Taking Medical Ethics Seriously. Moving from the Extraordinary to the Ordinary

Transcript

• 00:00Is Osler Osler?
• 00:03So he was in in this fundamental
• 00:06argument with Welch as to what the
• 00:10primary identity or identification
• 00:12of the academic physician should be.
• 00:15In 1911, the Interurban Club
• 00:18debated Osler versus Welch.
• 00:20Now, Osler had already left America.
• 00:23By 1905, he became the Regis
• 00:26Professor of Medicine in Oxford.
• 00:28And that is a way of saying
• 00:30that he lost the fight,
• 00:31at least a local fight, in Baltimore.
• 00:34The Interurban Club was a early
• 00:38academic association stretching
• 00:40from Boston to Baltimore.
• 00:42It included Harvard, Yale, Columbia,
• 00:47University of Pennsylvania,
• 00:49and Hopkins.
• 00:50And there was this inner dialogue.
• 00:52And then there was, of course,
• 00:54the dinners that followed.
• 00:56And there were arguments about which ideal
• 01:00was preferable for the Osler followers.
• 01:06There was a complaint.
• 01:07The medical schools and teaching
• 01:09hospitals are producing laboratory
• 01:11men instead of clinicians noticed men.
• 01:14Of course there were very few women,
• 01:16and it was also stated the laboratory
• 01:18can never become and never should
• 01:20become the predominating factor in
• 01:22the practice of medicine and probably
• 01:25the Bible of the early Osler position
• 01:28about the prominence of clinical care.
• 01:31And the center of interest and
• 01:33focus of concern should be the
• 01:36patient as opposed to the disease.
• 01:38With Francis Peabody,
• 01:39who was a Harvard professor.
• 01:41He was the head of medical services,
• 01:43the Boston City Hospital in 1923.
• 01:47The care of the patient is the Ortex,
• 01:50from my point of view of medical
• 01:52ethics through the 20th century.
• 01:55Now why is this important?
• 01:57It's because there there there was
• 01:59this inner tension that was either
• 02:02articulated or was implicit in the
• 02:06training of physicians until the mid 1980s.
• 02:09Now most people would say the
• 02:12medical ethics was formulated and
• 02:15organized as a formal discipline.
• 02:18In the late 1960s,
• 02:20during this period of activism,
• 02:22the birth of feminism,
• 02:24gay rights, environmentalism,
• 02:25etcetera,
• 02:25patient rights became came to
• 02:28the fore for a number of reasons
• 02:31which we didn't go into.
• 02:32And as the sensitivities as it were
• 02:36for patient autonomy and for the
• 02:38care of the patient became more
• 02:40and more dominant against this
• 02:42other Welch research orientation,
• 02:44the articulation for a broader based
• 02:48education for medical students and for
• 02:52residents became articulated in 1898.
• 02:57Here at Yale,
• 02:59the Ulsler position was
• 03:01articulated in the following way.
• 03:03You're going out to a ministry,
• 03:05a ministry to which you cannot be worthy
• 03:08unless you hold it to be a priesthood.
• 03:10Now, that's a little hyperbole,
• 03:12hyperbolic, I would say,
• 03:13but I think the sentiment and
• 03:16the ethos is quite clear.
• 03:18Then we have 80 years later,
• 03:21the AAMC, That's the American
• 03:24academic medical school panel,
• 03:25I think something like that,
• 03:27and it doesn't matter.
• 03:29But the Medical College, excuse me,
• 03:31that's the organizing organization for
• 03:33medical school standards and accreditation,
• 03:36developed a report called the General
• 03:40Professional Education of the Physician,
• 03:42the GPE report,
• 03:44where the scientific training was explicitly
• 03:48articulated to be balanced by human dignity,
• 03:52patient feelings,
• 03:53holistic health,
• 03:54ethical and social responsibilities.
• 03:57Now,
• 03:57this is not a remarkable menu,
• 03:59as it were, for clinical care,
• 04:01but it is remarkable is that it became
• 04:04a formalized prescription for the
• 04:06education of medical students for
• 04:08the mid 1980s until the period here.
• 04:11And for those of you who
• 04:12are in medical school,
• 04:14it is worthy of noting that this
• 04:16is a fully formalized program and
• 04:19the medical school's responsible
• 04:22to balance a broad based baculat,
• 04:26education, general education skills
• 04:28and promote respect and concern
• 04:30for patient general welfare,
• 04:32clinical clerkship structured
• 04:33to reinforce those values.
• 04:36Pedagogic emphasis on critical and
• 04:38independent thinking and education as a
• 04:41professional faculty goal must be rewarded.
• 04:44These are all ethically based.
• 04:47These are all, as it were,
• 04:50implemented to balance the tendency
• 04:52for medical students and residents
• 04:55to focus on disease at the expense
• 04:58of the comprehensive care and view
• 05:01of the patient suffering an illness.
• 05:04Dr. Yale. I call him Howard Spiro.
• 05:06He was a gastroenterologist.
• 05:08How many in the room know who
• 05:11Howard Spiro was?
• 05:12Right the older generations.
• 05:14It's interesting how short our memories are.
• 05:18But he really was the epiphany
• 05:20of of Yale medicine.
• 05:21He wrote the primary text in
• 05:23Gastroenterology and was an extremely
• 05:26influential medical educator.
• 05:28And he made this observation
• 05:30towards the end of his career.
• 05:33During medical education,
• 05:34we first teach the students science,
• 05:37and then we teach them detachment.
• 05:39To these barriers of human understanding,
• 05:42they later add the armor of pride
• 05:44and the fortress of a desk between
• 05:47themselves and their patients.
• 05:49Students begin their medical
• 05:50education with the cargo of empathy,
• 05:53but we teach them to see themselves
• 05:55as experts,
• 05:56to fix what is damaged and to
• 05:59rule out disease in their field.
• 06:01That's quite an indictment.
• 06:03That's already 10 years after the report.
• 06:06And there was a comment,
• 06:09which I just think is so poignant,
• 06:13that was made just 20 years ago.
• 06:17Despite their reputation for vanity,
• 06:20many mental health professionals
• 06:21and medical students in particular.
• 06:24It's interesting how they're
• 06:25locked together here,
• 06:26fail to recognize their own importance.
• 06:29They come and go among patients as if their
• 06:32knowledge and skills were all that counted,
• 06:34their persons not at all.
• 06:37The remark is pertinent,
• 06:38for it points to the underlying
• 06:40vision that drives the profession.
• 06:42The medical students are not looking for
• 06:44personal engagement with the patient.
• 06:46They don't really want their
• 06:47person to make a difference.
• 06:49That is not the importance they are after.
• 06:51Rather,
• 06:51they want to learn why not to
• 06:53heal the patient with a precise
• 06:56and controlled intervention.
• 06:57The exact dosage of the exact drug
• 07:00chosen after an exact diagnosis,
• 07:02based on meticulous and exact analysis
• 07:06of spinal fluids and brain scans.
• 07:09Full disclosure, if I'm sick,
• 07:11I want a physician who is as
• 07:13meticulous as described here.
• 07:15But at the same time,
• 07:16I also want a physician who
• 07:18cares about me as a person.
• 07:20So this is the thesis.
• 07:23Medicine is fundamentally
• 07:24committed to its moral agenda.
• 07:27Its grounding is in the ethics of care.
• 07:30In other words,
• 07:32everything that physicians
• 07:33and nurses and other
• 07:35healthcare professionals are taught
• 07:37and do is in the employee in the
• 07:40service to this ethical mandate.
• 07:43Common views of bioethics or medical
• 07:45ethics are too narrow in focus and
• 07:48in many ways follow the partition
• 07:50of medicine established by the
• 07:53scientific dissection of disease.
• 07:55From the moral point of view, illness,
• 07:57the patient's frame of reference,
• 08:00must guide the physician.
• 08:01This is a philosophy of care which
• 08:04encompasses not only extraordinary
• 08:07clinical scenarios but also the ordinary.
• 08:10Moving from the extraordinary to the
• 08:13ordinary signifies that medical ethics
• 08:15is not a specialty within medicine,
• 08:18but sits at the heart of clinical care.
• 08:23I wrote a book, 20 How Many.
• 08:26It's almost 25 years ago.
• 08:27It's called Confessions of the Medicine Man.
• 08:29It's autobiographical.
• 08:30It's full of clinical vignettes.
• 08:32Italicize.
• 08:33That's what people normally read.
• 08:35But the argument in this book is
• 08:39fundamentally the thesis I just gave.
• 08:41Medicine's foundational ethics
• 08:42frame the character of the field
• 08:44and the science and technology
• 08:46applied to serving the patient care
• 08:49in the service of that mandate.
