Everyday Clinical Ethics: Essential Skills and Educational Case Scenarios.

Bioethics conjures images of dramatic healthcare challenges, yet everyday clinical ethics issues unfold regularly. Without sufficient ethical awareness and a relevant working skillset, clinicians can feel ill-equipped to respond to the ethical dimensions of everyday care. Bioethicists were interviewed to identify the essential skills associated with everyday clinical ethics and to identify educational case scenarios to illustrate everyday clinical ethics. Individual, semi-structured interviews were conducted with a convenience sample of bioethicists. Bioethicists were asked: (1) What are the essential skills required for everyday clinical ethics? And (2) What are potential educational case scenarios to illustrate and teach everyday clinical ethics? Participant interviews were analyzed using qualitative content analysis. Twenty-five (25) bioethicists completed interviews (64% female; mean 14.76 years bioethics experience; 80% white). Five categories of general skills and three categories of ethics-specific skills essential for everyday clinical ethics were identified. General skills included: (1) Awareness of Core Values and Self-Reflective Capacity; (2) Perspective-Taking and Empathic Presence; (3) Communication and Relational Skills; (4) Cultural Humility and Respect; and (5) Organizational Understanding and Know-How. Ethics-specific skills included: (1) Ethical Awareness; (2) Ethical Knowledge and Literacy; and (3) Ethical Analysis and Interaction. Collectively, these skills comprise a Toolbox of Everyday Clinical Ethics Skills. Educational case scenarios were identified to promote everyday ethics. Bioethicists identified skills essential to everyday clinical ethics. Educational case scenarios were identified for the purpose of promoting proficiency in this domain. Future research could explore the impact of integrating educational case scenarios on clinicians' ethical competencies.

How Should Organizations Be Held Accountable for Promoting Environments That Foster Social Connection?

Growing familiarity with health risks of loneliness and isolation underscores the importance of social connection in patients' lived environments and communities. Deficits in social connection are linked to poor cognitive, mental, and physical health and premature death. Design interventions for physical environments-structures, spaces, and soundscapes, for example-can foster social connection, support, and resilience. This article canvasses urban interventions that can support human health investment and development. This article also suggests that designers of community policies, programs, structures, and spaces should be accountable for promoting social connection to help generate measurable health outcomes, such as longevity.

A troubling foundational inconsistency: autonomy and collective agency in critical care decision-making.

'Shared' decision-making is heralded as the gold standard of how medical decisions should be reached, yet how does one 'share' a decision when any attempt to do so will undermine autonomous decision-making? And what exactly is being shared? While some authors have described parallels in literature, philosophical examination of shared agency remains largely uninvestigated as an explanation in bioethics. In the following, shared decision-making will be explained as occurring when a group, generally comprised of a patient and or their family, and the medical team become a genuine intentional subject which acts as a collective agent. Collective agency can better explain how some medical decisions are reached, contrary to the traditional understanding and operationalization of 'autonomy' in bioethics. Paradoxically, this often occurs in the setting of high-stakes moral decision-making, where conventional wisdom would suggest individuals would most want to exercise autonomous action according to their personally held values and beliefs. This explication of shared decision-making suggests a social ontology ought to inform or displace significant aspects of autonomy as construed in bioethics. It will be argued that joint commitments are a fundamental part of human life, informing and explaining much human behavior, and thus suggesting that autonomy - conceived of as discrete, individuated moral reasoning of a singular moral agent - is not an unalloyed 'good.'

Telling Stories with Data.

The fidelity provided by rich, nuanced ethics consult narratives does not proscribe efforts to advance the profession by using data to assess performance and demonstrate value. While these two approaches have been described as in conflict with one another, the former sets the bar to which the latter should aim; to achieve this, consult data should, minimally, do two things: (1) tell the story of the case, as best as possible, in language easily accessible to both ethicists and non-ethicists alike; and (2) do so in a way that elements of interest can be aggregated, disambiguated, and analyzed. Here we present a three-component system designed with that in mind. First, the Armstrong Clinical Ethics Coding System (ACECS) produces a set of six codes that tell a simplified story of the case. These six codes form a meta narrative, which, like meta data, can be aggregated, disambiguated, and analyzed. Second, we use a data model to uncover the stories those data tell. The results allow us to understand relationships, recognize patterns, and reveal insights that are otherwise not discoverable when using narratives alone. Third, due to tremendous heterogeneity among cases, we represent findings visually using techniques borrowed from data storytelling, a powerful means to demonstrate the value of a consult service to administrators and others. The ability to derive meta narratives from an aggregate of case narratives allows us to describe, in detail, the work of our consult service in a manner directly comparable to other services that use the system while we preserve unprecedented case-level nuance. If adopted broadly, this functionality suggests a means to undergird the legitimacy of the ethics consult practice itself in an evidence-based manner similar to that which undergirds other domains of healthcare.

