Scroll down for abstracts of authored and edited books, articles/chapters, and other publications. For a full list of scholarship and presentations, please refer to my CV.
Authored Books
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Basics of Bioethics, Fourth Edition
Robert M. Veatch and Laura K. Guidry-Grimes NY: Routledge, 2020 The Basics of Bioethics, Fourth Edition offers an easy-to-follow introduction to this dynamic field, intended for healthcare professionals, teachers, students, and anyone interested in bioethics. Accessible and enjoyable for readers of all backgrounds, the book contains numerous cases—including ones that recently have dominated international headlines—to help anchor the broader discussion. The text is suitable for use in short courses in schools of medicine, nursing, and other health professions; continuing professional education; various undergraduate departments; and adult education. Chapters are organized around common moral themes in order to help readers understand the values and other connections that tie together different positions in bioethics. This fourth edition adds a new chapter on alternative frameworks in bioethics, including narrative ethics and casuistry, feminist approaches, care ethics, and virtue ethics. Due to significant advances in genetics and reproductive possibilities, this new edition devotes a full chapter to each. The combined teaching, research, and clinical experience of the two authors helps make this edition current with the evolving field of bioethics, while still embedding the major issues in a systematic framework that allows readers easily to navigate the larger field. |
Edited Volumes
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Applying Nonideal Theory to Bioethics: Living and Dying in a Nonideal World
Eds. Elizabeth Victor and Laura K. Guidry-Grimes NY: Springer, 2021 This book offers new essays exploring concepts and applications of nonideal theory in bioethics. Nonideal theory refers to an analytic approach to moral and political philosophy (especially in relation to justice), according to which we should not assume that there will be perfect compliance with principles, that there will be favorable circumstances for just institutions and right action, or that reasoners are capable of being impartial. Nonideal theory takes the world as it actually is, in all of its imperfections. Bioethicists have called for greater attention to how nonideal theory can serve as a guide in the messy realities they face daily. Although many bioethicists implicitly assume nonideal theory in their work, there is the need for more explicit engagement with this theoretical outlook. A nonideal approach to bioethics would start by examining the sociopolitical realities of healthcare and the embeddedness of moral actors in those realities. How are bioethicists to navigate systemic injustices when completing research, giving guidance for patient care, and contributing to medical and public health policies? When there are no good options and when moral agents are enmeshed in their sociopolitical viewpoints, how should moral theorizing proceed? What do bioethical issues and principles look like from the perspective of historically marginalized persons? These are just a few of the questions that motivate nonideal theory within bioethics. This book begins in Part I with an overview of the foundational tenets of nonideal theory, what nonideal theory can offer bioethics, and why it may be preferable to ideal theory in addressing moral dilemmas in the clinic and beyond. In Part II, authors discuss applications of nonideal theory in many areas of bioethics, including reflections on environmental harms, racism and minority health, healthcare injustices during incarceration and detention, and other vulnerabilities experienced by patients from clinical and public health perspectives. The chapters within each section demonstrate the breadth in scope that nonideal theory encompasses, bringing together diverse theorists and approaches into one collection. |
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Moral Expertise: New Essays from Theoretical and Clinical Bioethics
Eds. Jamie Carlin Watson and Laura K. Guidry-Grimes NY: Springer, 2018 This collection addresses whether ethicists, like authorities in other fields, can speak as experts in their subject matter. Though ethics consultation is a growing practice in medical contexts, there remain difficult questions about the role of ethicists in professional decision-making. Contributors examine the nature and plausibility of moral expertise, the relationship between character and expertise, the nature and limits of moral authority, how one might become a moral expert, and the trustworthiness of moral testimony. This volume engages with the growing literature in these debates and offers new perspectives from both academics and practitioners. The readings will be of particular interest to bioethicists, clinicians, ethics committees, and students of social epistemology. These new essays promise to advance discussions in the professionalization and accreditation of ethics consultation. |
Articles and Book Chapters
"Constructing Meaningful Avenues for Agency: A Role for Nurses in Caring for Persons with Disabilities"
Laura Guidry-Grimes
In Nursing Ethics: Normative Foundations, Advanced Concepts, and Emerging Issues, eds. Michael J. Deem and Jennifer Hagerty Lingler, in press.
Abstract: The aim of this chapter is to elucidate how persons with disabilities can be rendered vulnerable in various clinical contexts, which has implications for how nurses should identify and address different types of barriers for patients in their care. The chapter begins by surveying the conceptual territory surrounding the term ‘disability,’ since how this term is conceptualized will make a difference for framing the nature of vulnerabilities as they arise. Next, the chapter examines how institutional environments (such as in hospitals and nursing homes) can limit opportunities for agency, and this discussion will include the challenges faced by persons with physical, intellectual, and psychiatric disabilities. This chapter emphasizes how nurses, nurse assistants, and healthcare facilities should proactively mitigate vulnerabilities for persons with disabilities and enable different forms of agency.
"Disability Rights and Disability Justice as Gestalt Shifts for Triage Decision-Making in a Pandemic"
In Disability Justice in Emergency Conditions, eds. Mercer Gary and Joel Michael Reynolds, in press.
Abtract: In this chapter, we begin by describing ableism as a systemic and historic form of bias that leads to a cascade of prejudice and disadvantage for disabled people; importantly, ableism runs parallel with other forms of bias such as racism, ageism, and classism. With this necessary background in place, we describe disability rights and disability justice as distinct frameworks for normative analysis and advocacy. We then investigate the central tensions surrounding triage of healthcare resources during a pandemic, specifically turning to the evolving moral and political discourse from 2020 through 2022 in relation to COVID-19. We discuss how an emphasis on disability rights was necessary to provide basic protections to persons with disabilities during this public health emergency; however, we also argue that disability justice has not been properly elevated or achieved during the pandemic. We then discuss the phenomenon of “informal triage,” which leads to denying healthcare resources to disabled persons even when scarcity does not necessitate it. Both formal and informal triage can be especially dangerous for multiply marginalized disabled persons, and a commitment to disability justice is ethically and politically important for reimagining the conditions that lead to formal or informal triage in the first place.
"Smuggled Donuts and Forbidden Fried Chicken: Analyzing Ethical Tensions around Family and Food Restrictions in Hospital Settings"
Megan Dean and Laura Guidry-Grimes
Hastings Center Report, in print
Abstract: It is a common practice for family members to bring food to hospitalized loved ones. However, in some cases this food contravenes a patient’s dietary plan. Such situations can create significant tension and distrust between healthcare professionals (HCPs) and families and may lead HCPs to doubt a family’s willingness or ability to support patient recovery. This paper offers an ethical analysis of these situations. We draw on Hilde Lindemann’s work to argue that feeding is an important way families discharge their moral functions of caring and holding family members in their identities. When family members are hospitalized, other means of performing these functions are limited. Acknowledging the ethical importance of family feeding alongside the medical need for dietary restrictions, we offer strategies for creative problem-solving that center diet as a subject for shared decision-making and regular, ongoing communication among HCPs, patients, and families.
"The Case of Louisiana's 'Medically Futile' Unborn Child List: Ethical Lessons at the post-Dobbs Intersection of Reproductive and Disability Justice"
Laura Guidry-Grimes, Joel Michael Reynolds, and Devan Stahl
Hastings Center Report 53.1 (2023): 3-6.
Abstract: Ableist attitudes and structures are increasingly recognized across all sectors of healthcare delivery. After Dobbs, novel questions arose in the USA concerning how to protect reproductive autonomy while avoiding discrimination against and devaluation of disabled persons. As a case study, we examine the Louisiana’s Department of Public Health August 1st Emergency Declaration, “List of Conditions that shall deem an Unborn Child ‘Medically Futile.’” We raise a number of medical, ethical, and public health concerns that lead us to argue the declaration should be rescinded. The ethically objectionable declaration provides valuable lessons concerning how to uphold both reproductive and disability justice in a post-Dobbs landscape.
“An Open Discussion of the Impact of OpenNotes on Clinical Ethics: A Justification for Harm-Based Exclusions from Clinical Ethics Documentation"
Holland Kaplan, Laura Guidry-Grimes, Paul Crutchfield, Adira Hulkower, Claire Horner, Joey E. Burke, and Savitri Fedson
Journal of Clinical Ethics 33.4 (2022): 303-313
Abstract: The OpenNotes (ON) mandate in the 21st Century Cures Act requires that patients or their legally authorized representatives be able to access their medical information in their electronic medical record (EMR) in real time. Ethics notes fall under the domain of this policy. We argue that ethics notes are unique from other clinical documentation in a number of ways: they lack best-practice guidelines, are written in the context of common misconceptions surrounding the purpose of ethics consultation, and often answer questions of a different nature than other documentation. Thus, we believe the clinical ethics community would benefit from clarification on when the withholding of ethics notes is justified. We provide recommendations for excluding information from ethics documentation based on the likelihood and magnitude of harm that may occur with particular disclosures and suggest approaches to decrease the potential harms that may occur. We define and explain six types of reasons to exclude information from ethics notes based on significant harms that are not addressed in the ON policy: (1) harmful revelations from a protected chart note; (2) negative emotional effects on patients or families; (3) the purpose of the consultation is undermined by harmful consequences; (4) avoidable negative impact on interpersonal dynamics; (5) inappropriate labeling or disclosure of medical, social, or financial information; and (6) inclusion of biasing or otherwise unfair information. We also suggest approaches to mitigate harm when excluding, including, reframing, or delaying release of information that is perceived to be relevant to an ethics case. Overall, we hope our analysis and recommendations will initiate a much-needed discussion about the impact of the ON mandate on clinical ethics documentation.
"Reimagining Commitments to Patients and the Public in Professional Oaths"
Laura Guidry-Grimes
Kennedy Institute of Ethics Journal 32.3 (2022): 261-296
Abstract: Robert Veatch argues that physician oaths should not be valued as substantive moral commitments, transformational rituals, or symbolic acts. Further, he insists that oath recitation in medical schools is immoral. I respond to Veatch’s criticisms and argue that, with alterations to their content and practice, oaths can have value for articulating moral commitments and building a sense of moral community within the profession. I break down Veatch’s multitude of objections to oaths over his career, and I suggest how medical schools can avoid the pitfalls identified by Veatch. A promising and innovative path forward is to integrate a commitment to diversity, equity, and inclusion—though with an understanding that a few lines in an oath are far from sufficient for institutional culture, faculty accountability, or students’ education.
"Disability Bioethics and the Commitment to Equality"
Laura Guidry-Grimes
Theoretical Medicine and Bioethics (2022): epub ahead of print.
