Medical Friendships in Assisted Dying

Transcript

• 00:00Good evening and welcome.
• 00:02I'm going to get us started.
• 00:05I think I know most of you.
• 00:06My name is Mark Mercurio.
• 00:07I'm the director of the program
• 00:09for Biomedical Ethics here
• 00:10at Yale School of Medicine.
• 00:11And on behalf of our associates,
• 00:13directors Sarah Holland,
• 00:14Jack Hughes, we're here tonight.
• 00:16And our manager, Karen Cole,
• 00:18welcome to the Evening Ethics seminar series.
• 00:21We have a terrific program tonight,
• 00:23which I'll get to in just a minute
• 00:25with my friend Seamus Clark.
• 00:26Before that,
• 00:27just a couple of quick announcements,
• 00:28if I could, please.
• 00:29There are some important events coming up.
• 00:31Which I hope you'll join us
• 00:33for next week on March 8th,
• 00:35same time,
• 00:36same place we will have Armand Dental
• 00:39Maria from Cincinnati Children's Hospital.
• 00:42Armand is a national authority
• 00:43on issues of of gender affirming
• 00:45care and he's going to be spending
• 00:48some time talking about that with
• 00:50us next week and I hope you'll
• 00:52be able to join us for that.
• 00:53In addition,
• 00:54on the 14th here at the CHILD Study Center,
• 00:56Cohen Auditorium also Lisa
• 00:57Campo Engelstein is going to
• 00:59be speaking on clinical care.
• 01:01For LGBTQ youth,
• 01:02Ethical case studies and least
• 01:04you might remember was a speaker
• 01:06not too long ago in this venue.
• 01:08I think that was just on zoom,
• 01:10but we had at least here a bit ago,
• 01:12so I'm delighted that she's coming back.
• 01:14So please join us for those two events
• 01:16as your time and interest allow.
• 01:18What's going to happen tonight is I am
• 01:22going to introduce Professor Clark,
• 01:25who is then going to speak for 45 minutes,
• 01:27plus or minus.
• 01:28This is all kind of loose,
• 01:30after which we'll have an exchange.
• 01:31Question and answer and an
• 01:33audience discussion.
• 01:33And I invite the folks on the webinar
• 01:35to send in your questions on the
• 01:37Q&A function on the on the zoom,
• 01:39not on the chat portion, but the Q&A portion.
• 01:41If you send that in,
• 01:43I'll be keeping an eye on this while
• 01:46Chalmers is answering questions and
• 01:47then we'll have a conversation and we
• 01:50will stop somewhere between 6:15 and 6:30,
• 01:53but we will stop at 6:30.
• 01:56So just to let you know if you're
• 01:58thinking is this going to go on all night,
• 01:59I know you're hoping it will,
• 02:00but it won't.
• 02:01So we will have a hard stop
• 02:03at 6:30 and we'll have a great
• 02:05conversation in the meantime,
• 02:06so welcome and thanks.
• 02:07Let me tell you about my friend
• 02:08Chalmers Clark.
• 02:09Chalmers presently teaches philosophy
• 02:10at the College of Staten Island,
• 02:12the City University of New York and
• 02:14at Wagner College, also on Staten Island.
• 02:16Yeah,
• 02:17he's also taught for three years
• 02:18on a temporary full time basis
• 02:20at the College of Nursing and
• 02:22Health Professions at Drexel
• 02:23University in Philadelphia.
• 02:24Prior to that,
• 02:25he taught philosophy at Union
• 02:26College and Business Ethics in
• 02:28the MBA program in the School of
• 02:30Management at Union Graduate College,
• 02:32which is now Clarkson University.
• 02:34He taught bioethics in the
• 02:36online Masters program
• 02:38for the Neiswanger Institute of Bioethics
• 02:40at the Stritch School of Medicine
• 02:42at Loyola University in Chicago.
• 02:44He has a background in naturalized
• 02:46epistemology and biomedical ethics.
• 02:48He received a BS from Union
• 02:50College Magicum Lauda,
• 02:51and after spending a year in the PhD
• 02:53program in Philosophy at Johns Hopkins,
• 02:55he received his MA and pH.
• 02:56D from the Graduate center of
• 02:59the City University of New York.
• 03:02Chalmers has been involved at Yale
• 03:03often on over the years and it's
• 03:04been my good fortune that we have
• 03:06paths have crossed a few times.
• 03:08And so it was actually my friend
• 03:10Tom Duffy who last year when I was
• 03:12planning this year who said to me see
• 03:15if we can get Chalmers to come back.
• 03:17So I am, as you all are,
• 03:19terribly sorry that Tom is not here for this,
• 03:22but this is yet one more gift from
• 03:23Tom that we got Chalmers back here
• 03:24to speak to us for a little bit.
• 03:26So with that,
• 03:27this is going to be a very informal evening.
• 03:29Chamber is the floor is yours and when
• 03:30you're done I'll come back up here.
• 03:32And I will moderate the Q&A session.
• 03:34Thank you for coming, Chalmers.
• 03:36Thank you very much.
• 03:40That folks hear me in the back.
• 03:41Oh, good. It's good. Great.
• 03:44OK. And I once was at a
• 03:48conference in Oxford actually,
• 03:50where at the Director of the
• 03:52conference said please people,
• 03:54if you it was Education Department.
• 03:56He said please people don't
• 03:58read your paper teaching.
• 04:00So I'm going to try to do that here and
• 04:02more of a narrative discussion rather
• 04:05than kind of drill and kill line by line.
• 04:08You know some of you have the paper,
• 04:10have seen the paper.
• 04:12Of assisted medical friendships and
• 04:17assisted dying of any any folks seen it?
• 04:20Some, yeah. OK.
• 04:21So because I I'll be referring to certain
• 04:24sections of it at a certain point.
• 04:28Anyway, what what I'm what I got interested
• 04:31in from this is actually my wife Nancy,
• 04:35who's here was a part of
• 04:37the the reason for it.
• 04:39She sowed the seed because in teaching
• 04:41bioethics all the focus is in proper,
• 04:44properly and to a great extent should
• 04:47be on patients and patients rights.
• 04:50But what about the doctors?
• 04:52What's their experience like?
• 04:53Don't you understand what
• 04:54they're going through?
• 04:55I mean this is no small potatoes.
• 04:58There, this is, you know,
• 04:59a major obstacle course they have
• 05:01to thread their way through, I mean.
• 05:04Everybody knows the biblical
• 05:06thou shalt not kill, right?
• 05:08And I mean it rings in your head.
• 05:10And I spoke to 11 physician and
• 05:12in the Netherlands actually
• 05:14that had a terrible experience.
• 05:17He was involved in assisted dying
• 05:19and he helped end a patient's life
• 05:22who had cancer of this esophagus
• 05:24and was suffering terribly.
• 05:27And you know, everything went appropriately,
• 05:29he said.
• 05:30But the next day he read in
• 05:33the paper a story.
• 05:35About an execution in the
• 05:37United States and he said.
• 05:39I knew better intellectually and the
• 05:41intellectual psychological divide
• 05:42is very important here, I think.
• 05:44That, he said.
• 05:45I knew better intellectually,
• 05:47but I just had the feeling that's what I do.
• 05:50Right.
• 05:51And it really kind of,
• 05:52it really sent him into a tailspin
• 05:54and he got out of the practice
• 05:57entirely for a while and he
• 05:59ultimately came back to it.
• 06:01Through something else that
• 06:02I want to talk about.
• 06:03That's kind of a main threat of this,
• 06:05through interaction with other
• 06:06people who have been there.
• 06:08There's a huge difference between insiders
• 06:11and outsiders to this issue it seems,
• 06:14and I'll talk about that a little bit.
• 06:16So after after sewing this Nancy,
• 06:19so she's here now, so sewing the seeds.
• 06:24I saw a video from the Netherlands
• 06:26and if you've read the paper,
• 06:28a guy named I, I I call it Doctor A.
• 06:32Of.
• 06:33Who was in this video?
• 06:35And they had some heavyweight
• 06:36people on the the panel.
• 06:37Roger Mudd was the moderator
• 06:39and they had Peggy Batten.
• 06:41Anybody heard of Peggy Batton,
• 06:43major philosopher and Carlos Gomez?
• 06:47He was a a anti assisted dying.
• 06:51Bella and.
• 06:53Of Dan Brock,
• 06:55another major player in philosophy
• 06:58and a woman named April Summers.
• 07:01Anyway so. That I I realized from
• 07:07watching this fellow I'm calling doctor
• 07:10a something is really going on here
• 07:13his whole affect you're talking to a
• 07:16patient that wanted to die as he said
• 07:18now I mean he was the the patient was
• 07:21so emphatic and when I did did talk to I
• 07:25did talk to doctor A in the Netherlands.
• 07:27He said I never saw anybody exit
• 07:30so quickly it was like he want he
• 07:32was you know like wanted to go.
• 07:34And that's that's the importance of that too.
• 07:37We'll see in a minute with a fellow
• 07:40named Peter Reagan from Oregon.
• 07:42He was in the.
• 07:45Death with Dignity Act, big advocate for it.
• 07:48And he got involved in the case
• 07:49and he said he had to be.
• 07:50I was almost blown away.
• 07:52By the difference between this
• 07:54and a natural death.
• 07:56Right.
• 07:56So something's going on with physician
• 07:58there and you know the preparation
• 07:59they get in Med school for it, right?
• 08:02Nada. Nothing, right?
• 08:04It's a personal journey.
• 08:05Journey.
• 08:06And so part of our project that
• 08:09I wrote was this colleague and
• 08:12now friend Garrett Kimsa.
• 08:14From the Netherlands.
• 08:17Was to try to think about a model of
• 08:20approaching it that would assist the
• 08:23physicians to you know get through a
• 08:27really challenging experience in a more.
• 08:30More and easier sort of way than you know,
• 08:33it's hit them.
• 08:34Too many bumps on the road.
• 08:37Well anyway,
• 08:38so after that video I was
• 08:40convinced you know this was this
• 08:42was something to undertake.
• 08:43So I here's here's the insider
• 08:45outsider stuff is comes up again.
• 08:48I I applied for a grant to come to the
• 08:51Netherlands to study it turned down.
• 08:54Actually the reason was pretty good,
• 08:57they said.
• 08:58Why can't you do it here?
• 09:00Reasons pretty clear.
• 09:01So I reapplied and I said you
• 09:03know why I need to go there?
• 09:04It's because of, you know,
• 09:06if you won't be prosecuted if you
• 09:09follow certain guidelines there.
• 09:10You know, the the courts,
• 09:12very interestingly,
• 09:13went to the medical profession
• 09:15to find out what they should do.
• 09:17I mean,
• 09:18just the opposite of what would happen here,
• 09:19right?
• 09:20You bring in the lawyers,
• 09:21you know they're going to
• 09:22tell you what to do.
• 09:24And so it's just the opposite.
• 09:27And I then I started on a search
• 09:29and I did a search for a tried to
• 09:32contact all kinds of people who would
• 09:34have be able to tell me somebody
• 09:37to go see when I'm over there.
• 09:39And. One of them was Peggy Batten.
• 09:43I wrote to her and.
• 09:46As bright and as sharp of a
• 09:48philosopher she she she tried.
• 09:51She basically shrugged it off.
• 09:53The project, I mean, what's the big deal?
• 09:55Patient autonomy.
• 09:56Patient autonomy.
