Accepting and Embracing Our Mortality.

Aging and death need to be seen as a single reality, aging-and-death. Separating them largely voids the lessons to be learned from aging, and the benefits of seeing life as a whole and learning a new sense of beauty, meaning, hope, and love. All the distinctive experiences central to our sense of ourselves as human beings are tied to recognition of our mortality. Living a full life means accepting and embracing death as not only inevitable, but necessary and desirable.

Out of This World: re-grounding justice through science fiction.

Good science fiction can be a successful vehicle for portraying justice. Science fiction can stimulate moral imagination in much the same way as the most effective justice theories, connecting the world in which we live with a range of alternative futures deliberately and creatively made plausible. A selective examination of classic and recent science fiction stories and novels provides contextual framing for considering questions of climate justice, virtuous personal action in the face of structural injustice, and the problem of what justice means when some people are regarded as "other." By connecting compelling images of individual responsibility with the complex challenges posed by striving for social justice, science fiction can also help render justice work appealing and achievable-an essential step that is reinforced in closing by a brief set of maxims.

Ethical Maxims for a Marginally Inhabitable Planet.

Bioethics has largely neglected the Anthropocene and its ethical challenges. This essay asks which ethical norms will serve us well in the face of the coming climate catastrophe. It sketches the climate changes likely for the year 2031 and offers six adaptive maxims, drawn from bioethics work in ICUs and hospices, to guide us through the devastation and transition following environmental and social collapse. These six maxims are: work hard to grasp the immensity of the change; cultivate radical hope; have a line in the sand; appreciate the astonishing opportunity of life at this time; train your body and mind; and act for the future generations of all species. Because we are already in an environmental collapse and the beginnings of social collapse, these maxims are relevant today as well as for the future.

Three Kinds of Humility in Bioethics Certification.

The author's skepticism about certifying bioethicists has a 20-year history. The hazards of certification include doubts about whether an online, multiple-choice exam measures what is important in bioethical deliberation. Other worries include the potential neglect of informal reasoning processes used by patients and families, the creation of a false sense of expertise, and how certification can disenfranchise lay members of ethics committees. This essay does not seek to reverse the growing trend toward certification but urges humility both in the process of certification and in interpreting the results. Humility is here defined through the works of Judith Andre and Jack Coulehan. Three kinds of humility are described as important for bioethics work: epistemic, moral, and ontological. The current qualifications for taking the certification exam are discussed, and suggestions for a better approach are offered.

Conscience, Moral Reasoning, and Skepticism.

There is much to admire in Lauris Kaldjian's explication of conscience and its uses for medical practitioners. Yet his claim that conscience is the final and best assessment of moral judgments is flawed, because it diminishes the influence of moral reasoning that balances and often corrects conscience. Skepticism about conscientious judgments is an important feature of ethics. Kaldjian's close linkage of conscience with moral integrity blunts the necessary recognition that one's conscience can be mistaken. His defense of physician refusals to refer patients gives insufficient weight to the idea that patients' actions in seeking services may also reflect conscientious judgments. Analyses of cases near the end of this essay present no problems with respecting physicians' conscientious refusals to provide services themselves, but they also mostly leave moral room for physicians to make referrals. Examination of these cases suggests other ways to resolve moral conflicts than recourse to one's conscience.

Who Will Teach Us to Die?: Reflections on Futility and Finitude.

Futility is a medical judgment, but more importantly it is a prognostic gesture for shaping relationships among doctors, patients, and their families. As such, the need for a concept of futility, or something like it, is personally and socially important to all of us. It is one of medicine's essential tools for teaching about finitude and mortality.

Embracing a broad spirituality in end of life discussions and advance care planning.

Advance care planning for end of life typically focuses on the mechanics of completing living wills and durable power of attorney documents. Even when spiritual aspects of end of life care are discussed, the dominant assumptions are those of traditional religious systems. A broad view of spirituality is needed, one that may involve traditional religious beliefs but also includes personal understandings of what is holy or sacred. Embracing this broad practice of spirituality will help both familial and professional caregivers honor an essential aspect of end of life discussions and promote greater discernment of the deep meaning in advance care documents.

Why Climate Literacy Is Health Literacy.

Health problems of global warming are daunting in severity and magnitude and will only get worse. Yet literacy about these problems is poor and plans to alleviate them are too early in development to be responsive to current levels of global threat and individual need. Social and ecological determinants of health and illness are exacerbated by excessive heat and flooding; lack of food, safe water, and secure shelter; and loss of arable land for farming. This article considers the nature and scope of ethicists' roles in awakening clinicians and the public to this crisis and offers 4 recommendations to reduce morbidity and mortality from climate change.

Evaluating the Role of Competency-Based Behavioral Interviewing in Holistic Medical School Admissions.

