Teaching of Medical Ethics Regarding Military, Genetic, Reproductive, and Student Ethics, and the Holocaust at the Uniformed Services University of the Health Sciences (USUHS) During Its First Fifty Years.

Introduction: The first class at USUHS took its initial course in medical ethics in 1977. I directed this course until recently when COVID first emerged. In this piece, I review what these students were taught during the first 3 of 8 class sessions involving children, end-of-life care, and rersearch.

Teaching of Medical Ethics Regarding Military, Genetic, Reproductive, Student Ethics, and the Holocaust at the Uniformed Services University of the Health Sciences (USUHS) During Its First Fifty Years.

Introduction: The first class at USUHS took its initial course in medical ethics in 1977. I directed this course until recently when COVID first emerged. In this piece, I review what these students were taught during the last 5 of 8 class sessions involving the military, genetic, reproduction, student ethics, and the Holocaust.

Should Providers Engage in Religious Discussions, and If They Should, Then with Whom?

AbstractPatients' spiritual views and, more generally, the meaning they feel in their lives is often, if not always, most important to them, especially when they have serious illness. Yet there are no standard requirements for providers to explore with patients their spiritual needs. Providers' views regarding their both taking initiatives to explore with patients needs and then to discuss with them their religious concerns if they want this vary widely.

Should Providers Ask Family Members What They Want When Establishing Surrogate Decision-Making?

AbstractIn this piece I discuss optimal approaches that providers may take when pursuing surrogate decision-making. A potential critical problem here is some providers' approach differing from that of others. To the extent that this occurs, the results may be arbitrary, and the harm from this may be profound since this may affect, of course, even whether some of these patients will live or die.

When Patients and Providers Feel Helpless: A Commentary on "Palliative Care for Refractory Depressive Symptoms in a Female Veteran Geriatric Patient".

AbstractWhether providers should ever help patients die when they profoundly suffer from seemingly irreversible psychiatric illness is globally controversial. For example, in 2016, the American Psychiatric Association held that psychiatrists should never help bring about such patients' deaths, whereas in the Netherlands this intervention has been permitted for 30 years, and the number has increased from 2 in 2011 to 83 in 2017. This commentary asks when, if ever, providers should give up on seeking to treat these patients.

How Should Therapists Treat Patients who are so Altruistic They Regularly Harm Themselves for the Sake of Others?

Mental health providers sometimes encounter patients who are exceptionally altruistic toward others and, at the same time, are willing to ignore their own needs and even significantly harm themselves to best achieve these ends for others. Traditionally, therapists have seen it to be their role to discern patients' negative symptoms, then seek to reduce them. This article reviews gains based on positive psychology that highlight the importance of therapists giving priority to supporting patients' strengths, particularly the sources of meaning they have in their lives.

Should Providers Advocate for Their Patients?

AbstractThis piece discusses several ways in which providers may advocate for patients and their families that go beyond what providers usually do to help their patients. A much more expanded view of advocacy is suggested. Real cases illustrating all interventions suggested are presented, and each is paradigmatic of numerous others.

Psychotherapeutic approaches: hopefully, globally effective.

Many patients have lasting disorders due, for example, to excessive and chronic childhood stress. For these patients, certain psychotherapeutic approaches may be maximally effective, and this may be universally the case. This piece is intended to give providers optimal tools for reaching and helping these patients who, otherwise, may remain among those worst off.

New Ways to Help Patients Worst Off.

AbstractThis introduction to highlights and expands four articles within this issue that propose somewhat new and radical innovations to help and further the interests of patients and families worst off. One article urges us to enable historically marginalized groups to participate more than they have in research; a second urges us to allocate limited resources that can be divided, such as vaccines and even ventilators, in a different way; a third urges us to help families find greater meaning when their loved ones are dying; and a fourth urges us to treat patients who illegally use drugs as caringly as is possible, though there may be limits to what providers can do. This piece also addresses the importance of providers bonding with patients, recognizing that some providers may be better at eliciting patients' trust than others, and thus the importance of connecting these patients with these providers since this may be the sole way these patients can optimally respond and do well.

When Should Providers Defer versus Impose Their Views?

AbstractThis piece discusses perhaps the most agonizing ethical decision ethics consultants and other providers encounter. This is the extent to which providers should defer decisions to patients or to their proxy decision makers as opposed to imposing their own views as to what they think is ethically right. It discusses the most difficult issues these providers may encounter, especially when they wish to depart from authoritative bodies' standards or guidelines, and it presents initial steps providers may take to help patients and their families work together to resolve these dilemmas more harmoniously.

