Medical Friendships in Assisted Dying

March 16, 2023

Information

March 1, 2023

Chalmers Clark, PhD

Associate Professor of Philosophy & Bioethics, Neiswanger Institute for Bioethics & Healthcare Leadership, Loyola University, Chicago

Lecturer, Neiswanger Institute for Bioethics, Stritch School of Medicine

Instructor, Drexel University College of Nursing and Health Professions, Philadelphia

ID9689

To CiteDCA Citation Guide

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&amp;A function on the on the zoom,
01:39not on the chat portion, but the Q&amp;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&amp;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&amp;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.