Journal Article Annotations
2016, 1st Quarter

Bioethics

Annotations by Christina Scully, MD
April 2016

• Singhvi A, Welch AN, Levitsky J, Singhvi D, Gordon EJ: Ethical considerations of transplantation and living donation for patients with alcohol-ic liver diseases
  AMA J Ethics 2016; 18(2):163-173
• This article reviews the ethical considerations when determining suitability of transplant recipients with alcoholic liver diseases (ALD), reminding us that the landscape is complicated by concerns about equitable distribution of scarce resources and social stigmatization of patients with substance use disorders. Currently, patients with ALD are subjected to additional protocols during evaluation of transplant candidacy, unique to ALD, which influence their waitlist status for liver transplant. Citing liver transplant outcome data, the article calls the prevailing practice of abstinence periods into question and suggests incorporating substance use treatment pre- and post-transplant.

• Trachsel M, Irwin SA, Biller-Andorno N, Hoff P, Riese F: Palliative psychiatry for severe and persistent mental illness
  Lancet Psychiatry 2016; 3(3):20
• This editorial proposes a complementary palliative care approach to patients with severe and persistent mental illness with the goal of improving quality of care, person-centeredness and autonomy for this subset of patients that are at risk of therapeutic neglect and overly aggressive care. It challenges psychiatrists to acknowledge scenarios where remaining treatment methods are burdensome and ultimately futile. It cites example of forgoing repeat hospitalizations and involuntary referring in patients with severe, enduring anorexia nervosa.

• Connor DM, Elkin GD, Lee K, Thompson V, Whelan H: The unbefriended patient: an exercise in ethical clinical reasoning
  J Gen Intern Med 2016; 31(1):128-132
• Patients who lack decision-making capacity and have no surrogates are known as “unbefriended” or “unrepresented.” They represent a growing segment of the population and, given increasing referrals for public guardianship, exceed legal resources. This article, via a case example, provides an overview of current available approaches to surrogate decision-making for unbefriended patients, including: public guardianship; physicians as surrogates (often with ethics committee involvement); trained volunteers as surrogates; detailed institutional pathways; non-profit organizations that identify adults at risk of becoming unbefriended patients, encourage documentation of healthcare wishes, and act as private conservator when/if clients lose capacity. Lastly, the article reminds us that there is often a contrast between patient-centered care and medical standard-defined quality care suggesting that multidisciplinary teams, including ethics committees, can protect against bias and explore emotional counter-transference and bias influences.