Program for Biomedical Ethics Presents: Organizational Challenges to Ethical Behavior

June 01, 2022

Information

May 25, 2022

David Berg, PhD

Clinical Professor in Psychiatry and Lecturer, College Seminar Program

Yale College

ID7882

To CiteDCA Citation Guide

00:00You're welcome.
00:04All right, ladies and gentlemen,
00:05thank you all for your.
00:08Attend your virtual attendance
00:10and to those who are in
00:12person in the room here.
00:14This is the my name's Jack Hughes.
00:16I'm an associate director along with
00:19Doctor Sarah Hull for the program
00:21of program for Biomedical Ethics,
00:23which is headed by Doctor Mark Mercurio
00:27who is here also just to remind
00:29you that we have sessions at least
00:32once and sometimes twice a month.
00:34Our next session will be Doctor
00:37Sarah Hall who is here today.
00:41And that will be in two weeks.
00:46June 8th OK.
00:50Today we are privileged to have.
00:54Mark, excuse me David Berg who is an
00:58organizational psychologist he has.
01:02He is a former professor at the at the
01:05School of Organization and Management.
01:07He is has been a consultant and
01:12he is interested in Group and
01:16organizational dynamics. He is.
01:19He is currently a clinical professor
01:24in the Department of Psychiatry.
01:25He's won several teaching awards
01:28and he is quite well known
01:32among undergraduate students,
01:34medical students, medical residents,
01:37psychiatry, residents, and faculty.
01:40He is a facile lecturer and has.
01:47Made us all very appreciative
01:48that he is joining us here today.
01:50He's going to talk about the.
01:55Ethical challenges of organs of
01:58organizations to right sorry.
02:02So our plan is for Professor
02:06Berg to speak for a few moments.
02:09If at any point you have questions,
02:12please send them to the chat or the no
02:16excuse me to the Q&amp;A Q&amp;A and we will
02:19feed those questions to Professor Berg.
02:22He will also be asking questions
02:25to which we hope you will respond.
02:29David, anything else you want to add.
02:31He will not be wearing a mask,
02:33I assume because he's going to be
02:35safely distanced from the rest of us.
02:38So thank you, Jack. Thank you very much.
02:41I'm going to talk to the people in the room.
02:44Those of you who are watching.
02:45I hope this will work for you as well.
02:48But talking to people I can't
02:50see is is a challenge that I'm
02:52really not up for at the moment.
02:54So I'll talk to the people in the room.
02:56I'm glad to be here,
02:57especially given that I'm not.
02:59On a physician,
03:01I'm not a professional ethicist.
03:04I'm an organizational psychologist
03:06and what I'd like to try to do is
03:09talk a little bit about how what
03:11I see as the normal aspects of
03:15organizational life that create
03:18challenges for ethical practice.
03:20Before I start,
03:21I'm going to ask this people
03:23in the room if there's anything
03:25they want to know about me,
03:27or because we don't have a relationship
03:29here and we're about to do some
03:31work without a relationship,
03:32and that that sort of violates
03:34the core tenant of mine that has
03:36to do with how work gets done,
03:38but if anything you want to know or
03:41anything you want to tell me about this this.
03:43This seminar,
03:44or this series that would help me get
03:47oriented to the process that would be great.
03:50Anybody wanna help me out here so
03:52we have honored guests come here
03:54and speak to us about their area of
03:56expertise and then we heard that but you,
04:00my friend, have license
04:01to say whatever you feel.
04:04He said on the subject
04:05we are very interested.
04:06Several of us in the programmer
04:08specifically in organizational ethics.
04:11Still, you're allowed,
04:12and you're certainly allowed
04:13to ask US questions and give
04:14us a bit of a hard time.
04:15By all means.
04:15OK, I probably won't give you a hard time.
04:19I hope to stimulate the way
04:22you think about. And that song.
04:24OK, now you're telling me how
04:26this system works here, right?
04:27OK, I appreciate that.
04:31Right exactly so let me what I have
04:34here that you can't see which is OK,
04:37is a rough, meandering outline for
04:40my 35 or 40 minutes, and it starts
04:43on the left with an introduction,
04:44which we're sort of almost done with.
04:47And then it goes to the general
04:49topic of professional ethics,
04:50and I'm going to tell you
04:51what I mean by that term,
04:53which I assume means something
04:54very different to everybody who
04:56is a regular attendant of this of
04:58this program and this seminar.
05:00But just so you know.
05:01Where I'm coming from then I'll move
05:03to a brief discussion of what I mean
05:06by an organization for organizations.
05:08And then the specific subtext
05:10category of that which is the general
05:13topic of intergroup relations.
05:15And from that I'll go to something
05:17that I've set up here is called
05:19worldly philosopher.
05:19I want to talk about a guy named
05:21Albert Hirschman, who is an economist.
05:24I don't like economists, so this is a real.
05:27This is a testimony to Albert Hirschman
05:29that I'm going to talk about Albert
05:31Hirschman and and then if we have time,
05:34I'll I'll talk briefly and make
05:36reference to the to concept.
05:38Of descent in organizations and
05:41it's rolling ethical behavior.
05:44OK. Ready OK? So far so good.
05:49OK,
05:49professional ethics.
05:50I'm going to define professional
05:53ethics for the purposes of of of
05:56today's talk in conversation as the
05:58guiding moral and practical standards
06:01to which members of a profession
06:03hold themselves accountable.
06:07The guiding moral and practical
06:09standards to which members of the of
06:12a profession hold themselves account.
06:16The other thing I'm going to say about
06:19that is that I believe these standards,
06:21both the moral and the practical ones,
06:24are negotiated.
06:25They're always negotiated.
06:27They're negotiated across time,
06:30across cultures, across people.
06:32So this is where we might
06:35have some conversation.
06:37I I take as axiomatic that moral and
06:40practical standards are negotiated.
06:42Now it's a leisure to see practical
06:45standards as negotiated since they are
06:47constantly revised with new knowledge
06:50or with new methods or new discoveries,
06:53it's sometimes a little harder to
06:54look at moral standards as negotiable,
06:57but that's my observation of
06:59human history and human culture,
07:00and I just lay it out for you that that.
07:03Moral standards too are negotiated.
07:07So the question then is what in
07:10the makeup of organizational life.
07:13Makes holding yourself accountable
07:17to certain moral and professional
07:19standards a challenge.
07:20And I think there are things and
07:22the challenge is not something
07:24that you can eradicate.
07:26It's something that you need to
07:29manage because the characters
07:31of organizations that I will.
07:33Layout or create these challenges.
07:37So unless you don't have organizations
07:40you can't avoid the challenges so.
07:43Organizations. All right, this is Karen.
07:47I hope you're going to tell me
07:48if you can see this. So this.
07:51Is bird's simple picture.
07:57Of an organization. It takes its name
08:01from the picture that I just drew.
08:03What kind of organizational
08:05organization is this?
08:06I'm asking the seven people
08:08in the room for a project.
08:11Yeah, it's a pyramidal organization, right?
08:14Meaning technically I would draw this,
08:16you know, whatever.
08:17But it's a pyramidal organization,
08:19and it defines traditionally
08:22meaning 19th century sociological
08:24bureaucratic organization.
08:25It defines two types of groups.
08:30It defines a group by hierarchy.
08:37Which means one's level of authority
08:41in the institution, and that defines
08:44another set of groups. By function.
08:50Now, part of the reason why organizations
08:54exist and look like this is not because
08:57somebody drew it up in the 19th century,
09:00but because human organization formed out
09:03of a specialization and differentiation.
09:07And once people found the both the
09:10efficiencies and the quality that comes
09:13from people deepening their expertise or
09:16their capabilities in a particular area,
09:19they confronted the problem
09:20of how to coordinate.
09:21Those increasingly separate
09:24areas of expertise.
09:26This should sound familiar to
09:28everybody in the room, right?
09:29They have modern terms for this,
09:31but it's an old problem with
09:34respect to organization,
09:35which is if you if not if everybody
09:37doesn't do anything which is a Guild.
09:39I make something,
09:40but if I specialize then I see my part
09:43much more clearly than I see some other
09:46part I know my part much better than I
09:49know somebody else's part and someone.
09:52Or some function needs to
09:55coordinate among the different
09:57parts if the service or product is.
10:00Requires that coordination.
10:02So if I smelt the metal and you solder
10:05it and somebody else engraves it,
10:07that's a coordination where I used
10:09to do all of those by myself.
10:12But we can make more pewter mugs
10:14if we do it that way.
10:16Then if I'm the only one doing them
10:18one at a time, I may not be as nice.
10:20They may not be as collectible,
10:22but I can do more. So.
10:25That also requires I'm going
10:29to use a particular word.
10:30It requires the parts by sort of
10:33explicit or tacit contract to subordinate
10:37themselves to the coordinating function.
10:40That is to say,
10:41I'm going to give you the legitimate right.
10:45To compel my behavior as it relates
10:47to the other parts of this system,
10:50because you are seeing the
10:51system and I'm seeing the part.
10:54OK,
10:54standard organization.
10:55Now what standard organization
10:57theory did not do was describe what
11:00I would call a third kind of group,
11:03which is implicit in this chart.
11:06But not articulate.
11:09Those hundreds in the room wanted,
11:10wanted,
11:11wanna take a guess as to what I'm
11:13giving you a hint by drawing a
11:15boundary around the organization.
11:193rd type of group.
11:213rd type of group yeah more.
11:24There are you.
11:25You could say there are.
11:27There are relationships with other
11:29blobs outside the organization,
11:30interorganizational relationships of
11:32people belonging to another organization.