PROBLEM: Holistic review is a multifaceted concept that aims to increase diversity and applicant fit with program needs by complementing traditional academic requirements with appraisal of a wider range of personal characteristics and experiences. Behavioral interviewing has been practiced and studied in human resources, business, and organizational psychology for over 50 years. Its premise is that future performance can be anticipated from past actions. However, many of the interview approaches within the holistic framework are resource intensive and logistically challenging. APPROACH: The Vanderbilt University School of Medicine instituted a competency-based behavioral interview (CBBI) to augment the selection process in 2012. Behavioral interviews are based on key competencies needed for entering students and require applicants to reflect on their actual experiences and what they learned from them. The authors reviewed 5 years of experience (2015-2019) to evaluate how CBBI scores contributed to the overall assessment of applicants for admission. OUTCOMES: The final admission committee decision for each applicant was determined by reviewing multiple factors, with no single assessment determining the final score. The CBBI and summary interview scores showed a strong association (P < .005), suggesting that the summary interviewer, who had access to the full applicant file, and the CBBI interviewer, who did not, assessed similar strengths despite the 2 different approaches, or that the strengths assessed tracked in the same direction. Students whose 2 interview scores were not aligned were less likely to be accepted to the school. NEXT STEPS: The review raised awareness about the cultural aspects of interpreting the competencies and the need to expand our cultural framework throughout interviewer training. Findings indicate that CBBIs have the potential to reduce bias related to over-reliance on standardized metrics; however, additional innovation and research are needed.

Why we should continue to worry about the therapeutic misconception.

In a recent article in The Journal of Clinical Ethics, David Wendler argues that worries about the therapeutic misconception (TM) are not only misconceived, but detract from the larger agenda of a proper informed consent for subjects involved in clinical research.1 By contrast, we argue that Wendler mischaracterizes those who support TM research, and that his arguments are fragmentary, often illogical, and neglect a critical difference between clinical care and clinical research. A clear explanation about the chief aim of research is, in fact, what gives the other elements in a consent process their meaning. We argue that informed consent must be both trial-specific and context-sensitive, and that concern about the TM is needed now more than ever.

Essential Reading for Bioethicists in the Anthropocene Era.

The multiple emergencies of global heating require bioethicists to embrace the dormant, comprehensive bioethics legacy of Van Rensselaer Potter, moving beyond the current narrower focus of the field on medicine and health care. We recommend readings that expand the core literature of bioethics to address key environmental issues. These are Jessica Pierce and Andrew Jameton's The Ethics of Environmentally Responsible Health Care; Dale Jamieson's Reason in a Dark Time; and David Wallace-Well's The Uninhabitable Earth. Because efforts to mitigate climate disasters are likely to be only partially successful, we also recommend the teachings of late Roman Stoicism and core texts of Buddhism, which provide ethical wisdom likely to be needed in the multiple crises of the Anthropocene.

The Future of Bioethics: It Shouldn't Take a Pandemic.

The Covid-19 pandemic has concentrated bioethics attention on the "lifeboat ethics" of rationing and fair allocation of scarce medical resources, such as testing, intensive care unit beds, and ventilators. This focus drives ethics resources away from persistent and systemic problems-in particular, the structural injustices that give rise to health disparities affecting disadvantaged communities of color. Bioethics, long allied with academic medicine and highly attentive to individual decision-making, has largely neglected its responsibility to address these difficult "upstream" issues. It is time to broaden our teaching, research, and practice to match the breadth of the field in order to help address these significant societal inequities and unmet health needs.

Religion, spirituality, and genetics: mapping the terrain for research purposes.

Genetic diseases often raise issues of profound importance for human self-understanding, such as one's identity, the family or community to which one belongs, and one's future or destiny. These deeper questions have commonly been seen as the purview of religion and spirituality. This essay explores how religion and spirituality are understood in the current US context and defined in the scholarly literature over the past 100 years. It is argued that a pragmatic, functional approach to religion and spirituality is important to understanding how patients respond to genetic diagnoses and participate in genetic therapies. A pragmatic, functional approach requires broadening the inquiry to include anything that provides a framework of transcendent meaning for the fundamental existential questions of human life. This approach also entails suspending questions about the truth claims of any particular religious/spiritual belief or practice. Three implications of adopting this broad working definition will be presented.

Healing skills for medical practice.

It is well recognized that physicians' relationships with their patients can have healing effects, but the skills in this area of medical practice are understudied. This article reports on research designed to identify a core set of healing skills. The authors interviewed 50 practitioners, who were identified by their peers as "healers," representing both allopathic and complementary medicine and alternative medicine. Interviews were tape-recorded, transcribed, made anonymous, and analyzed independently, and differences were reconciled by discussion. Eight skills emerged as pivotal from the transcripts of these interviews: do the little things; take time; be open and listen; find something to like, to love; remove barriers; let the patient explain; share authority; and be committed. Mastery of these skills would provide enduring improvements in patient care and reaffirm medicine's calling as a healing profession.

Healing Skills from the Underserved Patient Perspective.

The purpose of this study was to identify physician actions that facilitate meaningful doctor-patient relationships, from the perspective of the medically underserved patient. Twenty-five patients were interviewed at the United Neighborhood Health Services Northeast Clinic in Nashville, Tennessee, which serves an underinsured patient population. Patients were asked to identify the qualities of engagement with their doctor that move beyond simple diagnosis and treatment. Interviews were audio-recorded, professionally transcribed, made anonymous, and analyzed by the grounded theory method of qualitative research. Six physician actions emerged as vital to the doctor-patient relationship. As presented in the words of the patient, they are: Sits down with me; Treats me like family; Cares about me as a person; Takes the time; Gets to the root of it; Will not push me away. How the doctor made the patient feel was vitally important to the clinical encounter.