Abstract: Robert Veatch’s The Foundations of Justice: Why the Retarded and the Rest of Us Have Claims to Equality (1986) delves into deep questions of justice through the case of a child with disabilities. I describe what is basically right about this vision, as well as what is problematic from the standpoint of contemporary disability bioethics. From there, I dive into the notion of vulnerability that is at play in his work. He describes disability as necessarily a condition of weakness, lesser-than existence, and neediness. When disability is viewed in this way as an inherently vulnerable state of being, the essential sociopolitical dimensions of disability receive inadequate attention, which, in turn, makes it impossible to identify injustices correctly. I connect these points to concrete challenges faced by disability communities during the COVID-19 pandemic, which have raised profound questions about the just use of scarce critical care resources. Any case drawn from the pandemic is a very different kind of case than that of the child in Veatch’s book, but a commonality is the question of who should get what limited resources when needs and urgency vary.
“Defining Mental Illness and Psychiatric Disability”
Laura Guidry-Grimes
In Disability Bioethics Reader, eds. Joel Michael Reynolds and Christine Wieseler. NY: Routledge, 2022: 273-281.
Abstract: Defining illness and disability is a value-laden enterprise. Value judgments go into deciding what facets of a lived condition are pathological or within the range of healthy human diversity. Not all problems presented by living are pathological, so a line or threshold has to be drawn somewhere. This definitional work is complex, messy, and evolving in all of medicine, but the challenge in psychiatry can be especially immense. The history of psychiatric diagnostic systems is riddled with unfortunate social biases (including racist, sexist, heterosexist, cissexist, classist, and others). With any of these attempts, emotional states, desires, ways of thinking and processing, and patterns of behavior are identified that presumably would benefit from some sort of medical intervention. The stakes for psychiatric diagnosis are significant: patient complaints can be taken seriously by healthcare professionals and insurance providers only if they have a diagnostic label attached to their concerns, but the label of mental illness also frequently heaps on stigma, discrimination, and distrust. This chapter begins by briefly describing the historical backdrop of nosology (the classification of disorders) in psychiatry. I summarize some controversial diagnostic categories as well as current criticisms of the Diagnostic and Statistical Manual of Mental Disorders, which is published by the American Psychiatric Association but has global influence. The purpose of this summary is neither to dismiss psychiatry as a medical field nor to demonize its practitioners. Rather, the aim is to highlight how problematic value judgments can creep into the construction of any nosological system.
"Vulnerability in Practice: Peeling Back the Layers, Avoiding Triggers, and Preventing Cascading Effects"
Elizabeth Victor, Florencia Luna, Laura Guidry-Grimes, and Alison Reiheld
Bioethics 36.5 (2022): epub ahead of print.
Abstract: The concept of vulnerability is widely used in bioethics, particularly in research ethics and public health ethics. The traditional approach construes vulnerability as inherent in individuals or the groups to which they belong and views vulnerability as requiring special protections. Florencia Luna and other bioethicists continue to challenge traditional ways of conceptualizing and applying the term. Luna began proposing a layered approach to this concept and recently extended this proposal to offer two new concepts to analyze the concept of vulnerability, namely understanding external conditions that trigger vulnerability and layers of vulnerability with cascading effects. Luna's conception of vulnerability is useful, which we demonstrate by applying her layered view and the new analyses in multiple contexts. We begin by outlining Luna's view and we use vignettes from healthcare involving transgender patients, the care of patients in psychiatric contexts, and research involving prisoners to illustrate how each part of Luna's concept elucidates important moral issues.
"Ethical Uncertainty in the Care of Hospitalized Older Adults: Challenges and Pandemic Considerations"
Nancy Berlinger, Laura Guidry-Grimes, and Adira Hulkower
Generations Today (2 March 2021): Web.
Abstract: The typical patient in an American hospital is an older adult. During the coronavirus pandemic, people ages 85 and older have had the highest rates of death from COVID-19, followed by people ages 75 to 84. When hospital physicians and nurses are unsure of “the right thing to do” for a patient, they are experiencing ethical uncertainty. These situations frequently arise in the care of an adult who lacks the capacity to make decisions about potentially life-sustaining interventions. This article focuses on ethical uncertainty in medical contexts involving older adults as patients. Our perspectives reflect healthcare ethics, a methodological approach that responds to ethical uncertainty arising in healthcare work. As scholars and researchers, we also reflect interdisciplinary work across fields such as gerontology, disability studies and bioethics.
"Against Personal Ventilator Reallocation"
Joel Michael Reynolds, Laura Guidry-Grimes, and Katie Savin
Cambridge Quarterly of Healthcare Ethics 30.2 (April 2021): 272-284.
Abstract: The COVID-19 pandemic has led to intense conversations about ventilator allocation and reallocation during a crisis standard of care. Multiple voices in the media and multiple state guidelines mention reallocation as a possibility. Drawing upon a range of neuroscientific, phenomenological, ethical, and socio-political considerations, we argue that taking away someone’s personal ventilator is a direct assault on their bodily and social integrity. We conclude that personal ventilators should not be part of reallocation pools and that triage protocols should be immediately clarified and explicitly state that personal ventilators will be protected in all cases.
“Disability Rights as a Necessary Framework for Crisis Standards of Care and the Future of Health Care”
Laura Guidry-Grimes, Katie Savin, Joseph A. Stramondo, Joel Michael Reynolds, Marina Tsaplina, Teresa Blankmeyer Burke, Angela Ballantyne, Eva Feder Kittay, Devan Stahl, Jackie Leach Scully, Rosemarie Garland-Thomson, Anita Tarzian, Doron Dorfman, and Joseph J. Fins
Hastings Center Report 50.3 (May/June 2020): 28-32.
Abstract: In this essay, we suggest practical ways to shift the framing of crisis standards of care toward disability justice. We elaborate on the vision statement provided in the 2010 National Academy of Medicine/Institute of Medicine, which emphasizes 1) fairness, 2) equitable processes, 3) community and provider engagement, education, and communication; and 4) the rule of law. We argue that interpreting these elements through disability justice entails a commitment to both distributive and recognitive justice. The disability rights movement’s demand “Nothing About Us, Without Us” requires substantive inclusion of disabled people in decision-making related to their interests, including in crisis planning before, during, and after a pandemic like COVID-19.
“Ethics and Expert Authority in the Patient-Psychotherapist Relationship”
Laura Guidry-Grimes and Jamie Carlin Watson
In Oxford Handbook of Psychotherapy Ethics, eds. Manuel Trachsel, Serife Tekin, Nikola Biller-Andorno, Jens Gaab, and John Z. Sadler. NY: Oxford University Press, 2021. 496-514.
Abstract: The consumer/survivor/ex-patient movement contends that individuals diagnosed with mental health conditions are routinely doubted or dismissed when they make claims about their needs, values, and interests. Too many therapists, the claim goes, take a parentalist stance toward their patients. Recent work on expertise shows how some patients can acquire competence with their medical condition sufficient for sophisticated participation in management of their care; that is, they can become “patient experts.” We argue that many psychotherapy patients can become patient experts and, thereby, benefit from attempts at robust shared decision-making (SDM). In these cases, attitudes of distrust and protectionism can lead to the moral failure of epistemic injustice, thereby harming both the patient and the therapeutic relationship. Drawing on recent literature on epistemic injustice, SDM, and expertise from epistemology, we contend that the success of SDM relies largely on the therapist’s appreciation of the varying types and degrees of expertise and epistemic advantage involved in decision-making.
"Covert Consciousness and Covert Ethics"
Laura Guidry-Grimes
Perspectives in Biology and Medicine 63.3 (Summer 2020): 553-569.
Abstract: Rights Come to Mind: Brain Injury, Ethics, and the Struggle for Consciousness by Joseph J. Fins offers rich narratives of families and patients who experience disorders of consciousness in flawed healthcare systems that are not clinically, structurally, financially, or ethically prepared to respond to the inherent complexities of these conditions. Only a few years after the publication of this book, the medical guidelines for these disorders officially changed with key publications in Neurology in 2018. Fins has called on bioethicists to respond to these significant developments, and this paper serves as a response to that call. I offer a critical analysis of a couple of Fins’s arguments, but I also emphasize the importance of these developments and Fins’s work for thinking through bedside and organizational ethics issues that arise in advocating for patients with disorders of consciousness.
"Overcoming Obstacles to Shared Mental Health Decision Making"
Laura Guidry-Grimes
AMA Journal of Ethics 22.5 (May 2020): E446-451.
Associated podcast
Abstract: Shared decision making (SDM) is practically difficult to implement in mental health practice but remains an ethical ideal for motivating therapeutic capacity in clinician-patient relationships; this discrepancy warrants attention from clinical and ethical perspectives. This article explores what some clinicians see as obstacles to even attempting SDM with patients with psychiatric disabilities. In particular, this article identifies 4 of these obstacles: a patient’s decision making incapacity, a patient’s poor insight, a health care professional’s therapeutic pessimism or personal dislike, and a patient’s or health care professional’s conflicting recovery orientations or goals of care. This article argues that each obstacle could be overcome in many cases and that health care professionals, patients, and their caregivers should remain dedicated to attempting SDM in mental health practice.
"Covert Administration of Medication in Food: A Worthwhile Moral Gamble?"
Laura Guidry-Grimes, Megan Dean, and Elizabeth Victor
Journal of Medical Ethics 47 (2021): 389-393.
Summary on JME Blog
Abstract: The covert administration of medication occurs with incapacitated patients without their knowledge, involving some form of deliberate deception in disguising or hiding the medication. Covert medication in food is a relatively common practice globally, including in institutional and homecare contexts. Until recently, it has received little attention in the bioethics literature, and there are few laws or rules governing the practice. In this paper, we discuss significant, but often overlooked, ethical issues related to covert medication in food. We emphasize the variety of ways in which eating has ethical importance, highlighting what is at risk if covert administration of medication in food is discovered. For example, losing trust in feeders and food due to covert medication may risk important opportunities for identity maintenance in contexts where identity is already unstable. Since therapeutic relationships may be jeopardized by a patient’s discovery that caregivers had secretly put medications in their food, this practice can result in an ongoing deception loop. While there may be circumstances in which covert medication is ethically justified, given a lack of suitable alternatives, we argue that in any particular case this practice should be continually re-evaluated in light of the building moral costs to the relational agent over time.
“Regulating Decisions for Incapacitated Pregnant Women”
D. Micah Hester, Leah Eisenberg, and Laura Guidry-Grimes
JAMA 322.9 (2019): 894-895.
Abstract: The Research Letter1 on state regulations regarding pregnant women who lack decisional capacity demonstrated variation of health legislation across states. Unfortunately, the analysis incorrectly characterized the state laws in Arkansas.
