Below are abstracts, links, slides, and handouts from some of the presentations I have given recently. Please do not distribute without permission, and please cite appropriately if used. For a full list of presentations, see my CV.
Click for Presentation
"Differing Ethical Perspectives on Assisted Suicide" (International Panel) International Conference on Clinical Ethics Consultation | Washington, DC (2016)
Abstract: This panel presents multiple perspectives on assisted suicide (AS) in different countries. The first panelist will emphasize that choice is not intrinsically valuable, so we should consider how adding AS to end-of-life options may or may not support autonomous decision making. In the U.S., we are still striving to improve end-of-life care, so offering AS should be analyzed against the backdrop of an imperfect health care system. The second panelist will discuss the passage of the new law in California, exploring concerns about our professional obligations to patients and our professions. She will analyze the concept of control that often seems to be the crux of the arguments in the U.S. and what is lost when that becomes the focus. The next panelist will provide reflections on the recent U.K. parliamentary debate on AS, focusing on the arguments on both sides with respect to the concept of vulnerability. She will discuss the ambivalent position of UK law with discretion ultimately left to the Crowne Prosecution Service, which has a potential discriminatory effect. Our last panelist will share perspectives from Central Europe. Lay organizations offer AS with little public control in Switzerland; Germany’s liberal legislation has recently been changed to prohibit Swiss-style AS; Austria has instituted restrictive legislation. The role of clinical ethics support will be illustrated by recent university hospital guidelines on responding to patients’ questions regarding AS.
Click for Presentation
"Futile Treatment: Is It Ever Ethically Permissible to Provide It?" American Association of Critical Care Nurses | Washington, DC (2015)
Abstract: I begin by giving a brief overview of what ethics is and what falls within the purview of a bioethics department within a hospital. Next I explore how ‘futility’ as a term could be used differently by clinicians, families, patients, ethicists, and I distinguish between biomedical and normative futility. I highlight the distress that healthcare providers can feel in being asked to provide care they deem futile or in being prevented from providing care that they do not believe to be futile. I mention existing professional standards related to the meaning of futility and correlated professional obligations that have ethical import. I demonstrate the moral uncertainties that can arise when there are different conceptions of futile care and related professional obligations by applying them to an actual clinical case that occurred in our Neonatal ICU.
Click for Presentation
"Ethical Bargaining and Parental Exclusion: A Clinical Case Analysis" Co-authored presentation with Elizabeth Victor Canadian Bioethics Society | Winnipeg, Manitoba (2015) International Conference on Clinical Ethics Consultation | New York, NY (2015) Abstract:We present an actual clinical case where the long-term health of a child was at stake, and the medical team handled their dispute with the father by making an ethically impermissible compromise. This case reveals the limits of ethical bargaining, which occurs when the involved parties choose not to pursue a morally preferable option for the sake of coming to a resolution. We argue that the bargain struck in this case was not within the range of morally permissible options, as it led to the denial of the mother’s parental standing and risking the future health of a child. Moreover, based on how the case was settled and later analyzed by an ethics committee, we contend that there is an obligation to acknowledge and confront potentially damaging family dynamics. In these instances, it can be morally urgent to enable the autonomy of all relevant caregivers, especially since the dominating decision-maker might not be fairly characterizing the role of other caregivers or representing the best interests of the patient and family.
Abstract: The question of whether a patient has insight is among the first to be considered in psychiatric contexts. There are several competing conceptions of ‘clinical insight,’ which broadly refers to a patient’s awareness of his/her medical condition. Current accounts generally have more demanding criteria than clinicians used in years past. Insight used to be considered all-or-nothing and unidimensional. Insight is now viewed more as a multidimensional and continuous construct. The precise specifications of the dimensions appear inadequate for providing clear guidance, though. Data on which groups of psychiatric patients tend to lack insight have changed dramatically over the years. Studies also give contradictory evidence regarding the frequency and consequences of poor insight. For example, some researchers claim that all psychiatric conditions compromise insight; others suggest that poor insight is only present in psychosis. Several studies find no correlation between level of insight and severity of psychopathology, but others come to the opposite conclusion. A number of crucial questions remain unanswered or fiercely debated. Given the conceptual ambiguities associated with insight determinations, there are significant ethical concerns about how patients’ decisions are weighed and evaluated in psychiatric care. Patients’ concerns about having their status as knowers denigrated can result in their distrust of clinicians, which in turn can hurt treatment compliance. After outlining some of the key disagreements in the literature about what clinical insight means, I will suggest ways in which clinical ethics services can contribute to therapeutic alliance building for patients whose insight level is uncertain.
