The prisoner’s dilemma: The role of medical professionals in executions

Elisabeth Armstrong

Journal of Medical Ethics

Originally posted 7 Sept 21

Here is an excerpt:

Clinician Participation in Executions is Either Wrong or Misguided

Clinicians might participate in executions out of an inappropriate commitment to capital punishment; this position of leveraging medical education and credentials to punish or harm has no grounding in ethical conversation. It is entirely inappropriate to undermine trust in the medical profession in service of one’s political or philosophical beliefs – those ought to be relegated to the voting booths.

However, some practitioners might be present at an execution out of a well-intentioned, but misguided commitment to preventing suffering. Their reasoning is along the lines, “If states are proceeding with an execution, shouldn’t a clinician be present to ensure there is no undue harm or suffering?” Writing on lethal injections, Dr. Sandeep Jahaur writes in the New York Times, “Barring physicians from executions will only increase the risk that prisoners will unduly suffer,” in violation of the Hippocratic Oath and the 8th Amendment of the US Constitution. He points out that no ethics board would allow the testing of execution drugs on human participants, therefore, in the absence of a “controlled investigation” it is important that a doctor is present to assist when things go awry.

Dr. Jahaur adds that if doctors (or other clinicians) do not assist, people with less experience are often called upon to insert catheters, assess and insert the IVs, mix and administer the drugs, monitor a patient’s vital signs, then confirm death; and of course, step in if anything goes wrong. Dr. Atul Gawande agrees that it is unlikely that a lethal injection could be performed without a physician without the occasional tragic mistake. As recently as October of 2014, the lack of involvement from clinicians resulted in the administration of an incorrect drug to an inmate – resulting in forty-three minutes of writhing and groaning before he died.

The Case for Ending Practitioner Participation

There is no denying that these cases of suffering are disturbing and compelling. Ultimately, however, the bioethical case for participation is grossly outweighed by the case against it: medical involvement on any level intrinsically violates the ethical principles of autonomy, beneficence, non-maleficence, and justice – compromising the foundations of the medical system. (Underline added.)

The info is here.

A taxonomy of conscientious objection in healthcare

Gamble, N., & Saad, T. (2021). 

Clinical Ethics. 

https://doi.org/10.1177/1477750921994283

Abstract

Conscientious Objection (CO) has become a highly contested topic in the bioethics literature and public policy. However, when CO is discussed, it is almost universally referred to as a single entity. Reality reveals a more nuanced picture. Healthcare professionals may object to a given action on numerous grounds. They may oppose an action because of its ends, its means, or because of factors that lay outside of both ends and means. Our paper develops a taxonomy of CO, which makes it possible to describe the refusals of healthcare professional with greater finesse. The application of this development will potentially allow for greater subtlety in public policy and academic discussions – some species of CO could be permitted while others could be prohibited.

Conclusion

The ethical analysis and framework we have presented demonstrate that conscience is intertwined with practical wisdom and is an intrinsic part of the work of healthcare professionals. The species of CO we have enumerated reveal that morality and values in healthcare are not only related to a few controversial ends, but to all ends and means in medicine, and the relationships between them.

The taxonomy we have presented will feasibly permit a more nuanced discussion of CO, where the issues surrounding and policy solutions for each species of CO can be discussed separately. Such a conversation

is an important task. After all, CO will not go away, even if specific belief systems rise or fall. CO exists

because humans have an innate awareness of the need to seek good and avoid evil, yet still arrive at disparate intellectual conclusions about what is right and wrong. Thus, if tolerant and amicable solutions

are to be developed for CO, conversations on CO in healthcare need to continue with a more integrated

understanding of practical reason and an awareness of broad involvement of conscience in medicine. We

hope our paper contributes to this end.

The info is here.

The Case of Dr. Oz: Ethics, Evidence, and Does Professional Self-Regulation Work?

Jon Tilburt, Megan Allyse, and Frederic Hafferty
AMA Journal of Ethics
February 2017, Volume 19, Number 2: 199-206.

Abstract

Dr. Mehmet Oz is widely known not just as a successful media personality donning the title “America’s Doctor®,” but, we suggest, also as a physician visibly out of step with his profession. A recent, unsuccessful attempt to censure Dr. Oz raises the issue of whether the medical profession can effectively self-regulate at all. It also raises concern that the medical profession’s self-regulation might be selectively activated, perhaps only when the subject of professional censure has achieved a level of public visibility. We argue here that the medical profession must look at itself with a healthy dose of self-doubt about whether it has sufficient knowledge of or handle on the less visible Dr. “Ozes” quietly operating under the profession’s presumptive endorsement.

