Pain is a complex concept, which presents numerous clinical and ethical complexities for caregivers and patients in burn care settings. Good clinical and ethical decision making in these settings demands attention to topics such as end-of-life practices and how to regard consent, refusal and other expressions of a patient’s autonomy.  One famous burn patient’s case has been particularly influential.

In 1973, Dax Cowart was critically injured in a propane gas explosion that took the life of his father. Cowart’s opposition to the ensuing care he received prompted him to pursue study of the legal and ethical issues related to his treatment following his recovery. Through his activism, Cowart opened the door to constructive discussions on ethical issues around burn care.

This June issue of the AMA Journal of Ethics® (@JournalofEthics) seeks to open dialogue about Cowart’s legacy and to consider various approaches and perspectives to help examine some of the most pressing clinical and ethical issues in burn care today.

Take a moment to consider this question: A skin graft from a pediatric burn patient’s twin could improve outcomes, but will cause pain, scarring and other negative outcomes for the twin. Is it ethical to put the twin at risk to help her sister?

  • Yes, if the twins’ parents give consent.
  • Yes, if the twins’ parents give consent, the donor twin assents, and an independent living donor advocate is involved.
  • No.

Give your answer and find responses to this question in the June issue of the AMA Journal of Ethics, which also explores ethical questions including, but not limited to, expressions of bias in burn care settings, pain management, surgical education practices, the nature and scope of clinicians' roles in burn prevention, whether and when live donor grafts are appropriate, and how to prioritize and weigh values such as survival, function, and cosmesis.

Articles include:

Is It Ethical to Treat Pain Differently in Children and Adults with Burns? Physicians have obligations to ensure that their own discomfort with children’s pain doesn’t lead them to make pain management decisions that could place a patient at greater risk and to engage in thoughtful, individualized pain management strategies. Long-term consequences of overzealous pain medication administration, for example, could include delayed recovery and integration or opioid dependence.

Problems and Costs That Could Be Addressed by Improved Burn and Wound Care Training in Health Professions Education. The current system of burn care delivery attempts to meet the needs of the nearly 500 000 patients in the United States who require medical treatment annually. However, specialization of care and lack of fundamental burn and wound care knowledge among graduating medical trainees has unintended consequences, leaving the system inefficient, with inherent inequities in care delivery and the potential to be overwhelmed in a mass casualty event.

While increasing accessibility to specialty burn centers through technology could mitigate some of these problems, increased education is more practical.

The Four-Quadrant Approach to Ethical Issues in Burn Care. Burn injuries raise questions about decision-making capacity, informed consent, medical decision making, patient autonomy, the patient-physician relationship, and medical futility that must be acutely addressed.

A commonly used approach to managing ethical challenges focuses on moral principles including respect for patient autonomy, beneficence, nonmaleficence, and justice. Another paradigm for ethical analysis is the “four-quadrant” approach, which poses questions for a given case regarding medical indications, patient preferences, quality of life, and contextual features.

Defining Adequate Quality and Safety Metrics for Burn Care. While current evidence-based practices might be applicable to caring for patients with routine diseases and common injury patterns, their application to burn care is less clear. Quality metrics created for large patient populations have failed to account for diseases that are not included in landmark research. Tasked to provide not only medically appropriate, but also high-quality and cost-effective care for patients, burn clinicians must find a balance between patient-specific quality metrics and external quality metrics.

In the AMA Journal of Ethics June podcast, expert Monica Gerrek, PhD, co-director of the Center of Biomedical Ethics at the MetroHealth System and co-director of the Institute of Burn Ethics, and burn survivor Andrea Rubin, discuss how burn teams can support patients’ autonomy in the aftermath of their injuries.

They also discuss the need to provide comprehensive and interdisciplinary care that responds to each individual patient. Listen to previous episodes of the podcast, “Ethics Talk,” or subscribe in iTunes or other services.

Meanwhile, the AMA Journal of Ethics Discussion Forum will explore navigating moral distress during training. The online discussion runs June 20–27. Learn from experts on the topic and ask your questions.

The Conley Art of Medicine and Conley Ethics Essay contests for medical students, residents, and fellows are now open through Sept. 25. Each has a $5,000 prize for the winning art entry.

The journal’s editorial focus is on commentaries and articles that offer practical advice and insights for medical students and physicians. Submit a manuscript for publication. The journal also invites original photographs, graphics, cartoons, drawings and paintings that explore the ethical dimensions of health or health care.

The AMA Journal of Ethics call for papers is now open. The journal invites original submissions for peer review consideration on themes that will be explored in 2019 issues.

A call for theme issue editors is also now open through October 1, 2018. The journal invites medical students, residents and fellows (MDs or DOs) in United States-based programs to apply to serve as theme issue editors for monthly issues to be published from December 2019 through November 2020.

A look ahead

Upcoming issues of the AMA Journal of Ethics will focus on religion and spirituality in health care practice, and ethics, policy and the roles of physicians in care of the dying. Sign up to receive email alerts when new issues are published.

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