Publications

2020-2021

Extremely Premature Infants, Scarcity, and the COVID-19 Pandemic (A Different View)
2020 November, Acta Paediatrica
Joseph W. Kaempf, Kevin M. Dirksen, and Nicholas J. Kockler

Scarcity is Nature's creative provenance, the wellspring of human conflict and subsequent adaptation. Deficiencies of food, shelter and basic safety are primary, but secondary privations real or imagined (material comforts, money, power and sex), are often perceived in-sufficient by humankind and drive history's discord.1 The COVID-19...
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Is the Life-Cycle Principle Justified as a Tie-Breaker in Triage Decision-Making Within Catholic Health Care? Part II.
2020 Fall, Health Care Ethics USA
Nicholas J. Kockler

A few questions may help clarify the analysis. These questions derive from the following components undergirding a distinctively Catholic approach to triage decision-making and the question of a life-cycle principle as a tie-breaker. These questions span the following areas: sources of morality, categorical exclusions, age as sole consideration, distinctive roles of age, aging as a universal human experience, ...
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Is the Life-Cycle Principle Justified as a Tie-Breaker in Triage Decision-Making Within Catholic Health Care? Part I
2020 Summer, Health Care Ethics USA
Nicholas J. Kockler

In the early weeks of the coronavirus pandemic, stories coming from the hard-hit areas of northern Italy generated tremendous moral concern about the role age may be playing in the rationing of scarce critical care resources to meet the needs of patients suffering from COVID-19.1 Indeed, it seemed that professional guidance affirmed the need for and use of age-based cut-offs in the allocation of critical care.2 Public health surveillance data on age-stratified...
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Periviability in a Pandemic: Good Ethics Still Considered Essential
2020 July, American Journal of Bioethics
Kevin M. Dirksen, Joseph W. Kaempf, and Nicholas J. Kockler

Haward et al. (2020) review how lifespan considerations and health outcomes might be considered in the allocation of scarce resources during the COVID-19 pandemic with particular attention toward extremely premature infants. Our experience developing medical staff guidelines for the care of extremely premature infants at our medical center (JWK) and coordinating region-wide responses to scarce resource allocation...
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Can’t Hit Pause? On the Constitutive Elements of Responsible Ventilator Management & the Apnea Test.
2020 June, American Journal of Bioethics
Kevin M. Dirksen and Lilith Judd

Berkowitz and Garrett (2020) provide the opportunity to consider the state of the apnea test in critical care medicine for mechanically ventilated patients suspected of death via neurological criteria, arguing for a shift toward obtaining explicit informed consent before proceeding. Especially in the setting of challenging clinical disagreements between families of patients and treating teams about the obligations of treating...
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Bylaws for Clinical Ethics Consultation at the Providence Center for Health Care Ethics
2020 Winter-Spring, Health Care Ethics, USA
Nicholas J. Kockler

At Providence in Oregon, our ethicists accompany caregivers, patients, and their families as they wrestle with complex and value-laden issues that often impact life and death decisions. Rooted in the notion of clinical ethics as professional practice, our ethics consultation service is staffed by professionally trained ethicists. While best practices, standards...
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The Inaugural Catholic Healthcare, Ethics Innovation Forum
2020 Winter-Spring, Health Care Ethics USA
Nicholas J. Kockler, Becket Gremmels, Kevin Murphy, and Mark Repenshek

Great ideas are shared. After discussing the possibility of sharing ideas and best practices at a recent Theology and Ethics Colloquium presented by the Catholic Health Association in St. Louis, we realized we do not have a venue as ethicists in Catholic health care to submit innovative ideas, present them to our colleagues, and enhance them together. Our hope was to...
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2018-2019

Extremely Premature Birth, Informed Written Consent, and the Greek Ideal of Sophrosyne

2018 December, Journal of Perinatology
Joseph W. Kaempf, M.D., Kevin M. Dirksen, M.Div., MSc

Most extremely premature infants die in the intensive care unit or suffer significant neurologic impairment. Many therapies result in unhealthy consequences, and the emotional and financial turmoil for families warrant reappraisal of our motives. Shared decision-making and informed consent in preference-sensitive conditions imply the family: (a) understands the medical problem... Read full article

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Integrating Ethics Services in a Catholic Health System in Oregon
2018 Spring, National Catholic Bioethics Quarterly
Nicholas J. Kockler and Kevin M. Dirksen