11:34I would say that's a special case of
11:37a general type of group which I would
11:40call for the moment and identity group,
11:42or some people would call
11:44it a historical group,
11:45meaning the groups to which
11:48people belong that they bring
11:50with them into the organization.
11:52So for example,
11:54if you're working in an organization,
11:57there are a whole bunch of group
12:00memberships that you bring with you
12:02when you come into that organization.
12:06Example. Take the easy simple ones.
12:11Depends on what you mean by easy
12:12and simple stay in the camera OK?
12:17In front of the yellow stuff.
12:18OK, it's kind of cool to hear my voice no OK,
12:22I'll stay in front of the camera.
12:23OK, some examples of these of
12:26these other kinds of groups?
12:29For example, I come into this
12:32organization as a psychologist.
12:35You could say, well,
12:36that's a function.
12:37Unless there are no
12:39functions for psychologists,
12:40in which case I come in as a psychologist.
12:43But the point is, even when I leave,
12:45I'm still a psychologist.
12:47That identity that group membership comes
12:51with me when I'm inside the organization
12:53and when I'm outside the organization.
12:55There are lots of such groups,
12:57right?
12:59Race, gender background nationality
13:02politics religion there are lots of them.
13:07We bring those into the organization.
13:09The reason this is I add this group
13:12is because the the point here is
13:14that the groups to which we belong
13:17inside an organization mediate our
13:20experience of that organization and
13:24the organizations experience of us.
13:27So having worked in a medical
13:28school for 20 years,
13:29I'm very familiar with what
13:31happens the first time you walk
13:34into a group of medical residents
13:36and say you're a psychologist.
13:39They treat you very respectfully.
13:41But they have no idea what
13:43you're doing there.
13:45Because they don't really know
13:47what a psychologist is doing
13:50in a medical organization.
13:53Or it it the example I use about
13:57the role of these groups is
13:59imagine that you were about to
14:01write an early retirement memo.
14:04You're about to write a memo
14:06to the organization saying,
14:07hey,
14:07we're offering a plan if you
14:09want to take early retirement,
14:10you get this number of years.
14:12Do you imagine a 55 year old is gonna
14:14write that memo the same way a 35
14:16year old is gonna write that memo?
14:20We certainly figure that a 55 year old's
14:23gonna read that memo differently than a
14:2535 year old memo is going to read it.
14:27And there is a sort of small example of how
14:30everything that happens in organizations.
14:32From my point of view,
14:33is experienced differently through the
14:35lens of the of the of the three broad
14:38types of groups that people belong to.
14:43Now. I'm gonna expand a little bit.
14:48On these three types of groups,
14:49because it's in these three types
14:52of groups that the challenges
14:54of organizations. Exist?
15:00What affects people's sort of
15:02behavior in organizations?
15:04From my point of view,
15:05is the current and historical
15:08relationships between the many
15:10groups to which they belong.
15:14Again, in a simple form,
15:16if there's a if there's a an impending
15:19strike with a unionized workforce,
15:22then the relationships between bargaining
15:24unit people and management are probably
15:27going to be strained in the weeks leading
15:30up to whatever the negotiation is.
15:32Because there's a historical relationship
15:35between union and management in a hospital.
15:38And there's a current situation
15:40between unity and management,
15:42namely impending negotiations.
15:43But it is true about all of
15:46these different kinds of groups.
15:48There's a history between various functions.
15:52Meaning, you know, I don't.
15:55I don't want to offend anybody,
15:57but everybody knows that their relationships
16:00between different functional groups take
16:03the finance people and the clinical people
16:06or the surgeons and the GI of the section.
16:13Those historical and then current functions.
16:17Influence how people behave in the moment.
16:18So let me take hierarchical
16:21because hierarchical groups are,
16:23in my opinion,
16:25arguably in modern organizations.
16:28Probably I don't understand a very
16:32important effect upon people's behavior,
16:35especially their ethical behavior.
16:37So why would hierarchy affect
16:40people's ethical behavior?
16:42Now everybody in this room's
16:44got to know this from the lived
16:46experience of being a physician or a
16:48a health care person in a hospital,
16:51so this is actually not a I'm
16:52going to give you my examples.
16:54I have dozens of them,
16:55but we all know them, right?
16:57We all know when.
16:58You've been challenged because of.
17:01Of of the hierarchical groups
17:02to which we belong,
17:03and I would say what that usually means
17:06is the people in the lower position
17:09in the hierarchy are vulnerable,
17:12structurally vulnerable in their
17:13relation to the people at the top.
17:16That means they write recommendations
17:17they have something to do with
17:19their pay and their career.
17:21They that's a structural vulnerability,
17:23has nothing to do with personalities.
17:25It has nothing to do with
17:27interpersonal relationships.
17:28It has to do with the structural nature.
17:31And if you go back to what I said before,
17:32that's built into any organization,
17:34that vulnerability is built in.
17:38So I'll give you my example.
17:41Years and years ago,
17:43a chief resident comes to me and with
17:45with the with the following distress.
17:48She has had an end of life
17:53conversation with a family,
17:54how they want to handle a
17:56terminally ill patient with cancer.
17:58They've had a long conversation conversation.
18:00She was trained for professional
18:02standards and and ethics,
18:04and they've come to decide it's
18:07going to be comfort care only.
18:09A couple of minutes after
18:11she had that conversation,
18:12she runs in to a an attending faculty
18:16member who is a cancer researcher.
18:20And the attending says,
18:22why did you do that?
18:26I was hoping to enroll
18:28that person in a trial.
18:33Now it is tempting to revile one or the
18:36other of the actors in this situation. Right?
18:40But from an organizational point of view,
18:44the attending physician who's being
18:46promoted and who may have been recruited
18:49and is certainly being promoted and
18:52is being tasked with doing medical
18:55cutting edge medical research.
18:57Doing her job.
18:59Maybe we'll have that discussion.
19:01And the medical the chief resident
19:05trained is doing her job.
19:07And when the attending says to the
19:10chief resident, why'd you do that?
19:12Don't do it again.
19:13The chief resident has an ethical dilemma.
19:18Which you've all seen, I'm sure,
19:20or experience dozens of times,
19:22and it's because.
19:25A chief resident relationship to
19:27attend to an attending physician.
19:29And I would suggest to you that there's
19:33another historical relationship,
19:35which is the relationship between
19:37research and clinical care.
19:40Which is also at play in this
19:42interaction and and oftentimes the
19:44relationship between functional groups
19:46has a hierarchical component to it.
19:49That is one of those groups is
19:52by the organization's goals.
19:54Advantage over other groups
19:57and that advantage creates the
19:59vulnerability that we're talking.
20:01I'm getting Vertigo here.
20:03You're getting Vertigo.
20:04I'm not even doing it.
20:05I'm just standing here,
20:06OK, good all right.
20:09So number one structural
20:11vulnerability of hierarchy can can
20:14create various kinds of ethical
20:17dilemmas and those ethical dilemmas.
20:20Often.
20:23Look at you. Look at you.
20:26Those ethical dilemmas often
20:29result in constraints on speech.
20:33Speech being the ways in which we confront,
20:38negotiate, work through ethical issues
20:42and hierarchy and historical relationships
20:45between groups can often suppress speech,
20:49making the the negotiation about
20:52ethical dilemmas more difficult,
20:54and that is true,
20:56both hierarchically and function.
20:57So you know if the surgeon
21:00says we're going to do X.
21:02Yeah, the gastroenterologist doesn't say no,
21:04we're not.
21:06And similarly with
21:09hierarchical situations, OK?
21:13Functional groups.
21:24The.
21:29Yeah, I'm looking at you,
21:30but looking at you doesn't have
21:32to look at me in order to say you
21:34told me to stand next to the.
21:35What are you doing to me, alright?
21:37We're done there's a there's a movie
21:40where somebody keeps running in front
21:42of the camera OK I wanted to do
21:45something which word you're probably
21:46familiar with to discuss a little
21:48bit about the challenges functional
21:50groups represent and organizations.
21:51And that is the the notion of ethnocentrism.
21:55Meaning all groups begin to see
21:58themselves at the center of the universe.
22:02And when they see themselves
22:03at the center of the universe,
22:04what accompanies that is a belief
22:07that their view of the world is
22:11superior to the views of others.
22:13It's normal, it's problematic,
22:16but it's not like only some
22:19groups are ethnocentric.
22:22All groups are ethnocentric,
22:23so if we might think that surgeons are
22:26ethnocentric but pediatricians are not.
22:29That's only because we're not a pediatrician.
22:31Right,
22:32because if we're a pediatrician,
22:34guess how we think about surgeons.
22:36But surgeons think they're better
22:38than pediatricians or pediatricians
22:40are much on the outside of a of
22:43a of a particular ring because
22:45of how they were trained,
22:48how they were raised,
22:50what the internal conversations within those
22:52functional groups are about other groups.
22:55Now, this makes it difficult.
22:57When you have to work with those
22:59other groups, because now I'm
23:00going to exaggerate this slightly,
23:02you're being asked to work with
23:05people for whom you have some.
23:09Disregard.
23:11It's trained disregard.
23:13You can train yourself not to say it,
23:16and you can train yourself,
23:17even not to feel it,
23:19but it's in the it's how we
23:22build the boundary around.
23:24Any functional group is by distinguishing
23:27it from other functional groups.
23:29So for example,
23:30when I used to teach second year
23:32sciatic residents and they would
23:33on a in their inpatient year,
23:35be asked to do some things for patients
23:38which they would call social work,
23:41like making a call to find
23:42them a place to go.