Abstract: In this paper, we highlight the ways in which heteronormativity marginalizes Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual populations (LGBTQIA) in clinical contexts. Recent research reveals that healthcare spaces and providers often convey micromessages that make this population feel anxious, unwelcome, or ashamed. Despite efforts to eliminate discriminatory practices and homophobic behavior, heteronormative ideals remain concretized in multiple ways, including small talk, healthcare forms, posters, brochures, intake procedures, and pronoun usage. LGBTQIA patients have reported fear of hostility, isolation, or refusal of service if they come out to their healthcare providers. Yet, if healthcare providers are to adequately enable patient autonomy and administer the standard of care for all patients, they need access to information related to sexual history and lifestyle. LGBTQIA individuals’ understandable avoidance of clinical encounters and hospitals’ general lack of initiative to reform healthcare spaces perpetuate one another. We analyze this perpetuating cycle and the double bind that results. Additionally, we discuss how and why consciousness raising and professional training on LGBTQIA issues will hit a number of obstacles and prove insufficient. For example, certain attempts to eradicate heteronormativity can result in a backlash, increasing tensions in waiting rooms or clumsiness in pronoun/patient reference on intake forms. We address the extent to which healthcare professionals have responsibilities to address heteronormativity as it arises interpersonally and institutionally, and we offer some considerations for concrete problem-solving.
Abstract: We begin by discussing the role of gatekeepers in relation to sexual autonomy and sexual rights, particularly in cases of cognitively disabled individuals who still retain sufficient decisional capacity for sexual activity and sexual expression. Recognizing that ‘the cognitively disabled’ are not one homogenous category, we will focus on individuals with early to moderate dementia who are in states of dependency on others (e.g., in a nursing home). Our aims are to 1) outline some systematic paternalistic efforts to suppress these individuals’ sexual experimentation and expression, 2) offer a choice-specific capacity framework as it relates to sexual decision-making, and 3) argue for ways in which institutions (especially medical) should respond to the particular vulnerabilities and interests of this population in relation to sexual identity. Shifting from an independence model of autonomy to a relational framework, we argue that sexual rights are positive as well as negative, and policies should provide supports and mechanisms for different forms of sexual expression. These provisions can ameliorate coercion concerns without leading to the extreme and unjust conclusion that all non-ideal agents should be prevented from pursuing sexual relationships or lifestyles. Individuals with early to moderate dementia could potentially develop or maintain their decisional capacity for sexual activity if (for instance) nursing home staff enabled autonomy by assisting these individuals to be active inquirers into sexual possibilities and by providing the conditions necessary for non-harmful sexual activity. The interdependence needs of the cognitively disabled should be recognized and accommodated; these needs do not, in themselves, justify exclusion or neglect. A precautionary principle that stifles their sexuality is unfair to this population, considering the importance sexuality generally has for identity and well-being.
Click for Presentation
"End of Life Decisions for People with Significant Intellectual Disabilities" Co-authored presentation with Marisa Brown, Carol Taylor, and Erin Leveton International Conference on Clinical Ethics Consultation | Paris, France (2014) Regional Clinical Ethics Symposium | Washington Hospital Center (2014)
Abstract: Our study analyzes and evaluates how guardians make end-of-life decisions for individuals with profound intellectual disability (PID) who have never had decisional capacity. This project explores two unique features of the moral problems associated with these decisions. The first is the complexity in identifying the best interests of the ward when, due to the PID, he or she has never had the ability to describe his/her wishes. In these instances, family members, lawyers, or other social service professionals are given the status of guardian and may be vested in making decisions that can either hasten or prolong the end-of-life process. We discuss some common questions and concerns associated with this “gold standard” of surrogate decision-making when applied to these individuals. For example, there are worries about surrogates completely de-personalizing the best interest standard, not making a concerted effort to determine the ward’s preferences (to the extent they might exist), or simply deferring to medical judgment without critical reflection. The second unique feature to be explored is developing an understanding of how these decisions are made and should be made within a patient-centered framework. In response to these challenges, we have surveyed local guardians about their experiences making end-of-life decisions for this population, and we solicited their thoughtful responses to case vignettes. This research was done with assistance from scholars, lawyers, and disability advocates. Additionally, we have constructed a web-based toolkit to assist guardians tasked with making decisions for wards with PID.
