Moral Choices in Health Care and Beyond

So this is a really interesting story that just hit my radar screen today as I was reading my most recent issue that I read every week of the Journal of the American Medical association. And I'd like to share it with you because I think it has some broad reaching implications, even if you're not in the medical world. This particular little discussion, I think, might have impact. So let me start off by the medical conundrum that started this discussion in the article that appeared in jama, and that is a story of an individual who's seeking out an internship and goes to the board at Harvard Mass General to be tested, orally tested, to see what his level of competency is as to whether he would qualify for an appointment in the as a resident. And it's a really grilling kind of discourse and inquiry by the senior people and renowned professors of medicine. And the first question they ask him is, so a patient comes in and this patient is a person that is on dialysis. And this is in the early days of dialysis, I might add. The technology was new. And this patient comes in with some delirium. And his values in his blood look like he's not suffering from toxemia and he has nystagmus, he's got equilibrium problems, balance disorders, and he's not appearing well. So what's wrong? That was the question asked of this candidate that was vying for the internship. And so he just really scoured his brain to think of what he had learned that might be applicable. And Fil finally was stumped and said, you know, I really don't know the answer to that question. And then the questioner said, well, you should have known the answer to this question that dialysis, you know, takes things out of the blood, not just toxins, but other things. And one of the things it takes out of the blood is vitamin B1, thiamine. And this patient was suffering from Wernicke's encephalopathy, which is an example of of vitamin B1 deficiency. And therefore the smart physician who treated this patient, who knew what it was, gave him an infusion of thiamine and he was cured. And you should have known that. So this case was reported to another gentleman who was just about to go through the same process and be tested for his internship. And that's where our story begins, because this person who wrote this most recent op ed piece in JAMA turned out to be Donald Berwick. And you probably know Dr. Berwick, internationally renowned pediatrician, health policy expert, was the appointee by Obama as the head of CMS and has written eloquently about the nature of what is medicine and what are the responsibilities of the medical world for the health of its population. And this particular story that I'm just relating to you comes in this op ed piece that Dr. Berwick was reporting to his own life when he came up for his exams for his residency. And he had spoken to this colleague, his senior, who had described this first question that he had been asked when he was going for his residency in which he got stumped by that question. And it was just like, this is the kind of questions you're going to get that are so challenging and you're going to be on the spot and be prepared. So Berwick went into his questioning period with that knowledge saying, oh, this is going to be. I'm sure they're going to ask things that I just don't know the answer and how am I going to handle this? So the esteemed group of questioners, as he sat there before them, the question they asked him, number one, was, so a patient comes in and they're on kidney dialysis and they don't have toxemia, but they have equilibrium disorders and they're hallucinating. What is the problem? It's the exact same question that his colleague, his senior, had been asked that he had unsuccessfully answered. And now he recognizes that he knows the answer because he's been told of this example by his senior. So now he's in a point of interesting dilemma. He can either look like he's very smart and not acknowledge that he already has heard this question and knows the answer and give the answer as Wernicke's encephalopathy and needs Simon, or he can honest up that he already has heard this question and answer and he has pre knowledge what is the ethical outcome. And here's where the story begins. And the conclusion of this story is really the takeaway. The conclusion doesn't really matter if you're in medicine or not. It just really matters whether you're a citizen of the world. The conclusion is silence is now political, either engagement or assist the harm. There is no third choice. That's the conclusion of the story. Now let me give you the story. So Berwick opts at that moment not to relate the fact that he already knew the answer to the question, but to go on and answer it as if he's the smartest Internet that was available. And he says, I'm not proud of the story. I'm not quoting from this JAMA editorial. I failed the test a day or two later, he goes on to say, I could not resist telling a close friend and mentor this story, which I thought maybe would be humorous. His reaction woke me up. He did not laugh. Instead, he said, I'm a bit disappointed in you. Don't. I realized that I was actually also disappointed in myself. I dropped the Brigham from my match list to become an intern, but that has never, not to this day, felt absolution. For me. A choice came a little cat feet, as Carl Sandburg's poem said, about fog rolling in on little cat feet. And for me to tell the truth or not when not is perhaps in the short term self interest was a bad decision. He goes on to say things in the close of this editorial that I think are very profound and a watchword for all of us as moral choices. This editorial is entitled Moral Choices for Today's Physicians. But we can just insert any other person other than a physician in this and it would be applicable. He goes on to say, in the past, an exploration of moral choices might have stopped with two levels personal honesty and proper organizational citizenship. But times have changed and the stakes and values are much higher. He goes on to say that ethics cannot be taken for granted, not when the interests to be served are those of society as a whole. The symptoms of organizational gluttony are rampant and the damage is severe. There is a sense of unfairness. This self interest, the defense of local stakes at the expense of fragile communities and disadvantaged populations goes far, far beyond the health care itself, in my view. I'm quoting now from Dr. Berwick's editorial the biggest travesty in current US social policy is not the failure alone to fund health care properly or the pricing games that are now being played by health care companies, but rather it is the nation's criminal justice system incarcerating and then stealing the spirit and hope of far by a larger proportion of our population than any other developed country in the world. If taking the life years and self respect of millions of youth with black individuals being imprisoned at more than five times the rate of whites, leaving them without choice, freedom or the hope of growth is not a health problem, then what is it? Second, he goes on to say, the harm done to our planet by intention to and denial of the facts of science is egregious and grievous as well. If poisoning the air, drying up the rivers and drowning the cities, our own and those of the poorest people on earth, and creating a tsunami of displaced people greater than the world has ever known before is not a health problem, that and what is it. Healers cannot deny leaving refugees at the gates unwanted or children unfed or families unfocused or basic medical care uncovered or relying on conflict rather than compassion. These are health problems. So is war. So is ignorance. So is hopelessness. So is blaming the blameless the work of a physician and I might add, parenthetically the work of a citizen of the world today. And certainly that and the privilege of being in the United States cannot stop at the door of the office or your profession, the threshold of an operating room or the front gate of a hospital. The rescue of a society and the restoration of political ethos that remembers to heal have become all of our jobs. Professional silence in the face of social injustice is wrong. It is chilling to see the great institutions of health care, hospital physician groups, scientific bodies, assume that the seat of bystander is available. That seat is gone. To try to avoid the political fray through silence is impossible because silence is now political. Either engage or assist the harm. There is no third choice. Pretty powerful message that is December 5, 2017 JAMA thank you, Dr. Birbik.