Faculty Bibliography

Moral distress is the experience of cognitive-emotional dissonance that arises when one feels compelled to act contrary to one's moral requirements. Moral distress is common, but under-recognized in medical education and training, and this relative inattention may undermine educators' efforts to promote empathy, ethical practice, and professionalism. Moral distress should be recognized as a feature of the clinical landscape, and addressed in conjunction with the related concerns of negative role modeling and the goals and efficacy of medical ethics curricula.

This retrospective of the last quarter century of clinical ethics offers an examination of some of the areas in which it should focus, and refocus, attention in the next.

Proportionality, as it pertains to palliative sedation, is the notion that sedation should be induced at the lowest degree effective for symptom control, so that the patient's consciousness may be preserved. The pursuit of proportionality in palliative sedation is a widely accepted imperative advocated in position statements and guidelines on this treatment. The priority assigned to the pursuit of proportionality, and the extent to which it is relevant for patients who qualify for palliative sedation, have been overstated.

Patients in the advanced stages of amyotrophic lateral sclerosis often are faced with the dilemma of whether to use or continue to use mechanical ventilation. Patients who elect to terminate ventilatory support may be subject to significant and even extreme respiratory symptoms. Severe dyspnea and other symptoms are sometimes treated with palliative sedation, which is generally recommended as a last resort approach to refractory symptoms. However, the preemptive use of palliative sedation is sometimes appropriate. The preemptive use of palliative sedation is examined through a case-based analysis of a patient with advanced amyotrophic lateral sclerosis.

Discussions about resource allocation commonly invoke concerns of unfair and variable decisions when physicians ration at the bedside. This concern is no less germane in disaster medicine, in which physicians make triage and allocation decisions under duress, and patients and their families may be challenged to self-advocate. Unfortunately, a real-time mechanism to support a process for ethical decision making may not be available to medical relief workers. Yet, resources for ethics decision support can be important for the moral well-being of the clinician, the ethical integrity of the relief effort, and to bolster the trust and confidence of the population receiving medical services. The need for clinical ethical support should be anticipated in disaster preparedness planning.