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Disorientations—major life experiences that make it difficult for individuals to know how to go on—are deeply familiar, in part because they are common. It is rare to have never experienced some form of disorientation in one’s own life, perhaps in response to grief, illness, or other significant events.
Two women are being trained for work on a factory assembly line. As products arrive on a conveyor belt, their task is to wrap each product and place it back on the belt. Their supervisor warns them that failing to wrap even one product is a firing offense, but once they get started, the work seems easy.
Many in the media and academia (myself included) have been discussing the Ebola crisis, and more specifically, the issues that arise as Ebola has traveled with infected patients and health care workers to the United States and infected other US citizens.
These discussions have been fascinating and frightening, but the terrifying truth is that Ebola is just the tip of the iceberg. Diseases have long traveled with patients, and as the phenomena of medical tourism and the more general globalization of health care grow, these problems are likely to grow as well.
Medical tourists are very good targets of opportunities for pathogens. Many are traveling with compromised or suppressed immune systems to destination countries for treatment with relatively high infection rates, including the risk of exposure to multi-drug–resistant pathogens.
Doctors typically distinguish commensals—the bugs we normally carry on our skin, mouth, digestive tracts, etc.—from pathogens, the harmful bacteria that cause disease through infection. But what is commensal for a person in India might be an exotic pathogen for a US population. Medical tourist patients are transporting their commensals and pathogens to the hospital environments of the destination countries to which they travel, and are exposed to the commensals and pathogens of hospitals and population at large in the destination country. These transmissions tax the health care system and the knowledge of physicians in the home country to whom the new microbe may be unknown, and diagnosis and treatment more difficult.
Air travel can involve each of the four classical modes of disease transmission: contact (e.g. body-to-body or touching an armrest), common vehicle (e.g. via food or water), vector (e.g. via insects or vermin), and airborne (although more recent planes are equipped with high efficiency particulate air (HEPA) filters reducing transmission risk, older planes are not).
We have seen several diseases travel in this way. The Severe Acute Respiratory Syndrome (SARS) outbreak of 2003 involved a three-hour flight from Hong Kong to Beijing carrying one SARS-infected passenger leading to sixteen passengers being subsequently confirmed as cases of SARS, with eight of those passengers sitting in the three rows in front of the passenger.
In January 2008, a new type of enzyme was detected in bacteria found in a fifty-nine-year-old man with a urinary tract infection being treated in Sweden. The man, Swedish but of Indian origin, had in the previous month undergone surgeries at two hospitals in India. The enzyme, labeled “New Delhi metallo-beta-lactamase-1 (NDM-1)” was able to disarm a lot of antibiotics, including one that was the last line of defenses against common respiratory and urinary tract infection.
In 2009, a study found that twenty-nine UK patients had tested positive for the bacteria-carrying NDM-1 and that seventeen of the twenty-nine (60%) had traveled to India or Pakistan in the year before. A majority of those seventeen received medical treatment while abroad in those countries, some for accidents or illness while traveling and others for medical tourism, either for kidney and bone marrow transplants or for cosmetic surgery.
High-income countries face significant problems with these infections. A 2002 study estimated that 1.7 million patients (ninety-nine thousand of whom died as a result) developed health care-acquired infections in the United States that year. In Europe these infections have been estimated to cause thirty-seven thousand deaths a year and add US $9.4 billion in direct costs
What can be done? Although in theory airline or national travel rules can prevent infected patients from boarding planes, detecting these infections in passengers is very difficult for the airline or immigration officials, and concerns about privacy of patients may chill some interventions. A 2007 case of a man who flew from the United States to Europe with extensively resistant tuberculosis and who ultimately circumvented authorities who tried to stop him on return by flying to Montreal, Canada and renting a car, shows some of the limits on these restrictions.
Part of the solution is technological. The HEPA filters discussed above on newer model planes reduce the risk substantially, and we can hope for more breakthroughs.
Part of the solution is better regulating the use of antibiotics: overuse of antibiotics when not effective or necessary, underuse of antibiotics when they are needed, failure to complete a full course of antibiotics, counterfeit drugs, and excessive antibiotic use in food animals. This is not a magic bullet, however, and we see problems even in countries with prescription systems such as the United States.
