Chapter 10: Ethics after the Ethics Committee
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Description
In this chapter, Dr. Ewer sketches how ethics evolved at the institution after the Ethics Committee was disbanded in 1993. He explains that Rebecca Pentz, PhD, was appointed head of ethics (though was uncertain if it had been formalized as a department at that time) and recounts a story to demonstrate how her perspective on handling ethical situations differed from his own. He notes that some of the original members of the disbanded ethics committee joined Dr. Pentz’s group.
Next he talks about Colleen Gallagher, PhD, who came to MD Anderson in XXX to head the Department of Integrated Ethics. He describes the leadership she has built and notes similarities in their perspectives. He talks about their collaboration on a book.
Next, Dr. Ewer explains his terms, “macro ethics and micro ethics.”
Identifier
EwerMS_02_20180725_C10
Publication Date
7-25-2018
City
Houston, Texas
Topics Covered
Overview; Ethics; Definitions, Explanations, Translations; Overview; MD Anderson History; MD Anderson Snapshot; The Researcher; Leadership; On Leadership; Institutional Politics; MD Anderson and Government; Human Stories; Offering Care, Compassion, Help; Patients; Patients, Treatment, Survivors
Transcript
Tacey A. Rosolowski, PhD:
Sure, sure. Tell me a bit more about the time when the Ethics Committee was shut down. I mean, you gave some of the broader context last time, but kind of the details of it we didn’t get to. How did that happen? What happened to these folks? And what happened to Ethics in the aftermath?
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
Well, the institution then hired a full-time ethicist, and her name was Rebecca Pentz, I believe. We called her Becky, but I think her name was Rebecca. Rebecca was, as far as I know, the spouse of a clergyman, and she was at the institution for a number of years, and she’s still active in ethics, as far as I know, but not here. She left. She was present for a couple of years, and then it’s probably not beyond comprehension that she and I locked horns on occasion.
Tacey A. Rosolowski, PhD:
So the Committee was shut down in 1993? Was that...?
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
I think so, yeah, yeah.
Tacey A. Rosolowski, PhD:
Okay, and so it was under Dr. LeMaistre that that happened.
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
Yeah, yeah.
Tacey A. Rosolowski, PhD:
Okay. So what were her credentials?
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
I don’t know.
Tacey A. Rosolowski, PhD:
Okay, so, all right. So what perspective did she bring at that point?
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
Well, she brought the perspective that... You know, it’s hard for me to say. She basically brought the perspective of somebody dealing with ethics, and that is to try to do the right thing. But we had one case—I don’t know whether I mentioned the case of the artist last time.
Tacey A. Rosolowski, PhD:
No, I don’t recall that.
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
Well, we had a situation of... And actually, the family of this artist has allowed me to discuss it, so this is not a HIPAA violation, although we didn’t have HIPAA at the time. But this was a patient who had sarcoma, and the first ethical problem that I had was that the doctor said, “Giving you more chemotherapy is a bad idea. Now, if you want to have more chemotherapy, and you’re fighting me for it, I’ll give you more chemotherapy, but only on condition that you agree to a do-not-resuscitate order, because you’re not going to survive it, and I don’t want you in the Intensive Care Unit for three months dying a slow death.” And the family said no. So this came up to the Ethi—and somehow or other I was involved in this. And the answer, again, looking at the appeals model, the answer is: can a patient be coerced into giving the right to reverse a do-not-resuscitate order? Can a patient forfeit that right? And is there a problem with that? And in my opinion, there is. And so this is unacceptable. You can say, “I’m not going to treat you because I don’t think that there is a meaningful benefit to you,” but you cannot say, “I’ll treat you if you agree to a do-not-resuscitate order.” Well, the patient was treated, and on the way out—because eventually they wanted to declare this patient unsalvageable—they basically said, “Well, you know, this patient should not be resuscitated if he dies in the ambulance.” And the ambulance driver said, “You know, when he’s in our hands we’ll make that decision. It’s not your concern anymore.” Ms. Pentz was involved in this, and I was involved in this. Now, with full disclosure, I saw this patient in the clinic, and it turned out that this individual had gone to the same high school I did, so there was a little bit of