John Moskop
Wake Forest University School of Medicine, Internal Medicine, Faculty Member
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Physician-assisted suicide (PAS) has been one of the most hotly debated bioethics and health policy issues of the past decade. Part I of this 2-part article defines key terms in the debate, reviews the history of the debate, and... more
Physician-assisted suicide (PAS) has been one of the most hotly debated bioethics and health policy issues of the past decade. Part I of this 2-part article defines key terms in the debate, reviews the history of the debate, and articulates leading arguments for and against legalization of the practice of PAS. Part II of the article will examine the role of emergency physicians in caring for patients who present to the emergency department after an incomplete or unsuccessful attempt at PAS.
Research Interests: Emergency Medicine, Bioethics, Family Medicine, Palliative Care, Health Policy, and 15 moreSuicide prevention, Medicine, Cross-Cultural Comparison, Humans, United States, Assisted Suicide, Clinical Sciences, Moral Obligations, Legalization, Terminal care, Emergency Physician, Treatment Refusal, Emergency Department, Physician Assisted Suicide, and Life support care
... Carolina Hu-manities Committee, and the general editors of this series, H. Tristram En-gelhardt ... We wish to thank Robert M. Adams and Jeffrie Murphy for allowing us to include ... (Adam's' Must God Create the... more
... Carolina Hu-manities Committee, and the general editors of this series, H. Tristram En-gelhardt ... We wish to thank Robert M. Adams and Jeffrie Murphy for allowing us to include ... (Adam's' Must God Create the Best?'originally appeared in the Philosophical Review, 81, 1972, and ...
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Background: More than 100,000 Americans with failing organs await transplantation, mostly from dead donors. Yet only a fraction of patients declared dead by neurological criteria (DNC) become organ donors. Discussion: Emergency physicians... more
Background: More than 100,000 Americans with failing organs await transplantation, mostly from dead donors. Yet only a fraction of patients declared dead by neurological criteria (DNC) become organ donors. Discussion: Emergency physicians (EPs) can improve solid organ donation in the following ways: providing perimortem critical care support to potential organ donors, promptly notifying organ procurement organizations (OPOs), asking neurocritical care specialists to evaluate selected emergency department patients for death based on established neurologic criteria, participating in research to advance these developments, implementing automatic OPO notification technologies, and educating the professional and lay communities about organ donation and transplantation, including exploration of opt-out (presumed consent) organ recovery policies. Conclusion: With future improvements in organ preservation and DNC assessment, EPs may become even more involved in the donation process. EPs should support and engage in efforts to promote organ donation and transplantation.
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Patients who are undocumented immigrants (UIs) frequently present to emergency departments in the United States, especially in communities with large immigrant populations. Emergency physicians confront important ethical issues when... more
Patients who are undocumented immigrants (UIs) frequently present to emergency departments in the United States, especially in communities with large immigrant populations. Emergency physicians confront important ethical issues when providing care for these patients. This article examines those ethical issues and recommends best practices in emergency care for UIs. After a brief introduction and description of the UI population, the article proposes central principles of emergency medical ethics as a framework for emergency physician decisions and actions. It then considers the role of law and public policy in health care for UIs, including the Emergency Medical Treatment and Labor Act, the Patient Protection and Affordable Care Act, and current practices of the US Immigration and Customs Enforcement agency. The article concludes with discussion of the scope of emergency physician practice and with recommendations regarding best practices in ED care for UIs.
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This is the strong response of Dr. Louis Del Guercio to the prospect of cutbacks in federal support for critical care, taken from his 1977 presidental address to the Society For Critical Care Medicine. Dr. Del Guercio’s remarks illustrate... more
This is the strong response of Dr. Louis Del Guercio to the prospect of cutbacks in federal support for critical care, taken from his 1977 presidental address to the Society For Critical Care Medicine. Dr. Del Guercio’s remarks illustrate one side of a continuing controversy about how much society ought to invest in critical care medicine, the care of patients with severe, life-threatening illness or injury. This paper will be devoted to an examination of that controversy. First, however, I would like to place the controversy within the broader context of concern about the cost of health care.
