Psychosomatics 40:369-379, October 1999
© 1999 The Academy of Psychosomatic Medine
An Annotated Bibliography for Ethics Training in Consultation-Liaison Psychiatry
Richard C. Preisman, M.D.,
Maurice D. Steinberg, M.D.,
Teresa A. Rummans, M.D.,
Stuart J. Youngner, M.D.,
Cavin P. Leeman, M.D.,
Marguerite S. Lederberg, M.D.,
Mary Ann A. Cohen, M.D.,
Owen S. Surman, M.D., and
Joel A. Blum, M.D.
Received February 1, 1999; accepted April 13, 1999. From the Franciscan Skemp Health Care, Mayo Health System, LaCrosse, Wisconsin; Long Island Jewish Medical Center, New Hyde Park, New York; Mayo Clinic, Rochester, New York; University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland, Ohio; State University of New York Downstate Medical Center, Brooklyn, New York; Memorial Sloan-Kettering Cancer Center, New York; Mount Sinai Hospital, New York; Massachusetts General Hospital, Boston, Massachusetts; and McGuire Veterans Affairs Medical Center, Richmond, Virginia. Address correspondence and reprint requests to Dr. Preisman, Department of Psychiatry, 800 West Avenue, South, Franciscan Skemp Health Care, Mayo Health System, LaCrosse, WI 54601–4728; e-mail: preisman.richard{at}mayo.edu
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ABSTRACT
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The expanding field of bioethics has created a need in psychiatry for rapid access to the complex bioethics literature. This is especially true in consultation-liaison work. An annotated bibliography was created by a task force of the Academy of Psychosomatic Medicine charged with exploring how psychiatrists function on bioethics committees. The bibliography is organized into headings that reflect how bioethical problems came to the attention of psychiatrists. Introductory references allow the reader an overview of the history of bioethics and a selection of useful textbooks. References are provided explaining how ethical principles are used. References are also organized by areas of medical work frequently visited by consultation-liaison psychiatrists.
Key Words: Bibliography • Ethics • Bioethics
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INTRODUCTION
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The role of psychiatry in bioethics activity has increased greatly during the past two decades, nowhere more than in consultation-liaison (C-L) psychiatry. Psychiatrists are now frequently members or chairs of bioethics committees, or consultants to them. Ethical issues are a frequent aspect of C-L work in the general hospital, especially around problems of informed consent or end-of-life decisions. The need for psychiatrists to have a ready guide to the vast ethics literature to help them in their ethics work is clear, and long overdue.
This bibliography has been developed over the past 5 years to meet that need, by Richard Preisman, M.D., and other members of the Academy of Psychosomatic Medicine's Task Force on the Role of the Psychiatrist on Hospital Bioethics Committees. This bibliography is meant to provide an introduction to the ethics literature, with a focus on topics of particular relevance to C-L psychiatry. The bibliography also provides a reasonably comprehensive view of bioethics generally, which should be of value to readers wishing to learn more about the field.
Because of the extensiveness of the literature, the current bibliography is necessarily selective and brief. Despite a review process involving many people, the bibliography is also inevitably subjective in its choices. Although lengthy, the bibliography is still only a starting point for psychiatrists interested in ethics. We have chosen not to address psychiatric ethics, which have been dealt with elsewhere. The current bibliography is meant to be used in C–L fellowship training, by referring to the articles marked with an asterisk, which represent basic reading appropriate for brief introductory exposure to the field. More extensive reading should enable the reader to achieve the following functions of the bibliography: 1) to develop the knowledge and understanding of how to reason ethically, and to do so from different ethical perspectives; 2) to develop an understanding of the ethical dimension of psychiatric consultations in the general hospital; 3) to develop an understanding of the emerging roles for psychiatry in bioethics, with a focus on general hospital work; and 4) to develop an understanding of the structure and functions of the hospital/health care bioethics committee and the basic skills necessary for effective participation and/or leadership of such committees.
Because the ethics literature grows so rapidly, the bibliography will require regular updating to keep it current. This step will be accomplished by posting it on the Academy of Psychosomatic Medicine's website (http://www.apm.org), where it can then be easily supplemented over time.
We would like to thank the Academy of Psychosomatic Medicine for its extensive support in developing this document.
The following is the table of contents and outline for the annotated bibliography.