• 09:56You know, they should go to,
• 09:58you know,
• 09:59doctors should just respect that
• 10:01and that's it.
• 10:02Right and then just before I then I I
• 10:05got got accepted for a grant funding
• 10:08to go the second second time around.
• 10:11And in going. Just before I went,
• 10:15I get a message from Peggy Batten, she says,
• 10:18oh, is this what you're talking about?
• 10:20And Peter Reagan, doctor Peter
• 10:24Reagan from Oregon in The Oregonian
• 10:27had written about his experience,
• 10:28and he said some extraordinary things.
• 10:31Maybe I might. Mention a few of them.
• 10:43You have this. We're ready and available.
• 10:49Well, I I called him and I talked to
• 10:52him on the phone and he said that.
• 10:55He wrote an article that became,
• 10:57you know, rather famous,
• 10:59called Helen about his patient Helen.
• 11:02And she wanted to be, you know,
• 11:05assisted to die. And in the US,
• 11:06I mean it's a whole different scenario
• 11:08than it is in the Netherlands because what
• 11:10we're talking about is writing a script.
• 11:12We're not talking about euthanasia
• 11:14in the sense of injecting a, a,
• 11:17a fatal dose of something into into them,
• 11:20right. And so Peter Reagan said he was,
• 11:23he was very shocked by the difference
• 11:25between this and a natural death,
• 11:27as I mentioned before.
• 11:28And when I talked to him,
• 11:30I said from what what you said.
• 11:32And The Oregonian said,
• 11:33it sounds like Helen was was there and
• 11:36ready and you were behind the curve.
• 11:39And he said absolutely.
• 11:41He said, you know, and you know,
• 11:43he started getting a little
• 11:45bit wistful on the day.
• 11:46He says it was a beautiful day,
• 11:48right?
• 11:49And you know,
• 11:50he's imagining what it would be
• 11:52like to check out himself under
• 11:54those kinds of circumstances.
• 11:56And he he found it.
• 11:57The irony of a little bit of punishing.
• 12:00To him and.
• 12:03So and then hit the biggest shot he had
• 12:06actually was her reaction, he said.
• 12:09He got there.
• 12:10Right, with the script.
• 12:11And he said, her attitude, as he said quote,
• 12:14he said it was kind of like,
• 12:15OK, where's the bus?
• 12:16Let's go.
• 12:17He said that shocked him,
• 12:19that shocked him rather deeply
• 12:21that she was so, you know,
• 12:23kind of like doctor's experience
• 12:24that she was so ready and he was not.
• 12:27He said. I even hesitated at signature.
• 12:30I mean, it's just a signature.
• 12:32Right.
• 12:32There's psychological and philosophical
• 12:34stuff going on that I wanted to get into.
• 12:38You know,
• 12:39two psychological conflicts roughly going on,
• 12:42one more philosophical, I think,
• 12:45and the other more psychological.
• 12:46The psychological,
• 12:47you know, being things like,
• 12:50I'm not sure how much credence
• 12:51you want to put into it,
• 12:53but like Freud,
• 12:54Freud said that the conscious mind can
• 12:58understand fully that it will someday die,
• 13:00he says,
• 13:01but the unconscious is utterly
• 13:03convinced of its own immortality.
• 13:05Right and being brought into the.
• 13:08Closer proximity.
• 13:10With, you know,
• 13:11dying like some of these
• 13:14positions where you have,
• 13:16you know,
• 13:16you have much more of a a test of 1's own,
• 13:20you know,
• 13:21sense of of our own mortality.
• 13:25And in the beginning of the
• 13:27paper I I'll read something from
• 13:29from Doctor Howard Grossman,
• 13:31who is a you he at the time he
• 13:34was a Manhattan internist who
• 13:36was involved in some cases.
• 13:39And now he's in Nevada.
• 13:41But he wrote.
• 13:42Doctor Howard Grossman,
• 13:43a Manhattan internist and plaintiff
• 13:45in the unsuccessful New York law
• 13:48lawsuit to the Supreme Court,
• 13:49bacco versus Quill,
• 13:50came forward to say anybody who's
• 13:53done it knows that it is a tremendous
• 13:55decision you carry with you forever.
• 13:58And this is a guy that's just like
• 14:01Doctor Reagan is just writing a script.
• 14:03I mean, what's the big deal from the outside?
• 14:06It's kind of like what's the
• 14:07big deal from the inside?
• 14:09Apparently it's a huge deal and it
• 14:11was a massive eye opener for me.
• 14:14Right about, you know,
• 14:15kind of a real interesting,
• 14:17you know,
• 14:17interesting from a philosophical point
• 14:19of view connection between direct
• 14:21human experience and the, you know,
• 14:23the area stuff we do in philosophy,
• 14:25theorizing and so on.
• 14:26I mean this is for real, right.
• 14:28And it's kind of like whoa, hold on.
• 14:32OK, on the.
• 14:34Psychological side, as you know,
• 14:37most people know about Kubler Ross.
• 14:40Right.
• 14:40What happens when people learn that
• 14:42they're going to die first thing?
• 14:46Denial, right? Denial, bargaining.
• 14:50You know, the routine that she goes through.
• 14:54And then anybody heard of Ernest Becker?
• 14:57He wrote a book that got a Pulitzer
• 14:59Prize in the 70s called Denial of Death,
• 15:02and his thesis was it got a Pulitzer.
• 15:04So I I haven't read the book and I
• 15:06I should have, but but his his basic
• 15:09thesis was that from childhood onward,
• 15:12the denial of death actually structures
• 15:15our conception of life. Right, so.
• 15:19That's another psychological conflict.
• 15:21But on the philosophical side,
• 15:23we have a a a very interesting
• 15:26conflict and it comes back to, well,
• 15:29you might say cognitive dissonance
• 15:30these days, Leon Festinger's
• 15:32work on cognitive dissonance.
• 15:35Does anybody know of it?
• 15:37It should be, yeah. It should be.
• 15:38Kind of known around town anyway.
• 15:42But what is cognitive dissonance?
• 15:44It's kind of a conflict between what
• 15:46you believe and what you do, right?
• 15:48And it's supposed to stir up, you know.
• 15:51Of disturbance and and and one's
• 15:54thoughts and one's behavior and it.
• 15:56But it has a very interesting you know,
• 15:59philosophically history.
• 15:59You could trace it back to Socrates,
• 16:02who had his, you know,
• 16:03Socratic method not of people
• 16:05really cheapen it.
• 16:06They say, Oh yeah,
• 16:07this question and answer,
• 16:08question and answer,
• 16:09it's much deeper than that in terms of
• 16:12what he's about and what he's trying to
• 16:14do because he has a more dialectical method,
• 16:17which is progressive with someone
• 16:19to try to pursue the truth.
• 16:21But he also has, as you know,
• 16:23Socrates could be pretty rough on people
• 16:25what it what was called the elenchus,
• 16:27which was a method of refutation which
• 16:30he would try to extract from somebody.
• 16:33You would try to extract from
• 16:36them a contradiction.
• 16:37Right, which is logical death, right?
• 16:39In logic, if you can prove a contradiction.
• 16:43If you assume a contradiction in your
• 16:45premises, you can prove anything,
• 16:47I mean anything.
• 16:49I can prove that Bill Rudin's
• 16:51house is made of Jello.
• 16:53Raspberry jello, in fact,
• 16:54with whipped cream and a cherry on top.
• 16:57I mean, if you can prove that.
• 17:00I mean, what have you proven?
• 17:01Nothing, right?
• 17:02So I mean from a logical point of view,
• 17:05a contradiction is is like as
• 17:07bad as it could be.
• 17:08But we see that you know this,
• 17:10the history of cognitive dissonance
• 17:12being used by Socrates where he
• 17:14would do that to the scholar named
• 17:17Julia Annas was analyzing his method
• 17:19and she said his purpose was to
• 17:23elicit shock first and then shame.
• 17:25So the social side of it is really important.
• 17:28I mentioned it with the doctor,
• 17:30called him a doctor, Jay.
• 17:33Who had that tough experience before?
• 17:36And he said basically getting back,
• 17:39you know, it's kind of,
• 17:40you've seen these stories about horses,
• 17:42worst thing you can do to them.
• 17:44Isolate them from the herd.
• 17:46Right.
• 17:46This idea of being, you know,
• 17:48an outcast or being a social pariah,
• 17:51right, is really disturbing.
• 17:53And when he felt like,
• 17:54I guess that's the way he was feeling and
• 17:57when he started talking to other other.
• 18:01Of physicians who have been
• 18:03involved in the process, he said.
• 18:04That helped him a lot.
• 18:05You know, being reintegrated into
• 18:07the the medical herd, if you will.
• 18:10Sorry, mark. Anyway.
• 18:14And then, you know, we get up to.
• 18:17Cognitive dissonance with the.
• 18:21Leon festinger.
• 18:24So on the philosophical side,
• 18:25let me I try to articulate what
• 18:28might amount to something like
• 18:30this serious cognitive dissonance.
• 18:32Philosopher named Alan Buchanan.
• 18:35Talked about what he called the paradigm.
• 18:39And he's talked,
• 18:40he said the very paradigm, you know,
• 18:43paradigms are not definitional.
• 18:44They're kind of like model
• 18:46model cases of something.
• 18:48But for example.
• 18:52The paradigm of a nutritious meal used
• 18:55to be steak, potatoes, butter, right?
• 18:58You know, very brown it.
• 19:00We've had a paradigm shift
• 19:02right now it's pretty green.
• 19:04Right. That's a paradigm shift,
• 19:05the the model of it, right?
• 19:07Or, you know, at the very model of
• 19:09an intellectual is Albert Einstein.
• 19:12Just look at the guy,
• 19:13you know he's got to be wicked smart, right?
• 19:17So. So we have these models,
• 19:21and he's saying the very paradigm
• 19:23of wrongdoing, as he put it.
• 19:24If anything is wrong in the world,
• 19:26the intentional taking of innocent
• 19:29personal life is wrong. Right and.
• 19:34So we have the paradigm.
• 19:39Whoops.
• 19:52Intentional taking of innocent personal life.
• 19:56Being wrong, right? Run, run, run.
• 20:01Disconnected from the universe.
• 20:04That should carry away.
• 20:08Whatever works. Oh, there you go.
• 20:09Yeah, better, yeah. Someone close.
• 20:14There we go. OK.
• 20:20My back. I'm back. OK.
• 20:23But physician assisted suicide or
• 20:25physician assistant dying fits very
• 20:27neatly into the paradigm, right?
• 20:30Cognitive dissonance, big time.
• 20:33Then Buchanan, being a philosopher, wants to,
• 20:37wants to say what can we do about that?
• 20:39And he says, well, what are the wrong
• 20:42making features of the paradigm,
• 20:43and English too is being prominent.
• 20:46He said the first is the removal
• 20:50of well-being from a person.
• 20:53He said the 2nd is a violation
• 20:55of the right to life, he said.
• 20:58But they really don't make muster because
• 21:00well-being is removed by the disease,
• 21:03typically, not by the act of ending the life.
• 21:07And he said inherent in the idea of having
• 21:13a right is the right to waive the right.
• 21:16Right autonomy issue again.
• 21:20Interestingly,
• 21:21somebody like Immanuel Kant would
• 21:23disagree strenuously with the second
• 21:25he wouldn't think you have the
• 21:27right to waive your right to life.
• 21:30So, for example, he said.
• 21:32Because we can only dispose
• 21:34of objects or things.
