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Salter EK, Hester DM, Vinarcsik L, Matheny Antommaria AH, Bester J, Blustein J, Wright Clayton E, Diekema DS, Iltis AS, Kopelman LM, Malone JR, Mercurio MR, Navin MC, Paquette ET, Pope TM, Rhodes R, Ross LF. Pediatric Decision Making: Consensus Recommendations. Pediatrics 2023; 152:e2023061832. [PMID: 37555276 DOI: 10.1542/peds.2023-061832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2023] [Indexed: 08/10/2023] Open
Abstract
Despite apparent disagreement in the scholarly literature on standards of pediatric decision making, a recognition that similar norms underpin many of the dominant frameworks motivated a June 2022 symposium "Best Interests and Beyond: Standards of Decision Making in Pediatrics" in St Louis, MO. Over the course of this 3-day symposium, 17 expert scholars (see author list) deliberated on the question "In the context of US pediatric care, what moral precepts ought to guide parents and clinicians in medical decision making for children?" The symposium and subsequent discussion generated 6 consensus recommendations for pediatric decision making, constructed with the primary goals of accessibility, teachability, and feasibility for practicing clinicians, parents, and legal guardians. In this article, we summarize these recommendations, including their justification, limitations, and remaining concerns.
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Affiliation(s)
| | - D Micah Hester
- University of Arkansas for Medical Sciences, College of Medicine, Department of Medical Humanities & Bioethics, Little Rock, Arkansas
- Arkansas Children's Hospital, Little Rock, Arkansas
| | | | - Armand H Matheny Antommaria
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | | | - Ellen Wright Clayton
- Vanderbilt University Medical Center & Vanderbilt University, Nashville, Tennessee
| | | | - Ana S Iltis
- Wake Forest University, Winston-Salem, North Carolina
| | - Loretta M Kopelman
- East Carolina University, Greenville, North Carolina
- Georgetown University, Washington, District of Columbia
| | | | | | - Mark C Navin
- Oakland University, Rochester, Michigan
- Corwell Health East, Southfield, Michigan
| | - Erin Talati Paquette
- Northwestern University, Chicago, Illinois
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | | | - Lainie F Ross
- University of Chicago, Chicago, Illinois
- University of Rochester, Rochester New York
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2
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Berkman ER, Hsu EK, Clark JD, Lewis-Newby M, Dick AAS, Diekema DS, Wightman AG. An Ethical Analysis of Obesity as a Contraindication to Pediatric Liver Transplant Candidacy. Am J Transplant 2023:S1600-6135(23)00360-X. [PMID: 36997027 DOI: 10.1016/j.ajt.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/22/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023]
Abstract
Childhood obesity is becoming more prevalent in the United States (U.S.) and worldwide, including among children in need of liver transplant. Unlike with heart and kidney failure, end stage liver disease (ESLD) is unique in that no widely available medical technology can re-create the life-sustaining function a failing liver. Therefore, delaying life-saving liver transplant for weight loss, for example, is much harder, if not impossible for many pediatric patients, especially those with acute liver failure. For adults in the U.S., guidelines consider obesity a contraindication to liver transplant. While formal guidelines are lacking in children, many pediatric transplant centers also consider obesity a contraindication to pediatric liver transplant. Variations in practice among pediatric institutions may result in biased and ad hoc decisions that worsen health care inequities. In this paper we define and report the prevalence of childhood obesity among children with ESLD, 2) review existing guidelines for liver transplant in adults with obesity, 3) examine pediatric liver transplant outcomes and 4) discuss the ethical considerations of utilizing obesity as a contraindication to pediatric liver transplant informed by the principles of utility, justice and respect for persons.
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Affiliation(s)
- Emily R Berkman
- Division of Pediatric Critical Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA; Division of Bioethics and Palliative Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA.
| | - Evelyn K Hsu
- Division of Pediatric Gastroenterology and Hepatology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jonna D Clark
- Division of Pediatric Critical Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA; Division of Bioethics and Palliative Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Mithya Lewis-Newby
- Division of Bioethics and Palliative Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA; Division of Cardiac Critical Care, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - André A S Dick
- Division of Transplantation, Section of Pediatric Transplantation, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Douglas S Diekema
- Division of Bioethics and Palliative Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA; Division of Pediatric Emergency Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Aaron G Wightman
- Division of Bioethics and Palliative Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA; Division of Pediatric Nephrology, University of Washington School of Medicine, Seattle Children's Hospital Seattle, Washington, USA
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3
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Berkman ER, Richardson KL, Clark JD, Dick AAS, Lewis-Newby M, Diekema DS, Wightman AG. An ethical analysis of obesity as a contraindication of pediatric kidney transplant candidacy. Pediatr Nephrol 2023; 38:345-356. [PMID: 35488137 DOI: 10.1007/s00467-022-05572-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 01/10/2023]
Abstract
The inclusion of body mass index (BMI) as a criterion for determining kidney transplant candidacy in children raises clinical and ethical challenges. Childhood obesity is on the rise and common among children with kidney failure. In addition, obesity is reported as an independent risk factor for the development of CKD and kidney failure. Resultantly, more children with obesity are anticipated to need kidney transplants. Most transplant centers around the world use high BMI as a relative or absolute contraindication for kidney transplant. However, use of obesity as a relative or absolute contraindication for pediatric kidney transplant is controversial. Empirical data demonstrating poorer outcomes following kidney transplant in obese pediatric patients are limited. In addition, pediatric obesity is distributed inequitably among groups. Unlike adults, most children lack independent agency to choose their food sources and exercise opportunities; they are dependent on their families for these choices. In this paper, we define childhood obesity and review (1) the association and impact of obesity on kidney disease and kidney transplant, (2) existing adult guidelines and rationale for using high BMI as a criterion for kidney transplant, (3) the prevalence of childhood obesity among children with kidney failure, and (4) the existing literature on obesity and pediatric kidney transplant outcomes. We then discuss ethical considerations related to the use of obesity as a criterion for kidney transplant.
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Affiliation(s)
- Emily R Berkman
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA.
- Division of Bioethics and Palliative Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA.
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA.
| | - Kelsey L Richardson
- Division of Pediatric Nephrology, Oregon Health Sciences University, Portland, OR, USA
| | - Jonna D Clark
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
- Division of Bioethics and Palliative Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
| | - André A S Dick
- Division of Transplantation, Section of Pediatric Transplantation, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Mithya Lewis-Newby
- Division of Bioethics and Palliative Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
- Division of Cardiac Critical Care, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Douglas S Diekema
- Division of Bioethics and Palliative Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
- Division of Pediatric Emergency Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Aaron G Wightman
- Division of Bioethics and Palliative Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
- Division of Pediatric Nephrology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
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Kim DH, Berkman E, Clark JD, Saifee NH, Diekema DS, Lewis-Newby M. Parental Refusals of Blood Transfusions from COVID-19 Vaccinated Donors for Children Needing Cardiac Surgery. Narrat Inq Bioeth 2023; 13:215-226. [PMID: 38661995 DOI: 10.1353/nib.2023.a924193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
There is a growing trend of refusal of blood transfusions from COVID-19 vaccinated donors. We highlight three cases where parents have refused blood transfusions from COVID-19 vaccinated donors on behalf of their children in the setting of congenital cardiac surgery. These families have also requested accommodations such as explicit identification of blood from COVID-19 vaccinated donors, directed donation from a COVID-19 unvaccinated family member, or use of a non-standard blood supplier. We address the ethical challenges posed by these issues. We describe the current screening and safety processes for standard blood donation and explore the importance of donor anonymity and challenges with directed donation and non-standard blood suppliers. We present an ethical framework using the Best Interest Standard, the Zone of Parental Discretion, and the Harm Principle when considering these refusals. Finally, we provide recommendations for how to approach these requests as they potentially become more commonplace in pediatrics.