The Bioethics of Built Space: Health Care Architecture as a Medical Intervention.

Decisions made in health care architecture have profound effects on patients, families, and staff. Drawing on research in medicine, neuroscience, and psychology, design is being used increasingly often to alter specific behaviors, mediate interpersonal interactions, and affect patient outcomes. As a result, the built environment in health care should in some instances be considered akin to a medical intervention, subject to ethical scrutiny and involving protections for those affected. Here we present two case studies. The first includes work aimed at manipulating the behavior of persons with neurocognitive impairments, often in long-term care facilities. This is done to ensure safety and minimize conflicts with staff, but it raises questions about freedom, consent, and disclosure. The second concerns design science in service of improved outcomes, which involves research on improving patient outcomes or the performance of health care teams. There is evidence that in some ICU designs, certain rooms correlate to better outcomes, giving rise to questions about equity and fairness. In other cases, a facility's architecture seems to be putting a finger on the scale of equipoise, raising questions about the intentionality of clinical judgment, freedom of choice, and disclosure. As a result of this innovation occurring outside the boundaries of traditional care delivery and oversight, important ethical questions emerge concerning both the individual patient and patient populations. We discuss, analyze, and make recommendations about each and suggest future directions for these and related issues.

The Surrogation of Surrogacy: The Perils and Pitfalls of Epistemic Authority.

While philosophers have long noted that having knowledge alone is not sufficient reason to act, in bioethics, we take epistemic authority to be sufficient justification for decisional authority. A bit of disambiguation focuses this concern; surrogation is a psychological phenomenon found in business practices whereby a measure of something of interest evolves to replace the thing itself. In an everyday example of surrogation, a manager tasked with increasing customer satisfaction begins to believe that the customer satisfaction survey score is in fact customer satisfaction. In the clinical setting, an equivalent would involve the belief that a surrogate decision-maker's wishes for the patient are the patient's own wishes. Recounting a father's unexpected life-or-death decision about treatment for an adult son, this essay explores the perils and pitfalls of taking epistemic authority to be sufficient justification for decisional authority.

A Listening Tour: Pediatric Clinical Ethics Rounds.

A two-year rounding program was initiated by the clinical ethics consult service (CECS) to improve ethics program integration and utilization at our 323-bed tertiary care pediatric hospital. Two critical variables were identified for improvement. One: identification of cases in which an ethics consult would have benefited clinical care but was not requested. Two: earlier detection of cases for which the medical team and/or family eventually sought ethics consultation but that worsened during the delay. Improvement relied on eliciting dialogue with the CECS by the medical team and/or patients and families, when it had either not occurred before or had not occurred when it would have been most beneficial. The indirect nature of the improvements sought posed a specific challenge: how does one elicit such action from others? How does a small program with less than one full-time equivalent position that is dedicated to clinical ethics, and little funding, effect such a process change across an organization with more than 600 physicians, 2,000 nurses, 600 medical students, and thousands of other clinicians and staff? The following accounts such an effort and the accompanying two-year study undertaken to document the results. The data presented demonstrate improvement in both identified variables: increased overall utilization of the CECS and earlier detection of cases in which the CECS is typically engaged.

Etiology and Manifestations of Iatrogenesis in Pediatrics.

There is general agreement in the literature of what ought to occur following iatrogenic harm. Senior members of the team should disclose what occurred and how the problem will be remedied. Those involved should express heartfelt regrets and apologize sincerely. But in the pediatric setting, parents, as surrogates, can sometimes place clinicians on the horns of a dilemma: respect parental autonomy, which may involve continuing nonadvised therapy, or uphold the patient's best interests, which may indicate another course of care. In other cases, clinicians themselves may initiate or continue care without real benefit. The young patients who may be harmed as a result often cannot understand an explanation, an apology, or, when warranted, receive reparation; what duties are owed them? In this paper, we first discuss iatrogenesis writ large and then propose the formulation of this concept in this latter context, where harm occurs as a result of counterpoise between two or more ethical obligations, which we term counterpoise iatrogenesis. We then articulate its etiology and manifestation through two true cases. We conclude with a re-examination of the meaning and function of autonomy in pediatrics and the designation of secondary victims.