Doctors, Technology Puzzles, and the Clinical Ethicist Detective

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Marleen Eijkholt, JD, PhD

I love puzzle rooms and detective novels. When medicine looks like a puzzle room, I become fascinated as a non-MD aspiring detective. When that medical mystery reveals an ethical problem, I really get in gear, as a clinical (neuro) ethicist.

Reading about the “Mystery of sonic weapon attacks at US embassy in Cuba” made me consider how physicians engage in a puzzle, and how piecing the story together leads to a hypothesis, as if in a puzzle room. Patients with strange and mysterious medical symptoms, suspicious circumstances, and the culprit? Uncertain – inexplicable narratives, patterns, and complaints that do not head in a clear prognostic direction. A story that continues to unravel. Doctors are detectives, and medicine can be a journey through a puzzle room to discover clues about the cause of ailments. Within the story, technology is the enemy but perhaps also a friend; providers embrace technology as it seems to promise a definitive answer.

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Image description: five white puzzle pieces are shown against a black background. Image source: Willi Heidelbach/Flickr Creative Commons.

The ethical problem: We do not make patients privy to the fact that medicine is something of a puzzle room, and that medicine’s technological tools carry substantial uncertainty. Instead, medical technology is presented as offering the path to a concrete solution. Uncertainty is rarely addressed by providers, or presented to patients who pay for expensive technologies, and equally who might suffer under their use. The medical world operates in a political and cultural system, which affects how providers want to see symptoms and technology. Patients get carried along with the tide. The embassy story made me think about the role of a clinical ethicist. Who challenges the patient, who challenges the doctor, who challenges the technology? Should clinical ethicists be detectives too?

What is/was going on in the Cuba case? Early news stories reported that a sonic weapon might have harmed American diplomats. Diplomats claimed hearing loss, speech problems, vision issues and nausea after perceiving high-pitched noises and thumps. Canadian diplomats (and their children!) might have been harmed too. Reports indicated uncertainty about the culprit: “None of this has a reasonable explanation.” Experts submitted that no detrimental sonic weapon with this power had yet been developed. However, plagued by symptoms, diplomats were called back for safety reasons; reasonably, they were not expected to endure permanent threats to their health, lives and livelihood.

Since the diplomats had not experienced blunt trauma, their condition was baffling. Research, as JAMA published, suggested that many of the 21 study participants showed various “objective” signs that could indicate neurologic injury, i.e., symptoms often found in individuals post-concussion. About the culprit, the authors stated: “The unique circumstances of these patients and the consistency of the clinical manifestations raised concern for a novel mechanism of a possible acquired brain injury from a directional exposure of undetermined etiology.” Per the study, MRI findings indicated a shift change in white matter, possibly suggesting a neurological foundation to the problem.

Critics of the study were less sure (see references 3, 5, 6, and 8 below). They questioned the MRI tool and laid out different approaches to the puzzle, in full public view. Critical analysists, including a Cuban author, labeled the symptoms as potentially psychosomatic, the result of a conversion disorder. Suggesting a mass-psychogenic illness, the authors submitted that the hype around Cuba generated a “bias,” creating anxiety and hypersensitivity. They contested the finding’s objectivity as based on self-report or subjective interpretations of the researchers. Hence objective conclusions were elusive. Critics offered that: “Medical diagnosis at any given time depends to some extent on the current state of scientific knowledge, historical and cultural context, and the framework through which a disease is conceptualized.” However, this context was explicitly ignored by another expert who favored a physical approach. In a Neurology Today article by Dan Hurley, Dr. Terry Fife stated: “Just because an MRI is normal doesn’t mean everything else is normal. Many conditions in the past that we thought were subjective turned out to be quite real.”

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Image description: a black silhouette of a figure walking, the figure’s head is a puzzle piece. The figure is against an orange background. Image source: Thomas Hawk/Flickr Creative Commons.

Intrigue around the sonic attacks made me consider how mechanistic conclusions are rarely called into question. In this case, the critical perspective came from fellow physicians, which is reassuring; the system does not often question mechanistic truths. I wonder what mechanisms exist in the real life clinic? I hear about cases in which the most powerful physician might reference MRI results, and oppose the withdrawal of life support. Contrary to the whole team of other providers, who describe the clinical picture as awful and exacerbating the patient’s suffering, as well the family, who indicate that the patient would not want continued life support, the physician objects to withdrawal, stating that the MRI tool does not confirm the clinical picture; this physician wishes to continue full steam ahead. Without questioning his tool (i.e., the MRI), or the technological questions of his colleagues, the patient is unreasonably made to suffer.

