Picking a Fight on Normative Ethics

Rosemary Flanigan
October 30, 2009

I have read the final article in the HEC Forum, the one by Tristram Engelhardt, Jr. who seriously questions whether or not one can define what a clinical ethicist is and does.

Maybe I’m just rarin’ to pick a fight, but I was disturbed by his paper.

He says, “The existence of clinical ethicists and ethics consultation is the result of a set of developments and commitments rooted in Enlightenment assumptions about the possibility of discovering through rational analysis and argument a canonical morality or at least a normative moral consensus. The difficulty is that these Enlightenment assumptions have proven false. Secular sound rational argument cannot resolve the important moral controversies we face, nor is there a non-controversial understanding of when consensus and by whom would be normative and for what. . .Ethics consultation is itself a matter for disagreement.”

I am not directly addressing CEC’s, but I am very concerned that his remarks be misread by ethics committee members, the education of whom has been a principal work of the Center during our 25 year history.

Is normative ethics possible for our committees to achieve? Yes, within parameters of the institution whether it be the mission and vision statement or the Ethical and Religious Directives for Catholic institutions or whatever states the purpose of the institution. Those, broadly speaking, express the presuppositions, assumptions, values on which the institution rests.

Argument (in a committee’s case consult) starts from there, and though the documents may express the aim and purpose broadly, there would be enough substance that we can craft our arguments to show the rationality of our responses within that institutional “ethic.”

I shall get off my high horse, but I don’t want the difficulties for credentialing clinical ethics consultants to erode the positive contributions made in clinical ethics by our committees.

Does this make sense?

Genetics, Jewish Diseases and Personalized Medicine

November 2-3, 2009
Kansas City Public Library

14 W 10th Street

Kansas City, MO 64105

Advances in genetics change the way we think about health, disease, and personal identity. This free two day conference features prominent panelists who will discuss the ethical implications of new discoveries in genetics.

Panelists include:

**Jon Entine - American Enterprise Institute
**Noam Zohar - Bar Ilan University, Israel - Rabbi and PhilosopherStephen Spielberg - Children's Mercy Hospital Pharmacogeneticist
**David Ewing Duncan - Journalist and Bioethicist
**Rabbi Elliot Dorff - American University of Judaism - Philosopher

**Chris Austin - National Institutes of Health - Geneticist

Links:

Conference Overview and Registration
Podcast, John Lantos, MD 13 minutes 47 seconds

Death and the Colostomy Bag

Rosemary Flanigan

October 26, 2009

There is a short but thoughtful piece in the new Hastings Center Report describing two clinical ethics consultants’ answering a pager on “Saturday Morning in the Clinic.”

The husband of a 7l-year old patient who had been in the surgical intensive care unit for eleven days following treatment for a small bowel obstruction faced a dilemma. His wife had told him—and all the members of the care team—that she’d “rather die than have a colostomy bag.” But she had become septic, requiring surgery on her previously resected intestine—likely resulting an an ostomy to save her life. What should he do?

The surgeon had told him that colostomies are sometimes reversible. So he had signed the consent form. But when the consult team spoke with the surgeon, the surgeon said that the patient, because of her condition, might have to wait a year before reversal could be considered.

And there was the rush and the young nurse’s reassuring the husband by saying, “It’s just a colostomy. She’ll die without it. Wouldn’t she rather live?”

And gradually the husband realized that no, she would not rather live.

But surgical preparations were being made at that moment and one member of the team stayed with the husband while the other fled to the operating theatre to say that consent had been revoked. The woman died two days later.

The consult team, reflecting afterwards on the harrowing Saturday morning event, realized that it was moral discernment that took over their lives during those hours: what they “needed to know” about the patient, her husband, her fears, his contradictory responses, that helped them through the process.

“[W]e found that our engagement in moral discernment was well served by our being continually alert to the changing conditions and circumstances of that Saturday morning in the clinic. . . .”

Preparation for case consults can never be pursued too aggressively in our ethics committee education. Do you agree?