"Moral Expertise in Clinical Ethics: Problems and Prospects"
Jamie Carlin Watson and Laura Guidry-Grimes
Harvard Medical School Bioethics Journal (Winter 2020): online.
Abstract: There is an increasing number of clinical ethics consultants in hospitals around the world, which raises the question: Can anyone be an expert in giving moral advice? We contend that clinical ethics expertise is obtainable. We review three common challenges to the idea that clinical ethicists can be moral experts and show that each fails to undermine its plausibility. We admit, however, that the conditions under which clinical ethics is practiced render acquiring and identifying moral expertise more difficult than expertise acquired under different conditions. We argue that a first step in identifying and developing expertise is understanding how the environment in which clinical ethicists work affects their ability to get adequate feedback on their advice. We think the prospects for acquiring and enhancing clinical ethics expertise depend on whether ethics services can use methods developed by psychologists to enhance expertise in similar environments to create mechanisms for eliciting reliable feedback on consulting practices.
“Clarifying a Clinical Ethics Service’s Value, the Visible and the Hidden"
Laura Guidry-Grimes, Marika Warren, Hannah Lipman, Kelly Kent, Kaarkuzhali Babu Krishnamurthy, Arlene Davis, Thomas May, Marycon Chin Jiro, and Jane Jankowski
Journal of Clinical Ethics 30.3 (Fall 2019): 251-261.
Abstract: Our aim in this paper is to clarify and demonstrate the distinct value that a clinical ethics service (CES) could and should have for an institution and those it serves. In this paper we describe how the value of a CES can be overt, but it is often hidden due to the systems-level and process-oriented nature of its work. Our aim is to a) elucidate the multifaceted value added by a CES, including value that tends to be hidden and b) suggest how to demonstrate value to others in a way that is not reductionistic or simplistic. We take the question of value to be primary and fundamental: It asks why a CES is worth having and how it contributes to ethical care of patients, and it calls for an answer beyond the mere listing of activities and quantifiable metrics.
"Homeless, Ill, and Psychiatrically Complex: The Grueling Carousel of Cassandra Lee"
Laura Guidry-Grimes
Hastings Center Report 49.4 (July-August 2019): 8-13.
Abstract: Ask any clinical ethics consultant, and they can tell you about their transformative cases—the ones
that challenged them to find creative solutions, to collaborate productively in tricky situations, to witness tragedy while maintaining professional equanimity, to reflect on their shortcomings and predilections. Some cases stick with us because all roads led to nowhere: every attempt to make steady progress on the central issues, to get to know the patient better, and to work toward principled resolutions had limited success. Those were the cases in which the clinical ethics consultant (as well as other members of the health care team) was left wondering, what more could we have done? The story I offer here is such a case. It involved a medically and psychiatrically complex patient who lived a precarious existence on her own, without the supports she needed to make her health issues manageable. Everyone involved in her care knew that there was only so much that could be done for her, given how our community outside the walls of the hospital had failed her. This backdrop created moral uncertainties for the ethics service in trying to support her and her health care team, but it also generated a responsibility to advocate for such vulnerable patients through partnerships with the community.
"Ethical Complexities in Assessing Patients' Insight"
Laura Guidry-Grimes
Journal of Medical Ethics 45 (2019): 178-182.
Summary on JME Blog
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 their mental illness. When a patient is described as lacking insight, there are significant implications for patient care and to what extent the patient is trusted as a knower. Insight is currently viewed as a multidimensional and continuous construct, but competing conceptions of insight still lack consensus on the specifics. Studies also give contradictory evidence regarding the frequency and consequences of poor insight. A number of crucial questions remain unanswered. After outlining some of the key theoretical disagreements about what insight means, I highlight ethical issues that have not received much attention in the literature. Given the conceptual ambiguities and the absence of standardized bedside tools, there are significant ethical concerns about insight assessments. I highlight two main ethical concerns, specifically that these assessments risk 1) marginalizing patients by setting unattainable ideals for self-knowledge and 2) minimizing the patient’s own perspective on their mental health. I close with recommendations for documenting and responding to concerns about poor insight, so patients who are vulnerable to losing epistemic trust are better supported in their therapeutic relationships.
"Posthumous HIV Disclosure and Relational Rupture"
Laura Guidry-Grimes and D. Micah Hester
Journal of Clinical Ethics 29.3 (Fall 2018): 196-200.
Abstract: In response to Anne L. Dalle Ave and David M. Shaw, we agree with their general argument but emphasize a moral risk of HIV disclosure in deceased donation cases: the risk of relational rupture. Because of the importance that close relationships have to our sense of self and our life plans, this kind of rupture can have long-ranging implications for surviving loved ones. Moreover, the now-deceased individual cannot participate in any relational mending. Our analysis reveals the hefty moral costs that disclosure can bring, which should influence what information is given to would-be donors and how organ procurement coordinators approach these conversations.
"Relational Autonomy in Action: Rethinking Dementia and Sexuality in Care Facilities"
Elizabeth Victor and Laura Guidry-Grimes
Nursing Ethics (July 2018), epub ahead of print.
Abstract: Caregivers and staff in long-term care facilities have fragile moral work in providing exemplary person-centered care. We analyze the ethical challenges of enabling sexual activity among residents in these facilities, focusing on residents with early to moderate dementia in states of daily dependency on professional caregivers. We highlight the delicate balance that capacity assessments for sexual activity have to strike; while caregivers should protect those who cannot give adequate consent, the denial of sexuality among residents can cause deep, long-ranging harms. We show how sexual agency features into an ongoing sense of self, and the imposition of inappropriate standards and expectations for sexual autonomy can lead to unwarranted obstacles to sexual activity. We offer starting points for constructing guidelines and framing responsibilities that care facilities and healthcare staff have in these ethically complicated situations.
"In the Balance: Weighing Preferences of Decisionally Incapacitated Patients"
Laura Guidry-Grimes
Hastings Center Report 48.3 (May-June 2018): 41-42.
Abstract: In this commentary on "Capacity for Preferences: Respecting Patients with Compromised Decision-Making" by Jason Wasserman and Mark Navin, I argue that distinguishing among preferences is critical for determining their comparative weight in relation to other moral interests. The authors focus on how "suboptimal" preferences are, but this sidesteps the critical questions in these cases. The authors underappreciate the nuanced guidance that the standards for surrogate decision-making can provide, which I demonstrate in my ethical analysis of their clinical case.
"'But It's a Gift!' Adherence Pressures Post-Transplant"
Laura Guidry-Grimes
Journal of Hospital Ethics 5.1 (Winter 2018): 21-27.
Abstract: “Gift” language is rampant in public campaigns, scholarly studies and analyses, and even in the hallways of hospitals when referring to transplantable organs. The organ-as-a-gift notion brings with it a number of social and moral implications, not only for motivating potential donors and their families but also for motivating recipients. The “gift ethic” in transplant contexts needs further analysis, especially given how “gift” language can structure moral relationships among donors, donors’ families, healthcare professionals (HCPs), organ procurement coordinators, prospective and past transplant recipients, and recipients’ support system. Although substantial literature explores the gift ethic as it relates to encouraging donation, there are far fewer studies and discussions on how this ethic impacts recipients. This issue merits investigation because transplant recipients are frequently subjected to moral remonstrations and various other pressures to respect their “gift,” but to what extent these pressures are justified is not always evident or obvious. My aim in this paper is two-fold. First, I will briefly analyze how organs could be a certain type of gift. Second, I will investigate the general moral obligations and justifiable expectations of organ recipients as implied by the gift ethic, and I will outline the limitations of those obligations and expectations.
"Knowledge Is Key for Safety-Net Providers: Undocumented Patients May Not Know Their Health-Related and Legal Rights"
Nancy Berlinger, Laura Guidry-Grimes, Adira Hulkower
Health Progress (July-August 2017): 9-14.
Winner: "Best Feature Article: Professional & Special Interest Magazine" - Catholic Press Association
Abstract: Immigration policy and health care — what's the connection? Safety-net hospitals, community health centers and health programs serving low-income populations almost inevitably will encounter undocumented immigrants as patients or prospective patients, as community members for whom health care access is an important avenue for integration into American society, and as persons whose health-related legal rights may be overlooked, imperiled or difficult to us. Knowing how this vulnerable group is similar to — and different from — other low-income patient populations is an important part of planning for and providing good care. A health care facility's administration, staff and clinicians should be educated and ready to take practical steps to protect the basic rights of these patients, manage typical challenges in their care and strengthen the safety net. In the words of Rob Marlin, a Cambridge, Mass., physician who trains colleagues to care for their immigrant patients, physicians and safety-net institutions need to have "greater knowledge of immigration policy to take care of our patients … [policy] is no longer a spectator sport."
"Inhospitable Health Care Spaces: Why Training on LGBTQIA Issues Is Not Enough"
Megan Dean, Elizabeth Victor, and Laura Guidry-Grimes
Journal of Bioethical Inquiry, vol.13, no. 4 (December 2016): 557-570.
Abstract: In an effort to address health care disparities in lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations, many hospitals and clinics institute diversity training meant to increase providers’ awareness of and sensitivity to this patient population. Despite these efforts, many health care spaces remain inhospitable to LGBTQ patients and their loved ones. Even in the absence of overt forms of discrimination, LGBTQ patients report feeling anxious, unwelcome, ashamed, and distrustful in health care encounters. We argue that these negative experiences are produced by a variety of subtle, ostensibly insignificant features of health care spaces and interpersonal interactions called microaggressions. Healthcare spaces and providers often convey heteronormative microaggressions, which communicate to LGBTQ—and, we suggest, intersex and asexual (IA)—people that their identities, experiences, and relationships are abnormal, pathological, unexpected, unwelcome, or shameful. We identify heteronormative microaggressions common to health care settings and specify how they negatively impact LGBTQIA patients. We argue that standard diversity training cannot sufficiently address heteronormative microaggressions. Despite these challenges, health care institutions and providers must take responsibility for heteronormative microaggressions and take steps to reduce their frequency and mitigate their effects on LGBTQIA care. We conclude by offering strategies for problem-solving at the level of medical education, institutional culture and policy, and individual awareness.
“The Case of Ms. D: A Family’s Request for Posthumous Procurement of Ovaries for Future Reproduction”
Laura Guidry-Grimes
Journal of Clinical Ethics, vol. 27, no.1 (Spring 2016): 51-58.
