EthicsLab

One of the most difficult problems facing hospitals and health systems today is scarcity of key medical resources. Unfortunately, blood product shortages are not uncommon, and they present significant challenges for patient care. Our guests in this episode developed a specific set of recommendations and a protocol for their hospitals to deal with these situations. They've also worked to establish a standard approach across their geographic region, which a lot of locations have not really been able to accomplish. We hope their insights and work can inform other ethicists, hospitals and cities looking to develop similar protocols. Our guests in this episode include Dr. Paul Hutchison, Pulmonary Critical Care Physician and Clinical Ethicist at Loyola University Medical Center, Maywood, Illinois. Dr. Kathy Neely, Physician and Ethicist at Northwestern Memorial Hospital, Northwestern Medicine, Chicago. Leah Eisenberg, Director of Clinical Ethics Consultation Services at UI Health, University of Illinois Chicago system. Also, an Attorney and Visiting Clinical Associate Professor in the Department of Medical Education. Additional resources relating to or referenced in this episode: How do I allocate blood products at the end of life? How Should Decision Science Inform Scarce Blood Product Allocation? Insights from Blood Products Management for Pre-Crisis Ethical Resource Allocation

According to the United States Centers for Disease Control and Prevention, more than 46 million, or 15% of all Americans live in rural areas. And, as more attention is given to meeting the health needs of this population, a significant gap in health between rural and urban Americans has emerged. Rural Americans are more likely to die from heart disease, cancer, unintentional injury, chronic respiratory disease, and stroke than their urban counterparts. Unintentional injury deaths are approximately 50 percent higher in rural areas, partly due to greater risk of death from motor vehicle crashes and opioid overdoses. These challenges underscore the important role that critical access hospitals play in helping to address these disparities. But what are the ethical considerations that should be looked at when caring for rural communities? In this episode, our guests offer their perspective and expertise on this important topic. Our guests in this episode include: Mary Homan, Southwest Division Vice President of Theology and Ethics for CommonSpirit Health. Leslie Kuhnel, Midwest Division Vice President of Theology and Ethics for CommonSpirit Health. Jason Lesandrini, Assistant Vice President, Ethics, Advance Care Planning and Spiritual Health, WellStar Health System. Additional resources relating to or referenced in this episode: A New Portrait of Rural America Health in Rural America Handbook for Rural Health Care Ethics: A Practical Guide for Professionals Where the Rubber Hits the Road: Implications for Organizational and Clinical Ethics in Rural Healthcare Settings Recognizing and Resolving Ethical Dilemmas in Rural Medicine

When you hear the phrase quality of life, what comes to mind? Having dinner with family, learning a language, watching a movie with friends? Or, does the image of a patient struggling to perform basic tasks such as bathing or getting dressed, or someone who is reliant on a ventilator to breathe come to mind? Despite its inherently subjective and multifaceted nature, quality of life is a term that is widely used in healthcare, particularly for making critical decisions that have life-altering consequences. It is a complex construct that encompasses a wide range of factors that affect a person's overall sense of well-being, including their physical health, emotional state, social connections, and financial stability. In this all new in-depth episode of EthicsLab, with our guests we explore how the concept of quality of life is used in medical decision making and shed light on the challenges this brings, especially to those in the disability community. We offer several solutions to how these challenges can be overcome. Our guests in this episode include: Dr. Devan Stahl, bioethicist and Assistant Professor of Religion at Baylor University specializing in clinical ethics and disability ethics. Melissa Crisp-Cooper (with support from husband Owen Cooper as her revoicer), Health Advocate at UCSF focused on educating clinicians on the needs of people with disabilities and how to interact with them as patients Dr. Clarissa Kripke, Clinical Professor of Family and Community Medicine at UCSF and Director of Office of Developmental Primary Care, a program dedicated to improving outcomes for people with developmental disabilities across the lifespan with an emphasis on adolescents and adults. Additional resources relating to or referenced in this episode: Misuses of “Quality of Life” Judgments in End-of-Life Care, Stahl Devan Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, Albert Jonsen, Mark Siegler, William Winslade Principles of Biomedical Ethics, Tom Beauchamp and James Childress Who Defines My Quality of Life?: Perspectives from Disability-Advocates and Caregivers (White Paper) Office of Developmental Primary Care A survey on self-assessed well-being in a cohort of chronic locked-in syndrome patients: happy majority, miserable minority, Bruno, Marie-Aurélie, et al. Using quality of life measures in the clinical setting, Higginson, Irene J., and Alison J. Carr Measuring quality of life: who should measure quality of life, Hall, A. J., and L. Kalra

