The Work: Reflections of Two Healthcare Ethicists

Those who work on responding to the ethical issues and decisions that arise in healthcare realize that we are invited into the most complex stories that patients, families , healthcare professionals and our communities have to offer. They not only involve value-laden clinical decisions about patient treatments, but community decisions about public health that sometimes place the autonomy of individuals against the common good of the community. When reflecting on the work of healthcare ethics, we thought we would ask a couple of colleagues with 25+ years of experience in this area what their thoughts are on this evolving work or calling.

Our guests in this episode include:

  • Dan O’Brien, who just retired as Senior Vice President of Ethics at Ascension Health
  • Carol Bayley, who just retied as Vice President of Ethics and Justice Education at Dignity Health

Both are highly regarded by their colleagues and have worked in diverse healthcare settings, from community hospitals to teaching hospitals and working to address pubic health issues in very diverse communities. They have lived the evolution of healthcare ethics over the past 25 years and the everyday challenges that arise. In this episode, we sit down and reflect on their experiences.

Artificial Intelligence: Issues Arising

 

In healthcare, we are able to capture ever increasing levels and types of data. The potential is there for more accurate diagnosis and more relevant which would better inform healthcare decisions and potentially avoid medical error or unnecessary treatments. Artificial intelligence technologies are increasingly accurate in text, in sound or in image recognition with the capability to process and analyze large volumes of data. They have the potential to lighten the load on healthcare professionals and therefore allowing them to spend more time with patients, potentially improving healthcare decision making and delivering higher quality healthcare. What are ethical questions that arise with this data, and with artificial intelligence technologies?

Our guest in this episode, Anita Ho, is a healthcare ethicist with a background in philosophy and public health and has worked university and hospital settings in Canada, The United States and Singapore. She is currently associate professor at the University of British Columbia Center for Applied Ethics, and Associate Professor at the Bioethics Program at the University of California, San Francisco. A focus of her work has been the ethical impact of innovative technologies such as artificial intelligence in healthcare. We are very pleased to be in conversation with Anita in this episode!

Resources Referenced in this Episode:

Goals of Care

Goals of care is a term so common to health care professionals and yet, our guests describe significant clinical experiences in which the lack of discussion around goals of care led to problematic cases. A goals of care conversation is an important element at the foundation of high quality discussions around code status. In this episode lead contributor Mark Repenshek, Executive Director of Ethics and Mission at Hospital Sisters Health System in Wisconsin, is in conversation with national experts and clinicians who discuss this important topic.

Our guests in this episode are:

  • Dr. Kenneth A. Berkowitz, MD FCCP Chief, Ethics Consultation at VHA National Center for Ethics in Health Care, Associate Professor of Medicine and Population Health at NYU School of Medicine
  • Dr. Tim Jessick, DO, Chair/Co-Founder Palliative Care Network of Wisconsin
    Palliative Medicine Physician, AdvocateAuroraHealth
  • Dr. Jill S. Lowery, Psy.D., Chief, Ethics Policy, National Center for Ethics in Health Care at Veterans Health Administration
  • Dr. James A. Tulsky, MD, Chair, Department of Psychosocial Oncology and Palliative Care at Dana-Farber Cancer Institute, Chief, Division of Palliative Medicine at Brigham and Women’s Hospital, Professor of Medicine at Harvard Medical School

Helpful Goals of Care Resources:

Informed Consent: Supporting Patient Autonomy

Informed consent is one of the foundational ethical principles in health care that supports patient autonomy, or stated differently, the patients right to self-determination. More and more the standard for what clinicians should inform patients about the risks benefits and alternatives of treatment are no longer determined by what a responsible body of physicians deems important, but rather by what a reasonable patient deems important. What is needed to meet that goal is a collaborative communication process between clinicians and patients that integrates the best evidence available with the patients values and preferences to promote high quality health care decisions. In the United States at least half of the states have adopted the reasonable patient standard regarding informed consent.

This episode of EthicsLab Essentials is led by lead contributor Rachelle Barina, VP – Mission Integration at SSM Health based in Wisconsin and is in conversation with two nationally known guests:

  • Dr. Jenny Heyl, Director of Ethics at Mercy Hospital in St. Louis
  • Dr. Kayhan Parsi, Professor of Bioethics at the Neiswanger Institute for Bioethics: Loyola University Chicago

Discharge Dilemmas: Patients with Disabilities

Consider someone leaving a hospital, after their care is completed at that location, to return to their home and local community. As discharge plans are made to continue their care, their healing, their rehabilitation, are there ethical challenges that arise? Can there be biases that shape that plan because of their ability, disability, lack of family support systems or resources available in the community? What are the frameworks, tools, approaches that an assist all involved? Our guests will offer their experience in these discharge plan dilemmas and offer the practical approaches they have utilized every day.

Joining us in conversation in this episode are:

  • Debjani Mukherjee, trained as clinical psychologist and clinical ethicist, is Director of the Donnelley Ethics Program at the Shirley Ryan Ability Lab, Associate Professor of Physical Medicine and Rehabilitation and Medical Education at Northwestern University, Feinberg School of Medicine.
  • Preya Tarsney, trained as a lawyer Bioethicist – Donnelley Ethics Program at the Shirley Ryan Ability Lab and a Lecturer of Physical Medicine & Rehabilitation at Northwestern University Feinberg School of Medicine and faculty lecturer at the University of Chicago, MacLean Center for Clinical Medical Ethics.
  • Kristi L. Kirschner MD is a physician in physical medicine and rehabilitation and has practiced in this area for 30 years. She also has a background in clinical ethics and physical disability ethics and a faculty member of the university of Illinois College of Medicine where she directs the sub-theme of Humanities in Ethics for the College of Medicine.