Abstract: The clinical ethics team became involved in a case when a family requested the posthumous removal of a patient’s ovaries for future reproductive use. This case presents a novel question for clinical ethicists, since the technology for posthumous female reproduction is still in development. In the bioethics literature, the standard position is to refuse to comply with such a request, unless there is explicit consent or evidence of explicit conversations that demonstrate the deceased would have wanted this option pursued. Ms D’s case, we suggest, offers an exception to this default position; complying with the family’s request could have been ethically permissible in this case, had it been medically feasible.
"Modelling Psychiatric Disability"
Laura Guidry-Grimes
Journal of Evaluation in Clinical Practice, Philosophy Thematic Issue, vol. 21, no. 3 (June 2015): 490-495.
Part of a dissertation chapter
Abstract: There has been inadequate philosophical attention to the claims of psychiatric user/survivor activist groups, though these groups represent a significant social justice movement. Many of the core concerns and claims emerging from this activism can be found in disability activism. A first step that must be taken is to question how mental illnesses are modeled. Biomedical modeling is heavily criticized by psychiatric users/survivors for being reductionistic and for perpetuating damaging presumptions about decline and pathology. Social constructionist modeling, on the other hand, tends to be overly dismissive of biological factors that are often at play with these sorts of impairments. A middle ground approach, interactionist modeling, promises to be responsive to demands for recognition from psychiatric users/survivors. I will first outline the core commitments of psychiatric user/survivors. Next, I will evaluate different models for mental illness by bringing together insights from user/survivor and disability activism. I conclude that interactionist modeling holds the best hope for supporting shared decision-making. This type of model braids together the expertise of patients and medical professionals.
"Ethical Bargaining and Parental Exclusion: A Clinical Case Analysis"
Laura Guidry-Grimes and Elizabeth Victor
Journal of Clinical Ethics, vol. 26, no. 3 (Fall 2015): 250-259.
Abstract: Although in clinical ethics there has been significant attention to when physicians should follow through with a parent’s wishes, there has been much less discussion of the obligation to solicit viewpoints and decisions from all caregivers who have equal moral and legal standing in relation to a pediatric patient. How should healthcare professionals respond when one caregiver dominates decision-making? We present a case that highlights how these problems played out in an ethical bargain. Ethical bargaining occurs when the parties involved choose not to pursue the morally preferable option for the sake of coming to a resolution. This case is not one of parental disagreement; rather, the medical team agreed to exclude the mother from decision-making if the father promised to bring back their son for necessary medical tests. We argue that there is an obligation to notice and acknowledge power asymmetries in the family unit, which in this case manifested as the marginalization of the female decision-maker by the male decision-maker. In these scenarios, clinicians should be careful to avoid treating the parents as one homogenous unit, and they should take action to enable caregiver autonomy and voice. While there are moral and practical limits to how and when physicians should intervene in family dynamics, we discuss the steps that the medical team should have taken in this case to avoid undermining the parental authority of the mother. We conclude by offering recommendations to address and enable caregiver autonomy at an institutional level, and we discuss the importance of tracking and responding to damaging family dynamics so as to prevent ethically impermissible bargaining.
“I Will Never Doubt Again: Hope and Responsible Belief in The Princess Bride"
Jamie Watson and Laura Guidry-Grimes
The Princess Bride and Philosophy (Popular Culture and Philosophy Series) -- based off of film The Princess Bride
Chicago: Open Court, 2015: 77-84.
Abstract: Buttercup promised to trust that Westley would return. But he was gone for five years. No word from him for five years! Plus, his ship was attacked by The Dread Pirate Roberts (who, by the way, takes no prisoners). Who could blame her for losing hope? Well, apparently, Westley could. In the guise of his assailant, Westley excoriates Buttercup for her upcoming marriage, mocking her promise to be faithful. Is Westley's outrage rational? Should Buttercup have held fast to hope, despite the overwhelming evidence that Westley was dead? These are questions about responsible belief. Starting with the ancient Greeks, many philosophers have claimed that, in order to be rational, we must follow the evidence wherever it leads and adjust our beliefs accordingly. If our evidence is strong, we should believe strongly; if it is weak, we should believe weakly. And if it is very weak or unclear, we should suspend belief altogether. If we believe without any evidence or against the evidence, we are acting irrationally; we have perhaps even succumbed to wishful thinking, which can ensnare the hopeful believer as thoroughly and quickly as lightning sand. Presumably, we all want to avoid wishful thinking. The world does not bend itself to our desires, whether we wish for a million florins, a miracle pill, or true love’s return. But should we be strictly beholden to evidence? In The Princess Bride, Westley’s attitude toward evidence is very different from Buttercup’s, and he is our hero. Vizzini’s confidence is not entirely unwarranted, yet he is a villain. We cannot help but to admire Inigo’s perseverance and twenty-year conviction that he will avenge his father. And yet, he has hardly any information about the identity of the killer and no evidence that he will find him. So, is there room for rationality in the space between diligently following the evidence and wishful thinking? Could hope be rational even when the evidence doesn’t look promising? And what role do personal values play in the extent to which our beliefs are rational?
“Expectation and Suffering with LVAD Deactivation”
Laura Guidry-Grimes and Nneka Sederstrom
American Journal of Bioethics, vol. 15, no. 7 (July 2015): 74-76.
Abstract: This case raises a number of ethical flags related to the meaning of LVAD deactivation, the quality of the consent and physician-patient relationship, how to respect a patient’s autonomy with unclear capacity status and apparently mixed wishes, the implications of depression and bipolar disorder for decision-making, and long-term concerns with keeping this patient on the LVAD as a bridge to transplant. We will not delve into all of these ethical issues, though they all deserve consideration, especially given the novel and growing challenges presented by ventricular assist devices. We will take it as a given that deactivating the LVAD is not categorically different from withdrawing other life-sustaining technologies, though we acknowledge there is bioethical disagreement on how to regard the hybrid (partially internal, partially external) status of VADs. Mr. B repeatedly begs for the deactivation of his bridge device, evidently with the understanding that doing so would hasten his death. Every capacitated adult has the legal and ethical right to refuse life-sustaining technologies. In Mr. B’s case, however, we have questions about his capacity and whether following through with his deactivation request would support his actual autonomy interests. In our analysis, we will discuss the complicating factors involved, which are not exhausted by his psychiatric diagnosis.
Case Commentary
Christian Carrozzo and Laura Guidry-Grimes
Mid-Atlantic Ethics Committee Newsletter (Winter 2015): 9-11.
Abstract: For this case commentary, we provide an ethical analysis of the following case:
Ken is a 52 year old man who has lived in a nursing home for the past 15 years. He is severely cognitively impaired, has no known family, and has an appointed guardian. While being transported to a dental visit, Ken is involved in a motor vehicle accident and is taken to a hospital. He is treated for traumatic injuries to the head and neck. After three days of care in the intensive care unit Ken has lost all neurological reflexes and physicians conclude that he will not survive his injuries. They initiate testing to confirm death by neurologic criteria. The organ procurement staff speak with the guardian to discuss whether Ken can be an organ donor (if he is declared dead by neurologic criteria, or after cardiac death).The guardian believes she cannot consent on Ken's behalf for organ donation if Ken has not previously expressed a willingness to donate his organs. An ethics consultation is requested to weigh in on this question.
"The Persistence of Agency through Social Institutions and Caring for Future Generations"
Elizabeth Victor and Laura Guidry-Grimes
International Journal of Feminist Approaches to Bioethics, vol. 7, no. 1 (Spring 2014): 122-141.
Abstract: We argue that we have obligations to future people that are similar in kind to obligations we have to current people. Modifying Michael Bratman’s account, we argue that as planning agents we must plan for the future to act practically in the present. Understanding ourselves as relationally autonomous implies that those plans will involve building affiliative bonds and caring for others. We conclude by grounding responsibility to future others by the way we plan through our social institutions. Our account fills out the story of responsibility to future generations by referring only to ourselves, our practical identities, and practical reason.
"Should the Police Hire a Psychic Detective?"
Laura Guidry-Grimes
Psych and Philosophy (Popular Culture and Philosophy Series) -- based off of TV show, Psych
Chicago: Open Court Publishing, 2013, pgs. 59-68.
Abstract: When Police Chief Karen Vick is confronted with Shawn Spencer, a self-proclaimed psychic who promises to help solve unsolvable cases, she faces a quandary: Can she trust Shawn’s claims that he can help bring about justice and make Santa Barbara safer? Even if she decides she can trust him, should she hire him? There are a number of ethical considerations embedded in these questions. In order to trust Shawn in this role, she must have reasonable evidence that he has psychic abilities along with the discipline and motivation necessary to work on cases for the department. In the literature, there is conflicting evidence as to whether a psychic has ever successfully helped solve a crime. However, Shawn has a record of calling in critical tips, and he repeatedly proves his uncanny ability to find unusual leads. But even if Shawn is useful, Vick still has to decide whether hiring him would be prudent. Would taxpayers agree to this use of funds? A 2001 Gallup poll found that 50% of people believe in ESP, and the Santa Barbara community might be even more inclined to believe Shawn’s claims, given the positive publicity he (generally) receives. Is Vick professionally and morally obligated to pursue nontraditional options when standard methods are ineffective or inefficient? Vick also has to consider whether hiring a purported psychic could give families false hope, and her other detectives (like Lassiter) might worry that hiring a psychic mocks their work. In this essay, I will unpack these ethical problems from Vick’s point of view, considering in turn the complex relationships that Shawn has with those in the police department.
"Vulnerabilities Compounded by Social Institutions"
Laura Guidry-Grimes and Elizabeth Victor
International Journal of Feminist Approaches to Bioethics, vol. 5, no. 2 (Fall 2012): 126-146.
Abstract: How can social institutions complicate and worsen vulnerabilities of particular individuals or groups? We begin by explicating how certain diagnoses within mental health and medicine operate as interactive kinds of labels and how such labels can create institutional barriers which hinder one’s capacity to achieve well-being. Interactive kind modeling is a conceptual tool that elucidates the ways in which labeling can signal to others how the labeled person ought to be treated, how such labeling comes about and is perceived, and how it compounds vulnerabilities. We argue that this shift in standpoint helps us recognize and mitigate compounded vulnerabilities.
"Another Roadblock to Including Women in Research"
Laura Guidry-Grimes and Elizabeth Victor
Hastings Center Report, vol. 42. no. 5 (Sept-Oct 2012): inside back cover.
Abstract: Scientists, clinicians, and bioethicists are worried about how so-called personhood measures would limit access to certain types of contraception, research involving stem cells, and access to fertility treatments. While these measures have been struck down in Colorado, South Dakota, California, and Mississippi, the bill signed into law in Oklahoma in February deserves critical scrutiny, particularly into the ways these legal measures influence eligibility for clinical research. Oklahoma's bill states that the laws of the state “shall be interpreted and construed to acknowledge on behalf of the unborn child at every stage of development all the rights, privileges, and immunities available to other persons, citizens, and residents of this state.”