Tools to facilitate any type of “certainty,” like MRIs, are popular reference points used to instill trust in our patients and our families. Just as the detective’s magnifying glass stands for scrutiny and expertise, the stethoscope stands for the physician’s trustworthiness. In foggy medical settings, heart monitors and MRI machines are powerful symbols to generate certainty and clarity. The health care setting presents them as supersonic tools. In cases where the results are questioned, the setting proposes that the patient must be “wrong” and not the technology. As illustrated in the Cuban diplomats’ case, the alternative explanation for their symptoms goes straight to mass psychogenic illness. Instead of having a somatic origin, because we could not view something, the symptoms must be caused by a mental state.

What is the role of a clinical ethicist within this culture? The story made me consider how much we need to walk into the medical puzzle room. Especially where medical tools are obstacles because of their presumed “definitive” clarity. Where physicians ignore questionable methodologies, should ethicists then be the detective? Pull out their magnifying glass, and use their tools of critical questions? Who should ask what is real and what is not? Whose role is it to challenge the patient, the doctor, the technology?

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Marleen Eijkholt, JD, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Obstetrics, Gynecology and Reproductive Biology in the Michigan State University College of Human Medicine. Dr. Eijkholt is also a Clinical Ethics Consultant at Spectrum Health System.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, May 31, 2018. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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Bioethics for Breakfast: Health Care Consolidations: Good News, Bad News, Fake News?

Bioethics for Breakfast Seminars in Medicine, Law and SocietyJohn Goddeeris, PhD, and Michael Herbert presented at the Bioethics for Breakfast event on May 10, 2018, offering perspective and insight on the topic, “Health Care Consolidations: Good News, Bad News, Fake News?” Leonard Fleck, PhD, moderated this session.

At the national level as well as in our state, the macro-level restructuring of health care delivery is impacting physician-patient clinical encounters, clinics, hospitals and health systems. As the engaged moderator for this session, Dr. Fleck guided those in attendance in examining downstream consequences of such restructuring and consolidations by posing questions to the two presenters: Dr. John Goddeeris, Professor of Economics, and Michael Herbert, Chief Executive Officer for the MSU HealthTeam.

Dr. Fleck asked the presenters to respond to the following questions: What are the basic statistics regarding health care consolidation? How does consolidation affect medical practice (and the core values of medicine)? Are patients better off as a result of consolidation? Does consolidation save the health care system money? Alternatively, does it give more pricing power to the hospital industry (against insurers who wish to demand discounts of various sorts)? Does this process have any significant effects for rural health care? Does this process increase or decrease disparities in the health care system, i.e., access to needed care for those less well off?

John Goddeeris
John Goddeeris, PhD, is a Professor of Economics in the Department of Economics in the College of Social Science at Michigan State University. Dr. Goddeeris’ expertise includes economic issues in health care, including health insurance and government programs. His research has been published widely in journals in economics, medicine, public health, and health policy. Dr. Goddeeris is a nonresident fellow in the Health Policy Center at the Urban Institute.

Michael Herbert
Michael Herbert, Chief Executive Officer for the MSU HealthTeam, is a consultant dedicated to assisting Academic Medical Centers in organizational design and operations, including hospital and faculty group practice operations, as well as Medical School operations, leadership development, strategic plan design and implementation and government policy development. He has served in a variety of high-level medical school and health system leadership positions in Michigan as well as in many other states, and was the Associate Deputy Regional Director in the Department of Veterans Affairs.

About Bioethics for Breakfast:
In 2010, Hall, Render, Killian, Heath & Lyman invited the Center for Ethics to partner on a bioethics seminar series. The Center for Ethics and Hall Render invite guests from the health professions, religious and community organizations, political circles, and the academy to engage in lively discussions of topics spanning the worlds of bioethics, health law, business, and policy. For each event, the Center selects from a wide range of controversial issues and provides two presenters either from our own faculty or invited guests, who offer distinctive, and sometimes clashing, perspectives. Those brief presentations are followed by a moderated open discussion.
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Episode 9: Reflecting on Early Bioethics: Fleck and Tomlinson

No Easy Answers in Bioethics logoEpisode 9 of No Easy Answers in Bioethics is now available! This episode features two senior Center faculty members, Director Tom Tomlinson, PhD, and Professor Len Fleck, PhD. Together they discuss and reflect on the accidental ways in which they entered the field of bioethics in the 1970s and ‘80s, also touching on the creation of the program that became the Center for Ethics around that same time. They discuss the changes they’ve seen around topics such as death and dying, advance directives, and advances in medical technologies. Finally, they speculate on where bioethics may be headed in the future.

Ways to Listen

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full episode transcript available.

This episodes wraps up the first “season” of No Easy Answers in Bioethics! Catch up on previous episodes this summer, and tune in this fall for new discussions around bioethics and research in the Center for Ethics.

About: No Easy Answers in Bioethics is a podcast series from the Center for Ethics and Humanities in the Life Sciences in the Michigan State University College of Human Medicine. Each month Center for Ethics faculty and their collaborators discuss their ongoing work and research across many areas of bioethics—clinical ethics, evidence-based medicine, health policy, medical education, neuroethics, shared decision-making, and more. Episodes are hosted by H-Net: Humanities and Social Sciences Online.