BIBLIOGRAPHY FOR ETHICS TRAINING IN CONSULTATION-LIAISON PSYCHIATRY
- INTRODUCTION TO BIOETHICS
- ETHICAL PRINCIPLES AND CONSTRUCTS
- Autonomy, Competence, Informed Consent, Advance Directives
- Nonmaleficence, Futility, Physician-Assisted Suicide, Withdrawal of Life Supports
- Beneficence, Truth-Telling, Confidentiality, Physician–Patient Relationship
- Justice, Allocation of Scarce Resources, Rationing
- THE ETHICS OF CARING
- PROFESSIONAL ETHICS, VIRTUE ETHICS
- CASUISTRY
- COMMUNITARIAN ETHICS
- THE HEALTHCARE ETHICS COMMITTEE
- CLINICAL ETHICS CONSULTATION
- ETHICS IN SPECIFIC AREAS
- AIDS
- Cancer
- Emergency Medicine and Critical Care
- Forensic Issues
- Genetics
- Geriatrics
- Hemodialysis
- Managed Care
- Neurology
- Obstetrics and Gynecology
- Pain Management
- Pediatrics
- Primary Care
- Psychiatric Disorders
- Research
- Surgery
- Transplantation Medicine
Asterisk (*) notes specific reading is recommended for fellows.
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I. INTRODUCTION TO BIOETHICS
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Three textbooks are listed, chosen from a number of excellent introductory books. The text by Beauchamp et al. is very helpful in developing ethical reasoning. The text by Jonsen et al. is practical, very useful on a daily basis, and most logical from a clinical perspective. The recent text by Fletcher is arranged around ethical problems. Rothman's recent book on the history of bioethics is a reasonable account of the implicit need for bioethics in modern care. The remaining papers address the interrelationship of medicine and philosophy, and of the special relationship C-L psychiatry has to bioethics.
Beauchamp TL, Childress JF: Principles of Biomedical Ethics, 4th Edition. New York, Oxford University Press, 1994
An essential text for developing ethical reasoning.
*Cassell EJ: The nature of suffering and the goals of medicine. N Engl J Med 1982; 306:639–645
A superb paper introducing suffering as a bedrock construct for ethical thinking.
Clinical Ethics Series: Special Reports. Psychosomatics 1997; 38:307–338
Five papers that explore the interface between C-L psychiatry and bioethics by Kornfeld DS, Youngner SJ, Steinberg MD, Powell T, and Lederberg MS. Of special note is the Lederberg MS paper listed specifically in Section Eight.
*Fletcher JC, Lombardo, PA, Marshall, MS, et al (eds): Introduction to Clinical Ethics, 2nd Edition. Frederick, MD, University Publishing Group, 1997
An excellent basic text organized around a typology of ethical problems.
Hayes JR: Consultation-liaison psychiatry and clinical ethics: a model for consultation and teaching. Gen Hosp Psychiatry 1986; 8:415–418
An interesting early paper on the importance of bioethics in C-L psychiatry.
*Jonsen AR, Siegler M, Winslade WJ: Clinical Ethics: A Practical Approach to Ethical Decisions, 3rd Edition. New York, McGraw-Hill, 1992
A concise, practical text for those approaching ethical problems in clinical work without a specific background in bioethics. The book is problem-oriented and has useful bibliographies.
Reich WT (ed): Encyclopedia of Bioethics, Revised Edition. New York, Simon and Schuster, Macmillan, 1995
As a single reference, this superb work has no peer in bioethics. It is an essential reference.
Rothman DJ: Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making. New York, Basic Books, 1991
A historical account of why bioethics is essential to medicine.
Strain JJ, Rhodes R, Moros DA, et al: Ethics in medical–psychiatric practice, in Medical–Psychiatric Practice, Vol 2, edited by Stoudemire, A, Fogel BS. Washington, DC, American Psychiatric Press, 1993, pp. 585–607
A brief overview of ethics in practice.
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II. ETHICAL PRINCIPLES AND CONSTRUCTS
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The outline roughly follows notions developed in the Beauchamp and Childress text.
A. Autonomy, Competence, Informed Consent, Advance Directives
*Appelbaum PS, Grisso T: Assessing patients' capacities to consent to treatment. N Engl J Med 1988; 319:1635–1668
This classic paper describes the method probably most widely used by C-L psychiatrists to assess capacity.
*Appelbaum PS, Grisso T: Capacities of hospitalized, medically ill patients to consent to treatment. Psychosomatics 1997; 38:119–125
Does the experience of serious illness distort or incapacitate an individual from involvement in informed consent? Here is a study that attempts to address this very important and fundamental question.
*Brock DW, Wartman SA: When competent patients make irrational choices. N Engl J Med 1990; 322:1595–1599
Irrational decision making is frequently encountered in patients and often leads to psychiatric consultations. The subject is explored thoroughly in this paper. Irrationality does not imply incompetency. (See also Faden R, Faden A: False belief and the refusal of medical treatment. J Med Ethics 1977; 3:133–136 [not in the bibliography]). There are several other papers listed next on this subject that are important.
Callahan D: Autonomy: a moral good, not a moral obsession. Hastings Cent Rep 1984; 14:40–42
See also the reference by Etzioni under "Communitarian Ethics."
