Program for Biomedical Ethics Presents: Organizational Challenges to Ethical Behavior

June 01, 2022

May 25, 2022

David Berg, PhD

Clinical Professor in Psychiatry and Lecturer, College Seminar Program

Yale College

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ID: 7882
To Cite: DCA Citation Guide

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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.