Bioethics for Breakfast: Values at the End of Life: The Logic of Palliative Care

Bioethics for Breakfast Seminars in Medicine, Law and SocietyRoi Livne, PhD, presented at the Bioethics for Breakfast event on October 4, 2018, offering perspective and insight on the topic “Values at the End of Life: The Logic of Palliative Care.” Leonard Fleck, PhD, moderated this session.

Over the past forty years, “the end of life” has become the center of extensive economic, policy, ethical, and medical discussions. Health economists measure and evaluate its cost; ethicists debate the morality of various approaches to “end-of-life care”; policymakers ponder alternative “end of life”-related policies; and clinicians apply a specialized approach (hospice and palliative care) to treat patients whom they diagnose as being at “the end of life.” How are those many-faceted conversations emblematic of this particular moment in history? How are the limits of what can be done, both medically and financially, to prolong life communicated to severely ill patients and families? Dr. Livne’s analysis drew from a combination of historical and ethnographic work conducted with palliative care clinicians in three California hospitals.

Roi Livne
Roi Livne is an Assistant Professor in the Department of Sociology at the University of Michigan. He received his PhD in sociology from the University of California, Berkeley in 2016. An economic sociologist at heart, he studies everyday economic life and its somewhat awkward intersections with morality. His book, Values at the End of Life: The Logic of Palliative Care is forthcoming this February in Harvard University Press. The book develops a historical and ethnographic account of the deeply personal relationships between financial considerations, emotional attachments, and moral arguments that motivate end-of-life decisions in American hospitals. Livne’s other research is on the techno-politics of sovereign debt management. He has published in the American Sociological Review and Socio-Economic Review.

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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Dr. Fleck facilitates occupational and environmental medicine workshop at Michigan conference

Leonard Fleck photoCenter Acting Director and Professor Dr. Len Fleck held a workshop at the annual Michigan Occupational Health Conference in Grand Rapids, MI on September 28. Dr. Fleck’s workshop was on “Occupational and Environmental Medicine: Ethical Challenges.”

The primary ethical challenge for physicians in occupational medicine is the dual loyalty challenge. More specifically, they are employed by (or contracting with) some large company to address health issues related to employees. In the workshop itself, attendees considered several concrete examples of this challenge, in particular, what might be regarded as emerging challenges related to emerging genetic technologies. A concern in many workplace situations that involve numerous chemicals is the health and safety of workers. Some workers may be susceptible to serious medical disorders related to such exposures for genetic reasons, but the required exposure might have to be over a prolonged period of time. An employer might offer to pay for whole genome sequencing to identify workers with such risks, in part for morally sound reasons (not wanting to cause avoidable harm to these workers), in part for more selfish economic reasons (not wanting to be at risk for large future health costs). An occupational physician would receive that information, and be expected to pass it along to an employer (who paid for it).

However, there are privacy rights that seem to be at risk; there are also issues of respect for patient autonomy. One worker, in the example Dr. Fleck gave to the audience, was found to be at 30% increased risk for colorectal cancer after ten years of exposure to a specific chemical. He did not want the physician to report that genetic vulnerability to his employer for fear of losing his job. He was willing to accept the risk. What is the right thing to do, all things considered? Several physicians said their responsibility extended only to determining “fitness to work.” And this worker was not going to drop dead next month or next year as a result of this vulnerability. So they would not report that result. Others asked about the details of the agreement with the company. Should the occupational physician strongly counsel this patient? One response was that this was the job of the primary care physician that this individual might have. In brief, discussion was vigorous and interesting.

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Medical workforce diversity research published in ‘Medical Education’

Karen Kelly-Blake photoLibby Bogdan-Lovis photoAn article from a multi-institution research team led by Center Assistant Professor Dr. Karen Kelly-Blake and Assistant Director Libby Bogdan-Lovis has been published in the September 2018 issue of Medical Education.

In “Rationales for expanding minority physician representation in the workforce: a scoping review,” the authors discuss “rationales for and approaches to expanding under‐represented minority (URM) physician representation in the medical workforce” found in their scoping review of fifteen years of literature.

The full text is available online via Wiley Online Library (MSU Library or other institutional access may be required to view this article).

Dr. Kelly-Blake and Libby Bogdan-Lovis further discussed their article in an interview for the Medical Education podcast series.

Related items from the Center:

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New commentary from Dr. Tomlinson in ‘American Journal of Bioethics’

Tom Tomlinson photoCenter Professor Dr. Tom Tomlinson has a new commentary in the September 2018 American Journal of Bioethics. In “Getting Off the Leash,” Dr. Tomlinson discusses “digital medicines” and what such technologies mean for patient privacy. He asks questions such as: do patients have a right to deceive their clinicians? Why would patients be deceptive?

The full text is available via Taylor & Francis Online (MSU Library or other institutional access may be required to view this article).