Drane JF: The many faces of competency. Hastings Cent Rep 1985; 15:17–21
A variable standard for assessing competency is proposed based upon the effectiveness of treatment and the dangers in the treatment. Autonomy and beneficience are balanced in this approach.
Katz M, Abbey S, Rydall A, et al: Psychiatric consultation for competency to refuse medical treatment. Psychosomatics 1995; 36:33–41
Are psychiatric consultations concerning competency different from consultations concerning other issues? This is one of the few studies addressing the issue.
Lippert GP, Stewart DE: The psychiatrist's role in determining competency to consent in the general hospital. Can J Psychiatry 1988; 33:250–253
Competency issues often lead to psychiatric consultation. Should they do so? What are the ethical issues in such a consultation? (See also the reference by Leeman under "Clinical Ethics Consultation.")
Pomerantz AS, deNesnera A: Informed consent, competency, and the illusion of rationality. Gen Hosp Psychiatry 1991; 13:138–142
This article addresses the complexity of human decision making and the difficulty in defining adequate decision making.
*Sullivan MD, Youngner SJ: Depression, competence and the right to refuse lifesaving medical treatment. Am J Psychiatry 1994; 151:971–978
Depression is frequently present in serious disease. How does it affect competency as a diagnosis? Do degrees of depression affect competency? (See also the reference by Ganzini on depression under "Psychiatric Disorders.")
B. Nonmaleficence, Futility, Physician-Assisted Suicide
*Block SD, Billings JA: Evaluating patient requests for euthanasia and assisted suicide in terminal illness: the role of the psychiatrist, in End-of-Life Decisions, edited by Steinberg MD, Youngner SJ. Washington, DC, American Psychiatric Press, 1998, pp. 205–234
An excellent discussion of clinical issues for psychiatrists in patients seeking to hasten death.
Brody H: Assisted death: a compassionate response to medical failure. N Engl J Med 1992; 327:1384–1388
Questions about "assisted suicide" are increasing and the C-L psychiatrist is being asked to evaluate patients with such requests. Issues of ethics, competence, and unattended human distress (especially pain, anxiety, and depression) are often intermingled. This paper is an excellent introduction to this complicated subject.
*Brody H, Campbell ML, Faber-Langendoen K, et al: Withdrawing intensive life-sustaining treatment: recommendations for compassionate clinical management. N Engl J Med 1997; 336:652–657
An excellent outline of the management of life-sustaining treatment with emphasis on compassion and caring.
Fins JJ, Bacchetta MD: The physician-assisted suicide and euthanasia debate: an annotated bibliography of representative articles. J Clin Ethics 1994; 5:329–340
For further reading on issues involved with shortening the life span (assisted suicide), here is a thorough scan of the literature. Pain, hospice care, and cross-cultural views are also discussed.
*Foley KM: Competent care for the dying instead of physician-assisted suicide. N Engl J Med 1997; 336:54–58
If one suspends one's own opinion about end-of-life decisions, and looks instead at the issues of care, one finds that many patients suffer from pain, psychiatric disorders, or social isolation. If these areas are addressed adequately, many requests for assisted death may disappear. Dr. Foley, along with Dr. Howard Brody, have elegantly written about this subject.
*Ganzini L, Lee MA: Psychiatry and assisted suicide in the United States. N Engl J Med 1997; 336:1824–1826
A state-of-the-art editorial on our current dilemmas about aiding patients in shortening life.
Halevy A, Brody BA, and the Houston City-Wide Task Force on Medical Futility: A multi-institution collaborative policy on medical futility. JAMA 1996; 276:571–574
An outstanding attempt to define and make ethical thought operational in a multi-hospital community.
Muskin P: The request to die: the role for a psychodynamic perspective in physician-assisted suicide. JAMA 1998; 279:323–328
A timely reminder of the importance of understanding psychodynamic issues in patients choosing to hasten death.
Schneiderman LJ. The futility debate: effective versus beneficial intervention. J Am Geriatr Soc 1994; 42:883–886
A good and brief paper describing issues of definition, debate, and the utility of the construct of futility.
Steinberg MD, Youngner SJ (eds): End-of-Life Decisions: A Psychosocial Perspective. Washington, DC, American Psychiatric Press, 1998
A comprehensive view of the emotional and psychiatric factors that affect end-of-life choices in various clinical populations, including children and AIDS patients.
*Youngner SJ: Applying futility: saying no is not enough. J Am Geriatr Soc 1994; 42:887–889
Goal setting, good communication, and education serve to minimize conflict over appropriate care. This brief statement is helpful in sorting out problems when futility is involved.