23:43They would say I didn't go to
23:45medical school to do social work.
23:47Now if you find yourself saying
23:49oh that's a terrible thing,
23:50you have all said this at
23:52some time in your experience.
23:54When you've been asked to do some task
23:57that was not what you were trained for,
23:59you reveal your historical
24:01relationship to other groups.
24:04The sort of.
24:05Underbelly of those relationships which
24:07we all work to deal with consciously.
24:10But Ethnocentrism is built in to
24:13the creation of boundaries around
24:15groups because we learn who we are
24:18by comparing ourselves with others.
24:21It's not the best way.
24:23There are ways of addressing it,
24:25which we'll talk about in a moment,
24:27but it is what it is.
24:29It it's it's the way groups are
24:32created and because groups are the
24:34building blocks of organizations.
24:36In organizations we have a fair amount of.
24:39Ethnocentrism.
24:44The last sort of set of groups are the
24:48identity or historical groups. These are.
24:55Arguably, even more difficult to
24:57talk about than either of the 1st 2.
25:01And the historical and current
25:04relationship among identity groups is.
25:09It is more fraught,
25:12usually with various kinds of
25:15pain and historical grievances.
25:18Not always. And not always in
25:20in the front of people's minds,
25:22but often because, again,
25:24that's the nature of belonging
25:26to different kinds of groups.
25:28We see it all around us with respect
25:31today to things like immigration or race.
25:35We see it historically with respect to
25:37those groups as well as going back as
25:40far as any of us can historically record.
25:43Gender relations,
25:45national sort of a geographic.
25:49Identifications those all get
25:52brought into organizations.
25:54So when all of us are
25:57trained in unconscious bias,
25:59we're trained as if that's
26:02in the individual mind.
26:04I would suggest to you that the bias
26:07that comes or the historical views
26:10of other groups comes to us from the
26:13the the cultures that we belong to,
26:17it's deposited in us.
26:18So when we intervene on the individual.
26:20Brain,
26:20I would argue we're intervening
26:22at the wrong level of analysis.
26:24It's what where that?
26:25How that gets into our brain.
26:27And that's about groups and
26:29about what groups teach their
26:31members about other groups.
26:33And that's where we eventually
26:35need to intervene.
26:36Now,
26:36how does that create?
26:39Ethical challenges the ethical
26:41challenges of identity groups are
26:44often out of our conscious awareness.
26:47The example I'll give is about five or
26:49six years ago there was a front page
26:51article in New York Times about huge
26:53studies at the NIH about the four month.
26:56You're all you know,
26:58more than the four month delay for African
27:01American women in getting a mammogram,
27:03and the NIH did every statistical
27:05thing they could to try to explain
27:08and understand why this was happening.
27:10They controlled for dozens of
27:12variables and the front page of the
27:15times the lead of the study said.
27:17We were searching for every explanation
27:20we could and at the end of the day
27:23the only thing we can attribute
27:25this to is racism. Now.
27:27Even in this room,
27:29I'm sure people are saying no.
27:31I said it's it's interactions
27:34of socioeconomic.
27:35And the 35,000 or whatever it was OK,
27:38not a randomized control trial,
27:40but looking for everything they
27:42could find and not a single not
27:46going to say a single,
27:47but no more than 2% of the
27:50of the healthcare providers.
27:52If you interviewed them who were
27:54involved in the healthcare of
27:56those 35,000 patients would say
27:58I'm prejudice against black people,
28:00which is why I delay them.
28:03But the finding in terms of looking
28:06at everything else,
28:07is that somewhere the historical
28:09relationship between groups makes
28:11its way into our decision making
28:13about same thing is true for the
28:15meta studies that are done year after
28:17year about drug company sponsored research,
28:21not a single researcher says,
28:23yeah.
28:23Of course, I've I.
28:26I change my findings
28:27because of who's funding me.
28:29Not a single person says that because
28:31not a single researcher believes it.
28:34But the meta analysis clearly and
28:37repeatedly shows that it has an impact.
28:40This is the impact of the groups
28:42to which you belong.
28:43That's not necessarily conscious,
28:44which makes the whole notion of
28:47this being an ethical dilemma very
28:49hard to confront because we think
28:51of ethics as something that's in the
28:54frontal lobe that we think about
28:56that we can reason about that we
28:59can set up principles for these
29:01kinds of ethical issues are buried.
29:05And harder to get. OK. So.
29:10So why do I have something up here
29:12called the worldly philosopher?
29:14Cause there's like this man named
29:16Albert Hirschman was an economist,
29:18wrote a book about markets and organizations.
29:21I won't bore you with it.
29:23But what he was trying to understand
29:27was what happens when you are a
29:30member of an organization and you
29:32see something that violates a
29:34moral or practical standard.
29:36Now in his case,
29:38that practical standard was
29:39good economic practices.
29:43So his question was what are your options?
29:46What do you do when you see that?
29:50And here's the title of his book.
29:54Is exit. Voice and loyalty.
30:01And the idea is you basically
30:04have three choices when you.
30:07See, I don't know why I'm picking.
30:10I'm not, you know, as they say,
30:12some of my best friends and
30:13I'm picking on surgeons.
30:14But medical student once told me about,
30:16you know we're talking about
30:17ethics and they said, you know,
30:18I saw somebody leave something in
30:20the patient, sew it up and then
30:21tell us not to tell anybody. OK,
30:24So what happens if you're shocked at this?
30:27You were never a medical student or
30:29you weren't paying attention because
30:31I heard dozens of these right?
30:33A different versions of this and
30:35I'm sure it's a small percentage.
30:37But you know, you're in the you're
30:39in a medical setting all the time.
30:41You're going to see one
30:41every once in a while.
30:42So what happens if you see it?
30:46What do you do?
30:47Now, if you're a medical student,
30:49what do you do?
30:54What did this not?
30:55What should you do?
30:56Because that runs into exactly what
30:58we're going to talk about here.
31:00But what do you think this
31:01medical student did talk to you?
31:04That's because I asked.
31:08That's probably true also.
31:10What didn't the medical student do?
31:16Even raise a question report
31:18to anything because of the the
31:21hierarchical vulnerability.
31:22So this is fundamentally and we
31:24talked about functional groups.
31:25We talked about the the hierarchy
31:27that's nested in functions,
31:29meaning some are more powerful than others.
31:31So what hershman's trying to figure out?
31:33And of course, with respect to identity,
31:35there's also historical power differences.
31:37What Hurshman is trying to figure
31:39out is what do you do when you see
31:41something and there's a power difference.
31:43There's a vulnerability to speaking,
31:45so he says, well, you can speak.
31:50Because his point is, if you speak,
31:52you give the organization the
31:55information it needs to change so
31:57that it's the quality of its efforts.
32:00The ethical. In our case,
32:01the ethical behavior improves,
32:04because clearly,
32:05if nobody's ever reporting these things.
32:08The organization never has the
32:10information to be either self regulating,
32:13which is one of the of course
32:15key components of a profession
32:16is that it is self regulating,
32:18or to change whatever its organizational
32:21practices are that are making this
32:25seem like it's the standard practice.
32:28So Kirshman said you can leave and
32:32in leaving you do give a piece of
32:35information in the organization.
32:36And as you know,
32:37over the last two or three years,
32:39I'm sure you're all talking about it.
32:40There are increasing concerns that
32:42large numbers of healthcare providers,
32:45nurses, physicians.
32:48Are going to leave the health care
32:50system because of the as a way of saying
32:54the way this organization is functioning.
32:56I don't want to be part of anymore
32:58either for ethical reasons or
33:01resource allocation decisions.
33:02Whatever has to be so you can leave.
33:05Hirshman says if you leave, you only give
33:08gross information to the organization.
33:11Meaning you left you didn't like something.
33:14And many organizations do
33:16not do exit interviews,
33:18and when they do do exit interviews,
33:19those are tricky because people don't want
33:22to burn any bridges structural vulnerability.
33:26They don't necessarily tell the truth.
33:27Their relationships are going to do so,
33:30leaving gross information.
33:32But you know,
33:34have you ever seen anybody leave Yale?
33:36You have.
33:37What is the announcement say?
33:40Ohh they got a better offer somewhere else.
33:42Ohh they had other opportunities.
33:45Oh they wanted to spend more time.
33:46Nobody ever says.
33:48If all you see is an exit, well,
33:51here are the three critiques that made
33:53them want to choose someplace else.
33:55Now some people will say that on the way out,
33:58I would suggest to you that's this.
34:00That's a combination of exit and voice.
34:03We've seen examples of that as well.
34:05I guess I'm going to space where
34:06that actually may have happened,
34:08but but.
34:09But so you can leave,
34:12you can also stay around
34:14and keep your mouth shut.
34:16But in that case,
34:18the the organization doesn't get
34:19any information about its ethical
34:22professional standards or practice.
34:25So Herschman is essentially saying this
34:28is the key for organizational learning.
34:31But C was an economist.
34:34So what I don't think he
34:36he he emphasized enough,
34:38was how difficult this is.
34:40In theory this is of course the
34:43way in which the organization gets
34:45the information it needs to refine
34:48it's professional ethical practice.
34:51But if anybody is ever been on a on a
34:54committee to review other people's,
34:58you know, professional activity,
34:59it's very challenging.
35:01And if you've ever been in a low power.
35:02Position then you can fill out a form.
35:05You think multiple times before
35:06you fill out that form because the
35:09structural vulnerability means
35:11you're not sure how confidential
35:13that form is. That's what it means
35:15to be structurally vulnerable.