• 08:51In the clinical context,
• 08:53the interpretation and application
• 08:55of scientific knowledge occurs
• 08:57in a framework oriented by human
• 08:59need and physicians obligations.
• 09:02Indeed, the science of medicine
• 09:03is cast in a moral framework,
• 09:06one that antecedes the epistemology proper.
• 09:10OK, epistemology we'll get to in a moment.
• 09:13Medical ethics thus addresses not
• 09:15only the ethically difficult case,
• 09:17but also encompasses all ordinary
• 09:22clinical encounters. Moral.
• 09:26Moral refers not only to right and wrong,
• 09:29but good and bad, better and worse,
• 09:32choices made on the basis of human need,
• 09:35desires and wants.
• 09:37Here moral is human valued,
• 09:41human centered, human derived,
• 09:43human constructed and human
• 09:46intended epistemology.
• 09:47It's what we know, how we know and who knows.
• 09:52Basically knowledge,
• 09:53facts,
• 09:53data and the ways such as obtained
• 09:56and processed.
• 09:57Here medicine's epistemology is its
• 10:00clinical science and technology and
• 10:02the issue at hand is how to fuse
• 10:05the moral and the epistemological.
• 10:08And I've written about moral epistemology,
• 10:11which is essentially a coordination
• 10:13of the two frames of reference.
• 10:15From the moral perspective,
• 10:17we begin by acknowledging that the
• 10:19doctor patient encounter is by its very
• 10:22nature a negotiated attempt to coordinate,
• 10:24if not combine,
• 10:26different frames of reference.
• 10:28Treating disease.
• 10:29Medical science applied to biological
• 10:31dysfunction does not necessarily coincide
• 10:34with effectively dealing with illness,
• 10:37the patient's psychological and
• 10:39social experience of the disease.
• 10:42Thus,
• 10:42the recurrent ethical question
• 10:44plaguing A reductionist,
• 10:46positivistic clinical science is
• 10:48to what extent the mechanistic,
• 10:50dehumanizing experience of becoming
• 10:52a medical object of scrutiny
• 10:55and therapy can be mitigated
• 10:57by counter balancing factors.
• 11:02They're an ether of values
• 11:04that envelops healthcare.
• 11:05All values governing care,
• 11:08both epistemological and ethical,
• 11:10are in flux and configured
• 11:12by each individual case.
• 11:15In medicine, this view is overwhelmingly
• 11:18self-evident and it hardly needs
• 11:20recitation for the socially based policy
• 11:23decisions of healthcare administrators.
• 11:25To the attention paid to
• 11:27the individual patient,
• 11:28the care delivered is allocated by
• 11:31a distillation of value choices.
• 11:34Medicine is embedded in a value system,
• 11:37and patients are subject to complex
• 11:40moral choices, whether declared or not.
• 11:44The very structure of corporate medicine
• 11:47determines the rationing of healthcare.
• 11:50It determines the prioritization
• 11:53of health dollars,
• 11:54it determines who gets treated and how,
• 11:58and it is fundamentally organized
• 12:01by a priority of values.
• 12:04In some instances,
• 12:05American medicine suffers irredeemably,
• 12:08I would argue from the corporation
• 12:11and and a commodification of
• 12:14medicine and as physicians,
• 12:16I've advocated and I won't do it today,
• 12:21but it's implicit in what I'm
• 12:23saying is that doctors have to
• 12:25be advocates for their patients.
• 12:27They have to be,
• 12:28as it were,
• 12:35supporting their patients
• 12:36in ways which can be.
• 12:44I'm having a senior moment and the
• 12:47senior moment is because the issue
• 12:48is so complex and I'm trying to
• 12:51summarize it in a way that makes sense.
• 12:54And the sense is simply that physicians
• 12:58must recognize their larger moral
• 13:01duty to their patient and subordinate
• 13:04their corporate responsibilities.
• 13:06That's putting it in the nutshell.
• 13:09Clinical care facts are only the
• 13:12beginning of the decision tree
• 13:14of options exercise or forsaken.
• 13:16What is the status of an objective
• 13:18fact in the clinical setting?
• 13:20First and foremost,
• 13:21all clinical facts are contextualized
• 13:24at several levels.
• 13:26From the strictly biological perspective,
• 13:28a concede in itself organic
• 13:31dysfunction is witnessed in a complex
• 13:33array of other integrated elements.
• 13:36No fact resides alone,
• 13:37for the array of facts must be
• 13:40regarded within the coordinated
• 13:42functions of the whole person.
• 13:44Considering the incompleteness
• 13:46of our scientific theory,
• 13:48the social construction of much of it,
• 13:50and the intimate relation of psychological
• 13:52and social factors in defining disease,
• 13:55the model of clinical medicine based on
• 13:58impersonal facts is not only incomplete,
• 14:01it is distorting the C word.
• 14:06From this point of view,
• 14:07each case must be constructed from a
• 14:10complex intermingling of psychological,
• 14:13cultural,
• 14:14social and physiological elements.
• 14:17Such construction tilts more heavily
• 14:19in One Direction or another,
• 14:21depending on the peculiarities
• 14:23of the individual affliction,
• 14:25the social context of illness,
• 14:27and the clinical options available.
• 14:29Construction here is being used
• 14:32deliberately because the narratives
• 14:34that presents the illness and the
• 14:36consequent disease designation
• 14:38and care exhibits plasticity.
• 14:40This is the art of the clinician.
• 14:44This idea was born in the mid 1940s.
• 14:47Charles Kangleham was a French physician
• 14:50and he wrote a Seminole text called
• 14:53The Normal and the Pathological.
• 14:55It was translated in 1966.
• 14:57It was written 20 years before
• 15:00that Kangleham,
• 15:01in observing that there's no fact which
• 15:04is normal or pathological in itself,
• 15:07shows the ever changing shifts of the
• 15:09normal and the pathological as constructs.
• 15:12He was concerned not only with
• 15:15distributive numeric scientific context
• 15:17in which the pathological is defined,
• 15:19but also the context of personal
• 15:22experience of illness as determined
• 15:24by the social mores of suffering and
• 15:26the very definition of dysfunction.
• 15:29In brief,
• 15:30illness determined by several
• 15:32misaligned factors was described
• 15:34as construction of these various
• 15:36elements and their realignment.
• 15:38The therapeutic process becomes
• 15:40a reconstruction.
• 15:46Disease, then, is defined within
• 15:48a complex of epistemological,
• 15:49social, and metaphysical claims
• 15:51that differed between cultures,
• 15:53And illness manifests amongst the
• 15:56given cultures individuals with
• 15:58variables difficult to predict
• 16:00or quantify with any accuracy.
• 16:03This means simply that while disease has
• 16:06certain physiological characteristics,
• 16:07with contemporary observations
• 16:09and supporting theories,
• 16:11other systems of understanding may
• 16:13determine a patient's experience of
• 16:15illness and even the effectiveness of
• 16:18therapy. Indeed, the very mythography,
• 16:20the organization of of how we categorize
• 16:23disease within biomedicine itself varies
• 16:26within Western science societies.
• 16:29In France delivers the culprit,
• 16:31in Germany it's the Poland,
• 16:33and in America, well,
• 16:34you can take your pick.
• 16:36And when we regard the controversies
• 16:39within orthodox allopathic practice,
• 16:41we clearly see that interpretation
• 16:43is basic to the clinical arts.
• 16:47Medicine is hermeneutics,
• 16:48medicine as interpretation.
• 16:50Clinical medicine,
• 16:51in its myriad dimensions functions
• 16:54as an interpretive discipline.
• 16:56It is much as all clinical facts must be
• 16:59interpreted from several points of view.
• 17:01First,
• 17:02in terms of clinical science alone,
• 17:04a finding must be understood within
• 17:07the encompassing context of one
• 17:09or more physiological systems,
• 17:11as well as the general condition
• 17:12of the patient.
• 17:13Taken as a whole,
• 17:14how often have we heard that the
• 17:16specialist taking over a case doesn't
• 17:19recognize everything else that's going on?
• 17:21And how critical it is to have a
• 17:24hospitalist who has a comprehensive
• 17:26view of the patient?
• 17:27The interpretive process may be
• 17:29reduced to algorithms and formulas,
• 17:31but more often the clinical evaluation
• 17:34requires application of general heuristics.
• 17:37Interpretive formulae rather
• 17:39than any prescribed strategy.
• 17:43Judgement requires the application of some
• 17:45general finding to a particular case,
• 17:47a deduction that may not be easily achieved.
• 17:51Perhaps more frequently,
• 17:52the data is simply not available or
• 17:56the diagnosis remains problematic.
• 17:58Once clinical definition's been reached,
• 18:01it must be subjected to interpretive
• 18:03decisions that include various
• 18:05psychosocial factors,
• 18:07local concerns of healthcare,
• 18:08and a host of other determinants
• 18:11beyond the bedside.