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Butler CR, Webster LB, Diekema DS. Staffing crisis capacity: a different approach to healthcare resource allocation for a different type of scarce resource. J Med Ethics 2022:medethics-2022-108262. [PMID: 35777960 PMCID: PMC9844994 DOI: 10.1136/jme-2022-108262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/24/2022] [Indexed: 06/15/2023]
Abstract
Severe staffing shortages have emerged as a prominent threat to maintaining usual standards of care during the COVID-2019 pandemic. In dire settings of crisis capacity, healthcare systems assume the ethical duty to maximise aggregate population-level benefit of existing resources. To this end, existing plans for rationing mechanical ventilators and intensive care unit beds in crisis capacity focus on selecting individual patients who are most likely to survive and prioritising these patients to receive scarce resources. However, staffing capacity is conceptually different from availability of these types of discrete resources, and the existing strategy of identifying and prioritising patients with the best prognosis cannot be readily adapted to fit this real-world scenario. We propose that two alternative approaches to staffing resource allocation offer a better conceptual fit: (1) prioritise the worst off: restrict access to acute care services and hospital admission for patients at relatively low clinical risk and (2) prioritise staff interventions with high near-term value: universally restrict selected interventions and treatments that require substantial staff time and/or energy but offer minimal near-term patient benefit. These strategies-while potentially resulting in care that deviates from usual standards-support the goal of maximising the aggregate benefit of scarce resources in crisis capacity settings triggered by staffing shortages. This ethical framework offers a foundation to support institutional leaders in developing operationalisable crisis capacity policies that promote fairness and support healthcare workers.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
- Hospital and Speciality Medicine, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
| | - Laura B Webster
- Bioethics Progam, Virginia Mason Medical Center, Seattle, Washington, USA
- Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
| | - Douglas S Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Trueman Katz Center for Pediatric Bioethics, Seattle Children's Research Institure, Seattle, Washington, USA
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Sun BZ, Wightman A, Diekema DS. Caregiver COVID-19 vaccination for solid organ transplant candidates. Am J Transplant 2022; 22:2135-2138. [PMID: 35485987 PMCID: PMC9111252 DOI: 10.1111/ajt.17078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 01/25/2023]
Abstract
An increasing proportion of transplant centers have implemented a mandate for vaccination against COVID-19 for solid organ transplant candidates. There has been comparatively little exploration of the ethical considerations of mandating vaccination of a candidate's primary caregiver, despite a high risk of transmission given the close nature of contact between the candidate and caregiver. We examine how a caregiver mandate can improve overall utility in organ allocation, particularly in circumstances where vaccine effectiveness at preventing transmission and serious disease is low among recipients but high in caregivers. Our analysis reveals how sensitive such mandates must be to the evolving circumstances of disease severity, transmissibility, and vaccine effectiveness: as the facts change, the degree of benefit gained and therefore the degree of infringement on access to transplant and caregiver choice that is tolerated will likewise change.
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Affiliation(s)
- Bob Z. Sun
- Department of PediatricsUniversity of WashingtonSeattleWashingtonUSA
| | - Aaron Wightman
- Department of PediatricsUniversity of WashingtonSeattleWashingtonUSA,Treuman Katz Center for Pediatric BioethicsSeattle Children’s HospitalSeattleWashingtonUSA
| | - Douglas S. Diekema
- Department of PediatricsUniversity of WashingtonSeattleWashingtonUSA,Treuman Katz Center for Pediatric BioethicsSeattle Children’s HospitalSeattleWashingtonUSA
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Abstract
Medical pharmaceutical and device manufacturers are essential in making products that benefit patients, and collaboration between health care clinicians and the industry is necessary for the design and manufacture of these medical products. However, health care clinicians must recognize that their duties and the interests of the industry may at times diverge. Relationships with the industry, even seemingly minor ones, have the potential to shape the decisions made on behalf of patients. The marketing divisions of pharmaceutical and medical device firms view health care clinicians as targets of their efforts, and some of the interactions that occur between the industry and health care clinicians have the potential to alter decision making in ways that may not necessarily benefit patients. Health care clinicians have an ethical duty to recognize situations and marketing strategies that are designed to influence their choice of diagnostic and therapeutic options for their patients. At a minimum, health care clinicians should be aware of the techniques used to attempt to alter their behavior and guard against them.
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Abstract
Medical pharmaceutical and device manufacturers are essential in making products that benefit patients, and collaboration between health care providers and industry is necessary in the design, testing, and manufacture of these medical products. However, health care providers must recognize that their duties and the interests of industry may, at times, diverge. Relationships with industry, even seemingly minor ones, have the potential to shape the decisions made on behalf of patients. The marketing divisions of pharmaceutical and medical device firms view health care providers as a target of their efforts, and some of the interactions that occur between industry and health care providers have the potential to alter decision making in ways that may not necessarily benefit patients. Health care providers have an ethical duty to recognize situations and marketing strategies that are designed to influence their choice of diagnostic and therapeutic options for their patients. Health care providers should be aware of the techniques used to attempt to alter their behavior and guard against them.
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Butler CR, Webster LB, Diekema DS, Gray MM, Sakata VL, Tonelli MR, Vranas KC. Perspectives of Triage Team Members Participating in Statewide Triage Simulations for Scarce Resource Allocation During the COVID-19 Pandemic in Washington State. JAMA Netw Open 2022; 5:e227639. [PMID: 35435971 PMCID: PMC9016492 DOI: 10.1001/jamanetworkopen.2022.7639] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE The COVID-19 pandemic prompted health care institutions worldwide to develop plans for allocation of scarce resources in crisis capacity settings. These plans frequently rely on rapid deployment of institutional triage teams that would be responsible for prioritizing patients to receive scarce resources; however, little is known about how these teams function or how to support team members participating in this unique task. OBJECTIVE To identify themes illuminating triage team members' perspectives and experiences pertaining to the triage process. DESIGN, SETTING, AND PARTICIPANTS This qualitative study was conducted using inductive thematic analysis of observations of Washington state triage team simulations and semistructured interviews with participants during the COVID-19 pandemic from December 2020 to February 2021. Participants included clinician and ethicist triage team members. Data were analyzed from December 2020 through November 2021. MAIN OUTCOMES AND MEASURES Emergent themes describing the triage process and experience of triage team members. RESULTS Among 41 triage team members (mean [SD] age, 50.3 [11.4] years; 21 [51.2%] women) who participated in 12 simulations and 21 follow-up interviews, there were 5 Asian individuals (12.2%) and 35 White individuals (85.4%); most participants worked in urban hospital settings (32 individuals [78.0%]). Three interrelated themes emerged from qualitative analysis: (1) understanding the broader approach to resource allocation: participants strove to understand operational and ethical foundations of the triage process, which was necessary to appreciate their team's specific role; (2) contending with uncertainty: team members could find it difficult or feel irresponsible making consequential decisions based on limited clinical and contextual patient information, and they grappled with ethically ambiguous features of individual cases and of the triage process as a whole; and (3) transforming mindset: participants struggled to disentangle narrow determinations about patients' likelihood of survival to discharge from implicit biases and other ethically relevant factors, such as quality of life. They cited the team's open deliberative process, as well as practice and personal experience with triage as important in helping to reshape their usual cognitive approach to align with this unique task. CONCLUSIONS AND RELEVANCE This study found that there were challenges in adapting clinical intuition and training to a distinctive role in the process of scarce resource allocation. These findings suggest that clinical experience, education in ethical and operational foundations of triage, and experiential training, such as triage simulations, may help prepare clinicians for this difficult role.