• 21:36Persons are not things their
• 21:39ends in themselves. Right.
• 21:41And therefore we have no
• 21:42right to dispose of them.
• 21:44You're a person, so you don't have the
• 21:46right to dispose of your own life too,
• 21:47so suicide for somebody like
• 21:50Immanuel Kant would be just wrong.
• 21:53Right.
• 21:54And it's.
• 21:55It's not a very compelling argument,
• 21:57most people think.
• 21:57Can't really blew it on that one,
• 21:59but.
• 22:02There is that argument there.
• 22:04So he tries to show us a way out of it.
• 22:07By way out of the paradigm.
• 22:10By saying that, you know,
• 22:12autonomy kind of like, say,
• 22:14really does save the day.
• 22:16But you still have to do deal
• 22:19with that psychological weight of.
• 22:21You know, violation of certain
• 22:23kinds of norms that many people
• 22:26would think are are criminal.
• 22:28All right, so.
• 22:36OK, So what? I when I went
• 22:39over to Holland, I went to.
• 22:44I went through the I I collected
• 22:46a list of people to see,
• 22:47and the one that came up most often for most
• 22:50people was a fellow named Garrett Kinsman.
• 22:53So I was very eager to see him.
• 22:57And here's the insider outsider
• 22:59response again. Somebody is,
• 23:01you know keen and is thoughtful is
• 23:04Peggy Batten was first like, you know,
• 23:07she kind of like brushed off the the
• 23:10whole idea of it being a problem and so.
• 23:13I finally went to see Garrett Kinsman.
• 23:15I was kind of like loaded for bear
• 23:17because I've been getting so many
• 23:18rejections on it being a serious problem.
• 23:20And he was like he said I've
• 23:22been thinking the same things.
• 23:23He said he was a big cigar smoker.
• 23:25Still is, he says.
• 23:27But I've been writing only writing,
• 23:29writing notes down about it on
• 23:31the back of my cigar boxes.
• 23:32He said we should work on this together.
• 23:34And I was kind of really, you know,
• 23:36he he went to it right away,
• 23:38but he's an insider.
• 23:39He's been involved in the process himself,
• 23:42involved in the.
• 23:43Groups and organizations like scale and Skin,
• 23:47or organized or ways in which they monitor
• 23:54assisted dying and in the Netherlands.
• 23:56And you know, he got it right away.
• 23:58Been there, done that.
• 24:00It been there, obviously had,
• 24:02you know, the experience.
• 24:03He knows it's there.
• 24:07So how are we going to get out of this?
• 24:08Well, one of the things we try to
• 24:11say can we construct some kind of
• 24:13model at least in entering edge
• 24:16of the wedge for physicians to
• 24:18start to deal with the experience.
• 24:20So I did some casting around and
• 24:22philosophical literature and a
• 24:24fellow has anybody read the article?
• 24:28And it's over, Debbie.
• 24:31Very short. I mean,
• 24:33very dramatic, very punchy.
• 24:35It was anonymous.
• 24:37I heard it was Timothy Quill
• 24:40it could the authority
• 24:41that wrote it, but anyway.
• 24:45Uh. There was a course,
• 24:48it created a lot of response
• 24:50and one of them was by.
• 24:53Pellegrino. Leon kass.
• 24:59Mark Siegler. And who's the other guy that
• 25:04started the Hastings Willard gangland?
• 25:07Right. Heavyweights. Doctors must not kill.
• 25:10They were very staunchly opposed to it.
• 25:12And then there was a response to that by a
• 25:15guy named either Kenneth Bow or Kennex Box.
• 25:18BAUXI don't know how to pronounce his name,
• 25:19I'm afraid. But anyway,
• 25:21the most interesting part of it, he said.
• 25:24No, there's guy and this.
• 25:26They're talking about active euthanasia,
• 25:28active killing, right?
• 25:29Not just writing a script.
• 25:31And he said there's got to be a place for it.
• 25:34And he said his best reason for it was,
• 25:38he said, in my 25 years of experience.
• 25:41He said the most ethical this
• 25:43is a virtual ethics kind of role
• 25:45modeling I did the most virtuous,
• 25:47most ethical people I've known in my 25
• 25:50years of practice would assist a loved one.
• 25:54Or a colleague and ending their lives,
• 25:57but they wouldn't with their patients.
• 25:59And he said that's strange,
• 26:01he said, but it shows.
• 26:02It showed to him that essentially
• 26:04it was an act of love.
• 26:07Now that's a heavy word, which to me,
• 26:10I if I were to redo the paper,
• 26:14I'd want to talk much more about that.
• 26:16Yeah. What are we talking about
• 26:17when we're talking about love?
• 26:18I mean, that's pretty weighty stuff.
• 26:21And how do you, you know,
• 26:22kind of clarify that?
• 26:25But that idea of a loving act
• 26:28led me over to Aristotle.
• 26:30Who talks about friendship?
• 26:31So it medical friendships, right?
• 26:34He talks about friendship and Aristotle.
• 26:36Has anybody read it?
• 26:39Some Aristotle?
• 26:40He is a Reed and 1/2 dense,
• 26:43but he has a stroboscopic mind.
• 26:46He takes objects and he goes.
• 26:49Some parts of analytic philosopher
• 26:51park salons right, takes them apart,
• 26:54says each part is has an integral
• 26:56role to play.
• 26:57Understand the role of each of its part.
• 26:59Now put it back together.
• 27:01Do you know who the founder of of logic is?
• 27:05Aristotle.
• 27:07OK, Socrates was the teacher of Plato.
• 27:09Plato was Eric, Teacher of Aristotle.
• 27:11Right. Socrates wrote nothing.
• 27:14I just recently just learned that very
• 27:17interesting point that, you know,
• 27:19why didn't he write anything?
• 27:21And I was informed it was because
• 27:24Socrates was opposed to writing.
• 27:26Said if you're doing philosophy has
• 27:28to be interpersonal. Public. Right.
• 27:30It's a social act, right? For for him.
• 27:35So he he thought writing actually
• 27:37degraded the quality of language.
• 27:40What a strange man.
• 27:42It really was.
• 27:43And he was, you know, more than wonderful.
• 27:45But he was very peculiar anyway,
• 27:48so.
• 27:53An Aristotle said that in French
• 27:56friendship he takes his stroboscope
• 27:57and chops it into three parts.
• 28:00Parts. What's a friend? Well, how?
• 28:02How many friends do you have on Facebook?
• 28:04These genuine friendships.
• 28:07It's kind of debased coinage of the word,
• 28:09is it not? So see if Aristotle
• 28:13props it up a bit, he says.
• 28:15There's three crucial type types of
• 28:17friendship, if you want to think about
• 28:19friendship more deeply, right? He says.
• 28:21There are friendships for utility.
• 28:22One hand washes the other.
• 28:24I do you a favor, you do me a favor.
• 28:26But how?
• 28:27How does the stability of that friendship go?
• 28:30If you don't keep up favors, you're history.
• 28:33Right. Not to doesn't go too deep.
• 28:35The other is friendships for pleasure.
• 28:37You know, your party pals, you,
• 28:39you know if you're going to go
• 28:41out with Jane and Jill and Jason,
• 28:43you're going to have a good time.
• 28:44They're always a lot of fun,
• 28:46but that's also kind of a thin
• 28:48veneer of a friendship, right?
• 28:50And Aristotle said.
• 28:51To have a genuine or real friendship,
• 28:55one has to have a friendship for virtue.
• 28:59Which then translated,
• 29:00now I'm getting closer to a a
• 29:03clearer conception of love.
• 29:05For he says, loving is the
• 29:08distinctive virtue of a friendship.
• 29:10So what kind of love is that
• 29:13that an Aristotle says.
• 29:15That it's the love of reciprocal love,
• 29:19of similar virtue,
• 29:21that you respect each other's character.
• 29:24So that has to be in place,
• 29:26no matter what else is going on for the
• 29:29friendship to for it to be an enduring,
• 29:31a real friendship.
• 29:34And he says,
• 29:35you can know that you don't
• 29:37don't have a genuine friendship.
• 29:39Because the quality of virtue is missing.
• 29:42If somebody asks you,
• 29:43a so-called Friend asks you to do
• 29:47something that's morally based.
• 29:49Because obviously they don't
• 29:51respect your character.
• 29:52That's Aristotle and say this is getting
• 29:54closer to what we're talking about.
• 29:55And then another very important
• 29:58figure in my quest to try to clarify
• 30:01the idea of of a medical friendship.
• 30:04Was Zeke Emmanuel?
• 30:06Do folks know Zeke who?
• 30:08Yes,
• 30:08you do.
• 30:11Anyway. Sorry he's been here. Ohh.
• 30:20Anyway, he wrote an article with his wife,
• 30:22Linda. And talked about friendship. Uh.
• 30:30But he he also, he is,
• 30:32he associated it with teaching.
• 30:34And that that rang bells for me too,
• 30:37because in Socratic method Socrates
• 30:39is teaching was the antithesis of the
• 30:43so-called pump and bucket model, right?
• 30:45I'm the teacher, you're the student.
• 30:47Pump, pump, pump. Exam time comes,
• 30:50you throw it back at me, right?
• 30:53How did Socrates teach?
• 30:55Anybody have a sense of that?
• 30:58But what is what his model was said?
• 31:00Well, I'm kind of like my mom.
• 31:02She was a midwife.
• 31:05What's going on there?
• 31:07Unpack that analogy.
• 31:08I told you Socrates is a lot deeper
• 31:10than a lot of people give them credit
• 31:12for when they talk about Socratic
• 31:14method in the law schools, for example.
• 31:17It's not just just this back and forth.
• 31:20Well, let's look at the analogy a second.
• 31:24What stands for what? What does the?
• 31:27What does the mother stand
• 31:29for in a teaching model?
• 31:32The student, right?
• 31:33What's the knowledge?
• 31:38And here you go. The child whose child is it?
• 31:44It's not, is it? Socrates is child.
• 31:46No, it's yours, right?
• 31:49So Socrates has it was a way
• 31:52of drawing out from people.
• 31:54You know what they more deeply understood,
• 31:57but maybe we're unclear about
• 31:59so this idea of a teacher.
• 32:02Friend model right?
• 32:03Struck me as being very right.
• 32:06So this interpersonal relationship.
• 32:10That's involved.
• 32:12And and and and a friendship.
• 32:15And which led me to.
• 32:18The guy I called Dr. E.
• 32:24Here. You have the essay that's at the
• 32:28bottom of page. 64 from the journal.
• 32:33And I have to say.
• 32:35Uh. Doctor Tom Duffy.
• 32:37This was his favorite
• 32:39part of the essay, said.
• 32:41It wasn't so much what you wrote,
• 32:42but what this guy wrote.
• 32:46So that was a backhanded compliment.
• 32:49But from him, I take it as I was
• 32:51telling Mark Mercurio about it,
• 32:53he was one of my real life heroes.
• 32:55I have vivid memories of him,
• 32:57and I'm not exaggerating when he would talk
• 33:00and he would get up and make a comment,
• 33:02especially in David Smith's
• 33:04end of life thing.
• 33:06I mean, my hair would bristle in the back.
• 33:09He had this searing way of
• 33:10getting right to the point and,
• 33:12you know, making it so vivid.
• 33:14You know, he was really
• 33:15a real life hero to me.
• 33:18Anyway, so Dr. E Dutch physician,
• 33:21who was he has not had serious backlash
• 33:24from a physician assisted dying.