In our two part series, we have been unpacking how health care ethics committees, ethics programs, and health care ethics consultants provide guidance to patients, their families and clinicians in hospitals and health care delivery sites. In this second episode, we focus on data that demonstrates the impact of ethics consultation. Our guests look to deepen the effectiveness of this service to all involved in health decision making. Our guests in this episode include: Dr. Ellen Fox Ellen Fox, President of Fox Ethics Consulting and a bioethics consultant, educator, researcher, and policymaker Mary Homan, Southwest Division Vice President of Theology and Ethics for CommonSpirit Health Mark Repenshek, Vice President of Ethics and Church Relations for Ascension This episode was recorded on multiple dates in mid 2021. Additional resources relating to or referenced in this episode: How Much Volume Should Healthcare Ethics Consult Services Have? Assessing ROI for Clinical Ethics Consultation Services Factors Associated with the Timing and Patient Outcomes of Clinical Ethics Consultation in a Catholic Health Care System Ethics Consultation in U.S. Hospitals: A National Follow-Up Study

It is not unusual for tough choice decisions to be made in health care. In those situations, what help can patients, their families or the clinical team receive? Health care ethics committees and health care ethics consultants provide guidance to patients, their families and clinicians in hospitals and health care delivery sites across the United States and throughout the world. According to the American Society of Bioethics and Humanities, “The goal of ethics consultation is to “improve health care outcomes through the identification, analysis and resolution of ethical issues in health care institutions,” How might better access to these resources be made more available. How might their impact be assessed? In this first episode, of a two part series, our guests explore the impact that ethics consultation has in the continuum of care, and dive deeper into just how big of an impact this service can have in clinical care. Our guests in this episode include: Dr. Ellen Fox Ellen Fox, President of Fox Ethics Consulting and a bioethics consultant, educator, researcher, and policymaker Mary Homan, Southwest Division Vice President of Theology and Ethics for CommonSpirit Health Mark Repenshek, Vice President of Ethics and Church Relations for Ascension This episode was recorded on multiple dates in mid 2021. Additional resources relating to or referenced in this episode: Ethics consultation in U.S. hospitals: A national follow-up study Ethics consultation in U.S. hospitals: New findings about consultation practices Examining Quality and Value in Ethics Consultation Services (subscription required) Health care ethics programs in U.S. hospitals: Results from a national survey Hiring Clinical Ethicists: Building on Gremmels' Staffing Model Approach

What type of influence should physicians, nurses and patients have on tough choice healthcare decisions? Clinicians want to offer their experience and their competence, so should they be neutral and simply support patient decisions? What type of influence would be helpful and what type would be inappropriate, coercive, or biased? In this episode, our guests explore these questions and a behavioral economics tool called “nudging”. Nudges are subtle changes to the design, framing of information, and decision options that can influence behaviors. These subtle changes, stemming from decision psychology, enable clinicians to inform patients of their options, while at the same time, being very intentional about avoiding manipulation of patient decisions. Our guests in this episode include: Joanna Hart, assistant professor of medicine and medical ethics and Health Policy at the University of Pennsylvania and core faculty of the palliative and advanced illness Research Center at Penn Jennifer Blumenthal-Barby, professor of medical ethics at Baylor College of Medicine Dr. Aliza Olive, pediatric intensivist currently working in Kansas City, Missouri This episode was recorded in December 2021. Additional resources relating to or referenced in this episode: Penn Medicine Nudge Unit Nudging for Ethics, Applying Small Changes To Promote Ethical Outcomes, University of Notre Dame The ethics of nudging: An overview, by Andreas T. Schmidt Good Ethics and Bad Choices: The Relevance of Behavioral Economics for Medical Ethics, by Jennifer Blumenthal-Barby The Ethics of Nudging, by Cass R. Sunstein Nudge Units to Improve the Delivery of Health Care, by Mitesh S. Patel, Kevin G. Volpp, and David A. Asch Designing Nudges for Success in Health Care, by Joseph D. Harrison