bonding. It also turned out that the patient’s father was a world-famous sculptor, who created the Prometheus at Rockefeller Center. His name is Manship; I don’t know whether you’ve come across the name, but Paul Manship was a very famous artist, and worked up until the ’60s. He did the Kennedy medal, the inaugural Kennedy medal, as far as I know. But anyway, this was... And his son was a very, very competent artist. So I was kind of interested in him, so I called up and said, “Did he make the trip?” “Yes, he did make the trip. He’s in a hospital in Boston, and they’re taking care of him.” Called up a few days later. “How is John doing?” “He’s going to go home.” And I said, “You know, I’m concerned enough about all of this, may I come and visit?” So I got into an airplane, and I flew up the Manships, and there’s John and his wife. Margaret was his wife. And I would not have chosen that quality of life, but they did. He was home, and she took care of him. And we talked a little bit about it, and everything that we had decided was a foregone conclusion turned out to be wrong. He didn’t die of his chemotherapy. He should have been resuscitated when they said, “No, don’t do it.” And here I am in Boston, interviewing them. I never wrote it up, but I wanted to write it up. But we’re not always right. And if one day you have nothing to do, you may come to my home, and in my home I have four paintings, which I bought—I didn’t get them free; I bought—from John Manship, the son of Paul, the creator of the Prometheus in Rockefeller Center.
Tacey A. Rosolowski, PhD:
I may take you up on that. (laughs) That’s very cool. That’s very cool.
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
So I was concerned enough about this to want to go and follow up, because what are we doing here? Are we creating self-fulfilling prophecies out of ethics that are wrong? Anyway.
Tacey A. Rosolowski, PhD:
No, that’s a wonderful example of how these things can evolve.
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
They can... I mean...
Tacey A. Rosolowski, PhD:
Humbling.
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
Yeah. So anyway, I don’t know how long Becky Pentz was here. She was here for a while. And then we had Marty Smith.
Tacey A. Rosolowski, PhD:
And just to connect the dots, so when she came in it was the Department of Ethics?
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
I don’t know whether it was a department or not, but she was a full-time ethicist, and she set up how things—how she wanted it done. Some members of the old committee joined her. I was never offered the opportunity. They didn’t want me at that [point?].
Tacey A. Rosolowski, PhD:
Okay. And did you have a sense of why that was?
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
That they didn’t want me? They just wanted new blood. I mean, clearly I had done some things that were good in ethics, but I’d also irritated... (laughs) I mean, in saying that the law could conflict with ethics, which I think we talked about last time, and how I gave them an example.
Tacey A. Rosolowski, PhD:
Who were the members, original members, of the committee who joined Becky Pentz?
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
Annette Bisanz was one, and I’m not sure of the others.
Tacey A. Rosolowski, PhD:
Yeah, that’s fine. Yeah, that’s fine. So after she left, there was a gentleman, Marty—
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
Smith.
Tacey A. Rosolowski, PhD:
—Marty Smith came in, and what kind of perspective did he bring?
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
Marty Smith was a Catholic priest. And he left the priesthood and, I believe, married. And he kept things going for some time, and then he left. I think he went to Cleveland Clinic, but I’m not sure. And then we have a series of interim people for a very short period of time, and then ultimately hired Colleen [Gallagher]. And Colleen has been a breath of fresh air in Ethics, as far as I’m concerned. First of all, she has common sense. Secondly, I think she’s incredibly insightful—not insightful causing a riot, but having insight—and can really understand different perspectives, and also isn’t susceptible to political pressures. She says, “No, never mind what the institution may have as a consequence; this is what Ethics thinks needs to be done.” So she’s been, I think, wonderful. I used to office in Ethics, and I think they were eager to get me out, but that had nothing to do with her, and now she and I have worked together. We’ve done a book together. And we had very, very similar ideas, except I don’t think that she embraces the concept of an ethics consult being like an appeals court. I think she has a more fundamental idea that ethics should be at the trial court level and not the appeals court level. But I’m not sure about that; that’s a question for Colleen.
