Reflections (and a poem) on the special work of nurses. Happy International Nurses Day!
Poetry and medicine have long been entwined. The experience of serious illness – your own or a loved one’s – is often a sentinel event in life. A point around which we orientate past and future happenings. Serious illness forces us outside of the routine. Serious illness forces reflection – it shoves mortality, morbidity, identity to the front of our minds.
Enter poetry – one of the tools with which humankind has made sense of itself since the beginning. A medium into which we can pour hurt, sorrow, anger, joy, disgust, love. Words not constrained by narrative. An art form taking rhythm from music, words from literature, and painting them into whatever shapes we may need at that moment. As long or as short as you like. As comforting or as shocking as the occasion requires. Softly spoken or made with iron. Pick up and read or slip into your pocket for later.
I am one of many doctors throughout history who has worked this lyrical tool to make sense of the practice of medicine. Poetry allows me to tell stories I do not want forgotten, gives solace to families, creates space for reflection, smooths balm for pain, and pays tribute to living.
The Hippocrates Initiative for Poetry in Medicine began in 2009. On the website, the founders describe it as, “…an interdisciplinary venture that investigates the synergy between medicine, the arts and health.” The founders published a reflective paper in the Lancet. It’s discussion of the history of poetry in medicine is informative and inspiring.
The 2022 poetry competition attracted more than 5000 entries from 22 different countries. I am honoured to be one of the commended poets in the Health Professional category, for my poem Love Alone. To read my thoughts on the poem, and to check out the other poets, click here. All poems will be published in the 2022 Hippocrates Prize Anthology which can be bought from the Hippocrates Press and will be released after the awards ceremony on 30th May, 830pm UK time.
As the world still reels from the COVID-19 pandemic, the awards ceremony will be virtual this year. If you’d like to dial in, entry is free but requires registering at this link.
If you would like to hear me, and others, reading our poems, there will be a virtual poetry reading featuring all the commended poets from the Health Professional category on Thursday 16th June at 6 – 730am Australian time. Click here to register.
Gender equality is a significant determinant of health for all people, of all genders, the world over. For example, people that don’t conform to strict male/female gender norms face discrimination, social isolation, and mental health issues arising from this. Restrictive gender norms that force women into economically and socially subservient positions provide fertile ground for violence against women. Norms that force men into traditionally masculine roles of toughness, breadwinning, and invincibility feed into potentially fatal risk taking behaviours and serious mental health issues.
Achieving gender equality is a global challenge. Science and medicine have a major role to play in this. We need research to deepen our understanding of the issues, ensuring the data we collect is rich and nuanced. We need to develop strategies to address inequality at international, national, and community levels. The healthcare workforce need to provide equitable care for all people and educate the community in practical ways that will support equality. We need to do cross-disciplinary research to ensure we understand how gender intersects with other social determinants of health such as socioeconomic status and race.
To do this well we need to look closely at our own backyard. Why are there persistent gender inequities in scientific, medical, and global health workforces? What pressures and unconscious biases cause the ‘leaky pipeline’ that squanders female talent in these sectors? How can we ensure that male researchers and doctors have equal opportunities to engage with their home and family life? The corporate world has shown us that more diverse workforces lead to greater productivity. There is evidence emerging that the gender of your healthcare provider may significantly affect how well they communicate with you, how accurately they interpret your symptoms, whether they offer you lifestyle advice, and may even affect your mortality. Imagine the meaningful change we could effect if we uncovered the drivers of these phenomena. We could use this knowledge to develop nuanced research questions and create precisely targeted, practical, effective healthcare strategies. In the corporate world, diversity is pursued to ensure that the corporate team understands their market better, leading to better advertising, more precise product targeting, ultimately translating into higher profits. In science and healthcare, we should pursue diversity in our workforce so that we understand our population better, enabling us to collect more meaningful data, communicate more effectively, understand their healthcare needs more fully, ultimately translating into the best health outcomes possible.