The information is here.

Institutional Betrayal: Inequity, Discrimination, Bullying, and Retaliation in Academia

Karen Pyke
Sociological Perspectives
Volume: 61 issue: 1, page(s): 5-13
Article first published online: January 9, 2018

Abstract

Institutions of higher learning dedicated to the pursuit of knowledge and committed to diversity should be exemplars of workplace equity. Sadly, they are not. Their failure to take appropriate action to protect employees from inequity, discrimination, bullying, and retaliation amounts to institutional betrayal. The professional code of ethics for sociology, a discipline committed to the study of inequality, instructs sociologists to “strive to eliminate bias in their professional activities” and not to “tolerate any forms of discrimination.” As such, sociologists should be the leaders on our campuses in recognizing institutional betrayals by academic administrators and in promoting workplace equity. Regrettably, we have not accepted this charge. In this address, I call for sociologists to embrace our professional responsibilities and apply our scholarly knowledge and commitments to the reduction of inequality in our own workplace. If we can’t do it here, can we do it anywhere?

The article is here.

Why Expertise Matters

Adam Frank
npr.org
Originally posted on April 7, 2017

Here is an excerpt:

The attack on expertise was given its most visceral form by British politician Michael Gove during the Brexit campaign last year when he famously claimed, "people in this country have had enough of experts." The same kinds of issues, however, are also at stake here in the U.S. in our discussions about "alternative facts," "fake news" and "denial" of various kinds. That issue can be put as a simple question: When does one opinion count more than another?

By definition, an expert is someone whose learning and experience lets them understand a subject deeper than you or I do (assuming we're not an expert in that subject, too). The weird thing about having to write this essay at all is this: Who would have a problem with that? Doesn't everyone want their brain surgery done by an expert surgeon rather than the guy who fixes their brakes? On the other hand, doesn't everyone want their brakes fixed by an expert auto mechanic rather than a brain surgeon who has never fixed a flat?

Every day, all of us entrust our lives to experts from airline pilots to pharmacists. Yet, somehow, we've come to a point where people can put their ignorance on a subject of national importance on display for all to see — and then call it a virtue.

Here at 13.7, we've seen this phenomenon many times. When we had a section for comments, it would quickly fill up with statements like "the climate is always changing" or "CO2 is a trace gas so it doesn't matter" when we a posted pieces on the science of climate change.

The article is here.

The Case of Dr. Oz: Ethics, Evidence, and Does Professional Self-Regulation Work?

Jon C. Tilburt, Megan Allyse, and Frederic W. Hafferty
AMA Journal of Ethics. February 2017, Volume 19, Number 2: 199-206.

Abstract

Dr. Mehmet Oz is widely known not just as a successful media personality donning the title “America’s Doctor®,” but, we suggest, also as a physician visibly out of step with his profession. A recent, unsuccessful attempt to censure Dr. Oz raises the issue of whether the medical profession can effectively self-regulate at all. It also raises concern that the medical profession’s self-regulation might be selectively activated, perhaps only when the subject of professional censure has achieved a level of public visibility. We argue here that the medical profession must look at itself with a healthy dose of self-doubt about whether it has sufficient knowledge of or handle on the less visible Dr. “Ozes” quietly operating under the profession’s presumptive endorsement.

The article is here.

Is It Time to Call Trump Mentally Ill?

Richard A. Friedman
The New York Times
Originally published February 17, 2017

Here are two excerpts:

A recent letter to the editor in this newspaper, signed by 35 psychiatrists, psychologists and social workers, put it this way: "We fear that too much is at stake to be silent." It continued, "We believe that the grave emotional instability indicated by Mr. Trump's speech and actions makes him incapable of serving safely as president."

But the attempt to diagnose a condition in President Trump and declare him mentally unfit to serve is misguided for several reasons.

First, all experts have political beliefs that probably distort their psychiatric judgment. Consider what my mostly liberal profession said of Senator Barry Goldwater, the Republican nominee for president in 1964, right before the election. Members of the American Psychiatric Association were surveyed about their assessment of Goldwater by the now-defunct Fact magazine. Many savaged him, calling him "paranoid," "grossly psychotic" and a "megalomaniac." Some provided diagnoses, like schizophrenia and narcissistic personality disorder.

They used their professional knowledge as a political weapon against a man they had never examined and who certainly would never have consented to their discussing his mental health in public.

