Chapter 09: The Ethics Committee at MD Anderson, Part II: Practicing Ethics in a Context of Innovation

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Chapter 09: The Ethics Committee at MD Anderson, Part II: Practicing Ethics in a Context of Innovation

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Dr. Ewer begins this chapter by discussing some political infighting in the Ethics Committee. He then goes on to describe how much of the committee’s work was conflict resolution. He gives an example to demonstrate.

Next, Dr. Ewer explains how pushback against Ethics Committee recommendations was often philosophical and rooted in the prevailing mindset that “a patient who doesn’t survive is a failure.” He explains that that mindset cannot serve the institution as cancer care and healthcare environment has evolved over the last 40 years. CLIP He also talks about the challenges of balancing ethical concerns with the creative impulse to push the research envelop that is also so important to the institution.

At the end of this chapter, he expresses concerns for the institution, its financial health, and how MD Anderson might be positioned for a takeover, which would destroy its research identity.

Identifier

EwerMS_02_20180725_C09

Publication Date

7-25-2018

City

Houston, Texas

Topics Covered

Building the Institution; Ethics; This is MD Anderson; MD Anderson Culture; Building/Transforming the Institution; Growth and/or Change; Obstacles, Challenges; Institutional Politics; Controversy; The Business of MD Anderson; The Institution and Finances

Transcript

Michael S. Ewer, MD, MPH, JD, LLM, MBA:

We’ve also had some political infighting. We had a clinician come in, and I think that she had the perception that she was going to be hired as the Head of Ethics, and wanted very much to take over the Ethics Committee. And we weren’t ready to hand it over to a relatively new physician. I believe she was a psychiatrist. Wasn’t here very long, and she disappeared from the institution very quickly. But there was some infighting there, and then ultimately Dr. LeMaistre said that we need to have a different direction.

Tacey A. Rosolowski, PhD:

Let me just ask: what was the basis for her belief that she would become Head of Ethics? Who was it that had provided her with that perspective?

Michael S. Ewer, MD, MPH, JD, LLM, MBA:

I was not involved with the interview process. I have no idea, except that the concept that somebody coming into a cancer center new, who was not an oncologist—she was a psychiatrist—coming in and thinking that they know all that needs to be known about this because they happen to have studied ethics somewhere, without some clinical correlation and objectivity of real life, some of us felt was arrogant.

Tacey A. Rosolowski, PhD:

Well, also seemed like maybe it was—when did this happen? Was it kind of near the end, before the committee was disbanded? I wonder if it was—

Michael S. Ewer, MD, MPH, JD, LLM, MBA:

Probably a year or two before.

Tacey A. Rosolowski, PhD:

Yeah, I wonder if it was sort of the initial kind of indications that there was something going on there.

Michael S. Ewer, MD, MPH, JD, LLM, MBA:

Maybe, maybe. I don’t know.

Tacey A. Rosolowski, PhD:

Interesting, interesting. What was the situation, as the committee evolved? You know, did you find there was unanimity? I mean, were there subgroups?

Michael S. Ewer, MD, MPH, JD, LLM, MBA:

Most of the time, people worked on the concept of we have a code of ethics and we want to do the right thing, and when families get in the way of us doing the right thing we have to acknowledge that there is this controversy and try to sort it out. Much of what the Ethics Committee did and still does is conflict resolution. If you have, for instance—and I may have given you this example before, and if I’m being repetitive then just cut me off—when I teach this, I give the example of a hypothetical physician. And a hypothetical physician is taking a position that he wants to give a certain treatment to somebody that someone else thinks has no chance of responding. Let’s say that individual is a nurse, and that nurse brings this to the Ethics Committee, and says, “Dr. So-and-so is torturing this poor woman because there’s no chance that she can have any response to this, and this is an ethical concern for me.” And there are two possibilities here: one is that the doctor knows that there is no possibility, and is doing this because he believes pleasing the family is important, or maybe there’s the possibility of a donation if we tell the family we went even way beyond what was normal. Maybe there is a conflict there, in which case this is a real ethical question. Other possibility is that the doctor feels that we have new medications now, “I think there’s a chance that this can actually help.” And that’s a medical question. That’s a question of medical skill and competence. That shouldn’t go to the Ethics Committee; that should go to the department chair. The department chair should say, “Yes, this is a good thing to try, and I’m with you, and let’s develop a protocol. We try it now; we’ll do it in the future.” That’s not an ethical question. Maybe bad judgment, but it’s not an ethical question. But doing it for the wrong reason is. And these are the concepts that I try to teach the Ethics Committee.

Tacey A. Rosolowski, PhD:

Yeah, interesting, yeah. So what is the circle within which ethics operates, and when is it someone else’s perspective that’s more important? Did you find that the institution...? Because, I mean, there’s always... Two things are in my mind, you know, because I do know Colleen Gallagher, and she talks to me about issues that come up, and one frustration she has is that people often don’t think to call Ethics in for help until the last minute, or they call for the wrong reason.