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Research Interests: Psychology, Medieval History, Death Studies, Social Problems, Environmental Health, and 14 moreCivil Rights, Public Health, Medicine, Syphilis, Disease Outbreaks, Humans, Europe, United States, Risk factors, Tattooing, Risk Factors, Acquired immunodeficiency syndrome, mass Screening, and Medical and Health Sciences
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The National Disaster Medical System (NDMS) was formulated to provide medical care for casualties of future large-scale natural disasters and military conflicts. We sent questionnaires to the 59 emergency medical directors of North... more
The National Disaster Medical System (NDMS) was formulated to provide medical care for casualties of future large-scale natural disasters and military conflicts. We sent questionnaires to the 59 emergency medical directors of North Carolina's participating hospitals in order to assess their views regarding the need for NDMS and the level of their hospital's preparedness. Responses were received from 78% (46) of the physicians surveyed. Of those responding, an overwhelming majority supported the need for a national plan like NDMS to treat casualties of a natural disaster or an overseas military conflict. Respondents also agreed that the participation of emergency department personnel, other physicians, and support personnel is essential for successful activation of NDMS. Responses to questions regarding level of preparedness, however, suggested that there is less than an optimal degree of preparedness for participation in NDMS.
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Like their philosophical colleagues, Christian moral theologians have written relatively little about the rights of retarded persons or about our responsibilities to them. It appears that the existence of retarded persons raises... more
Like their philosophical colleagues, Christian moral theologians have written relatively little about the rights of retarded persons or about our responsibilities to them. It appears that the existence of retarded persons raises difficulties for certain theological as well as philosophical approaches to ethics. Nevertheless, two contemporary American Protestant theologians, Joseph Fletcher and Stanley Hauerwas, have directly addressed the issue of our responsibilities regarding those with different natural endowments. In this paper, I will first review and evaluate the positions adopted by Fletcher and Hauerwas. We will see that despite a common Christian heritage, their approaches stand in striking contrast to one another. I will then attempt to suggest an acceptable middle ground between the two positions.
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Gareth Matthews’ paper [5] is a penetrating discussion of two closely related topics. In the first part of the paper, he offers a description and analysis of what he has called the “Standard Developmental Account” of children’s... more
Gareth Matthews’ paper [5] is a penetrating discussion of two closely related topics. In the first part of the paper, he offers a description and analysis of what he has called the “Standard Developmental Account” of children’s conceptions of death. In the second part of the paper he focuses on an in-depth study of terminally ill children and compares its findings with the Standard Developmental Account. My commentary will explore the implications Matthews draws from these studies for the questions of whether and how to inform seriously ill children about their disease and help them participate in decisions about its treatment.
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In order to assess the value of civil defence planning for a nuclear attack, this paper focuses on a specific local example—the official civil defence plan of Pitt County, North Carolina, USA. Pitt County has been designated a host area... more
In order to assess the value of civil defence planning for a nuclear attack, this paper focuses on a specific local example—the official civil defence plan of Pitt County, North Carolina, USA. Pitt County has been designated a host area in which all of its 90 000 residents and 75 000 evacuees from neighbouring target areas are to be sheltered. After a brief review of this plan, three crucial questions are considered: (1) Will the evacuees designated for shelter in Pitt County arrive? (2) Will county officials be able to provide for the needs of the sheltered population? (3) If the population is sheltered as planned, will they survive a nuclear war? Doubts are expressed about whether each of these goals could be achieved. For example, it is estimated that 13.5 per cent of persons in shelters would be exposed to lethal doses of fallout radiation, but the plan makes no mention of the danger of acute radiation sickness. In view of the serious weaknesses identified in the plan, the paper concludes that efforts...
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In his many contributions to the bioethics literature over the past quarter century, H. Tristram Engelhardt, Jr. has addressed the question of the moral status of children a number of times, sometimes in passing and occasionally at... more
In his many contributions to the bioethics literature over the past quarter century, H. Tristram Engelhardt, Jr. has addressed the question of the moral status of children a number of times, sometimes in passing and occasionally at greater length.1 Engelhardt typically distinguishes the moral status of younger children, including infants, from that of older children and adults; in this paper I will focus on his discussions of younger children.
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This article examines two currently disputed issues regarding public policy for mentally retarded people. First, questions are raised about the legal tradition of viewing mental competence as an all-or-nothing attribute. It is argued that... more
This article examines two currently disputed issues regarding public policy for mentally retarded people. First, questions are raised about the legal tradition of viewing mental competence as an all-or-nothing attribute. It is argued that recently developed limited competence and limited guardianship laws can provide greater freedom for retarded people without sacrificing needed protection. Second, the question of who should act paternalistically for retarded people incapable of acting for themselves is examined. Rothman's claim that special formal advocates are the best representatives for retarded people is discussed and criticized. It is argued that parents, professionals and legal advocates should share decision-making authority on behalf of those who are incompetent.