Ethical issues are embedded in every patient encounter. In the majority of patient-care situations in Catholic health care, caregivers practice in ways that reflect the mission, values, and ethical commitments of their professions. Therefore, ethical issues rarely become problematic or interfere with or delay appropriate care. Yet questions for ethicists arise when these issues create barriers to the ethically sound delivery of...
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Health Zones in Oregon: Exploring an Ethical Deliberation Process in County Public Health
2018 January-March, Ethics, Medicine, and Public Health
K.M. Dirksen, S.D. Present, P. Mason, and D. Emerick

Clackamas County, an administrative division in the State of Oregon on the west coast of the United States, has provided training in ethics and a decision-making framework to members of its public health advisory committee in an attempt to develop an ethical deliberation mechanism in public health. The goal of this mechanism is to ensure that
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Complex Considerations: 'Right to Try' Laws Raise Ethical Concerns
2018 March-April, Health Progress
Nicholas J. Kockler, Ph.D., M.S.

In 2015, the Oregon legislature passed a "Right to Try" law allowing a qualified patient to use an investigational product, meaning one that has not been approved by the U.S. Food and Drug Administration, when the product is offered by a lawfully authorized health care practitioner for the purposes of treating a terminal illness.1 To date, 38 states have passed Right to Try laws, and in 2017 the U.S. Senate...Read the full article

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Caring for Patients with a History of Illicit Intravenous Drug Use: Ethical Obligations from Bedside to Boardroom
Winter 2017, Health Care Ethics USA
Nicholas J. Kockler

A few years ago, Infection Control in one of our ministries asked for an ethicist’s perspective of whether it was ethically permissible to unilaterally remove a peripherally-inserted central catheter (PICC) from a person who tampered with it and who had a history of illicit intravenous drug use. The tampering concern was precipitated by regulations on... Read full article

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2016-2017

Erasmus Mundus Master of Bioethics: A case for an effective model for international bioethics education
2017 November, Medicine, Health Care and Philosophy
Jan Piasecki, Kevin Dirksen and Hamilton Inbadas

Designing bioethics curriculum for international postgraduate students is a challenging task. There are at least two main questions, which have to be resolved in advance: (1) what is a purpose of a particular teaching program and (2) how to respectfully arrange a classroom for students coming from different cultural and professional backgrounds. In our paper we analyze the case of the Erasmus Mundus Master of Bioethics program
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Shared decision-making, value pluralism and the zone of parental discretion (A Different View – A Reply).
2017 June, Acta Paediatrica
Joseph W. Kaempf, Nicholas J. Kockler, and Mark W. Tomlinson

‘Good ethics start with good facts’ wrote John Lantos and William Meadow in a 2009 editorial addressing periviability controversies – debates that continue to generate lively discussion amongst neonatologists, obstetricians, ethicists and families 1. How do we best promote shared decision‐making with pregnant women who, through no fault of their own, might deliver an extremely premature infant?
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Decision Zone at the Margins of Life and Good Health: The Role of Medical Staff Guidelines for the Care of Extremely Early Gestation Pregnancies and Premature Infants
2017 January, The American Journal of Bioethics
Kevin M. Dirksen, M.Div., MSc, Joseph W. Kaempf, M.D., Mark W. Tomlinson, M.D., and Nicole M. Schmidt, M.D.

Some physicians would offer or recommend comfort care in periviability situations where others routinely provide fetal resuscitation and neonatal intensive care unit (NICU) care (Peerzada, Richardson, and Burns 2004). Staff and other health care professionals may report moral distress as a consequence of divergent approaches to critical situations ascribed to be the result of mere difference of opinion. Read the full article

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2014-2015

Competencies Required for Clinical Ethics
Consultation as Coaching
2015 Fall, Health Care Ethics USA
Nicholas J. Kockler, Ph.D, M.S. and Kevin M. Dirksen, M.Div, MSC

Editors note: A version of this paper was presented by the authors at the International Conference on Clinical Ethics Consultation in May 2015.

Elsewhere we have described our philosophy and practice of clinical ethics consultation as coaching; 1 here, we wish to describe the competencies required for performing ethics consultation in this manner. We define coaching as a set of activities performed by one person (or more) to assist and support another individual or group striving to achieve excellence in a given field or discipline. 2 This coaching modality3 may be distinguished from other.