C. Beneficence, Truth-Telling, Confidentiality, Physician–Patient Relationship
*Drickamer MA, Lachs MS: Should patients with Alzheimer's disease be told their diagnosis? N Engl J Med 1992; 326:947–951
As genetic testing becomes more frequent, the problems with communicating information will increase. Truth-telling is explored in this article and sheds light on this difficult area of the doctor–patient relationship.
Emanuel EJ, Emanuel LL: Four models of the physician–patient relationship. JAMA 1992; 267:2221–2226
State-of-the-art analysis of physician–patient interaction, useful for understanding its evolution.
*Winslade WS: Confidentiality. Encyclopedia of Bioethics, Revised Edition, edited by Reich WT. New York, Simon and Schuster, London, UK, Prentice-Hall, 1995, pp. 451–459
An excellent introductory essay on this important topic across a number of situations, including genetic testing and AIDS.
D. Justice, Allocation of Scarce Resources, Rationing
The titles of some of the excellent articles listed next are self-explanatory.
Bayer R, Callahan D, Fletcher J, et al: The care of the terminally ill: morality and economics. N Engl J Med 1983; 309:1490–1494
Caplan AL: Organ transplant rationing: a window to the future. Health Progress, June 1987, pp. 40–45
Daniels NW: Why saying no to the patients in the United States is so hard: cost containment, justice, and provider autonomy. N Engl J Med 1986; 14:1380–1383
*Fleck LM: Just caring: health care organ rationing and informed democratic deliberation. J Med Philos 1994; 19:367–388
An excellent exploration of rationing from an ethics-of-caring approach.
Grumet GW: Healthcare rationing through inconvenience: the third party's secret weapon. N Engl J Med 1989; 321:607–611
Hadorn DC: The problem of discrimination in health care priority setting. JAMA 1992; 268:1454–1459
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III. THE ETHICS OF CARING
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Reasoning from ethical principles can seem arid and intellectualizing. An important literature has been developing that stresses caring. This approach complements intellectual arguments and softens and humanizes these arguments. Ethical conclusions without a caring approach seem incomplete.
*Gilligan C: In a Different Voice: Psychological Theory and Women's Development. Cambridge, MA, Harvard University Press, 1982
An historic landmark book in feminist moral theory. Caring as an equivalent to justice in women's development is a revolutionary way of viewing ethical issues.
McCarrick PM, Darragh M: Feminist perspectives on bioethics. Kennedy Institute of Ethics Journal 1996; 6:85–103
A concise and recent bibliography on this important approach to bioethics. As contrasted with the principled approach to ethical analysis, the ethics of caring produces a humane and often less intellectualized approach to the anguishing decisions in the acute hospital situation.
*Ross JW, Glaser JW, Rasinski-Gregory D, et al (eds.): Health Care Ethics Committees: The Next Generation. Chicago, IL, American Hospital Publishing, 1993, pp. 23–24
A brief description of the ethics of caring that will, we hope, lead the reader to explore this topic further.
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IV. PROFESSIONAL ETHICS, VIRTUE ETHICS
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The ethics of medicine is historically interwoven with the development of the profession. For ethical behavior to be central to medicine, this dimension must be grasped.
Mooreim EH: Am I my brother's warden: responding to the unethical or incompetent colleague. Hastings Cent Rep 1993; 23:19–27
Discusses why physicians should personally help to pursue incompetent and unethical colleagues, provides useful guidance as to how to do so, and includes references to the entire field of physicians' obligations to respond to unethical, incompetent, and impaired colleagues.
Pellegrino ED: In search of integrity. JAMA 1991; 266:2454–2455
Virtue, ethics, and character are briefly and thoroughly discussed in this fine article.
Pellegrino ED: Character, virtue and self-interest in the ethics of the profession. J Contemp Health Law Policy 1989; 5:53–73
What is character? How does self-interest affect ethical behavior? From medicine's inception this dialogue has shaped patient care, availability of care, and, to a significant degree, the quality of care. Grasping this tension is most important.
*Reed RR, Evans D: The deprofessionalization of medicine: causes, effects and responses. JAMA 1987; 258:3279–3282
What constitutes professionalism? Ethics is a prominent part of medicine as a profession and would be severely undermined by damage to certain aspects of the profession. This article introduces this subject.
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V. CASUISTRY
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Jonsen AR: Casuistry and clinical ethics. Theoretical Medicine 1986; 7:65–74
Case ethics is intrinsically casuistic. So are aspects of the law and, more important, so is clinical medicine to a remarkable degree. We are grateful for Jonsen and Toulmin's book The Abuse of Casuistry in 1988. Although this book was not included in the bibliography, the book is of great significance to modern bioethics. For those who wish to gain "experienced wisdom" as contrasted to factual knowledge, casuistry will be appealing.
