31st Annual Florida Bioethics Conference:
Debates, Decisions, Solutions

Session 1   |   Session 2  |   Session 3

About the FBN

Founded 31 years ago, the Florida Bioethics Network is one of the oldest and largest bioethics networks in the country. It is committed to education and to identifying practical solutions to daily challenges faced by Florida hospitals, hospices, and nursing homes. For more information visit https://fbn.miami.edu/index.html or email fbn@med.miami.edu.

Session 1, Dr. Ray Moseley: Ethics Service Tune-up: Consultations, Policies, Education (ethics service mission, structure, and function; withdrawal of life-sustaining treatment; futility; family challenges) 

Ethics committees are not like most hospital committees. This fact is often the cause of under-appreciation of the effort required of ethics committee members and of the institutional support needed by a functioning ethics committee. In fact, a fully functioning ethics committee is appropriately termed a “Clinical Ethics Service.” Ethics committee members require training/education; this is especially true for members who participate in clinical ethics consultations. Ethics committees should engage in staff and community education, review relevant policies, and support a 24/7 clinical ethics consult function. This session will discuss membership issues (who should be on the committee, privacy issues, conflicts of interest, etc.), how to structure a staff educational program and a clinical ethics consult service, and how best to run an ethics meeting. The practical value of an effective ethics service – and how best to articulate that value – to institutions, colleagues, and patients will also be addressed.

The most common ethical issues that ethics services address revolve around the end of life, including withdrawal of life sustaining treatment, Advance Directives, and requests to provide futile care and treatments. Addressing these issues requires a combination of knowledge and skills, including an understanding of the legal framework in Florida and how to help physicians and family understand patient rights. This session will address some of the common misunderstandings about Advance Directives and clinical futility, focusing on policy issues and common ethics consultation situations. Strategies for consultations will be discussed, including how the “facilitation” and “expert” formats work and when to use them. Helpful tips for appropriate consult documentation in the electronic health record will also be explored. 

Session 2, Dr. Louis Voigt: Ethical Challenges in Oncology

Cancer remains the second leading cause of death in the US and one of the most feared diseases to patients and families. Cancer presents many unique ethical conundrums for patients, families, and clinicians surrounding diagnosis, treatment, research, cost, survivorship, palliative care, and mortality. The complexities and emotional impacts of cancer diagnoses can lead to ethically fraught relationships among clinicians, patients, and their caregivers. Many patients with cancer fit Kenneth Kipnis’ medical, deferential, situational, and allocational varieties of vulnerability, which can profoundly impact their approaches to treatment. People with advanced or refractory cancer are more likely to enroll in first-in-human clinical trials and are more prone to therapeutic misconception and misestimation. The financial burden of a cancer diagnosis is profound: nearly half of all cancer patients deplete their life savings within two years of diagnosis. The integration of molecular and genomic testing in the management of many cancers materializes the concept of precision oncology and allows for application of innovative therapies, but their economic costs can be overwhelming.

Additional ethical challenges that are specific to oncology include the unbridled optimism and therapeutic illusion among some clinicians, patients and caregivers, fertility preservation in children and adults diagnosed with cancer, the prolonged use of blood products for patients with refractory leukemia or lymphoma who are no longer candidates for cancer-directed therapies, ambiguity surrounding the disclosure of the results of testing for cancer predisposition genes, the duty to disclose and reappraise genetic findings of undetermined significance, research involving minors and the downstream use of their oncologic data, and increasing integration of artificial intelligence and machine learning into new models of cancer care and prognostication.

This presentation is an opportunity for bioethicists, healthcare professionals, and interested patients, caregivers and advocacy groups to review ethical challenges that are unique to cancer care and research, discuss the perspectives of patients, caregivers and clinicians facing these taxing issues, and learn about pragmatic recommendations for consensus building and problem solving.

Session 3, Dr. Kenneth Goodman: “Persistent Legislative State” – Futility Policies, Best Practice and the Law

Every hospital in Florida grapples with cases in which loving, loyal, grief-stricken, guilt-ridden family members insist dying family members endure medical interventions that do not work. These interventions produce, at best, trivial prolongations of life and, frequently, significant increases in suffering. They not only do not work, they ensure that patients die badly. Why do clinicians and their hospitals agree to do this to patients? The best hypothesis to explain this is that our colleagues are fearful of getting in some sort of legal trouble if they do not.

