Life as an Extreme Sport

Nazis & Structure: The Inherent Conflict-of-Interest in Bioethics?

This month’s free article from the Journal of Medical Ethics is a doozy: a medical student looks at Nazi physicians, moral luck, and the circumstances that conspire to create the situation where doctors feel that their participation in something as hindsight-reprehensible as the T4 euthanasia program is not only acceptable but morally sanctioned. It’s worth a read.

The interesting thing that stands out to me – aside from Colaianni’s excellent description of medical training that brings up impressions of systematic brainwashing (which may not be intentional but is there nonetheless) – is that it really impresses the need for watchdogs outside the system.

It’s perhaps fitting that I stumbled across this free access article when I was trying to get the feel for another debate raging across articles and commentaries: whether or not physicians needed to advocate for removal of end-of-life care in medically futile cases to the degree that they advocate for care in cases where the religious beliefs of parents conflict with best-accepted medical care. The argument, at least what I was able to glean from the abstracts available to folks without university affiliation or the ability to pay for a yearly subscription, seems to be that because of 11 cases (only five of which remain unresolved) of parents believing life support must be maintained until a miracle occurs, out of 203 total cases, physicians should advocate more strongly for legal recourse to end care. Why is it fitting? Because at least in my mind, that debate over religion and standards of care already started me thinking of the role of bio/medical ethicists in a hospital situation, and the concept I’ve been kicking around for a while: that by being situated within hospitals, embedded with physicians (if not physicians themselves), the ability of a bio/medical ethicist to do their job is compromised.

Colaianni writes that about hierarchy in medicine, and how the medical student reports to the intern reports to the resident reports to the chief resident and all the way up, Old MacDonald’s Farm style. Much like military structure, you’re taught to listen to those in charge and follow command structure; placing the ethicist within this doesn’t necessarily create an escape-valve, because the pressures that are on the physicians – loyalty to people, the institute, etc – aren’t alleviated by simply having another (different) title.

In particular, this quote stood out:

…three junior physicians marked brief questionnaires about mentally handicapped individuals with a red ‘+’ (for death) or a blue ‘—’ (for life). In this way murder was systematised, sanitised, ‘medicalised’ and sanctioned.

Ethicists are expected to function within the system, where things are systematized, sanitized, medicalized, and sanctioned. As any whistleblower knows, stepping outside of the institution that you function within is extremely hard – and can carry heavy penalties. Is it any wonder, then, that we hear of repeated scandals regarding ethics boards, hospitals, or even the public sector? In each case, the people who are expected to stand up and say “no, wait, hang on” are presented immediately with an extreme conflict-of-interest: standing up and speaking out against colleagues; friends; the system that supports their work and signs their paycheck.

What, then, is the solution? The obvious pie-in-the-sky one isn’t at all pragmatic: independent and transparent ethics committees. But money is the immediate issue there, so what if instead of trying to overhaul the entire system, we overhauled just one part of it? Instead of, say, the University of Minnesota bioethicists policing in-house research and medical practice, what if they policed Duke’s research and medicine? Duke’s bioethicists could then police UNC (as we wouldn’t want to create a system of reciprocity where UMinn would ignore Duke’s violations in exchange for Duke ignoring theirs). UNC could police Stanford who could police the University of Washington who could… and so on. While this would not remove issues (and in fact would create new ones), it would at least alleviate the immediate conflicts-of-multiple-interests issue. It is, in the very least, worth a consideration.