No Easy Answers in Bioethics Podcast

Plastic Surgeons on Snapchat: Stahl and Vercler - Episode 10

November 8, 2018 Devan Stahl photoChristian Vercler photo

Would you ever consent to have your medical procedure broadcast on social media? This episode addresses a trend known as Snapchat surgeons – plastic surgeons who amass sometimes millions of followers on the social media platform Snapchat by posting uncensored videos of operations they are performing. These videos are often highly stylized, comedic, and meant to entertain.

Guests Dr. Devan Stahl, Assistant Professor in the Center for Ethics and the Department of Pediatrics and Human Development, and Dr. Christian Vercler, Clinical Associate Professor of Plastic Surgery in the Department of Surgery at the University of Michigan and Co-Chief of the Clinical Ethics Service in the Center for Bioethics and Social Sciences in Medicine, have published research on the subject, most notably in the AMA Journal of Ethics in April of this year. Together they offer their insight and expertise on the issue, and discuss whether these Snapchat performances are ethical. They also delve into the societal norms and power dynamics at play, and address how to move forward within the profession of plastic surgery in a world where social media seems to be here to stay.

Listen now on H-Net

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: "While We Walk (2004)" by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License.

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Episode Transcript

Liz McDaniel: Hello and welcome to another episode of No Easy Answers in Bioethics, the podcast from the Center for Ethics and Humanities in the Life Sciences at the Michigan State University College of Human Medicine. We are back after a bit of a hiatus between seasons, and we’re starting season two today with an episode on Snapchat surgeons – plastic surgeons who amass sometimes millions of followers on the social media platform Snapchat by posting uncensored video of operations they are performing in a way that is often highly stylized, comedic, and meant to entertain. Guests Dr. Devan Stahl from the Center for Ethics and Dr. Christian Vercler from the University of Michigan have published research on the subject, most notably in the AMA Journal of Ethics in April of this year. Together they offer their insight and expertise on the issue, and discuss whether these Snapchat performances are ethical. They also delve into the societal norms and power dynamics at play, and address how to move forward within the profession of plastic surgery in a world where social media seems to be here to stay.

Devan Stahl: My name is Devan Stahl, I'm an assistant professor of clinical ethics here at Michigan State University in the Center for Ethics and Humanities in the Life Sciences.

Christian Vercler: I'm Christian Vercler, I'm an associate professor of plastic surgery, I also have an appointment in the Center for Bioethics and Social Sciences in Medicine at the University of Michigan.

DS: Thanks, Christian. So, we got together because you introduced me to this super interesting topic, in the realm of surgical ethics, that I was completely unaware of. And we wrote this great paper that everyone should check out after the podcast through the AMA Journal of Ethics. But, maybe Christian you could tell me how you first heard about this topic of Snapchat surgeons.

CV: Yeah, so I'm a plastic surgeon at the University of Michigan, and so you can imagine what we do is pretty, uh, ivory tower. Some people would say that I'm out of touch with what the everyday plastic surgeon does. And, I really had no idea about what was going on with people, plastic surgeons using social media. And one of my nurses let me know that a former trainee of our institution had a Snapchat, I guess channel, or he was on Snapchat, and he was posting all sorts of videos of him performing operations. And he also had kind of a shtick that he would do. And the one that she first showed me was him dressed up as Prince Charming, singing "when you wish upon a star your dreams come true," and it was him dressed as Prince Charming and the patient, that was a princess lying on the operating room table, and then it cut to a woman's breast that had been augmented. And that was pretty shocking. And, uh, I was pretty shocked, and said, I gotta show people this because this is something that's sort of crazy, um, I can't imagine that this is something that really exists out there and that my colleagues in plastic surgery are doing.

DS: Yeah, absolutely. So, when you started showing me this, I also had that same reaction of like, wow, I can't believe people are doing this. It's so performative, it's so intimate, it's so revealing. It's just a lot of things. And, you know, this is a podcast, people can't see us, but we're fairly young, hip people, right? [Both laugh]

CV: Right.

DS: So, you know, that it shocked us, we're not, you know, old prudes. I mean, we, we saw this and thought, gosh I just cannot believe that this is happening, and is anyone talking about this. And really not a lot of people were aware that this is happening, or at least not in our world of academia. So we thought, let's explore what's really going on here, um, are there ethical issues that are popping up. I think, maybe our gut reactions were yes, there seems to be something a little off about these performances, about the way that women are being treated in these videos. And it's, you know, almost always this male surgeon with this female patient, and what are the kind of gender dynamics going on there. Um, so I want us to dig in to all that kind of stuff. But before we do, maybe we should just sort of set up what Snapchat is. So, if you're listening to this podcast you're probably super savvy on all the social media, but it's worth noting. So, you know, maybe we first had Facebook, um, which most people are aware of and apparently most people in the world belong to. Then we have Twitter, which is more, you know, sort of the talking points, we have Instagram which is more of the pictures, but then we get Snapchat, which – and you explained this to me and I actually didn't know it – what was the original intent of Snapchat?

CV: Yeah, so it's interesting. Snapchat was these guys who were college students at Stanford – not, they dropped out of Stanford once they developed, uh Snapchat. But they, the idea was that you could get your girlfriend or, or someone on campus that you wanted a naked selfie of, that they could send it to you and it would, the text message or the photo would self-destruct in a certain number of hours. Initially it was, you could sort of set how, how many hours it would be in existence before it would go away. And the story, and I don't know if it's apocryphal or not, was that one of the guys who developed this had sent a nude selfie of himself to someone and was regretting it and said, gosh, we should be able to figure this out so that these, we can have so much fun sending these sort of messages to one another, but then they would go away so it's not permanent. And they first called it "peek-a-boo" [Picaboo], which is why the Snapchat symbol is a ghost.

DS: Yeah, which makes a ton of sense. And I had never thought about that before, but I always thought, oh, why is there that weird ghost as its symbol, but-

CV: Yeah.

DS: -That's why. But Snapchat is huge, right, so, and it is expanded beyond the sort of, the initial purpose of sending nude selfies. It has gotten much bigger than that. They have news channels on it now, there's all sorts of, you know, things you can do with it. Um, so maybe can you explain some of that? I know it has a huge population of people that visit Snapchat. And who are those people?

CV: Well it's pretty interesting, about 25 percent of Snapchat users are under the age of 18. So, uh, and then the rest of them are over the age of 18, but really it's not, there's not a whole lot of Gen Xers really using it. But I think it's mostly Millennials and younger. And there's all kinds of crazy things that you see on there. A lot of models or tastemakers or influencers have Snapchat channels where they kind of document their life and show how fabulous they, they're being. Or there's, there's a gentleman who basically just is constantly broadcasting his life on Snapchat, everywhere he goes, and sort of just showing the way he lives his life. The interesting thing is that, you know I talked about that one surgeon that I had heard about, and then I, when I started looking at it more in-depth, there's all sorts of surgeons who are on there, uh, broadcasting their videos. It's not just a few. There's a large cohort, a growing cohort of people who are putting their operations on Snapchat, getting, um, because it's sort of interesting to watch. People really like to see this sort of thing I guess.

DS: I guess, because some of these guys have like a million followers, right?

CV: Right. Yeah.

DS: So, it is actually a large population of people who find like watching these surgeries really interesting. So, not, not sort of remote. I mean, we were like, we've never heard of this. But some of these guys have a million followers-

CV: Right.

DS: So it might have just been us that didn't realize that this was happening.

CV: Right.

DS: Yeah, and so, I guess what should be obvious, but maybe isn't at this point is that what makes Snapchat different than a lot of other social media is that there's very little filter on it. So there's a lot, there's not very much censorship so you can post nudes.

CV: Right.

DS: Where as most social media will prohibit that. So it can, they have rules against pornography, but I think what counts as pornography verses nudity is a little sort of sketchy. And that might influence how you sort of see these videos, because they're, they're nude women, usually. So, that's okay. And they're apparently not pornographic because surgeons are in the room? I think that's an open question about what constitutes pornography, right, but um, so something we can think about more.

CV: Yeah I think that's a really interesting point, because I think context matters. You know, surgeons, plastic surgeons in particular, are pretty used to objectifying the female body, medicalizing it, and thinking about it in, in medical terms. And so, for one plastic surgeon to show another plastic surgeon an image of a naked woman and discussing her breasts, that's sort of what plastic surgeons do. Why is that okay, and why is that not just two guys being gross? Well it's, it's because there's this idea that it's within the scope of their medical profession, and that, um, that somehow because we've taken these sort of professional oaths, and we hold ourselves to a certain standard, that we're not doing it in some nefarious way. That somehow you're doing this exchange of information between two surgeons, and it's for the benefit of the patient. Taking those same types of images and putting them in a different context, I think completely changes the meaning. And so, putting it in a context of sort of a jocular, you know, context where people are young and goofing around and, and potentially female bodies are being sexualized by other users of Snapchat, to have a surgeon putting those types of images in there I think changes the meaning and, and that's why it's not okay.

DS: Yeah, potentially. And so I think we should set the stage, cause I think this is really sort of hard to imagine, it immediately sounds sort of suspect, but I always tell people, it's worse than you think. Sort of whatever you had in your head. 'Cause I think a lot of us have maybe watched some reality television where there's surgery happening, which generally does try to keep it pretty professional and more or less true to what really goes on in the operating room. But, these videos are super stylized. So, to sort of set the stage, it's usually, I'd say a young-ish male surgeon with a cohort of young, pretty nurses, who are aiding him. Um, he'll usually give some sort of like cool monologue about all the cool stuff he's gonna do, um, I'd say there's sort of like a bro culture happening because the guys are always like, “oh yeah, I'm totally, it's totally going to be amazing, she's gonna look so great after I do this.” They'll frequently like break into dance, so all the, and all the nurses will sort of dance along. They'll sing, they'll, I've watched some of the surgeons like excise fat and sink it into a basketball hoop. I mean, it's just sort of very jocular, very, sort of, you know, it's a performance.

CV: Right.

