The Program in Medicine & Human Values is dedicated to furthering research in bioethics and policy development. Our location in the San Francisco Bay Area, a world research hub, gives us resources that simply can't be found elsewhere. As a community hospital, our facilities are perfect for research in bioethics. Often, research in bioethics is never applied beyond the university hospital. Our research prioritie aim at being "applied" in every hospital, regardless of academic affiliation. Our faculty and visiting scholars contribute distinguished scholarship to the literature and promote institutional and regional dialog through research collaborations and institutional partnerships.
Ethics as an Element of Quality
In Winter 2005, the Program administered the Staff Ethics Survey to its medical staff, clinicians, administration and select support staff. As a self-completed survey, the tool was to assess perceptions of the facility’s ethical health care practices and institutional culture as well as knowledge of ethical health care practices, and views on institutional support for ethical health care practice.
The results of the Staff Ethics Survey provided a flood of information with which we aimed to create a performance improvement plan. However, when we presented the information to our hospital quality experts, they were reluctant to buy in. It seemed as though ethics wasn't recognized as an element pf quality care. Quality care, as defined by the Institute of Medicine, is: "The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." Surely ethics falls under this definition. Yet quality is only measured in things like how many heart attack patients who have problems with their heart pumping blood to their body were prescribed an ACE inhibitor after discharge; or how many pneumonia patients received an initial antibiotic within four hours of admission. Could we add to that to make quality even better? Could we add a little humanism to the hospital experience? Why not ask, “How many patients with capacity that were admitted to the ICU received advice on preparing an advance directive?”
We want to change this. On January 24 & 25, we hosted a colloquium, with experts from bioethics, medicine, health policy, and quality improvement, that addressed this very issue. A follow up meeting will take place in November 2008. We have developed a white paper that you can read
here.
Proactive Ethics Intervention to Improve ICU Care
In 2006, our visiting scholar, Dr. Larry Schneiderman from UC San Diego proposed a study of “proactive ethics intervention.” Proactive ethics intervention is a service provided by the hospital, with the patient’s consent, in which a clinical ethicist evaluates a patient’s case after some ‘trigger’ indicates that there may be some manifest or latent ethical issues involved. For us, this trigger is a stay of five days or longer in the ICU (the goal of care in the ICU, with the exception of transplant patients, is to get you in, well and out as quickly as possible); possibly indicating a poor prognosis.
This study will investigate whether or not proactive ethics intervention has any affect on patient satisfaction, provider satisfaction, and length of stay.
Ethics & Transplantation
Human organs continue to be scarce in the United States and waiting times for transplantation can be very lengthy. This often results in increased potential for clinical decompensation and even death while waiting. Some patients resort to listing at multiple institutions so as to increase their chance at obtaining a deceased donor organ. Receiving an organ from a living donor is also an option for some patients. This project explores a more extreme strategy: organ tourism. Organ tourism (traveling to a foreign country to obtain an transplant) is ethically problematic for various reasons, including the execution of live individuals for the organs. We are interviewing adults who traveled from the US to another country with the express intent of obtaining liver or kidney transplantation, to understand their motives for foreign transplantation, their transplant experience, and their post-transplant outcomes. We also interview their US physicians to explore the incidence and nature of their ethical discomfort with organ tourism. Our results will help us shape guidance to physicians in dealing with patients who express a desire to participate in organ tourism.
Moral Reasoning in Medicine
In response to a body of research that suggests that development of moral reasoning plateaus at a certain point in individuals, we aimed to develop an instrument that refuted this argument. We hypothesized that instruments used in measuring moral reasoning were systematically flawed. The instruments that have been developed; the Defining Issues Test (DIT), the Sociomoral Reflection Measure (SRM) and the Moral Judgment Interview (MJI); have largely produced data that showed no developmental change in moral reasoning by medical students over the course of time. But what if these findings do not accurately represent the real processes of moral reasoning? What is there is something unique about doctors? In stark contrast to these conclusions, there has been a small amount of research by J. R. Rest and S. P. McNeel that has shown some rather significant developmental change while using these instruments in liberal arts undergraduates as a result of their education and teaching methodology they received. All of these instruments are based on Lawrence Kohlberg’s “Stages of Moral Development.” We’ve got ten years of data and are still collecting. For more information, email
ethics@sutterhealth.org.
Commercialism in Medicine
In March, 2004, the CPMC Program in Medicine and Human Values invited a group of leading bioethicists to San Francisco to discuss the ways in which commercialism has changed the practice of medicine. Drs. Jonathan Moreno (University of Virginia), Larry Churchill (Vanderbilt University), Joe Fins (Cornell University, New York Presbyterian Hospital), Mark Siegler (University of Chicago), Jacob Needleman (San Francisco State University) and Rosamund Rhodes (Mt. Sinai Medical Center) spent two days discussing the issues.
You can read the paers produced at this colloquium in the Fall (2007) issue of the Cambridge Quarterly of Healthcare Ethics. See
Our Publications.
