Justifying Clinical Deception: Some Amendments to Brummett and Salter.

In Abram Brummett and Erica K. Salter's excellent paper, "Mapping the Moral Terrain of Clinical Deception," they rightly note that it is sometimes ethically appropriate for health care professionals to deceive patients and families. However, they also note that because doing so violates a prima facie duty of honesty, the ethical burden of proof falls upon the deceiver. Hence, they also provide a sophisticated framework for determining whether any given case is warranted. I applaud their overall approach but also critique some of their claims, in particular, their conclusion that lies of commission require greater justification than those of omission and their conflation of the principles of beneficence and nonmaleficence. I also urge them to give greater attention to how power asymmetries should be accounted for and to the impact such deceptive choices might have on the clinician's character.

Activism and the Clinical Ethicist.

Although clinical ethics scholarship and practice has largely avoided assuming an activist stance, the many health care crises of the last eighteen months motivated a distinct change: On listserves, in blog postings, and in published essays, activist language has permeated conversations over such issues as the impact of triage policies on persons with disabilities and of color, and how the health care system has historically failed African Americans. In this paper, I defend this turn, arguing that clinical ethicists should embrace activism-generally, and with particular emphasis on institutional, mesolevel concerns. Ethicists are often uniquely situated to understand the structural factors that regularly motivate clinical ethics cases, and they are often in a privileged position to be effective change agents. In making this case, I also stress the need not to overstep one's skills and to be acutely cognizant of the political risks associated with such work.

Guidance for Medical Ethicists to Enhance Social Cooperation to Mitigate the Pandemic.

The Covid-19 pandemic has presented major challenges to society, exposing preexisting ethical weaknesses in the modern social fabric's ability to respond. Distrust in government and a lessened authority of science to determine facts have both been exacerbated by the polarization and disinformation enhanced by social media. These have impaired society's willingness to comply with and persevere with social distancing, which has been the most powerful initial response to mitigate the pandemic. These preexisting weaknesses also threaten the future acceptance of vaccination and contact tracing, two other tools needed to combat epidemics. Medical ethicists might best help in this situation by promoting truth-telling, encouraging the rational adjudication of facts, providing transparent decision-making and advocating the virtue of cooperation to maximize the common good. Those interventions should be aimed at the social level. The same elements of emphasizing cooperation and beneficence also apply to the design of triage protocols for when resources are overwhelmed. A life-stages approach increases beneficence and reduces harms. Triage should be kept as simple and straightforward as reasonably possible to avoid unwieldly application during a pandemic.

Deception and the Clinical Ethicist.

In this article, I defend a discomfiting thesis: The clinical ethicist should sometimes be an active participant in the deception of patients and families. The case for this conclusion builds off Sissela Bok's seminal analysis of lying, from which I emphasize that, despite some common intuitions to the contrary, there is prima facie no morally relevant difference between lies of omission and commission. I then discuss deception's prevalence in medical encounters, noting that the ethicist is often embedded in corresponding decisions, and explicate the realities that underlie these tough cases. Among those realities is the fallacy that deception can always be avoided through better communication. I conclude with an elaboration of ethicists' role-model status and argue that they can turn the deception into a powerful teaching moment about the complexity of ethics reasoning.

Protecting Moral Integrity Through Justified Exemption.

Medical professionals have a duty to prioritize patient needs and well-being, even when doing so is deemed distasteful or unpleasant. This does not mean, however, that such professionals are obliged to provide medical interventions when participation threatens their core moral integrity. Myriad state and federal "conscience clause" statutes and regulations have codified such protections, but in a way that makes it too easy to claim exemption. This essay argues that, given professional obligations and systemic power asymmetries, the burden of proof falls upon professionals to show that participation in the requested service represents a genuine threat to their integrity, as opposed to being merely offensive or economically disadvantageous. It concludes with a suggested mechanism for determining whether the exemption request is justified.

ContextProvider: Context awareness for medical monitoring applications.

Smartphones are sensor-rich and Internet-enabled. With their on-board sensors, web services, social media, and external biosensors, smartphones can provide contextual information about the device, user, and environment, thereby enabling the creation of rich, biologically driven applications. We introduce ContextProvider, a framework that offers a unified, query-able interface to contextual data on the device. Unlike other context-based frameworks, ContextProvider offers interactive user feedback, self-adaptive sensor polling, and minimal reliance on third-party infrastructure. ContextProvider also allows for rapid development of new context and bio-aware applications. Evaluation of ContextProvider shows the incorporation of an additional monitoring sensor into the framework with fewer than 100 lines of Java code. With adaptive sensor monitoring, power consumption per sensor can be reduced down to 1% overhead. Finally, through the use of context, accuracy of data interpretation can be improved by up to 80%.

Institutional culture and individual behavior: creating an ethical environment.

Much of the work in professional ethics sees ethical problems as resulting from ethical ignorance, ethical failure or evil intent. While this approach gets at real and valid concerns, it does not capture the whole story because it does not take into account the underlying professional or institutional culture in which moral decision making is imbedded. My argument in this paper is that this culture plays a powerful and sometimes determinant role in establishing the nature of the ethical debate, i.e., it helps to define what are viable action options, what is the organization's genuine mission, and what behaviors will be rewarded or criticized. Given these conclusions, I also argue that consulting ethicists need more than an understanding of ethics theory, concepts and principles; they also need a sufficiently rich understanding of organizational culture and a willingness and an ability to critique that culture.

Cruel choices: autonomy and critical care decision-making.

Although autonomy is clearly still the paradigm in bioethics, there is increasing concern over its value and feasibility. In agreeing with those concerns, I argue that autonomy is not just a status, but a skill, one that must be developed and maintained. I also argue that nearly all health-care interactions do anything but promote such decisional skills, since they rely upon assent, rather than upon genuinely autonomous consent. Thus, throughout most of their medical lives, patients are socialised to be heteronomous, rather than autonomous. Yet, at the worst possible time--critical care decision-making--when life and death consequences are attached to the choices, the paradigm shifts and real consent is sought, even demanded, thereby making an often traumatic situation even harder. I go on, though, to also reject paternalistic models of beneficence as an alternative. Rather, I conclude that the problem is so fundamental in healthcare that a genuine solution would require a radical restructuring. I recommend steps that can be taken in the interim to improve the situation and to move toward such a restructuring.