disease becomes inconsequential in the discussion. As such, the medical enterprise should move forward with research in UTx. In doing so, considering the ethical implications of UTx remains essential-and we must remember to pair innovation with regulation.

Plate reader-based cell viability assays for glioprotection using primary rat optic nerve head astrocytes.

Optic nerve head astrocytes (ONHAs) are the major glia cell type in the non-myelinated optic nerve head where they contribute critically to extracellular matrix synthesis during development and throughout life. In glaucoma, and in related disorders affecting the optic nerve and the optic nerve head, pathological changes include altered astrocyte gene and protein expression resulting in their activation and extracellular matrix remodeling. ONHAs are highly sensitive to mechanical and oxidative stress resulting in the initiation of axon damage early during pathogenesis. Furthermore, ONHAs are crucial for the maintenance of retinal ganglion cell physiology and function. Therefore, glioprotective strategies with the goal to preserve and/or restore the structural and functional viability of ONHA in order to slow glaucoma and related pathologies are of high clinical relevance. Herein, we describe the development of standardized methods that will allow for the systematic advancement of such glioprotective strategies. These include isolation, purification and culture of primary adult rat ONHAs, optimized immunocytochemical protocols for cell type validation, as well as plate reader-based assays determining cellular viability, proliferation and the intracellular redox state. We validated and standardized our protocols by performing a glioprotection study using primary ONHAs. Specifically, we measured protection against exogenously-applied oxidative stress using tert-butylhydroperoxide (tBHP) as a model of disease-mediated oxidative stress in the retina and optic nerve head by the prototypic antioxidant, 6-hydroxy-2,5,7,8-tetramethylchroman-2-carboxylic acid (Trolox). Levels of oxidative stress were increased in the response to exogenously applied tBHP and were assessed by 6-carboxy-2', 7' dichlorodihydrofluorescein diacetate (DCFDA) fluorescence. Normalized DCFDA fluorescence showed a maximal 5.1-fold increase; the half-maximal effect (EC50) for tBHP was 212 ± 25 µM. This was paralleled very effectively in the assays measuring cell death and cell viability with half-maximal effects of 241 ± 20 µM and 194 ± 5 µM for tBHP in the lactate dehydrogenase (LDH) release and the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) conversion assays, respectively. Pre-treatment with 100 µM Trolox decreased the sensitivity of ONHAs to tBHP. Half-maximal effects increased to 396 ± 12 µM tBHP in the LDH release assay and to 383 ± 3 µM tBHP in the MTT assay. Vehicle treatment (0.1% v/v ethanol) did not significantly affect cellular responses to tBHP. Antioxidant treatment increases ONHA viability and reduces the deleterious effects of oxidative stress. Our experiments provide important feasibility data for utilizing primary rat ONHAs in plate reader-based assays assessing novel therapeutics for glioprotection of the optic nerve and the optic nerve head in glaucoma and related disorders. Furthermore, our novel, standardized protocols have the potential to be readily adapted to high-throughput and high-content testing strategies.

On Strengthening Compassionate Care for Muslim Patients.

In this piece, I contribute to an ongoing conversation on compassionate care for Muslim patients. I address the various barriers hindering such care and ways in which to work around them. In providing an introductory understanding of general Islamic beliefs on the definition of life, the use of palliative care, etc., I hope this reflection can offer insight into the general background of Muslim patients and spark interest in further reading and research.

Deactivation of Left Ventricular Assist Devices at the End of Life: Narrative Review and Ethical Framework.

Left ventricular assist devices (LVADs) have become an increasingly common advanced therapy in patients with severe symptomatic heart failure. Their unique nature in prolonging life through incorporation into the circulatory system raises ethical questions regarding patient identity and values, device ontology, and treatment categorization; approaching requests for LVAD deactivation requires consideration of these factors, among others. To that end, clinicians would benefit from a deeper understanding of: 1) the history and nature of LVADs; 2) the wider context of device deactivation and associated ethical considerations; and 3) an introductory framework incorporating best practices in requests for LVAD deactivation (specifically in controversial situations without obvious medical or device-related complications). In such decisions, heart failure teams can safeguard patient preferences without compromising ethical practice through more explicit advance care planning before LVAD implantation, early integration of hospice and palliative medicine specialists (maintained throughout the disease process), and further research interrogating behaviors and attitudes related to LVAD deactivation.

Interatrial Stent to Treat Stiff Left Atrium Syndrome.

BACKGROUND: Catheter ablation for atrial fibrillation (CAAF) can result in stiff left atrial syndrome (SLAS) in up to 8% of patients. SLAS can be challenging to diagnose and difficult to distinguish from heart failure with preserved ejection fraction (HFpEF), presenting with similar signs and symptoms. CASE PRESENTATION: We report the first case of using an interatrial stent to maintain therapeutic benefit of atrial septostomy in a patient with symptomatic SLAS. While interatrial shunt devices have preliminarily been shown to be safe and efficacious for the treatment of HFpEF, their utilization in those with SLAS has not previously been described [1]. CONCLUSIONS: In patients with prior CAAF, SLAS should be considered to explain dyspnea when alternative processes have been excluded. Treatment of SLAS can be challenging with medical therapy alone, and septostomy may provide significant symptomatic benefit in these patients. Interatrial stenting can improve the patency of such interventions.

Family presence in the trauma setting: A case study.

The topic of family presence during resuscitation (FPDR) has been in the medical literature for several decades. However, these discussions have largely failed to delineate a difference between resuscitation of patients in cardiac arrest and the resuscitation and stabilisation of trauma victims before a necessary procedure. Through a case-based scenario, this primer aims to explore the ethical considerations of FPDR in emergent trauma care - particularly in the case of a motor vehicle collision. In doing so, consideration is given to the relevant aspects of patient dignity and privacy; as well as to the benefits of exposing family to clinician efforts, including how FPDR can aid in the grieving process.