Goldwater sued (successfully) and, as a result, in 1973 the A.P.A. developed the Goldwater Rule. It says that psychiatrists can discuss mental health issues with the news media, but that it is unethical for them to diagnose mental illnesses in people they have not examined and whose consent they have not received.

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There is one last reason we should avoid psychiatrically labeling our leaders: It lets them off the moral hook. Not all misbehavior reflects psychopathology; the fact is that ordinary human meanness and incompetence are far more common than mental illness. We should not be in the business of medicalizing bad actors.

The article is here.

Reframing Research Ethics: Towards a Professional Ethics for the Social Sciences

Nathan Emmerich
Sociological Research Online, 21 (4), 7
DOI: 10.5153/sro.4127

Abstract

This article is premised on the idea that were we able to articulate a positive vision of the social scientist's professional ethics, this would enable us to reframe social science research ethics as something internal to the profession. As such, rather than suffering under the imperialism of a research ethics constructed for the purposes of governing biomedical research, social scientists might argue for ethical self-regulation with greater force. I seek to provide the requisite basis for such an 'ethics' by, first, suggesting that the conditions which gave rise to biomedical research ethics are not replicated within the social sciences. Second, I argue that social science research can be considered as the moral equivalent of the 'true professions.' Not only does it have an ultimate end, but it is one that is – or, at least, should be – shared by the state and society as a whole. I then present a reading of confidentiality as a methodological – and not simply ethical – aspect of research, one that offers further support for the view that social scientists should attend to their professional ethics and the internal standards of their disciplines, rather than the contemporary discourse of research ethics that is rooted in the bioethical literature. Finally, and by way of a conclusion, I consider the consequences of the idea that social scientists should adopt a professional ethics and propose that the Clinical Ethics Committee might provide an alternative model for the governance of social science research.

The article is here.

A Unified Code of Ethics for Health Professionals: Insights From an IOM Workshop.

Matthew K. Wynia, Sandeep P. Kishore, & Cynthia D. Belar
JAMA, 2014;311(8):799-800.

Here is an excerpt:

Professional obligations under these social contracts are often expressed in codes of ethics; although, unlike laws and regulations, the level of public engagement in developing professional codes has traditionally been limited. Still, when professional codes have failed to meet societal expectations, they have been publicly criticized and eventually changed, such as when the American Medical Association's code initially failed to fully obligate physicians to care for patients with human immunodeficiency virus infection.

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First, a new social contract should be articulated in a code of ethics that does not focus on the roles and obligations of just 1 subset of health professionals. The traditional approach to professionalism in health care has separated health professionals according to education and credentialing, with each group seeking to establish its own social contract. In negotiating their social roles, this separation has allowed groups at times to ignore, show little regard for, or even be overtly hostile toward the roles of other groups (for example, in debates over scope of practice and payment issues). This approach is counterproductive in today's health care environment, which demands teamwork.

(cut)

Second, transdisciplinary professionalism demands more than a 1-time listing of shared values by a multidisciplinary group. A meaningful transdisciplinary professionalism will entail the creation of new institutional frameworks, which are required for 'defining, debating, declaring, distributing and enforcing" the expectations and standards that health care professionals and the public agree should govern work in the health care arena'.

The article is here.

Corruption? Here? Bill would require ethics training for N.J. elected officials

By S. P. Sullivan
NJ.com
Originally posted May 9, 2016

In an effort to stem public corruption scandals, the state Senate on Monday unanimously passed a bill that would require all New Jersey elected officials undergo ethics training as soon as they're elected.

The bill (S84) mandates elected officials take the training within six months of their first term. Officials who skip out on the ethics education would face a $5,000 fine.

Sponsors of the legislation point to investigations by the state Comptroller's Office, which over the years has detailed many examples of public corruption, as evidence that the training is needed.

The article is here.

A Code of Ethics for Health Care Ethics Consultants

Anita J. Tarzian & Lucia D. Wocial
American Journal of Bioethics 15 (5):38-51 (2015)

Abstract

For decades a debate has played out in the literature about who bioethicists are, what they do, whether they can be considered professionals qua bioethicists, and, if so, what professional responsibilities they are called to uphold. Health care ethics consultants are bioethicists who work in health care settings. They have been seeking guidance documents that speak to their special relationships/duties toward those they serve. By approving a Code of Ethics and Professional Responsibilities for Health Care Ethics Consultants, the American Society for Bioethics and Humanities (ASBH) has moved the professionalization debate forward in a significant way. This first code of ethics focuses on individuals who provide health care ethics consultation (HCEC) in clinical settings. The evolution of the code's development, implications for the field of HCEC and bioethics, and considerations for future directions are presented here.