• 18:12In short,
• 18:13clinical facts must be contextualized
• 18:15at several levels of analysis
• 18:18and integrated within various
• 18:20frames of reference.
• 18:21At each stage,
• 18:22an assortment of values vie for
• 18:24dominance in prescribing the course
• 18:26of action for an individual patient.
• 18:29Now,
• 18:29I hope you appreciate that what
• 18:31I'm doing here is I'm slipping
• 18:33the epistemological confidence
• 18:35of our laboratory data.
• 18:36The objective criteria we have
• 18:39for disease with recognizing any
• 18:41patient one is using the values of
• 18:45understanding what that patient's
• 18:47optimal outcome might be and
• 18:50contextualize that in terms of age,
• 18:53other disease factors,
• 18:55social supports and the the various
• 18:59other elements that go into the care.
• 19:02Objectivity alone hardly suffices.
• 19:04Formulate rules seldom fulfill their billing,
• 19:08prescribed regulations failed
• 19:10to mediate humane healthcare.
• 19:12So given the multi dimensional
• 19:14nature of medical reasoning,
• 19:15how might we characterize
• 19:18the clinicians hermeneutics,
• 19:19the clinicians interpretive faculty?
• 19:21And the point here is that it's
• 19:25very very difficult to tease apart
• 19:28the so-called epistemology all
• 19:30by itself without its supporting
• 19:32value system that organizes,
• 19:34regulates it and finally distills decisions.
• 19:40Object divorced from personal value
• 19:43is embraced precisely because such
• 19:45knowledge is regarded as making
• 19:47facts universal and it is the
• 19:50universality of scientific knowledge
• 19:52that affords its authority.
• 19:54And who could quarrel with the
• 19:55triumphs of such an approach,
• 19:56which has served medicine so well?
• 19:58And I'm certainly not arguing the contrary.
• 20:02What I am arguing is that the
• 20:04claim is in the care of the ill.
• 20:07The limitations of biomedical objectivity
• 20:09require a recasting of medicine's
• 20:12priorities for the view from nowhere.
• 20:14The absent perspective is not
• 20:17only inappropriate for medicine,
• 20:19but it's unobtainable.
• 20:21Medicine's epistemology is thoroughly
• 20:23embedded in non positivist values.
• 20:26Positivism is radical objectivity
• 20:29and these constitute A moral
• 20:32structure that ultimately orders
• 20:34and defines clinical science.
• 20:37So let's break out of an archaic mindset.
• 20:40We must formulate an approach to
• 20:43medicine which still incorporates
• 20:45scientific ideals and yes,
• 20:46distances itself from an
• 20:49inapplicable positive As ideal,
• 20:51clinical medicine is scientific,
• 20:53but it possesses a character
• 20:56that distinguishes itself from
• 20:58physics or chemistry.
• 21:00The key differentiating factors need to
• 21:03balance choices within the particular
• 21:05context of an individual patient.
• 21:08While general scientific laws apply,
• 21:11the individuality of disease and
• 21:13the constraints of the personal
• 21:15setting undermine the application
• 21:16of a positive as ideal that
• 21:19operates only within the universal.
• 21:27Finally, the ordinary the circumstantial
• 21:31demands and needs of an individual or
• 21:34patient require diverse value judgments
• 21:36to interpret and apply clinical data.
• 21:39Indeed, objective assessment takes off
• 21:41particular meaning in the context of the
• 21:44social and existential status of the patient,
• 21:47and thereby a complex calculus of
• 21:50values determines therapeutic goals.
• 21:52To synthesize diverse elements,
• 21:54which must be integrated for clinical
• 21:57care depends on an overarching
• 21:59understanding of the patient,
• 22:01and that coordinated product is achieved
• 22:04by a complex synthesis of facts
• 22:07and judgments from several domains.
• 22:09This process relies on clinical facts
• 22:11as well as on personal judgments
• 22:14and subjective assessments.
• 22:16In an ongoing negotiation between
• 22:18the patient and doctor,
• 22:24the ordinary setting requires healthcare
• 22:26providers to identify and address the
• 22:29judgments that govern the complex
• 22:30synthesis of these various elements
• 22:32and account for the interplay of
• 22:34values that govern this practice.
• 22:37The constructive, excuse me,
• 22:40the constructivism of medicine.
• 22:42It recognizes the fundamental
• 22:44difference between the scientists
• 22:45search for the real and the physicians
• 22:48pursuit of the therapeutic.
• 22:49While general scientific laws apply,
• 22:52the individuality of disease and
• 22:54constraints in the personal setting
• 22:57undermine the application of a
• 23:00positiveness ideal that operates
• 23:02only within the universal.
• 23:04So let's take medical ethics seriously.
• 23:06With this huge broad horizon
• 23:09that I've that I've sketched,
• 23:11the day-to-day practice of
• 23:13medicine enacts the precept that
• 23:15medicine is fundamentally ethical.
• 23:17To strengthen that understanding,
• 23:20healthcare providers must remind
• 23:22themselves that clinical science
• 23:24and its applications are tools for
• 23:26fulfilling their fundamental and defining
• 23:29moral responsibilities to patients.
• 23:31Clinical science and service
• 23:33of patients is value laden.
• 23:36Clinical decision making is a dialectical
• 23:39process of professional recommendation
• 23:42and patient understanding and choice.
• 23:44Respect for patient autonomy is more than
• 23:47informed consent and demands from us.
• 23:49An ever present effort to preserve patient
• 23:52dignity and the economies of practice
• 23:55must balance efficiency with efficacy,
• 23:58which in turn depend on some measure
• 24:00of empathetic, personalized care.
• 24:03Case number two.
• 24:05We're coming close to the end.
• 24:08The conceit of informed consent.
• 24:11Doctor John misses Valise, died on Monday.
• 24:15Doctor Ruth Who was she?
• 24:18A Haitian woman with four kids,
• 24:193:00 to 12:00.
• 24:20I enrolled her in the protocol
• 24:22and she didn't make it.
• 24:24Sorry about the decision. I don't know.
• 24:27She knew her chances. Give me a break.
• 24:29Do you really think she understood
• 24:31what the risks were?
• 24:32What the complications might be?
• 24:34The survival curves, Doctor John.
• 24:37She made an informed decision.
• 24:39Nothing was held back.
• 24:41Yet.
• 24:42Real
• 24:44ethical concerns.
• 24:45So this is the radical.
• 24:48When I say it,
• 24:49I smile because it's hardly radical.
• 24:52The radical proposal Let's
• 24:55take medical ethics seriously.
• 24:57Let's put a section in the medical
• 24:59chart addressing medical ethics.
• 25:01Let's go on rounds and identify what a
• 25:04moral issue might be in any given patient.
• 25:07Let's make sure that what is taught in the
• 25:11lecture hall is enacted at the bedside.
• 25:14Lasting moral lessons are learned at
• 25:16the bedside, not in the classroom.
• 25:18The tools for practicing and ethical
• 25:20medicine may be obtained in lecture.
• 25:22The enactment must occur with the patient.
• 25:25Empirical research is amply show the
• 25:28students are more deeply influenced
• 25:29by the behavior of role models than by
• 25:32the material presented in coursework.
• 25:34In short,
• 25:35the moral encounter occurs in the
• 25:37intimacy of the doctor patient relationship.
• 25:40Contemporary practice requires A
• 25:42directive and a means to enhance
• 25:45that relationship.
• 25:47Both remedial and proactive responses
• 25:49are required to strengthen the weakened
• 25:51personal bond between doctor and patient.
• 25:54So characteristic of modern medicine.
• 25:56I contend that placing medical ethics
• 25:59firmly into the heart of the medical chart,
• 26:02you know,
• 26:03the EKGI thought that was cute.
• 26:05As a constituent,
• 26:06part of the medical evaluation
• 26:07is a mechanism that represents
• 26:09an important step in the process.
• 26:12The routine articulation of ethical
• 26:14concerns may provide the most direct
• 26:16way of pulling medical ethics from the
• 26:19periphery of medical landscape into
• 26:21its very center, where it belongs.
• 26:23The section devoted to ethical concerns
• 26:26reminds caregivers of the values and
• 26:29premises of the core patient care.
• 26:33Teaching ethical principles,
• 26:35moral theories, medical jurisprudence,
• 26:36and the other components of
• 26:39medical ethics may be seen as
• 26:41the tools of this enterprise.
• 26:42A robust curriculum is required,
• 26:45but let's put the horse before the cart.
• 26:47Make identifying and addressing
• 26:49ethical concerns a part of the routine
• 26:52ethical clinical evaluation through
• 26:54an ethics workshop the work up.
• 26:57Just as the student learns to use the
• 27:00stethoscope to escalate the heart,
• 27:02he or she should learn the basics
• 27:04of moral reasoning and apply
• 27:06them to the clinical scenario.
