Imagine, for a moment, that you are the triage officer at a large hospital and you face the following dilemma:
The emergency room has requested the admission of a twenty-five-year-old asthmatic patient with acute respiratory failure. The probability of survival without intensive care is low; the probability of survival with intensive care is high.The intensive care unit is full, however. The choices are to discharge either a patient with multi-organ failure or an elective surgery patient. The prognosis for the former is poor, although continued treatment would not be futile according to the patient's surgeon and family. The prognosis for the elective surgery patient is good, but the attending surgeon says his patient (who has underlying chronic obstructive pulmonary disease) would face significant complications if discharged.
Should you admit the asthmatic patient to the intensive care unit, and, if so, to which bed?
If you are tempted to dismiss the exercise as academic or exaggerated, don't. The problem presented here is similar to those dealt with regularly by bioethicist Bob Baker. A professor of philosophy at the College since 1973, Baker is one of a small number of philosophers who study moral issues in the fields of medical treatment and research. Today, he is a familiar figure in hospitals as he discusses such issues as the distribution of scarce medical resources with doctors and other health care professionals.
Baker acknowledges that what he does may seem unlikely to those who see philosophy in narrow terms. “I know that to many people philosophers are involved in an arcance, abstruse discipline that has nothing to do with doctors and patients — and yet it happened. And this coming together has led to real progress. Patients today have more of a voice in their own treatment than they once did, and many of the medical-moral problems that once seemed so intractable have been resolved.”
For example:
“Back in the 1970s we had to figure out whether it was proper — whether it made sense — to disconnect ventilators from patients, the 'do not resuscitate' decisions. The challenge was to think of an approach that would fit the medical tradition, respect patients, and still allow physicians to honor the wishes of families not to have death prolonged. I think collectively society has solved this rather well. Today, nobody protests turning off ventilators.
“Another good example is what has happened with reproductive technologies. A quarter of a century ago Louise Brown was born — the first test-tube baby. The Browns had wanted to reproduce — a fundamental drive — and the physicians were only helping them. The only thing that was odd was that the egg and sperm were united outside the uterus and then reimplanted. People were upset, but bioethicists almost universally said, 'Relax, this is not a bad thing.' Today everybody accepts it.”
The idea that doctors ought to work out, in a formal sense, what duties they owe to their patients and the public goes back centuries. The Greek Hippocratic oath required physicians above all to “do no harm,” and English physician Thomas Percival wrote a professional code of ethics in the early eighteenth century. Today's medical ethics, or bioethics, involves medicine, nursing, law, sociology, philosophy, and theology. It is what happened, Baker says, when “you took the discussion of what we ought to do out of the hands of doctors alone and brought in philosophers, the public, theologians, and other people.”
That kind of change happened, Baker says, for several reasons.
“One thing that has changed over the past thirty years is that we are simply a more open society today,” he says. “We have a confessional culture that wants to discuss things in a public way.”
Technological advances that help prolong human life have presented new challenges to use the technology wisely. “We're asking pretty fundamental questions these days,” Baker says. “What kind of life are we to lead? Do we want to lead a life in which we're physically impaired? Is it worth living if our mental processes go?”
Other impetuses for change are not as obvious. Baker says one spur was the antiwar and civil rights movements of the 1960s and 1970s.
“When you think of the civil rights movement, it's about empowering people who have no rights,” he says. “You once could think of hospitals as a world of horizontals and verticals. The patients were the horizontals — they had no voice, no rights. The doctors and nurses were the empowered verticals, with all the decisionmaking power. Then middle-class people started to be treated in non-emergency contexts — radiation therapy for cancer, for example As they and their families began to want a part in the decisionmaking, they found physicians unreceptive. They looked for allies and found philosophers to be good allies.”
Another reason for the change in attitude about bioethics, he says, is the “failure” of the party that used to be at the bedside along with the physicians — religion.
“The reason that bioethics can play the role that religion once played has nothing to do with a loss of faith in society. It has everything to do with the fact that we've realized how deeply multicultural we are. We now recognize that there are Jehovah's Witnesses, Muslims, and many other faiths across America; we now recognize that Catholics, Protestants, and Jews have different ideas of death; we now recognize that as all these people come into the medical mix, we need someone who can provide ethical insight without tying it to any specific religion.”
The result of the changes, he says, is a healthy openness about the most fundamental issues. “We have managed to take what can be narrow, technical, clinical, and legalistic, and opened the discussion so that the public can see the larger philosophical issues,” he says.
The societal change has been remarkable; so, too, has been the path of Bob Baker. He was born in the Bronx, where he lived in a housing project and attended a public school that, he says, “looked more like a prison than any prison I was to teach in later.” An asthmatic before there was really effective treatment for the condition, he became a reader, devouring piles of books. A mediocre student for many years, he challenged himself late in high school and earned straight A's in his senior year. He graduated from CCNY in 1959 — the first person in his immediate family to go to college — and headed for the University of Minnesota, where he earned his Ph.D.
He joined the faculty at Wayne State University in Detroit, a good location for his growing interest in the antiwar and civil rights movements.