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This paper considers whether Rawls' theory of justice as fairness may be used to justify a human right to health care. Though Rawls himself does not discuss health care, other writers have applied Rawls' theory to the... more
This paper considers whether Rawls' theory of justice as fairness may be used to justify a human right to health care. Though Rawls himself does not discuss health care, other writers have applied Rawls' theory to the provision of health care. Ronald Green argues that contractors in the original position would establish a basic right to health care. Green's proposal, however, requires considerable relaxation of the constraints Rawls places on the original position and thus jeopardizes Rawls' arguments for the two principles of justice. Norman Daniels claims that health care is best understood as a means for helping to achieve Rawls' goal of equality of fair opportunity. Daniels acknowledges, however, that his interpretation cannot justify a basic right to health care; rather, it would at best require that certain kinds of care be made available to certain kinds of individuals. Finally, in place of the notion of health care as a human right, it is suggested that the provision of health care is a social ideal which may inspire the creation of specific legal rights. On this view, social provision of health care may properly vary significantly from culture to culture. Despite this variability, social systems may still be criticized on moral grounds.
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For several years, organ transplantation has been one of the most highly publicized therapies of modern medicine, a kind of symbol of our high-technology, high-cost efforts to save lives. Children have played an important role in this... more
For several years, organ transplantation has been one of the most highly publicized therapies of modern medicine, a kind of symbol of our high-technology, high-cost efforts to save lives. Children have played an important role in this history; the media focused public attention on Charles and Marilyn Fiske's search for a donated liver for their daughter Jamie in late 1982 ~ and on Baby Fae's 20-day survival in 1984 with a transplanted baboon heart. 2 These cases, especially that of Baby Fae, evoked a flood of controversy and raised a host of complicated issues. In reviewing ethical issues in transplantation for children, this paper touches on some of the medical, scientific, economic, political, and social issues with which ethical issues are unavoidably linked. Three principles of ethics--beneficence, autonomy, and justice--form a framework for the discussion. First, consider the principle of beneficence, which enjoins us to act for the benefit or good of another or others. Benefitting the sick is arguably the fundamental goal of health care and the fundamental professional commitment of the physician. 3 In the case of transplantation, the primary benefits we seek to provide are the preservation of life (a necessary condition for any other benefit) and the improvement of its quality. Thus we speak of organ donors as giving the gift of life. The mere intention to benefit someone, however, is not by itself a sufficient justification for action. If it were, Dr. Bailey's belief that a baboon heart could be of benefit to Baby Fae 4 would have been enough to justify the transplant, and the widespread questioning of his grounds for that belief 59 would be irrelevant to the question of whether that experiment should have been attempted. Rather, scientific medicine demands that our beneficent intentions be well grounded in fact, and thus we look first to animal research
Research Interests: Pediatrics, Economic Justice, Medical Ethics, Resource Allocation, Autonomy, and 12 moreRisk assessment, Medicine, Transplantation, Humans, Child, Federal Government, Beneficence, Risk Assessment, Personal autonomy, parental consent, Tissue and organ procurement, and Paediatrics and reproductive medicine
In this second edition of Death to Dust: What Happens to Dead Bodies?, emergency physician/bioethicist Kenneth Iserson has revised and expanded the original 1994 edition. The second edition improves on its predecessor in several ways.... more
In this second edition of Death to Dust: What Happens to Dead Bodies?, emergency physician/bioethicist Kenneth Iserson has revised and expanded the original 1994 edition. The second edition improves on its predecessor in several ways. First, it updates information on several important topics, such as rates of organ donation and the number of patients awaiting organ transplantation. Second, it includes new information in a number of topic areas, such as embalming, mummification, and cryonics. Third, the design of the book, including the page layout, graphs, and illustrations, is much clearer and more attractive. The goals and organization of the second edition, however, remain unchanged from the first.
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Millions of patients present to US EDs each year with symptoms concerning for acute coronary syndrome (ACS), but fewer than 10% are ultimately diagnosed with ACS. Well-tested and externally validated accelerated diagnostic protocols were... more
Millions of patients present to US EDs each year with symptoms concerning for acute coronary syndrome (ACS), but fewer than 10% are ultimately diagnosed with ACS. Well-tested and externally validated accelerated diagnostic protocols were developed to aid providers in risk stratifying patients with possible ACS and have become central components of current ED practice guidelines. Nevertheless, the fear of missing ACS continues to be a strong motivator for ED providers to pursue further testing for their patients. An ethical dilemma arises when the provider must balance the risk of ACS if the patient is discharged compared with the potential harms caused by a cardiac workup. Providers should be familiar with the ethical principles relevant to this dilemma in order to determine what is in the best interests of the patient.