Though there are many examples of uncontroversial refusal to provide inefffective therapies, something about do-not-resuscitate orders and death are parsed as justification to act against medical and nursing judgment – even as patient will die in both kinds of cases.

This presentation is aimed to spark discussion and debate about a model, standard-of-care policy to make plain that love, loyalty and evidence-free hope are in some or many cases no credible substitute for honoring evidence-based clinical judgment... however fallible. It might even be the case that new computing tools will improve evidence needed to justify decisions not to offer or provide ineffective interventions.

BIOS

Ray Moseley, PhD

Dr. Moseley received his Master's Degree in Philosophy and Medical Ethics at the University of Tennessee and completed his Doctorate in Bioethics at the Kennedy Institute of Ethics at Georgetown University in Washington, D.C.

Dr. Moseley is the Director of the UF Health Clinical Ethics Service and holds the Grace H. Osborn Professorship in Bioethics and is a member of the Bioethics, Law and Medical Professionalism Program, Department of Community Health and Family Medicine, in the University of Florida College of Medicine.

He is the Founder and Senior Board Member of the Florida Bioethics Network (FBN) and played a key role in the development of the FBN as a significant statewide resource.  Dr. Moseley is an expert on hospital ethics services/committees and research ethics, and he is the author of the widely used CITI Training modules for members of clinical ethics committees/services and serves as vice chair of the UF IRB. 

His research focuses on technological approaches to effectively addressing clinical ethics issues. His recent projects include the development of an innovative Ipad App to develop Video Advance Directives, and a major NIH project to create and evaluate an interactive electronic informed consent process. His latest research is using AI and natural language processing to extract information from an electronic medical record to determine whether threshold criteria are met to implement a patient’s Advance Directive His publications include articles on “Withdrawal of Life-Sustaining Medical Treatment”, “Advance Medical Directives”, “Genetic Testing”, and “Ethics Committees”.

Louis Voigt, MD, MBE

Dr. Voigt is a graduate of the State University of Haiti School of Medicine. He completed his residency training in Internal Medicine and fellowship training in Pulmonary Disease at New York Methodist Hospital and fellowship training in Critical Care Medicine at Memorial Sloan Kettering Cancer Center. He holds a Masters of Bioethics degree from Columbia University and certifications by the American Board of Internal Medicine in Internal Medicine, Pulmonary Disease, Critical Care Medicine, and Hospice and Palliative Medicine.

He is an Associate Professor of Medicine in Clinical Anesthesiology and of Clinical Medicine in the Department of Medicine at the Weill Cornell Medical College. At Memorial Sloan Kettering Cancer Center, he is an Attending Physician in the Department of Medicine and in the Department of Anesthesiology, Pain and Critical Care Medicine, the Chairperson of the Ethics Committee, and the Medical Consultant for Advanced Cardiac Life Support by the American Heart Association.

Current research interests include ethical issues surrounding artificial intelligence and predictive models, end of life care, decisional capacity, advance directives, decision-making processes for critically ill patients, and ICU-related complications such as delirium.

Kenneth W. Goodman, PhD

FBN Director Kenneth W. Goodman, PhD, FACMI, FACE, is founder and director of the University of Miami Miller School of Medicine’s Institute for Bioethics and Health Policy and director of the university’s Ethics Programs. The Institute has been designated a World Health Organization Collaborating Center in Ethics and Global Health Policy, one of 14 in the world and the only one in the United States.

Dr. Goodman is a Professor of Medicine at the University of Miami with appointments in the Department of Philosophy, School of Nursing and Health Studies and Department of Public Health Sciences.

He is immediate past chair of the Ethics Committee of AMIA (American Medical Informatics Association), for which organization he co-founded the Ethical, Legal and Social Issues Working Group. He has been elected as a Fellow of the American College of Medical Informatics (FACMI). He is also a Fellow of the American College of Epidemiology (FACE) and The Hastings Center.

He directs ethics services for the UHealth and Jackson Memorial Hospital systems.