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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

ID
7882

Transcript

  • 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&A Q&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.