Link: Saturday Morning in the Clinic, The Hastings Center Report, September/October 2009

No Country for Sick Men

Myra Christopher
President/CEO
Center for Practical Bioethics
October 23, 2009

A Fellow and former staff member at the Center for Practical Bioethics, Dr. Erika Blacksher, had the chance to hear T.R. Reid speak in Lawrence, Kansas last night. In an email to me this morning, she said, "His message is a moral one: we have to cover everyone (to save money, improve health, and to be fair)."

Sounds like a win/win/win to me.

Reid recently wrote a compelling article in Newsweek titled, “No Country for Sick Men,” that I think is one of the best things I have read on healthcare reform from an ethical perspective. If you haven't read it, I urge you to do so.

Link: “No Country for Sick Men,” Newsweek, September 12 2009

Bending the Cost Curve

Bending the cost curve was the focus of the third of four public forums on healthcare reform sponsored by the Center for Practical Bioethics. The October 20th forum featured a keynote address from Marcia Nielsen, PhD, Vice Chancellor of Public Policy & Planning at the University of Kansas Medical Center.

A responder panel included the following:

*Tom Handley, FSA, MAAA, L& E Actuaries and Consultants
*Rene Bollier, MD, Kansas City Family Medical Care
*John Lantos, MD, John B. Francis Chair in Bioethics at the Center for Practical Bioethics and director of Children's Mercy Bioethics Center, served as a panelist and moderator.

The fourth and final forum of the series is scheduled for Tuesday, October 27. For more information go to www.practicalbioethics.org.

Links:

**Keynote, Marcia Nielsen, PhD, 25 minutes 44 seconds

**PowerPoint

**Responder Panel, 24 minutes 47 seconds

**Q & A, 22 minutes 48 seconds

**Podcast: Bending the Cost Curve, Marcia Nielsen, PhD and Rene Bollier, MD, The Bioethics Channel, 16 minutes 27 seconds

Health Coverage for All

The second of four public forums on healthcare reform sponsored by the Center for Practical Bioethics took place October 13, 2009 in Kansas City.

The focus – health coverage for all. Steve Roling of the Healthcare Foundation of Greater Kansas City provided the keynote address. A responder panel included the following:

*Rex Archer, MD, MPH, Director, Kansas City, Missouri Health Department

*George Flanagan, DMin, MA, program associate, Center for Practical Bioethics

*William Pankey, MD, Chief Medical Officer, Swope Health Services

*Keith Wisdom, CFO, United Healthcare Midwest

Links:

*Health Coverage for All, Steve Roling, William Pankey, MD, The Bioethics Channel, 9 minutes 34 seconds

*Steve Roling keynote remarks, 33 minutes 11 seconds

*Responder panel, 22 minutes 33 seconds

*Q & A, 33 minutes 40 seconds

Health Reform and the Common Good

Rosemary Flanigan

October 19, 2009

Dan Callahan, co-founder of the Hastings Center and still Senior Researcher and President Emeritus, in an article in Commonweal, “America’s Blind Spot” identifies the lack of a sense of the common good as the “blind spot” in all our talk of healthcare reform.

We have heard of “justice” and “rights” as the language of reform, but the radical individualism of our U.S. culture overrides such principles. “We are told,” he says, “that the market system that brings us prosperity, jobs, and a cornucopia of cheap consumer goods will also work its magic in health care if we let it, never mind that there is no good evidence to support that leap from commerce to health care.”

There is no widespread agreement about the role of government in healthcare reform. Think of all the taunts of “socialized medicine”—yet close to half of American healthcare is government-supported—mainly through Medicare, Medicaid, and the Veterans Administration. Admonitions by supporters of reform that “we’re all in this together” is a flabby underpinning to Aristotle’s insight about our very nature as “social beings” and thus our need to look out for one another’s good.

So we limp along in our efforts. Dan says, “I have not painted a hopeful picture about the common good in American health care. That simply does not seem possible.” Sad but true.

Meanwhile, the Center continues its series—this coming Tuesday will be “Bending the Cost Curve: Increasing Revenues and Decreasing Costs” with Dr. Marcia Nielsen, Ph.D., from KU and a panel of physicians and an actuariest (is there such a word???)

