The 18th Annual American Society for Bioethics and Humanities Meeting was held October 6-9 in Washington, DC. Center faculty Libby Bogdan-Lovis, Karen Kelly-Blake, Devan Stahl, and Len Fleck presented at the conference. The post below details each researcher’s presentation in their own words.
Libby Bogdan-Lovis, MA
Assistant Director, Center for Ethics and Humanities in the Life Sciences
In concert with research collaborators Karen Kelly-Blake, Nanibaa’ Garrison, (Seattle Children’s Hospital) and Faith Fletcher (University of Illinois Chicago), we presented “Medicine’s Mirror Image Agenda: Covert Costs of Racial/Ethnic Concordance in the Medical Workforce.” Our project is supported by the contributions of research assistants Brittany Ajegba (MSU College of Human Medicine student), Nichole Smith (Vanderbilt premedical undergraduate), and Morgann Brafford (MSU psychology/anthropology undergraduate).
Our team reported results of a 2000-2015 scoping literature review to examine presumed benefits of matching underrepresented minority (URM) physicians with patients sharing similar race/ethnic identities. In our analysis we considered the nature of medical workforce policy strategies. We reported that the most frequently cited rationales for increasing the URM medical workforce were service commitment and enhanced physician-patient relationship. The primary strategy for achieving this goal was pipeline programs. We argued that even though URMs provide a substantial proportion of medical care to the underserved, and quite possibly such workforce patterns reflect focused altruism to serve one’s own, parity and service rhetoric may covertly shape the professional lives of Native American, African American, and Latino underrepresented minority (URM) physicians. We questioned whether those strategies might not unevenly affect URM physicians, selectively placing service expectations not similarly placed on their non-minority physician colleagues. We concluded by explaining that social justice of the profession entails equitable sharing of responsibility to meet the needs of the underserved and that social justice in the profession demands that URM physicians deserve an unfettered future and should not be viewed as instruments to fix societal structural determinants of health.
Devan Stahl, PhD
Assistant Professor, Center for Ethics and Humanities in the Life Sciences
This year at ASBH I had the opportunity to organize and lead two sessions. First, as the co-leader of the Bioethics and Christian Theology Affinity Group, I helped to organize a panel which featured Dr. Lydia Dugdale’s new book, Dying in the Twenty-First Century: Toward a New Ethical Framework for the Art of Dying Well. Dr. Dugdale’s presentation was followed by two responses by Dr. Paul Scherz and Dr. Mark Cherry. The session was well-attended and generated much conversation.
The next day, I helped to lead a workshop: “Responding to Those Who Hope for a Miracle: Conceptual Resources and Practical Responses for Clinical Ethicists” with Drs. Trevor Bibler, Myrick Shinall and Ashley Stevens. The workshop began with an overview of the theological concepts that frequently accompany the beliefs of patients and families who hope for a miracle. We then presented case studies to show four ways patients employ the term “miracle” as they struggle to understand God and strategies for responding to these four types of invocators. We lead breakout sessions to help attendees identify the types of miracle language discussed and best practices for responding to each. The session was very popular, which unfortunately meant several people could not fit in the space provided. Positively, the workshop had a lot of good discussion and participation by attendees.
Len Fleck, PhD
Professor, Center for Ethics and Humanities in the Life Sciences
I presented Saturday morning at ASBH. The title of my presentation was “Last Chance Therapies: LVAD and a Heart Transplant?” The ethical issue I was addressing here is related to cardiac transplantation. Only about 2200 hearts are available for transplantation each year in the US, so this is an absolutely scarce resource. Dick Cheney, former Vice-President, after five heart attacks (starting at age 37) and every imaginable cardiac intervention to sustain his life, was diagnosed as being in late-stage heart failure in late 2010. He had surgically implanted at that time a Left Ventricular Assist Device [LVAD] to maintain marginal heart function. He almost died in surgery, spent 40 days in the ICU, and was listed for a heart transplant. He received that transplant at age 71 in 2012. Many will argue (including me) that Cheney had had his “fair innings,” and that a younger person, a bit further down on the transplant list, should have gotten that transplant. But that person died instead (the “unknown” patient, and without any monument).
The Cheney story is what provoked my research. There are about 3700 patients on the heart transplant list now, though 300,000 patients die of heart failure [HF] each year in the US. Roughly 30,000 of them would be candidates for a heart transplant (though no one would advocate adding 30,000 “excess” candidates to the heart transplant list). Many transplant surgeons regretted that numerous “good” candidates died while on the list who would have done well with a transplant if they could have hung on a bit longer. So, about fifteen years ago, LVADs were provided to such patients to sustain cardiac function as a “bridge to transplant.” The cost of implanting an LVAD is $250,000, though that cost rises to $500,000 with major complications. As many as 70% of patients receiving an LVAD will suffer such complications (sepsis, device failure, stroke, bleeding in the gut).
One ethically relevant point is that the LVAD intervention adds substantially to the cost of saving a heart transplant patient without saving any more patients (still 2200). But another ethically relevant point is that it does alter who lives and who dies on the list. One could argue that this is all a matter of ethically neutral chance. This would be true before LVADs were used as a bridge to transplant. This is less obviously true in the post-LVAD world. For one thing, patients with congenital heart defects (now in their 20s, 30s, 40s) do not have the LVAD option. That means they have just one shot at life prolongation whereas LVAD patients have two shots. I argue that patients with congenital heart disease should have some degree of priority over the LVAD patients. As things are now those congenital heart defect patients have a 40% greater chance of dying on the transplant list compared to the LVAD patients. I ask, “Is that fair?”
What I report here is only the tip of the iceberg compared to what I discovered in the medical literature. I asked in the title of my presentation whether end-stage cardiac patients should have to choose between an LVAD (some prolonged life for certain) and a spot on the heart transplant list (rolling the dice). As things are now, 30% of LVAD patients die within a year of implantation and 40% survive four years, though often with significantly diminished quality of life. In contrast, 60% of cardiac transplant patients will be alive ten years later with acceptable quality of life. Requiring patients now to choose one or the other would be regarded by many as being ethically problematic. Still, I concluded by arguing that if the complication rate for LVADs could be brought below 10% and if four-year survival could be brought above 80%, then it would be ethically preferable that heart failure patients above age 60 should have to choose either an LVAD or a transplant list spot, but not both.