• 33:26Experience puts the matter as follows,
• 33:29and my practice, the average
• 33:31number of PhD cases is 2 per year.
• 33:34As it is in 50% of Dutch practices,
• 33:37an intensive interaction between
• 33:39physician and patient is very important.
• 33:41So it's this, you know,
• 33:43professional distance issue versus
• 33:44personal relationship that you
• 33:46know it's there's a blending going
• 33:49on and either direction is going
• 33:51to be be a wrong move, right.
• 33:53You have to somehow hit hit the
• 33:56mean of as Aristotle might say.
• 33:59An intensive interaction between
• 34:00physician and patient is very important.
• 34:02The process of coming to an
• 34:04interpersonal agreement is at the
• 34:06heart of a well realized participant.
• 34:08Physician patient relationship.
• 34:10Euthanasia is the final stage of
• 34:12the inter subjective process.
• 34:14The patient informs the doctor
• 34:16about his or her complaints and the
• 34:18doctor informs the patient about the
• 34:20possibilities of medical treatment.
• 34:21It is a process with equal.
• 34:25Positions for both parties.
• 34:29Right. So the professional has
• 34:32to come down a bit, you know?
• 34:34To interact with the patient more
• 34:37personally, but you have to keep
• 34:39some professional distance as well.
• 34:44As Doctor Ray contributed
• 34:46quite wonderfully this time,
• 34:48this this guy was extremely candid with me.
• 34:50He's the one I told you about.
• 34:52That said, when he when he.
• 34:56Helped his patient and his life,
• 34:58the one that was in the video said he
• 35:01never saw anybody make an exit so quickly.
• 35:04And he also told me other
• 35:05things about, you know,
• 35:06he said it's really important to have.
• 35:09You know, come to some understanding
• 35:11between the two of you and kind
• 35:13of echoing Aristotle, he said.
• 35:14You can't, you, you,
• 35:16you have to respect my experience here too.
• 35:19Right. And you know, treat it right,
• 35:21the patient has to respect
• 35:23the physician's experience.
• 35:26And he's he says this.
• 35:29Doctor A also spoke of mutual
• 35:32respect for the process.
• 35:33He said it is important for you to
• 35:35make your limits clear to a patient.
• 35:37Doctor A then gave a personal example
• 35:40of one kind of behavioral problem
• 35:41that some that he would resist.
• 35:43I do not like it when a patient
• 35:45wants to make a party out of it.
• 35:47Apparently some do right.
• 35:50So some patients want to organize
• 35:52a party around their bed.
• 35:53I do not want to do euthanasia
• 35:55in an atmosphere like that.
• 35:57For doctor a,
• 35:58the situation has also made
• 35:59difficult both if he had,
• 36:00if he did not like the patient,
• 36:02or if the patient was a good friend.
• 36:04Doctor Ray said.
• 36:05I find the decision making
• 36:07process very difficult when I
• 36:08do not like the person at all.
• 36:10When I feel antipathy towards the patient,
• 36:12I'll ask my colleague take over.
• 36:14On the other hand,
• 36:15with somebody as a personal friend,
• 36:17I'll also ask my colleagues as well.
• 36:21And he also said some interesting
• 36:23things because I I got into it pretty
• 36:26deeply with him and he was very candid.
• 36:28You know how he how he handled
• 36:30the situation afterwards,
• 36:31he said I would do various things, he said.
• 36:34He said I might, for example,
• 36:35light a candle like a votive candle.
• 36:38You know,
• 36:39after the experience and he said.
• 36:40And sometimes they would just lie
• 36:42in my partner's arms.
• 36:46Pretty heavy duty.
• 36:56But he also made the point about, you know,
• 36:59a a more personal connections is important,
• 37:02but professional distance, he said.
• 37:04You have to have it to do your job.
• 37:07Right. You're not there just to,
• 37:08you know, comfort and,
• 37:10you know, hug your friends
• 37:11and so forth before they die.
• 37:14You're there to do a job and you need to
• 37:16do it and do it well like a professional.
• 37:18So it's this kind of interplay between the.
• 37:23Professional distance and professional
• 37:25and personal relationship.
• 37:27And if you do notice another thing,
• 37:29just kind of come up to
• 37:31the doctor's experience.
• 37:32If do you do have a more
• 37:34personal relationship,
• 37:35what happens when your your
• 37:37your patient dies?
• 37:41You're open to grief, right?
• 37:43He was a friend.
• 37:45You become more friends,
• 37:46it's, you know, it's right.
• 37:48So what was this that struck me
• 37:50more and more that, you know,
• 37:52this experience is really something
• 37:54that needs to be discussed
• 37:56probably in the medical schools.
• 38:00OK. So concluding part of it,
• 38:02although I want to say a little bit more.
• 38:05On the psychological side PAD,
• 38:08physicians have to be prepared to
• 38:10encounter conflicts regarding their
• 38:12unconscious picture of their own mortality.
• 38:14And the philosophical side.
• 38:17There is a conceptual conflict regarding
• 38:19the paradigm of a wrongful act and its
• 38:22apparent coincidence with PID practice.
• 38:24We have shown important arguments that
• 38:26indicate that they do not in fact coincide.
• 38:29But one has to wonder how clear
• 38:31the difference is in the moral
• 38:32consciousness of the physician.
• 38:38Being inside again is a very different
• 38:41world than being on the outside.
• 38:45Given these conflicts and their
• 38:47implications for PID practice,
• 38:48it seems evident that specialty practice,
• 38:50in the manner of doctor Kevorkian's
• 38:52proposal advocating for a subspecialty
• 38:54in medicine called obituary.
• 38:56You heard about this?
• 38:59Well, yeah, it's a little bizarre, right?
• 39:01He said there should be a sub out.
• 39:04Did you also know that Doctor
• 39:06Kevorkian was not a medical doctor?
• 39:09The pathologist?
• 39:11Which is really important, as you know,
• 39:13the Hippocratic tradition.
• 39:16You know, and learning something about that.
• 39:19You know, he was immune from that.
• 39:23We believe that if assisted dying becomes
• 39:26part of a physician's practice, it should.
• 39:28It should only be as an exception.
• 39:31And never as the rule we have sketched
• 39:34a middle ground model that tries
• 39:36to balance personal relationships
• 39:37and professional objectivity.
• 39:39It is our conviction that in PAD
• 39:41practice they closed their patient and
• 39:44physician bond if well structured,
• 39:46well realized and well tended to
• 39:48will improve quality of care and
• 39:50end of life treatment for both
• 39:51patient and the physician.
• 40:02OK, that's what you pass it.
• 40:05In the. I have a little handout.
• 40:10It's I I just recently was in
• 40:13contact with Doctor Howard Grossman,
• 40:15who is mentioned in the
• 40:17beginning of the article.
• 40:18He's the fellow that said anybody who
• 40:20has done it knows it's a tremendous
• 40:22decision that you carry with you forever,
• 40:24and he gave me permission to quote him from
• 40:29his response to our e-mail communication.
• 40:33And what he what he says about you know,
• 40:36the article. Itself,
• 40:38which I asked him to,
• 40:39he might look at.
• 40:43And he says. Uh. Thanks for
• 40:47sharing that thoughtful article.
• 40:48It's interesting.
• 40:49I think the idea of a medical friendship
• 40:51is actually something that has
• 40:53permeated my entire practice over the years,
• 40:55so he was kind of doing it intuitively.
• 40:58Which is pretty cool.
• 41:00Most of the time it was spent in practice,
• 41:03heavily weighted to serving LGBTQ plus
• 41:06people and people living with HIV.
• 41:09I took care of in large number of
• 41:11actual friends and acquaintances,
• 41:12defining the lines that allowed
• 41:14those friendships,
• 41:15some closer than others,
• 41:17but many in my social
• 41:19circle and at the same time,
• 41:20having the necessary professional distance
• 41:22has always been the biggest challenge.
• 41:25So he reiterates that theme.
• 41:27Which I take as a confirmation of some
• 41:29of the things that we've been saying.
• 41:37He said. But that that kind of relationship
• 41:39in my practice has allowed me to get through
• 41:42the most harrowing times without burning out.
• 41:45So physician assisted dying was
• 41:46just the logical next step.
• 41:48It does require tremendous amount of trust,
• 41:51both on the part of patient and provider,
• 41:54as you say, especially in an environment
• 41:56of significant legal risk. For myself,
• 41:59I never saw the moral dilemma in this so.
• 42:02I find that quite interesting.
• 42:05Anyway, he says it does stay
• 42:07with one through the years.
• 42:09Then we are going to communicate further,
• 42:12but that hasn't happened yet unfortunately.
• 42:15But but it shall.
• 42:17So in looking over the paperwork,
• 42:19I'd like to do more exploration
• 42:22than was done here on this.
• 42:25Of professional distance,
• 42:27personal relationship. Uh.
• 42:31Being such a fundamental part
• 42:34of position assisted dying.
• 42:36And I'd also like to think
• 42:38more about the the that word,
• 42:40that big word, the L word love.
• 42:44And I have a little story about that
• 42:46to tell you that that I think it's.
• 42:50It's useful to pursue,
• 42:51and I've been trying to pursue it,
• 42:53but I haven't yet gotten made contact.
• 42:56Just do folks here know Margaret Farley?
• 43:02Well, you may know, she wrote.
• 43:04She's at Yale dip school.
• 43:07And she wrote a book called Just Love.
• 43:10That got her into a little
• 43:11hot water with the Vatican.
• 43:13I mean, it was all over the papers.
• 43:14It became kind of a big thing,
• 43:16but they had a conference for
• 43:18her here that I attended and with
• 43:20a lot of different speakers.
• 43:22And at the end she finally got
• 43:24up to speak and she said I
• 43:26don't want to be misunderstood.
• 43:28She said love is not the answer,
• 43:30it's the problem.
• 43:33And I thought I that stuck with me.
• 43:35I thought that was really important
• 43:36because from a virtue ethics point of view,
• 43:39what that amounts to is how to do it.
• 43:42Right.
• 43:45Especially in. I mean, she was talking
• 43:47in the context of justice too, right?
• 43:49Like in the courts and so forth like that.
• 43:52You know, how do you treat
• 43:54people you know with love?
• 43:55Under those circumstances,
• 43:56it is not the answer, right?
• 43:59It's the problem.
• 44:00How do you do it? And it's unique.
• 44:03I mean, that thing about virtue ethics,
• 44:05it's about becoming good.
• 44:07It's not defining it, which takes practice,
• 44:09practice, practice like a sport
• 44:11or like being a musician.
• 44:13Or maybe, as some people here are
• 44:17intending to be a surgeon, right?
• 44:20You're never perfect at it.
• 44:22You'll always be mistakes.
• 44:23But the more you practice,
• 44:25especially under good guidance,
• 44:26the better you get, right?
• 44:29So how do you do?
• 44:31Question is,
• 44:31how do you do it in a virtual
• 44:33ethical kind of sense?
• 44:34I take that as something that I'd like
• 44:36to explore more deeply in the paper.
• 44:40So with that I think. I am.
• 44:43Done with my harangue.
• 44:44I hope it was more of a narrative
• 44:46than a harangue, but. Uh.
• 44:48I'd like to turn it over to questions
• 44:51folks might have on on the topic.
• 44:55Thank you very much.
• 44:56Now which however you're most comfortable
• 44:58if you'd like to stay seating or
• 44:59if you'd like to come up here,
• 45:00I'm going to read these questions to you.