Link: America’s Blind Spot: Health Care & the Common Good, Daniel Callahan, Commonweal
October 9, 2009

CPR Rates among Elderly and Minorities

Rosemary Flanigan
Distinguished Fellow
Center for Practical Bioethics

October 16, 2009

A July 2, 2009 article in the New England Journal of Medicine suggests NO improvement in elderly survival following CPR from ’92-’05; in-hospital deaths preceded by CPR increased, and the proportion of survivors discharged home after undergoing CPR decreased.

And the article associates higher rates of CPR but lower rates of survival after CPR to race. That is most interesting, I think. Justice denied over the centuries is most apparent today in the lack of trust in the healthcare system shown by blacks—shown here in their expectations of CPR as has been shown elsewhere in their low rate of advance directive planning. Talk about complexity!

The journal article ends: “This study provides information useful to older patients and their clinicians in their decision about whether to choose to be resuscitated, since the proportion of elderly patients who choose resuscitation is directly related to the probability of survival that is presented to these patients. Our findings also provide a stimulus to understand the association between race and survival, with the goals of not only eliminating racial disparities in the quality of medical care but also understanding factors associated with the incidence of CPR and the rate of survival after CPR for patients of all races.”

What if an ethics committee invited some emergency room professionals to a short meeting in which this article is discussed? What if the committee invited some GPs to the same meeting?

Facts don’t always change moral assumptions, but sometimes they do.

Reflecting on Moral Habits

Rosemary Flanigan

October 14, 2009

This is teaching week for me—to medical students working on their Bioethics M.A. and to nursing ethics committee members. With the students, I want to show them how their moral sense develops and how we often argue with ourselves over those conclusions—or certainly with others about their conclusions. And that arguing is “doing” ethics if it is so framed and if it is good reasoning (thus a nose-to-nose look at logical fallacies).

My hope is that they know there is no judgment that cannot be challenged. We may still cling to it following the ethical reflection, but we’ll know why.

But with the nurses (and less time), I’m making them reflect on moral habits. After all, each of us is bundled habits (or bundles of bundled habits), and here again, we need to take some time to reflect on whether or not we are becoming what we hope to become.

With all the new docs entering the profession presuming on the aid of ethics committees and all the nurses knowing they are expected to be reflective in their profession, what a marvelous future ethics committees have—if they are constantly upgrading themselves. But that leads me to credentialing, and I’m not ready to take that subject on –not yet.

So give a whoop and holler that you’re part of the movement.

Pallimed: A Hospice & Palliative Medicine Blog: PBS NOW Gundersen Lutheran Hospital & Advanced Care Planning

Our friend Christian Sinclair reviews PBS program on advance care planning that aired this past Friday.

Pallimed: A Hospice & Palliative Medicine Blog: PBS NOW Gundersen Lutheran Hospital & Advanced Care Planning

Good Ethics Starts with Good Facts

The Center for Practical Bioethics kicked off Healthcare Reform 2009: Truth, Justice and the American Way with a public forum October 6 entitled, “Good Ethics Starts with Good Facts.”

The session featured presentations by John Carney, the Center’s vice president for aging and end of life, Teresa Brooks, JD, Polsinelli Shughart in Washington, DC, and Max Skidmore PhD of the University of Missouri-Kansas City.

The next session will address "Coverage for All." Details below. Register online by clicking here.

Links:

Podcast: Teresa Brooks- Polsinelli Shughart, Max Skidmore, PhD- University of Missouri-Kansas City, 13 minutes 45 seconds

Remarks by:

Myra Christopher, Center president and CEO (9 minutes 36 seconds)

John Carney, Center vice president for aging and end of life. (20 minutes 27 seconds)Powerpoint here.