On February 8th, The Lancet medical journal will launch a special theme issue on women in science, medicine, and global health. For a journal of such stature to engage with these issues is heartening and inspiring. I look forward to the rich array of content and the resulting insights and new directions we will discover. In a review paper for the Lancet Women issue, Dr Geordan Shannon, I, and a team of other authors set out to review the evidence for why gender equality in science, medicine, and global health matters. We conclude that, “…we are in the position to demand more from the evidence, to innovate beyond current discourses, and to realise true gender equality for everyone, everywhere. Achieving gender equality is not simply instrumental for health and development; its impact has wide-ranging benefits and is a matter of fairness and social justice for everyone.” Bravo, #LancetWomen – I am privileged to be one of you.
This blog post was originally published on the Journal of Medical Ethics Blog
Ethics is a philosophical discipline. The bedrock of philosophical scholarship is the construction of arguments – a set of reasons that justify a particular position. Philosophers spend years cultivating critical reasoning skills and applying them to many and varied problems. While philosophy has universal application, it is often erroneously perceived as an ‘ivory tower’ discipline, more concerned with abstract ideas and concepts than with ‘real world’ problems. Academic ethicists supposedly spend their time writing papers and pontificating on big issues like euthanasia, the importance of autonomy, and human rights. Those of us who work in the ‘real’ world of healthcare, know that it is rarely as the academic papers make it seem.
Clinical ethics should be different. Clinicians of all stripes think through ethical problems and make ethical decisions every day. Clinical ethics services (CES) are increasingly available as a resource to assist with difficult ethical decisions. There are a multitude of models for the delivery of CES. The goal they have in common is to provide decision-making support and/or advice to healthcare practitioners, and/or patients and families, grappling with difficult ethical situations. But what is it that CES actually do to provide this support? The truth is that no one is sure, or at least no one agrees completely. The nature of clinical ethics expertise remains up for debate. Some say that CES really function as a conflict resolution and mediation service. Some say their major contribution is in debriefing and managing moral distress. The more cynical among us may cast CES as a defensive mechanism for hospitals – being convened so that there is evidence of due process for legally controversial decisions.
All of the above are true. Some CES are only convened ad hoc, often in the context of legal controversy. Some CES function no differently to a mediation service. These services, in my view, are not actually providing clinical ethics consultation. Skills in conflict resolution and facilitation of discussion are important for clinical ethicists, but are not sufficient. It may be necessary for a hospital to go through due process, but merely convening a committee and discussing the issue is not sufficient – the discussion must be of a particular deliberative nature. Clinicians, and institutions, refer cases to CES when they need help making an ethically difficult decision. Making good ethical decisions involves critically appraising the arguments for and against possible courses of action. Assumptions need to be identified and challenged. Moral intuitions need to be explored and questioned. The rationale for the chosen course of action needs to be cogent and be made explicit. Clinical ethics expertise is in helping clinicians build a comprehensively considered, well-reasoned justification for their decision. In short – it’s all about the arguments.
Lest this sound too cold and analytical, I wish to stress that nothing can be critically appraised, or argued for or against in a robust manner, without considering the human complexity and rich narratives that inform people’s values and life views. In healthcare, difficult ethical decisions often arise in the context of interpersonal conflict, high emotions, and moral distress. Skills in conflict resolution, mediation, facilitation of discussion, and narrative exploration are necessary for a clinical ethics team. These skills enable them to engage meaningfully with all of the people involved in decision-making and gather the information required to do the philosophical work of developing a robust argument for how to proceed. What matters to people, what their emotional responses are to a situation, and how a particular event makes sense in their lives, are key components that must be made coherent with the medical facts of the case and incorporated into the rationale for a decision.
Philosophical work – that of critical reasoning and argumentation – is not well understood by many clinicians. We are trained in the scientific method and are adept at critically appraising scientific papers to inform clinical practice. We are much less familiar with philosophical methods of reasoning and with critically appraising philosophical papers. The ethical complexity of healthcare is increasing and the ethics literature is expanding. It is important for all clinicians to keep abreast of the ethics literature that is relevant to their practice, and even more so for those involved in clinical ethics consultation work.
In a paper I co-author with Peter Ellerton, we present a critical appraisal worksheet designed to assist clinicians to actively read ethics papers and critically appraise the arguments presented. We have used this worksheet in our own ethics journal club and found it to be a useful shared framework. Additionally, education that focuses on the critical appraisal of arguments hones this cognitive skill more generally. Clinicians are then more able to apply these critical reasoning skills in real time in clinical ethics consultation work, and in day to day ethical decision making. Ethics in the emotive, conflicted, ‘real world’ of healthcare, is still all about the arguments.