DS: I don't know what, how else to describe it. And it's a very sort of particular performance that's meant to be fun. I think it's also maybe meant to be educational, or at least that's what they'll say. But mostly it's this like very stylized, like they are, the surgeon is the person who you're supposed to focus on, and he's putting on a performance for you so you know how great he is, and how fun plastic surgery is while he's doing it. Does that sound fair?

CV: Yeah, I think that's, that's one of the, you know, the complaints is that it makes it seem like it's all fun and games, and at whose expense? You know, there's a, there's a... I guess, I guess they're a willing patient. And we should talk about what, you know, because these patients apparently give consent, but, um, you know, in some sense it's hard to watch these without feeling that somehow the dignity of the patient is being cast aside, for sure. And, you know, the question's been raised, you know, is the safety of the patient being cast aside? And, is, or compromised in some way. And are, you know, in this performance, what is being conveyed to potential, to potential patients is that this is all just fun and games, there aren't, there can't possibly be any real risks to this if everyone's just having fun. And this is just a good time for everyone involved. When there really are significant risks of undergoing any kind of surgical procedure, particularly these sort of elective procedures. Which are done, you know, at the patient's behest.

DS: Yeah, I think that's a good point. So, it totally minimizes any sort of risk, because yeah, exactly, you wouldn't be dancing and singing and doing all this kind of stuff if there was real risk involved. Like these are professionals, they take oaths, you know, if it, if it were risky, you'd think they wouldn't act this way. But of course we know that's not true. I think the other element of this that, um, maybe is the most disturbing to me is just the way that the surgeons talk about women's bodies. So I think this is what struck me at first, is there's a lot of groping, there's a lot of like smacking of body parts, there's a lot of, um, you know, “she's gonna look so hot,” “she's gonna look so tight,” “her husband is gonna be so happy with the results of this.” So there's a lot of like sort of overt sexualizing of the body, which presumably was part of the reason that these patients went to the surgeon. So, you know, they wanted a certain body type. But, I get so uncomfortable when they talk about women's bodies this way. You know, they're, “look at that ass.” I mean, just, it's vulgar-

CV: Mm-hmm.

DS: Some of it is very vulgar. And it's the kind of, like you wouldn't allow a man to talk to a woman like that in public, you'd just sort of probably be disturbed by that. But because it's the surgeon and because the woman consented to this surgery and presumably wants this surgery, I don't know, do you think that makes is more okay?

CV: Uh, no. [Both laugh] I don't think it's okay, but I guess, then, you know, the charge to be leveled that I'm just, you know, a prudish person who lives in an ivory tower, that I'm out of touch with reality. But I think that, that, you know the surgeons, you know, for better or for worse, surgeons are allowed a lot of leeway and power in society. And to do these types of activities, I think is a, a misuse of the power and an abuse of the power. And what I think, what I think we're seeing is this sort of conflation of the male gaze that, you know, that, the idea that men sit around and stare at women's bodies, and project certain kinds of norms that they think are, you know are normative onto them from sort of a male perspective. That that's sort of being overlaid with the medical gaze, which again may or may not be appropriate depending on your point of view, but which occurs when physicians interpret the bodies of their patients in a medical way and describe them. You know that's something that happens all the time, and is something that often doesn't happen in public, or in a performative way, it actually usually happens behind closed doors between professionals. But what's I think jarring about seeing these videos is that there's this overlay of the two types of objectification of bodies, in a public way, that's also performative and clearly meant to entertain. I think, I like to use the term "medutainment" to describe what I think is going on, where it's really, clearly the intent is to entertain the viewer. Wink, wink, I'm educating you. The idea is that, you know, oh, of course we're just educating our patients and are educating the public on these types of things, and people really, you know, want that kind of knowledge, and, “aren't I a great person because I'm educating the public.” But really, it's just entertaining them, it's just for the shock and awe value. And, again, to utilize patients' bodies in that way, I think is transgressive.

DS: Mm-hmm. Yeah I love that the medical gaze, so Christian and I are both into Michel Foucault, right. So this idea that, and I think he was the first to introduce this, at least the phrase-

CV: Yeah.

DS: -That the doctor has to kind of look at their patient as an object, and you hear this when you, you know, you're in the hospital all the time. The patient with blah-blah-blah in room six, you know patients rarely get names. And, you know, some of that's distancing from how difficult it is to be a physician, but some of it really is just, I need to view my patient this way so that I can really get at the problem. And if I sort of have to conceptualize their whole humanity all the time, that makes my job potentially more difficult. And whether that's right or wrong, it is often how it works. But then you sort of layer that on with how men look, objectify women too, it gets a little sort of confusing, and I think both of, you're right, they're both happening here. And when we first started talking about this, I thought, gosh it's so much like the old freak show.

CV: Right.

DS: I used to teach a course on the history of the American freak show, and really what propelled the freak show, what made it socially acceptable in a society where it might not have been otherwise, was the alliance with scientists and physicians. Who would come and say, you know, it's okay to look at this person like this for, you know, you might think it's entertainment but it's actually not because you're learning about human bodies. So whether that person was from, you know, some remote country that no had ever met someone from that part of the world before, or they were unusually tall, or short, or fat, or skinny. I mean, this, when you add the sort of scientific perspective, it legitimizes it. And I think that's what's happening here too, is that if men were doing this outside of the profession of medicine, we would potentially find it unacceptable. But because they're educating us about what happens in surgery, and they have that professional clout, then we think it about, the context suddenly becomes very different. But, we now look back at the freak show and say, nope, that was probably inappropriate, whether or not physicians were attached. So maybe one day we'll look back on this and think the same? Or maybe this will just become kind of more par for the course, maybe this is sort of a fad that's not going away. What do you think?

CV: Well you know, when I talk to, I'm not a very popular person at plastic surgery meetings, because I, I'm kind of a downer when I talk about this and how I think it's a bad idea because I think in general, at our national plastic surgery meetings, there's all kinds of seminars that you can take about to be more effective on social media, how to build your brand, how to get more followers and viewers and all that sort of thing. And that there's, there's this celebrity culture it seems to kind of, people, more people want to be a part of it, including plastic surgeons. And so, you know, the statement's often been made to me that, you know, this is, there's no going, there's no turning back from this. And you can be ethical, as ethical and professional as you wanna be, but if you don't have a million followers on Instagram or Snapchat, you're gonna become irrelevant. And so, the thought is that this is where people live, they live in social media, and bringing knowledge to where the people are in the way that they want to hear it is what surgeons should be doing. Those are the arguments that I hear, and the pushback that I get, when I, at our sort of national level, have tried to address what I think is inappropriate behavior. People say, get with the times, there's really no going back, patients consent to this, so what's the big deal.

DS: Yeah, that's what I hear too. When, as soon as I sort of start to describe this people, people's first reaction is, well, are they consenting? Are these patients possibly consenting to this? And you say yes, I mean, people do presumably consent, I mean we're not in the room when that happens, but you'd think by now these guys would have been sued had these patients not consented to this.

CV: Right.

DS: So there, I think there's good reason to assume they are consenting, and that they do understand the stakes and the performance. Because a lot of these doctors will say that they get patients from this. Like most of their patients watch them on Snapchat first, and then ask for surgery. So, it's apparently so, it becomes so popular that they're allowed to then have a very select pool of people they'll perform these surgeries on, because they've become so popular. So it's certainly helping their bottom line, it's helping their practice. You know, whatever that says about our culture and, and what we want to participate in, it certainly is helping them. And maybe this is the future. I'm not sure I wanna say doctors aren't allowed to use social media, that seems too far. But at the same time, you have to be able to point out some of these practices and say, gosh, this seems really exploitative. This seems like we're pathologizing something about a woman's body that ought not to be. But it's kind of, it's slippery, it's hard to put your hands on exactly what is wrong here.

CV: Yeah, I think that there's two, I think we should come back and talk more about the pathologizing of bodies, but certainly I think that consent is necessary, but it's not sufficient for the ethical use of patients' images. Whether it's on a website or social media or a YouTube channel or Instagram account. That the surgeon owes it to their patient to not exploit them, and that even if a patient is sort of complicit in their own exploitation, that because, I would argue, that surgeons and any physicians are supposed to hold themselves to a higher standard of respect for the person who's trusting them with their body, that they're violating a professional norm. If you wanna say that it, maybe it's, you know some people might say, well don't, you can't say it's unethical, but certainly I would say it violates a professional norm of surgeons sort of showing respect to the body and not exploiting their patients or any physicians really shouldn't be exploiting their patients for their own benefit. And it's hard to argue that if the surgeons weren't benefiting from this, they wouldn't be doing it.

DS: Mm-hmm.

CV: So clearly it's to their benefit, and it's hard to understand what benefit the patient's getting from this. Maybe they're getting their 15 seconds of fame, but it's, it's hard to quantify that that's really worth it.

DS: Right. And I think we came to this sort of pathologizing insight because the majority of these surgeries are labiaplasties, right.

CV: Mm-hmm.

DS: So, this is a very popular Snapchat surgery, and, my guess is that maybe people don't even know what this is? So, can you just sort of briefly, what is a labiaplasty?

CV: Well so it's, it's actually interesting, the rise in labiaplasties in plastic surgery has gone up 40 percent in the past year. And I think it's even going up even more. So this is a thing where if your labia minora are slightly larger, you can have them sort of cut down to size. And so, often times when you see someone describing this, one of the things they'll say, “we're gonna give you a neat and tucked-in look so you don't have a loose sloppy look” or whatever. It's sort of awful, but essentially, and they also tout this as vaginal rejuvenation, which is sort of interesting when you think about normal labia, the labia minora hang outside the labia majora. And the look that's being preferred by patients who get this is that the labia minora are quote unquote “tucked-in”-side the labia majora. Which is the look of little babies, or what we call Tanner Stage 1. Which is sort of this classification system of how you describe someone and where they are in going through puberty. And so this idea of vaginal rejuvenation, you know, in concert with doing labiaplasties is making a Tanner Stage 4, which is a post-pubertal appearance, and kind of turning, quote turning back the clock, that's what plastic surgeons do best, we turn back the clock, and turning you back to a Tanner Stage 1 to give you the look of someone who hasn't gone through puberty. And so that's really a little upsetting when it's put that way, I think. But it's, but if you look at what these websites or what people post on their Snapchat—again you can't show this on Instagram, but guys will show this on Snapchat, because it's uncensored. You get the sense that normal genitalia, we're being told it looks abnormal and it needs to be changed and made better.

