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

January 10, 2024

Information

November 1, 2023

Alfred Imre Tauber, MD

Professor of Philosophy (tenured, 1998), College of Arts and Sciences, Boston University Zoltan Kohn Professor of Medicine, Boston University School of Medicine;Professor of Philosophy, emeritus, College of Arts and Sciences, Boston University Zoltan Kohn Professor of Medicine, emeritus, School of Medicine, Boston University

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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&amp;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.