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Although voluntarily stopping eating and drinking (VSED) as a way to hasten one’s death is not yet a widely recognized practice in the United States, it has received increasing attention in the medical and bioethics literature in recent... more
Although voluntarily stopping eating and drinking (VSED) as a way to hasten one’s death is not yet a widely recognized practice in the United States, it has received increasing attention in the medical and bioethics literature in recent years. After a brief review of the broader context of human death and dying, this article poses and examines 11 conceptual, personal, and public policy questions about VSED. The article identifies essential features of VSED and discusses whether VSED is a type of suicide. It identifies reasons why people may or may not choose VSED, and it considers responses by family members and professional caregivers to people who have chosen VSED. It also considers how public policies may permit and regulate or restrict the practice of VSED. Examination of these questions is designed to increase understanding of VSED and to inform moral evaluation of this practice.
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Emergency physicians frequently interact with law enforcement officers and patients in their custody. As always, the emergency physician's primary professional responsibility is to promote patient welfare, and his or her first duty is... more
Emergency physicians frequently interact with law enforcement officers and patients in their custody. As always, the emergency physician's primary professional responsibility is to promote patient welfare, and his or her first duty is to the patient. Emergency physicians should treat criminals, suspects, and prisoners with the same respect and attention they afford other patients while ensuring the safety of staff, visitors, and other patients. Respect for patient privacy and protection of confidentiality are of paramount importance to the patient-physician relationship. Simultaneously, emergency physicians should attempt to accommodate law enforcement personnel in a professional manner, enlisting their aid when necessary. Often this relates to the emergency physician's socially imposed duties, governed by state laws, to report infectious diseases, suspicion of abuse or neglect, and threats of harm. It is the emergency physician's duty to maintain patient confidentiality...
Research Interests: Emergency Medicine, Medicine, Law Enforcement, Safety, Humans, and 13 moreDuty, Confidentiality, Clinical Sciences, Neglect, Prisoners, Medical Emergency, Harm, Medicine and Health Sciences, Criminals, Mandatory reporting, Medical specialties, Health Insurance Portability and Accountability Act, and Physician-Patient Relations
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... 308, 309 Bailey, Joseph, 32, 33, 38 Baily, Ashley, 308 Baker, Iosephirre, 30, 39 Bamett, Henry, 261 Bamhart, Henry, 35 Bayard, Thomas, 46 Beecher, HK, 98 Behrman, Richard, 261 Bellevue Hospital Outdoor Bureau of Relief, 249, 251... more
... 308, 309 Bailey, Joseph, 32, 33, 38 Baily, Ashley, 308 Baker, Iosephirre, 30, 39 Bamett, Henry, 261 Bamhart, Henry, 35 Bayard, Thomas, 46 Beecher, HK, 98 Behrman, Richard, 261 Bellevue Hospital Outdoor Bureau of Relief, 249, 251 Benevolence, 332 Bentsen, Lloyd, 60 ...
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In this paper, I have sought to highlight the pioneering contributions made by Dan Clouser to the emerging field of bioethics. Building on Clouser’s advice, I have also offered additional suggestions regarding the methods and core content... more
In this paper, I have sought to highlight the pioneering contributions made by Dan Clouser to the emerging field of bioethics. Building on Clouser’s advice, I have also offered additional suggestions regarding the methods and core content of bioethics instruction in medical schools. Due in no small measure to Clouser’s work, I am confident that bioethics will continue to evolve and expand into the twenty-first century and beyond.
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As several of the authors in this volume point out, the concepts of sanctity of life and Menschenwurde (human dignity) have played significant roles in the theology, philosophy, and jurisprudence of the Western world. These concepts refer... more
As several of the authors in this volume point out, the concepts of sanctity of life and Menschenwurde (human dignity) have played significant roles in the theology, philosophy, and jurisprudence of the Western world. These concepts refer to basic values which have been and continue to be both widely and deeply held. The aim of this volume is to investigate whether and how sanctity of life and Menschenwurde can help to address pressing moral issues in contemporary medicine. In the title of his contribution, H. Tristram Engelhardt, Jr. [4], poses a specific question, “Can these concepts help direct the use of resources in critical care?” Engelhardt’s answer is that their usefulness for this purpose is very limited. He argues that these concepts lack the conceptual clarity and rational grounding necessary to dictate specific and compelling answers to our moral and policy questions regarding the proper use of critical care.