DS: Yeah. I think that was maybe the most shocking thing I learned, is that what women want apparently is, you know, labia that look like they're pre-pubescent. That is so, so disturbing. And certainly, the physician has a role in that, right? It wasn't, it's not just a bunch of women who've never heard of this coming to the doctor saying this is what I want. I mean, they're perpetuating this idea that they're within the range of normal variation, there is “good and bad,” “before and after,” “pre-pubescent post-pubescent,” and what we really want is this like pre-pubescent ideal, and you know, we could say that about of course a lot of plastic surgery and a lot of what women want.

CV: Right.

DS: To look younger, but not to look like infants, right? [Laughs]

CV: Yeah.

DS: Hopefully not.

CV: No.

DS: But that's really what they're asking for, and, gosh, super disturbing.

CV: Yeah, you know, clearly I don't think, you know, not to downplay. Some people have, have problems where a labiaplasty is an appropriate operation. I have performed them, and so it's not that that's necessarily a bad operation. But, you know, I think that you have to think if, they're doing almost twice as many now as we were three years ago, it's not that there's been a rash of some horrible disease that's caused this. It's that perceptions about what's normal and abnormal have changed in society, and there may be a few factors that are, that are, have effected changing what is considered normal. But certainly one of those things is what's being shown on, in the venue of these social media outlets.

DS: Yeah. So, Christian, I mean, what, what do we do? We see this, and you and I and most people I've shown it to find it super disturbing. That the Snapchat performance is too much, right. So, we're not saying no social media, but we're saying these performances are exploitative, and damaging potentially to women’s psyches and their bodies. What's, how do we move forward?

CV: Well, that's interesting. I've, I've written some things for the plastic surgery literature, to try to establish some concrete guidelines where this would be clearly outside what's considered normal, so I've published that. I'm currently on the ethics committee of the American Society of Plastic [Surgeons], we're the ones who deal with complaints about this. So, if you see something like this and it bothers you, you can complain to the American Society of Plastic [Surgeons]. Or to the state licensing boards. And, you know, the, one of the hallmarks of the profession is that it's self-regulating. And so, I may be naive, but I think that what needs to happen is that this needs to be regulated more by the professions and by the physicians. It's gonna be difficult to regulate from a state or federal standpoint because it would, it's covered under free speech. You know, people claim, “well I'm just expressing my free speech, who cares if I'm exploiting people.” You know, at a, at a federal level or a state level it's hard to legislate that. But physicians are in charge of who gets to, you know plastic surgeons are in charge of who gets to be a plastic surgeon. You know, the American Board of Plastic [Surgeons] consists of other people like me who decide who's in and who's out. And so, I personally am working towards making it more difficult to be in if this is the way that you're gonna treat your patients. Now, I'm speaking primarily about these egregious cases that we've used. There's plenty of plastic surgeons who are on social media who are doing things in a respectful manner, and they're actually are improving communication and education. But there are these outliers that I think give, that leave a bad taste in our mouth, and that give us a bad name. Give plastic surgeons in general a bad name. So I'm hoping for the ability to improve regulation of this within plastic surgery.

DS: Yeah, that seems like the best way to move forward. So I am super glad that there are people like you [laughs], who are important enough in the profession to sort of set some standards. And so I guess we'll just have to sort of wait and see in the future if that's able to happen, and maybe the rest of us in the meantime could just be a little bit more suspect of what's going on here. You know, whatever voice we have, we're just gonna say, you know, this isn't how we want women to be treated, this isn't how we want surgeons to act, and, you know, we can voice that now and you can fix the problem for us. [Laughs]

CV: Yeah, I think the thing is too is that I show everyone I can. I mean, I subjected you to this [Devan laughs] when I said here take a look at this, this is awful, because I think that in some ways some of these surgeons live in an echo chamber, where they're surrounded by people who are telling them that this is really great. And if that's the case, then they're not hearing any voices of reason saying, you know, maybe you've crossed the line here. And so, having, you know, sensible people view this sort of thing and say is this really, is this really appropriate? Is this the way I want, do I want, you know, do I want my kids to open my Snapchat account and accidentally see something like this? You know, again, 25 percent of Snapchat users are under the age of 18, and there's a lot of naked bodies. So, you know, is that, is that what we want? Or do we want something that's, you know, a little bit safer for the viewers who are actually using it.

DS: Yeah. Absolutely. Well thanks, Christian, this was a really great conversation. And I, I thank you so much for your insight. And hopefully we'll put a link to our article and your other articles about social media-

CV: Sure.

DS: -With this podcast on our website. Thanks so much.

CV: Yeah, thank you.

LM: Thank you for joining us today on No Easy Answers in Bioethics. Please visit us online at bioethics.msu.edu for full episode transcripts and other resources related to this episode. A special thank you to H-Net: Humanities and Social Sciences Online for hosting this series. This episode of No Easy Answers in Bioethics was produced and edited by Liz McDaniel in the Center for Ethics. Music is by Antony Raijekov via Free Music Archive.

No Easy Answers in Bioethics Podcast

Reflecting on Early Bioethics: Fleck and Tomlinson - Episode 9

May 10, 2018 Len Fleck photoTom Tomlinson photo

What issues were bioethicists concerned with in the early days of the field? This episode features two senior Center faculty members, Director Tom Tomlinson, PhD, and Professor Len Fleck, PhD. Together they discuss and reflect on the accidental ways in which they entered the field of bioethics in the ‘70s and ‘80s, also touching on the creation of the program that became the Center for Ethics around that same time, and the early days of the College of Human Medicine. They discuss the changes they’ve seen around topics such as death and dying, advance directives, and advances in medical technologies. Finally, they speculate on where bioethics may be headed in the future.

Listen now on H-Net

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: "While We Walk (2004)" by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License.

Episode Transcript

Liz McDaniel: Hello and welcome to another episode of No Easy Answers in Bioethics, the podcast from the Center for Ethics and Humanities in the Life Sciences at the Michigan State University College of Human Medicine. This episode features two senior faculty members from the Center, Director Tom Tomlinson and Professor Len Fleck. Together they discuss and reflect on the accidental ways in which they entered the field of bioethics in the 1970s and ‘80s, also touching on the creation of the program that became the Center for Ethics around that same time. They discuss the changes they’ve seen around topics such as death and dying, advance directives, and advances in medical technologies. Finally, they speculate on where bioethics may be headed in the future.

Tom Tomlinson: Okay, well, hello everybody, my name is Tom Tomlinson, I'm the Director of the Center for Ethics and Humanities in the Life Sciences here at Michigan State, and as it happens I’m also an alumnus of MSU, getting my PhD here in 1980.

Len Fleck: And I'm Len Fleck, I'm a professor of philosophy and medical ethics in the Center for Ethics here at Michigan State University, and I came here in 1985.

TT: So, Len and I are like two old bioethicists rocking on the front porch, I think, today. [Laughs] So we thought we, you know, we'd like kind of reminisce, or whatever the right word might be, around a couple of general areas. One is just to talk a little bit about how each of us got into bioethics, in the early days of the field certainly. Not quite the dawn of bioethics, but shortly thereafter. About 10 AM, maybe. I'll also talk a bit about the Center itself, and some of its history and trajectory. And also, and then finally I think, just talking about the field itself, then and now. And, you know, what we see as the similarities, what's the same, and what's different. So, Len, why don't you start and tell us about sort of how you got into this bioethics racket. [Laughs]

LF: My story is probably a story that's repeated by lots of other bioethicists, I got into the field accidentally. In my graduate work I was doing American philosophy and the history of modern European philosophy, and my first teaching position outside of St. Louis University was at St. Mary's College in Notre Dame, Indiana back in 1971. They were supposed to merge with Notre Dame, Notre Dame was going to go co-ed. The merger fell through, a bunch of St. Mary's women transferred over to Notre Dame. St. Mary's was worried about their financial viability and they wanted to offer, again, a nursing program in order to attract more women to the college. And they needed somebody to teach a course in health care ethics. And there were only three of us in the department, and it sounded interesting to me, so that was how I ended up developing a course in bioethics way back in 1972. At a time when the number of books on, that were related to bioethics on a library shelf would have covered no more than one or two feet, nothing more than that, and the Hastings Center Report was about eight pages in length.

TT: Yeah, right. So I think I kind of stumbled also into bioethics, which is not surprising, considering there wasn't really a field, and there wasn't a clear career path. Maybe there's not, oh now there's a much more clear career path at least in some ways. But, I had, when I was discharged from the army, I ended up going to the master's program in philosophy here at Michigan State University, and one of my mentors during my master's program was Martin Benjamin. And Martin Benjamin actually started the first bioethics course at Michigan State in 1975. So that was kind of pioneering, and so he had an interest. And then later when I had, my wife got a job before me because she was the theater major so she had better prospects for employment than I did as a philosopher. Anyway, we went off and then I came back in '78 to finish my dissertation. And it so happened that in 1977, what was then called the medical humanities program had been started. And I ended up being the first graduate assistant for the medical humanities program, and that then involved a lot of work related to the medical humanities and medical ethics, and I think that's kind of what got me really hooked. And then I ended up incorporating medical ethics cases into my dissertation at the time, so that's how I got started. So, you know, it's different though today.

LF: Yes, that's right, it's very different today. Because there are formal programs, a lot of master's degree programs, some PhD programs, that are directly aimed at training bioethicists.

TT: Mmhm. So there are, there are pathways to going into bioethics now, and there weren't really then. You had no idea what the prospects might be for employment--

LF: That's right.

TT: --as a bioethicist.

LF: I mean there were, in my case, there were a lot of accidents along the way in terms of how my own competence in various area of bioethics evolved. And so, there were some early grants I had when I was at Indiana University in South Bend after St. Mary's College, that looked at community dialogues about issues related to death and dying. Because the death and dying issues, those were among the early issues related to bioethics.

TT: Mmhm.