Click for presentation
"Demands for Recognition and the Psychiatric User/Survivor Movement" National Endowment for the Humanities Colloquium | Hood College, honorarium provided (2014)
Abstract: By and large, philosophical scholarship has not taken much notice of the psychiatric user/survivor movement, even though it began in the 1970s and even though the activists believe that they are pushing an important civil rights and human rights agenda. Especially after the movement branched into groups that have more nuanced positions than those proposed by those within the anti-psychiatry camp, it is philosophically and morally important to analyze what these groups aim to accomplish and what their underlying concerns are. It is not my intention to critique or defend all of their claims. Rather, I will focus on how their demand for recognition parallels a similar demand among disability rights advocates. Recognition, as a moral and political aim, involves more than mere acknowledgement of difference; rather, it involves positive accommodations and reevaluating what the group identities mean for individuals. For disability activists and psychiatric user/survivors, the call for recognition is tied to having their varied modes of being (i.e., those that are not able-bodied and able-minded) respected, accepted, and accommodated. A Strawsonian framework will help unpack what this duty means interpersonally. I will argue that a wholly objective attitude toward psychiatrically disabled individuals will strip them of their ability to have variant modes of being identified and respected, and this type of attitude further disempowers an already vulnerable population. If an objective attitude toward them is ever justified, it should be reserved only for those rare and extreme disorders that have significantly deteriorated the individual’s agential capacities. The duty of recognition, therefore, will come into conflict with the duty of beneficence when the individual’s fundamental capacities are compromised or suspected of being compromised. Keeping this tension in mind is important for having a clear and precise account of what recognition does and does not require for this population.
"Sexual Agency within Regulated Health Care Systems" Panel with Elizabeth Victor and Andrea Pitts American Philosophical Association, Eastern Division: Society for LGBTQ Philosophy Panel | Baltimore, MD (2013)
Abstract:Sexual agency is more than the capacity to choose, engage in, or refuse sex acts; it involves a social dimension in which others recognize and respect one’s identity. This form of relational sexual agency becomes apparent in cases where one’s sexual expression is mitigated by institutional forces. In this panel, we will focus on three biomedical settings wherein current heteronormative policy guidelines regulate forms of sex and sexual expression. Our papers will examine health care systems and policy within the contexts of: U.S. prisons, assisted-living facilities for aging populations, and care facilities for individuals with permanent cognitive impairment. First, through an examination of correctional health care systems, our first panelist will argue that policies and practices stemming from the 2003 Prison Rape Elimination Act can lead to serious epistemic injustices for LGBTQ prison populations. Focusing on the context of assisted-living facilities, our second panelist will use queer theory and a theory of relational autonomy to critically examine “gold standard” sexual decision-making capacity measures and suggest ways in which these measures might be altered to enable sexual autonomy in LGBTQ elderly populations. Then, turning to the context of care facilities for individuals with permanent cognitive impairment, our third panelist will use queer theory and disability theory to argue that persons with cognitive disabilities have a right to sexual autonomy (something that is contested) and that care facilities should implement a policy that enables non-heteronormative forms of sexual autonomy.
Click for Presentation
"Vulnerabilities and Institutional Barriers in Clinical and Public Health Contexts" Co-authored presentation with Elizabeth Victor Human Development and Capabilities Association | Managua, Nicaragua (2013)
This presentation builds off of our paper "Vulnerabilities Compounded by Social Institutions" and our invited talk at the Pan American Health Organization in 2013 (see below). This presentation also incorporates a policy tool for identifying and mitigating compounded vulnerabilities.
Abstract: In the case of a patient with significant medical needs and signs of mental illness, at what point does the suspected psychiatric condition compromise the patient's capacity to refuse medically recommended and time-sensitive treatment? Determining the appropriate response to this question is a relevant topic to clinical ethics consultation, thought it can cause significant consternation and moral distress. I will begin by describing actual cases where patients refused treatment for pressing medical conditions while exhibiting possible signs of mental illness. In order to unpack the ethical complexities embedded in these cases and others of a similar nature, I will analyze and evaluate competing models of capacity, giving preference to a version of the sliding scale model. In each of these approaches, clinicians have to weigh patient well-being against respect for patient autonomy. What constitutes the authentic or "true" self of a mentally ill patient can be questionable, though, and their symptoms can raise further doubts about their ability to make autonomous decisions. I argue for a revised sliding scale model that avoids over-idealization and admits flexibility can protect mentally ill individuals from hard paternalist interventions without pointlessly tying the hands of medical professionals who want to promote patients' well-being.