We also need much better transparency and reaction time. Some countries reacted quickly to the report of the NDM-1 cases discussed above in issuing travel warnings and informing home country physicians, while others did not.
Finally, as became evident with Ebola, we need better protocols in place to screen returning medical tourism patients and to engage in infection control when needed.
Headline image credit: Ebola virus virion by CDC microbiologist Cynthia Goldsmith. Public domain via Wikimedia Commons.
The inherent significance of bioethics and social science in medicine is now widely accepted… at least on the surface. Despite an assortment of practical problems—limited curricular time compounded by increased concern for “whitespace”—few today deny outright that ethical practice and humanistic patient engagement are important and need to be taught. But public acknowledgements all too often are undercut by a different reality, a form of hidden curriculum that overpowers institutional rhetoric and the best-laid syllabi. Most medical schools now make an effort to acknowledge that ethics and humanities training is part of their mission and we have seen growing inclusion of bioethics and medical humanities in medical curricula. However, more curricular time, in and of itself, is not enough.
Even with increases in contact hours, the value of medical ethics and humanities can be undercut by problems of frequency and duration. Many schools have dedicated significant time to bioethics when measured in contact hours, but in the form of intensive seminars that are effectively quarantined from the rest of the curriculum. While this is a challenge for modular curricula in general, it can be harder for students to integrate ethics and humanities content into biomedical contexts. Irrespective of the number of contact hours, placing bioethics in a curricular ghetto risks sending a message that it is simply is a hoop to jump through, something to eventually be set aside as one returns to the real curriculum.
While partitioning ethics and humanities content presents problems, the integration of ethics into systems-based curricula poses different challenges. While, case-based formats make integration easier, they limit the extent to which one can teach core concepts themselves. For organ systems curricula, where ethics lectures often are “sprinkled in,” the linkages with the biomedical components of the course are underspecified or inherently weak. Medical ethics and humanities are diffused in actual practice such that attempts at thematic alignment with organ systems curricula often are noticeably artificial. In turn, there is an unintentional but palpable message that ethics is an interruption to medical learning. Anyone who has delivered an ethics lecture, sandwiched between two pathology lectures in a GI course knows this feeling only too well.
Finally, there is a misalignment of goals and assessment in bioethics that remains a significant challenge. Certainly, one goal of ethics and humanities education in medical curricula is to provide concrete information about legal directives and consensus opinions. Most of us, however, want to go beyond a purely instrumental approach to ethics and promote the ability to empathize with patients and think critically about ethical and humanistic features of patient care. These issues are much more important than an instrumental approach. While there are a variety of ways to assess these higher-order capacities within a course, board exams loom large in the medical student consciousness (and rightfully so). On a multiple choice exam, being reflexive about one’s ethical framework and exploring the large supply of contingencies surrounding a particular case is a recipe for disaster. In turn, I often find myself encouraging students to pursue interesting and creative lines of thought or to challenge consensus statements from professional bodies, only to end the discussion by warning that they should abandon all such efforts on board exams. Most would agree that ethics is a dialogical activity, yet the examinations with the highest stakes send hidden messages that it is formulaic and instrumental. When “assessment drives learning,” it is difficult for students to set aside concerns about gateway exams and engage the genuine complexity of ethics.
While these challenges are curricular, pedagogical, and even cultural, I think there are practical ways that medical schools, and even individual instructors, can destabilize the messages of this hidden curriculum. First, with regard to assessment, we can teach both complex and instrumental ethical methodologies. While this may appear a rather dismal prospect, it can be made respectable by explicating the conditions under which each way of thinking is useful (e.g. the former in real life, the latter on exams). Students then learn not only to turn on and off particular test taking strategies, but this also bolsters their ability to be critical and reflexive—in this case about a instrumental processes of ethical decision-making that are problematic, but nonetheless widespread, even in practice.