Laura Guidry-Grimes
In Nursing Ethics: Normative Foundations, Advanced Concepts, and Emerging Issues, eds. Michael J. Deem and Jennifer Hagerty Lingler, in press.
Abstract: The aim of this chapter is to elucidate how persons with disabilities can be rendered vulnerable in various clinical contexts, which has implications for how nurses should identify and address different types of barriers for patients in their care. The chapter begins by surveying the conceptual territory surrounding the term ‘disability,’ since how this term is conceptualized will make a difference for framing the nature of vulnerabilities as they arise. Next, the chapter examines how institutional environments (such as in hospitals and nursing homes) can limit opportunities for agency, and this discussion will include the challenges faced by persons with physical, intellectual, and psychiatric disabilities. This chapter emphasizes how nurses, nurse assistants, and healthcare facilities should proactively mitigate vulnerabilities for persons with disabilities and enable different forms of agency.
"Disability Rights and Disability Justice as Gestalt Shifts for Triage Decision-Making in a Pandemic"
In Disability Justice in Emergency Conditions, eds. Mercer Gary and Joel Michael Reynolds, in press.
Abtract: In this chapter, we begin by describing ableism as a systemic and historic form of bias that leads to a cascade of prejudice and disadvantage for disabled people; importantly, ableism runs parallel with other forms of bias such as racism, ageism, and classism. With this necessary background in place, we describe disability rights and disability justice as distinct frameworks for normative analysis and advocacy. We then investigate the central tensions surrounding triage of healthcare resources during a pandemic, specifically turning to the evolving moral and political discourse from 2020 through 2022 in relation to COVID-19. We discuss how an emphasis on disability rights was necessary to provide basic protections to persons with disabilities during this public health emergency; however, we also argue that disability justice has not been properly elevated or achieved during the pandemic. We then discuss the phenomenon of “informal triage,” which leads to denying healthcare resources to disabled persons even when scarcity does not necessitate it. Both formal and informal triage can be especially dangerous for multiply marginalized disabled persons, and a commitment to disability justice is ethically and politically important for reimagining the conditions that lead to formal or informal triage in the first place.
"Smuggled Donuts and Forbidden Fried Chicken: Analyzing Ethical Tensions around Family and Food Restrictions in Hospital Settings"
Megan Dean and Laura Guidry-Grimes
Hastings Center Report, in print
Abstract: It is a common practice for family members to bring food to hospitalized loved ones. However, in some cases this food contravenes a patient’s dietary plan. Such situations can create significant tension and distrust between healthcare professionals (HCPs) and families and may lead HCPs to doubt a family’s willingness or ability to support patient recovery. This paper offers an ethical analysis of these situations. We draw on Hilde Lindemann’s work to argue that feeding is an important way families discharge their moral functions of caring and holding family members in their identities. When family members are hospitalized, other means of performing these functions are limited. Acknowledging the ethical importance of family feeding alongside the medical need for dietary restrictions, we offer strategies for creative problem-solving that center diet as a subject for shared decision-making and regular, ongoing communication among HCPs, patients, and families.
"The Case of Louisiana's 'Medically Futile' Unborn Child List: Ethical Lessons at the post-Dobbs Intersection of Reproductive and Disability Justice"
Laura Guidry-Grimes, Joel Michael Reynolds, and Devan Stahl
Hastings Center Report 53.1 (2023): 3-6.
Abstract: Ableist attitudes and structures are increasingly recognized across all sectors of healthcare delivery. After Dobbs, novel questions arose in the USA concerning how to protect reproductive autonomy while avoiding discrimination against and devaluation of disabled persons. As a case study, we examine the Louisiana’s Department of Public Health August 1st Emergency Declaration, “List of Conditions that shall deem an Unborn Child ‘Medically Futile.’” We raise a number of medical, ethical, and public health concerns that lead us to argue the declaration should be rescinded. The ethically objectionable declaration provides valuable lessons concerning how to uphold both reproductive and disability justice in a post-Dobbs landscape.
“An Open Discussion of the Impact of OpenNotes on Clinical Ethics: A Justification for Harm-Based Exclusions from Clinical Ethics Documentation"
Holland Kaplan, Laura Guidry-Grimes, Paul Crutchfield, Adira Hulkower, Claire Horner, Joey E. Burke, and Savitri Fedson
Journal of Clinical Ethics 33.4 (2022): 303-313
Abstract: The OpenNotes (ON) mandate in the 21st Century Cures Act requires that patients or their legally authorized representatives be able to access their medical information in their electronic medical record (EMR) in real time. Ethics notes fall under the domain of this policy. We argue that ethics notes are unique from other clinical documentation in a number of ways: they lack best-practice guidelines, are written in the context of common misconceptions surrounding the purpose of ethics consultation, and often answer questions of a different nature than other documentation. Thus, we believe the clinical ethics community would benefit from clarification on when the withholding of ethics notes is justified. We provide recommendations for excluding information from ethics documentation based on the likelihood and magnitude of harm that may occur with particular disclosures and suggest approaches to decrease the potential harms that may occur. We define and explain six types of reasons to exclude information from ethics notes based on significant harms that are not addressed in the ON policy: (1) harmful revelations from a protected chart note; (2) negative emotional effects on patients or families; (3) the purpose of the consultation is undermined by harmful consequences; (4) avoidable negative impact on interpersonal dynamics; (5) inappropriate labeling or disclosure of medical, social, or financial information; and (6) inclusion of biasing or otherwise unfair information. We also suggest approaches to mitigate harm when excluding, including, reframing, or delaying release of information that is perceived to be relevant to an ethics case. Overall, we hope our analysis and recommendations will initiate a much-needed discussion about the impact of the ON mandate on clinical ethics documentation.
"Reimagining Commitments to Patients and the Public in Professional Oaths"
Laura Guidry-Grimes
Kennedy Institute of Ethics Journal 32.3 (2022): 261-296
Abstract: Robert Veatch argues that physician oaths should not be valued as substantive moral commitments, transformational rituals, or symbolic acts. Further, he insists that oath recitation in medical schools is immoral. I respond to Veatch’s criticisms and argue that, with alterations to their content and practice, oaths can have value for articulating moral commitments and building a sense of moral community within the profession. I break down Veatch’s multitude of objections to oaths over his career, and I suggest how medical schools can avoid the pitfalls identified by Veatch. A promising and innovative path forward is to integrate a commitment to diversity, equity, and inclusion—though with an understanding that a few lines in an oath are far from sufficient for institutional culture, faculty accountability, or students’ education.
"Disability Bioethics and the Commitment to Equality"
Laura Guidry-Grimes
Theoretical Medicine and Bioethics (2022): epub ahead of print.
Abstract: Robert Veatch’s The Foundations of Justice: Why the Retarded and the Rest of Us Have Claims to Equality (1986) delves into deep questions of justice through the case of a child with disabilities. I describe what is basically right about this vision, as well as what is problematic from the standpoint of contemporary disability bioethics. From there, I dive into the notion of vulnerability that is at play in his work. He describes disability as necessarily a condition of weakness, lesser-than existence, and neediness. When disability is viewed in this way as an inherently vulnerable state of being, the essential sociopolitical dimensions of disability receive inadequate attention, which, in turn, makes it impossible to identify injustices correctly. I connect these points to concrete challenges faced by disability communities during the COVID-19 pandemic, which have raised profound questions about the just use of scarce critical care resources. Any case drawn from the pandemic is a very different kind of case than that of the child in Veatch’s book, but a commonality is the question of who should get what limited resources when needs and urgency vary.
“Defining Mental Illness and Psychiatric Disability”
Laura Guidry-Grimes
In Disability Bioethics Reader, eds. Joel Michael Reynolds and Christine Wieseler. NY: Routledge, 2022: 273-281.
Abstract: Defining illness and disability is a value-laden enterprise. Value judgments go into deciding what facets of a lived condition are pathological or within the range of healthy human diversity. Not all problems presented by living are pathological, so a line or threshold has to be drawn somewhere. This definitional work is complex, messy, and evolving in all of medicine, but the challenge in psychiatry can be especially immense. The history of psychiatric diagnostic systems is riddled with unfortunate social biases (including racist, sexist, heterosexist, cissexist, classist, and others). With any of these attempts, emotional states, desires, ways of thinking and processing, and patterns of behavior are identified that presumably would benefit from some sort of medical intervention. The stakes for psychiatric diagnosis are significant: patient complaints can be taken seriously by healthcare professionals and insurance providers only if they have a diagnostic label attached to their concerns, but the label of mental illness also frequently heaps on stigma, discrimination, and distrust. This chapter begins by briefly describing the historical backdrop of nosology (the classification of disorders) in psychiatry. I summarize some controversial diagnostic categories as well as current criticisms of the Diagnostic and Statistical Manual of Mental Disorders, which is published by the American Psychiatric Association but has global influence. The purpose of this summary is neither to dismiss psychiatry as a medical field nor to demonize its practitioners. Rather, the aim is to highlight how problematic value judgments can creep into the construction of any nosological system.
"Vulnerability in Practice: Peeling Back the Layers, Avoiding Triggers, and Preventing Cascading Effects"
Elizabeth Victor, Florencia Luna, Laura Guidry-Grimes, and Alison Reiheld
Bioethics 36.5 (2022): epub ahead of print.
Abstract: The concept of vulnerability is widely used in bioethics, particularly in research ethics and public health ethics. The traditional approach construes vulnerability as inherent in individuals or the groups to which they belong and views vulnerability as requiring special protections. Florencia Luna and other bioethicists continue to challenge traditional ways of conceptualizing and applying the term. Luna began proposing a layered approach to this concept and recently extended this proposal to offer two new concepts to analyze the concept of vulnerability, namely understanding external conditions that trigger vulnerability and layers of vulnerability with cascading effects. Luna's conception of vulnerability is useful, which we demonstrate by applying her layered view and the new analyses in multiple contexts. We begin by outlining Luna's view and we use vignettes from healthcare involving transgender patients, the care of patients in psychiatric contexts, and research involving prisoners to illustrate how each part of Luna's concept elucidates important moral issues.
"Ethical Uncertainty in the Care of Hospitalized Older Adults: Challenges and Pandemic Considerations"
Nancy Berlinger, Laura Guidry-Grimes, and Adira Hulkower
Generations Today (2 March 2021): Web.