• 45:01OK. It might be easiest thing for
• 45:03you to do is just to stay there.
• 45:05Sorry about that.
• 45:06And Karen Scott, that's quite all right.
• 45:08Karen's got the microphone for
• 45:09the folks in the audience,
• 45:11and again for folks on zoom,
• 45:14you can send me questions or comments
• 45:16through the Q&A portion, not read them.
• 45:18The criticisms withering,
• 45:20withering criticism.
• 45:20We don't want any pale.
• 45:22We want withering criticisms here.
• 45:25This is, this is from philosophy.
• 45:28And if you don't have opposition,
• 45:30you ain't got much.
• 45:33Yeah, that's a blood sport philosophy then.
• 45:35They're not. They're not kidding.
• 45:37They're not kidding. So I mean,
• 45:41I'd like to ask something just briefly.
• 45:43If I could Chalmers place because
• 45:45we didn't get into it much.
• 45:46You touched on a little bit,
• 45:47but I want to get a little bit more
• 45:49actually this is from Buchanan.
• 45:50So Buchanan so so this is the
• 45:52this is the intentional taking
• 45:54of an innocent person's life.
• 45:56See I remember what it stood for and
• 45:58this is an absolute wrong which of
• 46:00course then framed that way physicians
• 46:01paradigm the paradigm of wrong.
• 46:04So this is the actual paradigm of wrong
• 46:06in which case physician assisted death
• 46:08by your Venn diagram here fits right
• 46:11smack dab in the middle of that parade.
• 46:13But you're saying that we get away
• 46:15from that and if you can get away
• 46:17from that himself or did others
• 46:19by saying hang on a second because
• 46:20it's not the physician he did
• 46:22it conceptually right.
• 46:23That's right the physician is intake he
• 46:26said there are two wrong making features
• 46:28he thought were prominent which was
• 46:30the removal of a person's well-being
• 46:33and and and ending somebody's life
• 46:36and violation of their right to life.
• 46:39But he thought the disease
• 46:41already deprives the.
• 46:43Person up their well-being.
• 46:45And right to life, he said,
• 46:47implies the right to waive the right.
• 46:50So it's autonomy really is really
• 46:52kind of the touchstone that he's
• 46:54talking about. I guess from a physician's
• 46:56point of view perhaps it comes down to
• 46:59to some extent trying decide what the
• 47:02mission or the role of a physician is.
• 47:04Right? Yeah. And and of course the
• 47:06the what people I don't think in this
• 47:08room is at that superficial level,
• 47:10but some well the rule is to save lives.
• 47:12But I I think we're all past that.
• 47:14But if the role is. And suffering.
• 47:18That's a fascinating question,
• 47:19because of course we could
• 47:20end all suffering today.
• 47:21We have big enough bombs we
• 47:23could stop all suffering.
• 47:25That's not necessarily our only role either.
• 47:28And to to try and find
• 47:30perhaps again that that.
• 47:32Aristotelian balance that that middle point
• 47:36where we're addressing this suffering,
• 47:38but it's not just about
• 47:39addressing the suffering.
• 47:41Yeah, the.
• 47:45The right. That, some people say.
• 47:49It's really not about cure.
• 47:50It's more about care,
• 47:52which leads me into something else.
• 47:54I'd like to rethink the whole essay from
• 47:57the perspective of the ethics of care,
• 48:00which is a relationship model, right?
• 48:03So the relationships should take
• 48:05priority over rules and regulations.
• 48:08I mean that's the Crucible
• 48:09if you think about it.
• 48:10I mean it's a very strong point
• 48:12about how we develop me morally.
• 48:14Carol Gilligan,
• 48:15Gilligan's in a different voice
• 48:17is kind of the touchstone for the
• 48:19for that where she talks about.
• 48:21First and foremost,
• 48:22we're in relationships and you know how
• 48:25to care for the care for those, right?
• 48:27Rather than by, as she talks about,
• 48:29you know,
• 48:29looking up to the sky for Conti and
• 48:31principles and that kind of stuff
• 48:33that we're embedded in, in any.
• 48:36She used the analogy of trampoline.
• 48:40Of relationships,
• 48:40you step here and you know,
• 48:42it has effects and implications elsewhere.
• 48:45So the relationship model is
• 48:47something that I would like
• 48:49to think about much more,
• 48:50right, that that's part of feminist ethics,
• 48:52which we talked about in
• 48:53this group not long ago.
• 48:54And that's at the core of that.
• 48:55Of course, Carol Gilligan is at
• 48:57the very core of that as well.
• 49:00And and that gets to your whole theme,
• 49:03which is that to make this work,
• 49:05if you will, my, my overriding,
• 49:07you make physician assisted death work.
• 49:09What's fundamental to that is
• 49:11the relationship between the
• 49:13physician and the patient, right?
• 49:14But do I read you correctly in
• 49:17saying that therefore you you
• 49:18endorse both the friendship and
• 49:20then in certain cases obviously the
• 49:22act of physician assisted death?
• 49:25Well, that was something we we tried to
• 49:27steer away from, but personally, yes.
• 49:30You know, I mean,
• 49:32you know what people are suffering,
• 49:34you know, horribly without any hope of.
• 49:37Ohh of improvement.
• 49:39I mean the incontinence, I mean the
• 49:42sense that their dignity is shot and so on.
• 49:45I mean, it's kind of like you can see
• 49:47why somebody would say, OK, yeah,
• 49:50pull the plug. Enough is enough.
• 49:52And if they say that and you have a
• 49:55good relationship with them, you know,
• 49:57they mean it and they're not asking
• 49:58you to do it in ways that you,
• 50:00you're uncomfortable with,
• 50:01like Doctor Ray said, you know,
• 50:03no parties around your bed,
• 50:04please, I'm not going to.
• 50:06I'm not going to participate in that.
• 50:08Then uh.
• 50:10Personally yes I I think you know
• 50:12it should be part part of it and I
• 50:15it was very interesting that Doctor
• 50:18Grossman's saying you know the trust
• 50:20between them is very important and
• 50:23I've done quite a bit of my own
• 50:25research and publishing and trust
• 50:28relationships and a big question for
• 50:31me in terms of of my program and
• 50:34trust you know how would how would patients.
• 50:38Feel if the the model of the physician
• 50:41did include especially here did
• 50:44include position assisted dying
• 50:46would trust increase or decrease
• 50:48say Oh no you can't let them do
• 50:50that you can't trust them you can't
• 50:52trust them positions are they say
• 50:54no I want want them to be there
• 50:56because I do trust my physician
• 50:58you know so there
• 50:59was a time when we talked about it's
• 51:01interesting how it feels like a long
• 51:03time ago but just prior to the pandemic
• 51:05there was time we talked about a problem
• 51:07we had in establishing those trusting.
• 51:08Relationships was the fact that you know
• 51:10you didn't see the same doctor twice
• 51:12you went to the physician once you.
• 51:14So we thought this was a real problem
• 51:16that that it whereas a generation is
• 51:18passionate still some of us I've been
• 51:19fortunate many are fortunate to have the
• 51:21same primary physician who follows us for
• 51:23years but that was less and less the model.
• 51:26But now we're on a whole different.
• 51:27I have I just met one of my physicians in
• 51:29real life for the first time someone who's
• 51:31been involved in my care for over a year.
• 51:33You know and and she said hey
• 51:34you want to come by in person.
• 51:35I said hey go crazy you know this
• 51:36is lovely and and actually got
• 51:38to meet her and shake her hand.
• 51:39It was, it was you know,
• 51:41because we actually know our physicians
• 51:43sometimes just through the a little teeny
• 51:45tiny picture on our cell phone and so
• 51:46that's we're even that much further move.
• 51:48But that's enough of me talking.
• 51:49I want to read you some questions
• 51:51and comments here, but did I see him?
• 51:52So we'll take one from the audience
• 51:53first then I'll get the ones on the web.
• 51:55Yes, Phil, we have a,
• 51:58we have a microphone actually,
• 51:59so everybody can hear what you're saying.
• 52:01Thank you.
• 52:03Can you hear me?
• 52:05Is that working? Yeah. So following up
• 52:07on one of your
• 52:10last points, I'm intrigued by the
• 52:13interplay of autonomy, ethics, care,
• 52:16love and trust as it relates to the
• 52:20intentional right to die. And you
• 52:22touched on that a bit.
• 52:24I mean, that brings into this
• 52:27a whole set of flavors of a
• 52:29different kind of perspective that
• 52:32makes this what you're doing.
• 52:35More intriguing.
• 52:35So I commend what you're doing. OK?
• 52:39Thank you, bill. So I have a question
• 52:42and comment here for you please.
• 52:45And no other realm of medicine
• 52:47is there specific consideration
• 52:48of the physician experience,
• 52:50some discussion regarding in
• 52:51quotes feudal care, but in those
• 52:53discussions the patients choice.
• 52:57Or that of their decision
• 52:58maker takes precedence.
• 53:00Why should this area be different?
• 53:02I ask as a physician,
• 53:03someone with personal experience,
• 53:05with a family member who wanted but
• 53:07could not access assisted dying,
• 53:09and someone who has given
• 53:10testimony to advocate for
• 53:11aid in dying in Connecticut.
• 53:13So why is this different?
• 53:15Well, I I'd. I'd refer to the
• 53:18concept of care there positions as.
• 53:21I mean end to end of end
• 53:23of end of life treatment.
• 53:25Sometimes there's nothing
• 53:25you can do for them,
• 53:27but you can always care for your patient.
• 53:29Always. And so, you know,
• 53:32that caring relationship I think
• 53:34should be part of the physician
• 53:36patient relationship front and center,
• 53:38but that's a reciprocal kind of thing.
• 53:41What about caring for your physician
• 53:43when they're in situations of of
• 53:46serious ethical and legal risk?
• 53:48Trying to do what you know you you
• 53:50want them to do as you as a patient.
• 53:52So this but so this,
• 53:54I mean she says that in no other
• 53:55realm of medicine is there a specific
• 53:57consideration of physician experience.
• 53:59But there are certainly other realms
• 54:00of medicine where the physician has a
• 54:02particularly difficult experience or
• 54:03feels jeopardized by the circumstances.
• 54:05So I I suppose what you're saying if
• 54:07we're having this friendship model
• 54:09to some extent it should go beyond
• 54:11issues of physician assisted death.
• 54:12Oh yeah,
• 54:13yeah, it's it's that reciprocity
• 54:14and you know but but I mean it's
• 54:17very challenging I would think.
• 54:18Their positions because you're stepping
• 54:21down somewhat from professional distance,
• 54:24right, to get more involved with
• 54:26the patient as more like a friend
• 54:29and you know a mutual teaching
• 54:31of each other in situations.
• 54:33And I think that that could over
• 54:35actually improve the practice
• 54:37terrifically and like your experience
• 54:39you were just mentioning where I,
• 54:41you know physicians kind of got a little
• 54:44more aggressive and organized themselves
• 54:46and say you know we're not going to.
• 54:48Succumb to these kinds of things.
• 54:50I saw a video with Ed Pellegrino
• 54:54where he was talking about,
• 54:56he says, doctors, hospitals.
• 54:57He said in my day,
• 54:59nobody would ever think of that as phases,
• 55:03but it's happening all the time now.
• 55:04And then he got emphatic and he said,
• 55:06but that doesn't make it right.
• 55:09What?
• 55:09What specific about doctor's hospital?