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VI. COMMUNITARIAN ETHICS
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Etzioni A: The Spirit of the Community: Rights, Responsibilities and the Communitarian Agenda. New York, Crown Publishers, 1993
A contrasting approach to the current ranking of autonomy as a supreme ethical value. Etzioni is a founder of this approach, and this recent book by him is noteworthy.
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VII.THE HEALTHCARE ETHICS COMMITTEE
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All physicians should be familiar with the workings of this Joint Commission on Accreditation of Healthcare Organizations–mandated hospital committee. Specifically, clinical liaison fellows should be especially conversant with its workings and with the special roles psychiatry may play in the functioning of the committee.
*Engel CC Jr: Psychiatrists and the general hospital ethics committee. Gen Hosp Psychiatry 1992; 14:29–35
The C-L psychiatrist has unique qualifications that are essential to an ethics committee. This article describes the psychiatric role as it is evolving.
Ethics Committees: Core Resources. Available through the Hastings Center, 255 Elm Road, Briarcliff Manor, NY 10510.
Excellent assistance in beginning to work on an ethics committee.
Fletcher JC, Siegler M: What are the goals of ethics consultation? A consensus statement. J Clin Ethics 1996; 7:122–126
This article explores the various structures involved in ethics consultation and goals: providing beneficent and nonmaleficent care, just decision making, and conflict resolution and informed health policies.
*Ross JW, Glazer JW, Rasinski-Gregory D, et al (eds): Health Care Ethics Committees: The Next Generation. Chicago, IL, American Hospital Publishing, 1993
An excellent survey of historical, clinical, organizational, legal, and ethical issues involved in creating and maintaining an effective health care ethics committee.
Scott GG: Resolving Conflict With Others and Within Yourself. Oakland, CA, New Harbinger Publications, 1990
An introduction to the emerging field of conflict resolution.
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VIII. CLINICAL ETHICS CONSULTATION
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*Lederberg MS: Making a situational diagnosis: psychiatrists at the interface of psychiatry and ethics in consultation-liaison psychiatry. Psychosomatics 1997; 38:327–338
This article by Lederberg is an especially valuable and practical view of how a psychiatrist functions when ethical problems occur.
*Leeman CP: Ethics consultations masking psychiatric issues in medicine. Arch Intern Med 1995; 155:1715–1717
An excellent introduction to the blurred boundary between these areas.
Powell T: Religion, race and reason: the case of LJ. J Clin Ethics 1995; 6:73–77
This interesting article discusses how sociocultural issues are a frequent part of ethical consultations and conflict resolution. Ethics committees must consider sociocultural variables in their reasoning process.
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IX. ETHICS IN SPECIFIC AREAS
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This is a group of papers that might have been classified under other headings but seem more fitting under specific areas of care. If bioethics were a more established and more widely taught discipline, most papers could be classified under specific areas of care.
A. AIDS
American Psychiatric Association Committee Report: AIDS policy: confidentiality and disclosure. Am J Psychiatry 1988; 145:541–542
In no other area of care is confidentiality so important. This subject is well reviewed here.
*Bayer R: AIDS and the ethics of prevention, research and care, in AIDS and Other Manifestations of HIV infection, edited by Wormser GP. Philadelphia, PA, Lippincott Raven, 1998, pp. 799–807
A sensitive and thorough overview of ethical issues for persons with AIDS.
Dilley JW, Shelp EE, Batki SL: Psychiatric and ethical issues in the care of patients with AIDS. Psychosomatics 1986; 27:562–566
A good overview.
Thomasma DC, McElhinney TK: Ethical concerns about AIDS. Pharos 1990; 53:7–11
Although earlier concerns about the ethical issues in care of the AIDS patient have quieted, it remains an important topic to focus upon in C-L work. This article reviews these issues briefly but concisely.
B. Cancer
Annas GJ: Informed consent, cancer and truth in prognosis. N Engl J Med 1994; 330:223–225
Simple "truth-telling" has been with us for a long time, but truth in prognostication is still very elusive.
Berry SR, Singer PA: The cancer-specific advance directive. Cancer 1998; 82:1570–1577
Do specific medical problems imply specific areas of concern for advance directives? This article begins to address this question.
Emanuel E: Ethics of treatment: palliative and terminal care, in Psycho-oncology, edited by Holland JC. New York, Oxford University Press, 1998, pp. 1096–1111
A good and concise overview with usable bibliography.
Emanuel EJ, Kass F: Ethical and legal aspects of caring for patients with cancer, in Cancer Medicine, 3rd Edition, edited by Holland JF, Bast RC, Kufe DW, et al. Philadelphia, PA, Lea & Febiger, 1993, pp. 2466–2480
An intelligent review.