• 27:09So there have been a number of suggestions
• 27:13as to how an ethics work up should look.
• 27:16This is one of the shortest ones.
• 27:18It was developed by Al Johnson a
• 27:22long time ago and he divides it
• 27:26into four fundamental questions,
• 27:28define the clinical problems,
• 27:29goals of treatment, etcetera and
• 27:31delineate And this is the key point.
• 27:34Obviously all the other
• 27:36things are self-evident,
• 27:37delineate the cost benefit ratios of care.
• 27:41These are seldom articulated in a formal way.
• 27:45It's sort of implicitly understood,
• 27:49but if one looks truly at cost benefit
• 27:52ratios in a critical eye and informs
• 27:55the patient very clearly what those are,
• 27:58it adds an entire dimension to
• 28:00the notion of patient autonomy
• 28:02and protecting patient dignity.
• 28:04Patient preferences maintain the
• 28:08patient's right to choose by
• 28:10determining preferences for care,
• 28:12assessing the competence of the patient.
• 28:14That's italicized with good reason.
• 28:17It takes a lot of work to establish
• 28:19how much a patient understands.
• 28:22I don't know if how many of you've
• 28:24been patients yourself,
• 28:25but I know that when I have been a patient,
• 28:27my reasoning is clouded,
• 28:30my prejudice is self-evident and my
• 28:34dependence on guidance is clear.
• 28:37Ability to cooperate with medical
• 28:39treatment if incompetent.
• 28:41Is there a health care proxy
• 28:43and advanced directives?
• 28:43Now of course this is formulaic,
• 28:46but the point is how seriously
• 28:48does one pursue the question as
• 28:50to what a patient understands?
• 28:51Is case number two, sought to illustrate.
• 28:56We prefer to believe that informed
• 29:01consent is indeed fulfilling its mandate.
• 29:04I have been a physician for too long
• 29:07and know how we often skip the details,
• 29:14quality of life,
• 29:16specify the prospects with or
• 29:19without treatment of a patient's
• 29:20recovery to find the physical,
• 29:22mental and social consequences of
• 29:25treatment success and of course explore
• 29:27the care in the event of treatment failure.
• 29:31We don't spend enough time.
• 29:32In my humble opinion,
• 29:34some services spend more time than
• 29:38others and it has to do with the
• 29:40ethos which is prevalent in that
• 29:43particular top down hierarchy.
• 29:47Finally, according to Johnson,
• 29:49it's contextual features clarify
• 29:51family or provider issues that
• 29:53may influence clinical decisions
• 29:55including allocation of resources,
• 29:57financial restraints,
• 29:58religious or cultural factors.
• 30:01Describe possible legal
• 30:02implications of treatment.
• 30:04Clinical researcher treating establish
• 30:06the scope of confidentiality.
• 30:09These are all issues which
• 30:10everyone is taught to consider
• 30:12and to specify if possible.
• 30:15I'm arguing that they have to be
• 30:17taken seriously and to do that
• 30:19they have to be articulated in
• 30:20the chart in a specific fashion.
• 30:24Now Thomas Saw even earlier suggested
• 30:28a six step ethics evaluation and
• 30:32I'll go through these quickly
• 30:34because they're basically a
• 30:35variation of what I just described.
• 30:37Identify the significant
• 30:38human factors of the case.
• 30:40And you know, we go through this
• 30:42in a in a very perfunctory way,
• 30:44Demographics, does he smoke?
• 30:46Drink, the psychiatric history,
• 30:47criminal record,
• 30:48etcetera, etcetera.
• 30:49But religious and political
• 30:51attitudes turn out to be very
• 30:54relevant to health care decisions.
• 30:56They need to be articulated.
• 30:58Step 2, explicitly define related
• 31:01value factors present for the patient,
• 31:04health care professional and other
• 31:06relevant persons involved in the case.
• 31:08And this has to do with trust,
• 31:10primarily.
• 31:11In fact.
• 31:12Does the patient understand
• 31:14what in fact is going on?
• 31:17And does the patient in fact trust
• 31:19that his or her care is prominently
• 31:22being considered in the largest
• 31:25social and psychological context?
• 31:27The delineate all ethical choices
• 31:29and major value conflicts,
• 31:31set priorities and values
• 31:33which are in conflict,
• 31:34identify the criteria by which
• 31:36a decision is made considering
• 31:38the underlying ethical norms,
• 31:40and finally critique the assumptions
• 31:42underlying the decision made
• 31:44in Step 5 and presents a final
• 31:46opinion and strategy for dealing
• 31:48with the moral issues identified.
• 31:50Now this is quite clear when there's
• 31:53a significant moral issue at hand,
• 31:58for instance pulling the plug on the
• 32:01patient with those on a ventilator
• 32:03or using an experimental medication
• 32:06or therapeutic intervention.
• 32:09But the argument that I'm trying to
• 32:12articulate with this with this schema,
• 32:15is that it takes a lot more
• 32:18work and consideration to do it
• 32:20with the ordinary patient.
• 32:21But the argument is that the moral
• 32:24concerns are the same whether in the
• 32:26dramatic setting or in the ordinary one.
• 32:28So the conclusions,
• 32:30as long as medical ethicists are perceived
• 32:33as practicing another subspecialty,
• 32:36medical ethics itself were
• 32:38regarded as somebody else's
• 32:40expertise and responsibility,
• 32:43and consequently the discipline and its
• 32:46practitioners are easily marginalized
• 32:48until dire circumstance calls for rescue.
• 32:51But if the discussion is raised
• 32:53to the moral plateau deserves the
• 32:56pursuit of an ethical medicine then
• 32:58encompasses not only medical ethics,
• 33:01but also includes a wide constellation
• 33:04of patient centered activities
• 33:06that contribute to humane care.
• 33:08Establishing an ethical concerns
• 33:10section in the medical records makes
• 33:13ethics the business and responsibility
• 33:15of every healthcare provider.
• 33:20More than judicial directives,
• 33:21risk management, and academic debate,
• 33:23morality of medicine defines
• 33:25the very foundation of practice,
• 33:28the moral substrate upon
• 33:30which clinical care is built.
• 33:32Most choices and actions,
• 33:34even the most mundane,
• 33:35enact some underlying value system.
• 33:38But such moral self consciousness is not
• 33:41ordinarily part of clinical practice.
• 33:44To assure the medical ethics
• 33:46flourishes as an integral component
• 33:48of every physician's training,
• 33:50conduct, and practice,
• 33:52the profession should renew efforts
• 33:54to embed moral self consciousness
• 33:57as an explicit exercise.
• 33:59Establish and Ethical Concerns
• 34:01section in the Medical record to
• 34:04enhance awareness of medical ethics
• 34:06as belonging to the core of routine
• 34:08practice is my take home message,
• 34:11and for those of you interested,
• 34:13there's all the literature
• 34:14relevant to that discussion.
• 34:16Thank you for your attention and I hope
• 34:19it's you understood what I tried to say.
• 34:30Thank you so much, Fred.
• 34:31That was that was fascinating and and we
• 34:34can get down to it in a couple minutes.
• 34:37So we have a couple things
• 34:38for those in the in the room.
• 34:40If you would Please wait
• 34:41and either Karen or Amir,
• 34:42someone's going to bring you the microphone.
• 34:44I'll call on it if you have a question,
• 34:46wait for the mic if you would,
• 34:47so that the folks online can
• 34:49also hear what you're saying.
• 34:50I think I'm going to have a
• 34:52seat next to my friend Fred here
• 34:54as we go through this stuff.
• 34:55We'll talk to the next half hour or so
• 34:58we'll go through some of this.
• 35:00I I notice I mean we have an
• 35:02interesting collection of folks
• 35:03in the room from people who
• 35:04have long standing ethicists,
• 35:06long standing clinicians
• 35:07and students as well.
• 35:09And so I'm looking forward to
• 35:11to contributions from everybody
• 35:14and at some point so if if if
• 35:16again can you get the right.
• 35:18So there's no rush for that right.
• 35:19Yet I I'll, I'll take the take
• 35:23the liberty of asking the first
• 35:25question if I could please.
• 35:27It seems as we got to the end in
• 35:31particular when you talked about
• 35:32Johnson and Siegler's the four box
• 35:34method of the you know the four basic
• 35:36components which many of us are used
• 35:39to seeing of basically the components
• 35:40of an ethics console that this is how
• 35:42we this is how we do an ethics console.
• 35:45And it is as if we're asking basically
• 35:47every time a patient's in the
• 35:49hospital that someone should do this,
• 35:51just like someone should take a
• 35:53past medical history or should
• 35:55evaluate the different organ
• 35:57systems or have a problem list.
