Fiester, Autumn

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  • Publication
    Ethical Considerations in Treating the Horse with Laminitis
    (2004-03-01) Fiester, Autumn; Mann, Lori
    The nature of laminitis - its unpredictable course, the severe pain and disability it causes, the lengthy convalescence it requires even when cured - poses challenging ethical quandaries for the clinicians who treat it and the owners whose horses suffer from it. Unique among equine ailments, this disease places owners and clinicians in the untenable position of trying to balance considerations that are very difficult to weigh against each other: the animal's pain, the unknown disease trajectory, the questionable possibility of full recovery, the limited usefulness of the animal post-laminitis, the financial drain of treatment, the financial loss of a formerly productive horse, the expense of maintaining a "pasture potato," the animal's frustration or distress during convalescence, etc. The pressing question in every case of laminitis is: where should we draw the line? The answer to this question will not only be different in every individual case of laminitis, but different owners and clinicians will often have divergent views even regarding the same case. In an ethical terrain that is so clearly "gray," absolutes are unlikely to be found. Instead, our essay hopes to clarify the ethical considerations involved in treating a horse with laminitis to facilitate the decision-making process regarding the specific cases encountered by clinicians in the field.
  • Publication
    Ethical Issues in Animal Cloning
    (2005-06-01) Fiester, Autumn
    The issue of human reproductive cloning has recently received a great deal attention in public discourse. Bioethicists, policy makers, and the media have been quick to identify the key ethical issues involved in human reproductive cloning and to argue, almost unanimously, for an international ban on such attempts. Meanwhile, scientists have proceeded with extensive research agendas in the cloning of animals. Despite this research, there has been little public discussion of the ethical issues raised by animal cloning projects. Polling data show that the public is decidedly against the cloning of animals. To understand the public’s reaction and fill the void of reasoned debate about the issue,we need to review the possible objections to animal cloning and assess the merits of the anti–animal cloning stance. Some objections to animal cloning (e.g., the impact of cloning on the population of unwanted animals) can be easily addressed, while others (e.g., the health of cloned animals) require more serious attention by the public and policy makers.
  • Publication
    Casuistry and the moral continuum: Evaluating animal biotechnology
    (2007-01-19) Fiester, Autumn
    While the science of animal biotechnology is advancing at a rapid pace, the ethical discussion about the boundaries the public might want to set is at the most nascent stage. There is a tendency in the public debate for opponents to favor an all-out ban on the science, while proponents want to grant it carte blanche. I argue that a more nuanced position on animal biotechnology considers individual projects to be located on a moral continuum, where some are clearly morally justified, others morally impermissible, and some lie in the ethical gray-zone. To begin to define this continuum, we use the bioethical method of casuistry to analyze one case at the end of moral permissibility, and we contrast it with a case that is located at the opposite end of the moral spectrum. I advocate this approach to assessing the moral merit of biotechnology projects because of its attention to the details of individual cases - the protocols, ends, and methods - on which an accurate moral judgment necessarily rests.
  • Publication
    What "Patient-Centered Care" Requires in Serious Cultural Conflict
    (2011-01-01) Fiester, Autumn
    The recent movement to provide “patient-centered care” has been hailed as a progressive step forward in meeting the needs of the very diverse patient population of the United States. The focus on patient-centered care has been embraced at all levels of American medicine: professional organizations, public advocacy groups, hospital administrators, medical school leadership, insurance carriers, and nursing schools. But while the ideal of patient-centered care is universally endorsed, the ethical obligations it entails have only begun to be explored. One of the most difficult circumstances in which to provide patient-centered care is in deep cultural conflict, where the values and priorities of the patient are in direct opposition to those of the clinical team. Given the mandate to provide care that is “culturally and linguistically appropriate,” the author asks what obligations providers have to meet patient demands when it is inconvenient, challenging, or, at the extreme, offensive and antithetical to mainstream values. Bariers are examined that patient-centered care in such cases is disruptive to the work-flow of the service, requires acknowledgement of illegitimate values, or entails discriminatory practices that constitute a personal insult or affront to the provider. The strategy invoked for this analysis is a search for common values that might provide a bridge between patients and providers in deep cultural conflict. The author concludes by responding to these important barriers to providing patient-centered care.
  • Publication
    Mediation and Advocacy
    (2012-01-01) Fiester, Autumn
  • Publication
    What Mediators Can Teach Physicians about Managing 'Difficult' Patients
    (2015-03-01) Fiester, Autumn
    Between 10% and 12% of patients are considered difficult by their treating physicians,1 indicating a widespread problem. Many physicians report feeling at a loss to know how to effectively manage challenging patient interactions.2 In extreme cases, physicians resort to refusing to treat hostile patients or dismissing them from their clinical practice.
  • Publication
  • Publication
    The Principlist Paradigm and the Problem of the False Negative: Why the Clinical Ethics We Teach Fails Patients
    (2007-07-01) Fiester, Autumn
    The clinical ethics framework that is typically taught to medical students and residents is deeply flawed, and the result of using this framework exclusively to resolve ethical conflicts at the bedside is compromised patient care. The author calls this framework the principlist paradigm and maintains that it blinds clinicians from seeing the full set of moral obligations they have to the patient and limits the range of options they see as available to navigate through ethical conflicts. Although it is important for the moral obligations it does recognize (e.g., those based on the principles of autonomy, beneficence, nonmaleficence, and justice), the principlist paradigm should not be used as the only moral template for case analysis. The author illustrates the paradigm’s limitations with a clinical case study, in which the treating clinicians failed to recognize three important moral obligations to the patient: the obligation to express regret, the obligation to apologize, and the obligation to make amends. The failure to recognize these widely accepted moral obligations can have tragic consequences. The principlist paradigm undertrains clinicians for the complex ethical dilemmas they face in practice, and medical ethics educators need to rethink the tools they offer student clinicians to guide their ethical analysis. The author advocates a reexamination of this standard approach to teaching clinical ethics.
  • Publication
    Teaching Nonauthoritarian Clinical Ethics: Using an Inventory of Values and Positions
    (2014-08-29) Fiester, Autumn
    One area of bioethics education with direct impact on the lives of patients, families, and providers is the training of clinical ethics consultants who practice in hospital-based settings. There is a universal call for increased skills and knowledge among practicing consultants, broad recognition that many are woefully undertrained, and a clear consensus that CECs must avoid an “authoritarian approach” to consultation—an approach, that is, in which the consultant imposes his or her values, ethical priorities, or religious convictions on the stakeholders in an ethics conflict. Yet little work has been done on how to teach CECs not to impose their values in an ethics consultation, or even on the dimensions of this problem. In this essay, I propose a tool for bioethical instruction that targets this question: how can CECs be taught a nonauthoritarian mode of ethical analysis and consultation that can avert the problem of values imposition?
  • Publication
    When It Hurts to Ask: Avoiding Moral Injury in Requests to Forgo Treatment
    (2014-03-01) Fiester, Autumn
    Clinicians commonly believe that "there is no harm in asking" patients with life-threatening illnesses if they would like to forgo aggressive therapy. In fact, many clinicians believe that the question is not only appropriate, but obligatory on grounds of patient empowerment and autonomy: Patients should be given all options, including the option to stop treatment. But in this piece, I argue that there is, indeed, serious -- and even traumatic -- harm in asking patients to forgo treatment if that request is perceived by the patient as evidence that the clinician devalues or questions the integrity of that patient's life. When such requests are perceived to imply: "Your life is not worth saving," the effect of the "ask" is insult and offense, not empowerment. I then argue how clinicians can avoid moral injury in conversations about withholding or withdrawing treatment.