The Elephant In The Room Presenter: Deborah Massey LCSW, ICADC II “ETHICS IS NOTHING ELSE THAN REVERENCE FOR LIFE.” ALBERT SCHWEITZER

The Elephant In The Room

Presenter: Deborah Massey LCSW, ICADC II

“ETHICS IS NOTHING ELSE THAN REVERENCE FOR LIFE.”

ALBERT SCHWEITZER

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The Elephant In The Room Workshop Agenda

2:00 - 2:15 Introductions and Ice Breaker

2:15 - 3:15 Part I

3:15 - 3:30 Break 3:30 - 4:30 Part II 4:30 - 4:45 Introspection 4:45 - 5:00 Closing Remarks/Questions/Evaluations

The Elephant In The RoomMichigan State University, College of Human Medicine, Center for Ethics

Humanities in the Life Sciences

What Is Bioethics?

EASY

ANSWER

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Bioethics is an activity; It is shared, reflective examination of ethical issues in health care, health science, and health policy. These fields have always had ethical standards without question, however we needed a more public andcritical discussion of these standards. Discussion, articulation, reflection and challenge most often compels revision.

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1ST Century Attitude relative to Medical Ethics and Modern Bioethics Atrocities

“It is not cruel to inflict on a few criminals, sufferings which may benefit multitudes

of innocent people through all centuries”.Celsius

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The Hippocratic Oath: Original Version

I swear by Apollo the physician, and Aesculapius the surgeon, likewise Hygeia and Panacea, and call all the gods and goddesses to witness, that I will observe and keep this underwritten oath, to the utmost of my power and judgment.

I will reverence my master who taught me the art. Equally with my parents, will I allow him things necessary for his support, and will consider his sons as brothers. I will teach them my art without reward or agreement; and I will impart all my acquirement, instructions, and whatever I know, to my master's children, as to my own; and likewise to all my pupils, who shall bind and tie themselves by a professional oath, but to none else.

With regard to healing the sick, I will devise and order for them the best diet, according to my judgment and means; and I will take care that they suffer no hurt or damage.

Nor shall any man's entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so. Moreover, I will give no sort of medicine to any pregnant woman, with a view to destroy the child.

https://en.wikipedia.org/wiki/Apollo

https://en.wikipedia.org/wiki/Asclepius

https://en.wikipedia.org/wiki/Hygieia

https://en.wikipedia.org/wiki/Panacea

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The Elephant In The Room(cont)

The Hippocratic Oath: Original Version

Further, I will comport myself and use my knowledge in a godly manner.

I will not cut for the stone, but will commit that affair entirely to the surgeons.

Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient; and I will willingly refrain from doing any injury or wrong from falsehood, and (in an especial manner) from acts of an amorous nature, whatever may be the rank of those who it may be my duty to cure, whether mistress or servant, bond or free.

Whatever, in the course of my practice, I may see or hear (even when not invited), whatever I may happen to obtain knowledge of, if it be not proper to repeat it, I will keep sacred and secret within my own breast.

If I faithfully observe this oath, may I thrive and prosper in my fortune and profession, and live in the estimation of posterity; or on breach thereof, may the reverse be my fate[4]

https://en.wikipedia.org/wiki/Lithotomy

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The Hippocratic Oath: Modern Version

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share

such knowledge as is mine with those who are to follow. I will apply, for the benefit of the sick, all measures

which are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I will remember

that there is art to medicine as well as science, and that warmth, sympathy, and understanding may

outweigh the surgeon's knife or the chemist's drug. I will not be ashamed to say "I know not," nor will I

fail to call in my colleagues when the skills of another are needed for a patient's recovery. I will respect the

privacy of my patients, for their problems are not disclosed to me that the world may know.

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The Elephant In The Room(cont)

The Hippocratic Oath: Modern Version

Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God. I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure. I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm. If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

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The Nuremburg Trials

December 9,1946 – August 20,1947

The Trials were a series of military tribunals, held by the allied forces after WWII most Notable for the prosecution of prominent members of the political, military, and economic leadership of Nazi Germany who allegedly planned, carried out, or otherwise participated in the Holocaust and other war crimes.

