Autonomy-based criticisms of the patient preference predictor

The patient preference predictor (PPP) is a proposed computer-based algorithm that would predict the treatment preferences of decisionally incapacitated patients. Incorporation of a PPP into the decision-making process has the potential to improve implementation of the substituted judgement standard by providing more accurate predictions of patients’ treatment preferences than reliance on surrogates alone. Yet, critics argue that methods for making treatment decisions for incapacitated patients should be judged on a number of factors beyond simply providing them with the treatments they would have chosen for themselves. These factors include the extent to which the decision-making process recognises patients’ freedom to choose and relies on evidence the patient themselves would take into account when making treatment decisions. These critics conclude that use of a PPP should be rejected on the grounds that it is inconsistent with these factors, especially as they relate to proper respect for patient autonomy. In this paper, we review and evaluate these criticisms. We argue that they do not provide reason to reject use of a PPP, thus supporting efforts to develop a full-scale PPP and to evaluate it in practice.

We Should Widen Access to Physician-Assisted Death

Typical philosophical discussions of physician-assisted death (“pad”) have focused on whether the practice can be permissible. We address a different question: assuming that pad can be morally permissible, how far does that permission extend? We will argue that granting requests for pad may be permissible even when the pad recipient can no longer speak for themselves. In particular, we argue against the ‘competency requirement’ that constrains pad-eligibility to presently-competent patients in most countries that have legalized pad. We think pad on terminally ill, incapacitated patients can be morally permissible in cases where advance directives or suitable surrogate decision-makers are available, and should be legally permissible in such cases as well. We argue that this view should be accepted on pain of inconsistency: by allowing surrogate decision-makers to request withdrawal of life-sustaining care on behalf of patients and by allowing patients to request pad, we rule out any plausible justification for imposing a competency requirement on pad.

What are the ethical conflicts faced by Mexican internists?

Background No studies have been conducted in Mexico to ascertain what ethical problems doctors working at hospitals deal with. This article aims to describe the ethical conflicts most commonly identified by Mexican internists and the importance they attribute to each of these conflicts. Methods Voluntary survey to the members of the Internal Medicine Association of Mexico. Results Responses were submitted by 347 internists. Half of those face ethical conflicts almost always or frequently. The most commonplace and relevant conflicts are those resulting from the clinical relationship (communication, confidentiality, informed consent, assessment of mental capacity, decisions involving incapacitated patients, and conflicts with family members), and secondly those problems related with the end of life (palliative care, withholding or withdrawing treatment, and “No CPR orders”). To resolve conflicts they seek support through protocols, Institutional Ethics Committees (IECs), and consultations with colleagues and, occasionally, with bioethics experts. Protocols and IECs are the tools most in demand among them. Conclusions 1) the most frequent and relevant conflicts are those caused by the clinical relationship, above all those due to doctor–patient communication, and secondly those due to problems which arise at the end of life; 2) though nearly all of them have doubts about how to resolve conflicts, the vast majority are satisfied with the way in which they do so; 3) to deal with conflicts, they seek support mainly in protocols, IECs, and consultation with colleagues; and 4) in order to resolve them better, what they most demand are protocols and IECs, but also bioethics consultants.

Administration of pro re nata medications by the nurse to incapacitated patients: An ethical perspective

The administration of pro re nata medications is the responsibility of the nurse. However, ethical uncertainties often happen due to the inability of incapacitated patients to collaborate with the nurse in the process of decision making for pro re nata medication administration. There is a lack of integrative knowledge and insufficient understanding regarding ethical considerations surrounding the administration of pro re nata medications to incapacitated patients. Therefore, they have been discussed in this paper and practical strategies to avoid unethical practices have been suggested. The complicated caring situation surrounding the administration of pro re nata medications is intertwined with ethical issues affecting the consideration of the patient's wishes and interventions that override them. The patient's right of autonomy and treatment refusal, surrogacy role, paternalism, and coercion are the main ethos of ethical pro re nata medication administration. Education and training can help nurses avoid legal and ethical issues in pro re nata medicines management and improve the quality and safety of healthcare. Empirical research is needed to improve our understanding of this phenomenon in the multidisciplinary environment of medicines management.