35:16That's what it means.
35:17And I remember I'm going to confess
35:20something I should not confess.
35:22I didn't do it. He says of course,
35:24but when I was in Graduate School
35:26and we used questionnaires right?
35:29And we worried about the
35:31response rate on questionnaires.
35:33There were little secrets that
35:35were told about how to give
35:37out an anonymous questionnaire,
35:39but keep track of it.
35:41So that you could follow up and or you know,
35:45find out you know how many you
35:47were getting back and from whom.
35:49You could write little tiny
35:50pencil numbers on the back of
35:52the questionnaire which you had
35:54then coded somewhere else, right?
35:56Or you could staple the staples
35:58in different directions,
35:59like let's say you want to know
36:01whether a particular PIN members
36:02vehicular department were returning it.
36:04So the Pediatrics the staple went this
36:06way and you know the oncology staple
36:09went this way and I never did any of that.
36:12But I suggest to you that that is a way
36:15of coping with trying to get information,
36:19but the deception that goes into
36:21that is a way of dealing with the
36:24fact that people are not going to.
36:27Often feel comfortable in the
36:29structurally vulnerable situation
36:30about what the UP group is going to
36:33do with the information they give.
36:35OK,
36:35so I think this is worth thinking
36:38about thinking about the conditions
36:41I was telling Mark about a colleague
36:44named Lauren Taylor who is struggling
36:46with this and one of the things she's
36:49she says is one way of dealing with
36:52the attention and the vulnerability,
36:53but also the discomfort of being in an
36:56organization that is doing something
36:58going UN quote wrong is to sit her.
37:01Her word is stay in and speak out.
37:08But Lauren, too, I think,
37:10is underestimating the
37:11vulnerability of that strategy,
37:13because here's what I'm going
37:15to get to my last point.
37:16Because stay and speak out is
37:20an individual level exhortation.
37:23Right you you're in an organization
37:27and you're seeing something
37:29the way you remain whole as an
37:33individual is not to quit because
37:35that may be not possible for you
37:38given that you need the job,
37:40et cetera that you're whatever your
37:42own goals are not to just go along,
37:45but to stay in and speak out.
37:49That's a heavy burden on an individual.
37:51I mean, I think it's an impossible burden
37:53on all but the most secure individuals.
37:55And you know how many secure
37:57individuals there are in organizations.
38:02Because everybody's worried about
38:04their reputation, everybody's worried
38:05about their standing, their legacy.
38:07Everybody feels that to to do.
38:10This puts them at some risk.
38:14So that leads me to the notion
38:18of dissent in organizations.
38:20And I, I say dissent because I
38:22want to at least propose that when
38:25one is in a position of authority.
38:28That the cultivation of responsible dissent.
38:32As much as the cultivation
38:34of responsible conformity,
38:36which we're much better at,
38:37that's what we call professionalism.
38:39Professionalism is the cultivation
38:41of conformity.
38:42Meaning this is what we do
38:44in these situations.
38:45We don't get angry.
38:46We don't call anybody names.
38:48We listen carefully,
38:49we do,
38:50and we conform to those professional
38:53standards and practices.
38:54It's crucial for the functioning
38:56of any organization in any profession.
38:58But as important is the cultivation
39:01of the capacity for dissent for
39:03supporting in the in a position of authority.
39:07Getting access.
39:07To this to the experiences of
39:10people in different parts of the
39:12organization who are not likely
39:14to contribute that as individuals.
39:17Because I would suggest to you that dissent.
39:22Is a group phenomenon.
39:24It's a communication between a
39:26group as we've talked about here,
39:29a functional group to another functional
39:31Group A hierarchical group to another
39:33hierarchical Group One identity
39:35group to another identity group,
39:36which can often be misunderstood
39:38as the behavior of an individual,
39:41because often it's an individual.
39:44Who speaks?
39:46But if we imagine, and I,
39:48I think this is always true,
39:50that there is a group behind
39:52any individual who speaks out.
39:54Meaning as you just said,
39:56what does the medical student do talks to me?
39:59Talks to other medical students,
40:02so there's if a medical student
40:05raises her hand and says hey,
40:07what do we do about this practice?
40:09You can be sure there are lots of
40:11other medical students who know that
40:13or have had similar experiences.
40:15And so rather than make it difficult
40:18for the organization to negotiate,
40:20its where it falls short on its
40:23own professional ethical standards.
40:25By focusing on an individual,
40:28I suggest to you that the thing you
40:30want to do is think about how to
40:32enable groups to talk about their experience.
40:41I'll stay on camera, but I'm
40:43done 45 minutes on the nose.
40:47All right, go ahead.
40:49We'll use Jack if we need to.
40:56Yeah, so so yeah, I'm
40:58really interested in this
41:00idea of of trying to
41:01foster dissent. So so we've been.
41:05Kind of a long
41:05story, but we've been trying
41:07to get feedback on different.
41:09Sort of ethics policies we put
41:11in place during the pandemic.
41:13And you know one area
41:16of real concern is. You know whether
41:20these policies have been used in
41:24a biased way with regard to race,
41:28ethnicity, socioeconomic status,
41:29and so that's that's been a,
41:30you know, a topic that we've
41:31been trying to get feedback from
41:33frontline clinicians about and.
41:38You know what
41:38we we've been particularly
41:40interested in the perspective of
41:43clinicians who are underrepresented in
41:45medicine. And it's it's been really
41:50challenging to get that perspective.
41:53We've done a lot of interviews and it's been
41:55like there's been a noticeable.
42:00Skew and who's volunteering
42:01for the interviews and we?
42:02I mean, we've we've gone to
42:05individuals and there's there's been
42:06a lot of discomfort and and. It's.
42:12It's it's been a real challenge,
42:14so I mean I think we're we're.
42:15We are seeing the effect of,
42:18you know, hierarchy and particularly.
42:23A racial and ethnic. But
42:30pressure to not give voice
42:33right to like conform
42:35and and so it's
42:36been something that we've
42:37really been wrestling with. I'm
42:38curious, sort of like
42:40what tools organizations
42:42have used that have
42:43successfully promoted dissent.
42:45And like that that sharing of
42:47information because it's something
42:48that I've been running into a brick
42:49wall on personally.
42:50So most organizations are not good at it
42:53because most organizations don't want
42:55to hear it because most organizations
42:58feel that the the people out there.
43:01Just take medical students.
43:02What do they know?
43:04I don't want them putting out demands.
43:07I don't want them telling
43:09me what their experience is.
43:10They don't have a whole lot of experience
43:12with either education or medicine,
43:13so I I certainly don't
43:16want to encourage that.
43:17She not here Jen's general orientation.
43:21So first you have to deal with
43:23the fact that I think many
43:24organizations don't want to hear it.
43:26And that means that people in
43:28organizations have had the experience
43:30of being invited to speak and either not
43:33listen to not responded to or punished.
43:35So it's that when I talk about the
43:37historical relationship between groups,
43:39what they mean is when you go ask,
43:40and you think it's denovo, hey,
43:43I I'm a genuinely interested person.
43:45Can you tell me what your experience is?
43:47There's a whole history that comes with that,
43:50so tackling the history.
43:53Would be my first step.
43:55So you say, well,
43:55how do you tackle a history?
43:56Well,
43:57for starters the first thing you do
43:59is you say I know there's a history.
44:02I know I'm part of that history.
44:04I'll give you a concrete example.
44:05Years ago, two or three Deans before.
44:09There was a renewal of a grant,
44:12and in the renewal of the grant
44:15was a community engagement piece.
44:17This is 1520 years ago,
44:19so whatever you may be thinking,
44:21that's contemporary.
44:22It's turns out to be just an echo,
44:25but 1520 years ago,
44:26and so I went to a meeting with
44:28the Dean and a whole bunch of
44:30people about how this might unfurl.
44:32And I was new,
44:33so they're talking about all the great
44:35things that Yale's doing in the community.
44:38And I say because I've been here,
44:40I was over in school.
44:41Imagine I'm doing projects in the
44:43Community organizational projects,
44:44and I say run into exactly what
44:46you're running into all the time,
44:48and I say,
44:50how about if we acknowledge that we're
44:52not doing such a great job historically,
44:54and that the point of getting this
44:56grant is in order to be able to try
44:59to begin to address the historical
45:01relationship between you and the community.
45:04Dead silence.
45:09Dean says, well, we could do that,
45:11but I don't think we're going to and off
45:13we go promoting all the stuff that yell
45:15does in the community and we got the grant.
45:18So whatever the comment was about,
45:20we need to address the history.
45:22Did not happen at that point,
45:24so I think you need to address the history.
45:25Now I'm going to give you a more concrete
45:27because the dressing history is difficult,
45:29but it starts with being able to say the
45:31words when you sit down to somebody.
45:33I know we have a difficult history.
45:37We not you and me we the
45:40groups to which we belong,
45:43and that we now are in a representational
45:46conversation about whether we intend it
45:49to be a representational one or not.
45:51Right? So the concrete thing is,
45:54if I'm right about this,
45:57then the way to collect information
45:58about this is not from individuals.
46:02That just heightens the vulnerability
46:04of the of the of the individual
46:06right of the the structural
46:07vulnerability of the individual.
46:09You're asking whether their
46:10physicians of African descent,
46:11whether they're underrepresented minorities,
46:13where their community members,
46:14and your Yale and white and male
46:17and just looking at you and escape.
46:19You represent that even if you're not right.
46:23It just heightens the vulnerability here.
46:25So how do you ask a group?
46:30You can ask a group.
46:32You can say without me here.
46:36Convene a group.
