Better

Though TP was fasting, he had a busy day planned, regardless (TP doesn't much care for services in general -- for as long as he can remember, the primary feeling he can recall experiencing in temple is boredom).  10:30 am featured a meeting with TP's clinical ethics professor, discussing all manner of topics, including potential paper topics.  We finally settled on an examination of the ethical considerations that attend DNR orders with newborns and older children (TP's clinical ethics practicum has involved rounding with one of the pediatric teams).  Very interesting, definitely.

We made arrangements for (1) general background readings on DNR orders; (2) then a literature review of DNR orders that specifically pertain to newborns and older children which the prof will review and approve; (3) followed by specific analysis of a case study (prof has several drawers full of case studies) for the actual paper itself.  We also planned to have me sit down with the prof's pediatric consult files, which contain the records and information regarding Prof's pediatric ethics consultations.  I'm thinking about trying to create an index for them for Prof so Prof can find what Prof needs in there more easily.

Man, I just feel so fortunate to have the opportunity to think about and work on such matters.  It really is a tremendous privilege to be doing what I am doing.

At 11 am, Prof and I ran off to MD (multidisciplinary) SICU (surgical ICU) rounds.  Clinical SICU rounds are separate from the MD rounds.  The former obviously involves the primary clinical team, while the latter is usually attended by nurses, OT/PTs, the critical care fellow, social workers, and care management specialists.  It was incredibly interesting.

At noon, we ran off to attend a lecture given by Dr. X, the author of a book of poetry regarding the medical profession.  He spoke of the propensity of our medical schools to take incredibly broad-based, brilliant, cultivated, talented people, and turn them into relatively cold, distant healers, and of the need to humanize the practice of medicine.  Obviously, such a sentiment would go over well in my program.

Another Prof of mine, however, did raise several fascinating concerns that attend the publication of patient narratives.  First, there are concerns, especially in the age of HIPAA, regarding confidentiality of a patient's medical records.  Note, I'm not just discussing the legal requirement of confidentiality, as important as that is, but there is obviously also an ethical dimension to confidentiality, that overlaps but is not constituted by the legal standard.

Dr. X responded that he obtained consent whenever he could, but admitted that many of the narratives in the book were decades old, such that consent was impossible to obtain.  He stated that he fictionalized the accounts where possible (change gender, age, characteristics, etc.), and that compromise on "both sides" was necessary for the sake of art.

This is completely unacceptable.  First off, one must be EXTREMELY careful about compromising patient confidentiality in any way, shape or form, even accidentally, let alone intentionally, regardless of the intended end.  Second, one of the keystones of modern medical ethics is the Kantian conception of human dignity -- that people are not to be used merely as means to an end.  In fact, being relatively well acquainted with the rise of medical ethics as a discipline in this country, I can say that he animating force behind the development was largely the revelation that much biomedical research in this nation had most assuredly violated that Kantian ethical requirement (most notably, the Tuskegee experiment, but there are many others -- too many).

Compromising confidentiality for the sake of art, as noble an end as that is (and few adore poetry more than TP), also seems to run afoul of the requirement.  Finally, if one fictionalizes the narratives, in what sense are they even the patient's narratives anymore? The importance of the fact that a patient plays the violin, rather than the fictionalized flute, may seem trivial, but may be of crucial important to the narrative.  What's more, the narrative has been arrogated to the writer.  The narrative is no longer owned by the patient when it is fictionalized.  It has become subsumed by the writer.

Needless to say, some in the audience had significant issues with Dr. X's lecture.

After the lecture, a bit dizzy for want of food and water, it was off to a three-hour seminar on Kant's ethics.  I have probably spent about 2 years, total, studying the work of Immanuel Kant (both his ethics and his epistemology), and the more I read his work, the more I admire and appreciate the man's brilliance.  Also, the more I read Kant, the less dogmatic and absolutist I find the man to be.  The man's contributions to moral theory simply cannot be overstated.  The modern study of ethics simply cannot avoid Kant.  In fact, I think there is ample justification for asserting that modern medical ethics owes an enormous debt to Kant -- many of its core principles draw heavily on Kant, whether the participants in the praxis realize it or not. 

Though I am sympathetic to relativism (don't even bother asking about it -- not a subject I discuss on this blog), there has never been a more elegant, articulate expression of objective morality than that from Kant. 

After a spirited class, it's off to teach legal research and writing to law students, which went fairly well considering my hungered state.  After class, I stood in the parking lot drinking water and eating reduced-fat Oreos (highly recommended), looking up at the cool night sky and the iridescent moon, and thought, what was I doing last year at this time? Sitting at a desk all day, writing useless bits of memoranda and paragraphs of argument, just wasting away intellectually and emotionally.

And now -- look at the richness of my intellectual life.  DNR orders, multidisciplinary SICU rounds, lectures on poems and the humanization of medical practice, ethics of confidentiality, deep analysis of Kant, teaching legal research & writing.  This is better.  This is much, much better. 

Comments

[Adrianne Truett]

Sounds like you're having a good time; I'm glad.

"What's more, the narrative has been arrogated to the writer. The narrative is no longer owned by the patient when it is fictionalized. It has become subsumed by the writer." -- Reminds me of a classmate who was doing her thesis on Bulgarian Jewish (or some smaller group) folk tales. A few students were outraged because she was committing the stories to paper, translating them, and thereby killing the living stories and doing irreparable damage to the culture; even if they consented, it was argued, since the subjects were unfamiliar with the nature of a college thesis or American academia, it could never be informed consent. The student's actions by simply going there, to her great-grandmother's hometown, would also be horribly damaging, because it would be forcibly exposing this untouched rural community to western ways of life. (Where are we -- Star Trek?) Yes, I know, that's not in the least related to what you're saying, but it amused me. And I like to hear myself talk :)

[Adrianne Truett]

Interesting info on that DNR link, btw. Rather different from the policies I'm hearing about out of the UK.

[TP]

I think it's analogous, Adrienne.

What have you heard about DNR practice in the UK?