• 55:11Right, run by doctors.
• 55:14Where doctors being, you know,
• 55:15kind of runners of the business rather
• 55:18than owners, not just running it,
• 55:19but owning it and owning it.
• 55:21Yeah. You know, Jack,
• 55:22you had a question of interest.
• 55:26Local reason. Could you give
• 55:27me your name? I know you. I think I do,
• 55:31really. My name is Jack Hughes.
• 55:33Jack Hughes, yes. You didn't
• 55:36you go to David Smith's?
• 55:38End of life group. In 2002 or so.
• 55:44That's that was in high school in 2002.
• 55:46It's got to be a mistake here.
• 55:49I I think I went
• 55:50once or twice, you know, you
• 55:52know Carol Pollard. Yes, of course.
• 55:57You're a memorable guy, Jack. I'm impressed.
• 56:02I don't. I I have no recollection.
• 56:05So there are there are many
• 56:07reasons why people choose to
• 56:10to want to end their lives
• 56:13because of they feel irrelevant,
• 56:17because not just because they hurt,
• 56:19but because they are.
• 56:20They feel like they're a burden,
• 56:22they feel isolated,
• 56:23they feel they have no use.
• 56:26And so I assume that's part,
• 56:28part of what
• 56:29is encompassed in the model that you are
• 56:32outlining is the need for the doctor.
• 56:35To to be able to unpack all
• 56:39those reasons and perhaps.
• 56:42Counteract or or to argue
• 56:45against this desire. OK, so OK,
• 56:50I just wanted to establish that.
• 56:51But that also means that
• 56:54there's a great deal of time
• 56:57involved in this relationship.
• 57:00I'm afraid so. And so. As in so many other
• 57:06aspects of the healthcare system,
• 57:08some people are going to have much more.
• 57:12Availability of physicians who are willing
• 57:15to work with them at the end of life.
• 57:18Rather than just having to go
• 57:21through what's usually available.
• 57:23So do we need to worry about?
• 57:29Discrimination or the limited
• 57:32availability of this kind of
• 57:34friendship at the end of life,
• 57:37probably, you know I mean it is you know
• 57:39it's it's an outsider kind of issue.
• 57:41But I I would like to see that
• 57:44outsider issue kind of trickle
• 57:46down into general practice more.
• 57:48Personally myself I think it would,
• 57:50I think it would ennoble and
• 57:52and strengthen the profession.
• 57:54I wrote an article called Trusted Medicine.
• 57:58I talked about how important
• 58:01trust is to have that trust,
• 58:03public trust in particular.
• 58:05And at the end of my talk I'd always
• 58:07say no more trust, no more profession,
• 58:10and the profession has huge benefits to it.
• 58:13And it's not just for, you know,
• 58:15financially it's, it's good,
• 58:17it's not great, should go into business
• 58:18if you want to make a lot of money,
• 58:20you know, and it's a lot of work.
• 58:23But I mean, there's are,
• 58:24there are social benefits, you know,
• 58:27the the the profession is high,
• 58:29highly regarded people trust you just
• 58:32because you're you're a medical professional.
• 58:36And you know it's, it's, it's,
• 58:38it's it's just so social standing.
• 58:40I think it's it's very strong there.
• 58:43As one of the reasons, I mean,
• 58:44you know what what would you,
• 58:46you know if you became,
• 58:48you know if if medicine became a.
• 58:52Part of. Social services, right?
• 58:56So you'd be a you'd be a civil servant.
• 59:00You know, if you're your position,
• 59:02who wants to do that?
• 59:03I mean,
• 59:04you do have a lot of professional autonomy,
• 59:06too.
• 59:06Your decision, you know,
• 59:08if responsible, you know,
• 59:10is up to you for the most part
• 59:12as a physician, right?
• 59:13You make a lot and your judgment matters,
• 59:16right?
• 59:17You're not being dictated to or well,
• 59:20I mean, that's part of the problem now with,
• 59:22you know, being part of a corporation,
• 59:24you know, hospitalists and so forth.
• 59:26You're working for somebody else.
• 59:28Rather than,
• 59:29you know,
• 59:30kind of independent professionals.
• 59:32Yeah, I think I'd like
• 59:34to say safe assessment,
• 59:36pie in the sky.
• 59:37I'd like to see that reversed.
• 59:40I think I and I and I I actually,
• 59:44Kenneth Arrow is Nobel laureate in
• 59:46economics and he talks about the importance,
• 59:48as he calls them, of the invisible,
• 59:50visible institutions.
• 59:53And those are institutions that are run on
• 59:56basically on on moral grounds and so forth.
• 59:59Like I I think the profession of
• 01:00:01medicine should be, you know,
• 01:00:03kind of oriented on moral grounds.
• 01:00:05You know, you're, you're here first
• 01:00:07and foremost for your patient,
• 01:00:09but that doesn't mean you should follow
• 01:00:11what the patient says slavishly.
• 01:00:13You're a professional,
• 01:00:14you have judgment,
• 01:00:15and that judgment needs to be respected.
• 01:00:19By not just the public,
• 01:00:20but by your patients as well,
• 01:00:22and never more respected than
• 01:00:23if you're in a situation where
• 01:00:25you're assisting somebody to die,
• 01:00:27you're crossing lines there.
• 01:00:28For the you know doctors must not kill
• 01:00:31the article by Pelegrino and pass and.
• 01:00:35Signaler and.
• 01:00:37Gangland,
• 01:00:38let me just defend the suits
• 01:00:41you you were implying some criticism
• 01:00:44of hospital administrations and,
• 01:00:45well, corporations.
• 01:00:46Yeah, I agree the problem
• 01:00:48with with corporate medicine.
• 01:00:50But we got to have suits to run the place.
• 01:00:54We have to have administration.
• 01:00:56I mean, no place.
• 01:00:57And because as we've
• 01:00:59heard earlier, you don't think doctors
• 01:01:00ought to be running the hospitals. So
• 01:01:03I just, just a word.
• 01:01:06Just in defending the,
• 01:01:08I think that you know,
• 01:01:10there there is a way through that.
• 01:01:13I taught at Union College, for example,
• 01:01:15and they had what they called the
• 01:01:17Limb program leadership and medicine,
• 01:01:20where they actually made it part
• 01:01:22of their training that they would
• 01:01:24go on to Albany Medical School,
• 01:01:25but they would come out with an MBA.
• 01:01:29So that you're really both, but,
• 01:01:31you know, don't let the dog you know wag.
• 01:01:34No, don't let the tail wag
• 01:01:36the dog kind of thing.
• 01:01:37What are you here for, first and foremost?
• 01:01:40And your patience. Right.
• 01:01:43And that's what the business
• 01:01:46should be oriented around. So
• 01:01:48Mark, while you're getting the mic,
• 01:01:50I'm going to read one more question
• 01:01:51first to Chalmers, please.
• 01:01:52It's an interesting question and anybody
• 01:01:54in the audience I want to pitch in
• 01:01:57which sub specialty of medicine is
• 01:01:58expected to own this space related to
• 01:02:00physician assisted death I assume.
• 01:02:02Is it primary care or palliative
• 01:02:04medicine or Hospice or some other area?
• 01:02:06Who, who do you think within our because
• 01:02:08you know where we are all specialists,
• 01:02:11which specialists should be managing this?
• 01:02:16Well, back to the relationship
• 01:02:17kind of thing. I my my first,
• 01:02:19my first thought on it,
• 01:02:21and I think it's it's,
• 01:02:23it's what what I'd want to defend.
• 01:02:24It is primary care.
• 01:02:27Because they're the closest.
• 01:02:29To the patient.
• 01:02:33Rather than a specialist to season
• 01:02:34for one and only one thing,
• 01:02:36they get a bigger picture.
• 01:02:37So the relationship I model I think
• 01:02:39would would dovetail more easily
• 01:02:41which is hopefully more longstanding
• 01:02:43than palliative medicine for example,
• 01:02:44or Hospice care. Yeah,
• 01:02:45I have to say that even in in, in some
• 01:02:47of you may know this and some may not.
• 01:02:49Even within the field of neonatology
• 01:02:51might have been asked by parents or
• 01:02:53a child who was clearly dying saying,
• 01:02:55you know, why are we dragging
• 01:02:57this out or is there something
• 01:02:58we can do to hurry this along?
• 01:03:00This is not. You know this,
• 01:03:02I think every everyone who works
• 01:03:04with critically ill patients may
• 01:03:06face this question sooner or later.
• 01:03:08Doctor Mark Siegel has a question.
• 01:03:10Thanks for the opportunity and thank you.
• 01:03:12So I I really appreciated your your talk
• 01:03:15today and you know there were parts of
• 01:03:18your presentation where I started to hear
• 01:03:21echoes of discussions about moral distress.
• 01:03:24So, so you were talking about moral distress.
• 01:03:30Votive candles, curling up with your partner.
• 01:03:33It's really hard for a
• 01:03:34long period after that.
• 01:03:36And you know my instinct when I'm
• 01:03:38working with trainees who are feeling
• 01:03:40moral distress is the first thing we
• 01:03:42should try to do is avoid it and,
• 01:03:44and and so I'm wondering
• 01:03:46particularly as a philosopher,
• 01:03:47you know what do you, how do you,
• 01:03:49how do you feel about these
• 01:03:51deep basic instincts?
• 01:03:53And how we choose our endeavor to
• 01:03:58process those feelings because to
• 01:04:00me part of what I'm thinking is
• 01:04:02that the more you have to think
• 01:04:04about it the more it starts to
• 01:04:06sound like a rationalization, right?
• 01:04:08Like like there's there's probably
• 01:04:10some sort of primal reason that
• 01:04:13we avoid killing patients. Yeah.
• 01:04:24Think about that a little bit.
• 01:04:30So what did you see?
• 01:04:31Could you repeat what
• 01:04:32you think the problem is?
• 01:04:33Well, you know, I I think that
• 01:04:36one way that I think about.
• 01:04:39Deep emotions that we feel
• 01:04:41in medicine is that they're
• 01:04:43sending us a signal, right?
• 01:04:45That there's, you know,
• 01:04:46we we go into medicine not because we
• 01:04:49sit down and think about the philosophy
• 01:04:52of doctor patient relationships.
• 01:04:53There's actually some deep.
• 01:04:57Caring relationship that we're
• 01:04:59trying to form with our
• 01:05:01patients and and that same.
• 01:05:06Duality with your patient is part of what
• 01:05:08I think dictates what you do every day,
• 01:05:10you know, when it comes to things like
• 01:05:12like beneficence, I want to my patient,
• 01:05:14when you say as a philosopher,
• 01:05:16in a way I have a a little
• 01:05:18bit of an axe to grind there.
• 01:05:20I did my dissertation on Willard
• 01:05:22Van Orman Klein, who was, you know,
• 01:05:25kind of arch analytic philosopher.
• 01:05:26But what he did was, you know,
• 01:05:28philosophers in a lot of ways I think
• 01:05:31have some serious problems, right.
• 01:05:33And he broke the barrier.
• 01:05:34I think he showed this.
• 01:05:36Philosophy should, you know,
• 01:05:37could not no longer be kind of
• 01:05:40distinct from the sciences,
• 01:05:42you know for since dakart because
• 01:05:44dejarte cojito ergo sum, right?
• 01:05:46I think therefore I am.
• 01:05:48That's its first certainty.
• 01:05:50Yeah, that you you cannot
• 01:05:52doubt that you think,
• 01:05:53because doubting is a form of thinking.