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Current federal policy, as reflected in the final Baby Doe rule, will have a chilling effect on the ability of doctors to care appropriately for severely disabled infants. The policy threatens to prolong life unjustifiably for such... more
Current federal policy, as reflected in the final Baby Doe rule, will have a chilling effect on the ability of doctors to care appropriately for severely disabled infants. The policy threatens to prolong life unjustifiably for such infants. It will force physicians to violate a duty to do no harm without compensating benefit. And it raises serious problems for the just distribution of health care.
Research Interests: Business, Philosophy, Applied Ethics, Decision Making, Medical Ethics, and 15 moreResource Allocation, Risk assessment, Medicine, Humans, Federal Government, United States, Newborn Infant, Neglect, Harm, Risk Assessment, Congenital abnormalities, Psychological Stress, Government Regulation, Delivery of Health Care, and Life support care
Ambulance diversion is a common and controversial method used by emergency departments (EDs) to reduce stress on individual departments and providers and relieve mismatches in the supply and demand for ED beds. Under this strategy,... more
Ambulance diversion is a common and controversial method used by emergency departments (EDs) to reduce stress on individual departments and providers and relieve mismatches in the supply and demand for ED beds. Under this strategy, ambulances bound for one hospital are redirected to another, usually under policies established by regional emergency medical services systems. Other responses to this mismatch include maladaptive behaviors (such as "boarding" in "hallway beds") and the development of terminology intended to normalize these practices, all of which are reviewed in this article. We examine the history and causes of diversion as well as the ethical foundations and practical consequences of it. We contend that (1) from a moral viewpoint, the most important stakeholder is the individual patient because diversion decisions are usually relative rather than absolute; (2) decisions regarding ambulance diversion should be made with careful consideration of indiv...
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... in fact, that if one substitutes perfect altruism for Rawls's own assumption of mutual disinterest as the ... This claim, however, cannot sustain the unqualified altruism of the greatest happiness principle. ... But willing that... more
... in fact, that if one substitutes perfect altruism for Rawls's own assumption of mutual disinterest as the ... This claim, however, cannot sustain the unqualified altruism of the greatest happiness principle. ... But willing that some individuals be forced to suffer for the good of others would ...
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In the current era of cost-containment, Congress may reconsider its support for the End-Stage Renal Disease Program. Substantial reductions in funding for this program could be made by eliminating non-beneficial, marginally beneficial,... more
In the current era of cost-containment, Congress may reconsider its support for the End-Stage Renal Disease Program. Substantial reductions in funding for this program could be made by eliminating non-beneficial, marginally beneficial, and relatively inefficient modes of treatment. These measures, however, will only postpone the inevitable day when clearly beneficial treatment must be withheld.
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In his book Engineered Death: Abortion, Suicide, Euthanasia and Senecide, John Woods uses an argument from analogy to establish the following conclusion: even if one grants that foetuses are not persons but only potential persons, killing... more
In his book Engineered Death: Abortion, Suicide, Euthanasia and Senecide, John Woods uses an argument from analogy to establish the following conclusion: even if one grants that foetuses are not persons but only potential persons, killing foetuses is murder. Murder, according to Woods, is the defeasibly wrongful violation of the right to life ascribed to persons. If this argument is successful, it would of course have profound consequences for the ongoing philosophical debate over the morality of abortion. Whether or not they hold that foetuses are persons, philosophers would be forced to adopt the same moral attitude toward foeticide as they would adopt toward the killing of persons. That is, the killing of foetuses and the killing of persons would be defeasibly wrong in the same way; their wrongfulness could be defeated only in special and limited circumstances, perhaps like those suggested by Judith Thomson in her “Defense of Abortion”.
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Civility is an essential feature of health care, as it is in so many other areas of human interaction. The article examines the meaning of civility, reviews its origins, and provides reasons for its moral significance in health care. It... more
Civility is an essential feature of health care, as it is in so many other areas of human interaction. The article examines the meaning of civility, reviews its origins, and provides reasons for its moral significance in health care. It describes common types of uncivil behavior by health care professionals, patients, and visitors in hospitals and other health care settings, and it suggests strategies to prevent and respond to uncivil behavior, including institutional codes of conduct and disciplinary procedures. The article concludes that uncivil behavior toward health care professionals, patients, and others subverts the moral goals of health care and is therefore unacceptable. Civility is a basic professional duty that health care professionals should embrace, model, and teach.