LF: And that's obvious why that would be the case. These are the kinds of problems that health professionals, physicians, and nurses would face on a regular basis. And in that community, and as a result of the community dialogues, we ended up actually creating the 42nd hospice program in the United States, hospice of St. Joseph County, and so that became, that was one way in which I acquired a certain kind of knowledge of, a firsthand knowledge of the problems related to health care ethics. Beyond that, I then got involved in, there were the health planning agencies that were being formed in the late 1970s to do something about controlling health care cost. And the health planning agencies had these very large community boards, typically with 50 or 60 members, for whom there had to be this training. And they wanted ethical issues related to resource allocation as part of the training of these board members. Because that's in effect what they were doing, they were deciding how many CT scanners or MRI scanners or ICU beds they were going to permit in a particular community. And that was what got me launched into thinking about all the issues related to health care justice, and resource allocation, and cost containment, and rationing, and so on.

TT: Yeah. That actually prompts a memory, because between my master's and my PhD there was a period of time when -- well, I take that back. After I got my PhD, there were no prospects for employment in Michigan because it was kind of the height of the recession under Carter, and—people may remember who he was [laughs]—and so I ended up taking a job with the Foreign Agricultural Service at the Department of Agriculture in DC. Because they called me to ask me whether I'd be interested, and since I was facing unemployment here in Michigan, I said yes. And I ended up, one of the things I ended up doing in part of this public relations sort of role is looking at all of the foreign agricultural trade press. So that was part of my job was to clip items of interest to the ag economist in the Foreign Agricultural Service, and at the time there was a lot of furor over animal, so called animal rights. Among people who were raising hogs and cattle and all kinds of things, chickens and so on. And that really prompted an interest of mine, so I acquired a lot of knowledge about the debates around animal rights at that time, and of course, when did Animal Liberation come out, Peter Singer's book?

LF: Late '70s, I think.

TT: Yeah, it's about the same, it was to the same time. And that ended up then, just sort of fast-forwarding a bit, sometime after I got the position on faculty, I remember Bruce Miller and I went around and made presentations to a number of the basic science departments, researchers doing lab animal work, around these questions. And the one, there was a delegation of faculty who went to the then-dean of the College of Human Medicine asking that I be fired.

LF: Oh.

[Both laugh]

TT: And thank God for Don Weston, because he told them to get the hell out of his office, or something to that effect. That’s probably actually what he said. So that was, and you and I were on fixed term appointments.

LF: That’s right. When I came here I was on a fixed, yep.

TT: One year, yearly fixed term appointments for like, what, ten years or something? Or close to that?

LF: No, I think by the early '90s Howard was successful in getting us tenure stream appointments.

TT: Yeah.

LF: I think that's when it was.

TT: Right. But then, if I, because I started in '81.

LF: Yeah.

TT: And you started in '85.

LF: '85.

TT: Yeah, okay.

LF: So, what was the Center doing? How did the Center get started?

TT: Yeah, so Andy Hunt, Andrew Hunt, was the founding dean, he was a pediatrician, was the founding dean of the College of Human Medicine. And I want to sort of underline "human medicine," because one of the philosophies of Andy and the small, relatively small group of other folks, senior faculty who sort of really energized the start of the college, was that they wanted to train physicians who really had a humanistic understanding of health and medical treatment and illness, and so on. Not just scientific, and that was quite deliberate on their part. And so when Andy stepped down as dean, I can't remember, I lose track of exactly when CHM started officially.

LF: '64 I think is the official start.

TT: '64? Really?

LF: Yeah.

TT: Okay. He, as a condition of stepping down he said, “I want to have a medical humanities program.” And so because he was the founding dean they said yes. And so that's how it started. And at the time there were several different tracks in training medical students in CHM, and so in some of those tracks, in fact, we were incorporating small group teaching around cases, you know, the same kind of approach and methodology that's very commonly used today. And we had guest speakers coming in all the time. Sam Gorovitz, for example, I remember is somebody that we brought in. One of the grandfathers, kinda--

LF: He would be a grandfather. His collection of readings was one of the very early collections that was, that would be used in a lot of courses in bioethics.

TT: Yeah, right, that's right. So, and then the Center continued as the medical humanities program for quite a number of years, and, funded, originally funded just through CHM, but then we got a grant actually from the National Endowment of the Humanities, of all things, to create faculty positions, and part of that grant committed us to providing assistance also to the College of Osteopathic Medicine at Michigan State University, and the College of Veterinary Medicine. And so then that would mean that every year, Andy Hunt and then later Howard Brody, would have to go around from dean to dean with hat in hand and say, okay, please cough up this amount of money because we need it to keep going. That was untenable in the long run, and so we persuaded, it must have been Howard and Andy and some others, persuaded the provost to consolidate all this funding into one single funding stream for the Center for Ethics and Humanities. So it then still had this pretty broad mission.

LF: So what were the kinds of issues that were the focus of the work of the Center from early on?

TT: Well I, you know, I was thinking about this the other day, and what was really, one of the things that's really striking to me is how much resistance there was at the time among a number of physicians to withdraw life-sustaining treatment. And, because it was seen as murder.

LF: Yes.

TT: That was actually a word that some people would use. And, at a kind of euthanasia, and so I it was very vigorously resisted, not by all physicians, but certainly by some. And so that was probably, on the clinical ethics side, I'd say, the major issue that animated, that bioethics was focused on. And then I also recalled the vocabulary that was used, there was active euthanasia, which was, you know, actually doing something like injecting someone, and there was passive euthanasia, which was just withdrawing treatment. So the very act of withdrawing treatment from somebody was called a kind of euthanasia.

LF: And the word euthanasia of course had all kinds of bad connotations--

TT: Oh sure.

LF: --because it was associated with Nazi Germany and World War II and so on.

TT: Right.

LF: And the other thing that I'll add historically, you know I mentioned that I had helped to found this hospice program in St. Joseph County. Well, today of course hospice would have a very, very excellent reputation as providing a more thoughtful, peaceful end-of-life care to individuals. But again, at the time, Tom, you're absolutely correct. There was significant resistance to the creation of that hospice program in South Bend, Indiana in St. Joseph County, there were a lot of physicians who thought of this, this is, you're just trying to kill people more quickly for whatever reason, and this is just not acceptable. And so there was a lot of community education that had to be done. And medical education to convince physicians that this, these were reasonable choices, and that individuals should be allowed to make them. I guess, part of the other thing in terms of the history of the emergence of bioethics, is the history of the 1960s. The civil rights movement, consumer rights, feminism, and so on.

TT: Oh yeah.

LF: And so all of that put a lot of emphasis on respect for the choices of individuals, and so that became the principle of respect for patient autonomy. And that sort of helped to facilitate dealing with some of the death and dying issues that were otherwise much more controversial at the time.

TT: Yeah. There are also legal developments, so it was during the '60s and even into the '70s where the doctrine of informed consent, not just plain consent, but informed consent was being developed and solidified, and I think that was also a, there was a lot of energy behind that, which also I think was one of the factors pushing against physicians and others who want to limit the choices that patients had, especially with regard to what was being done to them.

LF: Mmhm, yes. And then if we fast-forward into the later part of the 1980s, part of what's going on is there is much more emphasis on health policy issues and cost issues and so on. There's more emphasis on health reform. You get into the early 1990s and you have the Clinton Task Force.

TT: The Clinton Task Force, yeah.

LF: Yeah, the Clinton Task Force on health reform. So, Howard Brody and I were a part of that, that of course was a failed effort, but at least we gave it a shot. And we learned a lot about some of the challenges that are faced with trying to reform the health care system, and the fact that it is so complex, and that there are so many different points of view regarding what counts as appropriate and cost-worthy kinds of healthcare. At the time, that was, it was relatively complex, it's gotten even more complex since then because of all the emerging medical technologies that you find in the health care system today.

TT: Yeah. Well, you know, it's just an example of how if you want to actually effect change, you have to take bioethical principles and analysis into a political realm. Because no one's going to make a bioethicist king, and--

LF: That's right.

TT: Probably for good reason. [Laughs] And so that's where you really encounter the sheer necessity of developing some political, you know, public relations even, skills. I remember that Howard and I, and maybe you were involved too in this, in the, must of been mid to late '80s when David Hollister, who was later the mayor of Lansing, but was then a legislator, a very active legislator in the Michigan Legislature, wanted to introduce a bill to create advance directives, to legalize advance directives in Michigan. Which, at the time, was something going on elsewhere in the country. And that was a very complicated political negotiation between those of us in the Center on the bioethics side, and Dave himself of course and a number of others, to try to empower patients, people as much as possible to direct their future health care. Against people who were concerned about the possibility that people would be allowed to die prematurely, or that they'd be allowed to die because of, because they had a poor quality of life. And merely because they had a poor quality of life. And so we had numerous negotiations, particularly with Michigan Right to Life, and the Michigan Catholic Conference, around those issues. And it was a very interesting struggle. We were ultimately successful in those discussions, I think, in creating a advance directive statute that has many fewer limitations than the ones found in a number of other states. So, for example, in Florida, you either have to be terminally ill or you have to be in a persistent vegetative state in order to trigger your advance directive. There is no such limitation here in Michigan. So we feel, we felt pretty good about that.

LF: Now if we go beyond the death and dying issues, because the field has evolved over the past 30, 40, 50 years. When you get into the early 1990s, this is when the Human Genome Project gets going. So this is a ten-year project to map the human genome, and so all of a sudden there are all these genetics issues, and an increasing capacity to control the genetic endowment of future possible children. This, all these things that were just sort of science fiction scenarios back in the '70s and '80s are becoming much more real today. And, in part as a result of the research that went on, and that continues to go on through the 1990s and now into the 2000s. Right currently the issues are around CRISPR/Cas9 as a gene editing technology, this has been a focal point of a lot of recent discussion. And of course the ability to do various kinds of genetic manipulation, raises the most difficult kinds of bioethics issues when we start talking about reproductive decision making, the development of pre-implantation genetic diagnosis, the ability to create these 8-cell embryos in vitro and to do genetic analysis of the embryos, and to allow parents then to choose embryos that are free of particular genetic disorders about which the parents might be concerned. All of that is raising a lot of the issues that we're faced with today.

