May Membership Meeting
The Relevance of Ill-Being to Critically Ill Patients-Without-Proxies
Patients-without-proxies (PWPs) are incapacitated patients who need medical care but have no advanced directive, living will and no designated or identifiable surrogates, making their values unknown. Despite PWPs representing almost a quarter of incapacitated ICU patients (White et al. 2006), research on PWPs is in a "dismal state," signaling an "urgent need for research to identify medical decision-making approaches" that involve them (Kim and Song 2018, 1233). Empirical evidence— including our own in the field of burn care (Ota et al. 2020)— demonstrates that PWPs are less likely to receive comfort care despite eventually succumbing to life-threatening injuries. This may be due in part to prognostic uncertainty when it comes to medical futility and an inclination to err on the side of administering treatment. However, since ICU treatment is far from benign (especially in burn care), many PWPs who end up passing away are exposed to greater harm than their non-disadvantaged peers. As an additional consideration to futility, we propose that some harms experienced by patients qualify as substantive harms—i.e., that some patients experience 'ill-being' (Kagan 2014). Ill-being differs from the common understanding of harm in that it represents more than a mere deprivation of well-being: it is not just something that is not worth having, it is worth not having. We propose that the predictable presence of ill-being in a patient's medical course is a helpful and morally relevant consideration to decision-making. We argue that it is an especially relevant consideration for PWPs who face substantial prognostic uncertainty.
Dr. Karel-Bart Celie, received his B.A. in Philosophy from Boston College and his M.D. from Columbia University, after which he went on to train in reconstructive plastic surgery at USC. He recently undertook a two-year Global Surgery Fellowship with Operation Smile while also completing a Masters in Practical Ethics at the University of Oxford. Broadly, his interests include healthcare inequity and a wide range of ethical challenges in global surgery.
April Membership Meeting
Beyond Behavior Contracts: Responding Effectively to Disruptive Patient Behaviors
Workplace violence in healthcare settings has risen. One contributing factor is a troubling upward trend in aggressive and abusive behaviors in hospitals, exhibited by patients, their families, and hospital staff. A common mechanism for addressing this is the behavior contract, also known as a behavioral agreement, used in response to patient or family behaviors that the care team deems disruptive, offensive, threatening, or otherwise unacceptable. Behavior contracts typically list the behaviors that the team finds unacceptable and propose consequences that may be invoked if the behaviors continue. While frequently used, there is no evidence that supports their effectiveness in dealing with disruptive and concerning behaviors in hospital settings. This presentation will explore the ethical, legal, and clinical implications of the use of in-patient behavior contracts, along with recent evidence that raises concerns about inequities in their use.
L. Syd M Johnson, PhD, HEC-C, is a philosopher/bioethicist/neuroethicist and Professor at the Center for Bioethics and Humanities at SUNY Upstate Medical University, and an ethics consultant at Upstate’s three hospitals. She’s an Associate Editor for Neuroethics, and a member of the NIH BRAIN Initiative Neuroethics Working Group, and is the chair of Upstate’s Hospital Ethics Committee. Dr. Johnson’s books include The Ethics of Uncertainty: Entangled Ethical and Epistemic Risks in Disorders of Consciousness; The Routledge Handbook of Neuroethics; Chimpanzee Rights: The Philosophers’ Brief; Philosophical, Medical, and Legal Controversies About Brain Death; Neuroethics and Nonhuman Animals; and The Three Pillars of Ethical Research with Nonhuman Primates. Her research focuses on ethical issues related to research ethics, animal ethics, xenotransplantation, and brain injuries, including brain death and disorders of consciousness.
Rachel Fabi, PhD, HEC-C, is an Associate Professor and Vice Chair for Education in the Center for Bioethics and Humanities at SUNY Upstate Medical University in Syracuse, New York, where she also serves as a clinical ethics consultant. In 2021, Dr. Fabi was elected to the Board of Directors of the American Society for Bioethics and Humanities, and in 2024 she was elected to the position of Secretary. She teaches courses on health advocacy and public health ethics, and her research focuses on the ethics of policies that affect immigrant health.