Second, we need to move beyond simply including more bioethics education and toward addressing its rhythms within our curricula. I have been fortunate enough to recently join a new medical school unencumbered by a historical (read: petrified) curriculum. In addition to an institutional culture genuinely amenable to ethics and humanities, our curriculum utilizes longitudinal courses that run in parallel to the biomedical systems courses. Instructors therefore have the ability to build the sort of conceptual complexity that truly attends ethics and students have the spaced practice that is key to their development. This structure therefore avoids the problems both of quarantining and random inclusion.
Finally, bioethics curricula need to develop less emphasis on information and a greater utilization of “threshold concepts”. No medical curriculum affords enough time to exhaust the terrain of bioethics and medical humanities. Certainly we need to accept the reality that we typically are not training ethics and humanities scholars, but, at a minimum, physicians with those competencies and even more ideal, physicians who embody those values. However, where the idea of delivering ethics at an appropriate level for physicians often serves as a call for simplicity, I believe it supplies a warrant for focus on our most complex concepts, which also are the most generative and useful. When training practitioners, epistemological concepts—for example, integrative and differentiating ways of thinking—often are eschewed in favor of simpler kinds of information that promote instrumental applications to situations, and a limited ability engage the messy nuances of real world situations. Richer, more complex threshold concepts—like the sociological imagination (the ability to see the interweaving of macro and micro level phenomena)—are broadly relevant and transposable to any number of complex situations.
In the contemporary landscape, few deny outright the significance of ethics and humanities in medicine. But the explicit messaging about their importance remains outmatched by implicit messages hidden in curricula. Having just returned from the annual meeting of the American Society for Bioethics and Humanities, I cannot help but feel that we are spending too much time fighting old battles by repetitiously announcing the relevance of bioethics and too little time confronting the more insidious, hidden messages nestled deeper in the trenches of curriculum and pedagogy. This is a critical challenge.
When Eleanor Roosevelt died on this day (7 November) in 1962, she was widely regarded as “the greatest woman in the world.” Not only was she the longest-tenured First Lady of the United States, but also a teacher, author, journalist, diplomat, and talk-show host. She became a major participant in the intense debates over civil rights, economic justice, multiculturalism, and human rights that remain central to policymaking today. As her husband’s most visible surrogate and collaborator, she became the surviving partner who carried their progressive reform agenda deep into the post-war era, helping millions of needy Americans gain a foothold in the middle class, dismantling Jim Crow laws in the South, and transforming the United States from an isolationist into an internationalist power. In spite of her celebrity, or more likely because of it, she had to endure a prolonged period of intense suffering and humiliation before dying, due in large part to her end-of-life care.
Roosevelt’s terminal agonies began in April 1960 when at 75 years of age, she consulted her personal physician, David Gurewitsch, for increasing fatigue. On detecting mild anemia and an abnormal bone marrow, he diagnosed “aplastic anemia” and warned Roosevelt that transfusions could bring temporary relief, but sooner or later, her marrow would break down completely and internal hemorrhaging would result. Roosevelt responded simply that she was “too busy to be sick.”
For a variety of arcane reasons, Roosevelt’s hematological disorder would be given a different name today – myelodysplastic disorder – and most likely treated with a bone marrow transplant. Unfortunately, in 1962 there was no effective treatment for Roosevelt’s hematologic disorder, and over the ensuing two years, Gurewitsch’s grim prognosis proved correct. Though she entered Columbia-Presbyterian Hospital in New York City repeatedly for tests and treatments, her “aplastic anemia” progressively worsened. Premarin produced only vaginal bleeding necessitating dilatation and curettage, transfusions temporary relief of her fatigue, but at the expense of severe bouts of chills and fever. Repeated courses of prednisone produced only the complications of a weakened immune system. By September 1962, deathly pale, covered with bruises and passing tarry stools, Roosevelt begged Gurewitsch in vain to let her die. She began spitting out pills or hiding them under her tongue, refused further tests and demanded to go home. Eight days after leaving the hospital, the TB bacillus was cultured from her bone marrow.
Eleanor Roosevelt with grandchildren Buzzie and Sistie Dall. Harris & Ewing, photographer, 1934. Public domain via Library of Congress.
