Two alternatives, each a little wrong

In the 1980s, neurosurgeon Dennis D. Spencer, M.D., HS ’77, was a leader in an investigational effort at Yale to transplant fetal cell tissue in the brains of Parkinson’s disease patients. Animal studies had shown that implanting the cells might reverse the tremors and other neurological problems caused by the disease. His research team applied for a grant from the National Institutes of Health (NIH) to carry out some of the first studies in humans. Unlike other teams applying for the grants, Spencer’s group refused to include placebo surgery as part of their study. The sham surgery would have required him to carry out all the steps of the transplant surgery—drilling a hole through a patient’s skull and inserting a needle into the hole—but without delivering any fetal cells. “My reading of the literature,” he now says, “showed that any placebo effect from surgery would have been short-lived. We believed that over time you could clearly judge the efficacy of the procedure without subjecting patients to an unnecessary risk. We felt to do so would be unethical.” NIH insisted on the placebo surgery. “We didn’t get funded.”

For Spencer, who is now interim dean of the School of Medicine, that experience marked the beginning of his need to study bioethics in a more focused way. “I started reading the literature on the ethics of using surgery as placebo. I read what happened in the past and that helped crystallize the issue for me.” He and his colleagues began a series of debates on the subject at NIH and neurosurgical society meetings. “For scientists, study controls and placebos are important, but you need to consider the ethical issues.” While no formal policy on placebo surgery resulted, “We got people to think about it.”

The need to think about, explore and, when possible, resolve such complex issues has increased at Yale and elsewhere as medicine has become more complex. Spencer is one of many Yale physicians who regularly encounter ethical challenges in their work. They have a number of resources available to advise them when necessary. The Yale-New Haven Hospital Bioethics Committee—a panel of physicians, nurses, lawyers, social workers, clergy, ethicists and community members—reviews dilemmas, sets guidelines for care and also looks into issues about the quality of hospital services and physician conduct. “As professionals,” says Thomas P. Duffy, M.D., professor of medicine and a founding member of the Bioethics Committee, “we have an obligation to monitor how all of us are performing as physicians. The actions of one reflect on all of us.”

When urgent bioethical dilemmas requiring swift, high-level decision making arise, physicians can turn to the hospital’s chief of staff, Peter N. Herbert, M.D. ’67, HS ’69, and attorneys for final arbitration. Any Yale investigator seeking to carry out experiments involving human subjects must file an application with one of four university institutional review boards that oversee the studies, based on federal guidelines. A variety of other departmental committees and individual experts are also available to help resolve disputes when they occur. “Ethics,” says Robert J. Levine, M.D., HS ’63, professor of medicine and a co-founder of the hospital ethics committee, “is civilized society’s alternative to violence in dispute resolution.”

Levine is co-chair of Yale’s Interdisciplinary Bioethics Project and director of the Donaghue Initiative in Biomedical and Behavioral Research Ethics at Yale. He points to the Greek origins of medical ethics as what he terms “a field for developing standards for behavior that is praiseworthy or blameworthy.” However, he also defines an ethical dilemma as one in which there are “two alternative courses of action, each of which is a little wrong.”

Disputes arise because opposing responses are possible. Nonetheless, dilemmas require resolution if the needs of individuals and society are to be met. Last autumn, Yale Medicine invited its readers to submit biomedical dilemmas they have encountered in the course of their work, and many of you responded with issues where a proper course of action was not necessarily obvious. Issues ranged from a family that insisted for religious reasons that a loved one who was suffering not receive pain medication to concerns about the professionalism of colleagues.

Working with Levine, Contributing Editor Marc Wortman and the editors of Yale Medicine selected four provocative and difficult-to-resolve dilemmas. Individual faculty members with relevant expertise were invited to reflect on one of the dilemmas and to present their views of the logic of a resolution. The dilemmas are presented anonymously but are based on real situations described by readers from around the country. YM