“I was part of an organization called New Detroit, whose objective was to prevent white flight and rebuild the inner city. I taught in community colleges to the black community at night and also worked with a group of physicians and psychiatrists who wanted to bring health care to the inner city. It was those physicians who began to consult me about problems they had in medical practice. I saw how exciting the intellectual issues were. Soon, instead of organizing teach-ins, I was organizing patients rights groups; and instead of using my skills to put together a demonstration, I used them to organize clinicians on a specific problem that affected health care.”
But, at a time when medical ethics was not yet an academic field, he encountered difficulties. He remembers filling out an academic activity sheet at Wayne State and being called before the dean on a charge of academic dishonesty. “I was accused of trying to take one of my hobbies — discussing medical ethics with psychiatrists — and passing it off as a professional activity.” (He was not penalized.) There are other discouraging incidents. He won a National Endowment for the Humanities fellowship and wanted to use it to study medical ethics; everyone he consulted, however, warned him that it would be professional suicide. (He did it anyway.)
“I loved working with patients, I loved working with physicians, and I found the intellectual issues incredibly intriguing,” he says. “I thought of it as major philosophical territory that would give new insights into problems that people had teased at for thousands of years.”
In 1973, Baker came to Union, which thus became one of the first undergraduate colleges in the country to offer a course in bioethics. “Union had a lot of premedical students, and there were two department chairs — Jan Ludwig in philosophy and Will Roth in biology — who thought it would be wonderful if our students had the opportunity to take courses in ethics and medicine.”
Within a couple of years, Baker realized he needed more training. “Here I was, teaching medical ethics without any clinical experience. So I wrote a grant proposal to a foundation, asking them to make an honest teacher out of me.” He received a grant for a two-year postdoctoral fellowship at Albany Medical College. He spent a quarter of the time taking courses and then had three six-month rotations in clinical oncology (cancer study), neonatology (newborn intensive care), and inpatient and outpatient psychiatry. He learned quickly that with the right approach, physicians and nurses were receptive. “If you make it clear that what you're doing is helping them think though some very difficult problems, they're happy to have you around. In almost thirty years I can count on the fingers of one hand the times I've had real opposition.”
One of the differences between a physician and a philosopher, Baker says, is that the latter can, and should, take very broad views. “Our horizon goes back 2,000 years to Plato and extends way off into the future,” he says. “We can act as a calming voice, pointing out dangers that other people don't see, putting things into a different perspective. We can ask the physician to engage in a dialogue about treatment that respects the patient's understanding of what the patient's values are. I just think there are enormous opportunities for people like me.”
The dilemma of the asthmatic patient was included in Gatekeeping in the Intensive Care Unit, a book written by Martin Strosberg, professor of management at the College, and Daniel Teres.
The authors note that American Medical Association Council on Ethical and Judicial Affairs guidelines say, “Once all the potential recipients have been studied, decision makers should allocate resources to maximize the number of lives saved, the number of years of life saved, and improvement in the quality of life.” Five ethical criteria care used — the urgency of the patient's condition, the likelihood of benefit to the patient, the impact of treatment in improving the quality of the patient's life, the duration of the benefit, and, in some cases, the amount of resources required for successful treatment.
The solution in the example cited: the asthmatic patient was admitted and the elective surgery patient was moved to a closely-watched bed on the surgical floor.
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Three degrees in eight years: The new Leadership in Medicine-Health Management Program
As medicine has changed during the past twenty-five years, so, too, has medical training.
When the College introduced its accelerated medical education program in the mid-1970s, students could earn a B.S. degree from Union and an M.D. from Albany Medical College in six years. It was a program, says Professor of Philosophy Bob Baker, designed to produce general practitioners.
In the late 1990s, representatives from Union and the medical college began to discuss what attributes would be needed by physicians in the twenty-first century. “It became clear that such a physician would have to cope with managed care, or at least the kinds of structural crises that led to managed care,” Baker recalls. “Also, since America is becoming increasingly multicultural, we wanted physicians who would be at ease dealing with different cultures. And we recognized that bioethics was becoming ever more important.
“Happily, Union had strengths in exactly those areas.”
The College's Graduate Management Institute had one of the four accredited graduate programs in health care administration in New York State; the undergraduate curriculum had strong courses in bioethics; and Union's Terms Abroad program was one of the best in the country.
“So we devised an eight-year program that we think is a model for training young people to be leaders of medicine in the twenty-first century,” Baker says. “We integrated the requirement of a term abroad, doubled the number of courses in bioethics, and created new courses in health policy.”
Called the Leadership in Medicine-Health Management Program, the new offering had 318 applicants for the fall of 2000. Sixty-seven were offered admission, and fourteen enrolled. They will spend their first four years at Union, taking thirty undergraduate courses — fifteen in science, fifteen non-science. They will complete an interdepartmental major in the humanities or social sciences, a special program in bioethics supplemented by a health services practicum, a term abroad or international experience, and a program in health care management at the Union College Center fior Clinical Leadership. They will receive a B.S. and an M.S. from Union and will be admitted automatically to Albany Medical College, providing they have met certain prerequisites (e.g., a 3.4 or better grade point average).