• 35:58This is one of the things that
• 35:59should be on every problem list.
• 36:01Is it basically like an ethics
• 36:03consult for every patient?
• 36:07Yeah.
• 36:09All right. So we're
• 36:10we're done a little early today. No.
• 36:14I made this proposal to my medical school.
• 36:17It was rejected. Full disclosure.
• 36:20The nurses loved it.
• 36:21The physicians hated it because
• 36:23they didn't have enough time.
• 36:24And there were other issues that
• 36:26were raised which we can talk about
• 36:29because there are practical concerns.
• 36:31But the nurses took it so seriously that
• 36:34they constructed A1 page questionnaire
• 36:38that they would do on intake.
• 36:40And in fact,
• 36:41the nurses were the ones who are
• 36:44willing to take on the responsibility
• 36:47of this abbreviated ethics evaluation.
• 36:50And the questions were very in
• 36:53some instances pointed and in other
• 36:55instances were were quite general.
• 36:58But the idea was to establish a protocol.
• 37:01And although I hate the notion of a protocol,
• 37:04but to go over the fundamental issues
• 37:08that face a patient entering a
• 37:11very strange environment who's very
• 37:14confused about why she or he are,
• 37:18is in this predicament and what
• 37:20the possibilities might be.
• 37:21And it's based essentially on what I,
• 37:26what I described there are far more
• 37:29thoughtful descriptions than these.
• 37:31But the reason I put these up,
• 37:33Mark, is because they're so simple.
• 37:37And I think that's that's helpful.
• 37:38So a reminder,
• 37:39we'll we're gonna start in one second.
• 37:40A reminder to the folks who are online,
• 37:42if you would submit your questions for
• 37:44the Q&A portion of the zoom function.
• 37:46Right. And then I'll get to
• 37:47some of that in a minute.
• 37:48In the meantime, let's start up
• 37:50here with Doctor Siegel first.
• 37:55Thank you, Doctor Talker.
• 37:57So I want to share an observation
• 37:58from the front lines in terms I practice in
• 38:01critical care for the
• 38:02most part. And one thing
• 38:04that seems to become more and
• 38:06more prominent over the last few
• 38:08years in the hospital is essentially
• 38:14moving the responsibility for discussing big
• 38:17issues like goals of care over to
• 38:19our palliative care colleagues.
• 38:22They they happen to
• 38:23do it extremely well.
• 38:25I think some of the history behind
• 38:27that dates back to some observations
• 38:30that patients with metastatic cancer
• 38:32are better served if there's a
• 38:34palliative care team caring for
• 38:36them alongside the oncologists,
• 38:38which I I think from a symptom
• 38:40management perspective actually
• 38:41is very persuasive. But
• 38:43but I'm seeing more and more that when big
• 38:47issues are coming up particularly
• 38:49surrounding end of life that
• 38:52there's this reflex to call
• 38:54in the palliative care team to have
• 38:57the end of life discussion even
• 38:59though they are not the primary team.
• 39:01So. So I I part of what worries
• 39:03me is I actually, you know,
• 39:05what you said today fully resonates with me.
• 39:08But I'm not so sure that that's
• 39:09the direction we're going
• 39:10because it seems to me
• 39:11that there's the
• 39:13primary team that's
• 39:13responsible for life
• 39:14saving care and and dealing
• 39:17with some of the science of
• 39:18medicine as you're referring it to.
• 39:20And then and then when somebody
• 39:21has to come and discuss values
• 39:22and goals and what's most important to you
• 39:25and whether you should be resuscitated
• 39:26if you have a cardiac arrest,
• 39:28there's a whole set of
• 39:29specialists now that seem to
• 39:31be responsible for that. So I'm I'm
• 39:33curious whether you're
• 39:34seeing anything similar
• 39:35in Boston and what your
• 39:36thoughts are about that
• 39:39your observations are are
• 39:41coated and and and spot on.
• 39:45I'm deliberately trying to be provocative
• 39:49and the goal here is to make physicians
• 39:53in general a more self-conscious
• 39:56about the moral dimensions of care.
• 40:00We are so easily seduced to be scientific,
• 40:04and that's why I began with Welch and Ulsler.
• 40:07That this is a inner tension within
• 40:10medicine that has been there from the very
• 40:14origin of modern scientific medicine.
• 40:16And we obviously select medical
• 40:20students for their competence to
• 40:23comprehend the science of medicine.
• 40:26And we emphasize it again and again,
• 40:28and from the quote I gave in the beginning,
• 40:31the empathy of medical
• 40:32students is usually very,
• 40:34very high and they are socialized as they go
• 40:37through residency and the empathetic index,
• 40:40the EI drops.
• 40:41And we have quantitative data to demonstrate
• 40:44that that in fact it's the case.
• 40:47And and this proposal is simply to
• 40:51get everyone to realign themselves
• 40:54with their earlier ideals,
• 40:57to recognize from deep resources why
• 41:00they're in medicine and from a practical
• 41:04point of view to go on ethics rounds,
• 41:07for instance, would have an enormous effect,
• 41:10I believe in reigniting the empathy that
• 41:14hopefully all of our students have.
• 41:18And mentorship,
• 41:19of course, is critical.
• 41:22And so the battle has to be fought
• 41:24really at the faculty level and
• 41:26then have some kind of drift down.
• 41:29And I failed in Boston.
• 41:32I have been successful in Chicago
• 41:34in a number of places.
• 41:36But this is moving against
• 41:39a huge cultural tide,
• 41:42and I recognize it as quixotic in a way.
• 41:46Which is not to say I don't
• 41:49believe it's valid,
• 41:50but we need to reignite a moral,
• 41:54moral sensitivity.
• 41:56So but but it doesn't have to be
• 41:58I don't think an an all or none
• 42:00in terms of the success of it.
• 42:01You know, so to say you failed and was.
• 42:03So I would think that for example if we
• 42:05were managing a patient on the medicine
• 42:07service and the patient had poorly
• 42:10controlled diabetes and we were well
• 42:12into the management of this patient.
• 42:15But the intern managing the case
• 42:17or the attending managing the case
• 42:19didn't know or hadn't discovered
• 42:21that the patient had diabetes.
• 42:22We'd say, well, this is clearly,
• 42:24you know, a failure in terms of how
• 42:25we're going to manage this patients,
• 42:27whatever problem he's in for this
• 42:28is something we need to know about.
• 42:30You know, and one could also say if
• 42:32we're in a situation where there's
• 42:34where there are critical issues at
• 42:35stake and the patient is a deeply
• 42:38religious individual and the attending
• 42:39or the intern was unaware of that.
• 42:41I mean, it's just to to somehow
• 42:43acknowledge that these both represent
• 42:45important lapses on our part as positions,
• 42:48one, the contextual features.
• 42:49The other is the fact, if you will,
• 42:51the quote facts of the case,
• 42:53the first of those four boxes.
• 42:54Right.
• 42:54But the other,
• 42:55the contextual features that are
• 42:56hugely important for how these things,
• 42:58particularly life and death matters,
• 43:00get managed.
• 43:00So I mean,
• 43:01I, you know,
• 43:02I wouldn't give up yet on the idea or
• 43:04on the chance of our success.
• 43:05That's why you're here. I'm with you.
• 43:07Someone else had a question back here.
• 43:10This ought to be challenging. Let's see. All
• 43:14right. Can can you hear me?
• 43:17I'm losing my voice a little bit.
• 43:19So thank you for for that that talk.
• 43:21That also really resonated with me.
• 43:23And excuse me,
• 43:24I do agree by the for the record,
• 43:26I tested COVID Negative.
• 43:28I do agree that that ethics should not
• 43:32be seen as this sort of extraordinary,
• 43:34like exceptional thing that we only need to
• 43:36cling to when we're with a difficult case.
• 43:39And I actually like I just finished a
• 43:41week on service and I I try to emphasize
• 43:42some of the salient ethical points of
• 43:44most of the cases that we round on.
• 43:46But you know,
• 43:47my one of my concerns though is you know,
• 43:50do you think do you think having it
• 43:53in the chart or the medical record is
• 43:54is the most effective way to do that?
• 43:56Only because already the the
• 43:58documentation burden seem very
• 43:59high and one of the main drivers of
• 44:02burnout seems to be like more screen
• 44:04time than FaceTime with patients.
• 44:06And is there another more human
• 44:07way to do that?
• 44:08Like you just said ethics rounds.
• 44:10What if ethics rounds is a part of
• 44:12consult rounds so when you're consulting
• 44:13on a patient you're talking about
• 44:15then rounds you're OK what are the
• 44:17ethical issues and maybe saying like
• 44:19the documentation isn't as important.
• 44:21I'm I'm just throwing this out there
• 44:23I just I'm I'm interested in how you
• 44:25reconcile with what I absolutely agree
• 44:27is a a a critical component that should
• 44:29be viewed as something that should
• 44:31be constitutively active rather than
• 44:33only activated when there's a problem.