Drug shortages in health care occur for many reasons and have negative impacts. According to the US Food and Drug Administration, “a high percentage of drug shortages have been, and continue to be, sterile injectables, including chemotherapy, anesthesia and other acute drugs”. And, even though drug shortages have declined in recent years, a significant number of shortages are still active and continue to negatively impact patient care. In this episode, we interview national experts who have focused their professional attention on this issue. Our guests in this episode include: Dr. Yoram Unguru, pediatric hematologist oncologist, clinical bioethicist, and chair of the ethics committee at Sinai Hospital in Baltimore. Dr. Unguru is also on faculty at the Berman Institute of Bioethics and leads a multidisciplinary, transnational working group examining the ethical and policy implications of chemotherapy shortages in childhood cancer. Dr. Andrew Shuman, associate professor at the University of Michigan medical school and a practicing head and neck cancer surgeon. Dr. Shuman is also a clinical ethicist who helps to run the clinical ethics service at The University of Michigan and has focused on issues related to access to medications that are scarce either due to cost or supply This episode was recorded in February 2021. Additional resources relating to or referenced in this episode: Drug Shortages: The View Across an Ocean Drug Shortages - U.S. Food & Drug Administration Drug Shortages - American Hospital Association The Drug Shortage Crisis in the United States Image Credit: Pavel_Chag, via Getty Images, found via promarket.org.

In March 2020, the coronavirus pandemic created a devastating impact within and outside the United States. COVID-19 made us painfully aware of systemic racism in healthcare with the allocation of scarce resources for vulnerable populations. In May 2020, the murder of George Floyd by a police officer brought the continued injustice of systemic racism into sharp focus for many Americans. The nation’s focus on confronting systemic racism highlighted foundational questions of bias against people of color in public health ethics and bioethics regarding providing fair and equitable responses to the coronavirus pandemic. Specifically, one example was the SOFA score tool, a proposed unbiased method to fairly allocate scarce resources like ventilators, was shown to be less likely to allocate resources to people of color compared to white Americans. In this podcast, we learn from experts why our resource allocation methods fail to be fair and equitable and how we can work towards an equitable approach to scarce resource allocation in particular and bioethics in general. Our guests in this episode include: Gina Campelia, Assistant Professor, Department of Bioethics and Humanities, University of Washington - School of Medicine Edwin Lindo, Assistant Dean for Social & Health Justice at University of Washington - School of Medicine Nneka Sederstrom, Chief Health Equity Officer, Hennepin Healthcare Jaime Konerman-Sease, our graduate intern at EthicsLab in 2020 and 2021, will be interviewing our guests. Jaime is completing her PhD in Healthcare Ethics and Theology at Saint Louis University. This episode was recorded on February 5, 2021. Additional resources relating to or referenced in this episode: The “Give Back”: Is There Room For It? Racial Disparities in the SOFA Score Among Patients Hospitalized with COVID-19 Assessment of Disparities Associated With a Crisis Standards of Care Resource Allocation Algorithm for Patients in 2 US Hospitals During the COVID-19 Pandemic Health equity and distributive justice considerations in Critical Care Resource Allocation Image Credit: Equality vs. Equity - by the Interaction Institute for Social Change | Artist: Angus Maguire.” Image Found: interactioninstitute.org and peacecorps.gov