Gurewitsch was elated. The new finding, he proclaimed, had increased Roosevelt’s chances of survival “by 5000%.” Roosevelt’s family, however, was unimpressed and insisted that their mother’s suffering had gone on long enough. Undeterred, Gurewitsch doubled the dose of TB medications, gave additional transfusions, and ordered tracheal suctioning and a urinary catheter inserted.
In spite of these measures, Roosevelt’s condition continued to deteriorate. Late in the afternoon of 7 November 1962 she ceased breathing. Attempts at closed chest resuscitation with mouth-to-mouth breathing and intra-cardiac adrenalin were unsuccessful.
Years later, when reflecting upon these events, Gurewitsch opined that: “He had not done well by [Roosevelt] toward the end. She had told him that if her illness flared up again and fatally that she did not want to linger on and expected him to save her from the protracted, helpless, dragging out of suffering. But he could not do it.” He said, “When the time came, his duty as a doctor prevented him.”
The ethical standards of morally optimal care for the dying we hold dear today had not yet been articulated when Roosevelt became ill and died. Most of them were violated (albeit unknowingly) by Roosevelt’s physicians in their desperate efforts to halt the progression of her hematological disorder: that of non-maleficence (i.e., avoiding harm); by pushing prednisone after it was having no apparent therapeutic effect; that of beneficence (i.e., limiting interventions to those that are beneficial); by performing cardiopulmonary resuscitation in the absence of any reasonable prospect of a favorable outcome; and that of futility (avoiding futile interventions); by continuing transfusions, performing tracheal suctioning and (some might even argue) beginning anti-tuberculosis therapy after it was clear that Roosevelt’s condition was terminal.
Roosevelt’s physicians also unknowingly violated the principle of respect for persons, by ignoring her repeated pleas to discontinue treatment. However, physician-patient relationships were more paternalistic then, and in 1962 many, if not most, physicians likely would have done as Gurewitsch did, believing as he did that their “duty as doctors” compelled them to preserve life at all cost.
Current bioethical concepts and attitudes would dictate a different, presumably more humane, end-of-life care for Eleanor Roosevelt from that received under the direction of Dr. David Gurewitsch. While arguments can be made about whether any ethical principles are timeless, Gurewitsch’s own retrospective angst over his treatment of Roosevelt, coupled with ancient precedents proscribing futile and/or maleficent interventions, and an already growing awareness of the importance of respect for patients’ wishes in the early part of the 20th century, suggest that even by 1962 standards, Roosevelt’s end-of-life care was misguided. Nevertheless, in criticizing Gurewitsch for his failure “to save [Roosevelt] from the protracted, helpless, dragging out of suffering,” one has to wonder if and when a present-day personal physician of a patient as prominent as Roosevelt would have the fortitude to inform her that nothing more can be done to halt the progression of the disorder that is slowly carrying her to her grave. One wonders further if and when that same personal physician would have the fortitude to inform a deeply concerned public that no further treatment will be given, because in his professional opinion, his famous patient’s condition is terminal and further interventions will only prolong her suffering.
Evidence that recent changes in the bioethics of dying have had an impact on the end-of-life care of famous patients is mixed. Former President Richard Nixon and another famous former First Lady, Jacqueline Kennedy Onassis, both had living wills and died peacefully after forgoing potentially life-prolonging interventions. The deaths of Nelson Mandela and Ariel Sharon were different. Though 95 years of age and clearly over-mastered by a severe lung infection as early as June 2013, Mandela was maintained on life support in a vegetative state for another six months before finally dying in December of that year. Sharon’s dying was even more protracted, thanks to the aggressive end-of-life care provided by Israeli physicians. After a massive hemorrhagic stroke destroyed his cognitive abilities in 2006, a series of surgeries and on-going medical care kept Sharon alive until renal failure finally ended his suffering in January 2014. Thus, although bioethical concepts and attitudes regarding end-of-life care have undergone radical changes since 1962, these contrasting cases suggest that those caring for world leaders at the end of their lives today are sometimes as incapable as Roosevelt’s physicians were a half century ago in saving their patients from the protracted suffering and indignities of a lingering death.