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Affiliation(s)
- Catherine R. Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle
- Veterans Affairs Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | - Laura B. Webster
- Bioethics Program, Virginia Mason Medical Center, Seattle, Washington
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle
| | - Douglas S. Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle
- Trueman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, Washington
| | - Megan M. Gray
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Vicki L. Sakata
- Department of Pediatrics, University of Washington School of Medicine, Seattle
- Northwest Healthcare Response Network, Seattle, Washington
| | - Mark R. Tonelli
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Kelly C. Vranas
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland
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Diekema DS. Rhetoric, Persuasion, Compulsion, and the Stubborn Problem of Vaccine Hesitancy. Perspect Biol Med 2022; 65:106-123. [PMID: 35307704 DOI: 10.1353/pbm.2022.0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Despite the impact of vaccination on the control and prevention of many infectious diseases, vaccine opposition and hesitancy remain significant barriers to fully protecting individuals and communities against serious disease. The primary response to the problem of vaccine hesitancy includes persuasion and some degree of compulsion, usually in the form of vaccine mandates. Persuasion, if it can be successfully leveraged to provide sufficient control of disease spread, is the ethically preferred approach. Yet persuasion has proven less than adequate, leading to increasing calls for vaccination mandates and the elimination of nonmedical exemptions to those mandates. Four scholars have recently examined the underlying causes of vaccine hesitancy in the interest of improving rhetoric surrounding vaccination. This article reviews those books and offers suggestions for optimizing the strategy of persuasion in the interest of reducing the need for compulsion.
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Butler CR, Webster LB, Sakata VL, Tonelli MR, Diekema DS, Gray MM. Functionality of Scarce Healthcare Resource Triage Teams During the COVID-19 Pandemic: A Multi-Institutional Simulation Study. Crit Care Explor 2022; 4:e0627. [PMID: 35083438 PMCID: PMC8785932 DOI: 10.1097/cce.0000000000000627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Plans for allocating scarce healthcare resources during the COVID-19 pandemic commonly involve the activation of institutional triage teams. These teams would be responsible for selecting patients who are most likely to survive to be prioritized to receive scarce resources. However, there is little empirical support for this approach. DESIGN High-fidelity triage-team simulation study. SETTING Healthcare institutions in Washington state. SUBJECTS Triage teams, consisting of at least two senior clinicians and a bioethicist. INTERVENTIONS Participants reviewed a limited amount of deidentified information for a diverse sample of critically ill patients. Teams then assigned each patient to one of five prioritization categories defined by likelihood of survival to hospital discharge. The process was refined based on observation and participant feedback after which a second phase of simulations was conducted. MEASUREMENTS AND MAIN RESULTS Feasibility was assessed by the time required for teams to perform their task. Prognostic accuracy was assessed by comparing teams' prediction about likelihood of survival to hospital discharge with real-world discharge outcomes. Agreement between the teams on prognostic categorization was evaluated using kappa statistics. Eleven triage team simulations (eight in phase 1 and three in phase 2) were conducted from December 2020 to February 2021. Overall, teams reviewed a median of 23 patient cases in each session (interquartile range [IQR], 17-29) and spent a median of 102 seconds (IQR, 50-268) per case. The concordance between expected survival and real-world survival to discharge was 71% (IQR, 64-76%). The overall agreement between teams for placement of patients into prognostic categories was moderate (weighted kappa = 0.53). CONCLUSIONS These findings support the potential feasibility, accuracy, and effectiveness of institutional triage teams informed by a limited set of patient information items as part of a strategy for allocating scarce resources in healthcare emergencies. Additional work is needed to refine the process and adapt it to local contexts.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle WA
- Veterans Affairs Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle WA
| | - Laura B Webster
- Virginia Mason Medical Center, Seattle, WA
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA
| | - Vicki L Sakata
- Northwest Healthcare Response Network, Seattle, WA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Mark R Tonelli
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Douglas S Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
- Trueman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle WA
| | - Megan M Gray
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
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12
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Kates OS, Stohs EJ, Pergam SA, Rakita RM, Michaels MG, Wolfe CR, Danziger-Isakov L, Ison MG, Blumberg EA, Razonable RR, Gordon EJ, Diekema DS. The limits of refusal: An ethical review of solid organ transplantation and vaccine hesitancy. Am J Transplant 2021; 21:2637-2645. [PMID: 33370501 PMCID: PMC8298607 DOI: 10.1111/ajt.16472] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/30/2020] [Accepted: 12/21/2020] [Indexed: 01/25/2023]
Abstract
Patients pursuing solid organ transplantation are encouraged to receive many vaccines on an accelerated timeline. Vaccination prior to transplantation offers the best chance of developing immunity and may expand the pool of donor organs that candidates can accept without needing posttransplant therapy. Furthermore, transplant recipients are at greater risk for acquiring vaccine-preventable illnesses or succumbing to severe sequelae of such illnesses. However, a rising rate of vaccine refusal has challenged transplant centers to address the phenomenon of vaccine hesitancy. Transplant centers may need to consider adopting a policy of denial of solid organ transplantation on the basis of vaccine refusal for non-medical reasons (i.e., philosophical or religious objections or personal beliefs that vaccines are unnecessary or unsafe). Arguments supporting such a policy are motivated by utility, stewardship, and beneficence. Arguments opposing such a policy emphasize justice and respect for persons, and seek to avoid worsening inequities or medical coercion. This paper examines these arguments and situates them within the special cases of pediatric transplantation, emergent transplantation, and living donation. Ultimately, a uniform national policy addressing vaccine refusal among transplant candidates is needed to resolve this ethical dilemma and establish a consistent, fair, and standard approach to vaccine refusal in transplantation.
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Affiliation(s)
- Olivia S. Kates
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA,Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Erica J. Stohs
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Steven A. Pergam
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA,Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Robert M. Rakita
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Marian G. Michaels
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Pittsburgh, School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Cameron R. Wolfe
- Division of Infectious Diseases, Duke University Medical School, Durham, NC, USA
| | - Lara Danziger-Isakov
- Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Michael G. Ison
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA,Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Emily A. Blumberg
- Department of Medicine, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA, USA
| | - Raymund R. Razonable
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Elisa J. Gordon
- Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Douglas S. Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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Sawyer KE, Dundas N, Snyder A, Diekema DS. Competencies and Milestones for Bioethics Trainees: Beyond ASBH’s Healthcare Ethics Consultant Certification and Core Competencies. The Journal of Clinical Ethics 2021. [DOI: 10.1086/jce2021322127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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14
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Diekema DS. Hans Jonas and the Ethics of Human Subjects Research. Hastings Cent Rep 2021; 50:8-9. [PMID: 32068284 DOI: 10.1002/hast.1077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In the 1960s, human experimentation and public funding of research increased significantly, and with the rise of the modern teaching hospital, the distinction between clinical care and experimentation became more and more blurred. Yet little in the way of meaningful government regulation existed in the United States prior to 1970. In 1966, Paul Freund, the president of the American Academy of Arts and Sciences, appointed an interdisciplinary working group to consult on the issues being raised by human experimentation. Contributions from the group were published in a 1969 issue of Daedalus titled Ethical Aspects of Experimentation with Human Subjects. In the lead essay, Hans Jonas challenged then-conventional understandings of the moral problems posed by research involving humans and argued for an alternative moral framework. To Jonas, it mattered whether the physician was trying to make the patient well rather than trying to find out how to improve the health of future patients.