The entire paper is here.

Nudging and Informed Consent

Shlomo Cohen
The American Journal of Bioethics
Volume 13, Issue 6, 2013

Abstract

Libertarian paternalism's notion of “nudging” refers to steering individual decision making so as to make choosers better off without breaching their free choice. If successful, this may offer an ideal synthesis between the duty to respect patient autonomy and that of beneficence, which at times favors paternalistic influence. A growing body of literature attempts to assess the merits of nudging in health care. However, this literature deals almost exclusively with health policy, while the question of the potential benefit of nudging for the practice of informed consent has escaped systematic analysis. This article focuses on this question. While it concedes that nudging could amount to improper exploitation of cognitive weaknesses, it defends the practice of nudging in a wide range of other conditions. The conclusion is that, when ethically legitimate, nudging offers an important new paradigm for informed consent, with a special potential to overcome the classical dilemma between paternalistic beneficence and respect for autonomy.

The entire article is here.

Why there would have been no torture without the psychologists

By Steven Reisner
Slate
Originally published December 12, 2014

Here is an excerpt:

The psychologists were vital to the torture program for one additional reason: The Justice Department’s Office of Legal Counsel had determined that the presence of psychologists and physicians, monitoring the state and condition of the prisoner being tortured, afforded protection for the CIA leadership and the Bush administration from liability and potential prosecution for the torture. Later, the OLC applied the same rules to the Defense Department’s “enhanced interrogation program,” which, according to an investigation by the Senate Armed Services Committee, was created and overseen by a team led by a clinical psychologist, and eventually overseen exclusively by clinical psychologists.

The entire article is here.

Who Should Decide What's in a Child's Best Interest?

By Robert MacDougall
Impact Ethics
Originally posted December 8, 2014

Here is an excerpt:

One might argue that state intervention would not constitute an imposition of Western values on First Nations families and children. Instead, one might claim that state intervention merely prevents First Nations Canadians from imposing their values on their children, who are not yet old enough to decide for themselves whether to follow the Western medical paradigm or the traditional aboriginal one. But this assumes that the default position of the state should be to treat children in accordance with the Western paradigm until the child is old enough to decide for him or herself. Rather than assume the Western paradigm when making treatment decisions for First Nations children, it makes more sense to treat them according to the values of their own parents.

The entire article is here.

The Tarasoff Rule: The Implications of Interstate Variation and Gaps in Professional Training

By Rebecca Johnson, Govind Persad, and Dominic Sisti
J Am Acad Psychiatry Law 42:4:469-477 (December 2014)

Abstract

Recent events have revived questions about the circumstances that ought to trigger therapists' duty to warn or protect. There is extensive interstate variation in duty to warn or protect statutes enacted and rulings made in the wake of the California Tarasoff ruling. These duties may be codified in legislative statutes, established in common law through court rulings, or remain unspecified. Furthermore, the duty to warn or protect is not only variable between states but also has been dynamic across time. In this article, we review the implications of this variability and dynamism, focusing on three sets of questions: first, what legal and ethics-related challenges do therapists in each of the three broad categories of states (states that mandate therapists to warn or protect, states that permit therapists to breach confidentiality for warnings but have no mandate, and states that give no guidance) face in handling threats of violence? Second, what training do therapists and other professionals involved in handling violent threats receive, and is this training adequate for the task that these professionals are charged with? Third, how have recent court cases changed the scope of the duty? We conclude by pointing to gaps in the empirical and conceptual scholarship surrounding the duty to warn or protect.

The entire article can be found here.

Episode 18: Critical Incidents and Psychologist Safety

If you have missed AM radio, then you will appreciate this episode.  John experiments with conference call software with his guests to discuss ethics and safety from a psychologist's point of view.  I apologize about the squeaks (Shannon's phone), scratches and other recording imperfections.

John's guests include Dr. Don McAleer, psychologist, gun owner, firearms instructor, firearm collector; Massad Ayoob, an international firearms and self-defense instructor, expert in lethal force encounters and shooting cases, and author; and, Dr. Shannon Clark, psychologist, FBI agent, active shooter and response instructor, and lifelong martial artist.