Michael S. Ewer, MD, MPH, JD, LLM, MBA:

“I know what I want to do. Why do I need her help?” (laughs)

Tacey A. Rosolowski, PhD:

Yeah, exactly. And so that’s a common theme you found at the time, too. Or not?

Michael S. Ewer, MD, MPH, JD, LLM, MBA:

If I know what direction I’m going to take, and I want you to hold my hand because I know it’s right, that’s a good reason to call the Ethics Committee. But if I’m not sure you’re going to hold my hand, you might scold me with one finger instead of giving me your hand. Then maybe I don’t need to call you. (laughs)

Tacey A. Rosolowski, PhD:

So was that...? Because the other thing is, in my mind, was as you folks are developing your approach and refining it and creating these concepts, how are you communicating to the institution at large that this kind of support and help is available? And were people taking advantage of it?

Michael S. Ewer, MD, MPH, JD, LLM, MBA:

Well, the Ethics Committee at that time met maybe monthly, and as required. So if somebody had a question, we would meet immediately, within a few hours, if we could, and not everybody could always attend, but we tried. So we would address questions, and then at our monthly meeting we would look at broader issues.

Tacey A. Rosolowski, PhD:

Did you feel people were taking full advantage of what you could do?

Michael S. Ewer, MD, MPH, JD, LLM, MBA:

Probably not. Almost certainly not. There was sometimes pushback, but the pushback wasn’t always “I have a different opinion.” The pushback, in many instances, was philosophical. MD Anderson had, and to some extent in some services still has, a philosophy of a patient who doesn’t survive is a failure. And I’m not willing to accept a failure prematurely. So if I need to move a patient down to the Intensive Care Unit to try to do the impossible, it is by trying to do the impossible today that makes it possible tomorrow, and a standard of care in the future. And do not get in my way of doing this. That is a vital philosophy of Anderson. Now, can that philosophy exist as broadly as it did 40 years ago? And my impression is that it can’t, but the thought process and the goals and the drive of how do we push the envelope of cancer care exists and must continue at all costs within the institution. So if I were talking to Peter Pisters right now, and I could say one thing to Peter Pisters, it would be do not lose the momentum of our creative thought process to push the envelope. Am I lecturing to you? I’m sorry.

Tacey A. Rosolowski, PhD:

No, I’m loving this. This is great. (laughter) No, this is terrific. I mean, I’m also seeing the kind of ongoing dilemmas that an ethicist, I mean, as physicians, would get into, because this inevitably raises the question when to stop, when to factor in human desires, family desires, all of that stuff. It’s just an ongoing wrestling match. So what’s your perspective on that? I mean, obviously some of it’s case-by-case, but in your teaching and guiding other people to think through this issue, how does that creativity and pushing the envelope balance with the human issues on the ground?

Michael S. Ewer, MD, MPH, JD, LLM, MBA:

If we continue to practice medicine according to the guidelines that have been established for the best medical care, then our grandchildren will experience the same problems as we are. We have to... There has to be a place in the world where we attempt to do the impossible. Only that way can we make progress. And if that means that we have to look at things with a wide-angle lens on our eyes, to grasp possibilities that others with a narrower focus would think are the way that we have to look at things, then we’re missing an opportunity for the future. We have to have the wide-angle lens on the camera.

Tacey A. Rosolowski, PhD:

Now, when you said if you could say one thing to Peter Pisters it would be to kind of put this idea front and center for him, is there some kind of concern that you have that with the current focus in the institution there might be a loss of focus on that?

Michael S. Ewer, MD, MPH, JD, LLM, MBA:

Healthcare in the United States has been criticized as being overly involved in matters of money. We spend 17, close to 18% of our gross domestic product on healthcare. To put that in perspective, that is approaching—not there yet, but approaching—double of what we spend on food. We spend about 10%, or 10.5%, of our gross domestic product on food. We eat three meals a day, at least some of us. What are we accomplishing with spending twice as much on healthcare as we do on food? And it’s not quite twice as much, but it’s getting there. We have the reality of third-party payers, of being out-of-network, of being in-network. We have the dilemma in our institution of the institution being filled to capacity, and we may not be making a profit because of what it is costing us to take care of patients in the style that we are taking care of. So to answer your question do I see a risk in this, the risk is a balance, and the balance is that if we do everything we possibly can to achieve the goals that I have mentioned, we may be so far unable from a fiscal point of view to maintain that, that we become potentially a liability, or even a possible target for takeover. And somebody says, you know, “There’s money to be made in Anderson; they’re not making any, but we can do it better. We can make a fortune here.” And there would be lots of people who would, I think, love to try, and we can’t let that happen. I don’t want that to happen.

Tacey A. Rosolowski, PhD:

Interesting. Um—

Michael S. Ewer, MD, MPH, JD, LLM, MBA:

How much of this is true and how much of this is my own concerns or speculation, time will tell.

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Chapter 09: The Ethics Committee at MD Anderson, Part II: Practicing Ethics in a Context of Innovation

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