Teresa Brooks, JD, Polsinelli Shughart, PC (17 minutes 14 seconds)

Max Skidmore, PhD, University of Missouri-Kansas City (13 minutes 21 seconds)

Reverend Bob Hill, Community Christian Church (12 minutes 13 seconds)

Glossary of Healthcare Reform Terms

Coverage for All

Session Two of Healthcare Reform 2009: Truth, Justice and the American Way

Tuesday, October 13
7-8:30 pm

Community Christian Church, 4601 Main, Kansas City, MO

Keynote: Steve Roling, President and CEO, Kansas City Healthcare Foundation

Session is free and open to the public. Register online by clicking here or email Donna Blackwood at dblackwood@practicalbioethics.org

Dutch Pediatricians Part Two

Rosemary Flanigan
Distinguished Fellow
Center for Practical Bioethics

Isn’t much of the moral distress suffered by professionals in healthcare today (besides not having enough time to do what you know you ought to do) the conflict of over the “right” thing to do—with patients, families, and fellow professionals.

But consider, as Hilde Lindemann tries to tell us, how we use language. Unless we can get to the level of another’s meaning, we are not helping them, no matter how many words we use.

“Let us remove the feeding tube from Granny” can be heard in so many different ways, and yet we often start our sentences there instead of asking questions of Granny and the family that may lead up to our prescription.

But if I read John Lantos correctly, what the Dutch pediatricians do—and the language they use in doing it—indicates something deeper than language, some reality that deters us from acting in the same way, no matter how we speak of it.

The “something out there” (killing infants if they fall within the Protocol’s limits) is understood or “meant” differently to Dutch and American pediatricians. The Dutchman justifies it; the American can’t. And no amount of “discussion” will lead to consensus.

But that attempt ought to be made, I think, before we agree to disagree—and hand the patient over to another provider.

Links:

Dutch pediatricians and letting babies die, Practical Bioethics, October 2

Autonomy, Beneficence, and Gezelligheid: Lessons in Moral Theory from the Dutch, Hilde Lindemann, The Hastings Center Report

Home Stretch for Health Reform

John Carney
Vice President for Aging and End of Life
Center for Practical Bioethics

The health reform debate lurches into October with an uncertain prognosis. John Carney of the Center for Practical Bioethics gives an update and talks about a series of Center public forums on health reform in this edition of The Bioethics Channel.

Links:

Podcast: Home Stretch for Health Reform, 11 minutes 5 seconds

Three Myths about the Ethics of Health Care Reform, Association of Bioethics Program Directors, October 1, 2009

Dutch Pediatricians and Letting Babies Die

Rosemary Flanigan

Distinguished Fellow

Center for Practical Bioethics

October 2, 2009

I have just read through the new Hastings Center Report and I am troubled over Hilde Lindemann's article, Autonomy, Beneficence, and Gezelligheid: Lessons in Moral Theory from the Dutch.

For years now, I've always started off "ethics" workshops by distinguishing between morality and ethics. I see morality as the "stuff" with which ethics deals. Without moral conclusions, I would have nothing with which to "do" my ethical analysis. And the sources of that morality are many-parents, neighborhoods, school, church/temple/meeting hall, etc.

The article deals with Dutch pediatricians who end the lives of babies who 1) have no chance of survival for more than a few days, even on life support; 2) those on life support who might survive after intensive treatment but would always suffer horribly; and 3) those who do not need life support and "whose suffering is severe, sustained, and cannot be alleviated."

Dutch pediatricians make no distinction between direct killing and letting babies die; they need no such distinction. I am still trying to get inside their sense of morality before I can make an intelligent comment.

HELP!!

Evaluating and Credentialing Ethics Committees

Rosemary Flanigan
October 1, 2009

In the first part of the 1990’s when our ethics committee reached out to encompass all the entities in our Carondelet Health system in KC (2 hospitals, 3 nursing homes, home care, etc.) we busily spread education about ethics in healthcare and how the ethics committee could help.

We were so busy seeking invitations from departments, affiliated groups, nursing homes, that we didn’t bother evaluating—heck! We were doing. And when I hear of the uneasy reliance on process, I remember our “evaluating by quantity” (“We educated x number of groups since last month. . . .”)

I don’t have the answer here—but even if we focus on outcomes, we shall need to qualify the quantification; otherwise, “the operation was a success but the patient died” aphorism will ring true.

Evaluation and credentialing of ethics committees—my two big areas of concern. We’ll persist in the discussion, I hope. THANKS.