11 No. 3
December 2008/January 2009
Unraveling healthcare's knottiest problems
Researcher’s alleged transgressions lead to more ethics oversight
“Is it reasonable for [a patient] to be able to demand everything be done regardless of what that does to the healthcare system financially, or to its ability to serve a wider population?”
“I don’t think the main role of the ethicist is to tell people what’s right and wrong. One who does that in my opinion abdicates one’s responsibility.”
Medicine and Compassion
Reaching across the silos to teach the "art" of healing
Things I've learned while I couldn't do my research
Egypt and Emory
Small collection, large footprint
Academic Exchange: How does Emory’s Center for Ethics differ from others across the country?
Paul Root Wolpe: The field of bioethics is very hot right now, and there are bioethics centers springing up all over the country. What’s different about Emory’s center is that it isn’t a bioethics center; it’s a general ethics center whose mandate is not only to concentrate on medical ethics but to think about ethics as broadly as possible. So it covers everything from social welfare ethics, environmental ethics, even creativity in the arts—whatever field we can think about in terms of the ethics of behavior and the ethics of social communication. That’s fairly unusual. There may be one or two others in the country. Thinking of things from an ethical perspective is very much ingrained in the DNA of the university. That’s reflected in our resources and the seriousness with which the administration takes the ethics center.
AE: What’s the role of the clinical ethicist?
PRW: One role is to facilitate communication and to help people elicit their own values, because an ethicist has much greater knowledge of the way these decisions have been made in the past, or at least the principles by which they’ve been made in the past. I don’t think the main role of the ethicist is to tell people what’s right and wrong. One who does that in my opinion abdicates one’s responsibility. That can be the role of pastoral care, when someone wants to make a decision and wants to know what their particular tradition has to say about it. In that case, someone might say, In our tradition this is right or that is right. I’m not an ethical relativist. One can evaluate behavior with certain kinds of moral values that are absolute, but within that realm is an enormous range of defensible ethical positions. In a pluralistic society, it’s impossible and wrong to impose any one group’s moral standards on the rest of the group.
AE: What evolution in bioethics have you seen over the last ten to fifteen years?
PRW: Bioethics was an obscure field a couple of decades or so ago. When I told people I was interested in it they almost never knew what I was talking about. Now it’s a central field in medical education and health. Ethics has become an important part of medical training and hospital administration. Almost all hospitals have ethics committees; fewer have a dedicated ethics consultant. In many, the head of the ethics committee serves that function, even though they’re rarely well trained in ethics. Having an actual clinical ethicist on staff is relatively rare. It’s still difficult to make the case to hospitals that they should invest money in that service. Once you actually install someone like that in a hospital, the amount of demand that person commands shows just how needed the position is.
AE: What are the big issues in bioethics today?
PRW: One of the most important in clinical ethics is simply healthcare access, delivery, and payment—people who can’t get proper healthcare because they don’t have the resources. That’s part of our Byzantine healthcare system. Economic problems figure very highly in some of the ethical dilemmas in hospitals. Organ transplants always have hosts of ethical issues around them. In pediatrics, another issue is parents who don’t want their children vaccinated, or questions of how far you go trying to save a child’s life when also causing enormous pain and suffering. Some issues are very specialized. I was asked once to go talk to dermatology residents. They told me about some remarkably interesting and troublesome ethical issues I haven’t heard before or since that are unique to dermatology. One was about skin tags—small flaps of skin that can develop on the body. Some people have many of them. When a dermatologist removes one, they send it off to be tested for cancer. Although they aren’t commonly cancerous, you don’t want to miss one. Some patients have many tags, and it costs money for each vial containing skin tags for cancer testing. If they put all thirty tags in one vial, they’re charged for one test, but the results won’t identify which tag is cancerous and the dermatologist won’t know where on that person’s skin they have the cancer. On the other hand, if each tag is placed in a separate vial, it’s going to cost an enormous amount of money. So what’s the right thing to do? Spend this enormous amount of money for a small chance there might be cancer, or send them all in, find out there’s cancer, and have to re-biopsy each site and then send them in separately? That’s a classic example of risk-benefit and use of resources, but it’s unique to dermatology.