• 01:05:55Catch 22, right? Have you?
• 01:05:57Do you try to doubt that you think
• 01:06:00you're thinking to to try to doubt it?
• 01:06:02But anyway,
• 01:06:03but that's a subjective certainty, right?
• 01:06:05And the problem for philosophy,
• 01:06:07epistemology of theory of
• 01:06:09knowledge since decart has been.
• 01:06:12How do you justify the existence
• 01:06:14of the external world?
• 01:06:15And the philosophers kind of
• 01:06:16have their nose up about science
• 01:06:18because science just assumes it.
• 01:06:19They're begging the question at issue,
• 01:06:21but fundamental question of knowledge.
• 01:06:24But Klein broke that barrier.
• 01:06:26Right.
• 01:06:26And it just, you see,
• 01:06:27said you can't separate them like that.
• 01:06:29And that opened up things like
• 01:06:32cognitive science, bioethics, right,
• 01:06:34where you're sharing information.
• 01:06:36And so I think philosophers should
• 01:06:38do more of that they need to.
• 01:06:39And for me,
• 01:06:40you know,
• 01:06:41being at and Yale bioethics and so
• 01:06:43forth and listening to people like
• 01:06:45Tom Duffy and and other people,
• 01:06:47Doctor Mercurio here and so forth,
• 01:06:50you know, people that,
• 01:06:51you know,
• 01:06:51travel in both fields and let
• 01:06:54them inform each other.
• 01:06:55That's the direction to go in,
• 01:06:57but that means you have to cross
• 01:07:00some disciplinary boundaries
• 01:07:01and I say more more power to it.
• 01:07:05Which gets to the reason raise on here.
• 01:07:07Since we're speaking French here in
• 01:07:08Latin and stuff, the raison d'etre
• 01:07:10of the entire program is is to is to
• 01:07:12try and marry these two disciplines.
• 01:07:13I have another question for you please.
• 01:07:15If suffering is to be ameliorated
• 01:07:17by assisting someone to die,
• 01:07:19then why is the suffering of
• 01:07:20all those who choose to die,
• 01:07:22not just those at the quote end of life,
• 01:07:24End Quote, subjected to countless
• 01:07:26suicide prevention strategies,
• 01:07:28programs, interventions,
• 01:07:29even commitment.
• 01:07:32Well, you want you do want to,
• 01:07:35you do want to save life when saving
• 01:07:37it is is rational and possible.
• 01:07:40But but not you don't want to save life,
• 01:07:42you know, you've probably heard the
• 01:07:44expression a lot of end of life care
• 01:07:47is not so much about trying to save
• 01:07:49a life as prolonging their death.
• 01:07:51Right that it's you know it's a it's
• 01:07:53it's really the wrong thing to do
• 01:07:55sometimes is to try to keep people alive.
• 01:07:58Well, the flip side,
• 01:07:59which I think maybe the speaker
• 01:08:00gets that as well, which is.
• 01:08:03Again to take the low hanging
• 01:08:05fruit in the conversation,
• 01:08:07most everybody who has worked in
• 01:08:08medicine or just has been on the
• 01:08:10planet long enough and it has family
• 01:08:11members is that that people can suffer
• 01:08:14from mental illness and be quite
• 01:08:16sure they want to die and six months
• 01:08:18later be very happy that they didn't
• 01:08:21and live for decades more in a happy state.
• 01:08:24So I think again in mental
• 01:08:26illness is is the easy,
• 01:08:27is the easy part,
• 01:08:29people with significant depression
• 01:08:31or bipolar disease that, that, that.
• 01:08:33Some of these folks who may want
• 01:08:35to die it may be again want to use
• 01:08:37it your rational but I think that's
• 01:08:38very different than people who are
• 01:08:40those questions are among the
• 01:08:41toughest are you are you certainly
• 01:08:43heard about the Dax case right.
• 01:08:45So maybe you want to you want
• 01:08:47to anybody know about Dax oh I
• 01:08:49think it was horribly burned.
• 01:08:52And he he won.
• 01:08:53He didn't wanna be treated he wanted
• 01:08:55to die and they kept him alive and he
• 01:08:58went on to live a very productive life.
• 01:09:00Became a lawyer very successful and so on.
• 01:09:03But he he ended up doing a lot of talks
• 01:09:06and he actually came to Union College
• 01:09:08oh where I was to give a talk about it
• 01:09:11and he said they were wrong to keep me alive.
• 01:09:14Yeah I have a better life now
• 01:09:15but they were still wrong.
• 01:09:16Very content.
• 01:09:17Right.
• 01:09:17They had a duty follow what I said personally
• 01:09:20I you know I'm I'm not sure what to say.
• 01:09:23About that.
• 01:09:25You know,
• 01:09:25that's a really tough question,
• 01:09:27right?
• 01:09:28The man who was condemned to life,
• 01:09:29I think, or something that's in
• 01:09:31the story of Dax Coward. Yeah.
• 01:09:32But it's a fascinating question, right?
• 01:09:33He he never reversed,
• 01:09:34despite the fact that he said yes,
• 01:09:36I'm happy with my life.
• 01:09:37He never reversed his stance,
• 01:09:38as far as I know that
• 01:09:40that maybe later in life,
• 01:09:41but when I was there.
• 01:09:44Rings of country anism that you have
• 01:09:46certain duties that you perform no
• 01:09:48matter what and that they violated
• 01:09:50that they had a duty to him as
• 01:09:52a patient if he meant meant it
• 01:09:54and he did mean it at the time.
• 01:09:57But it wasn't just that they were not
• 01:09:59in the case of Dex Coward, right,
• 01:10:01which is going to an extreme example of
• 01:10:03suffering the patient with massive burns.
• 01:10:05It wasn't just that they were not act
• 01:10:09taking active measures to end his life,
• 01:10:11but of course they were
• 01:10:12forcing on him active measures.
• 01:10:14To rehabilitate, if you will,
• 01:10:16his skin, which is a horribly painful,
• 01:10:18protracted experience,
• 01:10:19which I think is where much of
• 01:10:21his anger came from. Yes, Sir.
• 01:10:25Thank you. From a practical
• 01:10:27perspective, have you interviewed
• 01:10:30and I know your name please? Sam Harrington.
• 01:10:32Sam Herron Harrington, Harrington.
• 01:10:35When I don't live here,
• 01:10:37I live in Maine where medical
• 01:10:39aid and dying is. More volume.
• 01:10:43I'll hold it closer. OK.
• 01:10:46So have you interviewed American
• 01:10:48physicians who participate
• 01:10:49in medical aid and dying?
• 01:10:52Well, I've talked to Tim Quill.
• 01:10:55And well, Howard Grossman,
• 01:10:57but you know that hasn't gone
• 01:10:59very far and I did talk to
• 01:11:01Peter Reagan knows telephones.
• 01:11:03I haven't really engaged
• 01:11:05with them very deeply,
• 01:11:07but you know I have had some and that
• 01:11:10would be something to do as well,
• 01:11:12the physicians sizing the paper
• 01:11:14to get more input from physicians
• 01:11:17both here and and abroad.
• 01:11:20The physicians I've spoken to
• 01:11:22about medical aid and dying in the
• 01:11:25states generally feel that they.
• 01:11:28Do create an intense
• 01:11:30relationship with their patients,
• 01:11:33although it's short and within the movement,
• 01:11:37there are physicians who feel
• 01:11:39that the only responsible way to
• 01:11:41participate is to actually be at
• 01:11:44the patient's bedside when they
• 01:11:46take the medicine and sort of.
• 01:11:48Nursed them through the process,
• 01:11:50fascinated by what Doctor Grossman there
• 01:11:53said said about he's he basically said
• 01:11:56implicitly he's been doing this all along.
• 01:11:58And good, let's formalize it and say,
• 01:12:01you know, if you're well in in Holland,
• 01:12:04you're supposed to declare.
• 01:12:06As a physician, whether you are to go into
• 01:12:10go into assisted suicide or not. Right.
• 01:12:15And then you declare it in medical school.
• 01:12:17And so that might be a practice to
• 01:12:19emulate here as a as an option as part
• 01:12:22of your training and then to, you know,
• 01:12:24get into different models of it.
• 01:12:26You know of course the pharmacology
• 01:12:28of it to do that correctly,
• 01:12:31but also the psychological implications
• 01:12:33and philosophical conflicts that
• 01:12:35you might experience yourself.
• 01:12:38But
• 01:12:38there is a group in the United States
• 01:12:41called AKA made American Clinicians
• 01:12:43Academy for medical aid and Dying,
• 01:12:46which is a so I don't know that self.
• 01:12:49Created group which is trying to
• 01:12:52promote responsible practices.
• 01:12:54And so in answer to the question
• 01:12:56who's going to, who's going to
• 01:12:58hold the responsibility for this,
• 01:13:01I would have preferred,
• 01:13:02I mean I sort of accept the primary
• 01:13:05care model as the physician who
• 01:13:07knows the patient best, but.
• 01:13:10It's fragmented also and my
• 01:13:12care has been fragmented.
• 01:13:14I have primary care physicians
• 01:13:17in different states.
• 01:13:18And a subspecialty is I think
• 01:13:22forming generically or you know
• 01:13:25spontaneously and trying to create a
• 01:13:30responsible practices in this regard.
• 01:13:36Thank you. It's good to see you, Sam.
• 01:13:42Other questions or comments?
• 01:13:47Yes, doctor hall.
• 01:13:51Thank you. Can you hear me?
• 01:13:54Yes, Sarah hall.
• 01:13:55I'm one of the associate directors
• 01:13:56of the program with Jack Hughes.
• 01:13:58But I I was not at the this
• 01:14:01thing in 2002, although I wasn't
• 01:14:02quite in high school either.
• 01:14:05No, he doesn't know. It told me. Yeah,
• 01:14:09so I think, you know, I'm, I'm.
• 01:14:11I'm still thinking about this concept
• 01:14:13of of friendship and I I I think I
• 01:14:16have a a some discomfort with the
• 01:14:18concept of a medical friendship
• 01:14:20particularly I'm sorry particularly
• 01:14:23in the context of you know this
• 01:14:25Aristotelian notion of friendship where
• 01:14:26often you know those sort of virtue
• 01:14:29based character based friendships.
• 01:14:30It's almost like this person's a
• 01:14:32second self and you know going back
• 01:14:34to sort of Jack's point about.
• 01:14:36Thinking about equity and patient access,
• 01:14:39umm, you know,
• 01:14:40I I take very seriously my duties
• 01:14:43to my existing patients.
• 01:14:45I think it's really important to make
• 01:14:46sure that I follow up on things I say
• 01:14:48I'm going to follow up on if I get a result,
• 01:14:50if I get a phone call,
• 01:14:51if I get a message, I, you know,
• 01:14:54I really prioritize answering promptly
• 01:14:56and thoroughly because that's a
• 01:14:57really important part of my duty.
• 01:14:59But I would definitely stop short
• 01:15:01of describing those relationships
• 01:15:03as friendships or even anything
• 01:15:05akin to friendships, you know?
• 01:15:06That because there is this distance and
• 01:15:08there are those boundaries and you know,
• 01:15:10a a friend in that true kind of the
• 01:15:12ultimate friend in the Aristotelian sense,
• 01:15:14that's someone who would have my cell
• 01:15:16phone number who could call me at anytime.