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15
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Affiliation(s)
- Douglas J Opel
- Department of Pediatrics, University of Washington School of Medicine, Seattle.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
| | - Douglas S Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
| | - Lainie Friedman Ross
- Department of Pediatrics, The University of Chicago, Chicago, Illinois.,MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, Illinois
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16
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Kett JC, Olszewski AE, Diekema DS, Wilfond BS, Wightman A. A 2020 Executive Order That Threatens Progress in Shared Decision-Making. Pediatrics 2021; 147:peds.2020-038794. [PMID: 33811178 DOI: 10.1542/peds.2020-038794] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2021] [Indexed: 11/24/2022] Open
Abstract
The “Executive Order on Protecting Vulnerable Newborn and Infant Children” threatens decades of progress in shared decision-making for imperiled newborns.
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Affiliation(s)
- Jennifer C Kett
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Seattle Children's Research Institute, Seattle, Washington; and .,Divisions of Bioethics and Palliative Care
| | - Aleksandra E Olszewski
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Seattle Children's Research Institute, Seattle, Washington; and.,Divisions of Bioethics and Palliative Care
| | - Douglas S Diekema
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Seattle Children's Research Institute, Seattle, Washington; and.,Divisions of Bioethics and Palliative Care.,Emergency Medicine
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Seattle Children's Research Institute, Seattle, Washington; and.,Divisions of Bioethics and Palliative Care.,Pulmonary and Sleep Medicine, and
| | - Aaron Wightman
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Seattle Children's Research Institute, Seattle, Washington; and.,Divisions of Bioethics and Palliative Care.,Nephrology, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
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17
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Kates OS, Diekema DS, Blumberg EA. Should Health Care Institutions Mandate SARS-CoV-2 Vaccination for Staff? Open Forum Infect Dis 2021; 8:ofab155. [PMID: 34183980 PMCID: PMC8083452 DOI: 10.1093/ofid/ofab155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/23/2021] [Indexed: 11/14/2022] Open
Abstract
Health care workers have been prioritized for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination, but vaccine hesitancy among workers may limit uptake. Institutions may wish to consider SARS-CoV-2 vaccine mandates for health care workers, but such proposals raise important ethical questions. Arguments supporting mandates emphasize the proposed favorable balance of harms and benefits for both individuals and communities, as well as moral duties of health care workers and organizations. Arguments in opposition seek to challenge some claims about utility and raise additional concerns about infringement on autonomy, damage to organizational relationships, and injustice. While available SARS-CoV-2 vaccines remain under an experimental designation, mandates may be excessively problematic, but following approval by the Food and Drug Administration mandates may be reconsidered. The authors summarize ethical arguments and practical considerations, concluding that mandates may be ethically permissible in select circumstances.
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Affiliation(s)
- Olivia S Kates
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA.,Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Douglas S Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Emily A Blumberg
- Department of Medicine, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania, USA
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18
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Benedetti DJ, Lewis-Newby M, Roberts JS, Diekema DS. Pandemics and Beyond: Considerations When Personal Risk and Professional Obligations Converge. The Journal of Clinical Ethics 2021. [DOI: 10.1086/jce2021321020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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19
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Jecker NS, Wightman AG, Diekema DS. Vaccine ethics: an ethical framework for global distribution of COVID-19 vaccines. J Med Ethics 2021:medethics-2020-107036. [PMID: 33593876 PMCID: PMC7887861 DOI: 10.1136/medethics-2020-107036] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 01/17/2021] [Accepted: 01/19/2021] [Indexed: 05/05/2023]
Abstract
This paper addresses the just distribution of vaccines against the SARS-CoV-2 virus and sets forth an ethical framework that prioritises frontline and essential workers, people at high risk of severe disease or death, and people at high risk of infection. Section I makes the case that vaccine distribution should occur at a global level in order to accelerate development and fair, efficient vaccine allocation. Section II puts forth ethical values to guide vaccine distribution including helping people with the greatest need, reducing health disparity, saving the most lives and promoting narrow social utility. It also responds to objections which claim that earlier years have more value than later years. Section III puts forth a practical ethical framework to aid decision-makers and compares it with alternatives.
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Affiliation(s)
- Nancy S Jecker
- University of Washington School of Medicine, Department of Bioethics and Humanities, Seattle, Washington, USA
| | - Aaron G Wightman
- Seattle Children's Hospital and Research Institute, Treuman Katz Center for Pediatric BIoethics, Seattle, Washington, USA
| | - Douglas S Diekema
- Seattle Children's Hospital and Research Institute, Treuman Katz Center for Pediatric BIoethics, Seattle, Washington, USA
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20
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Affiliation(s)
- Douglas J Opel
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Douglas S Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Lainie Friedman Ross
- Department of Pediatrics, The University of Chicago, Chicago, Illinois.,MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, Illinois
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21
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Benedetti DJ, Lewis-Newby M, Roberts JS, Diekema DS. Pandemics and Beyond: Considerations When Personal Risk and Professional Obligations Converge. J Clin Ethics 2021; 32:20-34. [PMID: 33656454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
With each novel infectious disease outbreak, there is scholarly attention to healthcare providers' obligation to assume personal risk while they care for infected patients. While most agree that healthcare providers have a duty to assume some degree of risk, the extent of this obligation remains uncertain. Furthermore, these analyses rarely examine healthcare institutions' obligations during these outbreaks. As a result, there is little practical guidance for healthcare institutions that are forced to weigh whether or when to exclude healthcare providers from providing care or allow them to opt out from providing care to protect themselves. This article uses the COVID-19 pandemic to examine the concept of risk and the professional duties of both healthcare providers and healthcare institutions, and proposes a framework that can be used to make concrete institutional policy choices. This framework should be a useful tool for any hospital, clinic, or health agency that must make these choices during the current pandemic and beyond.
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Affiliation(s)
- Daniel J Benedetti
- Assistant Professor of Pediatrics in the Department of Pediatrics, Division of Hematology/Oncology, the Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee USA.
| | - Mythya Lewis-Newby
- Associate Professor of Pediatrics in the Division of Pediatric Critical Care Medicine at Seattle Children's Hospital, University of Washington School of Medicine, and Treuman Katz Center for Pediatric Bioethics in Seattle, Washington USA.
| | - Joan S Roberts
- Associate Professor of Pediatrics in the Division of Pediatric Critical Care Medicine at Seattle Children's Hospital, University of Washington School of Medicine in Seattle, Washington USA.
| | - Douglas S Diekema
- Professor of Pediatrics at the University of Washington School of Medicine and Director of Education, Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute in Seattle, Washington USA.