TT: Mmhm. Yeah. And I think, you know, it's just another example of how the creation of new technologies creates new choices where there were no choices. You don't have choices, you don't have an ethical problem.

LF: Right.

TT: You've just got tragedy, or whatever. So, I mean, it's similar in lots of ways to the introduction of dialysis as a technology. And, you know, before dialysis if you had end-stage renal disease, there wasn't anything to really be done. You were going to die. With dialysis, now we've got decisions to make. And at the time, of course, it was because we didn't have enough machines or facilities relative to need. There were also cost issues percolating in the background. And so this is in part the recurring story of bioethics is as advancing technology gives us these new choices, we're faced with ethical question where before we didn't have those problems. I think the question for me is in what regard are those questions different in nature to the ones that were raised previously. Sometimes I see, this where I think, you know, everything that's old is new again.

LF: Yes.

TT: [Laughs] That there, that in bioethics there's a lot of, you see the same kinds of issues, the same kinds of questions occurring over and over again, but being raised in these new contexts.

LF: And, when they're raised in new context, the details often make a difference. So we have to pay attention to the details. We have to pay attention to, in terms of genetics and cancer today, these targeted cancer therapies, and the varying degrees of success that these different drugs have for different individuals with different genetic endowment, or whose cancer is distinguished by the genetic analysis that might be done to their cancer. So you've got those kinds of issues. The other issues that are emerging today have to do with the human brain, and so all the issues of neuroethics and so on. And again, there's a lot of medical scientific detail, there are all kinds of interventions that we're attempting today that, deep brain stimulation in connection with Parkinson's, for example. And potential consequences of doing that and how serious they are, and do you give patients choices on this, or are there some choices that shouldn't even be offered to patients and that physicians should avoid getting involved with. I mean, those are all recurring kinds of themes within bioethics.

TT: Mmhm, yeah, right. Right. I mean, I think one of the things that's, for me, is a little more distinctive about some of the advances in neurological treatment and interventions are the more fundamental, sort of maybe ontological [laughs] that's too fancy a word, questions that they raise about personal identity. So, you know, as more and more, as you create these interventions that do things to my brain, that may affect my behavior, in ways that don't seem to be, seem to be created by a machine, or by some technology rather than me. What is the boundary between me and my brain implant? Can I say, oh, I'm sorry, my brain implant again. Please excuse it. It doesn't know what it's doing. [Laughs] So those, I think, are, maybe they're precedents in bioethics, but for me those are the most, the newest kinds of arenas that are, questions that are being raised by advances in neurotechnologies.

LF: What we're trying, I mean, sometimes we ask the question, how do we identify what someone's real self is? And is it not my real self if there is say some kind of psychiatric disorder that makes me different from the way in which I want to be. And then if we have a drug that can in one way or another correct that disorder, make me more like other people, is that my real self? Or, alternatively, we have Kay [Redfield Jamison] who wrote this book An Unquiet Mind, and in that, and in her story, the story that she tells about herself, and she's a very prominent researcher at Johns Hopkins University, she has to deal with bipolar disorder. And this is something that was really wrecking her life in many ways, and of course we have very good drugs that can help individuals with that disorder to deal with it. But she really loved the manic states, and she sort of felt that this was her real self, and she got all kinds of praise because she would turn out these scientific articles.

TT: Very much more creative.

LF: That’s right, more creative, more productive. She loved that version of herself, and when, when she would take the various medications that would bring her to the more normal psychological level, this was just a dull and uninteresting version of herself. She didn't really want that self, but the alternative was if you want the mania and so on, you also had to take some very bad consequences regarding the kinds of choices that she made. She engaged in, for example, this extraordinarily, these extraordinary spending sprees.

TT: Spending sprees, yeah right.

LF: That resulted in bankruptcy and so on.

TT: Right. Well you need a targeted mania drug.

LF: A targeted mania drug, yes.

TT: Just for the creative part.

LF: Yep, yes, that's right.

TT: I mean I think, you know, of course this, you know, this all edges into, you know, this sort of transhumanist.

LF: Oh yes.

TT: Yes, all these ideas about how we're going to sort of leave our biological selves behind, have ultimate control over every aspect of our lives. That's what some people find kind of frightening.

LF: Well, what's even more frightening and more transhumanist than we might care to accept is the idea that we would create these robots with artificial intelligence, and so future versions of HAL from [2001: A Space Odyssey] who would be smarter than any humans and would ultimately replicate themselves, and kind of push us out of the way.

TT: Yeah.

LF: These of course are, I believe, science fiction scenarios. Interesting reading, but I don't think that stuff like that will really happen.

TT: Yeah. Well, I mean, here's another thing that's coming into medicine, of course, and that is the use of artificial intelligence to be making diagnoses, and prescribing therapies, and providing prognosis, and doing all the things that ordinary human doctors have done for millennia. And. I think that, I think there's interesting work to be done in bioethics there, too. And not just bioethics, but also sociological and psychological studies of what the impact may be on the nature of the doctor patient relationship. And the patient's experience. This is going to be a real revolution that may have consequences -- we should really try to understand as best we can what the consequences of that are going to be. Is it going to be unemployment for physicians, is that going to be one of the consequences?

LF: I don't think physicians worry too much about that. But, the, part of the ideas you were suggesting was you have these massive computers that can manage huge amounts of data about hundreds of thousands or millions of patients, and, in effect, say doctor this is how you outta think about responding to the needs of this particular patient before you now. And the doctor caring for that patient might have what you would call in intuition that I don't think that's quite right for this patient, but if they act on that intuition you get a bad outcome--

TT: His reimbursement's going to drop.

LF: That’s right, yes, that's right.

TT: [Laughs] If he's not following that protocol.

LF: And there are, and there would be legal problems, why did you do that? Why did you trust your one micro brain to make that judgement when we're got this billions of--

TT: Yeah, your one gigibot, your one gigabyte brain. [Laughs]

LF: Yeah, to go against the several terabyte brain that's associated with the computer that produces big data.

TT: Yeah. I think I, this is, now we're kind of wandering a bit but that's okay. So, I, there's something I saw recently that, that said that the biggest problem for artificial intelligence is what we call common sense. So you can build algorithms, you can train, you know, these computers with neural networks and all this kind of stuff, to recognize things or to make decisions better than humans, but when it comes to decisions that revolve a kind of a common sense, or some kind of background knowledge that is highly, highly contextual in its relevance, that's the big challenge as I understand it to something real artificial intelligence that approaches human intelligence. I hope we never cross it.

LF: Yes, me too.

TT: [Laughs]

LF: And on that note, I think need to conclude.

TT: Well this has been fun.

LF: Yes.

TT: Thanks everybody.

LM: Thank you for joining us today on No Easy Answers in Bioethics. Please visit us online at bioethics.msu.edu, and follow us on Twitter @MSUbioethics. This episode of No Easy Answers in Bioethics was produced and edited by Liz McDaniel.

No Easy Answers in Bioethics Podcast

‘Imaging and Imagining Illness’: Devan and Darian Stahl - Episode 7

March 8, 2018 Devan Stahl photoDarian Stahl photo - Photo Credit: © Concordia University/ Lisa Graves

The recently released book Imaging and Imagining Illness: Becoming Whole in a Broken Body began as a collaboration between sisters Devan Stahl, Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Pediatrics and Human Development, and Darian Goldin Stahl, artist and printmaker. The edited volume examines the impact of medical imaging technologies on patients and our wider culture. In this episode, guests Devan and Darian share the personal origins of their collaboration. They discuss Darian’s artistic process, how audiences have reacted to the artwork, and how they came to invite other scholars to build on their work. By and large, Devan and Darian’s story delves into the intersection of art, illness, disability, and self-identity.

Book cover: Imaging and Imagining Illness

Listen now on H-Net

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: "While We Walk (2004)" by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License.
Darian Goldin Stahl Photo Credit: © Concordia University/ Lisa Graves.

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Episode Transcript

Liz McDaniel: Hello and welcome to another episode of No Easy Answers in Bioethics, the podcast from the Center for Ethics and Humanities in the Life Sciences at the Michigan State University College of Human Medicine. Today’s episode focuses on the intersection of art, illness, disability, and self-identity. The recently released book 'Imaging and Imagining Illness: Becoming Whole in a Broken Body' began as a collaboration between sisters Devan Stahl, Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Pediatrics and Human Development, and Darian Goldin Stahl, artist and printmaker. The edited volume examines the impact of medical imaging technologies on patients and our wider culture. In this episode, guests Devan and Darian share the personal origins of their collaboration. They discuss Darian’s artistic process, how audiences have reacted to the artwork, and how they came to invite other scholars to build on their work.

Devan Stahl: Hello my name Devan Stahl and I work here at the Center for Ethics and Humanities in the Life Sciences, as an Assistant Professor of clinical ethics.

Darian Goldin Stahl: And I am Darian Goldin Stahl and I hold an MFA in Printmaking from the University of Alberta in Canada, and I am currently a Humanities PhD student at Concordia University in Montreal.

Devan: So, you might notice that our voices sound similar, and this is because we are sisters.

Darian: Yeah you might have noticed that we have the exact same last name.

Devan: Another great signal that we might be related. So today we’re going to let you know who is talking. I, Devan, will be speaking from the patient experience, and Darian will be speaking as an artist. If you get confused, I say just sit back and take in our melodious voices. [Both laugh] So today we’re gonna talk about a book that Darian and I wrote, called ‘Imaging and Imagining Illness’ that has recently been released from Cascade Books and you can find on Amazon! ‘Imaging and Imagining Illness’ is an edited volume that examines the impact of medical imaging technologies on patients and our wider culture. This book began as a collaborative project between Darian and myself about five years ago. Does that sound right Darian?

Darian: Yeah that sounds right. I knew that I wanted to collaborate with you as the focus of my MFA research in visualizing disease starting in 2012-2013.

Devan: And your MFA is your Master’s of Fine Art, is that right?

Darian: That’s right.