Tacey A. Rosolowski, PhD:
Tell me about the book you worked on.
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
I thought about doing an ethics book, and I talked with her a little bit, and I got Elsevier to agree to publish it, and I was the senior person on that book, and I asked her to join me as collaborator and co-author. And halfway through I realized I had made a mistake, that the effort that she was putting in was far greater than mine, and that she needed to be the senior author on that book and not me. And so I turned it over to her, and we continued to collaborate. So it’s not Ewer & Gallagher; it’s Gallagher & Ewer. And I think she appreciated that, and we have worked very, very closely together. She’s even been over at our home once. She got to see Manship’s paintings. (laughter)
Tacey A. Rosolowski, PhD:
Lucky her!
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
And that is the... You know, I don’t do anything in ethics anymore, except that we have an abstract going to ASCO Supportive Care—I don’t know whether it’ll be accepted or not—and that is the impact of right-to-try legislation. I don’t know whether you’re aware of right-to-try legislation. People with end-stage disease, who are not eligible for a clinical trial, can ask a pharmaceutical company to release the drug for them to try. The pharmaceutical company may say yes or it may say no, but this is a double-edged sword. Does this interfere with accrual on research protocols if half the people are going to get a placebo? And we’re going to try to find out whether it really works. And people will say, “No, I don’t want to be in a placebo group; I want the drug. I’m not going to get on the trial. I want it on the right-to-try.” So this can have a negative impact. So anyway, we submitted this abstract. Do you want to see it? I’ll send it to you.
Tacey A. Rosolowski, PhD:
Yeah, I’d love to see it. Absolutely. What have you learned from working so closely with Dr. Gallagher?
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
I don’t know that we’ve worked so closely. We have a very cordial working relationship. What have I learned? I have learned that ethics is alive and well and being handled very appropriately in our institution. Has ethics changed? No, ethics hasn’t changed since the time of the Greeks: it’s do the right thing. But ethics has two components, and they have to be balanced, and I believe that Dr. Gallagher balances them. I don’t know whether we talked about the two components.
Tacey A. Rosolowski, PhD:
No, I was going to ask you what they are.
Michael S. Ewer, MD, MPH, JD, LLM, MBA:
The two components are macro-ethics and micro-ethics. And I don’t think I ever got credit for coining those terms, but I probably coined them, but others may have coined them and published them. Whether they got them from me or not doesn’t matter. But micro-ethics is if you come to me and I am the zealous advocate of dealing with your concerns, and the zealous advocate of doing what you wish for me to do, that’s a micro-ethical situation. But let’s take the situation of you have an infection, and the likelihood of you recovering from this infection, because you’ve had 12 heart attacks, is very, very small, but giving you an antibiotic can produce bacterial resistance that could affect everybody else in the Intensive Care Unit. Can that be considered? Can it be considered that putting you on life support for end-stage disease may cost tens of thousands, or hundreds of thousands, of dollars that you’re not going to pay, but society is going to pay. Can societal risks and benefits be looked at? And they become a macro-ethical component. And where is the balance? So if you have a beehive philosophy of only considering macro-ethics, then the individual has no value, and that’s kind of what the Nazis did. If you have a situation where an individual and their benefits has no restrictions, then you wind up with patients, and we have had them, in our Intensive Care Unit for three months that are this close to being braindead, and everybody knows that they can’t be helped regardless, and we spend millions of dollars keeping them alive to placate a family. Where is that balance? And my view is it’s really close to the micro, but not absolute. It’s far away from only considering macro. We do not want to have a situation ever that considers only the benefit of the hive; at least, not in our culture.
Recommended Citation
Ewer, Michael S. MD and Rosolowski, Tacey A. PhD, "Chapter 10: Ethics after the Ethics Committee" (2018). Interview Chapters. 812.
https://openworks.mdanderson.org/mchv_interviewchapters/812
Conditions Governing Access
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