It’s one of the classic, thorny, intractable issues in bioethics and law. Multiple jurisdictions around the world have grappled with the polarising arguments for and against access to termination of pregnancy. Historically, women’s perspectives have been silenced. In Queensland, abortion remains on the Criminal Code, although there are some common law defences for seeking or carrying out a termination of pregnancy.
The Queensland Law Reform Commission is reviewing the laws around termination of pregnancy. My colleagues, Dr Andrew McGee and Dr Sally Sheldon, and I wrote a submission to this review, which prompted us to reflect on the interminable conflict in discussions about this issue. In this paper, we make a case for the decriminalisation of abortion based on the ethical intractability of the issue, and by highlighting under-recognised risks to women inherent in pregnancy and childbirth. The paper was published in the Australian and New Zealand Journal of Obstetrics and Gynaecology a few weeks ago.
Access to the full text of the article requires institutional library access. Click here to read the write up by QUT.
May women no longer be silenced. Here’s hoping for constructive law reform in Queensland.
I wrote this song ten years ago. The inspiration for it arose from research I was doing for a medical ethics presentation that I titled, Who’s your Daddies?….or Mummies? Ethical issues in assisted reproduction for same sex couples. I know, nerdy backstory, but there you have it.
The clincher argument for this issue revolves around children’s wellbeing, a subject that was of particular interest to me as a budding paediatrician. So, I read every paper published in the international literature on outcomes for children brought up by same sex couples and came up with absolutely zip evidence that there was any harm being done. In fact, even back then, there was pretty decent evidence that the children of same sex couples were doing at least as well as those from traditional nuclear families. What shocked me as I did this research, was the thinly veiled hate that crept into the academic literature on the subject. At the time, I was a senior medical student, bathed in the evidence-based, critical, open-minded environment of the University of Newcastle. It was a moment where I felt a little piece of innocence drift away, realising that even at the upper echelons of academia, there were people who remained slaves to dogma, cherry-picking their way to confirming their own biases.
At the time, neither major political party was the slightest bit supportive of removing discrimination for LGBTIQ+ people. With rare, partial exceptions, same sex couples didn’t have access to assisted reproduction and were not allowed on the adoption register. As a heterosexual, cis-female I had never needed to consider systemically constructed obstacles to having a family. And the more I thought about it, the angrier I got.
This song was born out my anger. Just downright, good old-fashioned pissed-off. Incensed that people could be so closed minded, so staggeringly impervious to evidence, reason, and compassion. It was born out of my frustration with politicians who, while paying lip service to social justice, refused to make a meaningful stand about the systemic discrimination against same sex couples and their families.
All this poured out into music, into this Song for a Shifting Zeitgeist.
I sensed back then that things were shifting, and thank goodness they have – somewhat. Labor always take too long to come to the party, but I salute the widespread reforms they legislated in 2009. Yet, here we are in 2017 – two days away from finding out the result of a non-binding, ludicrously expensive postal survey to see whether the majority of Australians of voting age think that consenting adults should be able to have a civil ceremony which formalises their declaration of love for each other. My ocular muscles strain from the rolling of my eyes. My heart aches when I think about what LGBTIQ+ people and their children have had to endure during the campaign.
When I wrote this song, I was on a year’s leave of absence from medical school, taken so I could spend time with music. To my band, now scattered around the world – thank you for the magic. Thank you for sharing my anger. I think Brendan shredded about five violin bows during this recording, and one more every time we performed it live! I can’t believe we recorded this ten years ago. Life slides by in a startling fashion. But what better way to release the song – adding a voice to the clamour for justice.
I hope the Zeitgeist has shifted. To all my LGBTIQ+ friends and family, to all the LGBTIQ+ people in Australia, in the world – I’m standing with you. Whatever the result of this survey – I’m with you. And so are millions of others. We create the Zeitgeist, we create the shift. This one’s for you.
Song for a Shifting Zeitgeist
Don’t look at me in that way
I’ve heard what you have to say
and like a child would
I’m going away
Is love just some exclusive game?