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22
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Sawyer KE, Dundas N, Snyder A, Diekema DS. Competencies and Milestones for Bioethics Trainees: Beyond ASBH's Healthcare Ethics Certification and Core Competencies. J Clin Ethics 2021; 32:127-148. [PMID: 34129529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Clinical ethics training programs are responsible for preparing their trainees to be competent ethics consultants worthy of the trust of patients, families, surrogates, and healthcare professionals. While the American Society for Bioethics and Humanities (ASBH) offers a certification examination for healthcare ethics consultants, no tools exist for the formal evaluation of ethics trainees to assess their progress toward competency. Medical specialties accredited by the Accreditation Council for Graduate Medical Education (ACGME) use milestones to report trainees' progress along a continuum of professional development as a means of "operationalizing and implementing" medical competencies. Utilizing the Core Competencies for Healthcare Ethics Consultation and the ACGME and American Board of Pediatrics' (ABP) Pediatric Milestones Project, we developed milestones for 17 subcompetencies in clinical ethics consultation and academic bioethics. As the field of clinical ethics becomes more standardized, such tools will be needed to promote the development of robust training programs and to certify that their graduates are competent practitioners.
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Affiliation(s)
- Kimberly E Sawyer
- St. Jude Children's Research Hospital, 262 Danny Thomas Place, M/S 278, Memphis, Tennessee 38105 USA.
| | - Nicolas Dundas
- Seattle Children's Research Institute, 1900 Ninth Ave., M/S JMB-6, Seattle, Washington 98101 USA.
| | - Anna Snyder
- Seattle Children's Hospital M/S OC.7.830, PO Box 5371, Seattle, Washington 98145-5005 USA.
| | - Douglas S Diekema
- Seattle Children's Research Institute, 1900 Ninth Ave., M/S JMB-6, Seattle, Washington 98101 USA.
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23
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Guerin RM, Diekema DS, Hizlan S, Weise KL. Do Clinical Ethics Fellowships Prepare Trainees for Their First Jobs? A National Survey of Former Clinical Ethics Fellows. The Journal of Clinical Ethics 2020. [DOI: 10.1086/jce2020314372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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24
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Laventhal NT, Basak RB, Dell ML, Elster N, Geis G, Macauley RC, Mercurio MR, Opel DJ, Shalowitz DI, Statter MB, Diekema DS. Professional Obligations of Clinicians and Institutions in Pediatric Care Settings during a Public Health Crisis: A Review. J Pediatr 2020; 224:10-15. [PMID: 32585238 PMCID: PMC7308757 DOI: 10.1016/j.jpeds.2020.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/18/2020] [Indexed: 11/24/2022]
Affiliation(s)
| | - Ratna B Basak
- Brookdale University Hospital Medical Center, Brooklyn, New York
| | - Mary Lynn Dell
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Nanette Elster
- Loyola University Stritch School of Medicine, Chicago, Illinois
| | - Gina Geis
- Albany Medical College, Albany, New York
| | | | | | - Douglas J Opel
- University of Washington School of Medicine, Seattle, Washington
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25
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Antommaria AHM, Gibb TS, McGuire AL, Wolpe PR, Wynia MK, Applewhite MK, Caplan A, Diekema DS, Hester DM, Lehmann LS, McLeod-Sordjan R, Schiff T, Tabor HK, Wieten SE, Eberl JT. Ventilator Triage Policies During the COVID-19 Pandemic at U.S. Hospitals Associated With Members of the Association of Bioethics Program Directors. Ann Intern Med 2020; 173:188-194. [PMID: 32330224 PMCID: PMC7207244 DOI: 10.7326/m20-1738] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The coronavirus disease 2019 pandemic has or threatens to overwhelm health care systems. Many institutions are developing ventilator triage policies. OBJECTIVE To characterize the development of ventilator triage policies and compare policy content. DESIGN Survey and mixed-methods content analysis. SETTING North American hospitals associated with members of the Association of Bioethics Program Directors. PARTICIPANTS Program directors. MEASUREMENTS Characteristics of institutions and policies, including triage criteria and triage committee membership. RESULTS Sixty-seven program directors responded (response rate, 91.8%); 36 (53.7%) hospitals did not yet have a policy, and 7 (10.4%) hospitals' policies could not be shared. The 29 institutions providing policies were relatively evenly distributed among the 4 U.S. geographic regions (range, 5 to 9 policies per region). Among the 26 unique policies analyzed, 3 (11.3%) were produced by state health departments. The most frequently cited triage criteria were benefit (25 policies [96.2%]), need (14 [53.8%]), age (13 [50.0%]), conservation of resources (10 [38.5%]), and lottery (9 [34.6%]). Twenty-one (80.8%) policies use scoring systems, and 20 of these (95.2%) use a version of the Sequential Organ Failure Assessment score. Among the policies that specify the triage team's composition (23 [88.5%]), all require or recommend a physician member, 20 (87.0%) a nurse, 16 (69.6%) an ethicist, 8 (34.8%) a chaplain, and 8 (34.8%) a respiratory therapist. Thirteen (50.0% of all policies) require or recommend that those making triage decisions not be involved in direct patient care, but only 2 (7.7%) require that their decisions be blinded to ethically irrelevant considerations. LIMITATION The results may not be generalizable to institutions without academic bioethics programs. CONCLUSION Over one half of respondents did not have ventilator triage policies. Policies have substantial heterogeneity, and many omit guidance on fair implementation. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Armand H Matheny Antommaria
- Ethics Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, University of Cincinnati School of Medicine, Cincinnati, Ohio (A.H.A.)
| | - Tyler S Gibb
- Program in Medical Ethics, Humanities & Law, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan (T.S.G.)
| | - Amy L McGuire
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas (A.L.M.)
| | - Paul Root Wolpe
- Center for Ethics and School of Medicine, Emory University, Atlanta, Georgia (P.R.W.)
| | - Matthew K Wynia
- University of Colorado Center for Bioethics and Humanities, Schools of Medicine and Public Health, and UC Health System, Aurora, Colorado (M.K.W.)
| | - Megan K Applewhite
- Alden March Bioethics Institute and Department of Surgery, Albany Medical College, Albany, New York (M.K.A.)
| | - Arthur Caplan
- Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York (A.C., T.S.)
| | - Douglas S Diekema
- Departments of Pediatrics and Bioethics & Humanities, University of Washington School of Medicine, Seattle, Washington, Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington (D.S.D.)
| | - D Micah Hester
- Department of Medical Humanities & Bioethics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas (D.M.H.)
| | - Lisa Soleymani Lehmann
- VA New England Healthcare System, Bedford, Massachusetts, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts (L.S.L.)
| | - Renee McLeod-Sordjan
- Division of Medical Ethics, Department of Medicine, Northwell Health System, New Hyde Park, New York, Hofstra Northwell School of Graduate Nursing and Physician Assistant Studies, Hofstra University, Hempstead, New York (R.M.)
| | - Tamar Schiff
- Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York (A.C., T.S.)
| | - Holly K Tabor
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California (H.K.T., S.E.W.)
| | - Sarah E Wieten
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California (H.K.T., S.E.W.)
| | - Jason T Eberl
- Albert Gnaegi Center for Health Care Ethics, Saint Louis University, St. Louis, Missouri (J.T.E.)
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Abstract
With a few notable exceptions, adolescents do not possess the legal authority to provide consent for or refuse medical interventions. However, in some situations, the question arises regarding whether a mature minor should be permitted to make a life-altering medical decision that would be challenged if made by the minor's parent. In this article, I explore what we currently know about the adolescent brain and how that knowledge should frame our understanding of adolescent decision-making. The prevailing approach to determining when adolescents should have their decisions respected in the medical and legal context, an approach that is focused on establishing capacity under a traditional informed consent model, will be reviewed and critiqued. I will suggest that the traditional model is insufficient and explore the implications for the adolescent role in health care decision-making.