Patients with Invisible Pain: How Might We See This Pain and Help These Patients More?

AbstractIn this piece I discuss two ways in which providers may become able to treat patients better. The first is for them to encourage all medical parties, including medical students, to always speak up. The second is to take initiatives to learn of pain that patients feel but neither show nor spontaneously report.

and Questions Regarding Death Anxiety, Forgiveness, and Patient Self-disclosure.

This commentary examines three critical therapeutic questions that arise for all patients, particularly for patients with psychiatric illness. These questions involve fearing death, forgiving oneself for past acts, and disclosing medical and psychiatric conditions to others. These questions, which can be critical to providing optimal medical care in some contexts, are prompted by the movie , as it might provoke questions regarding death and self-disclosure in patients.

Ethical considerations for psychedelic-assisted therapy in military clinical settings.

Psychedelic treatments, particularly 3,4-methylenedioxymethamphetamine (MDMA)-assisted and psilocybin-assisted therapies, have recently seen renewed interest in their clinical potential to treat various mental health conditions. Clinical trials for both MDMA-assisted and psilocybin-assisted therapies have shown to be highly efficacious for post-traumatic stress disorder and major depression. Recent research trials for psychedelic-assisted therapies (PAT) have demonstrated that although they are resource-intensive, their effects are rapid-acting, durable and cost-effective.

Questions Care Providers Should Ask When They Have Ethical Discretion.

AbstractSince some care providers give colleagues' interests priority over patients' and families', they are at risk of imposing their bias on patients without knowing this. In this piece I discuss how the risk increases when care providers have greater discretion and how they can best avoid this risk. I discuss identifying these situations, assessing them, and then, based on what they have concluded, intervening and use their having inadequate resources, their seeing what patients want as futile, and their making decisions regarding surrogate decision makers as paradigmatic examples.

Endoscopic Approaches to the Paramedian Skull Base: An Anatomic Comparison of Contralateral Endonasal and Transmaxillary Strategies.

Background: The expanded endoscopic endonasal approach (EEA) is limited laterally by the internal carotid artery (ICA). The EEA to the paramedian skull base often requires complex maneuvers such as dissection of the Eustachian tube (ET) and foramen lacerum (FL), and ICA manipulation. An endoscopic contralateral transmaxillary approach (CTMA) has the potential to provide adequate exposure of the paramedian skull base while bypassing manipulation of the aforementioned anatomic structures.

Should Ethics Consultants Make their Findings Transparent? How Important Is "Intimacy" between Patients and Careproviders?

A recently enacted law permits patients to see their electronic medical record (EMR) immediately after their careprovider writes in it. In this article I discuss a proposal that authors make in this issue of The Journal of Clinical Ethics, that ethics consultants (ECs) keep their notes in a separate section of the EMR that patients cannot access when their ethics notes may be troubling to patients, to avoid unduly harming them. I discuss this concern and three more widely applicable clinical goals: to help patients feel safe; to gain patients' trust; and to provide hope to patients, when possible.

When Should Careproviders Deviate from Consensus?

Consensus documents may be extremely helpful. They may, however, also do harm. They may, for example, suggest interventions that are less than optimal, especially when they apply to patients whose situations are at the "outer margins" of their applicability.

Assessing Patients Who Seek Help Ending Their Lives.

As a result of end-of-life movements in a number of states, psychiatrists may be drawn into the capacity assessment of patients requesting assistance to end their lives. Such assessments cannot follow the mere technicalities of common clinical interviews, not simply because of the finality of the choice, but also because of the limitations of common cognitive assessments. The Committee on Professionalism and Ethics of the Group for the Advancement of Psychiatry consequently proposes an interview for such purposes that explores a patient's emotional capacity through a narrative inquiry about the patient's life, past coping, and reversible emotional states.

Seeing the Invisible.

This article focuses on three different ways that we may demean people by seeing them as less than they are, and describes ways we may best avoid doing this. More specifically, I explain how we may not see the physical and emotional issues that plague patients and others. This may be because they choose not to disclose their difficulties to us.

Beyond the Basics: More Ways that Ethics Consultants Can Help Patients.

The primary task of ethics consultants is to work with patients-and sometimes also their families-to discern and then meet patients' and families' needs and wants to the extent possible. That is primarily a cognitive endeavor. Yet the feelings of patients and ethics consultants may determine what they can work together to accomplish.