Autism and Advance Directives: Determining Capability and the Use of Health-Care Tools to Aid in Effective Communication and Decision-Making.

With the growing number of individuals with Autism Spectrum Disorder (ASD) reaching the age of consent, health-care providers must be prepared to bridge gaps in their knowledge of ASD. This is especially true for clinicians who may have to determine if a person with ASD has the capacity to engage in end-of-life decision making, complete advance directives, or act as a surrogate decision maker for someone else. This paper provides an overview of the unique characteristics of autism as related to the communication, cognitive processing, and the capability to participate in advance care planning and, when acting as a surrogate decision maker, to consider the values and preferences of others. In addition, we examine the roles and responsibilities of clinician as facilitator of shared health-care decision making communication with the individual who has autism. Consideration is given to determining capacity, planning for atypical responses, the impact or lack of influence of the framing effect, and strategies for presenting information. Finally, we will offer health-care providers information and examples for adapting their existing end-of-life decision-making tools and conversation guides to meet the communication needs of persons with ASD.

Disaster Ethics: Shifting Priorities in an Unstable and Dangerous Environment.

Emergency and critical care medicine are fraught with ethically challenging decision making for clinicians, patients, and families. Time and resource constraints, decisional-impaired patients, and emotionally overwhelmed family members make obtaining informed consent, discussing withholding or withdrawing of life-sustaining treatments, and respecting patient values and preferences difficult. When illness or trauma is secondary to disaster, ethical considerations increase and change based on number of casualties, type of disaster, and anticipated life cycle of the crisis. This article considers the ethical issues that arise when health providers are confronted with the challenges of caring for victims of disaster.

Withholding versus withdrawing treatment: artificial nutrition and hydration as a model.

PURPOSE OF REVIEW: This article explores various cultural perspectives of withholding and withdrawing of life-sustaining treatment utilizing a case involving artificial nutrition and hydration (ANH) to guide ethical discussion. RECENT FINDINGS: In the United States, there is a general consensus in the medical, ethical, and legal communities that the withholding and withdrawing of life-sustaining treatment are morally equivalent at the end of life. Despite this consensus, the withdrawal of treatment is still emotionally difficult, particularly with ANH. Recent literature challenges the evidence base that feeding tubes for people with advanced dementia lead to significant harm. In light of these new findings, we will reconsider end-of-life decision making that concerns ANH to determine whether these new findings undermine previous ethical arguments and to consider how to best educate and support patients and families during the decision-making process. SUMMARY: Despite many believing that there is no ethical, medical, or moral difference between withholding and withdrawing of life-sustaining treatment, there is no denying it is emotionally taxing, particularly withdrawal of ANH. Upholding the patient's values during high-quality shared decision making, facilitating rapport, and utilizing time limited trials will help, even when treatment is considered medically ineffective.

Ethical dimensions of disparities in depression research and treatment in the pharmacogenomic era.

Disparities in access to, and utilization of, treatment for depression among African-American and Caucasian elderly adults have been well-documented. Less fully explored are the multidimensional factors responsible for these disparities. The intersection of cultural constructs, socioeconomic factors, multiple levels of racism, and stigma attending both mental health issues and older age may help to explain disparities in the treatment of the depressed elderly. Personalized medicine with its promise of developing interventions tailored to an individual's health needs and genetically related response to treatment might seem a promising antidote to the documented underutilization of standard depression treatments by African Americans. However, this paper examines the multidimensional factors associated with disparities in effective treatment of depression among African-American and Caucasian elderly adults and argues the scientific and ethical importance of pursuing various paths to address multiple levels and sources of stigma and mistrust if pharmacogenomics is to help, rather than exacerbate, disparities in depression treatment. Seven recommendations are offered to increase the likelihood that developments in pharmacogenomics will reduce disparities in depression treatment.

Practicing preventive ethics, protecting patients: challenges of the electronic health record.

Implementation of guidelines regarding breaches of electronic health information requires an anticipatory stance and physician and patient education regarding security and monitoring measures and methods of redress. Adopting a preventive ethics, rather than a crisis management, model may also increase physician awareness of how the information they choose to include and privilege within the health record may expose patients to added harms if not done mindfully.

Conflicts of interest: are informed consent an appropriate mode and disclosure an appropriate remedy?

Conflict of interest (COI) in dentistry is typically thought to arise when a dentist's exercise of professional judgment for the sake of a patient's interest is compromised by a secondary interest such as increase of reputation or financial gain. Disclosure of conflict of interest is often recommended as a remedy to prevent the erosion of the fiduciary relationship and to permit patients to take steps to protect their own interests. Borrowing the concept of a reasonable patient from discussions of disclosure standards for informed consent, this paper offers a patient-centered definition of COI: a COI exists when the presence of a dentist's secondary interest undermines the reasonableness of a reasonable patient's reliance on his or her dentist's professional judgment. It then argues that disclosure of COI (modeled on other disclosures during informed consent) is an inadequate remedy for the breach of ethics presented by COI and an inadequate strategy to prevent harms associated with COI. It also examines research indicating that disclosure of COI has perverse effects on the informed consent process and patient decision-making, so that disclosure of COI actually inhibits patients from taking steps to protect their own welfare.