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Affiliation(s)
- Douglas S Diekema
- Division of Bioethics and Palliative Care, Department of Pediatrics, School of Medicine, University of Washington and Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
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27
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Affiliation(s)
| | | | - Douglas S Diekema
- University of Washington School of Medicine
- Seattle Children's Hospital
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28
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Guerin RM, Diekema DS, Hizlan S, Weise KL. Do Clinical Ethics Fellowships Prepare Trainees for their First Jobs? A National Survey of Former Clinical Ethics Fellows. J Clin Ethics 2020; 31:372-380. [PMID: 33259342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Clinical ethics consultants provide a range of services in hospital settings and in teaching environments. Training to achieve the skills needed to meet the expectations of employers comes in various forms, ranging from on-the-job training to formal fellowship training programs. We surveyed graduates of clinical ethics fellowships to evaluate their self-reported preparedness for their first job after fellowship training. The results indicated several areas of need, including greater exposure to program-building skills, quality improvement skills, and approaches to working with members of higher administration. These data will be of use to educators as well as to fellows who advocate for elements of training in preparation for their first position.
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Affiliation(s)
- Robert M Guerin
- University Hospitals Cleveland Medical Center; and Case Western Reserve University Department of Bioethics, Cleveland, OH USA.
| | - Douglas S Diekema
- Treuman Katz Center for Pediatric Bioethics; and Institutional Review Board Committee, Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA USA.
| | | | - Kathryn L Weise
- Retired, Department of Pediatrics, School of Medicine, and Department of Bioethics, Case Western Reserve University, Cleveland, OH USA.
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29
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Diekema DS. Decision Making on Behalf of Children: Understanding the Role of the Harm Principle. The Journal of Clinical Ethics 2019. [DOI: 10.1086/jce2019303207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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30
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Diekema DS. Decision Making on Behalf of Children: Understanding the Role of the Harm Principle. J Clin Ethics 2019; 30:207-212. [PMID: 31573963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Thirty years ago, Buchanan and Brock distinguished between guidance principles and interference principles in the setting of surrogate decision making on behalf of children and incompetent adult patients. They suggested that the best interest standard could serve as a guidance principle, but was insufficient as an interference principle. In this issue of The Journal of Clinical Ethics, Ross argues that the best interest standard can serve as neither a guidance or interference principle for decision making on behalf of children, but that her model of constrained parental autonomy can serve as both. I will argue that Buchanan and Brock were correct that a single model or standard cannot serve as both a guidance and interference principle in pediatrics and that the best interest standard is a sufficient guidance principle. The harm principle fulfills the conditions necessary for an interference principle, at least insofar as deciding when state intervention to interfere with parental decision making is justified.
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Affiliation(s)
- Douglas S Diekema
- Professor at the University of Washington-Seattle and is Director of Education at the Treuman Katz Center for Pediatric Bioethics at Seattle Children's Hospital in Seattle, Washington USA.
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31
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Berkman ER, Clark JD, Diekema DS, Lewis-Newby M. "We Can Do Anything but We Can't Do Everything": Exploring the Perceived Impact of International Pediatric Programs on U.S. PICUs. Front Pediatr 2019; 7:470. [PMID: 31803696 PMCID: PMC6873788 DOI: 10.3389/fped.2019.00470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 10/28/2019] [Indexed: 11/29/2022] Open
Abstract
Purpose: Every year, an increasing number of international patients seek medical care in the United States (U.S.), yet little is known about their impact. Based on single institution experiences, we wanted to explore the perceived impact of international pediatric patients on large academic U.S. pediatric intensive care units (PICUs), as they are already taxed systems. Methods: To explore current perceptions, seven geographically diverse institutions who advertise care for international patients on their websites and have ≥24 PICU beds were identified after IRB approval was obtained. We consented and interviewed PICU division chiefs or medical directors from each institution regarding their demographics and international patients. Common themes were identified. Results: Participating institutions were diverse in geographic location, census, and resource allocation strategies. Five of the seven institutions reported the presence of a formal international patient program. Four of those five reported an increase in international patients receiving PICU care over the past 5 years. International patients sought complex surgeries, advanced cancer treatments and metabolic/genetic evaluations. We identified three primary domains that require further exploration and research: (1) cultural and language differences leading to barriers in providing optimal care to international patients (2) institutional financial considerations, and (3) perceived positive and negative impact on the care of local/domestic patient populations. Conclusions: The presence of international programs raises a number of important ethical questions, including whether clinicians have a greater duty to serve residents of the local community as opposed to international patients when resources are limited. Further exploration is warranted.
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Affiliation(s)
- Emily R Berkman
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, United States
| | - Jonna D Clark
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, United States
| | - Douglas S Diekema
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, United States.,Division of Pediatric Emergency Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States
| | - Mithya Lewis-Newby
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, United States.,Division of Pediatric Critical Care Medicine, Section of Pediatric Cardiac Critical Care, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States
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32
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Hester DM, Lang KR, Garrison NA, Diekema DS. Agreed: The Harm Principle Cannot Replace the Best Interest Standard … but the Best Interest Standard Cannot Replace The Harm Principle Either. Am J Bioeth 2018; 18:38-40. [PMID: 30133400 DOI: 10.1080/15265161.2018.1485759] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
| | | | | | - Douglas S Diekema
- c Seattle Children's Research Institute and University of Washington
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33
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Jecker NS, Wightman AG, Rosenberg AR, Diekema DS. Fairly Allocating Space in an Immunotherapy Production Facility: Reply to Critics. Am J Bioeth 2018; 18:W9-W12. [PMID: 29697346 DOI: 10.1080/15265161.2018.1452994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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34
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Jecker NS, Wightman AG, Rosenberg AR, Diekema DS. Ethical Guidance for Selecting Clinical Trials to Receive Limited Space in an Immunotherapy Production Facility. Am J Bioeth 2018; 18:58-67. [PMID: 29621473 DOI: 10.1080/15265161.2018.1444817] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Our aims are to (1) set forth a multiprinciple system for selecting among clinical trials competing for limited space in an immunotherapy production facility that supplies products under investigation by scientific investigators; (2) defend this system by appealing to justice principles; and (3) illustrate our proposal by showing how it might be implemented. Our overarching aim is to assist manufacturers of immunotherapeutic products and other potentially breakthrough experimental therapies with the ethical task of prioritizing requests from scientific investigators when production capacity is limited.
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35
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Affiliation(s)
- Seema K Shah
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Department of Pediatrics, University of Washington, Seattle
| | - Abby R Rosenberg
- University of Washington School of Medicine, Division of Hematology/Oncology, Department of Pediatrics, Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle
| | - Douglas S Diekema
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Department of Pediatrics, University of Washington, Seattle
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36
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Affiliation(s)
- Seema K Shah
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington.,Division of Bioethics, Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Abby R Rosenberg
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington.,Division of Hematology/Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Douglas S Diekema
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington.,Division of Bioethics, Department of Pediatrics, University of Washington School of Medicine, Seattle
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37
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Abstract
Policies to remove parents' ability to opt-out from school immunization requirements on the basis of religious or personal beliefs (ie, nonmedical exemptions) may be a useful strategy to increase immunization rates and prevent outbreaks of vaccine-preventable disease. However, there is uncertainty about the effectiveness of this strategy and the range of possible outcomes. We advocate for a more deliberative process through which a broad range of outcomes is scrutinized and the balance of values underlying the policy decision to eliminate nonmedical exemptions is clearly articulated. We identify 3 outcomes that require particular consideration before policies to eliminate nonmedical exemptions are implemented widely and outline a process for making the values underlying such policies more explicit.