Since its advent in the early 1970s, bioethics has exploded, with practitioners’ thinking expressed not only in still-expanding scholarly venues but also in the gamut of popular media. Not surprisingly, bioethicists’ disputes are often linked with technological advances of relatively recent vintage, including organ transplantation and artificial-reproductive measures like preimplantation genetic diagnosis and prenatal genetic testing. It’s therefore tempting to figure that the only pertinent reflective sources are recent as well, extending back — glancingly at most — to Immanuel Kant’s groundbreaking 18th-century reflections on autonomy. Surely Plato, who perforce could not have tackled such issues, has nothing at all to contribute to current debates.
This view is false — and dangerously so — because it deprives us of avenues and impetuses of reflection that are distinctive and could help us negotiate present quandaries. First, key topics in contemporary bioethics are richly addressed in Greek thought both within Plato’s corpus and through his critical engagement with Hippocratic medicine. This is so regarding the nature of the doctor-patient tie, medical professionalism, and medicine’s societal embedment, whose construction ineluctably concerns us all individually and as citizens irrespective of profession.
Second, the most pressing bioethical topics — whatever their identity — ultimately grip us not on technological grounds but instead for their bearing on human flourishing (in Greek, eudaimonia). Surprisingly, this foundational plane is often not singled out in bioethical discussions, which regularly tend toward circumscription. The fundamental grip obtains either way, but its neglect as a conscious focus harms our prospects for existing in a way that is most thoughtful, accountable, and holistic. Again a look at Plato can help, for his handling of all salient topics shows fruitfully expansive contextualization.
Regarding the doctor-patient tie, attempts to circumvent Scylla and Charybdis — extremes of paternalism and autonomy, both oppositional modes — are garnering significant bioethical attention. Dismayingly given the stakes, prominent attempts to reconceive the tie fail because they veer into paternalism, allegedly supplanted by autonomy’s growing preeminence in recent decades. If tweaking and reconfiguration of existing templates are insufficient, what sources not yet plumbed might offer fresh reference points for bioethical conversation?
Prima facie, invoking Plato, staunch proponent of top-down autocracy in the Republic, looks misguided. In fact, however, the trajectory of his thought — Republic to Laws via the Statesman — provides a rare look at how this profound ancient philosopher came at once to recognize core human fallibility and to stare firmly at its implications without capitulating to pessimism about human aptitudes generally. Captivated no longer by the extravagant gifts of a few — philosophers of Kallipolis, the Republic’s ideal city — Plato comes to appreciate for the first time the intellectual and ethical aptitudes of ordinary citizens and nonphilosophical professionals.
Human motivation occupies Plato in the Laws, his final dialogue. His unprecedented handling of it there and philosophical trajectory on the topic warrant our consideration. While the Republic shows Plato’s unvarnished confidence in philosophers to rule — indeed, even one would suffice (502b, 540d) — the Laws insists that human nature as such entails that no one could govern without succumbing to arrogance and injustice (713c). Even one with “adequate” theoretical understanding could not properly restrain himself should he come to be in charge: far from reliably promoting communal welfare as his paramount concern, he would be distracted by and cater to his own yearnings (875b). “Adequate” understanding is what we have at best, but only “genuine” apprehension — that of philosophers in the Republic, seen in the Laws as purely wishful — would assure incorruptibility.
The Laws’ collaborative model of the optimal doctor-patient tie in Magnesia, that dialogue’s ideal city, is one striking outcome of Plato’s recognition that even the best among us are fallible in both insight and character. Shared human aptitudes enable reciprocal exchanges of logoi (rational accounts), with patients’ contributing as equal, even superior, partners concerning eudaimonia. This doctor-patient tie is firmly rooted in society at large, which means for Plato that there is close and unveiled continuity between medicine and human existence generally in values’ application. From a contemporary standpoint, the Laws suggests a fresh approach — one that Plato himself arrived at only by pressing past the Republic’s attachment to philosophers’ profound intellectual and values-edge, whose bioethical counterpart is a persistent investment in the same regarding physicians.