Devan: Okay, about 10 years ago I was diagnosed with Multiple Sclerosis or MS, and my physician diagnosed me in part by looking at some MRIs. Because MS affects the nerve connections in my body, every year or so I get hundreds of images of my brain and spine, so that my doctors can monitor my disease progression. And so now I associate my disease with these particular images. Now if you’ve never had an MRI, they can be, well, a bit of a nightmare. When I get MRIs, technicians strap down my head, they put an IV in my arm, so that they can put dye into my blood stream, and the sessions can last about three hours. Now the tube they put you in is super narrow, and it’s very loud in kind of this arrhythmic way, so there is really no way to fall asleep, and you have to be very careful not to move or they have to start all over again. Needless to say, this is not the most enjoyable experience. And as I described what it was like to have MS and what it was like to get these MRIs and see all these images of my body, Darian and I found that we had this kind of odd scholarly interest that we shared. We were both really interested in Renaissance anatomical textbooks. Might sound like a bit of a non sequitur but we’ll get to how that’s involved in a second. So at the time I was teaching a course at St. Louis University called “Freaks and the Medical Body,” which examines the ways in which medicine has participated in the freak show, and how our understanding of the normal body and the abnormal body has changed over time. I showed my class images from Vesalius’ classic text “de Fabrica,” and compared these images of human bodies to the textbooks we have today and the images we see from medical imagining technologies, such as MRIs.

Darian: And while Devan was teaching this course, a couple states away at this exact same time I was earning my Bachelor’s of Fine Arts in printmaking at Indiana University in Bloomington. And my own interests in, maybe, dubious depictions of the body began when I took a course on the History of Anatomy. I became fascinated by the deeply held misconceptions of our anatomies, like how Galen depicted the human body with a five-lobed liver, or the belief that there was an extra organ at the base of our skull, called the rete mirabile, which were both illustrated in anatomy textbooks well into the Renaissance. These misconceptions of the human body were held for so long, because it was assumed we shared more anatomy in common with other mammals. Whereas barn animals could easily be dissected, and it was extremely rare to dissect humans until the late Renaissance.
As Devan mentioned, Vesalius’ illustrations of anatomy were truly groundbreaking, because he performed human dissections himself and used first-hand observation to correct false anatomical beliefs. He also rendered the body in a completely new and elegant manner. Before the photographic breakthroughs of the late 19th century, anatomists relied on printmakers to illustrate how the body worked. Because, of course, all of these images of anatomy had to be hand-carved into woodblocks, inked up, pressed into paper, and bound into pages in order to disseminated. The evolution of craft and collaborative relationship between anatomists and printmakers is perhaps best evident in Vesalius and Stephan von Kalkar’s anatomy tome, “de Fabrica.” In these images of the body, the cadaver is not lying down, but almost dancing across the Italian countryside. Well, until the figure’s muscles are so dissected that and he has to prop himself up against a pillar in order to keep from crumbling to the ground. I loved how the cadaver felt as if he were still alive and teaching us about his inner body. This union of function and aesthetics was so intriguing to me because of the stark contrast to how we depict the body in medical images today, which are unmoving, generic, anonymous, and completely objectified. Vesalius and Kalkar’s prints made me reconsider the purpose of anatomical images.

Devan: Darian I love how you describe that as the body sort of dancing because I hadn't thought of it quite that way before. If- I encourage people to look at these images, but they're always like in a field or in the city and they're, you know, maybe his hand is raised up, but yeah they're sort of, and they're meant to be pushed together right? So in the textbook maybe they're sort of separated but when you put them all together he's sort of twirling around in these sort of different landscapes.

Darian: Yeah there is, it's called an accordion file, and you can kind of imagine this, just folding of a very long sheet of paper into a zig-zag and you, it fits into the book and you can also pull it out, and that's when you can see all of the figures side-by-side and it is this twirling, the hands are going up into the air, and pointing above and below, and it's a beautiful way to depict the body.

Devan: Yeah and so you compare that to maybe like ‘Gray's Anatomy’ which is you know it's sort of this big move toward you know you just want to see the heart on a page sort of drawn in its simplest terms with kind of the arrows pointing to it which is a very different way of depicting the body than that sort of dancing across the Italian country scape.

Darian: Yeah they were built meant to be educational, but somehow there was this gap between subjectivity and objectivity.

Devan: Yeah, yeah so the pictures in ‘Gray's Anatomy’ are meant to be more objective, and objective means that you can't, you know, be dancing. Apparently dancing is quite subjective. [Both laugh]

Darian: Apparently.

Devan: Okay, so, so Darian and I began thinking, what if there was a way to depict the body in ways that were more like how those older artists depict them in textbooks? So, how could we recreate something of what Vesalius was doing? How could a medical image signal more about the human experience than a simple MRI or a scan could allow?

Darian: And this initial idea started my research into the body as a metaphorical vehicle for narrative, and how medical images can include context, movement, and atmosphere that tell us something more about the lived experiences of the patient, like her daily life living with chronic illness. The patient in this case of course being you, Devan. She began writing about her memories of being diagnosed, thinking ahead to an altered future, and the unease she felt with the unpredictability of her body. Then I began to depict these narratives visually.
And I had this breakthrough moment in the process of visualizing disease when Devan mailed me a CD of her MRI scans that she received from her doctor. This cache of medical scans moved all through her head, face, and body, but I couldn’t recognize Devan in a single image. I thought about what was missing in these pixelated, black and white images of anatomy, and I concluded that it was skin. I sought out the scans that perhaps held a clue to her identity, like the curve of the ear, or an impression of the cheek. But the scans sliced right through your face [both laugh] and the images became monstrous and completely unrecognizable. And I then decided to return flesh to these scans, in the hope of rehumanizing their anonymous qualities.

Devan: Was that the first time you ever thought of me as a monster? I am the older sister, so… [both laugh]

Darian: Maybe not, but… yeah it was quite horrifying especially going from maybe the front to the back where it’s going through the nose and all the teeth, and I just, I wanted to see the face and it wasn't there.

Devan: Right.

Darian: So in order to inflesh these scans again I discovered a way of kind of “scanning” my own skin, and then I would layer them with Devan’s MRI scans through the printmaking process. And after so much trial and error, I found that if I lightly dusted powdered charcoal over very smooth paper, and pressed my body into it, the oils of my skin and the weave of my clothes lifted the charcoal, and left a perfect negative impression of my body in the paper. It was kind of amazing to see the amount of clarity I was able to achieve with this technique. You could see the creases of my lips, the movement of my eye lashes, and even the copious amount hairs on my chin—which I wasn’t really aware of before this moment.

Devan: They’re very fine baby hairs.

Darian: [Laughs] Yeah, it was a bit of a surprise. So, after joining these skin scans with Devan’s MRI scans I was able to create a fully fleshed out figure. And then I placed this new figure in the context of the home. Maybe instead of dancing around the Italian countryside it made more sense for this depiction of Devan to be in the home as maybe the space where she has the time to contemplate living with disease. I depicted this figure at the foot of stairs or looking down narrow hallways imagining how her body might navigate these spaces in the future as her disease progresses. And I see this figure as symbolizing our collaborative process. Our scans have combined to form this new, kind of third figure that exists between us, who represents our goals to give context to the medicalized body.

Devan: Yeah, and you sort of literally press your flesh into those scans, so it's my brain or my spine and your sort of pressed flesh, so we become this one figure in your art.

Darian: Yeah. It wasn’t too difficult to line up, your scans and my body. I think the only thing I really had to do was make my- make the scans shorter. Because you’re very tall. [Laughs]

Devan: I am very tall, I’m a lot taller than my sister Darian. Yeah, so, and just a plug for Darian’s art, you should go check out her website, dariangoldinstahl.com. D-a-r-i-a-n-g-o-l-d-i-n-s-t-a-h-l.com. And she has all of the past exhibits that she’s done and lots of pictures, so you should check them out. It’s hard to convey exactly on a podcast. So folks should check it out.

Darian: Yeah, it is a visual medium.

Devan: It is a visual medium, that’s right. And, I've been to now a couple of exhibits with you where I've been able to sort of stand back and see people as they comment on your art and it seems like people really respond well to it. Would you say that?

Darian: Yes! I would say that the responses have been overwhelmingly positive, though it really does depend on who the audience is in that moment. I’ve found that caretakers have a very emotional response. I have tried to leave the figure that I portray in these prints very open, with little definite features, so that anyone is able to project their own experiences onto this image. And during my master’s program, my advisor began caretaking for her ill father. And when I first showed her this work, she was able to immediately identify with the images being shown. Even though the figure is portrayed as a woman, she felt the concern of moving her father up and down stairs and through the other domestic spaces of her home. You know, caretakers are often isolated and overworked, physically and emotionally. And I felt what I was doing in this moment was building a community in the gallery space that tries to combat this isolation. Another group that has a very different response is physicians. They are fascinated by my use of the scans, I think it's something that they see in their everyday lives completely transformed into a fine art piece, but they still try to read the scans. A member of my thesis committee was a neurologist, and she was concerned that the MRI scans weren’t portrayed clearly enough. It was almost a warning to me that I would receive criticism if my audience couldn’t see the lesions in Devan’s brain scans.

Devan: Which is pretty funny because I don't think anyone but a physician could possibly see that, right?

Darian: Right. And-

Devan: You have to be trained.

Darian: This is a thing that has never happened. Nobody has ever asked me to point out the lesions in the artwork. I use the scans as a greater metaphor for living with the disease, and I think the audience is able to, to feel that, and they’re not searching for the lesions.

Devan: Yeah but the physicians are, I remember at least once when we presented maybe at an academic conference and there's a physician in the audience, when we put up one of these scans they immediately know what my diagnosis is before we say anything about it. They can tell right away.

Darian: Really? I can’t tell at all. I don’t know, I’m not a technician or doctor.

Devan: Right, and you can sort of be trained. I mean enough physicians have helped me to see them, to see those spots, so I can now see them because I've been sort of trained by my physicians to see that. But it's not, it’s certainly not something you'd be able to tell without any kind of training.

Darian: Right. The lesions aren’t so huge, at least to my perspective, that I would see the scan and immediately know something was wrong, quite the opposite. They just look like a beautiful regular brain, Devan.