If primary health care professionals are to serve and accompany the transgender community well, what would that look like? What would need our attention? What approaches have proved helpful and supportive? What would accompaniment require from health care professionals? Our guests today are either health professionals who are transgender or who have devoted their professional lives to serving the transgender community. Our guests in this episode include: Shane Snowdon, past/founding director of the National Center for LGBTQ Health and Equity at UC San Francisco, past/founding director of the National LGBTQ Health and Aging Program at the Human Rights Campaign and Principal at EdgeWork Consulting Jamison Green, policy consultant for business, educational, and governmental institutions, and past president of the World Professional Association for Transgender Health (WPATH) Lin Frasier, psychotherapist with a specialty of working with trans people, past president of the World Professional Association for Transgender Health (WPATH), former co-chair of the Global Education Initiative and co-chair of the ethics committee for WPATH Dr. Colt St. Amand, Clinical Psychologist, Author, Family Medicine Resident Physician and Chief Educational Officer of the Gender Education Network Sr. Luisa Derouen, a Dominican Sister of Peace who has been offering Spiritual Direction and accompaniment with transgender individuals across the country for over 22 years This episode was recorded on multiple dates in 2019 and 2020. Additional resources relating to or referenced in this episode: World Professional Organization for Transgender Health (WPATH) Hear me Now Podcast on Transgender Health (Providence Institute for Human Caring) God Is On Your Side: A Statement from Catholic Bishops on Protecting LGBT Youth (Tyler Clementi Foundation)

Offering a composite picture of someone with a drug addiction is not easy. It is not specific to gender, age, income, education, ethnicity, or geography. In this second episode on addiction and medically supervised injection rooms, we go to Melbourne Australia and speak to health care leaders there, on their experience with these programs. Again, these programs aim to a) respond to the addiction health issues of those who are dependent on injection drugs, and b) respond to the broader public health impact of addiction on a community, such as a high amount of drug overdose or the transmission of infectious disease through the sharing of infected needles. Our guests in this episode include: Dr Yvonne Benomo, Director of the Department of Addiction Medicine at St Vincent Hospital in Melbourne, Australia and Associate Professor at the Department of Medicine University of Melbourne Dan Fleming, Group Manager of Ethics and Formation at St Vincent’s Health Australia, Fellow in the Law, Health and Justice Research Center in the University of Technology Sydney, Adjunct Lecturer and the Institute for Ethics and Society at the University of Notre Dame, Australia This episode was recorded on November 18, 2019 Additional resources relating to or referenced in this episode: ITQ - Might We Celebrate A Small Step, by Daniel J. Fleming

Harm reduction programs like needle exchange programs or medically supervised injection sites aim to a) respond to the addiction health issues of those who are dependent on injection drugs, and b) respond to the broader public health impact of addiction on a community such as a high amount of drug overdose or the transmission of infectious disease through the sharing of infected needles. These harm reduction programs are having an impact, but some have questioned whether such programs inappropriately cooperate with drug abuse. Our two guests today will offer us insight into that question and the impactful experience of two such harm reduction programs at Providence Health Care in Vancouver, British Columbia, Canada. Our guests in this episode include: Scott Harrison, Director for Urban Health, Indigenous Health, Substance Use, Maternity and Neonatal Intensive Care at Providence Health Care Christopher DeBono, Vice President of Mission, People and Ethics also at Providence Health Care This episode was recorded on January 23, 2020 Additional resources relating to or referenced in this episode: Assessing the Ethical Issues in "Safe Injection" Sites by Carol Bayley, and Fr. Charles Bouchard Catholic Ethicists on HIV/AIDS Prevention, by James Keenan Catholic Participation in Needle- and Syringe-Exchange Programs for Injection-Drug Users: An Ethical Analysis, by Daniel Sulmasy Safe Injection Sites: A Moral Reflection, by Steven Bozza and Jeffrey Berger

Today, tough choice healthcare ethics dilemmas are discussed by patients, their loved ones and health care professionals. These discussions are about the care and treatment plan of the patient based on their values. Most often these discussions and decisions have been held in person. As healthcare moves to virtual care, especially in our current COVID19 environment, what would virtual ethics discussions or consultations look like? What would be important to pay attention to? Our guests today have offered such virtual ethics discussions on tough choice decisions with patients. Our guests in this episode include: Cristie Cole-Horsburgh, lawyer and staff ethicist with the Cleveland Clinic, Center for Bioethics Dr. Mahwish Ahmad, physician and transplant ethicist with the Cleveland Clinic, Center for Bioethics This episode was recorded on March 4, 2020 Resources referenced in this episode: Cleveland Clinic Center for Bioethics Virtual Ethics Consultation