*Faber-Langendoen K: Resuscitation of patients with metastatic cancer: is transient benefit still futile? Arch Intern Med 1991; 151:235–239
A fine account of futility as a construct in decision making as cancer progresses. (See also Section IIB.)
Leikin S: The role of adolescents concerning their cancer therapy. Cancer 1993; 71(10suppl):3342–3346
Adolescents, in transition from childhood to adulthood, present particular ethical concerns.
C. Emergency Medicine and Critical Care
McCarthy CR: To be or not to be: waiving informed consent in emergency research. Kennedy Institute of Ethics 1995; 5:155–162
Emergency services and C-L psychiatry are frequently joined. Emergency care as a setting for research poses many ethical dilemmas. This article is an excellent summary of these issues.
D. Forensic Issues and Psychiatric Evaluation
*Appelbaum PS: Ethics in evolution: the incompatibility of clinical and forensic functions. Am J Psychiatry 1997; 154:445–446
How should psychiatrists handle requests for evaluations of people who are not patients? This is an excellent paper on an important and complex subject.
*Strausburger LH, Gutheil TG, Brodsky A: On wearing two hats: role conflict in serving as both psychotherapist and expert witness. Am J Psychiatry 1997; 154:448–455
There are frequent requests to evaluate individuals with a forensic problem. This article explores the ethical conflicts inherent in this request for evaluation.
E. Genetics
Elias A, Annas GJ: Generic consent for genetic screening. N Engl J Med 1994; 330:1611–1613
Consent issues take new meaning as genetic screening becomes more prominent. This paper introduces the complexity of consent and confidentiality in this growing area of medicine.
*Juengst ET: Priorities in professional ethics and social policy for human genetics. JAMA 1991; 266:1835–1836
The new technology involving genetics and disease poses new and complicated ethical problems. Here is a brief introduction to the topic.
Lantos J, Siegler M, Cuttler L: Ethical issues in growth hormone therapy. JAMA 1989; 261:1020–1024
Should medical intervention be used for designer or cosmetic reasons? Genetic interventions pose questions such as this in new and challenging ways.
F. Geriatrics
Callahan D, Topinkova E, ter Mevlen R (eds): Symposium. Caring for an aging world: allocation of scarce resources. Hastings Cent Rep 1994; 24:3–41
A very good overview of aging and scarcity.
Cassel CK, Jameton AL: Dementia in the elderly: an analysis of medical responsibility. Ann Intern Med 1981; 94:802–807
Care of the elderly poses many questions for physicians, including ethical issues.
Field MF, Cassel CK (eds): Approaching Death: Improving Care at the End of Life. Washington, DC, National Academic Press, 1997
Post SG: Alzheimer's disease. Clin Geriatr Med 1994; 10:379–392
A tightly argued account of ethical reasoning concerning dementia.
Stanley B, Guido J, Stanley M, et al: The elderly patient and informed consent. Empirical findings. JAMA 1984; 252:1302–1306
Consent issues in care of the elderly are especially important. This article is a good overview.
Uhlmann RF, Clark H, Pearlman RA, et al: Medical management decisions in nursing home patients: Ann Intern Med 1987; 106:879–885
Patients in nursing homes present ethical challenges. Although not intrinsically different from other areas of geriatric care, ethical thinking may often be minimal when working in this area.
G. Hemodialysis
Cohen LM, McCue JD, Germain M, et al: Denying the dying: advance directives and dialysis discontinuation. Psychosomatics 1997; 38:27–34
The topic of advance directives is often addressed as a separate entity from the practice of daily medicine. Here is a look at how patients and their physicians facing the issue of dying actually handle it in a dialysis setting.
Segjal A, Galbraith A, Chesney M, et al: How strictly do dialysis patients want their advance directives followed? JAMA 1992; 267:59–63
Do advance directives bind caregivers to specific kinds of care precisely? How do patients feel about the explicit nature of their advance directives? This article explores this issue in dialysis but also raises questions in other areas of care.
H. Managed Care
Brody H, Clancy C: Managed care: Jekyll or Hyde? JAMA 1995; 273:338–339
A brief look at ethical involvement with managed care.
Council on Ethical and Judicial Affairs, American Medical Association: Ethical issues in managed care. JAMA 1995; 273:330–335
A good general review of ethical dilemmas in managed care settings.
*Darragh M, McCarrick PM: Managed health care: new ethical issues for all. Kennedy Institute of Ethics Journal 1996; 6:189–207
A current annotated bibliography done recently, providing a concise review of ethical issues involving managed care.
Emanuel EJ, Dubler NN: Preserving physician–patient relationship in the era of managed care. JAMA 1996; 273:323–329
An important paper focusing on the physician–patient relationship in an ever changing care system.