Devan: Oh, thanks Darian. [Laughter]

Darian: But, there have also been a few times where viewers find the images quite alienating, and maybe too charged and emotional to engage with at all. One gallery goer asked me why I would make art so sad, when art is supposed to make you feel happy. And others have asked me why I don’t include more, maybe, rainbow colors, and still others won’t talk with me at all about the work. I remember one time during my master’s I invited a professor into my studio for a critique, and he basically refused to talk about the work once he saw it. Maybe I hit a nerve with him, and he didn’t want to go there? I really couldn’t say, but I don’t think that this work is overly sad. I think of it as an honest portrayal of a very real possibility of impairment, and it deserves its own contemplative space.

Devan: Yeah, I also don't see your art as sad. I mean, some of the initial art was very black and white, but that's because the MRIs themselves are black and white and so it fit the theme. A lot of your more recent work does have a lot of those brighter colors in it, so that is somewhat of a change but, yeah it's not, it's only sad if you think that impairment itself is something to be sad about, which I don't, and I don't think you do either. So to me it's sort of it's celebrating like this fuller body and a fuller experience. Which is not sad. Which isn't to say it's not never- it, you know it might be sad sometimes, but that's certainly not the emotion that I associate with your art or with my disease.

Darian: Right. I feel the same way, I get why people might feel that way when they're looking at it, but I also think that they're bringing their own emotions to the table.

Devan: Right, art is sort of this reflective experience where people are, they bring as much to it as maybe they, maybe a lot more than you intended.

Darian: Exactly, and that's the beautiful aspect of art is that it has this multiplicity of interpretation, which is perfectly fine. [Laughter] That’s what I want people to come away with is how it fits and relates to their own experiences.

Devan: And what's so great about that, I love that word multiplicity because, kind of the idea initially was that these images have a single interpretation, right? They say something very particular, they say something that the physician is looking for, and you either have it or you don't. Whereas as the artist you're allowing for kind of a multiple interpretations of that image, a kind of multiplicity of all sorts of different subjectivities that can go into that, and that's very different than what it would be used for in the medical setting.

Darian: Yeah, it's a completely different language, but still drawing from the same core set of symbols, and I think that there's room for more subjectivity in the medical side of things it doesn't just have to be this singular purpose image. Maybe for a diagnosis, but to acknowledge that images are powerful and will have more than one effect to anyone that sees them.

Devan: Absolutely. So, Darian and I also began presenting our work together as I said at different medical conferences, at medical humanities conferences and bioethics conferences, and writing papers about this collaboration. And we began thinking, so if my narrative and Darian’s art can come together in this way, might other scholars from other disciplines also have something to offer our project? Darian sees my MRIs differently than my doctors do, and even than I do. So, could a philosopher, or a theologian, or a visual culture theorist also see them differently? And then we thought maybe we can invite these other scholars to read my narrative and Darian’s description of her art, and build on our work. So, in the- ‘Imaging Imagining Illness,’ this book we’re talking about, I begin this volume with a short pathography, which is an illness narrative describing some of my interactions with the medical community, and my initial diagnosis. I explain how I experience the process of MRI scans, interacting with various clinicians, and the influence my illness has on my self-identity.

Darian: In the next chapter, I give my own interpretation of Devan’s illness and bodily images through my fine art prints and artist statements. I add my own remembrance of her diagnosis and how it affected our family and then my artistic direction going forward.

Devan: Then Dr. Therese Jones reflects on my story and Darian’s art through the lens of the medical humanities. Dr. Jones picks up on the themes of liminality, pathography, and identity formation in illness.

Darian: Next Dr. Kirsten Ostherr’s chapter details the history of medical “technovision,” and the ways in which patients can use creative forms of expression to reclaim their body identities. Using the lens of visual culture and media studies, Dr. Ostherr describes how patients can disrupt the biomedicalization of life and empower themselves in the digital age.

Devan: Then the final two chapters reflect on all four of the previous chapters, adding additional layers of meaning and interpretation. Dr. Ellen Armour writes as a theologian interested in biopower and resistance. Dr. Armour’s chapter is concerned with how certain images and narratives can mirror or resist our modern ways of knowing and being in the world. And then Dr. Jeffrey Bishop, a physician and philosopher in bioethics, considers the power ontology of medicine, as well as patient empowerment and the dark gift of bodily frailty. Dr. Bishop emphasizes what’s gained in self-giving.

Darian: And we were also lucky enough to have Rosemarie Garland-Thomson write the foreword, in which she highlights the field of other women who create disability art. And on a personal level I had been studying Rosemarie’s writings for my dissertation, and she had quickly become an essential scholar for my research topics. So I was overjoyed, it was such an honor to have Rosemarie reflect on our collaboration, and to be grouped together with other incredible women working on the topics of disability. I had known these other artists Rosemarie discusses for years, when I was studying for my MFA thesis defense. Riva Lehrer out of Chicago, Laura Ferguson from New York City, and Katherine Sherwood in San Francisco are all my personal art stars. So to be considered in their orbit is a dream.

Devan: And well-deserved, Darian, I would say.

Darian: Thank you!

Devan: So what we end up with, in this volume is sort of a work that builds upon itself. The authors are reading the other authors and building on their ideas, and sometimes challenging them. And I conclude the book with some reflections on the themes that came up, including the power of biomedicine and how patients can resist it or submit to it, how medical imaging affects identity formation, and how patients like myself might be transformed through chronic illness but also through art.

Darian: The arc of the book traverses the MRI scan from idol to icon. At first the MRI confines and limits Devan and becomes the only way her doctor can see her, whereas my art helps to turn the MRI into an image that incorporates Devan’s reality.

Devan: Right, Darian’s art and these other multiple interpretations offered by the contributors turn an image that once felt very intimidating and alienating into an image that reflects more of who I am and may even change the way others see themselves.

Darian: As far as my own artwork, our book has given me a new perspective on the importance of flesh, which has since taken on an even more preeminent role in my printmaking practice. In her medical scans, Devan’s flesh is punctured and set aside. The labor in giving back this flesh that was lost in the pursuit of a diagnosis, is seen as a kind of transubstantiation for our other authors. Skin’s employment in shifting Devan’s scans from an image on a screen to real-life relation with flesh gives shelter, care, and identity to Devan’s internal anatomy. We hope that this process allows others to see their scans differently, and perhaps even inspires them to reclaim and re-present their own scans into a personal vision of identity.

Devan: So we’re very proud of the book, which again you can get from Wipf and Stock Publishers or from Amazon.com, and if you feel like it, and if you like the book you should feel free to add a review!

Darian: Yes, please give us a review, but only if it’s positive. [Laughter] If it’s negative don’t, just ignore that.

Devan: That’s right if you don’t like the book you can just keep that to yourself. [Laughter] Alright thanks Darian.

Darian: Thank you Devan. Thank you everybody else who is listening!

LM: Thank you for joining us today on No Easy Answers in Bioethics. Please visit us online at bioethics.msu.edu, and follow us on Twitter @MSUbioethics. This episode of No Easy Answers in Bioethics was produced and edited by Liz McDaniel.

No Easy Answers in Bioethics Podcast

Organ Donation Models: Eijkholt and Fleck - Episode 8

April 6, 2018 Marleen Eijkholt photoLeonard Fleck photo

What kinds of organ donation models exist around the world, and how effective are those models? This episode on organ donation models features Center Assistant Professor Dr. Marleen Eijkholt and Center Professor Dr. Len Fleck. Combining their clinical ethics and health policy expertise, they sat down together to discuss ethical issues within current organ donation models, stemming from recent legislation passed in the Netherlands to implement an opt-out system of organ donation. Drs. Fleck and Eijkholt discuss positive and negative aspects of opt-out and opt-in systems, also drawing from other countries around the world. Additionally they discuss reasons why individuals may choose not to be organ donors, and the types of situations that can emerge at the bedside when grieving individuals do not want their loved one’s organs to be donated.

Listen now on H-Net

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: "While We Walk (2004)" by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License.

Episode Transcript

Liz McDaniel: Hello and welcome to another episode of No Easy Answers in Bioethics, the podcast from the Center for Ethics and Humanities in the Life Sciences at the Michigan State University College of Human Medicine. Today’s episode features Center faculty members Leonard Fleck and Marleen Eijkholt. They sat down together to discuss ethical issues within current organ donation models, stemming from the recent legislation passed in the Netherlands to implement an opt-out system of organ donation. Drs. Fleck and Eijkholt discuss opt-out and opt-in systems, also drawing from other countries around the world. They also discuss reasons why individuals may choose not to be organ donors, and the types of situations that can emerge at the bedside when grieving individuals do not want their loved one’s organs to be donated.

Len Fleck: Hello everyone, I'm Len Fleck from the Center for Ethics here at Michigan State University, and I'd like to introduce Marleen.

Marleen Eijkholt: I'm Marleen Eijkholt, I am part of the Center for Ethics and Humanities in the Life Sciences too. Normally I'm located in Grand Rapids, and I'm an assistant professor of clinical neuroethics. And I'm sitting here with Dr. Fleck, who just introduced himself, the reason being is that, you can hear in my accent, I'm not from here. I was originally born in the Netherlands, and a couple of weeks ago the Netherlands introduced a change in the organ donation system. And currently we have an opt-in system, and the legislator adopted the legislation to move to an opt-out system. And this legislation will be fully implemented and introduced only in 2020, but talking about this change in legislation with Dr. Fleck, we came from quite some different perspectives. And I think we, yeah, we're, we'd like to talk a little bit about opt-in, opt-out, organ procurement systems and so forth. And what I found very interesting is that, and I don't want to put words in your mouth, Len, or Dr. Fleck, what's the best way of talking to you, but, um, it sounded like you thought that the opt-out was a pretty good idea, and I had a little bit more reservations about this. And I think we're both pretty rational and reasonable people, so it sounds like, yeah there isn't a uniform agreement on what is the best system for getting organs. So maybe should start, and why should we get organs in the first place, Len?

