Rationally Speaking | Official Podcast of New York City Skeptics - Current Episodes - RS 160 - Live at NECSS -- Jacob Appel on "Tackling bioethical dilemmas"
"What bioethicists do -- we may do 2 things. One, in the hospital setting -- and I've done this in the past, I actually don't do this at the moment -- bioethicists help adjudicate or guide patients, clinicians, family members in coming to ethical choices about individual patients. I should add, much of that is not telling people what to do or even telling people what their options are. It's helping them have permission to do what they want to do anyway... A consultant in a way. I will add it's one of the few fields that gets easier and easier as you get older and older. You get more gravitas because you're about 80 and you have a long gray beard...
The other thing bioethicists do is they offer public guidance on challenging issues that the nexus of law, medicine and ethics to clinicians out in the field so they can follow some general rubric on what to do... you could say as a white Klansman, "I would like a white Christian doctor to treat me." That strikes most of us as fairly unreasonable. Or you could be an African-American criminal defendant who asked the court to appoint an African-American psychiatrist to do your forensic evaluation, because a white doctor just can't understand what I've been through. A lot of us would think that's more reasonable.
Yet designing a rule that applies in one circumstance and not the other is extraordinarily difficult... you might be a male out there who wants a male urologist because he doesn't want women touching his private parts. Something you might think reasonable. Or you could want a male urologist because we all know that “men cut straighter”... What the hospital does not want to do is to be in the position of figuring out which one you are. Yet, to me that's just in a meaningful way, that's exactly what we have to do.
Therefore, if you have a policy in advance, you can ensure some rough sense of justice but inevitably… Procrustes, the Greek innkeeper with one size bed. If you were too short, he stretched you. If you were too long, he'd cut off your feet? The hospital doesn't want to find itself doing that either... if we announce that as the policy, if you're an Orthodox Jew, you can request a male doctor but if you're a bigot, you can't. Lots of bigots are going to say they're Orthodox Jews and we're going to be right back where we started...
How strong will you have to have this belief? The patient who comes to the hospital and is 85 years old says, "You know, I have a new boyfriend. He's a Jehovah's Witness, so I am, too." The daughter comes forward and says, "My mother was a Methodist until last Thursday"...
Paula and Tom [Lichy], by the way, were a British high profile couple who were deaf. They would have had a deaf daughter. They wanted to go forward with this... To the British authorities, there wasn't very much difference between their choice and actually just deafening a hearing newborn...
There is this principle, which I didn't invent but I've been popularizing. It's called the Copenhagen interpretation of ethics. Essentially, it states that as soon as you interact in any way with a situation, you acquire some moral responsibility for it. If there's a drought in some geographical region, and you fly out there and you start selling bottles of water to people, a lot of people will look at you and say, "God. That's reprehensible. Why don't you give the water to these poor people who are going to die without it? Why are you demanding money for the water?" Yet of course, there's millions of other people who never even went to the country nor said anything about it, and no one is criticizing them for not giving bottles of water to people who need it. They're criticizing the people who interacted with the situation in some way...
The question of whether trace amounts of Lithium should be added to the drinking water. A number of psychiatrists have written about this. It turns out that a certain percentage of the drinking water in this country already has Lithium in it naturally. And the areas where it does seem to have a substantially lower suicide rate. This is the finding that is replicated in Greece, in Turkey, in Great Britain, in Japan. The science is pretty good.
Now the first question you should ask is, would it be ethical to divert water from those areas where it's in the water supply, the areas where it's not? If you embrace that theory, then why wouldn't it be just as ethical to actually add synthetic Lithium, in the same way we add fluoride to the drinking water? I will tell you, if you raise this question, even without offering a definitive answer, you will get more hate mail than you could possibly imagine...
Historically, the great questions from bioethics were scenarios where a patient or a patient's family wanted to stop care. Society, religious or cultural reasons wanted to enforce care upon them. You can think, Caroline Quinn, Nancy Rosanne, Terri Schiavo.
We have now turned that on its head. Now increasingly, the cases are those where the family is saying desperately, "We want more care." The hospital or society is saying, "You've exhausted your version of care. In the new priority system, nobody is worth $5- $10 million of health care in one shot. You're out of luck." It's easy by the way, relatively easy, when the patient is comatose or in a vegetative state. But you have patients like Slim Watson for example, who was a prison guard in North Carolina in 2000. Written up at length in the Wall Street Journal. He could walk around the hospital, bright and cheerful, entertaining the pediatric patients, and was in the prime of health. Except he needed a drug that caused roughly $5 million a month.
Is anybody worth $5 million a month? The answer is, "It is if you are the patient, and not if you're not"...
If you buy a house because it's close to the train station and it's a flat driveway, you won’t have to shovel, it and lots of other rational reasons… you're less likely to be happy with it in the long run than if you buy the house because you just liked it. I think that's somewhat translatable to many bioethics decisions...
The difference between bioethics as it applies in hospitals and many other areas of society is there are a lot of different right answers depending on who you are...
Lester Thurow. He explains why we got into the challenging situation with health care right now in this country. He says, "Because Americans are divided by 2 different principles. On the one hand, by nature, we're libertarian. We believe that if there's some treatment or intervention out there that is available, that anybody who has the resources for it should be able to buy it."
Some European countries don't let you do that, which is why those patients come here. Here, a high end treatment, Bill Gates can go out and get it. We don't feel comfortable saying no. But we're also egalitarian by nature. If we let one wealthy person have it, then we want to find a way to let everybody have it. A rising tide raises all boats even if the boats shouldn't rise.
Suddenly, everybody is buying this something that may not be societally cost effective. The result of that is we end up helping visible victims at the expense of invisible victims. Because people see Slim Watson and his $5 million and they say, "I don't want him to die." They don't see too many people who didn't get flu shots, or the 500,000 people who didn't get mammograms, because of Slim Watson’s $5 million worth of care...
In the 1920's, there were 2 treatments for an acute heart attack in New York City. Most people would prescribe 6 months of bed rest. This cardiologist… at the height of prohibition, prescribed beer, and would write beer prescriptions. Everybody laughs. But it turns out the people who got beer did a lot better. Not because beer cured heart disease. I'm not telling you that. Don't go home and have your elderly drink beer. But the people who got bed rest without anticoagulants died in large number of blood clots. The beer was utterly neutral...
Historically, many of the people in bioethics starting when there was the bioethics revolution of the 60's and 70's, were what we would call liberal Christian thinkers. Many of the underlying principles of bioethics… really do stem from people who thought that what doctors were doing may have been well intentioned but was blind to the larger picture of making the world a better place. I think many of those people, although religiously motivated, developed a set of principles that largely embrace secular values like autonomy...
I think I would be a fool to say that bioethicists, certainly in the hospital setting, don't have biases. I think it's important to be aware of these biases with yourself. And they can actually prove very helpful. You can say to the patient who is a fundamentalist Christian. "I can't speak to your tradition but I'm an Orthodox Jew and this is what I believe. This may help you to some degree." You can also just try to [speak to] them neutrally. But it would be a mistake I think to tell them, "I don't have any religious bias whatsoever, and this is the right answer."...
I'm a fat guy who lives in San Francisco with a trolley line literally outside my front living room. You're scaring the hell out of me...
Virtue ethics was basically all we practiced for many, many years, though we didn't call it that. We asked the senior doctor at the hospital what he thought the right thing to do was"