Sessions and Themes
- Shifting the paradigm: Vikas Saini
- Magical thinking and Modern medicine: Harvey Fineberg
- What makes us do it?
- What will it take to get us there?: Don Berwick
- What are the knowledge gaps in avoiding avoidable care?
- Case discussions
- What are the ethical issues?
- Medical journals and the issue of avoidable care
- The schizophrenic life of the hospital CEO
- A reason to change: Shannon Brownlee
- Social responsibility of physicians: Bernard Lown
- Behavior-changing Best practices
- Global dimensions of unnecessary care: Julio Frenk
- Payment mechanisms and the Culture of medicine
- Choosing wisely and beyond: What are the next steps?
- How can patients help drive the needed change?
Shannon Brownlee’s ethics panel introduction
Below is Shannon Brownlee’s introductory speech from the ‘What are the ethical issues’ panel.
Thank you all for being here today – distinguished panelists and participants.
I want to tell you a story. That’s what writers do, tell stories. It’s not my story, it is Diane Meier’s, and I hope I tell it correctly. She told it to me years ago, and it haunts still, which is why I want to relate it to you.
The patient was an elderly Hispanic man. He barely spoke English, and he was dying of lung cancer when Diane met him. Mr. S., as she calls him, had watched his wife succumb to lung cancer three years earlier. When he was diagnosed with the same disease, he wanted no part of the side effects his wife had gone through. He declined chemotherapy, radiation, and surgery, saying he wanted to die at home, surrounded by his family.
The hospital sent him home, but a few months later, Mr. S. was brought in to the emergency room by his grown children. He was delirious and suffering seizures from metastases in his brain. The hospital admitted him to the neurology department, where he was stabilized.
When Diane entered his room, she found a frail, emaciated man. He had a nasogastric feeding tube, and he was thrashing was in his bed, yelling unintelligibly, and pinned down in 4-point restraints.
Diane went to find the neurology resident in charge, and asked him what was going on. The resident told her that Mr. S. had pulled out his feeding tube repeatedly, and that was why he was in restraints. And then, the young doctor looked at Diane, with enormous distress in his eyes, and said, “ ‘If I don’t keep Mr. S. in restraints, he’ll die.’ ”
There’s a concept in the medical ethics literature called moral distress — it’s a description of how one feels when you know what is ethically appropriate, but you are unable to do what’s right because of obstacles that are inherent in the situation. Moral distress was first described in 1984 in a book on nursing ethics and the term is mostly used in relation to nurses, who often feel trapped between the doctor’s orders and the suffering of patients.
Obviously moral distress is not limited to nurses. Diane’s story about the dying man haunts me because there was suffering on both ends of the stethoscope. The story of Mr. S gave me some insight into clinicians’ struggles, and it a measure of compassion – a way to integrate my own conflicting feelings about the role clinicians play in the delivery of unnecessary care.
Here is the conflict. On the one hand, it was a physician who wrote the orders for Mr. S to be put in 4-point restraints. It is, after all, always a clinician who writes an order for an unnecessary drug, who performs an unneeded catheterization, who admits a patient to the ICU when what the patient really wants is to die at home.
On the other hand, many clinicians feel trapped in a system that often pushes them to do the wrong thing. A system that makes it easy to do harm. And just like that young neurology resident, they feel a terrible distress.
Clearly the prime directive of medicine, primum non nocere, which I think would sound a lot better if it were pronounced with an Italian accent, is inadequate to the task of helping clinicians perform the balancing act that is inherent in the practice of medicine. Of balancing the potential for harm from not doing enough, which is where thinking about medical ethics has tended to dwell, against the harm from doing too much.
This leads us to many questions, a few of which I’ll name here:
1.Why do we perceive errors of commission as lesser sins than errors of omission?
2. And why do we not consider it an error, or at least unethical, to fail to inform patients about the true costs, both financial and physical, of medical care, and its limitations?
3. How can it be ethical to use a shiny, new, and often very expensive technology, like a robot, or a drug-eluting stent, or a new surgical technique, as a marketing tool to bring in paying customers? And how can we continue to use it without bothering to find out if it actually works?
I’ll stop there.
My request to this panel is the answer to an admittedly blunt question: Do we need a new medical ethic? Because clearly, just saying no to harm is not enough.
I won’t go into lengthy introductions. Please read this panel’s bios. Diane Meier, Howard Brody, and Jerry Hoffman are highly accomplished, recognized in their fields, but they are here today because they also have thought deeply about the meaning of professionalism. Howard Brody has the added distinction of being a bioethicist by training.
Jerry Hoffman will lead off with some overarching principles. Howard Brody will bring an ethicist’s perspective, and Diane Meier will bring us full circle to the this problem of moral distress.