Abstract: The typical patient in an American hospital is an older adult. During the coronavirus pandemic, people ages 85 and older have had the highest rates of death from COVID-19, followed by people ages 75 to 84. When hospital physicians and nurses are unsure of “the right thing to do” for a patient, they are experiencing ethical uncertainty. These situations frequently arise in the care of an adult who lacks the capacity to make decisions about potentially life-sustaining interventions. This article focuses on ethical uncertainty in medical contexts involving older adults as patients. Our perspectives reflect healthcare ethics, a methodological approach that responds to ethical uncertainty arising in healthcare work. As scholars and researchers, we also reflect interdisciplinary work across fields such as gerontology, disability studies and bioethics.
"Against Personal Ventilator Reallocation"
Joel Michael Reynolds, Laura Guidry-Grimes, and Katie Savin
Cambridge Quarterly of Healthcare Ethics 30.2 (April 2021): 272-284.
Abstract: The COVID-19 pandemic has led to intense conversations about ventilator allocation and reallocation during a crisis standard of care. Multiple voices in the media and multiple state guidelines mention reallocation as a possibility. Drawing upon a range of neuroscientific, phenomenological, ethical, and socio-political considerations, we argue that taking away someone’s personal ventilator is a direct assault on their bodily and social integrity. We conclude that personal ventilators should not be part of reallocation pools and that triage protocols should be immediately clarified and explicitly state that personal ventilators will be protected in all cases.
“Disability Rights as a Necessary Framework for Crisis Standards of Care and the Future of Health Care”
Laura Guidry-Grimes, Katie Savin, Joseph A. Stramondo, Joel Michael Reynolds, Marina Tsaplina, Teresa Blankmeyer Burke, Angela Ballantyne, Eva Feder Kittay, Devan Stahl, Jackie Leach Scully, Rosemarie Garland-Thomson, Anita Tarzian, Doron Dorfman, and Joseph J. Fins
Hastings Center Report 50.3 (May/June 2020): 28-32.
Abstract: In this essay, we suggest practical ways to shift the framing of crisis standards of care toward disability justice. We elaborate on the vision statement provided in the 2010 National Academy of Medicine/Institute of Medicine, which emphasizes 1) fairness, 2) equitable processes, 3) community and provider engagement, education, and communication; and 4) the rule of law. We argue that interpreting these elements through disability justice entails a commitment to both distributive and recognitive justice. The disability rights movement’s demand “Nothing About Us, Without Us” requires substantive inclusion of disabled people in decision-making related to their interests, including in crisis planning before, during, and after a pandemic like COVID-19.
“Ethics and Expert Authority in the Patient-Psychotherapist Relationship”
Laura Guidry-Grimes and Jamie Carlin Watson
In Oxford Handbook of Psychotherapy Ethics, eds. Manuel Trachsel, Serife Tekin, Nikola Biller-Andorno, Jens Gaab, and John Z. Sadler. NY: Oxford University Press, 2021. 496-514.
Abstract: The consumer/survivor/ex-patient movement contends that individuals diagnosed with mental health conditions are routinely doubted or dismissed when they make claims about their needs, values, and interests. Too many therapists, the claim goes, take a parentalist stance toward their patients. Recent work on expertise shows how some patients can acquire competence with their medical condition sufficient for sophisticated participation in management of their care; that is, they can become “patient experts.” We argue that many psychotherapy patients can become patient experts and, thereby, benefit from attempts at robust shared decision-making (SDM). In these cases, attitudes of distrust and protectionism can lead to the moral failure of epistemic injustice, thereby harming both the patient and the therapeutic relationship. Drawing on recent literature on epistemic injustice, SDM, and expertise from epistemology, we contend that the success of SDM relies largely on the therapist’s appreciation of the varying types and degrees of expertise and epistemic advantage involved in decision-making.
"Covert Consciousness and Covert Ethics"
Laura Guidry-Grimes
Perspectives in Biology and Medicine 63.3 (Summer 2020): 553-569.
Abstract: Rights Come to Mind: Brain Injury, Ethics, and the Struggle for Consciousness by Joseph J. Fins offers rich narratives of families and patients who experience disorders of consciousness in flawed healthcare systems that are not clinically, structurally, financially, or ethically prepared to respond to the inherent complexities of these conditions. Only a few years after the publication of this book, the medical guidelines for these disorders officially changed with key publications in Neurology in 2018. Fins has called on bioethicists to respond to these significant developments, and this paper serves as a response to that call. I offer a critical analysis of a couple of Fins’s arguments, but I also emphasize the importance of these developments and Fins’s work for thinking through bedside and organizational ethics issues that arise in advocating for patients with disorders of consciousness.
"Overcoming Obstacles to Shared Mental Health Decision Making"
Laura Guidry-Grimes
AMA Journal of Ethics 22.5 (May 2020): E446-451.
Associated podcast
Abstract: Shared decision making (SDM) is practically difficult to implement in mental health practice but remains an ethical ideal for motivating therapeutic capacity in clinician-patient relationships; this discrepancy warrants attention from clinical and ethical perspectives. This article explores what some clinicians see as obstacles to even attempting SDM with patients with psychiatric disabilities. In particular, this article identifies 4 of these obstacles: a patient’s decision making incapacity, a patient’s poor insight, a health care professional’s therapeutic pessimism or personal dislike, and a patient’s or health care professional’s conflicting recovery orientations or goals of care. This article argues that each obstacle could be overcome in many cases and that health care professionals, patients, and their caregivers should remain dedicated to attempting SDM in mental health practice.
"Covert Administration of Medication in Food: A Worthwhile Moral Gamble?"
Laura Guidry-Grimes, Megan Dean, and Elizabeth Victor
Journal of Medical Ethics 47 (2021): 389-393.
Summary on JME Blog
Abstract: The covert administration of medication occurs with incapacitated patients without their knowledge, involving some form of deliberate deception in disguising or hiding the medication. Covert medication in food is a relatively common practice globally, including in institutional and homecare contexts. Until recently, it has received little attention in the bioethics literature, and there are few laws or rules governing the practice. In this paper, we discuss significant, but often overlooked, ethical issues related to covert medication in food. We emphasize the variety of ways in which eating has ethical importance, highlighting what is at risk if covert administration of medication in food is discovered. For example, losing trust in feeders and food due to covert medication may risk important opportunities for identity maintenance in contexts where identity is already unstable. Since therapeutic relationships may be jeopardized by a patient’s discovery that caregivers had secretly put medications in their food, this practice can result in an ongoing deception loop. While there may be circumstances in which covert medication is ethically justified, given a lack of suitable alternatives, we argue that in any particular case this practice should be continually re-evaluated in light of the building moral costs to the relational agent over time.
“Regulating Decisions for Incapacitated Pregnant Women”
D. Micah Hester, Leah Eisenberg, and Laura Guidry-Grimes
JAMA 322.9 (2019): 894-895.
Abstract: The Research Letter1 on state regulations regarding pregnant women who lack decisional capacity demonstrated variation of health legislation across states. Unfortunately, the analysis incorrectly characterized the state laws in Arkansas.
"Moral Expertise in Clinical Ethics: Problems and Prospects"
Jamie Carlin Watson and Laura Guidry-Grimes
Harvard Medical School Bioethics Journal (Winter 2020): online.
Abstract: There is an increasing number of clinical ethics consultants in hospitals around the world, which raises the question: Can anyone be an expert in giving moral advice? We contend that clinical ethics expertise is obtainable. We review three common challenges to the idea that clinical ethicists can be moral experts and show that each fails to undermine its plausibility. We admit, however, that the conditions under which clinical ethics is practiced render acquiring and identifying moral expertise more difficult than expertise acquired under different conditions. We argue that a first step in identifying and developing expertise is understanding how the environment in which clinical ethicists work affects their ability to get adequate feedback on their advice. We think the prospects for acquiring and enhancing clinical ethics expertise depend on whether ethics services can use methods developed by psychologists to enhance expertise in similar environments to create mechanisms for eliciting reliable feedback on consulting practices.
“Clarifying a Clinical Ethics Service’s Value, the Visible and the Hidden"
Laura Guidry-Grimes, Marika Warren, Hannah Lipman, Kelly Kent, Kaarkuzhali Babu Krishnamurthy, Arlene Davis, Thomas May, Marycon Chin Jiro, and Jane Jankowski
Journal of Clinical Ethics 30.3 (Fall 2019): 251-261.
Abstract: Our aim in this paper is to clarify and demonstrate the distinct value that a clinical ethics service (CES) could and should have for an institution and those it serves. In this paper we describe how the value of a CES can be overt, but it is often hidden due to the systems-level and process-oriented nature of its work. Our aim is to a) elucidate the multifaceted value added by a CES, including value that tends to be hidden and b) suggest how to demonstrate value to others in a way that is not reductionistic or simplistic. We take the question of value to be primary and fundamental: It asks why a CES is worth having and how it contributes to ethical care of patients, and it calls for an answer beyond the mere listing of activities and quantifiable metrics.
"Homeless, Ill, and Psychiatrically Complex: The Grueling Carousel of Cassandra Lee"
Laura Guidry-Grimes
Hastings Center Report 49.4 (July-August 2019): 8-13.
Abstract: Ask any clinical ethics consultant, and they can tell you about their transformative cases—the ones
that challenged them to find creative solutions, to collaborate productively in tricky situations, to witness tragedy while maintaining professional equanimity, to reflect on their shortcomings and predilections. Some cases stick with us because all roads led to nowhere: every attempt to make steady progress on the central issues, to get to know the patient better, and to work toward principled resolutions had limited success. Those were the cases in which the clinical ethics consultant (as well as other members of the health care team) was left wondering, what more could we have done? The story I offer here is such a case. It involved a medically and psychiatrically complex patient who lived a precarious existence on her own, without the supports she needed to make her health issues manageable. Everyone involved in her care knew that there was only so much that could be done for her, given how our community outside the walls of the hospital had failed her. This backdrop created moral uncertainties for the ethics service in trying to support her and her health care team, but it also generated a responsibility to advocate for such vulnerable patients through partnerships with the community.
"Ethical Complexities in Assessing Patients' Insight"
Laura Guidry-Grimes
Journal of Medical Ethics 45 (2019): 178-182.
Summary on JME Blog
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 their mental illness. When a patient is described as lacking insight, there are significant implications for patient care and to what extent the patient is trusted as a knower. Insight is currently viewed as a multidimensional and continuous construct, but competing conceptions of insight still lack consensus on the specifics. Studies also give contradictory evidence regarding the frequency and consequences of poor insight. A number of crucial questions remain unanswered. After outlining some of the key theoretical disagreements about what insight means, I highlight ethical issues that have not received much attention in the literature. Given the conceptual ambiguities and the absence of standardized bedside tools, there are significant ethical concerns about insight assessments. I highlight two main ethical concerns, specifically that these assessments risk 1) marginalizing patients by setting unattainable ideals for self-knowledge and 2) minimizing the patient’s own perspective on their mental health. I close with recommendations for documenting and responding to concerns about poor insight, so patients who are vulnerable to losing epistemic trust are better supported in their therapeutic relationships.