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Affiliation(s)
- Douglas J Opel
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington.,Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Jason L Schwartz
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Saad B Omer
- Departments of Epidemiology and Global Health, Emory University School of Public Health, Atlanta, Georgia.,Emory Vaccine Center, Atlanta, Georgia
| | - Ross Silverman
- Department of Health Policy and Management, Indiana University Fairbanks School of Public Health, Indianapolis.,Indiana University McKinney School of Law, Indianapolis
| | - Jeff Duchin
- Public Health-Seattle and King County, Seattle, Washington.,Department of Epidemiology, University of Washington School of Public Health, Seattle.,Department of Medicine, University of Washington School of Medicine, Seattle
| | - Eric Kodish
- Pediatric Institute and Department of Bioethics, Cleveland Clinic, Cleveland, Ohio
| | - Douglas S Diekema
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington.,Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Edgar K Marcuse
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Walt Orenstein
- Emory Vaccine Center, Atlanta, Georgia.,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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38
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Jecker NS, Wightman AG, Rosenberg AR, Diekema DS. From protection to entitlement: selecting research subjects for early phase clinical trials involving breakthrough therapies. J Med Ethics 2017; 43:391-400. [PMID: 28408724 DOI: 10.1136/medethics-2016-103868] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 01/25/2017] [Accepted: 02/13/2017] [Indexed: 06/07/2023]
Abstract
Our goals are to (1) set forth and defend a multiprinciple system for selecting individuals who meet trial eligibility criteria to participate in early phase clinical trials testing chimeric antigen receptor (CAR T-cell) for acute lymphoblastic leukaemia when demand for participation exceeds spaces available in a trial; (2) show the relevance of these selection criteria to other breakthrough experimental therapies; (3) argue that distinct distributive justice criteria apply to breakthrough experimental therapies, standard research and healthcare and (4) argue that as evidence of benefit increases, the emphasis of justice in research shifts from protecting subjects from harm to ensuring fair access to benefits.
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Affiliation(s)
- Nancy S Jecker
- University of Washington School of Medicine, Department of Bioethics & Humanities, Seattle, Washington, USA
| | - Aaron G Wightman
- University of Washington School of Medicine, Department of Pediatrics and Seattle Children's Hospital, Division of Nephrology, Seattle, Washington, USA
| | - Abby R Rosenberg
- University of Washington School of Medicine, Department of Pediatrics and Seattle Children's Hospital, Division of Hematology-Oncology, Seattle, Washington, USA
| | - Douglas S Diekema
- University of Washington Department of Pediatrics and Seattle Children's Hospital, Division of Emergency Medicine, Seattle, Washington, USA
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39
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Abstract
When minors are asked to assist medical educators by acting as standardized patients (SPs), there is a potential for the minors to be exploited. Minors deserve protection from exploitation. Such protection has been written into regulations governing medical research and into child labor laws. But there are no similar guidelines for minors' work in medical education. This article addresses the question of whether there should be rules. Should minors be required to give their informed consent or assent? Are there certain practices that could cause harm for the children who become SPs? We present a controversial case and ask a number of experts to consider the ethical issues that arise when minors are asked to act as SPs in medical education.
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Affiliation(s)
| | | | | | - John D Lantos
- Children's Mercy Kansas City, Kansas City, Missouri; and
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40
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Kelley MC, Brazg T, Wilfond BS, Lengua LJ, Rivin BE, Martin-Herz SP, Diekema DS. Ethical challenges in research with orphans and vulnerable children: a qualitative study of researcher experiences. Int Health 2016; 8:187-96. [DOI: 10.1093/inthealth/ihw020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 03/03/2016] [Indexed: 11/12/2022] Open
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41
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Affiliation(s)
- Andrea J Hoopes
- Adolescent Medicine Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Gina S Sucato
- Division of Adolescent Medicine, Department of Pediatrics, University of Washington, Seattle3Group Health, Seattle, Washington
| | - Douglas S Diekema
- Treuman Katz Center for Pediatric Bioethics, Seattle, Washington5Division of Bioethics, Department of Pediatrics, University of Washington, Seattle
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42
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Opel DJ, Kronman MP, Diekema DS, Marcuse EK, Duchin JS, Kodish E. Childhood Vaccine Exemption Policy: The Case for a Less Restrictive Alternative. Pediatrics 2016; 137:peds.2015-4230. [PMID: 26993127 PMCID: PMC4811320 DOI: 10.1542/peds.2015-4230] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/25/2016] [Indexed: 11/24/2022] Open
Affiliation(s)
- Douglas J Opel
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, and Departments of Pediatrics and
| | | | - Douglas S Diekema
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, and Departments of Pediatrics and Departments of Health Services and
| | | | - Jeffrey S Duchin
- Medicine, University of Washington School of Medicine, Seattle, Washington; Epidemiology, University of Washington School of Public Health, Seattle, Washington; Communicable Disease Epidemiology and Immunization Section, Public Health-Seattle and King County, Seattle, Washington; and
| | - Eric Kodish
- Department of Bioethics, Center for Ethics, Humanities and Spiritual Care, Cleveland Clinic, Cleveland, Ohio
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43
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Weaver MS, Diekema DS, Carr A, Triplett B. Matched Marrow, Sibling Shadow: The Epidemiology, Experience, and Ethics of Sibling Donors of Stem Cells. J Adolesc Young Adult Oncol 2016; 4:100-4. [PMID: 26812663 DOI: 10.1089/jayao.2014.0051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Meaghann S Weaver
- 1 Department of Oncology, St. Jude Children's Research Hospital , Memphis, Tennessee
| | - Douglas S Diekema
- 2 Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute , Seattle, Washington
| | - Ashley Carr
- 3 Child Life Program, St. Jude Children's Research Hospital , Memphis, Tennessee
| | - Brandon Triplett
- 4 Department of Bone Marrow Transplant, St. Jude Children's Research Hospital , Memphis, Tennessee
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44
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Mancini ME, Diekema DS, Hoadley TA, Kadlec KD, Leveille MH, McGowan JE, Munkwitz MM, Panchal AR, Sayre MR, Sinz EH. Part 3: Ethical Issues: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2016; 132:S383-96. [PMID: 26472991 DOI: 10.1161/cir.0000000000000254] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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45
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Diekema DS, Wilfond BS. Decision-Making for Children with Disabilities: Parental Discretion and Moral Ambiguity. Perspect Biol Med 2016; 58:328-331. [PMID: 27157350 DOI: 10.1353/pbm.2016.0007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
We argue that medical decisions on behalf of children should be made with the welfare of the child as the primary interest, that parents should generally be allowed to determine which options optimize the interests of their child, and that those decisions should be formally challenged only when the parental decision places the child at substantial risk of a serious harm as compared to the option favored by the health-care provider. In situations where moral ambiguity exists and no possible solution could unequivocally be declared the right or good one, a parental decision favoring one or the other of the reasonable options should be supported. Parents should be provided with adequate time to consider information provided and weigh the various options presented. If parents find themselves unable to make a decision, we suggest several strategies for shared decision-making. Finally, we recommend setting time points for reassessment of the situation following each therapeutic change to allow reevaluation of whether the chosen path should be altered.