• 44:35We should be more proactive than
• 44:37reactive when it comes to ethics,
• 44:38with the very real pressures of
• 44:40time pressure and and documentation
• 44:42burnout and and all of the factors
• 44:45that play that actually might
• 44:47might paradoxically compromise
• 44:48physician patient relationships.
• 44:49Further,
• 44:50if there is an increasing
• 44:52burden of documentation,
• 44:54yeah, this proposal is clearly subversive.
• 44:58It is moving against the tide of of
• 45:03being efficient and effective with
• 45:07enormous demands for documentation
• 45:10and and all the rest of it.
• 45:15I I personally think that if we had
• 45:20ethical rounds just once a week
• 45:24as part of a normal curriculum,
• 45:27clinical curriculum in all the disciplines,
• 45:30medicine, Pediatrics,
• 45:31especially psychiatry I suspect
• 45:33would be also a very fruitful
• 45:38place to have such discussions.
• 45:40Surgical services maybe less so.
• 45:43It may be the most needed of and it's
• 45:50it's something that would have to be
• 45:52implemented in the very incremental fashion.
• 45:54This isn't something that could just be done.
• 45:57The nurses in Boston,
• 45:58at Boston Medical Center were willing
• 46:01to do this intake and identify issues
• 46:03which would then be taken up by the team,
• 46:06which I think would also be an incremental
• 46:08way to start something like this.
• 46:11The idea is simply to try to make
• 46:13moral reasoning a more crucial
• 46:17component of clinical care.
• 46:19And the mantra that Mark and I were
• 46:22talking about, the Georgetown mantra,
• 46:23you know, beneficence, autonomy,
• 46:25etcetera, etcetera, it's not enough.
• 46:28I mean, it's a formula. It's.
• 46:30And if you know the formula,
• 46:33it's like F equals MA.
• 46:35It's it has this restrictive utility but
• 46:38that's not that's not where we live.
• 46:43On the upside to, and I know
• 46:45that you know this stuff, Fred,
• 46:46and I think many of you know it as well,
• 46:49having travelled around and
• 46:50travelling around to to medical
• 46:51centers all over the country,
• 46:53the notion of someone from the Ethics
• 46:55Committee, again, it's too bad.
• 46:56It gets relegated to those who are
• 46:58supposed to be specialist in ethics.
• 46:59But having someone from the Ethics
• 47:01Committee embedded on rounds in the ICU,
• 47:03for example,
• 47:05is not a rare occurrence and it's
• 47:06something that you're I think you're
• 47:08going to see actually here going forward.
• 47:09We've had
• 47:12person power, manpower,
• 47:13what's what's the right word to use.
• 47:15I mean issues in terms of trying to
• 47:17get people who are have the both
• 47:19the time and expertise to do it.
• 47:21But this is something that's that
• 47:22you're going to be seeing here,
• 47:24certainly not on a level that
• 47:25perhaps we might wish we could do.
• 47:27But you know,
• 47:28we we need to start somewhere and to
• 47:30and to have to have that presence there.
• 47:33I have a question here from a
• 47:34student for you, Doctor Tom.
• 47:35Thank you Doctor Tom for this,
• 47:37for the work that you do.
• 47:39I completely agree that ethics rounds need
• 47:41to be a key part of medical education.
• 47:44Do you recommend that this
• 47:45happens in the early years of
• 47:47medical education or continually
• 47:48through the physician's career?
• 47:50This is from an MPH bioethics student.
• 47:54Love you.
• 47:58It should be from the very beginning
• 48:01and it should continue throughout.
• 48:03I don't see why it would stop.
• 48:06It needs to be reinforced and I'd love that.
• 48:11Just getting back to Mark's point
• 48:14about having an ethicist in the ICU,
• 48:16that's really a natural
• 48:18nest for this to occur,
• 48:20and from there it might spread.
• 48:25There we go
• 48:26back there. If we could please you
• 48:30have a question also.
• 48:31All right. So then then the
• 48:32gentleman right here afterwards.
• 48:33Thank you for for your talk as a first.
• 48:38There we go as a first weak link in
• 48:39this whole chain. Can you hear me now?
• 48:41OK, perfect.
• 48:42As the first year medical student,
• 48:44I'm just wondering what are
• 48:46things that we can do practically
• 48:49right because there there there
• 48:51are medical decisions that don't
• 48:54seem as value based,
• 48:57it more scientific based, but
• 48:59there's a lot of grade and I would argue most
• 49:02of it's grade. So what are things
• 49:04that we can do as students
• 49:05that don't necessarily require
• 49:07curriculum LED initiatives to keep
• 49:11us thinking about medical ethics
• 49:12as we think as future clinicians
• 49:15keep asking naive questions,
• 49:20challenge what's going on?
• 49:22You have a fresh set of eyes.
• 49:26You're not expected to be toeing the line.
• 49:30You have the opportunity to reframe the
• 49:34issues and just by asking questions,
• 49:38hopefully provocative ones,
• 49:39you get people to think about it.
• 49:45You know I've I've talked
• 49:47and and you're the cure by
• 49:49the way you guys in the back there
• 49:51and and others that you're the cure.
• 49:53I have written about and talked about
• 49:55what I've called moral arthritis,
• 49:56which basically refers to those of
• 49:58us who were more senior within the
• 50:00profession getting a little bit stiff,
• 50:02having a little bit trouble with flexibility,
• 50:05perhaps getting set in our ways and
• 50:07wanting to do things because that's the
• 50:08way we learned it back in 1985 which might
• 50:11not necessarily be the best way to go.
• 50:13And I and I have long maintained that
• 50:16the cure for moral arthritis is students,
• 50:19is working with trainees,
• 50:20is working with them with those
• 50:22fresh sets of eyes.
• 50:22Say, I know this is how you've
• 50:24done it for the past 40 years,
• 50:25but explain to me why you do it
• 50:27that way instead of this way.
• 50:28And of course, never accept the explanation,
• 50:30'cause that's how I was trained.
• 50:32Or because that's how we've always done it,
• 50:33'cause that's just another way of saying I
• 50:34don't know what the hell I'm talking about.
• 50:36You know,
• 50:36we we've got to do better than
• 50:37'cause that's how I was trained or
• 50:39that's how I've always done it.
• 50:39So yeah,
• 50:40I mean you know you got to be
• 50:42respectful to the old guys but you got
• 50:45a challenge and that's what hopefully
• 50:47gets us a little bit less stiff guess
• 50:49it's a little bit more flexible.
• 50:52This gentleman here has a question.
• 50:53Please.
• 50:55Yes. So I I think I'm,
• 50:57I might be the only nurse
• 50:59in the room but as you know one
• 51:01of the minority in the room.
• 51:03I I'm kind
• 51:04of baffled on why this needs to be taught.
• 51:08I, I we're in medicine.
• 51:10It's it's it's it's a profession
• 51:13that you know involves compassion
• 51:16and you know in nursing I I'm
• 51:17right there with your nurses,
• 51:19especially nurses of my generation of
• 51:21been doing it for you know, 40 years
• 51:28just, you know, don't get
• 51:29it just don't get it. Why?
• 51:31Why this is so difficult?
• 51:34Well, you're socialized quite differently.
• 51:38You're socialized around the
• 51:41patient and I think physicians are
• 51:46socialized in a more complex arena
• 51:50where the patient is only part of it.
• 51:53When I say that I'm,
• 51:54I'm referring to the patient as a person.
• 51:57I'm referring to the patients in terms
• 52:01of his or her biology, pathology.
• 52:04And I really do believe that the
• 52:08sociological setting of being a nurse
• 52:11is different than being a physician.
• 52:14And there
• 52:18was an interesting comment made by
• 52:20somebody and I forget who is that with
• 52:23the rise of women medical students
• 52:26which occurred John Leventhal,
• 52:28Meyer classmates in our class was
• 52:3110% right John and now it's over 50%.
• 52:34And then with the with the shift in
• 52:39that demographic, it saved medicine.
• 52:43I I don't, I didn't say it,
• 52:44someone else said it.
• 52:45I have to agree with it that there is,
• 52:48you know, some very deep
• 52:50socialization which occurs which
• 52:54seems to have some cultural basis.
• 52:58And I think that the the
• 52:59effects of that are being seen.
• 53:03That's a gross generalization,
• 53:04A bias for sure. But that's my bias
• 53:07and I think there's there's some
• 53:09evidence to hold it to be true.
• 53:13Fred, when you talk about the
• 53:16the the different socialization,
• 53:18a different framework perhaps between
• 53:19physicians and nurses through that.
• 53:21So I have I don't know if she
• 53:22might even be watching this.