That not every person can play?
A path through eternity
or maybe, just today
The way you think is perfect that’s clear
Self-righteousness cloaking your fear
If we keep them dark and childless
maybe they’ll disappear
Live and let live can’t you do?
Must love be like yours to be true?
See I don’t understand –
what’s it matter to you?
Now shake your head and wash your hands
It’s a vote-killer all through the land
‘So many things that I can’t do
unless I ignore this stand’
What will it take for you
to open and see deeper truth?
Maybe it’ll be on Judgement Day
when we all go to heaven too.
Vocals, piano, and songwriting: Melanie Jansen
Guitar, mixing, and mastery: Matthew Giusti
Bass: Sam Bewsher
Drums: Shannon Hurry
Violin: Brendan Daugherty
The Veneto region in Italy is a fascinating place. It extends from the mountain range it shares with Austria in the north, to the Adriatic sea in the east, with Lake Garda (Italy’s largest lake) in the west. Since about the 8th century it was part of the Venetian Republic and, after a bit of back and forth involving the Austrian empire and Napoleon it became part of the Kingdom of Italy in 1866. Veneto has a population of about 5 million people, its capital city is Venice, and most inhabitants speak both Italian and Venetian. It is a region of stunning natural beauty and fairy tale-like cities. This was my first visit to Verona and I was captivated by her marble lined streets, the winding river, Roman and medieval architecture, and the whispers of Shakespearean lovers. Venetian cities seem to have this effect on me – I have waxed lyrical about Padua in another post, and while I know many tourists love to hate Venice, I have loved her from the moment I set foot there as a teenage backpacker and she has remained under my skin ever since.
While eating and drinking is ubiquitously well done in Italy, in my experience, Venetians are particularly adept at the evening drinks and small plates dining scene. Verona and Venice are both fabulous cities to bar hop and dine in. Cichetti (Italian tapas-like small plates) bars abound, glasses of local wine and beer flow freely, and the relatively relaxed Italian approach to licensing allows for the spill of characteristically chic patrons onto the footpaths and into the squares, adding to the vibe of joyful celebration.
We had some memorable dinners in Verona. Ristorante Il Desco was the scene of our wedding anniversary dinner. We were served a delicious tasting menu of modern Veronese dishes accompanied by both local and international wines. The restaurant is warm and elegant with a very knowledgeable staff. Lunch at Ristorante 12 Apostoli was an interesting culinary and historical experience. This place has been serving food since the mid-18th century. We chose the local tasting menu and loved all five of the courses of traditional food. The Sommelier recommended a single bottle of Valpolicella Ripasso to match the whole lunch and his advice proved very sound. After lunch, we were shown around the restaurant’s wine cellar, a tour that has become particularly interesting in recent years as, during some routine maintenance work, tradespeople stumbled across a sacred temple dating back to the first century after Christ and parts of the foundations of a medieval tower house, all sitting below the cellar! This part of the restaurant is now an archaeological site that was excavated under the supervision of the Ministry of Heritage and Culture. Another eating and drinking venue I can highly recommend is Osteria del Bugiardo. It’s casual (in a chic, Veronese kind of way) and fun, you can get bar snacks or more substantial meals, all of which are super-tasty, the wine by the glass is tops and from the owners’ own local vineyards. We visited this place three times in three days!