Trial Outcomes

1. 16 of 23 were found guilty of “Crimes against Humanity”

2. 7 were sentenced to death by execution

3. Verdict contained section “Permissible Medical experiments” which became the basis for the Nuremburg Code

Atrocities that Stimulated Discussion

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Voluntary Consent : is essential

research based on prior animal work

risks justified by anticipated benefits

Only qualified scientists conduct research

Avoid mental and physical suffering

If death or disabling injury is expected, research should not be conducted

Served as the first international standard for the conduct of research

The degree of risk should :“never exceed the humanitarian importance of problem” or “be minimized through proper preparations”

Participants should be free to withdraw

These basic and legal obligations in human research

The model for many professional and governmental codes since the 1950s

The first professional ethical code for medical researchers

1947 The Nuremburg Code: Codes of Research Ethics

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1932-1972 Tuskegee Syphilis Experiment 399 black men with Syphilis and about 200 men without syphilis participated The men were recruited without informed consent and they were not told that they were participants in a research study In the 1940s Penicillin was found to be effective in the treatment of Syphilis. The Study continued ….

Those infected were NOT informed or treated with the antibiotic Never received drugs for their conditions or told that they existed Spouses and children of the subjects also contracted Syphilis

Exposed in 1972 – During the 40 years of the study numerous papers were authored by the PHS team. Specialists in Syphilis around the world all knew of this long term study of untreated Syphilis.

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Late 1950s -1970 The Willow brook Hepatitis Study

Deliberately infected children with hepatitis for research purposes

Coercive measures to admit new children

Researchers defended the action, claiming that the vast majority would acquire the infection at Willow brook anyway, given the overcrowded, unsanitary conditions, and because only children whose parents had given consent were included

Closed the doors to new patients, claiming overcrowded conditions. However, the hepatitis program, was able to continue to admit new patients. Thus in some cases, parents found they were unable to admit their child to Willow brook unless they agreed to participation in the hepatitis studies

“EXPOSED IN 1972- “GERALDO RIVERA”

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The Aftermath

◦ Changes were made to prevent the moral breaches that occurred in Tuskegee from happening again.

◦ On May 4,1997- Surviving participants of the Tuskegee Syphilis Study gathered at the White House and witnessed President Clinton’s apology on behalf of the US government.

◦ Willow brook was closed in 1987. Federal civil rights legislation was introduced to protect people with disabilities.

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Establishment of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research

Established by the U.S. Congress to identify ethical principles to guide all human research

In 1979, Commission published the Belmont Report

Remains the cornerstone for all federal regulations on human research and sets the standard for ethics in medical care.

1979 The Belmont Report

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Four guiding principles that ultimately emerged from the findings of The Belmont Report and publication of Principles of Biomedical Ethics Autonomy: Respect for persons (informed consent, confidentiality, truth telling, competence)

Beneficence: Contribute to the human good (paternalism, substituted judgment, public health)

* Nonmaleficence: NOT ENOUGH to just do good…MUST prevent and do no harm. (PAS, euthanasia, competence, medical error, profit)Justice: Fair & equitable distribution (rationing, futility, treatment)

Fast Forward to the Mid 80’s

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Settings with Power imbalance

Economically disadvantaged

Racial & Ethnic minorities- immigrants

Uninsured- Poor

Children-Elderly-Homeless

Those with human critical & incurable illness

Chronic health conditions

Mental illness

Those who often encounter barriers to accessing healthcare services

OTHERS….

Medical Ethics Protecting Vulnerable Populations

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The Elephant in The Room

DO NO HARM!!!!

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Influences that often impact the quality therapeutic relationship:

Providers’ and Patient’s worldview

Providers’ and Patients’ personality type

Provider’s Helping Model

Provider Expectation and Patient Motivation

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Worldview is defined as a “view of life”, which is “a comprehensive interpretation

or image of the universe and humanity”.

Integrity, dignity, expectation, self-efficacy and trust are variables impacted in the therapeutic relationship and the ones most affected by one’s worldview.

World View

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Friedman suggests that Type A behavior is expressed in (3) major Symptoms1) Free-floating hostility, which can be triggered by even minor incidents

2) Time urgency and impatience, which causes irritation and exasperation usually described as being short-fused

3) Competitive drive, which causes stress and an achievement driven mentality

Descriptive Adjectives: Ambitious, Rigidly organized, Highly Status-conscious, Sensitive, Anxious, Proactive

Personality Type A

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1) Noted to live at lower stress levels in contrast to Type A

2) Work steadily and enjoy achievement however the stem of their unconscious character

disregards physical/mental stress when they do not achieve

3) When faced with competition, losing is not focused upon; enjoyment may be received

regardless of winning or losing

Descriptive Adjectives: Laid Back, Creative, Methodical, Often Reflective, Thoughtful of the “outer and inner world”.