Street Medicine is local and international. In this second episode on Street Medicine we hear about health care leaders in Portland, Oregon responding to the needs in their community. The challenge? Nationally, Oregon has the fourth highest rate of homelessness and the second highest rate of families without shelter. In recent years Portland’s chronic homelessness has increased at twice the national rate. The homeless population is growing older, more disabled, and is on the streets for longer periods of time. The homeless in any community face stigma, social isolation, and loss of relationships. They suffer a disproportionate burden of illness and premature death. The life expectancy of a homeless person is 47 years. The healthcare leaders collaborating in the Portland Street Medicine program are working to shape a different future. Our guests in this episode include: Dr. Dan Bissell, emergency physician and co-founder and executive director of Portland Street Medicine Drew Grabham, social worker and board member of Portland Street Medicine This episode was recorded on April 10, 2020 Resources referenced in this episode: Portland Street Medicine

A 2019 White House Report tells us that half a million people are homeless each night in the UnitedStates.In 1992, Dr. Jim Withers began doing street rounds in Pittsburgh, Pennsylvania, bringing medical care to the homeless. Since that time the Street Medicine Institute he founded has grown to become international organization. In 2015, CNN named Dr Withers as one of their “Top Ten Heroes.” How might healthcare best include and serve people living without any shelter? This episode was recorded on March 16, 2020 Resources referenced in this episode: The Street Medicine Institute American College of Physicians - Dr. James S. Withers, MD, FACP, on 26 years of treating the homeless and living by the motto, "Go to the people." CNN -Top 10 CNN Hero Dr. Jim Withers

COVID19 has caused all of us to prepare and it has also demanded something from us. We hear many stories of the technical and resource preparation. In this episode we speak with three physicians from California and Washington state about their preparation and what it has demanded from them. We hear people in frontier territory wanting to offer their best. Some might even call this the crafting of virtue. Our guests in this episode include: Dr. Bethany Kapp, dual boarded in Emergency Medicine and Palliative Medicine, CHI Franciscan, Tacoma, WA Dr. Mojdeh Talebian, pulmonologist and ICU physician, System Medical Director Critical Care, Director ICU & Pulmonary Services, Sequoia Hospital Redwood City, CA Dr. Anita Chandrasena, pulmonologist, Chief Medical Officer, Northern California Division-Bay Area, CommonSpirit Health, Redwood City, CA Three physicians, responding to COVID19… and diving deep. This episode was recorded on April 1st, 2020

On March 11, the World Health Organization (WHO) declared COVID-19 a pandemic, pointing to the over 118,000 cases of the coronavirus illness in over 110 countries and territories around the world and the sustained risk of further global spread. To discuss some of the ethical issues regarding COVID-19 we are joined by Dr. Ken Iserson and Becket Gremmels. This episode was recorded on Friday March 20, 2020. Our guests in this episode include: Dr. Ken Iserson, Professor Emeritus of Emergency Medicine at The University of Arizona, Medical Director (Emeritus) of the Southern Arizona Rescue Association (search & rescue), a Supervisory Physician with Arizona’s Disaster Medical Assistance Team (AZ-1), and a member of the American Red Cross disaster response team. Becket Gremmels, System Director of Ethics for CHRISTUS Health based in Irving, Texas. CHRISTUS Health can be found in 60 US cities and is comprised of 60 hospitals and long-term care facilities, as well as 175 clinics and outpatient centers. Additional resources relating to or referenced in this episode: Improvised Medicine: Providing Care in Extreme Environments, Ken Iserson Joint Statement on Multiple Patients Per Ventilator Must I Respond If My Health Is at Risk, Ken Iserson Triage in Medicine, Part II-Underlying Values and Principles, John Moskop and Ken Iserson