Hall RCW: Legal precedents affecting managed care. The physician's responsibilities to patients. Psychosomatics 1994; 35:105–117
Ethical problems in managed care often involve litigation. This article introducesthis subject.
Mechanic D, Schlesinger M: The impact of managed care on patient's trust in medical care and their physicians. JAMA 1996; 275:1693–1697
Interpersonal trust between patient and physician may be eroded by managed care, especially involving concern about competence of care, gatekeeping, and capitation. This paper reviews these topics.
Pellegrino ED: Ethics. JAMA 1994; 271:1668–1670
A brief but excellent introduction to ethics and managed care.
I. Neurology
Brody BA: Ethical questions raised by the persistent vegetative patient. Hastings Cent Rep 1988; 18:33–37
Persistent vegetative state, more than any specific neurological syndrome, has helped to form ethical and legal thinking about care of the incompetent individual and legalities. This is a good introduction.
Burack JH, Back AL, Pearlman RA: Provoking non-epileptic seizures: the ethics of deceptive diagnosis testing. Hastings Cent Rep 1997; 27:24–33
Deception in the evaluation of epilepsy is an established procedure. Is this deviation from truth-telling justified?
J. Obstetrics and Gynecology
American Medical Association Board of Trustees Report: Legal interventions during pregnancy. Court-ordered medical treatments and legal penalties for potentially harmful behavior by pregnant women. JAMA 1990; 264:2663–2670
Do women have responsibilities during pregnancy and can their rights be suspended to protect the fetus? This paper highlights this conflict that not infrequently leads to psychiatric consultations.
*Annas GJ: Pregnant women as fetal containers. Hastings Cent Rep 1986; 16:13–14
See annotation under the last reference.
Annas GJ: Protecting the liberty of pregnant patients. N Engl J Med 1987; 316:1213–1214
See the aforementioned annotations.
Coverdale JH, Chervenak FA, McCullough LB, et al: Ethically justified clinically comprehensive guidelines for the management of the depressed pregnant patient. Am J Obstet Gynecol 1996; 174:169–173
Depression during pregnancy poses serious clinical and ethical problems. This is an excellent discussion of a frequent dilemma.
*Gabinet L: A protocol for assessing competence to parent a newborn. Gen Hosp Psychiatry 1986; 8:263–272
Psychiatric consultation occurs with some frequency because of concerns about the parenting ability following delivery. What constitutes "competence" in this arena? How is "competence to parent" similar or different from "competence to give informed consent"?
McNaughton M: Ethics and reproduction. Am J Obstet Gynecol 1990; 162:879–882
A brief overview useful for consulting in this area of care.
K. Pain Management
Emanuel EJ: Pain and symptom control: patient rights and physicians responsibilities. Hematol Oncol Clin North Am 1996; 10:20–55
A good overview on the boundary of ethics and pain control.
Melzack R: The tragedy of needless pain. Sci Am 1990; 262:27–33
A good and brief review of problems with pain control. (Also see Foley under Physician-Assisted Suicide. Dr. Foley's exceptional work on pain management has long been standard reading for C-L psychiatrists.)
Walco GA, Cassidy RD, Schechter NL: Pain, hurt and harm: the ethics of pain control in infants and children. N Engl J Med 1994; 331:541–544
Children have mostly been left out of the ethics of pain control. Here is a good summary of thought on this subject.
L. Pediatrics
American Academy of Pediatrics Committee on Bioethics: Guidelines on forgoing life-sustaining medical treatment. Pediatrics 1994; 93:532–536
Comprehensive proposal for balancing patient and family rights and professional standards.
*Cassidy RC, Fleischman A (eds): Pediatric Ethics: From Principles to Practice. Amsterdam, The Netherlands, Harwood Academic Publishers, 1996
The best guide for clinicians needing to deal with ethically loaded decisions in pediatric care: chapters on forgoing treatment, confidentiality, truth-telling, palliative care, etc.
Leikiu S: Minors' assent or dissent to medical treatment. J Pediatr 1983; 102:169–176
Applies developmentally sensitive guidelines to evaluation of minors' capacity and ethical rights.
M. Primary Care
Brody H, Tomlinson T: Ethics in primary care: setting aside common misunderstandings. Primary Care 1986; 13:225–240
A good overview on this subject.
N. Psychiatric Disorders
Applebaum PS: Voluntary hospitalization and due process: the dilemma of Zinermon v Burch. Hospital and Community Psychiatry 1990; 41:1059–1060
Discusses the conflict between encouraging voluntary hospitalization and preserving due process.
