Volume 20, Issue 3, March 2020, Page 24-27.

‘Shared’ decision-making is heralded as the gold standard of how medical decisions should be reached, yet how does one ‘share’ a decision when any attempt to do so will undermine _autonomous_ decision-making? And what exactly is being shared? While some authors have described parallels in literature, philosophical examination of shared agency remains largely uninvestigated as an explanation in bioethics. In the following, shared decision-making will be explained as occurring when a group, generally comprised of a patient and or their family, (...) and the medical team become a genuine intentional subject which acts as a collective agent. Collective agency can better explain how some medical decisions are reached, contrary to the traditional understanding and operationalization of ‘autonomy’ in bioethics. Paradoxically, this often occurs in the setting of high-stakes moral decision-making, where conventional wisdom would suggest individuals would _most_ want to exercise autonomous action according to their personally held values and beliefs. This explication of shared decision-making suggests a social ontology ought to inform or displace significant aspects of autonomy as construed in bioethics. It will be argued that joint commitments are a fundamental part of human life, informing and explaining much human behavior, and thus suggesting that autonomy - conceived of as discrete, individuated moral reasoning of a singular moral agent - is not an unalloyed ‘good.’. (shrink)

Hastings Center Report, Volume 52, Issue 2, Page 32-40, March‐April 2022.

The fidelity provided by rich, nuanced ethics consult narratives does not proscribe efforts to advance the profession by using data to assess performance and demonstrate value. While these two approaches have been described as in conflict with one another, the former sets the bar to which the latter should aim; to achieve this, consult data should, minimally, do two things: (1) tell the story of the case, as best as possible, in language easily accessible to both ethicists and non-ethicists alike; (...) and (2) do so in a way that elements of interest can be aggregated, disambiguated, and analyzed. Here we present a three-component system designed with that in mind.First, the Armstrong Clinical Ethics Coding System (ACECS) produces a set of six codes that tell a simplified story of the case. These six codes form a meta narrative, which, like meta data, can be aggregated, disambiguated, and analyzed. Second, we use a data model to uncover the stories those data tell. The results allow us to understand relationships, recognize patterns, and reveal insights that are otherwise not discoverable when using narratives alone. Third, due to tremendous heterogeneity among cases, we represent findings visually using techniques borrowed from data storytelling, a powerful means to demonstrate the value of a consult service to administrators and others. The ability to derive meta narratives from an aggregate of case narratives allows us to describe, in detail, the work of our consult service in a manner directly comparable to other services that use the system while we preserve unprecedented case-level nuance. If adopted broadly, this functionality suggests a means to undergird the legitimacy of the ethics consult practice itself in an evidence-based manner similar to that which undergirds other domains of healthcare. (shrink)

A two-year rounding program was initiated by the clinical ethics consult service (CECS) to improve ethics program integration and utilization at our 323-bed tertiary care pediatric hospital. Two critical variables were identified for improvement. One: identification of cases in which an ethics consult would have benefited clinical care but was not requested. Two: earlier detection of cases for which the medical team and/or family eventually sought ethics consultation but that worsened during the delay. Improvement relied on eliciting dialogue with the (...) CECS by the medical team and/or patients and families, when it had either not occurred before or had not occurred when it would have been most beneficial. The indirect nature of the improvements sought posed a specific challenge: how does one elicit such action from others? How does a small program with less than one full-time equivalent position that is dedicated to clinical ethics, and little funding, effect such a process change across an organization with more than 600 physicians, 2,000 nurses, 600 medical students, and thousands of other clinicians and staff? The following accounts such an effort and the accompanying two-year study undertaken to document the results. The data presented demonstrate improvement in both identified variables: increased overall utilization of the CECS and earlier detection of cases in which the CECS is typically engaged. (shrink)

Hastings Center Report, Volume 52, Issue 1, Page 4-7, January/February 2022.