We hear many stories these days about immigration. Certainly, healthcare workers see undocumented individuals in Emergency Rooms or clinics. What is that experience like of being undocumented and needing healthcare? What would be helpful for clinicians to know? Does healthcare ethics have something to say on this topic? Today we hear from two healthcare leaders on these issues. One, who was an undocumented person and who later became a physician in the United States, and the other is the healthcare leader who supported her journey. Our guests in this episode include: Mark G. Kuczewski, PhD, is the Fr. Michael I. English, S.J., Professor of Medical Ethics and also Director of the Neiswanger Institute for Bioethics and Health Policy at Loyola University, Chicago Dr Johana Mejias-Beck, internal medicine pediatrics specialist, currently at the University of Missouri, Kansas…and one of the first undocumented students to attend the first medical school in the country to accept applicants with DACA status. Additional resources relating to or referenced in this episode: Limbo Really Exists: Undocumented Youth at Risk, Mark Kuczewski, Johana Mejias-Beck, Amy Blair, and Matthew Fitz Treating Fear: Sanctuary Doctoring, Loyola University Chicago - Neiswanger Institute

As we look back on 2019 and forward to 2020, our guests are editors of key healthcare ethics journals with an international readership: Gregory E. Kaebnick, Editor, The Hastings Center Report Leslie LeBlanc, Managing Editor, Journal of Clinical Ethics Nate Hibner, Primary Editor, Health Care Ethics USA and Director of Ethics at the Catholic Health Association of the United States What are the issues in health care ethics that are impacting ethics committees, health systems, public policy and patients over the past year? What issues do they expect to continue and emerge within the next year? What are they hearing from authors and readers? What key articles published in their journals published in the last year might they recommend to you, our listeners? We explore these questions and more in this episode of EthicsLab. Additional resources relating to or referenced in this episode: Of Slide Rules and Stethoscopes: AI and the Future of Doctoring, Robert D. Truog Patient as Gift, Lydia Dugdale Changing the Question, Daniel Brudney The Inner Life of Ethicists: The Importance of Cultivating an Interior Life, Paul J. Waddell Ethics and Medical Standards of Care: Hysterectomy, Tubal Ligation or Salpingectomy?. Sr. Patricia Talone and Amy Warner

Health disparities and health outcomes for African Americans, is egregious… A 2019 report identified that African American Adults, compared to non-Hispanic white adults, are: 44% More likely to die from stroke 20% more likely to have asthma 40% more likely to die from breast cancer 25% more likely to die from heart disease 52% more likely to die from cervical cancer 23% more likely to be obese 72% more likely to be diabetic Regarding pain medication, a 2019 published article offered that the pain of African Americans is systematically under-diagnosed and under-treated Our guests today will offer stories and discuss insights on end of life care in the African American community. Our guests in this episode include: Patrick Smith, professor at the Duke Divinity School and associate faculty with the Trent Center for Bioethics, Humanities, and History of Medicine at Duke University School of Medicine. Dr Farr Curlin, Josiah C. Trent Professor of Medical Humanities in the Trent Center for Bioethics, Humanities and History of Medicine, and Co-Director of the Theology Medicine, and Culture Initiative at Duke Divinity School. Claretta Dupree, Chair of the Academy of Fellows at the Center for Bioethics and Human Dignity at Trinity International University, Deerfield, Illinois. Additional resources relating to or referenced in this episode: Center for Practical Bioethics, Richard Payne, MD Palliative Care in the African American Community Perceptual Contributions to Racial Bias in Pain Recognition Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs About Biological Differences Between Blacks and Whites

New research findings regarding HIV status will impact how we understand and practice disclosure of HIV status of patients... specifically whether or not to disclose a sick patients’ HIV serostatus to their family or partner. The new research demonstrates that when an HIV-positive person sticks to their treatment, their HIV is undetectable and untransmittable (U=U). Our three guests are working together on bioethical projects to spread the awareness of U=U. Our guests in this episode include: Jamie Crist, JD, MA a Clinical Ethics Fellow at the Baylor College of Medicine, Houston Texas and doing clinical ethics consultation at Houston Methodist Hospital. Jamie has a JD and Masters in Bioethics at Case Western University. Nicole Meredyth, MD, is a clinical ethics fellow at Weil Cornell Medicine in New York Presbyterian Hospital. She is also completing her surgical residency at Weil Cornell University. Nekee Pandya, MD; is a clinical ethics fellow at Weil Cornell Hospital and also a hospitalist at that hospital. Additional resources relating to or referenced in this episode: HIV Law and Policy CDC HIV Treatment as Prevention HIV viral load and transmissibility of HIV infection: undetectable equals untransmittable