"Posthumous HIV Disclosure and Relational Rupture"
Laura Guidry-Grimes and D. Micah Hester
Journal of Clinical Ethics 29.3 (Fall 2018): 196-200.
Abstract: In response to Anne L. Dalle Ave and David M. Shaw, we agree with their general argument but emphasize a moral risk of HIV disclosure in deceased donation cases: the risk of relational rupture. Because of the importance that close relationships have to our sense of self and our life plans, this kind of rupture can have long-ranging implications for surviving loved ones. Moreover, the now-deceased individual cannot participate in any relational mending. Our analysis reveals the hefty moral costs that disclosure can bring, which should influence what information is given to would-be donors and how organ procurement coordinators approach these conversations.
"Relational Autonomy in Action: Rethinking Dementia and Sexuality in Care Facilities"
Elizabeth Victor and Laura Guidry-Grimes
Nursing Ethics (July 2018), epub ahead of print.
Abstract: Caregivers and staff in long-term care facilities have fragile moral work in providing exemplary person-centered care. We analyze the ethical challenges of enabling sexual activity among residents in these facilities, focusing on residents with early to moderate dementia in states of daily dependency on professional caregivers. We highlight the delicate balance that capacity assessments for sexual activity have to strike; while caregivers should protect those who cannot give adequate consent, the denial of sexuality among residents can cause deep, long-ranging harms. We show how sexual agency features into an ongoing sense of self, and the imposition of inappropriate standards and expectations for sexual autonomy can lead to unwarranted obstacles to sexual activity. We offer starting points for constructing guidelines and framing responsibilities that care facilities and healthcare staff have in these ethically complicated situations.
"In the Balance: Weighing Preferences of Decisionally Incapacitated Patients"
Laura Guidry-Grimes
Hastings Center Report 48.3 (May-June 2018): 41-42.
Abstract: In this commentary on "Capacity for Preferences: Respecting Patients with Compromised Decision-Making" by Jason Wasserman and Mark Navin, I argue that distinguishing among preferences is critical for determining their comparative weight in relation to other moral interests. The authors focus on how "suboptimal" preferences are, but this sidesteps the critical questions in these cases. The authors underappreciate the nuanced guidance that the standards for surrogate decision-making can provide, which I demonstrate in my ethical analysis of their clinical case.
"'But It's a Gift!' Adherence Pressures Post-Transplant"
Laura Guidry-Grimes
Journal of Hospital Ethics 5.1 (Winter 2018): 21-27.
Abstract: “Gift” language is rampant in public campaigns, scholarly studies and analyses, and even in the hallways of hospitals when referring to transplantable organs. The organ-as-a-gift notion brings with it a number of social and moral implications, not only for motivating potential donors and their families but also for motivating recipients. The “gift ethic” in transplant contexts needs further analysis, especially given how “gift” language can structure moral relationships among donors, donors’ families, healthcare professionals (HCPs), organ procurement coordinators, prospective and past transplant recipients, and recipients’ support system. Although substantial literature explores the gift ethic as it relates to encouraging donation, there are far fewer studies and discussions on how this ethic impacts recipients. This issue merits investigation because transplant recipients are frequently subjected to moral remonstrations and various other pressures to respect their “gift,” but to what extent these pressures are justified is not always evident or obvious. My aim in this paper is two-fold. First, I will briefly analyze how organs could be a certain type of gift. Second, I will investigate the general moral obligations and justifiable expectations of organ recipients as implied by the gift ethic, and I will outline the limitations of those obligations and expectations.
"Knowledge Is Key for Safety-Net Providers: Undocumented Patients May Not Know Their Health-Related and Legal Rights"
Nancy Berlinger, Laura Guidry-Grimes, Adira Hulkower
Health Progress (July-August 2017): 9-14.
Winner: "Best Feature Article: Professional & Special Interest Magazine" - Catholic Press Association
Abstract: Immigration policy and health care — what's the connection? Safety-net hospitals, community health centers and health programs serving low-income populations almost inevitably will encounter undocumented immigrants as patients or prospective patients, as community members for whom health care access is an important avenue for integration into American society, and as persons whose health-related legal rights may be overlooked, imperiled or difficult to us. Knowing how this vulnerable group is similar to — and different from — other low-income patient populations is an important part of planning for and providing good care. A health care facility's administration, staff and clinicians should be educated and ready to take practical steps to protect the basic rights of these patients, manage typical challenges in their care and strengthen the safety net. In the words of Rob Marlin, a Cambridge, Mass., physician who trains colleagues to care for their immigrant patients, physicians and safety-net institutions need to have "greater knowledge of immigration policy to take care of our patients … [policy] is no longer a spectator sport."
"Inhospitable Health Care Spaces: Why Training on LGBTQIA Issues Is Not Enough"
Megan Dean, Elizabeth Victor, and Laura Guidry-Grimes
Journal of Bioethical Inquiry, vol.13, no. 4 (December 2016): 557-570.
Abstract: In an effort to address health care disparities in lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations, many hospitals and clinics institute diversity training meant to increase providers’ awareness of and sensitivity to this patient population. Despite these efforts, many health care spaces remain inhospitable to LGBTQ patients and their loved ones. Even in the absence of overt forms of discrimination, LGBTQ patients report feeling anxious, unwelcome, ashamed, and distrustful in health care encounters. We argue that these negative experiences are produced by a variety of subtle, ostensibly insignificant features of health care spaces and interpersonal interactions called microaggressions. Healthcare spaces and providers often convey heteronormative microaggressions, which communicate to LGBTQ—and, we suggest, intersex and asexual (IA)—people that their identities, experiences, and relationships are abnormal, pathological, unexpected, unwelcome, or shameful. We identify heteronormative microaggressions common to health care settings and specify how they negatively impact LGBTQIA patients. We argue that standard diversity training cannot sufficiently address heteronormative microaggressions. Despite these challenges, health care institutions and providers must take responsibility for heteronormative microaggressions and take steps to reduce their frequency and mitigate their effects on LGBTQIA care. We conclude by offering strategies for problem-solving at the level of medical education, institutional culture and policy, and individual awareness.
“The Case of Ms. D: A Family’s Request for Posthumous Procurement of Ovaries for Future Reproduction”
Laura Guidry-Grimes
Journal of Clinical Ethics, vol. 27, no.1 (Spring 2016): 51-58.
Abstract: The clinical ethics team became involved in a case when a family requested the posthumous removal of a patient’s ovaries for future reproductive use. This case presents a novel question for clinical ethicists, since the technology for posthumous female reproduction is still in development. In the bioethics literature, the standard position is to refuse to comply with such a request, unless there is explicit consent or evidence of explicit conversations that demonstrate the deceased would have wanted this option pursued. Ms D’s case, we suggest, offers an exception to this default position; complying with the family’s request could have been ethically permissible in this case, had it been medically feasible.
"Modelling Psychiatric Disability"
Laura Guidry-Grimes
Journal of Evaluation in Clinical Practice, Philosophy Thematic Issue, vol. 21, no. 3 (June 2015): 490-495.
Part of a dissertation chapter
Abstract: There has been inadequate philosophical attention to the claims of psychiatric user/survivor activist groups, though these groups represent a significant social justice movement. Many of the core concerns and claims emerging from this activism can be found in disability activism. A first step that must be taken is to question how mental illnesses are modeled. Biomedical modeling is heavily criticized by psychiatric users/survivors for being reductionistic and for perpetuating damaging presumptions about decline and pathology. Social constructionist modeling, on the other hand, tends to be overly dismissive of biological factors that are often at play with these sorts of impairments. A middle ground approach, interactionist modeling, promises to be responsive to demands for recognition from psychiatric users/survivors. I will first outline the core commitments of psychiatric user/survivors. Next, I will evaluate different models for mental illness by bringing together insights from user/survivor and disability activism. I conclude that interactionist modeling holds the best hope for supporting shared decision-making. This type of model braids together the expertise of patients and medical professionals.
"Ethical Bargaining and Parental Exclusion: A Clinical Case Analysis"
Laura Guidry-Grimes and Elizabeth Victor
Journal of Clinical Ethics, vol. 26, no. 3 (Fall 2015): 250-259.
Abstract: Although in clinical ethics there has been significant attention to when physicians should follow through with a parent’s wishes, there has been much less discussion of the obligation to solicit viewpoints and decisions from all caregivers who have equal moral and legal standing in relation to a pediatric patient. How should healthcare professionals respond when one caregiver dominates decision-making? We present a case that highlights how these problems played out in an ethical bargain. Ethical bargaining occurs when the parties involved choose not to pursue the morally preferable option for the sake of coming to a resolution. This case is not one of parental disagreement; rather, the medical team agreed to exclude the mother from decision-making if the father promised to bring back their son for necessary medical tests. We argue that there is an obligation to notice and acknowledge power asymmetries in the family unit, which in this case manifested as the marginalization of the female decision-maker by the male decision-maker. In these scenarios, clinicians should be careful to avoid treating the parents as one homogenous unit, and they should take action to enable caregiver autonomy and voice. While there are moral and practical limits to how and when physicians should intervene in family dynamics, we discuss the steps that the medical team should have taken in this case to avoid undermining the parental authority of the mother. We conclude by offering recommendations to address and enable caregiver autonomy at an institutional level, and we discuss the importance of tracking and responding to damaging family dynamics so as to prevent ethically impermissible bargaining.
“I Will Never Doubt Again: Hope and Responsible Belief in The Princess Bride"
Jamie Watson and Laura Guidry-Grimes
The Princess Bride and Philosophy (Popular Culture and Philosophy Series) -- based off of film The Princess Bride
Chicago: Open Court, 2015: 77-84.