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Dr. Stahl gives talk at neonatal nurses conference

Devan Stahl photoOn April 30, Center Assistant Professor Dr. Devan Stahl gave a plenary address at the State of Wisconsin Association of Neonatal Nurses Annual Education Conference, titled “Palliative Care and End of Life Ethics in the NICU.” Using case studies, she discussed the ethical and medical complexities surrounding decisions for the treatment of severely ill infants, strategies for interacting with families who request inappropriate or non-beneficial treatment for their child, and the obligations of care providers to protect the best interests of infants. 150 nurses from Wisconsin and surrounding states were in attendance.

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Dr. Tomlinson co-author of medical education article

Tom Tomlinson photoCenter Director and Professor Dr. Tom Tomlinson is co-author of an article in the open access e-journal MedEdPublish. The article, “Reframing Professionalism: The Virtuous Professional,” was written by College of Human Medicine faculty members William Wadland, Margaret Thompson, Donna Mulder, Tom Tomlinson, Steven Roskos, John Foglio, John Molidor, and Janet Osuch.

Abstract: In response to prevalent unprofessional behaviors during the 1990s, the medical school administration at Michigan State University’s College of Human Medicine developed a student curriculum for professional development, called “The Virtuous Student Physician.” However, as students adopted these professional aspirations and attributes, they noted that faculty members were not being held to the same standards.

The medical school’s senior associate dean for faculty affairs and development convened a task force to reframe professionalism for all faculty, residents, and students. Our first step was to survey our faculty regarding their awareness of the student professionalism curriculum and their own perceived professional weaknesses. This survey showed the following: most faculty members were aware of “The Virtuous Student Physician” curriculum, that faculty members identified social responsibility as the most difficult attribute to achieve, and that the most difficult behavior identified was working to resolve problem behaviors with colleagues.

The task force then developed a new curriculum “The Virtuous Professional: A System of Professional Development for Students, Residents, and Faculty.” The task force identified three core virtues (Courage, Humility, and Mercy) and reframed the professional attributes encompassed by these virtues to be aspirational for the entire learning community. The faculty of the College subsequently adopted the new principles and practices, including the use of routine, anonymous student evaluation of faculty professionalism.

We are currently collecting data from student evaluations of their clinical faculty members. We plan to use this feedback to guide faculty development and recognize those who model exemplary professionalism as well as to address those who engage in unprofessional behavior.

The full text is available online from AMEE MedEdPublish.

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Dr. Cabrera speaks at nutrition, enhancement conferences in April

Laura Cabrera photoCenter Assistant Professor Dr. Laura Cabrera recently spoke at the Michigan Academy of Nutrition and Dietetics annual conference, held April 26-27 in Bay City, MI. Dr. Cabrera spoke on “Dietetics and Ethics: What is your Professional Role?” Her talk aimed to provide guidance on understanding and identifying ethical issues that registered dietitian nutritionists (RDNs) and nutrition and dietetic technicians, registered (NDTRs) may face in their practices. Her session was well attended and interactive.

Dr. Cabrera also traveled to New Jersey to speak at the Ethics of Enhancement Workshop at Rutgers University-Camden, held April 27. There she spoke on “Neuroenhancement: Rethinking Human Values.” Her talk aimed to explore the way values affect and are affected by enhancing cognitive, affective and social abilities, and argued that a social responsibility framework could help us bridge the tensions underlying the interplay of values and neuroenhancement practices.

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Dr. Stahl co-author of article in new ‘American Journal of Bioethics’ issue

Devan Stahl photoAuthors Trevor M. Bibler (Baylor College of Medicine), Myrick C. Shinall, Jr. (Vanderbilt University Medical Center), and Center Assistant Professor Dr. Devan Stahl have a target article in the May 2018 American Journal of Bioethics, on “Responding to Those Who Hope for a Miracle: Practices for Clinical Bioethicists.” Additionally, AJOB published correspondence from the authors, “Response to Open Peer Commentaries on “Responding to Those Who Hope for a Miracle: Practices for Clinical Bioethicists”,” where the three authors discuss significant points of disagreement, clarification, and agreement from the responses to their article.

Abstract: Significant challenges arise for clinical care teams when a patient or surrogate decision-maker hopes a miracle will occur. This article answers the question, “How should clinical bioethicists respond when a medical decision-maker uses the hope for a miracle to orient her medical decisions?” We argue the ethicist must first understand the complexity of the miracle-invocation. To this end, we provide a taxonomy of miracle-invocations that assist the ethicist in analyzing the invocator’s conceptions of God, community, and self. After the ethicist appreciates how these concepts influence the invocator’s worldview, she can begin responding to this hope with specific practices. We discuss these practices in detail and offer concrete recommendations for a justified response to the hope for a miracle.

The full text as well as the response are available online through Taylor & Francis Online (MSU Library or other institutional access may be required to view these articles).

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