• 01:15:17And while you know,
• 01:15:18looking through just at the one case
• 01:15:20of a patient and physician that
• 01:15:22that's that seems perhaps lovely
• 01:15:24to have that kind of relationship.
• 01:15:26Realistically,
• 01:15:27there's absolutely no way I could
• 01:15:29sustain that level of relationship
• 01:15:30with all of my patients.
• 01:15:32And so then you know that sort
• 01:15:33of brings into mind the criticism
• 01:15:35of of concierge medicine.
• 01:15:36For example,
• 01:15:37where does that mean that I I should
• 01:15:39only have a fraction of the number
• 01:15:40of patients so that I could give
• 01:15:42them this round the clock dedication
• 01:15:44and in that case then access is
• 01:15:46even more compromised?
• 01:15:47Or do I give everyone my cell phone number,
• 01:15:49have decided that I'm don't have
• 01:15:51any right to a personal life or a
• 01:15:53vacation or anything like that ever
• 01:15:55because I'm always on call 24/7 365,
• 01:15:58never with coverage because that's
• 01:15:59how I am for a friend for example.
• 01:16:02And so you know how, how,
• 01:16:04how do we think about setting boundaries?
• 01:16:07In ways where patients get the
• 01:16:09care they need,
• 01:16:09but but physicians also and this ties
• 01:16:11back to Mark's issue too about about
• 01:16:13moral distress because it is very
• 01:16:15morally distressing and especially if
• 01:16:17you don't have those professional boundaries,
• 01:16:19I think it's much easier to
• 01:16:20get caught into that.
• 01:16:22How what, what are some of the,
• 01:16:24the.
• 01:16:24Guardrails or principles that we can
• 01:16:27think about to make sure that we can
• 01:16:29have these kinds of close trusting
• 01:16:31relationships which are admittedly
• 01:16:33very difficult with current time pressures,
• 01:16:35but also sort of preserve.
• 01:16:37The the integrity of the fact that it,
• 01:16:40it is fundamentally friendship is
• 01:16:42sort of a relationship of equals
• 01:16:44where as the physician patient
• 01:16:46relationship is all there's
• 01:16:48always a power differential even if
• 01:16:49we don't want there to be one there
• 01:16:51is one and and I think in a in the
• 01:16:53friendship and it's truest sense
• 01:16:54there isn't a power differential.
• 01:16:56So how how do we reconcile those
• 01:16:58those two sort of competing claims.
• 01:17:01Which really? Reply to that by.
• 01:17:08Just reflecting again upon Aristotle's point,
• 01:17:11because he said for every virtue.
• 01:17:13There's a tendency to be avoided,
• 01:17:16which is a voice of virtue,
• 01:17:18of the vice of excess or the vice of defect,
• 01:17:21like courage, for example, right?
• 01:17:23That the defect of courage of course,
• 01:17:26is cowardice,
• 01:17:27but says too much courage if not done wisely.
• 01:17:32Is rash, right? It's stupid, right?
• 01:17:34It's you know what you want to be courageous.
• 01:17:37So and you're a soldier,
• 01:17:39so you're charged the hill
• 01:17:40without counting the enemy.
• 01:17:41That's not courageous, that's,
• 01:17:43you know, that's rash and dysfunctional.
• 01:17:45So it's it's really this kind
• 01:17:48of balancing act, right,
• 01:17:49that becomes very much kind of
• 01:17:52dependent upon the person in their own
• 01:17:54development of judgment in these things.
• 01:17:56Whether you know I agree with you that
• 01:17:58the word friendship and the word love,
• 01:18:00right that that disturbs me.
• 01:18:02So it disturbs me and what we've
• 01:18:04extracted from it is more like respect
• 01:18:07than for a person than a friendship,
• 01:18:09right?
• 01:18:09I mean and and that disturbs me a little
• 01:18:12bit but I but I what is it was an
• 01:18:14attempt to find some kind of middle ground,
• 01:18:17you know, kind of a starting point,
• 01:18:18not in a finishing point.
• 01:18:19I I think the project really needs much more,
• 01:18:23much fuller articulation.
• 01:18:24I'd really like to work on it more myself.
• 01:18:28About how, how you would do that.
• 01:18:29But I mean, there's a lot of
• 01:18:31ways in which things are done.
• 01:18:32I mean, anybody heard of Robert Buckman?
• 01:18:36He, he talked about Breaking Bad news.
• 01:18:38How do you do that?
• 01:18:39And he had,
• 01:18:40he had methodologies and you know they
• 01:18:42often come out of psychology, right.
• 01:18:44So how how they would do it,
• 01:18:46you know,
• 01:18:46like you're taking off the white coat,
• 01:18:48you don't stand above them and so forth.
• 01:18:52And what he would do with his people
• 01:18:54that they were working on it and
• 01:18:55you have like a working group,
• 01:18:57he would video them.
• 01:18:58You know,
• 01:18:59like you do in an art class and then
• 01:19:01you put it up for everybody to talk about it.
• 01:19:03What do you think about what
• 01:19:04so and so did here?
• 01:19:05And you get comments on it
• 01:19:07and it just becomes a more,
• 01:19:08much more educational process.
• 01:19:10Back to Zika,
• 01:19:12Manuel's point about having,
• 01:19:13you know, be the friendship,
• 01:19:15be more of a teaching relationship as well.
• 01:19:18And for me,
• 01:19:19the teaching relationship of course
• 01:19:20being more Socratic where you're drawing
• 01:19:22out from people things rather than
• 01:19:24just trying to give them information, right.
• 01:19:28So, but we have these concepts.
• 01:19:30I confront it in philosophy a lot.
• 01:19:32I also teach logic.
• 01:19:34And you know,
• 01:19:35a real stumbling block for the
• 01:19:37students is the concept of valid.
• 01:19:41Because we know it in common language,
• 01:19:43it means true.
• 01:19:44It does not mean true in in
• 01:19:47logic it means if,
• 01:19:50if if your premises are true,
• 01:19:52your conclusion is guaranteed to be
• 01:19:54true by the form of the argument.
• 01:19:56Much more complex concept.
• 01:19:58So valid just does not mean true, right?
• 01:20:01And same thing here.
• 01:20:02When you say friendship right,
• 01:20:04certain things come to our mind about it,
• 01:20:06but I'm saying medical
• 01:20:07friendship to try to say that
• 01:20:09we need to integrate something.
• 01:20:11From there into this and try to
• 01:20:13come up with with a workable
• 01:20:16solution or mean between the
• 01:20:18extremes and Aristotle sense. So
• 01:20:21Chambers if I if I'm reading you
• 01:20:23correctly the medical friendship that
• 01:20:25you're talking about is going to have
• 01:20:27a greater degree of intimacy than a
• 01:20:30completely detached physician patient
• 01:20:32relationship but not necessarily the
• 01:20:34level of intimacy that you're talking
• 01:20:35about with friends in general that
• 01:20:37we have which is 24/7 accessibility
• 01:20:38and we approach each other as equals
• 01:20:40and we tell each other all our.
• 01:20:41Secrets etcetera, etcetera,
• 01:20:42you know, whatever.
• 01:20:43So it's a level of intimacy somewhere
• 01:20:45between a completely detached
• 01:20:47physician patient relationship and
• 01:20:48and what we may think of friendship
• 01:20:51and the common use of the word.
• 01:20:53So the medical friendship
• 01:20:54might be something in between.
• 01:20:55Yeah, that's well yeah that's the
• 01:20:57that's the effort and I, I, I, I.
• 01:21:00Frankly admit, I don't think
• 01:21:02I've actually clarified it yet.
• 01:21:04But I I think I have initiated what
• 01:21:06I hope I have done is initiated
• 01:21:08the inquiry in a direction that
• 01:21:10might be productive, you know,
• 01:21:11but it requires a lot more work in terms of,
• 01:21:14you know, what that adjustment means.
• 01:21:16But I mean, it's not only for the patient,
• 01:21:19it's also for the physician to
• 01:21:20carry caring for their own sense
• 01:21:22of self and integrity. And
• 01:21:24presumably this is not, this need not be
• 01:21:26limited to issues of assistance dying.
• 01:21:30Ohh, I'd like to say a trickle down.
• 01:21:32As I said, really. Yeah.
• 01:21:33I mean it was strengthened the profession,
• 01:21:35I think. I mean the. But.
• 01:21:39It was a David mechanic,
• 01:21:41talked about the erosion of trust in
• 01:21:43the medical profession and so on.
• 01:21:45I mean, and that's, you know, too much trust.
• 01:21:49Again, it's a virtue.
• 01:21:50Too much blind trust,
• 01:21:52blind obedience and that kind of thing.
• 01:21:53That's not good either. Right.
• 01:21:55So how do you find that middle ground?
• 01:21:58Try practice work at it.
• 01:22:00There isn't an absolute answer,
• 01:22:02but you can make progress.
• 01:22:04That's, I think,
• 01:22:05Aristotle's message and
• 01:22:06get a lot better at it.
• 01:22:08And that was the whole foundation
• 01:22:10of virtue ethics. No? Was that?
• 01:22:13That and the and and the practice,
• 01:22:16but also the imitation because I
• 01:22:18think one thing is going to lead
• 01:22:20us in the direction you're talking
• 01:22:22about potentially is if there are
• 01:22:23some role models that people are
• 01:22:25drawn to within the profession.
• 01:22:28You know, people who are Tom Duffy is
• 01:22:30a much better people like Tim Quill,
• 01:22:32who came here years ago and spoke to
• 01:22:34us in this room but was seen as a very,
• 01:22:38you know, controversial figure certainly.
• 01:22:40But people like Tom Duffy, for example,
• 01:22:43people who are very widely and highly
• 01:22:45respected and there are others in this
• 01:22:47room as well that I think that some of.
• 01:22:50What you're seeking is potentially found
• 01:22:53in the imitation of of respected mentors.
• 01:22:56Absolutely. And I don't know how
• 01:22:58many of you know he's he would be
• 01:23:01an mark would be an example himself.
• 01:23:04He was working as a practicing physician and
• 01:23:07kind of got hooked by philosophy poor man.
• 01:23:10And he decided to get a Masters
• 01:23:13degree in philosophy here at Yale.
• 01:23:15Now that's what we need to do and
• 01:23:17philosophers need to do that,
• 01:23:18do it from the other side too.
• 01:23:20Especially, you know, if they're
• 01:23:22thinking about medical ethics and so on,
• 01:23:24they need more exposure and
• 01:23:26experience to the medical world.
• 01:23:28I mean, for me it was a huge eye
• 01:23:30opener being able to talk to,
• 01:23:32you know, physicians who've been
• 01:23:33in this kind of experience.
• 01:23:34It's so remote from my experience.
• 01:23:39So
• 01:23:39this is the space where philosophy
• 01:23:41and medicine come together.
• 01:23:42And Chalmers were very grateful
• 01:23:44for your talk this evening.
• 01:23:45And of course, you're a longstanding
• 01:23:47son of Yale, but you can never
• 01:23:50have too much of this Yale.
• 01:23:53Thank you very much.
• 01:23:54That's cool with that.
• 01:23:56Thank you.
• 01:23:59Thank you, folks.
• 01:24:00We'll be back here in one week
• 01:24:02with Doctor and Samaria talking
• 01:24:04about gender affirming chair.
• 01:24:06And I wish you all a beautiful night.
• 01:24:08Thank you once again.
• 01:24:11Discussion was better than
• 01:24:12the paper, so thank you.