Paying Attention: Looking Back, Looking Forward (2019)

As we look back on 2018 and forward to 2019, our guests are editors of key healthcare ethics journals with an international readership:

  • Gregory  E. Kaebnick, Editor, The Hastings Center Report – The Hastings Center
  • Leslie LeBlanc, Managing Editor, Journal of Clinical Ethics
  • Fr. Charles BouchardEditor, Health Care Ethics USA – Catholic Health Association of the United States

What are the issues in health care ethics that are impacting ethics committees, health systems, public policy and patients over the past year? What issues do they expect to continue and emerge within the next year? What key articles published in their journals published in the last year might they recommend to you, our listeners? These questions and others, our guests discuss in this episode of the EthicsLab Podcast.

Resources Referenced in this Episode:

Psychiatric Disability and Life Threatening Non-Adherence

Imagine a patient who suffers from an underlying psychiatric disability and comes to a hospital with a critical illness after prolonged non-adherence to a medical treatment plan. Because of their inability to follow a treatment plan, the patient now faces an end-of-life situation, even though the condition would otherwise not be considered terminal. I am sure you can understand that such stories are both tragic and ethically complex. These stories not only   cause moral distress for the healthcare team caring for the patient, but also alarm and confuse patients and their families. Ethics committees in hospitals are asked to consult on the ethics complexities in cases like these. Our guests will reflect on such patient stories and offer their ethical reflections on the challenges, naming the components of complexity, and what is important for ethics committee members to pay attention to in patient stories like these.

Our guests in this episode are:

  • Carol Taylor, a professor of Medicine and Nursing at Georgetown University, past Director of the Pellegrino Center for Clinical Bioethics. Carol is now a Senior Scholar at the Kennedy Institute of Ethics.
  • Michael Pottash, Attending Physician in Palliative Medicine at MedStar Washington Hospital Center, He is also an Assistant Professor of Clinical Medicine at Georgetown University School of Medicine.
  • Laura Guidry-Grimes, is an Assistant Professor of Medical Humanities in Bioethics, at the University of Arkansas for Medical Science. She is also a clinical ethicist at the Children’s Hospital in Little Rock, Arkansas.
  • Sarah Kleinfeld, is a Geriatric Psychiatrist at the VA Medical Center in Washington DC. She works with elderly patients with a range of psychiatric illnesses like Bipolar disorder and Schizophrenia.

Resources Referenced in this Episode:

Mental Health and Discrimination: Mass Shooting Stereotypes

In the wake of past and more recent mass shootings, mental illness has been pointed to in some public statements as the root cause of mass shootings: Statements such as…1) “We don’t need a gun database, we need a mental health database in the United States”, or…2) “People don’t kill people, the mentally ill do”. With such statements, mental illness can become conflated with criminality, mass violence and other tragic events. Discrimination, false stereotypes and increased stigma for mental health patients has become a concern. As an example, when New York passed the Secure Ammunition and Firearms Enforcement (SAFE) Act in 2013, a core component of the law required mental health practitioners to report any patient who was “likely” to be violent to the health department, for potential inclusion in a database. Other states have since enacted similar legal requirements. Mental Health practitioners were concerned that the requirement to report, and anxiety about legal liability, would lead to over-reporting. Would mental health patients lose trust in the confidentiality of their health care? Would mental health patients receive an over vigilant surveillance. One year after enacting this law in New York, the New York Times, reported that the number of names within the SAFE Act database quickly rose to 34,500 names.

What are the harms that occur when mental health is named as the key reason for mass shootings? Is there a deeper complexity to be understood?  To shed light and research data on that greater complexity, we are joined by Dr Jonathan Metzl, physician, psychiatrist, Professor of Sociology and Psychiatry, and the Director of the Center for Medicine, Health, and Society, at Vanderbilt University in Nashville, Tennessee.

Resources Referenced in this Episode:

Organ Donation: Foundational Ethical Approaches

The big picture is that 115,000 men, women and children await organ transplants in the United States. Even the largest football stadium in the US could not fit the number of patients on the national transplant waiting list. In 2016, 33,600 transplants brought new life to patients and their families. Since 1988, 683,000 transplants have taken place in this country.

In this episode, our lead contributor Becket Gremmels, speaks to a transplant surgeon, an ICU doctor and a health care ethicist about some of the foundational ethical approaches that honor organ donors, the patients who receive those organs, and the health care professionals who care for both.

Our guests in this episode include:

  • Dr. Carol Bayley, past Vice President for Ethics and Justice Education at Dignity Health, San Francisco
  • Dr. Anji Wall, Abdominal Transplant Surgeon at Baylor Medical Center, Dallas
  • Dr. Wes Ely, Intensivist at Vanderbilt University Medical Center and Nashville VA Hospital, Nashville

Do Not Resuscitate Orders: Key Ethical Issues

As patients, surrogate decision makers, and clinicians discuss goals of care, questions arise regarding what interventions will physiologically work and what interventions will honor the patient’s values. Do Not Resuscitate Orders are one of the interventions frequently discussed. Our lead contributor on this episode (Mark Repenshek, Executive Director for Ethics & Mission at Hospital Sisters Health System, in Wisconsin) is in conversation with guest to explore a number of ethical issues related to Do Not Resuscitate orders that include, but are not limited to: a) Patient/Surrogate desires for full resuscitation despite the intervention’s lack of efficacy in specific clinical circumstances, b) Consideration of partial codes as a “compromise” co-status, c) A physicians’ professional right to limit the use of resuscitation efforts in certain circumstances. The episode also introduces a new series within the EthicsLab Podcast called EthicsLab Essentials. This new series is designed to be an introductory series of modules to enrich ethics committee members.