The "Good" in Healthcare
I was a bit out of my depth last Saturday, as I presented a brief talk on the ethics of healthcare at Johns Hopkins University as part of the Symposium on Christian Faith, Reason and Vocation: Professional Ethics. I am neither a professional ethicist, nor an academic. Yet, ethics underpins every moment of every day as I practice medicine.
To know what is right and to do what is right is my earnest hope. It is a place of relying upon the transforming power of the gospel, changing my own heart and bringing about unity where there is division, even in the body of Christ. May it be so. Amen.
The slides for last Saturday morning's talk are linked here.
How might one go about starting the conversation on the ethics of healthcare? Here I've found that borrowing on the classic medical ethics framework of beneficence (doing good), non-malevolence (abstaining from evil), respect (or autonomy), and justice are useful to the conversation on healthcare.
The Old Testament prophet, Micah, puts this another way, "He has shown thee, o man, what is good and what the Lord requires of thee: to do justly, to love mercy, and to walk humbly with thy God." (Micah 6: 8). What does this speak into "Make America Great Again" as it comes into contact with global health? Here I am reminded of Jesus' words to a religious lawyer of His day.
"One of them, an expert in the law, tested him with this question: 36 “Teacher, which is the greatest commandment in the Law?”
37 Jesus replied: “‘Love the Lord your God with all your heart and with all your soul and with all your mind.’ 38 This is the first and greatest commandment. 39 And the second is like it: ‘Love your neighbor as yourself.’ 40 All the Law and the Prophets hang on these two commandments.” - Matthew 22: 25-38
Who is our neighbor? To whom should we ally ourselves when we have been told that God so loves the world? Who is created in the image of God? We often see ourselves created in His image, but what about an unborn baby? Muslim women? A disabled child? Black mothers demonstrating against police violence? Rohingya refugees? An elderly man from another country?As the CDC cuts the budget for global disease outbreak prevention, what will happen if there is another Ebola outbreak? We recall that the impact of this outbreak reached our own soil, and that is a real life concern in US healthcare, but should we not also be concerned about our neighbors in Africa?
Closer to home, an individual's autonomy is often juxtaposed to what is good for others around him or her. Here a physician is depicted administering a vaccine to an infant, but the infant has much greater protection from influenza if everyone around him or her is vaccinated.
In his recent remarks, Speaker Paul Ryan cast the repeal of the individual mandate in terms of freedom, saying "You should have the freedom and the flexibility to choose the care that's best for you." But what is the impact of that freedom? One of my slides show some harms versus benefits of freedom with respect to coverage.
I think of the "golden rule", as Jesus was winding down the Sermon on the Mount. "So in everything, do unto others as you would have them do to you, for this sums up the Law and the Prophets." How should that inspire us to work toward aligning the healthcare system with what is good?
Even in purely practical terms, the US per capita health expenditure (how much we spend on every American) is thousands of dollars per year higher than most other developed countries, even though those countries enjoy a longer life expectancy. In the Journal of the American Medical Association (JAMA) an ethicist recently proposed a new ethics framework of universal access, equitable access, affordable access, quality and choice. This seems a tall order.
Just taking equitable access as a case study (or perhaps settling for the stepping stone of less inequality of access), the Reverend Dr Martin Luther King, Jr, had powerful words. "Of all the forms of inequality, injustice in health care is the most shocking and inhumane." (AP, 1966).
Yet, what is justice? How does justice add up with fairness? With equality? Starting points are unequal, and that has a lifelong impact.
The ethics of healthcare plays out in current events such as the debate on freedom of religion versus vaccine requirements. 85% of children who have died of influenza this year were unvaccinated! We run the risk of emerging deadly and global infectious disease outbreaks as US funding for prevention is scaled back. The present impact of inequality is a 25 year difference in life expectancy between adjoining neighborhoods in New Orleans. Neighborhoods, not whole zip codes! Finally, as many work to restrain the burgeoning cost of healthcare, many states are pushing for the legalization of physician-assisted suicide. As people face unbearable healthcare bills, especially in "cost-sharing" or "skin-in-the-game" health insurance plans and as elders age with costly dementia, the vulnerable are at risk for coercion. When does "right" or "choice" become "duty" in such a system?