Now, onto the wine. Veneto produces the most wine out of all the Italian regions, in volume it produces roughly half as much as the whole of Australia. It is famous for Prosecco, Soave, Amarone, Valpolicella, and the very sweet and rich Recioto. Valpolicella is the viticultural zone and the wine there is made mostly from a blend of the grape varieties Rondinella, Corvina Veronese, and Molinara. Standard Valpolicella is usually made without oak and is drunk young. It is generally a fun, light, bright red wine with red fruit flavours. Valpolicella Classico denotes wines that are made from grapes grown in a particular part of the Valpolicella region, and Valpolicella Superiore are wines that are aged for at least 1 year and have at least 12% alcohol. Amarone is the biggest wine of the group, made from these same grape varieties however they are dried before being fermented, leading to a much richer and more concentrated wine with a very high alcohol content. Recioto is a sweet wine, made in a similar fashion to Amarone but the grapes are left to dry for longer. Recioto is a dessert wine that people who say they don’t like dessert wine (or ‘stickies’ as we call them in Australia) might enjoy, because although it is sweet, it is less viscous and sticky than many we are used to, and some even retain a bit of tannin. Valpolicella Ripasso falls in between on the taste spectrum – it is Valpolicella that has been macerated with the fermented lees of Amarone or Recioto, giving the wine more complexity, tannin and alcohol. During my time in Veneto, I tried different examples of all of these levels of Valpolicella reds and some of them were really wonderful. I am not generally a big fan of fruity, round, high alcohol red wines, but the good examples of Amarone that I had were perfect when paired with the rich meat dishes of the region. In fact, at Osteria del Bugiardo one night, we had fun working our way from the standard Valpolicella through Superiore, Ripasso, Amarone to Recioto, pairing the wine with increasingly heavy and complex dishes as we went. Actually, except the Recioto. I eschewed dessert (as usual) and had a glass of Recioto on its own instead.
Throughout our time in Veneto, one producer that stood out in general was Pieropan. I was disappointed that I didn’t have enough time to visit the this winery, however I tried quite a few of their wines in restaurants in Verona and Lake Garda. Out of all the Soave wines I tried, the Pieropan Soave Classico was my favourite. Soave is the main white wine of the Veneto region, made from Garganega and Trebbiano grapes. Overall, I think it is hard to find offensively bad wine in this region, however, compared to other Italian regions, it seems easy to find wine that is quite boring. I wondered if there was a reason for this and so consulted my bible, the Oxford Companion to Wine, and learned that the Veneto region has been criticised for unscrupulously enlarging their DOC zones and allowing for very high yields, which has led to production of a high proportion of characterless wines.
The Veneto wine area that I did have time to explore a little was Bardolino. Bardolino is on the shores of Lake Garda, another piece of stunning natural beauty in this region. While it is my understanding that Bardolino wine is just as vulnerable to the problems of high yields and relaxed standards in Veneto generally, we tasted some intriguing and lovely wine here. The Bardolinese should know a thing or two about winemaking – there is evidence of it being done in this area since the 8th century BC. Bardolino wines are made from the same grape varieties as Valpolicella but are allowed up to 20% of blending from several other grape varieties. Bardolino has DOC status and Bardolino Superiore (aged for at least one year) is a DOCG. The town of Bardolino has a wine museum inside the Zeni winery and is most certainly worth a visit, both to learn about the history of wine making in the area and to taste the Zeni wines. You can book a private tasting in the downstairs tasting room where you will be taken through a variety of their wines for a small fee. You can also do a more informal, and free of charge, tasting at the bar upstairs. However, the highlight of our wine touring in Bardolino was a visit to Le Fraghe winery. Le Fraghe is owned by Matilde Poggi, a woman who has been making wine in this area since 1984, and since 2009 has been growing wine grapes that are certified organic. Matilde is also the president of the Federazione Italian Vignaioli Indipendenti (Italian Federation of Independent Grape Growers) and is passionate about promoting the local wine industry. She is no stranger to innovation, and has been bottling some of her wines under screw cap since 2008 – a rare occurrence in Italy!
To have a tasting at Le Fraghe you need an appointment as it is a small business without the all-day cellar door operation that Australians are accustomed to. We tasted all five of the current Le Fraghe wines and enjoyed each of them. Characteristic of the region, they are generally lighter in style but I found all of them interesting. My favourite was the standard Bardolino, made from 80% corvina and 20% rondinella with no other blending wines. It had a spicy and slightly floral nose, blue fruits and cherries on the palate, medium bodied with a little bit of tannin, excellent balance, and quite a bit of length. I had a pang of homesickness imagining drinking it with friends on a warm Brisbane evening with cheese and charcuterie or grilled meats. It is also surprisingly economical at 7 euro a bottle from the cellar door and only a whisper more than that in local restaurants such as Trattoria Villa (lunch here is worth a blog post on its own – it was enchanting and delicious). Alas, Le Fraghe does not ship to Australia, however they gave me the names of their importers – watch this space, I shall be doing some research to see if I can find this wine Down Under…
Italy. The seat of the Renaissance; home of Leonardo da Vinci, Michaelangelo Buonarroti, Giotto di Bondone, and countless other artists; makers of pizza, risotto, bistecca, pasta, mozzarella cheese, balsamic vinegar, and olive oil; drinkers of Barolo, Chianti, Lambrusco, Amarone, and Prosecco; designers of Ducati, Ferrari, Lamborghini, Dolce & Gabbana, Prada, Salvatore Ferragamo….
