No abstract

The coronavirus disease (COVID-19) crisis provoked an organizational ethics dilemma: how to develop ethical pandemic policy while upholding our organizational mission to deliver relationship- and patient-centered care. Tasked with producing a recommendation about whether healthcare workers and essential personnel should receive priority access to limited medical resources during the pandemic, the bioethics department and survey and interview methodologists at our institution implemented a deliberative approach that included the perspectives of healthcare professionals and patient stakeholders in the policy development process. Involving the community more, not less, during a crisis required balancing the need to act quickly to garner stakeholder perspectives, uncertainty about the extent and duration of the pandemic, and disagreement among ethicists about the most ethically supportable way to allocate scarce resources. This article explains the process undertaken to garner stakeholder input as it relates to organizational ethics, recounts the stakeholder perspectives shared and how they informed the triage policy developed, and offers suggestions for how other organizations may integrate stakeholder involvement in ethical decision-making as well as directions for future research and public health work.

Ohio's governor recently signed into law Senate Bill 127, a bill that makes it a fourth-degree felony for a health care provider to perform an abortion "when the probable post-fertilization age of the unborn child is 20 weeks or greater," joining a series of other states that have enacted such legislation or are moving toward similar legislation. Twenty-week bans have salient implications for women's health, quality of care, and access to services, particularly in the context of the delivery of prenatal care. Because of the timeline of the initiation of prenatal care and assessments of fetal genetic and anatomic anomalies, patients may increasingly find themselves at or near the 20-week postfertilization gestational threshold when they have insufficient information to decide about continuing or ending the pregnancy. This law thus leaves women and families with limited time to obtain a genetic or anatomic diagnosis, restricts access to abortion care at a crucial decision-making time in the pregnancy, and has significant implications for the patient-physician relationship. This law also has ramifications for women and health care providers outside of Ohio, because patients who have made the choice to end a pregnancy will have to cross state lines for abortion care. It is important for obstetric providers to be aware of the ramifications of 20-week bans and take steps to ensure that pregnant women receive high-quality care despite the burdens imposed on the health care decision-making process.

Unique ethical issues arise in the provision of gender-affirming care to transgender and gender diverse people. One of the distinctive trends in transgender health care has been the development of interdisciplinary specialty teams with expertise in gender-affirming care. Clinical ethicists can play an important role on these teams in helping gender variant patients and gender-affirming providers navigate complex ethical issues, creating opportunities for enhancing patient experience, and easing provider moral uncertainty. Many opportunities exist for clinical ethicists to lend their skills to this area of clinical care. It is important for interdisciplinary transgender health care teams and other health care professionals providing transgender-specific care to understand the ethical issues involved in such care, the ways in which ethics expertise can be a resource, and the benefits and drawbacks of integrating a clinical ethicist into their team.

Decisions about continuing or terminating a pregnancy touch on profound, individualized questions about bodily integrity, reproductive autonomy, deeply held values regarding one's capacity for parenthood, and, in the case of a high-risk pregnancy, the risks one is willing to take to have a baby. So far as possible, reproductive decisions are made between a patient, in some cases her partner, and her medical provider. However, this standard framework cannot be applied if the patient lacks decision-making capacity. In this essay, we discuss one such case that came before our clinical ethics team. We describe the challenges of respecting a patient's reproductive preferences when the patient cannot share what those preferences are, and we argue that decisions regarding reproductive health care should not be treated with exceptionalism. Rather, they should proceed under the normal processes of surrogate decision-making, including the application of substituted judgment. This approach enables us to take the patient's values into account when considering the questions implicated in reproductive health care, just as we do for other kinds of health care decisions in which a patient's deeply held values are salient.