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Ethics

#LancetWomen

By | Ethics, Medicine, Uncategorized | No Comments

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.

We need more arguments in clinical ethics

By | Ethics, Uncategorized | No Comments

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.

Abortion: an intractable debate, and women wear the risk

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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.

It wasn’t just about the wine…

By | Arts, Ethics, Uncategorized | One Comment

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…

 

An unexpected first stop…

By | Churchill Fellowship, Ethics, Uncategorized | No Comments

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.

Inspired, grateful, and a little star-struck.

By | Ethics | 4 Comments

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!

A collection

By | Uncategorized | 4 Comments

The content on this blog may seem like a random collection of stuff. It is a collection, however it’s not random, but an honest collection of things that interest me. I feel a little bit weird about blogging. Maybe I’m too close to the X end of Gen Y for it to feel like a natural thing to do, or maybe, like many people, I’m not convinced anyone will be that interested in what I write. Despite this slightly weird feeling, I decided to go ahead and start a blog because my reasons for starting it are not focused on necessarily developing a following, but rather that I have a few interests and pursuits that I think it would be helpful (definitely for me and maybe for others) to write about and collate, and a blog seemed like a good way to do that.

The catalyst for creating this blog was my Churchill Fellowship. I’m travelling around the world to research ways to enrich and inform paediatric clinical ethics services and thought a blog would be a good way to document my experience, and also to post about ethics issues more generally. After the Churchill Fellowship, I’ll be studying for my ICU fellowship exam, and I’d like to share some of my notes/podcasts. Throughout my medical career, I’ve been exquisitely grateful for blogs such as Deranged Physiology and Anaesthesia MCQ, but I’ve noticed there is a little gap in online information available that is specific to paediatric ICU, and so I thought if I posted up some of my study stuff, it might be helpful to others. I’m also planning to post about travel and, in particular, wine. I haven’t been on a holiday to a place without a wine region either at the destination or en route to it in about a decade. Writing about wine will help me remember what wineries I’ve been to, what wines I liked, and might even be useful to refer to for future WSET study. You’ll also eventually find posts reflecting on the human experience of illness and caregiving. I’ve always been drawn to the arts, and have been writing poems and stories my whole life. I think reflective writing and interaction with the medical humanities can add immeasurably to the practice of medicine.

Lots of people told me I should have lots of separate blogs. One for wine, one for poetry, one for ICU, and one for ethics. Some people said to combine ethics and ICU into one (my ‘professional’ blog) and put the other ‘fun’ things in another blog. I was warned about the need for a ‘professional profile’ quite separate to my ‘personal life’. To craft a ‘wine persona’ and an ‘ICU persona’ and an ‘arts persona’.

I listened to all this advice and then chose not to take it. The first reason is pragmatic – there is no chance I will have time to run more than one blog in any meaningful way. The second is that it felt disingenuous to create different blogs with their accompanying “personas”. I am only one person. I do not become a different person when I leave my home and arrive at work, nor when I leave at the conclusion of a medical journal club to go to a poetry workshop. Like most people, I behave in different ways depending on what is appropriate to the setting, but I am not a different person. I don’t have separate personae for each activity that I do. Occasionally, maybe a parent of a child I have cared for in ICU will stumble across my blog. Maybe future employers will find it. I have no problem with them knowing I am interested in ethics, wine, travel and the arts as well as intensive care medicine. None of these things make me less of a committed and professional doctor. All of them make me a fun dinner party guest 

I can’t promise I’ll be posting at a particular frequency – it’s likely I’ll post in fits and starts depending on a host of factors. As my content increases, I’ll arrange things under headings so that people can find what they are interested in. Comments are welcome, particularly on factual content related to ICU stuff – the closer we can get to peer review the better! However, I will moderate comments, and some may not be published. I love robust discussion but not all of my posts will be intended for this purpose.

If you’d like to contact me directly, details are on the blog front page.

Salute!