This presentation was part of the monographic series hosted by the Office of Gender, Diversity, and Human Rights. I was invited to discuss different conceptions of 'vulnerability' in the bioethics literature and to provide my own preferred understanding of it (drawing on my co-authored paper on the topic). This presentation also incorporated some of PAHO's projects and general public health concerns, such as those related to poverty and indigenous populations. Furthermore, I show how, in countries where abortion is illegal, medical and legal institutions compound vulnerabilities when they obligate healthcare providers to report cases of self-induced abortion when women seek medical attention afterwards.
The purpose of this brown bag lunch is to a) clarify what privacy and confidentiality are and why they matter, b) highlight some representative laws from the region on this issue, c) explain and implement some of the distinctive tools of bioethics, and d) provide some concrete recommendations for ameliorating this situation so as to better advocate for and protect the patient. Following the presentation, you are invited to an open discussion addressing, among others, the following questions:
How should the moral claims to privacy and confidentiality be weighed against other interests, obligations, and values – especially given the resource limitations and cultural contexts of this area?
What additional measures and safeguards could feasibly, effectively, and responsibly protect patient privacy and confidentiality?
Abstract: The Food and Drug Administration has recently reviewed studies on ECT’s efficacy and safety, and they have yet to devote a concerted effort to discussing the ethical issues surrounding consent procedures for ECT. I aim to outline some of the core concerns, given that 1) many facts about the therapeutic mechanisms and side effects of ECT are still less than certain; 2) ECT often affects patients’ short-term and long-term memory; and 3) ECT is frequently used for vulnerable populations. Studies show that many patients who consent to ECT often do not believe that their choice was truly voluntary. Informed consent procedures are complicated even further given how ECT can dramatically change the patient's sense of self. If we adopt a psychological continuity view of personal identity, and if ECT causes dramatic alterations in memory, personality, and narrative, then this therapy can significantly disrupt a patient’s identity. This possibility has ramifications for proxy decision-making as well. I outline core ethical considerations for consent procedures for ECT and provide some recommendations.
Click for Presentation
"Courage in the Everyday and in Extremis: Civilian and Combatant Virtue in Harry Potter" Ethics Across the Curriculum | Young Harris College, honorarium (2014) Ethics and Children's Literature: A Symposium | DePauw University (2012)
Abstract: Especially since children are vulnerable in many contexts and often view themselves as powerless, they face numerous situations that inspire fear. The Harry Potter series takes place within the context of an overarching war, and Harry Potter, Neville Longbottom, and Severus Snape each experience the civilian-combatant shift. Their courage both in everyday life and in warfare distinguish them as moral heroes. Aristotle defines ‘courage’ as “a mean with respect to things that inspire confidence or fear” (NE III.7, 1116a10). Through the characters of Harry, Neville, and Severus, I will analyze how this virtue develops along different tracks, given the particularities of the person and the situation. Their moral perception, moral imagination, and moral sense are all colored by the losses they have endured and in what ways that are connected to the war. Aristotle describes how the attainment of virtue requires a gradual calibration process that takes account of who we are and how we stand toward our emotions and desires. Someone can be courageous in battle and not in everyday life and vice versa. Harry, Neville, and Severus demonstrate how the roles of civilian and soldier present their own challenges when it comes to attaining the virtue of courage.
This presentation is based on our paper "Vulnerabilities Compounded by Social Institutions."
Click for Presentation
Ethics Case Work-Up: Psychiatry Sibley Hospital, Ethics Advisory Committee | Washington, DC (2012) Supplemental handout available here
This was an invited lecture on capacity determinations among psychiatric populations. I discuss a case that was brought to Georgetown Hospital in which a patient refused medically indicated surgery and allegedly had Bipolar Disorder. Working through the moral dimensions of the case, I use the sliding scale framework to assess the patient's capacity (based on available facts given in her medical records) to make this refusal.
EthicsAware is a program created by a high school student to raise awareness about ethical issues and moral behavior. I was invited to discuss a topic within applied ethics and engage the students in a friendly debate. My presentation focused on the notion of complicity in the political and private spheres. If I buy clothing manufactured in a sweatshop, am I complicitous for financially supporting an unjust institution? If I stand by while a student is being bullied, am I responsible for my silence?