46:37Ask this question and come back to
46:39me with what the group generates.
46:42You compose the group any way you want.
46:44Or maybe there are even groups
46:46that exist already on campus of
46:48minority faculty who explicitly
46:49come together because they have
46:51thoughts and feelings about what
46:52it's like to be part of that group,
46:54and doing clinical care or research
46:56or whatever has to be so using the
46:59existing groups and inquiring of groups.
47:02Without being in control of that interviewer,
47:07you know, because I got asked
47:08the same questions everybody.
47:09This is insane.
47:12Asking the same questions of
47:13anybody acts as if all of these
47:16are from groups are the same.
47:18Why would you ask the same question of
47:20everybody be like doing a health intake
47:22and ask the same questions of men and women.
47:24Now we can all laugh about
47:26that because 35 years ago,
47:28that's exactly what happened.
47:31There had to be a Women's Health division
47:34in the federal government because the
47:36£150 male was the standard of care.
47:40So we didn't really ask about
47:42even in that regard.
47:4450% of the population.
47:46So I would say the key
47:48is to ask about groups.
47:49Ask groups about their experience,
47:51not individuals.
47:52Yeah,
47:53so this
47:54this kind of touches on your point
47:55about groups versus individual,
47:56but taking it back to the
47:58left side of the chart,
47:59the the identity group and you
48:00pointed out it was very interesting.
48:02You pointed out that we when
48:04we have certain ideas in mind,
48:06prejudices perhaps that we think
48:08that we're unethical behavior that
48:09we think is actually an individual
48:11choice or decision is in fact part
48:13of the group that they identify
48:15with and that you point out.
48:17So we're kind of going out at the wrong
48:18way when we try and change the individual.
48:20Correct, so this I mean seems
48:23to me that then the best
48:24thing we can do is do a
48:25better job teaching kindergarten
48:27and fixing these groups.
48:29But in terms of trying to fix an
48:31organization now, I don't know how
48:33much power that an organization
48:34organization sees a problem with.
48:36Sexism, racism, whatever.
48:37We see a problem with and we say now we want
48:40to address this within the organization.
48:42I take your point that, well,
48:43really, we need to address
48:45this within the whole society.
48:47But and and and of course,
48:49it's going to take as many years and
48:50maybe one or two generations and so,
48:52but what, what would you say?
48:54Practical points for the organization.
48:56So there's the practical point.
48:58What you just did Park was,
48:59you said, well, this is a big thing.
49:01I can understand that if we could
49:03address it at the societal level,
49:05but we have, for example,
49:06men and women in this institution.
49:09We could put men and
49:11women in this institution.
49:12We could collect data from men and women
49:14in this institution as groups about
49:16their experience in the institution.
49:19We don't have to go to the
49:20societal level either to fix it
49:22or to collect data about it.
49:23We can begin to address it in
49:26the institutions that we have.
49:27We give you a concrete example
49:29of the intersection when,
49:30because you brought it up when when
49:34Yale started to started when Yale
49:38was actually had a whatever it was a
49:40title 9 consent decree from federal
49:42government which created the Title 9 Office,
49:44you know.
49:45So you have to do certain things because
49:46the government's looking at you and saying,
49:48hey.
49:49There's not good stuff going on here,
49:51and you need to work on it,
49:52right?
49:52So one of the things that the
49:56organization did was it started
49:58to do things for undergraduates.
50:01Like films about bystander effect etcetera.
50:06All this is true,
50:07but if I'm right I may not be.
50:11And we're talking about structural
50:13vulnerability and hierarchy,
50:15and we're talking about where
50:17we learn about other groups.
50:20Where should we have started that training?
50:23Where should we have started
50:25that investigation?
50:26Where should we have asked a question?
50:27What are we doing that's contributing
50:30to this cultural environment in in the
50:33relationships between men and women,
50:35where should we have started?
50:38We should have started here.
50:41We should have asked a question in the
50:44highest levels of what are we doing?
50:48We should have at least asked a
50:50question what are we doing as a group,
50:52which I would call a leadership group.
50:54Now the leadership group tends
50:56to be more male and it tends to,
50:58so it tends to have other groups in it.
51:01But the group might have started
51:03with what are we doing as a group?
51:06Not what are you as an individual doing?
51:09My behavior is above reproach fine,
51:11but what are you doing that might contribute
51:14to a culture that has 19 year olds?
51:17Not following ethical behavior
51:20in their relationships.
51:22Relationship between men and women.
51:23We did not start there and and
51:26if you take seriously a group,
51:28an intergroup perspective,
51:29this group's going to have much more
51:32influence on what goes on down here.
51:34Then this group.
51:38All right, thank you. We have some questions
51:42from our zoom audience and I would like to
51:45pose some of these questions to you. Oh,
51:47by the way, those everyone should
51:49know that we have a hard stop at 6:30.
51:52So if you have a question that
51:54we have not been able to address,
51:57we apologize. It may be a great question.
51:59It's no reflection on you,
52:01but we do have to stop at that time.
52:04So all right. First question. Can you
52:07comment on the
52:08impact of unions on organizational ethics,
52:13particularly speaking to the
52:15ability of those on the bottom
52:18of the hierarchy to speak up?
52:23Great question. So the question
52:27of unions and organizations.
52:29From my perspective,
52:30having worked in that area for
52:32years at one point is complicated.
52:35It's complicated because there's a history,
52:38so let me illustrate again that
52:39if you start today and you don't
52:41take into account the history,
52:43you have one view of of, for example,
52:46union management relations.
52:48If you take a historical view,
52:49you have a slightly different view or
52:52radically different view, etcetera.
52:54So I would say unions are organizations
52:57just like medical schools or organizations.
53:00And that means that the the effect of
53:04these different groups inside unions.
53:07Is is just as capable as suppressing
53:09speech because of vulnerability as
53:11as any hierarchical group in any
53:14organization and it would be foolish
53:17to think that because unions in general
53:19are in a hierarchical relationship to
53:22management ownership that they then
53:25don't do anything to suppress, they don't.
53:28They're not subject to the same quote,
53:29UN quote laws of of suppression of speech,
53:32than any other organization is.
53:34They are, in my opinion, in my experience.
53:37So they unions would have the same
53:40obligation to deal with information
53:44dissent about their practices.
53:46Great practices,
53:47corrupt practices,
53:48as any organization would have the obligation
53:52to to take a look at those practices.
53:55Now the history which sometimes gets
53:57washed away is that you know you go
54:00back long enough if you ever taken a
54:02course on history of the labor movement,
54:05it's the it's for me.
54:07One of the most amazing illustrations
54:09of organized dissent that I've ever
54:12seen at the turn of the 20th century,
54:15when the sweatshops were in existence.
54:17And the kodaks and whatever the
54:21worlds were running company towns.
54:23The labor movement stopped all the labor.
54:27In order to form the labor movement.
54:30And that meant they got people who were poor.
54:34To withhold their labor,
54:36which means to put themselves at risk,
54:38and people who could have run in to take
54:40those jobs which we have seen since to stop.
54:43If that had not happened,
54:44there wouldn't be any union unions today and
54:47some people may wish that had been the case.
54:50But when you're working 12 to 16
54:51hours a day and there's a triangle
54:53waste fire and you know you're you
54:55can't go to the bathroom,
54:57etcetera.
54:57You at that point historically you
54:59needed some protection from your the
55:02vulnerability that you that you experienced.
55:04So that's deep into.
55:06That's part of the history.
55:08Just like and if you have
55:10done research at Yale,
55:11just like Tuskegee is deep in
55:13the history of the relationship
55:15between minority communities,
55:17especially the African American Community,
55:18and research and elite research
55:20institutions like this happened 100 years
55:23ago or 80 years ago, front and center.
55:25So when you think about unions A,
55:28they're an organization.
55:29Like anything else,
55:30they can suppress dissent.
55:31But be that history is always present,
55:34and.
55:34Oftentimes doesn't get talked about much
55:37like history doesn't get talked about
55:39in most relationships between those,
55:42all right? Thank you, David.
55:44Next question, how does an organization
55:47or quote sub organization create a space
55:50in which dissent can be provided or voiced?
55:53Now you've partially addressed that with the.
55:56So just once, a couple sentences on that,
55:59I think it helps to be to
56:03be looking for it meaning.
56:05I think most of the time when
56:07we do not respond to dissent,
56:10it's not because it's not there.
56:11It's because we don't notice it because
56:14it's because of the vulnerability.
56:17Dissent is going to be thrown
56:20out there very gently.
56:22And the people who throw it out
56:25there are gonna be very careful
56:27to see how it's responded to.
56:29And if it's not responded to,
56:31they either crawl away or
56:33they tend to escalate it,
56:34and then at some risk to themselves that
56:37escalation actually paradoxically serves
56:38as a way of dismissing the dissent.
56:41So what I would say to you
56:43is look for the dissent.
56:46Encourage it, rather than,
56:48you know, just roll over it.
56:51So if somebody makes a joke.
56:55About rounds or a joke about their clerkship.
57:01Or a joke about the clinic's
57:04subtle little kind of joke.
57:07Ask about it. Don't laugh with it,
57:09or imagine to yourself that the joke is
57:12a way of of feathering something in to
57:15see how it's going to be responded to.
57:18You can do more than that.
57:19You can do a very you know how many
57:21of you have as physicians have
57:23ever at the end of the rotation,
57:25gotten your team together and said?
57:26So? How did the rotation go?
57:28Now, in Bird's view what you've
57:31done is you've taken this.
57:37Right, and you've asked a question that
57:40has in it a higher representatives of
57:44hierarchical groups with a history.