But it was not for the fashion, fast cars, food and wine that I visited Italy (though I admit they made the trip particularly fun!) Italy, or more specifically the Veneto region, is home to the Fondazione Lanza – a Centre for Advanced Studies in Ethics and Bioethics, and also to one of the longest established Paediatric clinical ethics committees in Europe. The Veneto region has a uniquely well-developed clinical ethics network – with 20 Health Ethics Committees (HEC) serving the region’s population of 5 million. This development was encouraged by the regional government in 2004. Prior to 2004, there were only a handful of HECs in Veneto – the longest established one being the Paediatric Clinical Ethics Committee which has been established for over 25 years. The current President of this Committee is Dr Enrico Furlan, a philosopher with a special interest in medical ethics, with whom I had the privilege to spend a large chunk of the day, talking about the history of their service, lessons they had learned over the years, and their goals for the future. There are many similarities between our services and we discussed at length the issue of evaluation of the quality of clinical ethics consultation. There is much to be done in this area and hopefully we can collaborate on research to inform this in the future.
The University of Padua has an impressive history in both medical and arts teaching. It was founded by a group of professors and students who left the University of Bologna in 1222 to create a place of learning that was committed to freedom of thought. Since then Copernicus, Galileo Galilei, Vesalio the anatomist and William Harvey, who first described the circulation of the blood, studied and taught here. The University also claims to have been the first university in the world to award a woman a university degree – Elena Lucrezia Cornaro Piscopia in 1678. The Fondazione Lanza is a centre within the University which, in collaboration with some other European universities, runs an annual, intensive, week-long course on medical humanities. Medical Humanities is a discipline that is concerned with the relationship between medicine and humanities subjects such as literature, philosophy, history and religion; arts such as painting, sculpture, cinema and writing; and social sciences such as anthropology and sociology. It seeks to humanise the practice of medicine, emphasising the human experience of illness and suffering and imparting knowledge and skills to healthcare practitioners to give them a rich and nuanced understanding of the person who is sick, not just the disease that afflicts them. Since the time of Hippocrates, medical practitioners have been broadly educated in these subjects as well as in clinical medicine. Following the Enlightenment, scientific knowledge blossomed exponentially and discoveries that changed the face of medicine forever were made, like antibiotics and anaesthesia. Discoveries like this have continued – from highly selective chemotherapy to the multitude of complex life sustaining therapies available in intensive care units. Science has served the human race fantastically, but in the latter half of the 20th century there was a growing recognition that healthcare was losing its human touch. Perhaps part of this is because we, as a profession, were seduced by the power of science, and with scientific knowledge being such an urgent requirement to be a competent doctor, huge chunks of our time is spent learning it and mastering the procedural skills that make up much of the bread and butter of our daily work. The huge volume of scientific knowledge that medical students, doctors in training, and consultants must master, keep abreast of and contribute to, has made medical curricula so crowded that there is little space for anything else. Even the study of ethics – a humanities subject that is very obviously central to the practice of medicine, is no longer a mandatory part of the medical school curriculum in Italy.
Centres like Fondazione Lanza attempt to remedy this by drawing attention back to the rich education that is available in the arts and humanities. Disease and suffering is a common theme in art throughout the ages, and studying these works teaches the historical and social context of disease and the medicines that treat it. Literature and film abound with stories of illness, and reading and watching these can give students a window through which to experience others’ suffering, increasing sensitivity to the breadth and nuance of the human experience of health and ill-health. I believe we mustn’t forget that responding compassionately and substantially to sick humans is as much the bread and butter of our daily work as is remembering lists of differential diagnoses and formulas for blood gas interpretation.
From a clinical ethics perspective, I think this kind of humanities education could add immeasurably. In my experience, much of the work involved in clinical ethics consultation is in gaining and facilitating a true understanding the narratives of all those involved, a task that cannot be accomplished without distinct sensitivity to the human experience, and a particular openness to entering other people’s worlds. Education in the humanities builds the cognitive and personal skills that enable us to do this.
