The Elephant In The Room
Presenter: Deborah Massey LCSW, ICADC II
“ETHICS IS NOTHING ELSE THAN REVERENCE FOR LIFE.”
ALBERT SCHWEITZ ER
The Elephant In The Room Workshop Agenda
2:00 - 2:15
Introductions and Ice Breaker
2:15 - 3:15
Part I
3:15 - 3:30
Break
3:30 - 4:30
Part II
4:30 - 4:45
Introspection
4:45 - 5:00
Closing Remarks/Questions/Evaluations
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Michigan State University, College of Human Medicine, Center for Ethics
Humanities in the Life Sciences
What Is Bioethics?
EASY
ANSWER
Bioethics is an activity; It is shared, reflective examination of
ethical issues in health care, health science, and health policy.
 These fields have always had ethical standards
without question, however we needed a more public and
critical discussion of these standards.
 Discussion, articulation, reflection and challenge most
often compels revision.
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1ST Century Attitude relative to Medical Ethics and Modern Bioethics Atrocities
“It is not cruel to inflict on a few criminals, sufferings which may benefit multitudes
of innocent people through all centuries”.
Celsius
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The Hippocratic Oath: Original Version
I swear by Apollo the physician, and Aesculapius the surgeon, likewise Hygeia and Panacea, and
call all the gods and goddesses to witness, that I will observe and keep this underwritten oath, to the utmost
of my power and judgment.
I will reverence my master who taught me the art. Equally with my parents, will I allow him things necessary
for his support, and will consider his sons as brothers. I will teach them my art without reward or agreement;
and I will impart all my acquirement, instructions, and whatever I know, to my master's children, as to my
own; and likewise to all my pupils, who shall bind and tie themselves by a professional oath, but to none
else.
With regard to healing the sick, I will devise and order for them the best diet, according to my judgment and
means; and I will take care that they suffer no hurt or damage.
Nor shall any man's entreaty prevail upon me to administer poison to anyone; neither will I counsel any
man to do so. Moreover, I will give no sort of medicine to any pregnant woman, with a view to destroy the
child.
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(cont)
The Hippocratic Oath: Original Version
Further, I will comport myself and use my knowledge in a godly manner.
I will not cut for the stone, but will commit that affair entirely to the surgeons.
Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient; and I
will willingly refrain from doing any injury or wrong from falsehood, and (in an especial manner) from
acts of an amorous nature, whatever may be the rank of those who it may be my duty to cure, whether
mistress or servant, bond or free.
Whatever, in the course of my practice, I may see or hear (even when not invited), whatever I may happen
to obtain knowledge of, if it be not proper to repeat it, I will keep sacred and secret within my own breast.
If I faithfully observe this oath, may I thrive and prosper in my fortune and profession, and live in the
estimation of posterity; or on breach thereof, may the reverse be my fate[4]
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The Hippocratic Oath: Modern Version
I swear
to fulfill, to the best of my ability and judgment, this covenant:
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share
such knowledge as is mine with those who are to follow. I will apply, for the benefit of the sick, all measures
which are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I will remember
that there is art to medicine as well as science, and that warmth, sympathy, and understanding may
outweigh the surgeon's knife or the chemist's drug. I will not be ashamed to say "I know not," nor will I
fail to call in my colleagues when the skills of another are needed for a patient's recovery. I will respect the
privacy of my patients, for their problems are not disclosed to me that the world may know.
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(cont)
The Hippocratic Oath: Modern Version
Most especially must I tread with care in matters of life and death. If it is given me to save
a life, all thanks. But it may also be within my power to take a life; this awesome
responsibility must be faced with great humbleness and awareness of my own frailty.
Above all, I must not play at God. I will remember that I do not treat a fever chart, a
cancerous growth, but a sick human being, whose illness may affect the person's family
and economic stability. My responsibility includes these related problems, if I am to care
adequately for the sick. I will prevent disease whenever I can, for prevention is preferable
to cure. I will remember that I remain a member of society, with special obligations to all
my fellow human beings, those sound of mind and body as well as the infirm. If I do not
violate this oath, may I enjoy life and art, respected while I live and remembered with
affection thereafter. May I always act so as to preserve the finest traditions of my calling
and may I long experience the joy of healing those who seek my help.
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Atrocities that Stimulated Discussion
The Nuremburg Trials
December 9,1946 – August 20,1947
The Trials were a series of military
tribunals, held by the allied forces after
WWII most Notable for the prosecution of
prominent members of the political,
military, and economic leadership of Nazi
Germany who allegedly planned, carried
out, or otherwise participated in the
Holocaust and other war crimes.