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46
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Abstract
Caring for patients affected with Ebola virus disease (EVD) while simultaneously preventing EVD transmission represents a central ethical challenge of the EVD epidemic. To address this challenge, we propose a model policy for resuscitation and emergent procedure policy of patients with EVD and set forth ethical principles that lend support to this policy. The policy and principles we propose bear relevance beyond the EVD epidemic, offering guidance for the care of patients with other highly contagious, virulent, and lethal diseases. The policy establishes (1) a limited code status for patients with confirmed or suspected EVD. Limited code status means that a code blue will not be called for patients with confirmed or suspected EVD at any stage of the disease; however, properly protected providers (those already in full protective equipment) may initiate resuscitative efforts if, in their clinical assessment, these efforts are likely to benefit the patient. The policy also requires that (2) resuscitation not be attempted for patients with advanced EVD, as resuscitation would be medically futile; (3) providers caring for or having contact with patients with confirmed or suspected EVD be properly protected and trained; (4) the treating team identify and treat in advance likely causes of cardiac and respiratory arrest to minimize the need for emergency response; (5) patients with EVD and their proxies be involved in care discussions; and (6) care team and provider discretion guide the care of patients with EVD. We discuss ethical issues involving medical futility and the duty to avoid harm and propose a utilitarian-based principle of triage to address resource scarcity in the emergency setting.
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Affiliation(s)
- Nancy S Jecker
- Department of Bioethics and Humanities, Seattle Children's Hospital, Seattle, WA.
| | - Denise M Dudzinski
- Department of Bioethics and Humanities, Seattle Children's Hospital, Seattle, WA
| | - Douglas S Diekema
- School of Medicine, University of Washington; and the Emergency Department, Seattle Children's Hospital, Seattle, WA; Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
| | - Mark Tonelli
- Department of Pulmonary and Critical Care Medicine, Seattle Children's Hospital, Seattle, WA
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47
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Kunz SN, McAdams RM, Diekema DS, Opel DJ. A Quality of Life Quandary: A Framework for Navigating Parental Refusal of Treatment for Co-Morbidities in Infants with Underlying Medical Conditions. The Journal of Clinical Ethics 2015. [DOI: 10.1086/jce2015261016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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48
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Abstract
Thousands of U.S. parents choose to refuse or delay the administration of selected vaccines to their children each year, and some choose not to vaccinate their children at all. While most physicians continue to provide care to these families over time, using each visit as an opportunity to educate and encourage vaccination, an increasing number of physicians are choosing to dismiss these families from their practice unless they agree to vaccinate their children. This paper will examine this emerging trend along with the reasons given by those who advocate such an approach. I will argue that the strategy of refusing to allow families into a clinic unless they agree to vaccinate their children is misguided, and the arguments for doing so fail to stand up to close scrutiny. Such a strategy does not benefit the child or the health of the community, and may have a negative impact on both. Furthermore, some of the arguments in support of dismissal policies ignore the importance of professional obligation and appear to favor self-interest over the interest of the patient.
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Affiliation(s)
- Douglas S Diekema
- Professor of Pediatrics in the Department of Pediatrics at the University of Washington School of Medicine with adjunct appointments in the Department of Bioethics & Humanities and the Department of Health Services in the School of Public Health. He also serves as the Director of Education for the Treuman Katz Center for Pediatric Bioethics at Seattle Children's Research Institute. He received his M.D. at the University of North Carolina School of Medicine in Chapel Hill, North Carolina, and his M.P.H. at the University of Washington School of Public Health in Seattle, Washington
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49
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Kunz SN, McAdams RM, Diekema DS, Opel DJ. A quality of life quandary: a framework for navigating parental refusal of treatment for co-morbidities in infants with underlying medical conditions. J Clin Ethics 2015; 26:16-23. [PMID: 25794289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Parental refusal of a recommended treatment is not an uncommon scenario in the neonatal intensive care unit. These refusals may be based upon the parents' perceptions of their child's projected quality of life. The inherent subjectivity of quality of life assessments, however, can exacerbate disagreement between parents and healthcare providers. We present a case of parental refusal of surgical intervention for necrotizing enterocolitis in an infant with Bartter syndrome and develop an ethical framework in which to consider the appropriateness of parental refusal based upon an infant's projected quality of life.
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Affiliation(s)
- Sarah N Kunz
- Neonatal-Perinatal Medicine, Boston Children's Hospital, Boston, Massachusetts USA
| | - Ryan M McAdams
- Pediatrics, Seattle Children's Hospital, Seattle, Washington USA
| | | | - Douglas J Opel
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, 1900 Ninth Avenue, M/S: JMBa-6, Seattle, Washington 98101 USA.
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50
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Grady C, Wiener L, Abdoler E, Trauernicht E, Zadeh S, Diekema DS, Wilfond BS, Wendler D. Assent in research: the voices of adolescents. J Adolesc Health 2014; 54:515-20. [PMID: 24630932 PMCID: PMC4047975 DOI: 10.1016/j.jadohealth.2014.02.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 02/07/2014] [Accepted: 02/07/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE Adolescents join clinical research after investigators obtain their positive agreement or "assent." Although intended to respect adolescents, little is known about the views of adolescents or their parents regarding assent or research enrollment decisions. This study aimed to better understand perspectives of adolescent research participants and their parents about assent and parental permission. METHODS Structured interviews were conducted with 13- through 17-year-old teens, enrolled in clinical research at the National Institutes of Health or Seattle Children's Hospital, and separately with one parent. RESULTS One hundred and seventy-seven adolescent-parent pairs were interviewed. Teens were well distributed by age and gender, represented a wide variety of research and illnesses ranging in severity from mild to life threatening; 20% were healthy volunteers. Teens and parents were generally satisfied with the assent/permission process. Normally, they made the enrollment decision together and teens wanted parents' input and support. About 25% of teens reported pressure to enroll, not only from parents or relatives but also from doctors/nurses/research teams. Only 2% of teens preferred not to sign a consent form. CONCLUSIONS Despite some differing views about how decisions should be made, the current assent/permission process is perceived as satisfactorily respectful by most teens in research. Many teens want to sign consent forms, and teens' signatures should generally be sought. Flexible guidance allows research teams and Institutional Review Boards to customize the assent process for teens in particular studies in order to facilitate an appropriate balance between giving teens a voice reflective of their emerging independence and enabling supportive collaboration with parents.
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Affiliation(s)
- Christine Grady
- Department of Bioethics, NIH Clinical Center, Bethesda, Maryland.
| | - Lori Wiener
- Pediatric Oncology Branch, National Cancer Institute
| | - Emily Abdoler
- Formerly at the Department of Bioethics, NIH Clinical Center, currently University of California San Francisco
| | - Emily Trauernicht
- Formerly summer student, Department of Bioethics, Currently at University of Virginia Medical School
| | - Sima Zadeh
- Pediatric Oncology Branch, National Cancer Institute
| | - Douglas S. Diekema
- Treuman Katz Center for Pediatric Bioethics, Seattle Childrens Research Institute
| | - Benjamin S. Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Childrens Research Institute
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