Evening Ethics Discussions
- April 5: "Racism and Discrimination in Medicine -When the Physician is the 'Victim'"with J. Nwando Olayiwola, MD, MPH, FAAFP
- March 27: "A Panel Discussion and viewing of documentary film: The State of Eugenics: The Story of Americans Sterilized Against Their Will"
- February 22: “A Terror Way Beyond Falling: Suffering, Suicide, and Physician Aid-In-Dying”
- January 31: “OMG, What R They Thinking: Adolescent Refusals of Important Medical Care” with Douglas Diekema, MD, MPH, 2018 David Green Memorial Speaker
In recent years, several cases involving adolescent patients refusing life-saving treatment (blood transfusions, cancer treatment) have been covered by national media outlets, raising questions about the role of the adolescent in medical decision-making. Should adolescents be allowed to refuse life-saving medical treatment? Does it matter whether their parents agree or disagree with their decision? Does the age of the adolescent matter? Using several case studies, we will discuss whether adolescents, as a rule, possess capacity of sufficient quality that their decisions should be respected even in the case of life-altering medical decisions. This session will touch on the traditional approach to determining when adolescents should have their decisions respected (including what the American Academy of Pediatrics Committee on Bioethics has said), the evolving understanding of adolescent brain development, and the implications of that “brain science” for how we should understand adolescent decision-making capacity. Please contact firstname.lastname@example.org for a pdf of the background reading for this event, “Adolescent Refusal of Lifesaving Treatment: Are We Asking the Right Questions?” by Douglas Diekema, MD, MPH. (Adolesc Med 022 (2011) 213228).
“The so-called ‘psychotically depressed’ person who tries to kill herself doesn’t do so out of quote ‘hopelessness’ or any abstract conviction that life’s assets and debits do not square. And surely not because death seems suddenly appealing. The person in whom Its invisible agony reaches a certain unendurable level will kill herself the same way a trapped person will eventually jump from the window of a burning high-rise. Make no mistake about people who leap from burning windows. Their terror of falling from a great height is still just as great as it would be for you or me standing speculatively at the same window just checking out the view; i.e. the fear of falling remains a constant. The variable here is the other terror, the fire’s flames: when the flames get close enough, falling to death becomes the slightly less terrible of two terrors. It’s not desiring the fall; it’s terror of the flames. And yet nobody down on the sidewalk, looking up and yelling ‘Don’t!’ and ‘Hang on!’, can understand the jump. Not really. You’d have to have personally been trapped and felt flames to really understand a terror way beyond falling.” -David Foster Wallace (2009), Infinite Jest, pg. 696.
In late 2016 the American Psychiatric Association (APA) stated that psychiatrists ought not participate in physician aid in dying (PAD) or euthanasia for non-terminal illnesses. This practice already occurs in some European countries. As Mark Komrad, a psychiatrist on the APA’s national ethics committee, explained, the organization was concerned about this practice for multiple reasons: that it communicates that there is no hope for persons with severe suffering due to psychiatric illness, that persons with psychiatric illness have impaired decision-making capacity, and that judgments about whether suffering is interminable depend upon patients’ assessments of whether treatments like ECT are acceptable, even though these assessments could be controversial or misinformed. In effect, Komrad and the APA have opposed this practice because they are concerned that vulnerable psychiatric patients whose suffering might be treatable could instead receive aid in dying.
It would undoubtedly be a bad thing if that worry came to fruition. Still, we’re concerned that the APA’s opposition to PAD for non-terminal psychiatric illness is too facile. We’ll argue that the central justifications for PAD in cases of terminal illness also apply to some cases where people suffer only from non-terminal psychiatric illness. Moreover, we argue that the APA’s reasons for excluding persons with non-terminal illness from PAD are not compelling.
On the other hand, we are also sensitive to the APA’s concerns about PAD and euthanasia, and agree that many persons with psychiatric illness who suffer from suicidal ideation should not have access to PAD. Furthermore, we regard psychiatric practices like involuntary civil commitment and involuntary medication to prevent suicide as generally justifiable even though they are, as we will argue, deeply at odds with the rationale for PAD for non-terminal, psychiatric illness.
The result, we think, is a serious dilemma: how do we reconcile the idea that medicine should be empowered to prevent persons from attempting suicide with the idea that severe and intractable suffering, even when it is due to a non-terminal illness, can make death seem a reasonable option?
There are 3 short background readings: (contact email@example.com for copies)
- “Capacity Evaluations of Psychiatric Patients Requesting Assisted Death in the Netherlands” by S.N. Doernberg, et.al. (Psychosomatics2016:57:556–565)
- “Psychiatric evaluations for individuals requesting assisted death in Washington and Oregon should not be mandatory” by Linda Ganzini, MD, MPH (General Hospital Psychiatry 36 (2014) 10–12
"A Panel Discussion and viewing of documentary film: The State of Eugenics: The Story of Americans Sterilized Against Their Will"
This Evening Ethics is presented in collaboration with UCEER (The University of Utah Center for Excellence in Ethical, Legal, and Social (ELSI) Issues in Genetic Research) and the Spencer S. Eccles Health Sciences Library (EHSL).
From the 1930s to the 1970s, more than 7000 people were sterilized, often against their wishes and without their knowledge, by the state of North Carolina. While not the only state to use official government channels to promote procure “eugenic sterilizations” for people deemed unworthy of reproducing, North Carolina has one of the best documented histories of the practice and subsequent attempts at reparations. This 80-minute documentary film portrays the lives and struggles of the people and families wronged, and now seeking justice. There will be no background reading for this session, but it will be one-half hour longer than our typical Evening Ethics program in order to have adequate time for the panel-led discussion after we view the film.
"Racism and Discrimination in Medicine -When the Physician is the 'Victim'"with J. Nwando Olayiwola, MD, MPH, FAAFP
This Evening Ethics is presented in collaboration with the Office of Inclusion and Outreach and the Spencer S. Eccles Health Sciences Library.
|J. Nwando Olayiwola, MD, MPH, FAAFP|
In medicine, there is almost a sacred covenant between the physician and the patient, in which the physician, under oath to "do no harm," feels personally responsible to cater to the needs of their patients, sometimes at the risk of their own wellness. Additionally, there is a high level of trust that patients extend to their physicians, not always earned, and often assumed. However, even with this, physicians are increasingly learning in course of their training about the impact of their own biases on patient care and outcomes. Much of our medical education and training, rightfully, exposes resultant health and health care disparities by virtue of physicians’ overt or covert prejudices that influence their care and their often unilateral power in relationships. However, what if that sacred relationship is distorted by the patient's prejudices? What if the relationship dynamic is shifted and the patient is the owner of that power? In many cases, that's a good thing- we want patients to feel more empowered and activated in their own care. We want patient voices to be heard and respected. But, in the case that a physician is subject to discrimination, racism or sexism by a patient, have we prepared ourselves for how to respond? What should that preparation look like? In this session, Dr. Olayiwola will share her perspective on her article, “Racism in Medicine: Shifting the Power,” our background reading for this session, linked here, and facilitate a dialogue around "-isms" and "-schisms" in medicine, how to prepare physicians and other health care professionals for these realities, how to understand microaggressions, and how to regain power and self-confidence.
Dr. Olayiwola is CEO & Founder, Inspire Health Solutions, LLC & Association of Minority Women Professionals, Chief Clinical Transformation Officer, Rubicon MD, Associate Clinical Professor, UCSF Department of Family & Community Medicine.