57:48Go to the look at the history
57:50of pimping in in the in,
57:52in the medical world, just the the
57:54publications about not just the word,
57:55but so if this person asks this person what
57:58do they think this person has this group?
58:00What do they think they're asking
58:02in the context of this relationship?
58:05Which is a very powerful hierarchical
58:07relationship in medicine.
58:09What if this person says hey,
58:11why don't you go over there?
58:14Make a sheet of paper of the things
58:15that went well about the about
58:17this rotation and things didn't
58:18go and then come back and give me
58:20the piece of paper I'll step out.
58:24Ask the group. Now it may not work
58:28because they're worried that one
58:29of these people is going to be a
58:30do gooder and tattle on somebody,
58:32but at least what it does is it says
58:34I don't need to control what you
58:37say and my presence is a powerful
58:40control on what you say because
58:43of the historical relationship
58:45hierarchical relationship in medicine.
58:49So David, you wouldn't think
58:51that necessarily asking.
58:52Well, what do you think went
58:53well about this rotation and
58:55what do you think could have
58:57been better? Is that marginally
59:00better, or is that it's got the same problem?
59:02It's got the same problem in the room.
59:04It's got the same problem and
59:06most people don't even do that.
59:07Most people what they do,
59:08and I would argue this is because
59:10we're mostly ambivalent about
59:11getting negative feedback. All of us.
59:13The whole world, me included, is.
59:16We've got three people and in.
59:18Our team and then after the last
59:20day we go up to one of them.
59:23And we say so, how was it?
59:26And we think we're getting good data.
59:29We do so.
59:30That person looks at me and says,
59:32I'll give you a great example.
59:33Let's say we had a difficult interaction
59:35on rounds and one of the residents
59:38did something, said something,
59:40made a mistake and I said, Gee,
59:42you know, that's not going to get you,
59:46you know, not going to get you to
59:47be a good doctor or something.
59:49Then I have some remorse, whatever.
59:50And then I go up afterwards.
59:51And I say, Gee,
59:53how do you think that went?
59:56What do you think?
59:57What do you think Jack was, you know,
59:59was it OK when I did with Jack?
01:00:01What is this person gonna say you did great.
01:00:04Don't worry about it.
01:00:06I think it was fine no
01:00:07matter what she's thinking.
01:00:09That's what she's going to say because look,
01:00:12I'm even standing because that's
01:00:14the metaphor for the heightened
01:00:15vulnerability of that person between an
01:00:17attending and a second year resident.
01:00:19And yet,
01:00:20I tend to think I'm getting good
01:00:22data because interpersonally,
01:00:24you're a thoughtful person.
01:00:26I trust you interpersonally,
01:00:27so I go person to person.
01:00:30I guess you what happened.
01:00:31You told me I walk away thinking,
01:00:32well, I got some good data there.
01:00:35Which is exactly the sort of
01:00:36your case across other kinds.
01:00:38It happens all the time.
01:00:41Partly because I really don't want to know,
01:00:43and partly because I don't know any better.
01:00:45I mean like nobody ever taught me
01:00:47that by getting somebody in the
01:00:48hallway and saying what do you think
01:00:50of that interaction over there?
01:00:52I might be distorting the data I
01:00:55might be making that an ethical
01:00:58practical challenge for that person
01:01:01to tell me her experience. Thank you.
01:01:05All right, another question.
01:01:07And then we'll share.
01:01:08Then we'll come to you.
01:01:10If there is institutional resistance
01:01:13to dissent is speaking
01:01:15by group sufficient?
01:01:16Does it just dilute vulnerability
01:01:18and proport in proportion to the
01:01:21size of the group? If so, might
01:01:23small groups be as effectively vulnerable as
01:01:26the individual? How can this be overcome?
01:01:30These are great questions and right on point.
01:01:36The size of the group makes a difference,
01:01:38so the questionnaire is right.
01:01:40The smaller the group,
01:01:42the more the impulse of any organization,
01:01:46and I'm not blaming it when
01:01:47we're in positions of authority,
01:01:49we will have the same impulse which is.
01:01:52To isolate or to think it's
01:01:55an isolated phenomenon,
01:01:56because that protects us from having to
01:01:59think about broader change in the system,
01:02:02and we're all homeostatic.
01:02:04You know creatures.
01:02:06So especially when we have responsibility
01:02:08for an institution to have to think,
01:02:10WOW, we have to take the well.
01:02:13We have rampant sexism in this organization.
01:02:16I don't want to have to think that
01:02:18because next thing I'm doing I'm doing
01:02:20marks doing which is post before,
01:02:21which is how the hell am I going to
01:02:23get my arms around this problem?
01:02:24This is a societal problem,
01:02:26so there's an impulse to say.
01:02:28Well, that's just a few malcontents.
01:02:32Well, if there's more than a few.
01:02:35That makes it harder to isolate that,
01:02:37so the questioner said,
01:02:38isn't there a risk that a
01:02:39resistant organization?
01:02:41I would say all organizations are
01:02:43resistant and I would suggest to you
01:02:45that that resistance isn't is just
01:02:47for a living organizational system,
01:02:49it's just like resistance in
01:02:50a personal system.
01:02:51If I say to you where your resistance is low,
01:02:53is that a good thing?
01:02:55No,
01:02:56that's a bad thing because resistance
01:02:58is a break against Willy nilly kinds of
01:03:01changes which are evolutionarily dangerous,
01:03:03right?
01:03:04So even organizational resistance
01:03:06has a positive quality to it in
01:03:09that it's conservative by nature.
01:03:11Resistance is conservative,
01:03:12which means there has to be a
01:03:15pretty good case made to change,
01:03:17and that case goes up to the extent that
01:03:19you got more rather than fewer people.
01:03:22The other thing that the questioner
01:03:24I think is asking is.
01:03:26Which I don't,
01:03:27which Hirshman doesn't really
01:03:28get into a little bit,
01:03:29which is what's the difference
01:03:32between respectful dissent,
01:03:33disrespectful dissent,
01:03:35dissent in an organization
01:03:38and political organizer?
01:03:40Where political organizing is
01:03:43putting pressure because of the by.
01:03:46By appealing to the organizations environment
01:03:48on the leadership of the organization.
01:03:50Whereas I would say dissent is
01:03:53putting pressure internally on the
01:03:55leadership of organization by saying
01:03:56hey there are a bunch of us who live
01:03:59and work in this organization who
01:04:01think you should know about something
01:04:03you're not paying attention to,
01:04:04and we feel strongly about.
01:04:06Political organization is that's not working.
01:04:10I'm now going to go to the New York Times.
01:04:13And that's another way
01:04:14of expanding the group,
01:04:15because as anybody who's done anything knows,
01:04:18as soon as you go to the New York Times,
01:04:19you got 5 or 600 people instantly
01:04:22on social media.
01:04:23And that's more than four or
01:04:24five people in the small group.
01:04:26You know,
01:04:26sending a respectful letter up the hierarchy.
01:04:29Now you know those are all forms of dissent,
01:04:32but.
01:04:34And and I think you'll you've seen
01:04:37here when dissent is not handled well,
01:04:41it actually increases the frustration,
01:04:43which is more likely to
01:04:45lead to political activity.
01:04:47All right Doctor Hull is this?
01:04:50Yes I wanted to ask you sort
01:04:53of a follow up question on what
01:04:56you were saying previously about.
01:04:57You know the example of going up
01:04:58to a resident and saying
01:05:00hey like was that OK what just happened?
01:05:02Because that sort of reminded me of a
01:05:04of a general tendency that I I think
01:05:06is just part of the human condition
01:05:08which is to ask these questions that
01:05:09are like leading the witness. Right?
01:05:11You're you're asking a question as if to
01:05:15elicit an actual. Actual
01:05:17opinion or information, but in fact
01:05:18you're just you want someone to
01:05:20cosign what what you're thinking.
01:05:21And I I joke about this on consults
01:05:23a lot where you know we'll get
01:05:24a question really
01:05:26someone's not interested in my
01:05:27opinion on something they want
01:05:28me to say. It's OK so that if
01:05:30something happens they can say
01:05:31Oh well. The cardiologist said that was OK
01:05:33and and I think there's some of
01:05:34that going on here too where a lot
01:05:36of times when we elicit feedback,
01:05:38we're sensitive.
01:05:38We we really don't want negative feedback.
01:05:40We kind of want reassurance that that was OK.
01:05:43And and you know what?
01:05:44What are are some strategies
01:05:46that you think are helpful for
01:05:47people in leadership roles?
01:05:49She's sort of get out of that
01:05:50mindset of wanting to elicit sort of
01:05:55superficially or nominally wanting to
01:05:56elicit feedback, but in fact
01:05:58wanting to to elicit reassurance
01:06:01because of this inertia and
01:06:04and resistance to change.
01:06:07And the stress of being
01:06:08working in an organization.
01:06:09So I have some compassion for for people.
01:06:12For those of us who do this.
01:06:14But what I would say is this the
01:06:16single piece of advice I would say
01:06:19is use your hierarchal authority
01:06:21to solicit critical information.
01:06:24Critical meaning, things that people want
01:06:27to change or want to be critical of.
01:06:30So instead of saying,
01:06:31how are things going or even
01:06:32instead of saying which I do,
01:06:34because I think it's just good form
01:06:35asking a balanced question, say.
01:06:37What's important to me?
01:06:40Is to know your experience about what
01:06:43was not comfortable, not ethical.
01:06:45That raised ethical in in the in the
01:06:47two weeks we just spent together.