Trial Outcomes
1. 16 of 23 were found guilty of “Crimes
against Humanity”
2. 7 were sentenced to death by execution
3. Verdict contained section “Permissible
Medical experiments” which became the
basis for the Nuremburg Code
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1947 The Nuremburg Code: Codes of Research Ethics
The first professional ethical code for medical researchers
Voluntary Consent : is essential
research based on prior animal work
The degree of risk should :“never exceed the
humanitarian importance of problem” or “be
minimized through proper preparations”
risks justified by anticipated benefits
Participants should be free to withdraw
Only qualified scientists conduct research
These basic and legal obligations in human research
Avoid mental and physical suffering
The model for many professional and governmental
codes since the 1950s
If death or disabling injury is expected, research
should not be conducted
Served as the first international standard for the
conduct of research
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1932-1972 Tuskegee Syphilis Experiment 399 black men with Syphilis and about 200
men without syphilis participated The men were recruited without informed consent and
they were not told that they were participants in a research study In the 1940s Penicillin
was found to be effective in the treatment of Syphilis. The Study continued ….
Those infected were NOT informed or treated with the antibiotic
Never received drugs for their conditions or told that they existed
Spouses and children of the subjects also contracted Syphilis
Exposed in 1972 – During the 40 years of the study numerous papers were authored by
the PHS team. Specialists in Syphilis around the world all knew of this long term study of
untreated Syphilis.
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Late 1950s -1970 The Willow brook Hepatitis Study
Deliberately infected children with hepatitis for research purposes
Coercive measures to admit new children
Researchers defended the action, claiming that the vast majority would acquire the
infection at Willow brook anyway, given the overcrowded, unsanitary conditions, and
because only children whose parents had given consent were included
Closed the doors to new patients, claiming overcrowded conditions. However, the
hepatitis program, was able to continue to admit new patients. Thus in some cases,
parents found they were unable to admit their child to Willow brook unless they agreed to
participation in the hepatitis studies
“EXPOSED IN 1972- “GERALDO RIVERA”
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The Aftermath
◦ Changes were made to prevent the moral breaches that occurred in Tuskegee from
happening again.
◦ On May 4,1997- Surviving participants of the Tuskegee Syphilis Study gathered at the
White House and witnessed President Clinton’s apology on behalf of the US
government.
◦ Willow brook was closed in 1987. Federal civil rights legislation was introduced to
protect people with disabilities.
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1979 The Belmont Report
Establishment of the National Commission for the Protection of Human Subjects of
Biomedical and Behavioral Research
Established by the U.S. Congress to identify ethical principles to guide all human
research
In 1979, Commission published the Belmont Report
Remains the cornerstone for all federal regulations on human research and sets the
standard for ethics in medical care.
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Fast Forward to the Mid 80’s
Four guiding principles that ultimately emerged from the findings of The
Belmont Report and publication of Principles of Biomedical Ethics
 Autonomy: Respect for persons (informed consent, confidentiality, truth
telling, competence)
Beneficence: Contribute to the human good (paternalism, substituted
judgment, public health)
* Nonmaleficence: NOT ENOUGH to just do good…MUST prevent and
do no harm. (PAS, euthanasia, competence, medical error, profit)Justice:
Fair & equitable distribution (rationing, futility, treatment)
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Medical Ethics Protecting Vulnerable Populations
 Settings with Power imbalance
 Economically disadvantaged
 Racial & Ethnic minorities- immigrants
 Uninsured- Poor
 Children-Elderly-Homeless
 Those with human critical & incurable illness
 Chronic health conditions
 Mental illness
 Those who often encounter barriers to accessing healthcare services
 OTHERS….
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DO NO HARM!!!!
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Provider Expectation and Patient Motivation
Influences that often impact the quality therapeutic relationship:
Providers’ and Patient’s worldview
Providers’ and Patients’ personality type
Provider’s Helping Model
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World View
Worldview is defined as a “view of life”, which is “a comprehensive interpretation
or image of the universe and humanity”.
Integrity, dignity, expectation, self-efficacy and trust are variables impacted in the
therapeutic relationship and the ones most affected by one’s worldview.
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Personality Type A
Friedman suggests that Type A behavior is expressed in (3) major Symptoms
1) Free-floating hostility, which can be triggered by even minor incidents
2) Time urgency and impatience, which causes irritation and exasperation usually
described as being short-fused
3) Competitive drive, which causes stress and an achievement driven mentality
Descriptive Adjectives: Ambitious, Rigidly organized, Highly Status-conscious,
Sensitive, Anxious, Proactive
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Personality Type B
1) Noted to live at lower stress levels in contrast to Type A
2) Work steadily and enjoy achievement however the stem of their unconscious character
disregards physical/mental stress when they do not achieve
3) When faced with competition, losing is not focused upon; enjoyment may be received
regardless of winning or losing
Descriptive Adjectives: Laid Back, Creative, Methodical, Often Reflective,
Thoughtful of the “outer and inner world”.