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Physicians’ Perspectives on Ethically Challenging Situations: Early Identification and Action
2015 July-September, AJOB Empirical Bioethics
Carol Pavlish, Katherine Brown-Saltzman, Kevin M. Dirksen and Alyssa Fine

Even though much has been written about ethical dilemmas and conflicts, little is known about situational factors that increase the risk for these difficult experiences to develop....Identifying risk factors for ethical conflicts shifts the gaze from downstream, rescue efforts on a case-by-case basis toward more proactive, integrated, and system-wide approaches (Foglia et al. 2012)....

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Incorporating Balanced Accountability in a Clinical
Ethics Fellowship Program
2014 June, The American Journal of Bioethics
Kevin M. Dirksen

As the emerging profession of clinical ethics continues to reflect on important questions such as attestation, certification, and accreditation (Magill 2013),Weise and Daly (2014) provide the opportunity to consider the degree to which clinical ethics consultants should accept accountability for the advice rendered in an ethics consult....

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2012-2013

Capacity: About Autonomy or Authorization?
2013, October-December, AJOB Neuroscience
James A. Hynds and Kevin M. Dirksen

Among other things, the authors of this interesting article remind us of a basic truth in clinical ethics, namely, that the mere possession of consciousness (i.e., being awake and aware) is not sufficient cognitive endowment to enjoy the right to make and have respected one’s decisions regarding medical care. It is necessary, in addition, that a patient possess a further endowment that clinicians and ethicists have come almost universally to call...

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The Existential Question in Palliative Sedation: Reply to Putman et al.
2013 May, Journal of Pain and Symptom Management
Kevin M. Dirksen, MDiv, MSc, James A. Hynds, LLB, PhD, Ayesha R. Bhavsar, PhD and Katherine Brown-Saltzman, MA, RN

To the Editor: Putman et al.1 provide an important contribution to the palliative sedation literature in evidencing that physicians see a critical difference between intending unconsciousness and merely tolerating it as a foreseen, although unintended consequence. They further examine whether physicians believe that a patient has the right to decide to hasten one’s death... Read full letter

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Dissenting on the Matter of Assent
2013, January-March, AJOB Neuroscience
Kevin M. Dirksen and Katherine Brown-Saltzman

Sheer vulnerability marks the patient in a minimally conscious state (MCS) who was previously diagnosed persistently vegetative: retaining a certain level of awareness but otherwise being profoundly impeded from engaging with the outside world (Posner et al. 2007, 360). That it is even a question of, as Wilkinson and Savulescu (2012) recently inquire in their title, “Is it better to be minimally conscious than vegetative?” is evidence enough...

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Uncovering the Real Work Behind Policy Development
2012 November, The American Journal of Bioethics
Kevin M. Dirksen and Katherine Brown-Saltzman

Clinical ethicists should appreciate that there must be a greater quality focus within their profession, especially in an area such as ethics policy work with its lasting influence on patients and providers. As Frolic and colleagues (2012) show, there is a dearth of scholarly literature addressing this activity; they call for practice standards and quality review to address this deficiency. Unfortunately, the development of practice standards and lessons from quality review will....

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Ethics Education Enhances Skills of Doctors in Training
2012 May-June, Health Progress               
John Tuohey, Ph.D. and Nicholas J. Kockler, Ph.D., MS

Samuel is a 36-year-old gentleman who was building a home with his girlfriend of six years. One day she drove out to the construction site and found him on the ground, not breathing, and pulseless. She dialed 911 and initiated CPR as best she could. When the EMTs arrived, they took over, managed to get a heartbeat and maintained his breathing on the way to the hospital. Upon admission he was… Read the full article

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The Historical Roots of Personalism
2012 by Bijdragen: International Journal for Philosophy and Theology
Kevin M. Dirksen and Paul T. Schotsmans

In line with Johan De Tavernier's recently produced historical survey of various articulations of personalism, detailing the origination and contribution of four European voices1, a further examination of the Boston personalist corpus is provided in this investigation. Indeed, De Tavernier claims to include 'American personalism', however, the article provides only a minimal treatment of personalism in the United Stated in favour of....

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Care Across Cultures: Does Every Patient Need to Know? 
2012 March-April, Health Progress
Marian Hodges, M.D., MPH and Barbara A. Segal, MA, MS

An 85-year-old Russian man is admitted to the hospital complaining of increasing back pain. In the ER, an abdominal CAT scan indicates evidence of new metastatic disease to his spine. The patient has limited English skills. When the admitting hospitalist and an interpreter enter the room, they see the patient surrounded by his daughter and other relatives talking in Russian... Read the full article

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2010-2011

End of Life: POLST Reflects Patient Wishes, Clinical Reality
2011 March-April, Health Progress
Rev. John Tuohey, Ph.D. and Marian O. Hodges, M.D.