01:06:49Full stop.
01:06:50Now the first time you do that,
01:06:52people are looking a little like
01:06:54whoa that kids can't be true.
01:06:55You can't really be asking this question.
01:06:58You really want reassurance,
01:06:59but if you do that consistently,
01:07:01which is you're using your
01:07:03authority to solicit what?
01:07:05What would be helpful
01:07:08information about ethical?
01:07:10So for Can you imagine in the story
01:07:12I told where the you know the surgeon
01:07:15afterwards says to the resident.
01:07:17Well,
01:07:18it would be really helpful to know
01:07:19if at any time during this rotation.
01:07:21You felt ethically compromised or
01:07:23you were on the edge of feeling
01:07:25Ethicon or you think I did something
01:07:27that puts you in a tough spot
01:07:28because to ask that question is to
01:07:31acknowledge that naturally I'm going
01:07:33to put you in a tough spot because
01:07:36I have different you know I have
01:07:39different objectives or based on
01:07:40what I'm doing in the organization.
01:07:44Resource allocation is a great one,
01:07:46but if if I if I went to and
01:07:47I said did it ever happen,
01:07:49I would have to be first accepting that
01:07:51maybe out of my awareness on identity,
01:07:54function and hierarchy I might have been
01:07:56putting you in a difficult situation
01:07:58as opposed to being defended against
01:08:00the possibility that I ever do that.
01:08:03So first I have to say, Yep,
01:08:04I could do that because I'm an agent.
01:08:07Of hierarchical groups and
01:08:08functional training and identity.
01:08:10Historical identity groups.
01:08:11So it's possible I put you
01:08:13in a difficult situation,
01:08:15and if I then say did I,
01:08:17and if I did,
01:08:18could you tell me when the first
01:08:20time I asked that question,
01:08:21nobody's going to say squat,
01:08:23but by the 6th rotation,
01:08:24medical students or residents are
01:08:26talking to each other and they're saying
01:08:28this guy asks the question every time.
01:08:30And you know, last month,
01:08:32Sally said, well, when you called me,
01:08:34you know, honey, it was really.
01:08:37I don't think that's a professional standard.
01:08:39You know what he said wasn't
01:08:41even aware of it?
01:08:42I'm sorry I'll try to work harder
01:08:44on that and then the next time
01:08:45that attending asks that question
01:08:47at the end of the rotation,
01:08:48is he or she's going to get
01:08:50three or four responses?
01:08:51It takes time,
01:08:53right?
01:08:53But using your authority to solicit
01:08:56that kind of information over
01:08:58time as opposed to using your
01:09:00authority to tacitly or explicitly
01:09:03get comforted or reassured,
01:09:04is is, in my experience,
01:09:06the only way to do it.
01:09:07And the great thing.
01:09:08About that just parenthetically is
01:09:10that you're still a representative,
01:09:12so that means if I'm the attending
01:09:14physician who asks that question.
01:09:15I'm not just changing my
01:09:18interpersonal relationships,
01:09:18potentially with the three or
01:09:20four residents on my team.
01:09:22Each rotation I'm a representative
01:09:24of attending physicians,
01:09:26so I'm making a little contribution
01:09:29to to changing the relationship
01:09:31between residents and and
01:09:33attendees because I'm still a
01:09:35representative of an attending group.
01:09:39Thank you all, right. Next question.
01:09:45What do you have against economists?
01:09:49Just kidding real question,
01:09:51I could go on and on,
01:09:54but what are some particular considerations
01:09:59in organizational ethics in healthcare
01:10:02versus business ethics more generally?
01:10:05Is there a distinction, and if so,
01:10:09where is that line that was?
01:10:11I added that at the?
01:10:13I'm not sure I'm qualified to answer the
01:10:17question since as an organizational person
01:10:19I look for the similar occurrences across
01:10:22different types of organizations, but.
01:10:25But my first impression is,
01:10:29and this is going to sound terrible, but.
01:10:32I I don't mean it to sound the
01:10:33way it does and I can explain it.
01:10:35If people are excited,
01:10:37but I think medicine is a profession.
01:10:40And I mean that in its classic sense.
01:10:43That is, it is the application of
01:10:46knowledge of a knowledge base to
01:10:49the to the care or to of people,
01:10:52and that knowledge base
01:10:54is constantly upgraded.
01:10:55It's a self regulating.
01:10:56It's a profession in that regard.
01:10:59Most organizations are quote UN quote,
01:11:03not professions.
01:11:05Their their systems of of production.
01:11:13They may be professional.
01:11:15When somebody is a professional manager,
01:11:18presumably there's a body of
01:11:20knowledge about practical and moral
01:11:22standards that governs that behavior.
01:11:25In my experience and this is, I'm not.
01:11:28I'm not bashing it, you know,
01:11:30like what's the single most
01:11:32important thing that an organ?
01:11:33What is most organizations in
01:11:35business to do to make money?
01:11:37That's what their.
01:11:38That's their function in society,
01:11:40right?
01:11:40To make products that are profitable
01:11:42in a capitalistic society,
01:11:43there's nothing in there about
01:11:46ethical behavior.
01:11:46There's nothing in there
01:11:48about professional behavior.
01:11:49Now I would say you know professional
01:11:52basketball is not a profession
01:11:55either because the word is you
01:11:57do whatever you need to do until
01:11:59the ref blows the whistle.
01:12:00There's not standards people
01:12:02may talk about standards,
01:12:03but they deteriorate or they get
01:12:06put in place more they issue is
01:12:09around winning and competing,
01:12:11and then we find out where the
01:12:13professional standards are.
01:12:15So and again, I'm not bashing it,
01:12:18that's what they're good at.
01:12:19That's what you know.
01:12:20Entrepreneurial creativity is all about.
01:12:22It's about finding efficiencies.
01:12:24You know, the economists,
01:12:25the market should be everybody gets
01:12:28the same information, you know.
01:12:30That's what makes a market.
01:12:32You can't make any money with
01:12:34everybody having the same information.
01:12:35You have to find the piece of
01:12:37information that nobody else
01:12:38has or you have to squirrel away
01:12:40information nobody has.
01:12:41That's what a copywriter a patent is right,
01:12:45because otherwise I don't have any advantage.
01:12:48So everybody has the same
01:12:49information all the time.
01:12:50It might be a Great Society,
01:12:52but you can't make any money.
01:12:55Even conservative economists who
01:12:57trumpet the market system they
01:13:00can want want their client to
01:13:02have just a little proprietary,
01:13:04just a little bit more information
01:13:06than somebody else.
01:13:06I want to give that information
01:13:08away that's not part of free,
01:13:10you know, information.
01:13:12So I think there's something special about
01:13:16about healthcare organizations,
01:13:18both because of their task,
01:13:20which is to care for people,
01:13:22and because they are arguably.
01:13:25The foundational profession in
01:13:27the in human society. So the
01:13:31the fact that the Milton Friedman
01:13:33and the Chicago School of
01:13:35Economists believe that the moral
01:13:38obligation of business executives
01:13:40is to maximize shareholder value.
01:13:42Shareholder return on investment.
01:13:45Does that have anything
01:13:46to do with your dislike of economists?
01:13:50This is some not not primarily by my dislike
01:13:53of economist is more personal than that.
01:13:56But yes, there is some theoretical.
01:14:00Notion about about about economics
01:14:04and morality, and even most economists
01:14:06would say you don't want private sector
01:14:09organizations deciding on public morality.
01:14:12You don't want them doing that.
01:14:13They're they're not the right place to do it.
01:14:14You want some duly constituted
01:14:17representative of the public of you know,
01:14:20to be debating the questions of morality.
01:14:22You don't want private sector organizations.
01:14:24Now that's changing with double and
01:14:26triple bottom line organizations, but.
01:14:28Doctor Mercurio has gets.
01:14:32Any questions?
01:14:35I think this is a big part of a lot
01:14:38of the struggle that's happening
01:14:39here at our medical school and
01:14:41perhaps elsewhere has to do with.
01:14:42I mean, I quite agree with
01:14:44you about the professions,
01:14:45and I think that that largely comes
01:14:47down to the fiduciary responsibility,
01:14:49which is, you know,
01:14:50is different than I'm here to
01:14:51make money for the owner or I'm
01:14:52here to make money for the owners,
01:14:53the stockholders,
01:14:55the fiduciary responsibility toward what
01:14:56some people want to call the customer.
01:14:58We still prefer to call them the patients.
01:15:02But this therein lies the struggle here,
01:15:04which is that that we've got that stress
01:15:08between the bottom line and the and the
01:15:10obligation we feel to not just our patients,
01:15:13but frankly also to are
01:15:14the others who are here.
01:15:16But we are our students and there's
01:15:19that conscience, constant tension,
01:15:20which I think looms over not just this,
01:15:22but every medical school.
01:15:24Because I mean,
01:15:25I feel it as a one of the triangles is
01:15:27probably closer to the bottom of the top,
01:15:29but I feel it with the the pressures
01:15:30that are clearly put on to.
01:15:32Manage the financial ship,
01:15:34sometimes at the expense of
01:15:36those to whom we have duties.
01:15:38At least,
01:15:39I think.
01:15:39And so when one is trying to
01:15:42hold back the tide of either one
01:15:44trying to serve 2 masters if you
01:15:46so I, I would say that you know.
01:15:54I would say as long as the United States is
01:15:57a culture where people are making money on
01:16:00health care at every step along the way,
01:16:02we're going to have this tension and there's
01:16:05money made at healthcare every step.