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Personality Type C
1) Appear quiet and introspective but actually frustrated and swallow anger
2) Appease others to the point of self-effacement and self-sacrifice
3) Polar opposites of Type A emotionally
Descriptive Adjectives: non-emotional, non-assertive
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Personality Type D
1) Negative outlook towards life and are pessimistic
2) Relatively small event can ruin their day
3) Socially withdrawn as a result of fear of rejection even if they like and feel
comfortable around people
4) Lack of self-assurance
5) Suppress their emotions which makes them the most vulnerable type to depression
Descriptive words: worry, irritability, gloom, social inhibition, reticence
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Biesser’s Models of Help
Evil model: The person is seen as willfully bad or possessed by evil spirits; the response
involves exorcism or incarceration.
Illness model: The person is viewed as a helpless victim of psychic trauma,
psychological or physical disorder, or chemical dependency; the response involves
treatment.
Problem-solving model: The person has a problem and intellect and rational thought can
be used to find a solution; the response involves technical consultation.
Crisis model: The person has experienced recent trauma or crisis; the response
involves crisis management.
Growth model: The person should celebrate his/her uniqueness and ability to develop
full potential; the response involves facilitating the individual’s capacities.
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Biesser’s Models of Help
Social issues model: The person is a victim of social forces or structural features of
society; the response involves community organization or social advocacy.
Suspect model: The person is seen as unproductive, irresponsible, and dependent on
society; the response involves minimal help with maximum policing.
Beneficiary model: The person has a right to a certain kind of help because he/she is a
member of that society; the response involves provision of services.
Deviance model: The person is deviant and may also be sick; the response involves
correction of deviant behavior.
Self-help model: The person is a victim of heredity, a dysfunctional family external
substances, or control by others; the response involves support and solidarity from like
sufferers.
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Effective interpersonal communication (IPC) between health care provider
and client is one of the most important elements for improving client
satisfaction, compliance and health outcomes.
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What are the Characteristics of Effective IPC?
Two-Way Dialogue
Partnership Between Provider and client
Atmosphere of Caring
Effective Bridging of Social Distance
Social Networks
Effective Use of Verbal Communication
Effective Use of Non-Verbal Communication
Opportunity for Patients to Speak About Their Illness
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Guidelines and Norms for Effective IPC.
1) Caring/socio-emotional communication
2) Diagnostic communication/problem solving
3) Counseling and Education
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Caring/socio-emotional communication
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Frame the encounter
Use appropriate non-verbal communication
Solicit feelings
Show positive regard
Validate the patient’s experience and efforts
Echo patients’ emotions
Express support and partnership
Give reassurance
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Diagnostic communication/problem solving
 Listen attentively and actively
 Encourage dialogue
 Avoid interruptions
 Avoid premature diagnosis and resist immediate follow-up
 Probe
 Ask about causes
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Counseling and Education
 Explore patient understanding
 Correct misunderstandings or
misinformation
 Use appropriate vocabulary
 Present information in blocks
 Use visual aids and/or printed materials
when possible
 Recommend concrete behavioral
Select an acceptable and feasible
treatment
Motivate patients to comply with
treatment
Summarize
Check for understanding and
absorption
Additional questions
Confirm Follow-up actions
changes
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The Provider’s “Interrogation Approach”
 Take Complete Breaths
 Monitor changes in your breathing rate
 Make an effort to actively listen
 Take a few minutes to process the information and reflect before responding.
 Try to avoid a lull in interaction by repeating what you’ve heard.
 Discuss challenging cases in case conference/supervision.
 Constantly check your motives
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REFERENCES
De Negri, B., et al (1990). Improving interpersonal communication between health care providers and clients.
Quality Assurance Methodology Refinement Series. Retrieved from
http://www.globalhealthcommunication.org/tool
Ong, L.M.L., et al (1995). Doctor-patient communication: A review of the literature. Social Science and
Medicine. 40(7), 903-908.
Street, R.L. Jr, et al (2007). Physicians’ communication and perceptions of patients: Is it how they look, how
they talk, or is it just the doctor? Social Science and Medicine. 65(3), 586-598.
Van Ryn, M., & Burke, J. (2000). The effect of patient race and socio-economic status on physicians’
perceptions of patients. Social Science and Medicine. 50(6), 813-828.
Williams, S., et al (2005. Socio-economic status of the patient and doctor-patient communication: does it make
a difference? Patient Education and Counseling, 56(2), 139-146.
Historical Information is the property of the Archives of the Walter Reed National Medical Center
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LIFE
EXPERIENCE
MANY MORE
????
IDIOSYNCRASIES
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