Roles of the Ethics Consultant: A Response to Vaughan and Colleagues and De Renzo.

We respond to commentaries on our article, "The Clinician as Clinical Ethics Consultant: An Empirical Method of Study," that appeared in the summer 2019 issue of The Journal of Clinical Ethics.

The Clinician as Clinical Ethics Consultant: An Empirical Method of Study.

Some 30 years ago the role of the clinical ethics consultant (CEC) was formalized. At the time, the perception of the role differed between two groups serving in that capacity, clinicians and nonclinicians. Differences in their roles reflected their training and experience. These divergent views were resolved semantically by designating the role of the CEC as "ethics facilitation." In practice the different perspectives have remained. However, the subsequent published literature on clinical ethics consultation has not adequately reflected the activity of the clinician as a CEC. There have been recurring unanswered calls for the acquisition of empirical data on the nature of the problems that prompt ethics consultation requests and the functions required to address them. The authors introduce a template that provides a means to acquire such data for clinician ethicists. A similar instrument could be constructed to reflect the role of the nonclinician ethicist serving in that capacity.

The research misconduct post hoc inquiry as a measure of institutional integrity (DR).

The terms, institutional and scientific, integrity appeared in the literature 986 times from 2005 to 2015. How has the term integrity, with its dual definition, a) The accuracy, completeness and consistency of data and b) the adherence to a code of moral values, been applied to an institution? The authors suggest that a post hoc inquiry be instituted following the finding of an individual act of research misconduct to determine if the sponsoring institution, actively or passively, played a contributory role and if corrective action was taken. This would serve as one measure of institutional integrity.

Psychiatric evaluation of mental capacity in the general hospital: a significant teaching opportunity.

BACKGROUND: Requests for evaluation of mental capacity in general hospitals have increased in frequency. OBJECTIVE: The authors sought to determine the interventions required to respond adequately and assess the initiating circumstances. METHOD: Questionnaires completed by psychiatric consultants were analyzed, and chart reviews were completed. RESULTS: Capacity evaluation alone resolved 32% of the requests; 31% required an evaluation plus additional interventions; 37% did not require a capacity evaluation. Patients threatening to leave against advice, and/or refusing treatments or procedures represented 64% of requests. Consultants successfully resolved 88% of such cases. CONCLUSION: A mental capacity evaluation alone was insufficient to resolve two-thirds of problems eliciting requests. Consultation-liaison psychiatrists can use these evaluations as teaching opportunities.

Research misconduct, NSF v NIH: Its nature and prevalence and the impact of their respective methods of investigation and adjudication.

The National Science Foundation (NSF) and the National Institutes of Health (NIH) have established separate administrative mechanisms for investigation and adjudication of alleged research misconduct. This report compares research misconduct at NSF and NIH and the possible effects of their respective methods of investigation and adjudication. Notable and paradoxical findings were identified: NIH supported four times the number of grants as NSF, yet NSF reviewed 2.5 times the number of research misconduct reports. NSF faculty were two-times more likely to be found guilty (88%) than faculty at NIH (42%). 83.6% of NSF offenders were guilty of plagiarism, vs. 4.8% at NIH. NSF trainees made up 6% of the guilty, vs. 42% at NIH. These findings are most likely related to the nature of their respective sciences, scientists, and the nature of their publications. Investigative policies and procedures are quite similar at these two agencies with the exception of the subpoena power available to the NSF's Office of the Inspector General (OIG) where it would be infrequently utilized in investigations of its predominant offense, plagiarism. However, it could prove useful if made available to the NIH Office of Research Integrity (ORI) for investigations of fabrication/falsification, its most common offense. Federal criteria for prosecution should be modified to increase the likelihood of prosecution of serious offenders referred by ORI.

Consultation-liaison psychiatry: contributions to medical practice.

Consultation-liaison psychiatry has recently been recommended for subspecialty status by the American Board of Psychiatry and Neurology with a name change to "psychosomatic medicine." Final approval by the American Board of Specialties is expected. Therefore, this is a propitious time to review what the author considers the significant contributions of consultation-liaison psychiatry to the practice of medicine, the education of its practitioners, and future opportunities and challenges. The articles mentioned have been published primarily in medical and surgical journals in which their authors believed they would have the greatest impact. Therefore, this is a body of work that is probably unknown to most psychiatrists outside of this field.

Can we measure out a life in coffee spoons?

Public policy decisions in medicine and other fields necessitate careful weighing of choices and consequences. Cost-benefit analyses have been offered as one way to facilitate such decisions. In "Quantifying the value of human life," L. Eugene Arnold asserts that mathematical models such as his offer greater clarity in making public policy decisions than is possible with the "intuitive" or "emotional" approach. In our opinion, problems associated with this quantitative analysis demonstrate a need for caution in applying such mathematical models to public policy decisions....

Commentary on "Sedation before ventilator withdrawal.

In any important article in the field of clinical ethics, the focus should not be on the specific case example, but rather on the issues it presents for thought and discussion. Barbara Springer Edwards and Winston M. Ueno achieve this end admirably. They present a terminally ill patient who requested termination of ventilator support, despite the overwhelming odds that he would die as a result. The authors ask whether or not the physician acted appropriately in accommodating the patient's wish and in sedating him to decrease suffering in his last moments. They present compelling arguments that sedation was warranted in this case. They also note correctly that competent patients have the right to refuse treatment. However, in addition to the question of sedation, this case raises other important issues, specifically those related to pain management and depression in the terminally ill....

Perspective: research misconduct: the search for a remedy.

Research misconduct-fabrication, falsification, and plagiarism-is an insidious problem in the scientific community today with the capacity to harm science, scientists, and the public. Federal agencies require that research trainees complete a course designed to deter such behavior, but the author could find no evidence to suggest that this effort has been effective. In fact, research shows that most cases of misconduct continue to go unreported.The author conducted a detailed examination of 146 individual Office of Research Integrity reports from 1992 to 2003 and determined that these acts of misconduct were the results of individual psychological traits and the circumstances in which the researchers found themselves. Therefore, a course in research misconduct, such as is now federally mandated, should not be expected to have a significant effect. However, a course developed specifically for support staff, who currently do not receive such training, might prove effective.Improving the quality of mentoring is essential to meaningfully deal with this issue. Therefore, the quality of mentorship should be a factor in the evaluation of training grants for funding. In addition, mentors should share responsibility for their trainees' published work. The whistleblower can also play a significant role in this effort. However, the potential whistleblower is deterred by a realistic fear of retaliation. Therefore, institutions must establish policies that acknowledge the whistleblower's contribution to the integrity of science and provide truly effective protection from retaliation. An increase in whistleblowing activity would provide greater, earlier exposure of misconduct and serve as a deterrent.