01:16:06I mean made. I don't just mean
01:16:09accumulated against a rainy day
01:16:11or surpluses against deficits,
01:16:13or I mean literally made for
01:16:16shareholders, et cetera.
01:16:17You're going to have this problem, I think.
01:16:20This is where I think the question is.
01:16:23How often is it talked about?
01:16:26That's the question and how often do we go?
01:16:28We collectively, not necessarily.
01:16:30The program on Biomedical Ethics,
01:16:33but how often do we talk about it?
01:16:37You know how often when we you know
01:16:40only have a week of insurance for
01:16:42somebody in an inpatient psychiatric
01:16:44facility and we don't think they're
01:16:46ready to go to be discharged?
01:16:48How often do we talk about making
01:16:49up a second diagnosis to protect
01:16:51that patient so that they can stay?
01:16:53And whether that's ethical or not?
01:16:56I mean, you know in classic terms,
01:16:57it's in a contient way.
01:16:59It's not ethical because you're lying to
01:17:01the insurance company in a utilitarian way.
01:17:03May be the only ethical thing you can do,
01:17:05and the question is,
01:17:06can you talk about it?
01:17:07Well,
01:17:07you can't talk about it because
01:17:09the lawyers say you can't talk
01:17:10about it if you talk about it,
01:17:11you're confessing to fraud so you can't do
01:17:14that well from an educational point of view,
01:17:17I think we got to talk about exactly
01:17:19what you were saying as often as we can,
01:17:21and then we may have to.
01:17:24Stay in,
01:17:25we may have to follow the laws or the
01:17:28guidelines or the billing procedures,
01:17:31but the speaking creates the
01:17:34talking about it educationally.
01:17:36Creates just incrementally the
01:17:38possibility that people as they move up
01:17:41are not making the mistake of thinking
01:17:43that they're behaving ethically.
01:17:45They're behaving the only way they
01:17:47can in a very difficult situation.
01:17:49And I think that's for me.
01:17:51I learned that teaching in a
01:17:53management class I was teaching
01:17:54a little ethical dilemma.
01:17:55Classic one you all know about,
01:17:57which is an innocent guys in the house,
01:17:58and the mob comes and they want
01:18:00to lynch the person.
01:18:01And they say, is he in your house?
01:18:04Well,
01:18:04the Kantian ethic is you have to
01:18:06tell the truth because if you lie,
01:18:08you're undermining the entire
01:18:10ethical system of the society.
01:18:12But if you tell the truth,
01:18:13they're going to lynch an innocent man.
01:18:14So what do you do?
01:18:17OK,
01:18:17so we're going through this
01:18:20classic and and we come to the
01:18:23utilitarian decision in the class.
01:18:24The class says,
01:18:25you know you lie and there's a
01:18:27divinity student in the class.
01:18:29In this management class and and,
01:18:31he says the key is to know you're
01:18:34lying as opposed to saying that
01:18:37the lie itself is a moral act.
01:18:40So his comment was if you have to lie,
01:18:43you need to preserve the fact
01:18:45that it was a
01:18:46lie and that it puts at risk something
01:18:48about the the the shared society we have.
01:18:51IE lying only works truth telling you know,
01:18:54lying only work because we presume
01:18:56truth telling he says the slippery
01:18:58slope is when you think that
01:19:00the line is itself immoral act.
01:19:01So if I have to, you know.
01:19:06Change a diagnosis for a patient in
01:19:08order to get them what they need.
01:19:11What what I what I don't want to do is say,
01:19:13well, that's OK because it's
01:19:15a corrupt system.
01:19:17What you want to say is I am being
01:19:20forced to violate what I consider to
01:19:22be an ethical principle for a what I
01:19:25consider to be a greater good and it
01:19:27feels kind of crappy all the way around.
01:19:29And that's what I mean by the
01:19:31maintaining the conversation as opposed
01:19:33to either not talking or saying well,
01:19:36that's the right thing to do because the
01:19:38patient wasn't ready to be discharged.
01:19:40It wasn't the right thing to do.
01:19:42Until we change society that that
01:19:44makes money and has insurance companies
01:19:47deciding when and how people get treated.
01:19:51Very difficult, I mean, as Lauren says,
01:19:53the stay and speak out.
01:19:54We live in a murky moral world.
01:19:58Now the question is how do we navigate
01:20:01our way through it? You know?
01:20:07I'm curious if there's specific academic
01:20:09medical centers specifically and and
01:20:12also outside of academic medicine.
01:20:14If there are particular organizations or
01:20:16like groups of organizations that
01:20:18you think do a really good job
01:20:20of allowing dissent, and more
01:20:24generally, allowing ethical behavior.
01:20:28So the question was, do I know of
01:20:30any other academic medical centers
01:20:31or organizations in general that
01:20:33do a better rather than worse job?
01:20:38I get this question a lot.
01:20:41You know about other sorts of things
01:20:44about organizations who's doing it well.
01:20:47And the simple answer is.
01:20:51I don't know any organization as well as I
01:20:53know this one because I live in this one.
01:20:56That mean that gives me certain advantages
01:20:59and certain disadvantages because I am
01:21:01just as encapsulated in my function and
01:21:04hierarchy and identity as anybody else is.
01:21:07What I do know is everybody's
01:21:09looking for a better place and that
01:21:12leads me to believe that.
01:21:14There are probably quote UN quote places
01:21:18that are more successful in engaging
01:21:20these kinds of issues than others,
01:21:23but marginally better.
01:21:25The vast majority are within
01:21:28one standard deviation,
01:21:30and so moving from going to one
01:21:32organization and learning about it,
01:21:33you'd recognize a lot of the stuff
01:21:35that you recognize around here,
01:21:37and you might pick up a tidbit
01:21:38here and there, but.
01:21:40By and large,
01:21:41the most organizations are
01:21:43struggling with the same sorts
01:21:44of issues that that we are now.
01:21:47You could say,
01:21:48OK bird,
01:21:48but your name is on a paper about outliers,
01:21:52which is true about door to balloon times.
01:21:54My name is on this where we looked at
01:21:57outliers to see what they were doing.
01:21:58Can't you give me an outlier?
01:22:01Just one hope.
01:22:05No. Meaning they probably exist,
01:22:09but I would be simplifying
01:22:12anything if I if I gave you one,
01:22:14because like I said at the beginning,
01:22:15I don't think I'm really qualified to to
01:22:18to characterize an entire organization
01:22:20in terms of how it's dealing with this.
01:22:25Alright, well I think we have
01:22:26time for one more question
01:22:28and I apologize to the folks
01:22:30that we haven't gotten to yet.
01:22:31Thank you so much for such
01:22:33an interesting talk.
01:22:35Can you tell us about your
01:22:36perception on the functionality
01:22:38of the hospital culture
01:22:39and stated mission statement?
01:22:42To cultivate an ethical culture?
01:22:44Excuse me, an ethical organization
01:22:45and cultivate responsible dissent.
01:22:49Some people are more skeptical about
01:22:51whether a mission statement of a
01:22:53hospital actually means anything.
01:22:56And doubt that the organization
01:22:58acts in a way that reflects all
01:23:00the stated value in the mission statement.
01:23:04Just is the word dissent in the
01:23:06hospital's mission statement.
01:23:07I don't think so. OK?
01:23:09I mean, I thought that's what I heard
01:23:11you that the question or say like so
01:23:13let me make a comment about missions.
01:23:16We have mission statement check check.
01:23:21OK, I'll talk to you and then, yeah, talk.
01:23:27I'm a mission statement skeptic.
01:23:30But not because I don't think we should
01:23:32have some aspirational language about
01:23:35about our organizational behavior.
01:23:38I do. I think I think, I think it's
01:23:41a long process of coming up with it,
01:23:44and I think it should be aspirational.
01:23:46The mistrust I have of mission statements
01:23:48is not that there shouldn't be an
01:23:50aspirational statement about our culture,
01:23:52it's how how we tie our the everyday
01:23:56decision making from strategy to operations.
01:24:00To the mission,
01:24:02and that's a very loosely coupled thing,
01:24:05so that makes the mission statements seem,
01:24:08if not hypocritical,
01:24:10not terribly meaningful or useful
01:24:12because people are not sitting
01:24:14around saying when they're about
01:24:16to make a decision about a patient.
01:24:18Does this align with our mission?
01:24:21And the reason they don't is because
01:24:23if they ask that question about each
01:24:25decision they run up against all
01:24:28these kinds of ethical dilemmas.
01:24:30And they would probably be immobilized.
01:24:34So most of us don't pay attention to
01:24:37mission statements as an aspirational
01:24:38statement because it would be
01:24:40too hard to operationalize,
01:24:42and we don't get a whole lot of help
01:24:44in translating aspirational statements
01:24:46to the gritty work of a clinic.
01:24:49Every Thursday from 1:00 to 5:00.
01:24:52Alright.
01:24:53Well, actually there is one other comment.
01:24:57Not everyone listening has a
01:24:59weak and tiny voice.
01:25:01Some of us are senior dogs
01:25:03with a strong bark and a potential bite.
01:25:07Is it if it
01:25:10is the responsibility of
01:25:11the senior staff to speak
01:25:13up where the junior folks
01:25:14are potentially intimidated and this
01:25:17actually is coming from a senior dog as you
01:25:21couldn't agree more, OK?
01:25:23All right, well this has been wonderful.
01:25:26David, thank you so much
01:25:28my pleasure this this is.
01:25:30And this is being recorded.
01:25:31It will be available on the program
01:25:34for Biomedical ethics website so.
01:25:39They there's a permanent resource,
01:25:41so thank you so much.
01:25:43Thank you for coming.