Padua itself is dripping in history. The building that houses Fondazione Lanza is beautiful renovation of a stately mansion in the centre of Padua. I went to view the Scrovegni chapel at night – Giotto sotto le stelle – and was enchanted by it. Every surface is covered in frescoes depicting the lives of Jesus of Nazareth and his mother Mary. Multiple other artworks and famous architectural pieces dot the city, including Donatello’s equestrian statue, Bo Palazzo and Caffe Pedrocchi. I stopped in to Caffe Pedrocchi to sample the famous coffee of the region – strong black coffee topped with a mint cream, a very refreshing afternoon pick-me-up! Just what you need before heading out for a walk around Padua’s beautiful streets, around the Prato della Valle, maybe stopping in at a wine bar to sit and reflect over a glass of the region’s best produce…
Before I departed on my Churchill travels many previous fellows told me to expect the unexpected and to not be surprised if opportunities to extend my original program sprang up. Churchill fellows, being generally inquisitive and enthusiastic types, also advised me to take as much advantage of everything that presented itself as possible!
I was lucky enough to be able to have a pre-Churchill holiday in one of my favourite places in the world (Italy) which was also my (planned) first stop on the Fellowship. Toward the end of my holiday I stumbled across the webpage for the annual conference of the European Association of Centres of Medical Ethics and noticed it was happening in a few days’ time in nearby Barcelona. I contacted the organisers who kindly arranged a last-minute registration, and with a quick re-jig of holiday plans, a short internal flight (such a novelty to us Australians!), and a very understanding husband, I landed in Barcelona.
The conference was hosted by the Institut Borja de Bioètica, Universitat Ramon Llull. The IBB was the first bioethics centre in Spain, established in 1976 by an obstetrician/gynaecologist with undergraduate training in philosophy and theology. The theme of the 2017 conference was “Justice in Healthcare: Values in Conflict” and the conference program was excellent. Keynote presentations were relevant, thoughtful and clearly communicated to a very multidisciplinary audience. I particularly enjoyed the talk by Dr Yvonne Denier, a philosopher from the University of Leuven. In Health Care Systems: At the Service of What? She took us on a thought-provoking trip through theories of justice and how they might be useful for healthcare. She characterised the value conflicts within healthcare systems as an incompatible triad, using the example of Butler who tells of a sign in a mechanic’s garage advising its customers about the services it provides:
We provide three kinds of services – cheap, quick and reliable. You can have any two…If it’s cheap and quick, it won’t be reliable. If it’s cheap and reliable, it won’t be quick. And if it’s quick and reliable, it won’t be cheap.
In healthcare, Dr Denier asserts that the values in conflict are, economic efficiency, justice, and decent quality care. She then went on to suggest ways that we can reconcile this incompatible triad and proved herself, in my opinion, to be one of those philosophers who can really speak to the practical application of philosophy. I think we can gain an immense amount by harnessing thinking like this in our day to day work in clinical medicine.
In the concurrent sessions, I was constantly conflicted about which room to be in as there were so many interesting presentations. I was also completely unable to do my usual thing of identifying a session that I could skip in order to explore the local sights! I have long been an advocate for the Capabilities Approach (CA) when dealing with issues of justice, particularly in the paediatric context. Dr Eva De Clercq spoke of using the CA when thinking about involving children in consent, and argued we should shift our paradigm to thinking of children who are active beings who are already part of society rather than as impaired adults needing preparation for adulthood. This, she argued, will build a model of capacity that is one of a common responsibility between child, parents and health care workers, where all seek to expand the child’s capability set. Based on my own experience working in paediatrics, Dr De Clercq’s ideas are a breath of fresh air and I can see real ways forward in their practical application. There were several presentations on different aspects of Moral Case Deliberation by brilliant researchers from the Netherlands. In my opinion, this group is doing some of the most thoughtful work on evaluating clinical ethics support in the world. Of particular novelty in this evaluative space, is the development of the Euro-MCD instrument. Another highlight of the conference for me was listening to Dr Alessandra Gasparetto, winner of the EACME Paul Schotsmans Prize for Talented PhD Scholars, present Ethics Experts: still wondering whether they do exist. How are they expected to help in clinical ethical decision-making? Dr Gasparetto gave a thoughtful and incisive analysis of the major models of clinical ethics support, highlighting the urgency of more clearly defining the role of clinical ethics and clinical ethicists. Watch this space – I believe there are some forthcoming publications which I will be sure to link to.