Trial by Triad: substituted judgment, mental illness and the right to die

Substituted judgment has increasingly become the accepted standard for rendering decisions for incapacitated adults in the USA. A broad exception exists with regard to patients with diminished capacity secondary to depressive disorders, as such patients’ previous wishes are generally not honoured when seeking to turn down life-preserving care or pursue aid-in-dying. The result is that physicians often force involuntary treatment on patients with poor medical prognoses and/or low quality of life (PMP/LQL) as a result of their depressive symptoms when similarly situated incapacitated patients without such depressive symptoms would have their previous wishes honoured via substituted judgment. This commentary argues for reconsidering this approach and for using a substituted judgment standard for a subset of EMP/LQL patients seeking death.

The Last Gift: Advanced Healthcare Directives and the Family Members of Incapacitated Patients

This article will provide an overview of the law related to the withdrawal of treatment from incapacitated adult patients in Ireland and the role of family members in such decisions. This overview will touch on the best interests test, how the wishes of an incapacitated patient may be assessed, and the tension that may arise between medical assessments and the views of the family of the patient. Cases arising in the UK and the USA will be discussed where relevant. It will be argued that family members should be provided with more information, particularly with respect to Do Not Attempt Resuscitation orders. The article calls for greater discussion about death and dying, and greater use of advance healthcare directives.

Kinerja keuangan rumah sakit syariah: pendekatan Maqashid Syariah Concordance (MSC)

The purpose of this research is to help the management of the Sultan Agung hospital to measure performance with Maqashid Syariah Concordance (MSC). This type of quantitative research analyzes the financial reports of Islamic hospitals from 2015 to 2019, the data is calculated by making an index according to the Maqashid Syariah Concordance (MSC) model. The results showed that the portion of dakwah and social costs (daksos) was very good when compared to the value of zakat mal, the role of the sharia committee was in accordance with its function, the cooperation between Sultan Agung hospital and Islamic banks had a smaller proportion compared to cooperation with conventional banks, then ZIS and treatment of incapacitated patients has not been distributed periodically. Abstrak Tujuan dilakukan penelitian ini adalah membantu manajemen rumah sakit Sultan Agung mengukur kinerja dengan Maqashid Syariah Concordance (MSC). Jenis penelitian kuantitatif dengan menganalisis laporan keuangan rumah sakit syariah selama 2015 hingga 2019, data dihitung dengan membuat indeks sesuai model Maqashid Syariah Concordance (MSC). Hasil penelitian menunjukan porsi biaya dakwah dan sosial (daksos) sangat baik jika dibandingkan dengan nilai zakat mal, peran komite syariah sudah sesuai dengan fungsinya, kerjasama rumah sakit Sultan Agung dengan bank syariah memiliki proporsi lebih kecil dibandingkan kerja sama dengan bank konvensional, selanjutnya ZIS dan treatment terhadap pasien tidak mampu belum terdistribusi secara periodik.

Forgoing life-sustaining treatment – a comparative analysis of regulations in Japan, Korea, Taiwan, and England

Background Regulations on forgoing life-sustaining treatment (LST) have developed in Asian countries including Japan, Korea and Taiwan. However, other countries are relatively unaware of these due to the language barrier. This article aims to describe and compare the relevant regulatory frameworks, using the (more familiar) situation in England as a point of reference. We undertook literature reviews to ascertain the legal and regulatory positions on forgoing LST in Japan, Korea, Taiwan, and England. Main text Findings from a literature review are first presented to describe the development of the regulatory frameworks surrounding the option of forgoing LST in each country. Based on the findings from the four countries, we suggest five ethically important points, reflection on which should help to inform the further development of regulatory frameworks concerning end-of-life care in these countries and beyond. There should be reflection on: (1) the definition of – and reasons for defining – the ‘terminal stage’ and associated criteria for making such judgements; Korea and Taiwan limit forgoing LST to patients in this stage, but there are risks associated with defining this too narrowly or broadly; (2) foregoing LST for patients who are not in this stage, as is allowed in Japan and England, because here too there are areas of controversy, including (in England) whether the law in this area does enough to respect the autonomy of (now) incapacitated patients; (3) whether ‘foregoing’ LST should encompass withholding and withdrawing treatment; this is also an ethically disputed area, particularly in the Asian countries we examine; (4) the family’s role in end-of-life decision-making, particularly as, compared with England, the three Asian countries traditionally place a greater emphasis on families and communities than on individuals; and (5) decision-making with and for those incapacitated patients who lack families, surrogate decision-makers or ADs. Conclusion Comparison of, and reflection on, the different legal positions that obtain in Japan, Korea, Taiwan, and England should prove informative and we particularly invite reflection on five areas, in the hope the ensuing discussions will help to establish better end-of-life regulatory frameworks in these countries and elsewhere.