We discuss the ethics of nonmaleficence (do no harm) versus personal safety.  It is no secret that psychologists are vulnerable to threat, assault, and stalking from patients and family members of patients.  The overarching goal is to start a discussion for psychologists and mental health professionals about potential dangers for mental health professionals and some options to help keep them safe.

Click here to earn 1 APA-approved CE credit

At the end of this podcast, the listener will be able to:

1. Outline your personal values related to safety in your professional life.
2. List the options to enhance personal safety in your office.
3. Describe several responsible steps to take if you decide to carry a firearm or house one in your office.

Click here to find on iTunes

Reading Material

Ken Pope: Therapists' Resources for Threats, Stalking, or Assaults by Patients

Robert B. Young: When a Psychiatrist Shoots to Kill 

Dave Grossman: On Killing: The Psychological Cost of Learning to Kill in War and Society

Massad Ayoob: In the Gravest Extreme: The Role of the Firearm in Personal Protection

Massad Ayoob: Deadly Force: Understanding Your Right to Self Defense

Massad Ayoob Information

Massad's Training Institute

Contact information for Shannon Clark

Shannon Clark

Trial of alleged Fort Hood shooter renews call for restraint

By Art Caplan
Clinical Psychiatry News
Originally posted August 2, 2013

One year ago this month, after the theater shooting in Aurora, Colo., I wrote a column for this newspaper headlined, “The Aurora Shootings: Why the Mental Health Community Must Show Restraint.” In this column, I talked about the risks inherent in offering public comments about a defendant’s mental state and about Section 7.3 of the American Psychiatric Association’s Principles of Medical Ethics, which state:

On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself or herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general.

However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”

The entire article is here.

Second VA doctor blows whistle on patient-care failures

By Dennis Wagner
The Republic
Originally published May 2, 2014

Here is an excerpt:

Both physicians, as well as other VA employees who asked not to be named for fear of retribution, said the Phoenix VA leadership disdains internal criticism and retaliates against those who speak out. In interviews and a written statement, Mitchell told The Republic she can no longer remain silent.

"I am violating the VA 'gag' order for ethical reasons," she wrote. "I am cognizant of the consequences. As a VA employee I have seen what happens to employees who speak up for patient safety and welfare within the system. The devastation of professional careers is usually the end result, and likely is the only transparent process that actually exists within the Phoenix VA Medical Center today."

The entire story is here.

Episode 8: The Dark Side of Ethics - False Risk Management Strategies

In this episode, John talks with Dr. Sam Knapp, Psychologist and Ethics Educator, about false risk management strategies.  Using the acculturation model as a guide, Sam and John discuss how some psychologists have learned false risk management strategies.  They discuss the possible erroneous rationale for these strategies.  John and Sam provide good clinical and ethical reasons as how these strategies can actually hinder high quality of services.  They also discuss ethics education in general and why learning about ethics codes do not necessarily enhance ethical practice.

At the end of the workshop the participants will be able to:

1. Explain the concept of a false risk management strategy,
2. Identify two false risk management strategies,
3. Outline how false risk management strategies hinder high quality psychological care.

Find this podcast in iTunes

Click here to purchase 1 APA-approved Continuing Education credit

Or listen directly here.





Resources

Podcast slides can be found here.

Knapp, Samuel; Handelsman, Mitchell M.; Gottlieb, Michael C.; VandeCreek, Leon D. The dark side of professional ethics. Professional Psychology: Research and Practice, Vol 44(6), Dec 2013, 371-377.

American Psychological Association's Ethical Principles of Psychologists and Code of Conduct

Handelsman, M. M., Gottlieb, M. C., & Knapp, S. (2005). Training ethical psychologists: An acculturation model. Professional Psychology: Research and Practice, 36, 59-65.

No Suicide Contracts: An Effective Strategy?
John Gavazzi

Senate challenger Milton Wolf apologizes for posting X-ray photos

By The Associated Press
The Kansas City Star
Originally published February 23, 2014

A tea party-backed Leawood radiologist who is trying to unseat longtime Republican U.S. Sen. Pat Roberts has apologized for posting X-ray photos of fatal gunshot wounds and medical injuries on his personal Facebook page several years ago. But he called the revelation about the images the work of a desperate incumbent.

In addition to the images, Milton Wolf also participated in online commentary layered with macabre jokes and descriptions of carnage, The Topeka Capital-Journal reported.

The report about the images, which came from hospitals in the Kansas City area on both sides of the state line, drew criticism from medical professionals who called their display on social media irresponsible.

The entire story is here.