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Dr. Fleck facilitates ethics workshop at Michigan pediatrics conference

Leonard Fleck photoOn September 14, Center Professor and Acting Director Dr. Leonard Fleck and Dr. Kenneth Pituch, MD, ran an ethics workshop at the Michigan Chapter of the American Academy of Pediatrics (MIAAP) 68th Annual Conference. The workshop, “Ethical Challenges in the Care of Seriously Ill Children,” focused on two cases: a growth attenuation case, and a Trisomy-18 newborn case.

The growth attenuation case involved a 7-year-old boy with severe developmental delay related to a CMV infection in utero. Parents are middle-aged and “not in great health.” They requested growth attenuation hormone therapy so that they would be able to manage the care of their child for many more years. No one doubts that they are devoted parents. The relevant ethical considerations concerned the best interests of this child and parental rights to make medical decisions for their children. On the face of it, it looks like the parents are making this decision for their benefit, i.e., easier care management for this child. While this is true, as the discussion brought out, it is also the case that this would be in the best interest of the child as well. More specifically, this child will not be deprived of any life experiences as a result of growth attenuation because of his severe developmental delay. Hence, growth attenuation does not represent a harm to this child.

Dr. Fleck and Dr. Pituch’s other case involved a Trisomy-18 newborn. In the past these children had dismal prospects. Virtually all of them died before age one, most often because of cardiac anomalies. Today, complex surgeries can be done on these children, all of which are risky. Consequently, some of these children can survive into their twenties, though this will be with severe cognitive deficiencies. The ethical challenge for pediatricians is determining what sort of conversation to have with parents regarding treatment or non-treatment options. In the case discussed, this was complicated by the fact that a representative of a Trisomy-18 support group contacted these parents one day after the birth to “assure” them that they did not have to choose non-treatment. The problem with these support groups is that they tend to be excessively optimistic and do not know the medically relevant and ethically relevant details associated with prospects for a particular infant. This can complicate the conversation that a pediatrician must have with these parents, and can potentially sow the seeds of distrust. What would clearly be the ethically and practically wrong thing to do would be to tell these parents to pay no attention to these support groups. Overall, the discussion in this workshop was lively and thoughtful.

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How can we protect patient rights and improve patient safety?

bbag-blog-image-logoEnding Medical Self-Regulation: Does Less Physician Control Improve Patient Safety and Protect Patient Rights?

Event Flyer

Medicine has long been one of the most self-regulating of all professions. In the 1970s, the new field of bioethics was designed to challenge this prevailing system. As Senator Ted Kennedy explained at the founding of Georgetown’s Kennedy Institute of Ethics, “Human life is too precious and the decisions regarding it too important to leave to any one group of specialists.” Still, even fifty years later, medicine remains largely self-regulating. And patients have suffered. In this presentation, Professor Pope will discuss recent initiatives to constrain the scope of physician discretion and how these initiatives improve patient safety and protect patient rights. He will place particular emphasis on the growing transition from traditional informed consent to shared decision-making with patient decision aids.

October 10 calendar iconJoin us for Dr. Pope’s lecture on Wednesday, October 10, 2018 from noon until 1 pm in person or online.

Thaddeus Mason Pope, JD, PhD, is Director of the Health Law Institute and Professor of Law and at Mitchell Hamline School of Law in Saint Paul, Minnesota. He is also: (1) Adjunct Professor with the Australian Centre for Health Law Research at Queensland University of Technology; (2) Adjunct Associate Professor with the Alden March Bioethics Institute at Albany Medical College; and (3) Visiting Professor of Medical Jurisprudence at St. Georges University. Professor Pope has over 140 publications in: leading medical journals, law reviews, bar journals, nursing journals, bioethics journals, and book chapters. He coauthors the definitive treatise The Right to Die: The Law of End-of-Life Decisionmaking. And he runs the Medical Futility Blog (with over three million page views).

In person: This lecture will take place in E4 Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? All webinars are recorded! Visit our archive of recorded lecturesTo receive reminders before each webinar, please subscribe to our mailing list.

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Dr. Stahl delivers keynote at Western Michigan University Medical Humanities conference

Devan Stahl photoThe Eighth Annual Western Michigan University Medical Humanities Conference was held September 13-14 in Kalamazoo, MI. Center Assistant Professor Dr. Devan Stahl and her sister Darian Goldin Stahl (dariangoldinstahl.com) delivered the keynote lecture on September 14, “Visualizing Chronic Illness in Medicine and the Arts.”

Based on their recently published book, Imaging and Imagining Illness, the presenters discussed the history of anatomical illustrations, the use of contemporary medical imaging technologies in the doctor-patient relationship, and how medical images affect persons living with chronic illness.

To hear more about this work from Darian and Dr. Stahl, listen to their episode of No Easy Answers in Bioethics, the Center’s podcast series: ‘Imaging and Imagining Illness’: Devan and Darian Stahl – Episode 7.

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