If values-spheres aren’t discrete, it’s unsurprising that medicine’s quest to demarcate medical from non-medical values, which extends back to the American Medical Association’s original Code of Medical Ethics (1847), has been combined with an inability to make it stick. In addition, a tension between the medical profession’s healing mission and associated virtues, on the one side, and other goods, particularly remuneration, on the other, is present already in that code. This conflict is now more overt, with rampancy foreseeable in financial incentives’ express provision to intensify or reduce care and to improve doctors’ behavior without concern for whether relevant qualities (e.g., self-restraint, courage) belong to practitioners themselves.
“As Plato rightly reminds us, professional and other endeavors transpire and gain their traction from their socio-political milieu”
Though medicine’s greater pecuniary occupation is far from an isolated event, the human import of it is great. Remuneration’s increasing use to shape doctors’ behavior is harmful not just because it sends the flawed message that health and remuneration are commensurable but for what it reveals more generally about our priorities. Plato’s nuanced account of goods (agatha), which does not orbit tangible items but covers whatever may be spoken of as good, may be helpful here, particularly its addressing of where and why goods are — or aren’t — cross-categorically translatable.
Furthermore, if Plato is right that certain appetites, including that for financial gain, are by nature insatiable — as weakly susceptible to real fulfillment as the odds of filling a sieve or leaky jar are dim (Gorgias 493a-494a) — then even as we hope to make doctors more virtuous via pecuniary incentives, we may actually be promoting vice. Engagement with Plato supports our retreat from calibrated remuneration and greater devotion to sources of inspiration that occupy the same plane of good as the features of doctors we want to promote. If the goods at issue aren’t commensurable, then the core reward for right conduct and attitudes by doctors shouldn’t be monetary but something more in keeping with the tier of good reflected thereby, such as appreciative expressions visible to the community (a Platonic example is seats of honor at athletic games, Laws 881b). Of course, this directional shift shouldn’t be sprung on doctors and medical students in a vacuum. Instead, human values-education (paideia) must be devotedly and thoughtfully instilled in educational curricula from primary school on up. From this vantage point, Plato’s vision of paideia as a lifelong endeavor is worth a fresh look.
As Plato rightly reminds us, professional and other endeavors transpire and gain their traction from their socio-political milieu: we belong first to human communities, with professions’ meaning and broader purposes rooted in that milieu. The guiding values and priorities of this human setting must be transparent and vigorously discussed by professionals and non-professionals alike, whose ability to weigh in is, as the Laws suggests, far more substantive than intra-professional standpoints usually acknowledge. This same line of thought, combined with Plato’s account of universal human fallibility, bears on the matter of medicine’s continued self-policing.
Linda Emanuel claims that “professional associations — whether national, state or county, specialty, licensing, or accrediting — are the natural parties to articulate tangible standards for professional accountability. Almost by definition, there are no other entities that have such ability and extensive responsibility to be the guardians of health care values — for the medical profession and for society” (53-54). Further, accountability “procedures” may include “a moral disposition, with only an internal conscience for monitoring accountability” (54). On grounds above all of our fallibility, which is strongly operative both with and absent malice, the Laws foregrounds reciprocal oversight of all, including high officials, not just from within but across professional and sociopolitical roles; crucially, no one venue is the arbiter in all cases. Whatever the number of intra-medical umbrellas that house the profession’s oversight, transparency operates within circumscribed bounds at most, and medicine remains the source of the very standards to which practitioners — and “good” patients — will be held. Moreover, endorsing moral self-oversight here without undergirding pedagogical and aspirational structures is less likely to be effective than to hold constant or even amplify countervailing motivations.
As can be only briefly suggested here, not only the themes but also their intertwining makes further bioethical consideration of Plato vastly promising. I’m not proposing our endorsement of Plato’s account as such. Rather, some positions themselves, alongside the rich expansiveness and trajectory of his explorations, are two of Plato’s greatest legacies to us — both of which, however, have been largely untapped to date. Not only does reflection on Plato stand to enrich current bioethical debates regarding the doctor-patient tie, medical professionalism, and medicine’s societal embedment, it offers a fresh orientation to pressing debates on other bioethical topics, prominent among them high-stakes discord over the technologically-spurred project of radical human “enhancement.”
Headline image credit: Doctor Office 1. Photo by Subconsci Productions. CC BY-SA 2.0 via Flickr