• 53:24If she is I have to give it.
• 53:24But I have a daughter who's a nurse and
• 53:26and she tells me a story which I'll which
• 53:30is actually for me a physiologic story.
• 53:33But it occurs to me it's the it's
• 53:34the there's an exact analogy
• 53:35to what you're talking about,
• 53:37the story of speaking with a a resident
• 53:40and who she's trying to explain to the
• 53:43patient's in respiratory distress.
• 53:45And they're standing
• 53:45outside the patient room.
• 53:47And the resident is saying, well,
• 53:48just how much distress does a
• 53:49patient appear to be in this?
• 53:50She's trying to say this patient
• 53:52rest restress and they're like 10
• 53:53feet from the patient, you know.
• 53:54And so I actually told her,
• 53:56I said, listen,
• 53:56I've got these little toy binoculars
• 53:57from when you were a kid.
• 53:58Take them and the next time a
• 54:00resident asks you that,
• 54:01hand them the binoculars and say,
• 54:02we'll take a look.
• 54:03See what you think you know because
• 54:05because there seems to be this
• 54:07incredible reluctance to actually
• 54:08physically get closer to look at
• 54:09how the chest is moving yourself.
• 54:12You know,
• 54:13and I it strikes me that from
• 54:14what you're saying,
• 54:15there may be a little bit of an
• 54:17analogy beyond just sub constant
• 54:18retractions that there might
• 54:20be an analogy in terms of
• 54:24that socialization engaging
• 54:25in that aspect of care,
• 54:27engaging in that aspect of care.
• 54:28And that that the comfort zone for
• 54:31many physicians is actually talking
• 54:33about the Eosinophil count as opposed
• 54:35to how frightened the patient is.
• 54:38Let me riff on that theme for a minute.
• 54:40When I was an intern, IA patient came in,
• 54:44a young woman with severe asthma.
• 54:47And it so happened that I had done some
• 54:50basic research on the biochemistry
• 54:53of asthma as a medical student.
• 54:55And I knew a lot.
• 54:56I mean, I really did know a lot
• 55:00and I did everything according to
• 55:03the book and the patient wasn't
• 55:06responding and I was very frustrated
• 55:08and then I got angry and then I
• 55:11called the anesthesiologist on call.
• 55:12I said this patient needs to be
• 55:15innovative and he went in there.
• 55:16He was the guy about my age also
• 55:19and comparable and training.
• 55:21And he sat with the patient for two hours,
• 55:24and the asthma attack broke.
• 55:28And
• 55:31he he came out of it, and he said,
• 55:32well, I talked her out of it,
• 55:34****** her out of it.
• 55:36Now there's several interpretations of that.
• 55:38One is the medication's finally took effect.
• 55:42But I knew that his patience
• 55:46and his his care of the patient
• 55:52was the salutary difference,
• 55:54and it was fundamentally,
• 55:56and in the end more effective than the
• 56:00armamentarium that I had concocted.
• 56:03And with that lesson,
• 56:08that lesson in in hubris has stayed
• 56:13with me for a long, long time.
• 56:16And Full disclosure,
• 56:20I became a physician because my mother
• 56:23was a chronic asthmatic and from a
• 56:26very young age I was convinced she
• 56:29would stop breathing at some point.
• 56:31And that's why I did basic research
• 56:33and asthma and all the rest of it,
• 56:35and all that pent up frustration,
• 56:38anger, confusion,
• 56:39fear that focused on this poor girl
• 56:43who was having the asthma attack.
• 56:45And I recognized that I really
• 56:48didn't want to deal with it,
• 56:50didn't want to deal with her as a patient,
• 56:52as a person.
• 56:53I just wanted to deal with the asthma,
• 56:56deal with the biochemistry,
• 56:57take care of everything that
• 56:59needed to be cared for.
• 57:01According to the textbook,
• 57:02it was the anesthesiologist
• 57:04who talked her out of it.
• 57:06And the point here of that vignette
• 57:10is this extraordinary universe of
• 57:13emotion and values and experience
• 57:16that you bring to a patient.
• 57:17Now,
• 57:18this particular case was highly charged
• 57:20for all the reasons I've stated,
• 57:23and I use it as a Full disclosure
• 57:25because it illustrates so
• 57:26clearly what I've been talking
• 57:28to you about for the past hour.
• 57:33Now, most cases are not so fraud,
• 57:35but that one was and it illustrates
• 57:38the point I'm trying to make.
• 57:40Thank you. Yes, please.
• 57:43It's lady right here.
• 57:48I'm a nurse too for about 40 years,
• 57:51So I know. But I appreciate what you just
• 57:55said about why you became a physician.
• 57:59I think I did a seminar up at Dartmouth
• 58:03College with 4th year medical students about
• 58:0720 years ago with a physician and all.
• 58:12Fourth year medical students had to
• 58:15take this seminar and it was kind
• 58:18of a group therapy to really examine
• 58:23why they went into the profession,
• 58:26why they wanted to go to medical
• 58:29school and what they were moving on to.
• 58:33And it was
• 58:37traumatic for a lot of them.
• 58:39I'll use that word because a lot of
• 58:44them had not thought about this,
• 58:46thought about questions,
• 58:48thought about why they were
• 58:51going into pathology. And sorry,
• 58:54getting to a point where they said,
• 58:57I really don't want to talk to anybody.
• 59:00I just want to do science.
• 59:01I want to have my head in microscope.
• 59:04I don't want to talk to people.
• 59:06And we had to drag that out in the group
• 59:11because they wouldn't talk in the group.
• 59:13And it was fascinating what
• 59:16they were moving on to and why.
• 59:19And one of the best questions I took from
• 59:23this was what experience in your life
• 59:26LED you to be where you are right now?
• 59:32Because there is an experience that
• 59:35brought you to where you are in
• 59:38medical school, nursing school, and
• 59:44it brought out truth in people.
• 59:47And it was, it's a great question, I think.
• 59:54So we'll reveal motivation and
• 59:58reveal what's in your heart and why.
• 01:00:00Why are you doing this?
• 01:00:03You don't want to be around
• 01:00:04people you do want to be.
• 01:00:05You don't want to talk to them.
• 01:00:06You do. Where are you and what
• 01:00:11motivated you to do this?
• 01:00:14You know, it's it's intense.
• 01:00:16Why are you keeping this going?
• 01:00:18If you know you don't want to talk to people,
• 01:00:22but you just wanted to do science, OK?
• 01:00:25You didn't have to go to
• 01:00:26medical school for that, right.
• 01:00:31Thank you. Please, please.
• 01:00:35I I was just thinking in a week and I
• 01:00:37have an extra comment from a student
• 01:00:39here but I was thinking that this is you
• 01:00:41know I'm into stories and so with and
• 01:00:44and and then and it's I think so much
• 01:00:46of your lesson here Fred is we really
• 01:00:48got to know this patient's story and
• 01:00:50and of course your beautiful point is
• 01:00:51yeah we got to know our own stories you
• 01:00:54know what's what's what's what's my story.
• 01:00:56You know why am I afraid of
• 01:00:57this but not afraid of that.
• 01:00:59Why do I embrace this and avoid that We got
• 01:01:02to know our own stories is a is a really.
• 01:01:04That's a beautiful point. Sir.
• 01:01:07If I could ask you a question
• 01:01:08from one of our medical students,
• 01:01:09and this gets down to it,
• 01:01:10to the Tauber proposition.
• 01:01:12All right, all right.
• 01:01:14To build on a previous point,
• 01:01:15as a medical student,
• 01:01:16I have encountered physicians who I
• 01:01:18would suspect would be resistant to
• 01:01:20change because of their own experiences,
• 01:01:22resulting in them becoming jaded
• 01:01:25and disillusioned.
• 01:01:26How do you,
• 01:01:27doctor Tauber envision achieving
• 01:01:28physician buy in to implement discussion
• 01:01:31of ethics and rounds or in charting?
• 01:01:34What can we do practically to get
• 01:01:37people to start talking about
• 01:01:39ethics surrounding patient care?
• 01:01:43It takes leadership from.
• 01:01:45I'm a top down kind of guy.
• 01:01:49If the leadership of the hospital or medical
• 01:01:54school recognizes this is important,
• 01:01:57rewards faculty for engaging appropriately,
• 01:02:03then we will have some effect.
• 01:02:06So it's a question of
• 01:02:08choosing the right right Dean,
• 01:02:09the right president of the hospital,
• 01:02:12the right corporate chief executive.
• 01:02:18I mean, these changes are within the context
• 01:02:23of a very complicated medical economy.
• 01:02:27And we're so driven by the economics
• 01:02:30of the people at the top usually
• 01:02:33are most concerned about that.
• 01:02:36Bills have to get paid.