In addition to the interesting conference program, the social functions were a lot of fun. This was my third visit to Barcelona and I felt, as I have every other time, that I’d have loved to stay longer. The buzz of the streets, the exquisite food and wine, the beauty of the architecture and the warmth of the people struck me anew. The conference was closed in truly Spanish style – after the closing address the team from IBB put on a famous song and started Flamenco dancing, quickly turning the conference into a joyful conga line! The Europeans aren’t just thoughtful ethicists, they really know how to party 🙂 I can unreservedly recommend the EACME conference to anyone in the world interested in medical ethics.
I found out that I had been awarded a Churchill Fellowship while I was on holidays in Japan. My husband and I were on a train from Tokyo to Yamanashi (one of Japan’s wine regions) when I checked my email on my phone and saw the congratulatory email from the Churchill Trust. I had to suppress a cheer (etiquette on Japanese trains not really allowing for a victory dance) and be content with poking my husband in the ribs, carving my face in half with my smile, and indulging in some attenuated fist pumps.
The Churchill Trust https://www.churchilltrust.com.au/ is an Australian trust that was established in 1965 to honour and perpetuate the memory of Sir Winston Churchill. Apparently, Sir Winston Churchill preferred the idea of a travelling scholarships scheme as his memorial, rather than having a fancy statue built. After Churchill’s death, countries around the world set up trusts in honour of him. In Australia, a huge public appeal was launched and had a spectacular response, in particular from a doorknock appeal run by the Returned Services League. You can read more about the history of the Trust here.
What this means is that since 1966, the Churchill Trust has awarded over 4100 Australians with Fellowships. To be awarded a Churchill Fellowship, people with particular expertise propose a project through which they will develop this expertise, and return to contribute to Australian society. If awarded, the Churchill Trust funds their travel and expenses for up to 8 weeks so that the Fellow can pursue their project. One of the many things I love about the Churchill Fellowships is that they are open to people from all walks of life. My cohort from 2016 included an optometrist, a panel beater, a sound recording artist, a radiation scientist and a chef to name just a few. Even before setting out on my Fellowship, meeting this group of people made my world bigger. I’m fascinated by all their projects and can’t wait to see the outcomes of their fellowships.
The one-liner to describe my project is: To enrich and inform development of paediatric clinical ethics services in Australia. Clinical Ethics Services (CES) are a funny thing. Ethics is relevant to all healthcare professionals in all specialties and ethical, or moral, dilemmas happen everywhere in healthcare. CES are increasingly common in hospitals and exist to give advice or help clinical staff to deal with these difficult moral problems. However, no one really knows what the best way to run CES is (there are probably many), we haven’t decided who should be allowed to call themselves a clinical ethicist, and we don’t know exactly how to measure whether a service is good quality or not. You can read more about CES in general, and in paediatric hospitals in particular, in a recent study done by our centre in Brisbane and published in BMJ Open Paediatrics.
During my Churchill Fellowship, I will visit several CES around the world to see how they function and how they think about and measure their outcomes. I am particularly interested in the best ways to teach robust moral reasoning to those working in CES, and so I am also visiting several universities with excellence in teaching ethics. Through my work in both clinical ethics and clinical medicine in Australia I am increasingly aware of the need to foster openness and compassion in healthcare workers. Being able to make good ethical decisions is uniquely dependent on understanding the narratives of all involved. There is some literature describing that engagement with the arts is one way to foster these skills, and so another thread running through my project is to explore these techniques.
So, I’m off – to Europe, Canada, the United Kingdom and the United States! I’m feeling grateful, inspired, and a little star struck by all the wonderful people I will have the opportunity to meet and learn from.
I’ll be chronicling my Churchill Fellowship adventure on this blog and will also be active on my Facebook page and Twitter @DrMJansen. Follow me if you’d like the updates!