Abstract: Buttercup promised to trust that Westley would return. But he was gone for five years. No word from him for five years! Plus, his ship was attacked by The Dread Pirate Roberts (who, by the way, takes no prisoners). Who could blame her for losing hope? Well, apparently, Westley could. In the guise of his assailant, Westley excoriates Buttercup for her upcoming marriage, mocking her promise to be faithful. Is Westley's outrage rational? Should Buttercup have held fast to hope, despite the overwhelming evidence that Westley was dead? These are questions about responsible belief. Starting with the ancient Greeks, many philosophers have claimed that, in order to be rational, we must follow the evidence wherever it leads and adjust our beliefs accordingly. If our evidence is strong, we should believe strongly; if it is weak, we should believe weakly. And if it is very weak or unclear, we should suspend belief altogether. If we believe without any evidence or against the evidence, we are acting irrationally; we have perhaps even succumbed to wishful thinking, which can ensnare the hopeful believer as thoroughly and quickly as lightning sand. Presumably, we all want to avoid wishful thinking. The world does not bend itself to our desires, whether we wish for a million florins, a miracle pill, or true love’s return. But should we be strictly beholden to evidence? In The Princess Bride, Westley’s attitude toward evidence is very different from Buttercup’s, and he is our hero. Vizzini’s confidence is not entirely unwarranted, yet he is a villain. We cannot help but to admire Inigo’s perseverance and twenty-year conviction that he will avenge his father. And yet, he has hardly any information about the identity of the killer and no evidence that he will find him. So, is there room for rationality in the space between diligently following the evidence and wishful thinking? Could hope be rational even when the evidence doesn’t look promising? And what role do personal values play in the extent to which our beliefs are rational?
“Expectation and Suffering with LVAD Deactivation”
Laura Guidry-Grimes and Nneka Sederstrom
American Journal of Bioethics, vol. 15, no. 7 (July 2015): 74-76.
Abstract: This case raises a number of ethical flags related to the meaning of LVAD deactivation, the quality of the consent and physician-patient relationship, how to respect a patient’s autonomy with unclear capacity status and apparently mixed wishes, the implications of depression and bipolar disorder for decision-making, and long-term concerns with keeping this patient on the LVAD as a bridge to transplant. We will not delve into all of these ethical issues, though they all deserve consideration, especially given the novel and growing challenges presented by ventricular assist devices. We will take it as a given that deactivating the LVAD is not categorically different from withdrawing other life-sustaining technologies, though we acknowledge there is bioethical disagreement on how to regard the hybrid (partially internal, partially external) status of VADs. Mr. B repeatedly begs for the deactivation of his bridge device, evidently with the understanding that doing so would hasten his death. Every capacitated adult has the legal and ethical right to refuse life-sustaining technologies. In Mr. B’s case, however, we have questions about his capacity and whether following through with his deactivation request would support his actual autonomy interests. In our analysis, we will discuss the complicating factors involved, which are not exhausted by his psychiatric diagnosis.
Case Commentary
Christian Carrozzo and Laura Guidry-Grimes
Mid-Atlantic Ethics Committee Newsletter (Winter 2015): 9-11.
Abstract: For this case commentary, we provide an ethical analysis of the following case:
Ken is a 52 year old man who has lived in a nursing home for the past 15 years. He is severely cognitively impaired, has no known family, and has an appointed guardian. While being transported to a dental visit, Ken is involved in a motor vehicle accident and is taken to a hospital. He is treated for traumatic injuries to the head and neck. After three days of care in the intensive care unit Ken has lost all neurological reflexes and physicians conclude that he will not survive his injuries. They initiate testing to confirm death by neurologic criteria. The organ procurement staff speak with the guardian to discuss whether Ken can be an organ donor (if he is declared dead by neurologic criteria, or after cardiac death).The guardian believes she cannot consent on Ken's behalf for organ donation if Ken has not previously expressed a willingness to donate his organs. An ethics consultation is requested to weigh in on this question.
"The Persistence of Agency through Social Institutions and Caring for Future Generations"
Elizabeth Victor and Laura Guidry-Grimes
International Journal of Feminist Approaches to Bioethics, vol. 7, no. 1 (Spring 2014): 122-141.
Abstract: We argue that we have obligations to future people that are similar in kind to obligations we have to current people. Modifying Michael Bratman’s account, we argue that as planning agents we must plan for the future to act practically in the present. Understanding ourselves as relationally autonomous implies that those plans will involve building affiliative bonds and caring for others. We conclude by grounding responsibility to future others by the way we plan through our social institutions. Our account fills out the story of responsibility to future generations by referring only to ourselves, our practical identities, and practical reason.
"Should the Police Hire a Psychic Detective?"
Laura Guidry-Grimes
Psych and Philosophy (Popular Culture and Philosophy Series) -- based off of TV show, Psych
Chicago: Open Court Publishing, 2013, pgs. 59-68.
Abstract: When Police Chief Karen Vick is confronted with Shawn Spencer, a self-proclaimed psychic who promises to help solve unsolvable cases, she faces a quandary: Can she trust Shawn’s claims that he can help bring about justice and make Santa Barbara safer? Even if she decides she can trust him, should she hire him? There are a number of ethical considerations embedded in these questions. In order to trust Shawn in this role, she must have reasonable evidence that he has psychic abilities along with the discipline and motivation necessary to work on cases for the department. In the literature, there is conflicting evidence as to whether a psychic has ever successfully helped solve a crime. However, Shawn has a record of calling in critical tips, and he repeatedly proves his uncanny ability to find unusual leads. But even if Shawn is useful, Vick still has to decide whether hiring him would be prudent. Would taxpayers agree to this use of funds? A 2001 Gallup poll found that 50% of people believe in ESP, and the Santa Barbara community might be even more inclined to believe Shawn’s claims, given the positive publicity he (generally) receives. Is Vick professionally and morally obligated to pursue nontraditional options when standard methods are ineffective or inefficient? Vick also has to consider whether hiring a purported psychic could give families false hope, and her other detectives (like Lassiter) might worry that hiring a psychic mocks their work. In this essay, I will unpack these ethical problems from Vick’s point of view, considering in turn the complex relationships that Shawn has with those in the police department.
"Vulnerabilities Compounded by Social Institutions"
Laura Guidry-Grimes and Elizabeth Victor
International Journal of Feminist Approaches to Bioethics, vol. 5, no. 2 (Fall 2012): 126-146.
Abstract: How can social institutions complicate and worsen vulnerabilities of particular individuals or groups? We begin by explicating how certain diagnoses within mental health and medicine operate as interactive kinds of labels and how such labels can create institutional barriers which hinder one’s capacity to achieve well-being. Interactive kind modeling is a conceptual tool that elucidates the ways in which labeling can signal to others how the labeled person ought to be treated, how such labeling comes about and is perceived, and how it compounds vulnerabilities. We argue that this shift in standpoint helps us recognize and mitigate compounded vulnerabilities.
"Another Roadblock to Including Women in Research"
Laura Guidry-Grimes and Elizabeth Victor
Hastings Center Report, vol. 42. no. 5 (Sept-Oct 2012): inside back cover.
Abstract: Scientists, clinicians, and bioethicists are worried about how so-called personhood measures would limit access to certain types of contraception, research involving stem cells, and access to fertility treatments. While these measures have been struck down in Colorado, South Dakota, California, and Mississippi, the bill signed into law in Oklahoma in February deserves critical scrutiny, particularly into the ways these legal measures influence eligibility for clinical research. Oklahoma's bill states that the laws of the state “shall be interpreted and construed to acknowledge on behalf of the unborn child at every stage of development all the rights, privileges, and immunities available to other persons, citizens, and residents of this state.”
Other Publications
"Correcting the Art of the Chart: Addressing Bias in Our Notes"
Sara Tariq and Laura Guidry-Grimes
National Collaborative for Education to Address the Social Determinants of Health Blog. August 2021
"Against Personal Ventilator Reallocation"
Joel Michael Reynolds, Laura Guidry-Grimes, and Katie Savin
Hastings Bioethics Forum. 31 July 2020.
“‘Will They Take My Vent?’: Ethical Considerations with Personal Ventilator Reallocation During COVID-19”
Laura Guidry-Grimes and Katie Savin
AJOB Blog. 15 April 2020.
“Confronting Disability Discrimination During the Pandemic”
Katie Savin and Laura Guidry-Grimes.
Hastings Bioethics Forum. 2 April 2020.
"Ethical Framework for Health Care Institutions and Guidelines for Institutional Ethics Services Responding to the Novel Coronavirus Pandemic: Managing Uncertainty, Safeguarding Communities, Guiding Practice"
Nancy Berlinger, Matthew Wynia, Tia Powell, D. Micah Hester, Aimee Milliken, Rachel Fabi, Felicia Cohn, Laura K. Guidry-Grimes, Jamie Carlin Watson, Lori Bruce, Elizabeth J. Chuang, Grace Oei, Jean Abbott, and Nancy Piper Jenks.
The Hastings Center, 2020, web.
“Responding to COVID-19 as a Regional Public Health Challenge: Preliminary Guidelines for Regional Collaboration Involving Hospitals”
Nancy Berlinger, Matthew Wynia, Aimee Milliken, Felicia Cohn, Laura K. Guidry-Grimes, Lori Bruce, Grace Oei, Hannah I. Lipman, Carla Cheatham
The Hastings Center, 2020, web.
"Conscientious Objections, Professional Limitations, and Hard Realities for Hospitals"
Laura Guidry-Grimes
IJFAB Blog. 29 Jan 2018.
Sara Tariq and Laura Guidry-Grimes
National Collaborative for Education to Address the Social Determinants of Health Blog. August 2021
"Against Personal Ventilator Reallocation"
Joel Michael Reynolds, Laura Guidry-Grimes, and Katie Savin
Hastings Bioethics Forum. 31 July 2020.
“‘Will They Take My Vent?’: Ethical Considerations with Personal Ventilator Reallocation During COVID-19”
Laura Guidry-Grimes and Katie Savin
AJOB Blog. 15 April 2020.
“Confronting Disability Discrimination During the Pandemic”
Katie Savin and Laura Guidry-Grimes.
Hastings Bioethics Forum. 2 April 2020.
"Ethical Framework for Health Care Institutions and Guidelines for Institutional Ethics Services Responding to the Novel Coronavirus Pandemic: Managing Uncertainty, Safeguarding Communities, Guiding Practice"
Nancy Berlinger, Matthew Wynia, Tia Powell, D. Micah Hester, Aimee Milliken, Rachel Fabi, Felicia Cohn, Laura K. Guidry-Grimes, Jamie Carlin Watson, Lori Bruce, Elizabeth J. Chuang, Grace Oei, Jean Abbott, and Nancy Piper Jenks.
The Hastings Center, 2020, web.
“Responding to COVID-19 as a Regional Public Health Challenge: Preliminary Guidelines for Regional Collaboration Involving Hospitals”
Nancy Berlinger, Matthew Wynia, Aimee Milliken, Felicia Cohn, Laura K. Guidry-Grimes, Lori Bruce, Grace Oei, Hannah I. Lipman, Carla Cheatham
The Hastings Center, 2020, web.
"Conscientious Objections, Professional Limitations, and Hard Realities for Hospitals"
Laura Guidry-Grimes
IJFAB Blog. 29 Jan 2018.