• 01:02:39I'll leave it at that. I don't
• 01:02:42want to get anybody in trouble.
• 01:02:47Follow up and then Dr. Zanano, please.
• 01:02:49So to tap on to what my colleagues said,
• 01:02:51you know, if it's if you can't teach empathy,
• 01:02:54would it be easier to teach self reflection?
• 01:02:59You know, if you're if, if you have,
• 01:03:02you know, anxiety or apprehension about
• 01:03:04taking care of an asthmatic patient,
• 01:03:06you know to kind of self reflect on
• 01:03:09that just to figure out what's going
• 01:03:11on within your own self to make it
• 01:03:13more comfortable to be around certain
• 01:03:15well, it really begins,
• 01:03:17it begins with the selective
• 01:03:19process for medical students.
• 01:03:21The M cats are very good at
• 01:03:24predicting success in medical school,
• 01:03:27not necessarily success in
• 01:03:29terms of physicianship.
• 01:03:31And I know that in various places
• 01:03:35there are some in depth interviews
• 01:03:38where the medical school admissions
• 01:03:40committee is trying to figure out
• 01:03:43who that individual really is.
• 01:03:45And that requires a lot of work.
• 01:03:47That requires some very potentially in
• 01:03:53depth analysis and it's mainly organized
• 01:03:57now to try to rule out sociopaths.
• 01:04:01But we would prefer I think to balance
• 01:04:03the other end of the spectrum as well.
• 01:04:08Thank you.
• 01:04:10I have a couple of comments.
• 01:04:12I've been struggling with this
• 01:04:13whole area too for a long time.
• 01:04:16Your talk reminded me of an incident
• 01:04:18when I was a medical student and
• 01:04:21had a complicated diabetic patient.
• 01:04:23And of course I learned all the all the
• 01:04:28all the numbers and stuff like that.
• 01:04:30And it was it was the interest of the
• 01:04:34attending who want didn't want to
• 01:04:35hear anything about the numbers but
• 01:04:37wanted to know why the patient had
• 01:04:3920 admissions in a year and a half.
• 01:04:42And that sort of triggered my thinking
• 01:04:46about how to approach this kind of thing.
• 01:04:51I can say the hospital here has
• 01:04:53been mixed about its approach.
• 01:04:56You know, we first got an Ethics
• 01:04:59Committee in 1985 and the hospital
• 01:05:03didn't want to fund it,
• 01:05:05had a few people who volunteered
• 01:05:08to sort of do it and the doctors
• 01:05:12were very threatened by it.
• 01:05:16They didn't want were afraid somebody
• 01:05:18was going to take away their control
• 01:05:21and authority and many of the referrals
• 01:05:25over the course of time came from
• 01:05:28nursing who were concerned about what
• 01:05:30was going on on the unit and found the
• 01:05:33Ethics Committee was a way to bring it
• 01:05:36up that allowed that kind of discussion.
• 01:05:40So I think at this point there
• 01:05:42is certain and it's wax and wane
• 01:05:45in terms of the of the hospital,
• 01:05:47but it's I think the the Ethics Committee
• 01:05:51acts in synergism in a way it encourages
• 01:05:54and helps people you know raise it
• 01:05:56a few times and you think about it.
• 01:05:58And so it it goes on just like I'm
• 01:06:00going to have a meeting tomorrow
• 01:06:02some of the staff concerned about
• 01:06:04a patient who may be hurting her
• 01:06:07pets and how do we think about that,
• 01:06:10how should we think about it.
• 01:06:12So it's an ongoing sort of
• 01:06:13endeavour to sort of struggle with.
• 01:06:17Sure.
• 01:06:22Nothing. Is there someone
• 01:06:23here to have a question,
• 01:06:26John, next please. Fred, thanks for coming
• 01:06:28and thanks for
• 01:06:29your talk today.
• 01:06:31There is in in medicine
• 01:06:33and certainly in Pediatrics thoughts about
• 01:06:35social determinants of health getting
• 01:06:37to know your patients better that way.
• 01:06:40Is there a way of merging ethics with
• 01:06:43some of this other way of
• 01:06:45thinking about patients
• 01:06:47because it does link to their
• 01:06:49lives, to their decisions,
• 01:06:52to how people want to be
• 01:06:54treated. And so I think,
• 01:06:55you know there is a movement out
• 01:06:57there and maybe maybe ethics needs to
• 01:06:59catch up with this other movement.
• 01:07:01Well the way I was casting ethics it
• 01:07:05includes all of that and so it's it's
• 01:07:08you can take it from any angle you you
• 01:07:12choose either more formal medical ethics
• 01:07:14or from the sociological point this
• 01:07:17this encompassing idea which I which I
• 01:07:20mentioned it deserves its own lecture.
• 01:07:23Constructivism, the construction of
• 01:07:25the patient involves all of these
• 01:07:27various factors and how you construct
• 01:07:30the case is really multifactorial and
• 01:07:34so you sure that's that's crucial.
• 01:07:41We have time for one more quick question
• 01:07:48anybody who. Go
• 01:07:51ahead take it.
• 01:07:53Hi, I great talk. I really agree.
• 01:07:55I'm really happy to hear this from
• 01:07:59leadership. I'm an AI ethicist now but
• 01:08:01medical ethics by training.
• 01:08:04So this is something I've been
• 01:08:06thinking about for a really long time.
• 01:08:08And I remember my first or
• 01:08:12introductory bioethics course
• 01:08:13was with a lot of
• 01:08:16medical students or pre medical
• 01:08:17students like first year of college.
• 01:08:18And I remember them bringing up
• 01:08:21the ventilator problem like if
• 01:08:22we have limited resources right
• 01:08:24like the classic issue and I
• 01:08:27remember all the students being like
• 01:08:29oh what when is that ever going to happen?
• 01:08:31And then COVID happened and it
• 01:08:34suddenly there was this reliance
• 01:08:36on clinical ethicists in a way
• 01:08:37that we hadn't previously seen.
• 01:08:39So I guess I wonder, are we maybe at
• 01:08:44a kind of like climax of this
• 01:08:47being able to shift over like it is
• 01:08:49this maybe a timely proposal
• 01:08:51now after kind of the impact
• 01:08:54that we've seen from COVID-19?
• 01:08:57And is there a way to kind of maybe,
• 01:09:00I mean this is a broad question.
• 01:09:01I guess that's the whole
• 01:09:02crux of your argument.
• 01:09:05But is it maybe do we need that
• 01:09:09to happen for us to kind of put
• 01:09:12pressure on a curriculum change or.
• 01:09:15Yeah, moving ethics away from
• 01:09:17just a a box ticking exercise?
• 01:09:19I guess
• 01:09:21you see the word emeritus up there.
• 01:09:25I've passed the baton.
• 01:09:28The idea of this discussion is to
• 01:09:31simply provoke renewed interest and
• 01:09:36efforts to prioritize and balance more
• 01:09:42effectively what everyone I think
• 01:09:43in the room probably understands.
• 01:09:46It's simply a question of
• 01:09:48catalyzing some change.
• 01:09:49And I hadn't thought about the
• 01:09:50COVID crisis in these terms.
• 01:09:53I've been retired by then,
• 01:09:56but I it must have been just
• 01:09:58a horror show everywhere. And
• 01:10:02we actually, just four weeks ago,
• 01:10:04right, we addressed here.
• 01:10:06We had Will Parker from
• 01:10:08University of Chicago.
• 01:10:08We talked about the exercises and the
• 01:10:10very real stuff we went through here
• 01:10:12during COVID which was a horror show indeed,
• 01:10:15trying to figure out how we were
• 01:10:16going to manage resources once
• 01:10:18the need outpaced through the
• 01:10:19resources here during the pandemic.
• 01:10:21And and indeed the baton has passed
• 01:10:24but the wisdom is appreciated.
• 01:10:25And to those to whom the baton has
• 01:10:28been passed and will be passed.
• 01:10:31This has been a a wonderful session
• 01:10:33and we thank you so much for coming.
• 01:10:35Thank you
• 01:10:38so and Fred, you don't want to
• 01:10:40leave without some Yale stuff so we
• 01:10:42have here is for you. Thank you.
• 01:10:44Thank you so
• 01:10:45much for coming.
• 01:10:46Thank you all for coming.
• 01:10:47We'll be back in two weeks where we're
• 01:10:49going to hear from Professor Moore,
• 01:10:51Brianna Moore from University of Texas.
• 01:10:52We're going to talk about virtue ethics.
• 01:10:54We spend a lot of time
• 01:10:55on principles and rights.
• 01:10:56Maybe I spent too much time on that.
• 01:10:57So we're going to bring in a
• 01:10:59scholar on virtue ethics to come
• 01:11:00and talk to us a bit about that.
• 01:11:01We'll hope to see you guys then.
• 01:11:03Take care.