In summary, the classic ethics framework applies to healthcare, and the Bible informs Christian ethics. World health, US healthcare and our own health intersect in ethical questions. Ethics concepts live in tension, one with another, and the answers are not always perfectly clear. Finally, health is our very first wealth (and freedom!).
BELOW ARE SOME OF MY PREPARED ANSWERS FOR THE PANEL QUESTIONS (we did not get to all of them, and my co-panelist had wonderful contributions as well):
Share about how your faith played a role in your decision to pursue a career in the field of medicine... The questions are open-ended and meant to allow time for extended reflection.
I was born with a syndrome of birth anomalies, so from the start of my life, I had intersection with the medical field. I credit my pediatrician for talking me into becoming a doctor. In fact, it is my first childhood memory. Fast forward to college, I prayed for God to make it clear to me whether or not that was what He wished me to pursue and also prayed for wisdom when choosing where to attend medical school. Thankfully, He led me here to Baltimore where I have been now for 25 years!
How does your faith inform your day-to-day and/or long-term practice in healthcare?
12 years ago, I decided to depart from my first practice and start my own. This was a huge leap of faith. The starting point was an ethical conflict with my former partners who had chosen to become concierge doctors. Running my own practice, remaining independent, and accepting most insurance is the outworking of faith as I seek to align my practice with what is good and to do my work with excellence.
Are there active ways in which you’ve planned how your faith would shape your practice, or are you surprised by the ways in which your faith has interacted with your practice over the years?
As a medical student and resident, I never would have imagined going into private practice, yet it has been a good fit. I never would have imagined starting my own practice, but through much prayer felt God’s call. The Scripture that kept coming to me around that time was of Israel crossing the Jordan River.
How does your faith influence patient-physician relationships? Relationships with colleagues/team? Conversations with families?
Managing the practice has been one of the most sanctifying aspects of my life. I have gotten in touch with my weaknesses and strengths and have learned to pray. Often, my prayer is “help!” We are called as Christians to die to self, to be servant leaders like our Lord. I do this very imperfectly. With patients, my witness is first to doctor with excellence. There are those “divine appointments”, opportunities to share my faith or help fellow believers draw upon theirs, but mostly it is a ministry of helping people live well.
Does faith factor into clinical decision-making?Will have to reflect more upon this. Certainly my faith constrains me from physician-assisted suicide. Counseling on sexuality takes a great deal of wisdom. “Pearls before swine” comes to mind. A pig tramples on the pearl, because it is of little value to it. Like Jesus, we can apply appreciative inquiry to gain an understanding of where someone is coming from, which builds the relationship.
What are some of the challenges you’ve faced in integrating faith (worldview, values, mission) in either clinical care or medical research?
Anti-science views within Christianity. Anti-Christian views within science. Limited time. Recently, I had a great intellectual debate with a materialist patient of mine; yet, I must remain cognizant of the next patient on my schedule.
Are there specific instances of conflict between your faith and your professional work/training that you've learned from?
Christian doctors should feel free to apply the knowledge we have gained through science. John Calvin said, "All truth is God's truth." Dr. Francis Collins stated something like this, "The Bible is not a science textbook. Nor is the science textbook a source on faith."
Have you encountered challenging interactions with team members regarding faith?
One of the partners in my old practice would often come by at the end of the day and ask things like, “So, Holly, what do Christians think about...”. It is hard to represent all of Christianity. I did love those conversations, truth be known,
Have you encountered tension between personal faith and institutional goals/protocols/decisions in the systems you’ve worked for/with?
When I was in training at Hopkins, I always felt uncomfortable with the amount of hubris that seemed required to succeed. We are called to humility as Christians and to pride as “Hopkins doctors.”
As a physician of faith, what are some of the most challenging ethical questions you see in the medical field today? How have these questions changed over the years? How do you approach these?
How can we best address healthcare inequality and social determinants of health?
How will we restrain the burgeoning cost of care while improving quality?
The push to legalize physician-assisted suicide is cast in terms like “medical aid in dying”, “compassionate choices”, etc. Everyone seems to be using words to change meaning, yet underlying dangers must be recognized. There needs to be more awareness in Christian communities as far as what is at stake. Here, I perceive that Catholics do better than Protestants.
How do you respond (both personally and professionally) to such challenges?
Prayer! Sabbath rest on Sundays to regain perspective. Journaling. Leaving the employ of Hopkins. Leaving my former practice and starting my own. Remaining an independent practice despite the challenges.