The case of Sarah is a good starting point: Sarah is a 95-year-old, frail woman living in a retirement home. She has hypertension and osteoporosis, and she has been slowly losing weight. She has discussed code status with her doctor and has asked for “Do Not Attempt Resuscitation” (DNAR), which is marked in her chart. One afternoon, the staff finds her down, unresponsive and cyanotic in the hallway… Read the full article

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A Fatal Conflict: Can Catholic Hospitals Refuse to Save Lives?
2011 Jan., Commonweal
John F. Tuohey, Ph.D.

It is commonly accepted that any entity that is part of the Catholic health-care ministry must offer its services in a manner consistent with the Ethical and Religious Directives for Catholic Health Care Services (ERDs), a publication of the United States Conference of Catholic Bishops (USCCB). The ERDs help distinguish Catholic health care from other systems, in part by… Read the full article

2008-2009

Ethical Considerations in the Risk-Benefit Analysis for Patients with Diminished Capacity
2009 Winter, Journal of Hospital Ethics
John Tuohey, Ph.D. and Jeffery T. Young, M.D.

Ms. Y is a 64-year-old woman who presented to the Emergency Department (ED) with chest pain, shortness of breath and a history of fainting. She consented to admission to a medical unit. She was diagnosed with aortic stenosis, presumably severe. The clinician recommended that Ms. Y receive cardiac catheterization…Ms. Y told the clinician she was not interested, but would take her vitamins… Download a PDF of the article

Redefining Death as a Way to Procure More Vital Organs: A Response
2009 Spring, Health Care Ethics USA
Rev. John Tuohey, Ph.D.

Recent ethical literature on organ donation in the United States focuses on the reality that there are far more patients on a waiting list for a transplant than there are donors. It is estimated that there are approximately 170,000 people living today in the United States who are recipients of an organ donation, yet as many as 7,000 patients die annually because there are not enough organs… Read the full article

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2006-2007

A Matrix for Ethical Decision Making in a Pandemic: The Oregon Tool for Emergency Preparedness
2007 November, Health Progress
Fr. John F. Tuohey, Ph.D.

In recent years, there has been a great deal of interest in emergency preparedness. This is especially true in light of concerns about a pandemic of the H5N1 virus, the “bird flu.” Ethical concerns include ensuring access to basic resources such as health care, and the duties of professionals to perform their task in the face of such events. Like other states, Oregon set out to establish an… Read the full article

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Screening for Aneuploidy: A Complex Ethical Issue
2007 Spring, Health Care Ethics USA
Rev. John Tuohey, Ph.D.

People often use the terms ‘risk’ and ‘chance’ interchangeably. We might hear before cardiac surgery, “There is a risk/chance of stroke with this procedure.” Greater care is found in research; an institutional review board (IRB) will generally look askance at language in a consent form suggesting there is a ‘chance’ of some effect. An IRB will insist that a consent form clearly state the ‘risks’ involved… Read the full article

Making Access A Priority
2007 March-April, Health Progress
Rev. John Tuohey, Ph.D.

In 2004, the Portland, Ore., Oregonian published a letter to the editor from the directors of the various ethics programs of the state's health care systems. I was among the signers, representing Seattle-based Providence Health & Services in Oregon. In the letter, we said that we planned to bring together the Portland area's top health care leaders and ethicists to discuss how we might better coordinate... Read the full article

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The Five People You Meet in a Pandemic—and What They Need from You Today
2006 Sept., The Hastings Center Bioethics Backgrounder
Nancy Berlinger and Jacob Moses in collaboration with Providence Center for Health Care Ethics

In April 2007, all state public health directors submitted their pandemic influenza preparedness plans to the Centers for Disease Control (CDC), in response to an assignment and template from the National Strategy for Pandemic Influenza, coordinated by the Departments of Health and Human Services (HHS) and Homeland Security. Officials were required to describe how they will deploy public… Read the full article

Ethics Consultation in Portland
2006 March-April, Health Progress
Fr. John Tuohey, Ph.D.
 
The Portland Service Area (PSA) of Providence Health System, Oregon Region, where I work, comprises three hospitals: Providence St. Vincent Medical Center and Providence Portland Medical Center, both of which have internal residency programs, and Providence Milwaukie Hospital, which has a family practice residency program. Each has an ethics committee. Historically, one responsibility of an ethics committee has been to provide a resource or forum for ethics consultations. Six years ago, the PSA committees… Read the full article

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