Bloch S, Chodoff P: Psychiatric Ethics, 2nd Edition. New York, Oxford University Press, 1991
A comprehensive textbook of ethical issues in psychiatry. Especially recommended chapters are Reich W: Psychiatric diagnosis as an ethical problem, pp. 101–131, and Miller R: The ethics of involuntary commitment to mental health treatment, pp. 265–287
Ganzini L, Lee MA, Heintz RT, et al: Do-not-resuscitate orders for depressed psychiatric inpatients. Hospital and Community Psychiatry 1992; 43:915–919
Discuss the dilemmas about resuscitation preferences of psychiatric inpatients whose decision-making capacity may be impaired by mental illness such as depression.
Ganzini L, Lee MA, Heintz RT, et al: Is the patient's self-determination act appropriate for elderly persons hospitalized for depression? J Clin Ethics 1993; 4:46–50
When and how does depression lead to difficulties with autonomous function? (See also the reference by Sullivan and Youngner under Section IIA.)
Ganzini L, Lee MA, Heintz RT: The capacity to make decisions in advance, and borderline personality disorder. J Clin Ethics 1994; 5:360–363
Many things distort forming a clear picture of reality. From a psychiatric standpoint, when do behaviors, mood, personality, style, defense mechanisms, etc. so distort one's picture of the world that informed consent is not possible? Does medical illness distort one's view? A literature is forming addressing this problem.
Meropol Neal J, Ford CV, Zaner RM: Factitious illness: an exploration in ethics. Perspect Biol Med 1985; 28:269–281
Truth-telling is a cornerstone of ethics. Most discussions focus on truth-telling by medical caregivers. Does the patient have responsibility for truth-telling? If so, what are the obligations of medical personnel? Is factitious illness to be treated as an illness? What is actually known about the behavior involved?
Wenger NS, Halpern J: The physician's role in completing advance directives: Ensuring patient's capacity to make healthcare decisions in advance. J Clin Ethics 1994; 5:320–323
Depression colors all decision making. How does depression interact with advance directives, and how should physicians and patient surrogates make decisions when depression is an issue?
O. Research
*Beecher HK: Ethics and clinical research. N Engl J Med 1966; 274:1354–1360
An extremely important paper historically and as a monument to the need for informed consent in research.
Carpenter WT, Schooler NR, Kane JM: The rationale and ethics of medication-free research in schizophrenia. Arch Gen Psychiatry 1997; 54:401–407
Increasingly, research into behavior is being ethically scrutinized. Consent, riskvs. benefit, and competency are a few of the troublesome areas.
Research ethics and the medical profession: Report of the Advisory Committee on Human Radiation Experiments. JAMA 1996; 276:403–409
A thoughtful, even-handed review of experiments that have not stood the test of time and a good analysis of issues and suggested interventions.
Rothman DJ: Ethics and human experimentation. Henry Beecher revisited. N Engl J Med 1987; 317:1195–1199
A fine follow-up to Beecher's important work in 1966, further validating the need for close monitoring of research.
P. Surgery
Youngner SJ, Cascorbi HF, Shuck JM: DNR in the operating room: not really a paradox. JAMA 1991; 266:2433–2434
How should a patient with a "DNR" status be treated when a variety of surgical procedures are indicated? Is surgical care under a DNR status a contradictory and possibly unacceptable position for surgery to proceed?
Q. Transplantation Medicine
*Loewy EH: Drinks, livers and values: should social value judgments enter into liver transplant decisions? J Clin Gastroenterol 1987; 9:436–441
With organs in scarce supply, how should organ transplantation be allocated? Should chronic alcoholism be a contraindication? How does one decide this? This article explores the issue that frequently involves C-L psychiatry in liver transplantation surgery.
Moss AH, Siegler M: Should alcoholics compete equally for liver transplantations? JAMA 1991; 265:295–1298
See aforementioned annotation.
*Surman OS, Purtilo R: Reevaluation of organ transplantation criteria: allocation of scarce resources to borderline candidates. Psychosomatics 1992; 33:202–212
A clear and thorough exploration of the ethics of exclusion and inclusion into transplantation programs.
Thomasma DC: Ethical issues and transplantation technology. Camb Q Healthc Ethics 1992; 4:333–343
A good overview of this issue.
*Youngner SJ, Allen RM, Bartlett ET, et al: Psychosocial and ethical implications of organ retrieval. N Engl J Med 1985; 313:321–324
Organ retrieval has important ethical aspects that may involve psychiatric assessment.
Youngner SJ, Arnold RM: Ethical, psychosocial and public policy implications of procuring organs from non-heart-beating cadaver donors. JAMA 1993; 269:2769–2774
More explicit problems involved with organ retrieval explored earlier by Youngner et al.
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CONCLUSION
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With the explosion of literature in bioethics new topics of interest will evolve, requiring changes and updates to the current bibliography. The ad hoc nature of the original task force will likely convert to a more permanent status in order to address these ongoing changes.
This article has been cited by other articles:
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ABSTRACT
INTRODUCTION