Personality Type B

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1) Appear quiet and introspective but actually frustrated and swallow anger

2) Appease others to the point of self-effacement and self-sacrifice

3) Polar opposites of Type A emotionally

Descriptive Adjectives: non-emotional, non-assertive

Personality Type C

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1) Negative outlook towards life and are pessimistic

2) Relatively small event can ruin their day

3) Socially withdrawn as a result of fear of rejection even if they like and feel

comfortable around people

4) Lack of self-assurance

5) Suppress their emotions which makes them the most vulnerable type to depression

Descriptive words: worry, irritability, gloom, social inhibition, reticence

Personality Type D


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Evil model: The person is seen as willfully bad or possessed by evil spirits; the response involves exorcism or incarceration.

Illness model: The person is viewed as a helpless victim of psychic trauma, psychological or physical disorder, or chemical dependency; the response involves treatment.

Problem-solving model: The person has a problem and intellect and rational thought can be used to find a solution; the response involves technical consultation.

Crisis model: The person has experienced recent trauma or crisis; the response involves crisis management.

Growth model: The person should celebrate his/her uniqueness and ability to develop full potential; the response involves facilitating the individual’s capacities.

Biesser’s Models of Help


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Social issues model: The person is a victim of social forces or structural features of society; the response involves community organization or social advocacy.

Suspect model: The person is seen as unproductive, irresponsible, and dependent on society; the response involves minimal help with maximum policing.

Beneficiary model: The person has a right to a certain kind of help because he/she is a member of that society; the response involves provision of services.

Deviance model: The person is deviant and may also be sick; the response involves correction of deviant behavior.

Self-help model: The person is a victim of heredity, a dysfunctional family external substances, or control by others; the response involves support and solidarity from like sufferers.

Biesser’s Models of Help


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Effective interpersonal communication (IPC) between health care

provider and client is one of the most important elements for improving client

satisfaction, compliance and health outcomes.

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What are the Characteristics of Effective IPC?

Two-Way Dialogue

Partnership Between Provider and client

Atmosphere of Caring

Effective Bridging of Social Distance

Social Networks

Effective Use of Verbal Communication

Effective Use of Non-Verbal Communication

Opportunity for Patients to Speak About Their Illness

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Guidelines and Norms for Effective IPC.

1) Caring/socio-emotional communication

2) Diagnostic communication/problem solving

3) Counseling and Education

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The Elephant in the Room

Frame the encounter Use appropriate non-verbal communication Solicit feelings Show positive regard Validate the patient’s experience and efforts Echo patients’ emotions Express support and partnership Give reassurance

Caring/socio-emotional communication

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Diagnostic communication/problem solving

Listen attentively and actively

Encourage dialogue

Avoid interruptions

Avoid premature diagnosis and resist immediate follow-up

Probe

Ask about causes

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Explore patient understanding

Correct misunderstandings or

misinformation

Use appropriate vocabulary

Present information in blocks

Use visual aids and/or printed materials

when possible

Recommend concrete behavioral changes

Select an acceptable and feasible

treatment

Motivate patients to comply with

treatment

Summarize

Check for understanding and

absorption

Additional questions

Confirm Follow-up actions

Counseling and Education


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The Provider’s “Interrogation Approach”

Take Complete Breaths

Monitor changes in your breathing rate

Make an effort to actively listen

Take a few minutes to process the information and reflect before responding.

Try to avoid a lull in interaction by repeating what you’ve heard.

Discuss challenging cases in case conference/supervision.

Constantly check your motives

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REFERENCES De Negri, B., et al (1990). Improving interpersonal communication between health care providers and clients. Quality Assurance Methodology Refinement Series. Retrieved from http://www.globalhealthcommunication.org/tool

Ong, L.M.L., et al (1995). Doctor-patient communication: A review of the literature. Social Science and Medicine. 40(7), 903-908.

Street, R.L. Jr, et al (2007). Physicians’ communication and perceptions of patients: Is it how they look, how they talk, or is it just the doctor? Social Science and Medicine. 65(3), 586-598.

Van Ryn, M., & Burke, J. (2000). The effect of patient race and socio-economic status on physicians’ perceptions of patients. Social Science and Medicine. 50(6), 813-828.

Williams, S., et al (2005. Socio-economic status of the patient and doctor-patient communication: does it make a difference? Patient Education and Counseling, 56(2), 139-146.

Historical Information is the property of the Archives of the Walter Reed National Medical Center

http://www.globalhealthcommunication.org/tool

http://www.globalhealthcommunication.org/tool

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IDEOLOGY

LIFE EXPERIENCE

PERSONALITY

TYPE

WORLDVIEW

IDIOSYNCRASIES

PREJUDICE

MANY MORE????

Documents

The Elephant In The Room Presenter: Deborah Massey LCSW, ICADC II “ETHICS IS NOTHING ELSE THAN REVERENCE FOR LIFE.” ALBERT SCHWEITZER