LF: Well, the biggest problem of course, is that right now in the United States there are about 140,000 people who are on waiting lists for major organ transplants. So we're talking about heart transplants, lung transplants, liver, pancreas, kidneys for the most part. Kidneys would be the largest single number, where there's a need, and as things are right now there's about 8,000 individuals who are on that transplant list who will die each year for lack of an organ transplant. And so this raises the question of well, are we doing enough by way of securing transplantable organs? And so we've already mentioned that there's this difference between an opt-in approach to securing transplantable organs, and an opt-out approach. And basically, just so everyone understands the difference, the opt-in approach is what we have in the United States. That essentially means that individuals would, for example, have to sign a driver’s license or some other document like that, something very simple, in effect saying, “I'm willing to be an organ donor. If I end up being in serious automobile accident or suffering some other kind of profound brain injury that would leave me in what is colloquially referred to as a brain dead state, then I'd be willing to donate my organs to others who might need them.” The problem with opt-in is that even though roughly 80 or 90 percent of Americans say they would be willing to donate their organs, in fact roughly about 40 percent of Americans have actually signed a driver’s license saying that they are available as an organ donor. And without signing anything, if they were to end up in that situation then it would be up to a family member or some other decision maker such as that to actually make a decision on behalf of that individual. Opt-out is the opposite. And what that means in practice is that individuals-- the assumption is that all of us are willing to be organ donors, perhaps in part because if we had the need to be an organ recipient, we would want to know that there were organs available to save our lives. And with the opt-out system, if I have some sort of serious reservation about being willing to donate organs, well I would have the right to sign a document, back of my driver’s license or something like that, saying that I don't want to donate my organs for whatever reason. You don't have to give a reason, you just have to say, “I don't want to donate my organs for any reason at all.” Now, the issue is, I mean there's an empirical question here, how effective are these systems, and in Europe a number of countries have adopted the opt-out system. It has led to some increase in supply of transplantable organs. And that increases seems to be somewhere between 5 and 25 percent, it varies a lot. But obviously as you and I will discuss, there are ethics issues that might be raised with regard to making a choice here. Why do you think opt-in is the better way to go?

ME: Well, thank you for, you know, explaining these models. And just to add one little part, so we're talking about models that are available to increase the amount of organs available, and of course there is also the, a model in which you could sell your organs, right. And some, like Iran has a regulated market, there are many countries out-- well there are some countries out in the world where illegal sales of organs is also available. But we're not talking about these countries. So your question is really why do I think that an opt-out model is problematic or an opt-in model is better. I find the whole question very interesting. So you mentioned a couple of countries in Europe have opt-out models and they have seen an increase in availability of organs. I think there are a couple of problems with an opt-out model. And one of the major things that I'm thinking about is the presumption that organs are basically property of everyone. So the idea is if you die, the basic presumption is that you give up your organs. And that, yeah, that therefore the organs are sort of property of everyone unless you say, "I don't want to give up my organs." You know, there is a presumption that they are shared material. And I feel that that is infringing on an assumption that my body parts are mine. And I'm not saying that this is necessarily unjustified, but I do think that there is a little bit of a hurdle and an obstacle that we need to really be more explicit about, that, what it means to give up your organs. So, in the Netherlands when they, you know the legislative history so far, it has been quite a struggle because of individuals who are saying on the one hand, you know, from a point of view of solidarity and shared resources access to healthcare, we should have an opt-out model. But on the other hand there are people who are saying well, if your body is yours, why should we automatically give them up? And come from the perspective that you have to opt-out instead of opt-in. So one of the premises here as well is that systems switch to an opt-out system because they feel that the education fails in an opt-in system. So the idea is that everyone's organs are their own, and if we can, as long as we can identify and educate people enough that giving up your organs is a good enough thing, then people would opt-in. But then the premise is that people are pretty lazy, and therefore not signing up, or maybe that they cannot be nudged strongly enough, but I believe that this is somewhat of a false assumption because it presumes that every rational person wants to give up their organs. And I don't think that that is necessarily, should necessarily be the case.

LF: Okay, now first of all I want to be careful to say that I am a strong supporter of respect for patient autonomy, and so under an opt-in system obviously individuals have to make an autonomous choice to sign their driver’s license and say, in effect, “I'm willing to give up my organs.” But under an opt-out system, it isn't the case that the state can simply take your organs, so to speak, against your will. It's still an autonomous system, it's just that the choice that somebody has to make is the choice to exit the system rather than to be included in the system. And so the burden of making that choice is placed upon those individuals who for whatever reason just strongly feel that they don't want to be organ donors, okay? So in that respect, the two systems are both, to my mind, respectful of the autonomy of those individuals. Now here's where I see a problem that I think we need to talk about, and that many people may not be aware of. Even when individuals have signed the back of their driver’s license and said, “I want to be an organ donor,” it's still common practice, typically done, that no one is actually, no physician, no transplant team is going to take those organs without first talking to family members or somebody who is a representative of that patient, to in effect get their permission to take those organs. Now, I kind of find that problematic because it seems to me that if we're about respecting patient autonomy, and if an individual has said, “I'm willing to donate my organs,” then my family should not be willing, or should not have permission to veto the choice that I've made.

ME: Yeah that's an interesting question. So I think what you're saying is that actually neither the opt-in system or the opt-out system are often pure, in a sense of a pure opt-out, pure opt-in. So in a lot of these models we have some family factor that plays into, um, into the system. So in an opt-in system, even if I, for example—and I am an organ donor—I have opted in, imagine my mom would say after, you know, if I would be lying on the table declared dead, my mom would say, “Marleen signed the form but she actually said she doesn't longer want to donate, and I don't think that she wanted to donate.” Then my mom gets some power in an opt-in system. In an opt-out system it can be the same thing. So I, for example, have not opted out, but my mother says, “Marleen didn't want to donate her organs,” then the providers would say well we'll follow the mother. And I believe that you're saying that that is somewhat problematic, am I understanding that?

LF: Yeah, yes that's correct. I, it seems problematic to me because in some sense it's going against the will that I've expressed. Now I understand of course people can change their minds, and you know we sign our driver’s licenses here, at least in the state of Michigan, like every four years or so, and so each time you would have an opportunity to make a different choice if you chose to make a different choice. In theory I suppose individuals could change their minds during that four-year interval, and if so it seems to me it would then be their responsibility to communicate that fact to family members so should they end up in a automobile or motorcycle accident or suffer some kind of profound head injury that would put them in that situation, family would know, yep, even though he signed his driver’s license, in fact he indicated to us just a couple years ago that he thought that that wasn't such a great idea, and he felt awkward or ashamed of having to not sign it in front of somebody at the driver’s license office. And so he signed it under a kind of semi-coercion. Okay, I can understand that. But then it is their responsibility to communicate that to somebody who would then make those decisions.

ME: Yeah, I, it is a very interesting problem to think about because of course family objections might not just be because they thought I changed my mind. You can have all sorts of family situations be active in the clinical setting that I see as a clinical ethicist. For example, grief. So individuals say, oh, I'm not ready to let my loved one go, and that's why they don't want to donate their organs. As a little side note, a lot of people might not know that for donation after death by neurological criteria, so by brain death, actually they'll keep the body warm. And that might for some people be a very challenging thing to say goodbye to a loved one while their body is warm, and breathing, if you like, by the ventilator. So it might be that a family member says you know, no, I am too upset, you cannot take their organs without respecting my wishes. There might be other reasons. So for example the providers do not want to enter into a fight, for example, with my mom. So if my mom says I don't want you to take my organs, um, yes she is standing in the way of my autonomous wishes, but the provider might say, you know, I'm just going to do what Marleen's mother says because I don't want to enter a fight with her. I think that it's true that it means not respecting autonomy, but that is really from a perspective where autonomy is very individual-centered. And if you take like a more relational concept of autonomy in which actually it's not just the individual that matters, but the whole family that matters, you can still say it's acceptable for family members to override the wishes of an individual. Although it's of course far from ideal. What I think the most crucial point in these, in these complying with family wishes is, is that it supports somewhat of trust in the system. If you get a very upset, aggressive grieving family that doesn't want the individual to donate, and you're taking out their organs anyway, so you're kind of pushing out the family from the bedside and saying, listen, your loved one has taken, has signed up to the register, we're going to take it regardless of what you're saying, you kind of get to a struggle where individuals will lose trust in the system. So I think that this is one of the major concerns why opt-in or opt-out systems are not as hard-lined as we often take them to be. And I, to some extent, I feel that there is a very big value in maintaining public trust in the organ transplantation system. Which is another reason why I believe that an opt-out system wouldn't work everywhere. In the Netherlands it probably will work because there is a big trust between the healthcare professionals, the government, and the citizens, so very few people will doubt, I hope, that their organs will be taken out prematurely. So in that way the system of an opt-out system in the Netherlands and in most of Europe will likely work. Would I believe that it might not necessarily work here. But, so maintaining trust in the system I think is a big argument and it's probably also a big argument, yeah, for, you know, a softer opt-out or a softer opt-in system. So public trust for me is kind of a practical but also an important consideration. What do you think about trust, Len?

LF: Oh, I think that's important as well. Now there are some, one of the things, we haven't mentioned, for example, Spain. Spain is taken as a kind of prime example of a system that is working extraordinarily well. Technically they have an opt-out system, but it's a very soft kind of opt-out. So they will always have a conversation with the family, but apparently the conversations that they have are had what you might call very, very skillfully. And in such a way that they elicit the autonomous support for doing, or for taking those organs for transplantation purposes. In that sense they are both building trust and respecting the autonomy of that family. One of the issues that has sometimes been raises is that - and again this is a kind of an empirical question, there's some rough empirical research out there to support this, but the concern is that some number of, some family members who have said no, I won't allow for a transplant to take place, have had regrets after the fact. They sort of realized, you know, that was a kind of hasty decision. If I think about it very hard I realize that there were six or seven other people whose lives could have been saved had I been willing to donate the organs of my loved one here. And I just, I acted on too emotional a basis, I didn't really think that through, I'm really sorry about that. And so that's one of the sort of side effects that can happen if individuals respond, in what is a crisis situation, too emotionally. So apparently the Spanish are very good at addressing the kind of emotional response that might result in a negative choice by a family. And getting them to think about that somewhat more carefully and understand what the need is and why it's important that they consider their choices very, very carefully.

ME: So just to pick up on that, I think it's um, that comment is not necessarily related to an opt-in or an opt-out system. So it's in both systems. You know where you allow family members to override the patient's or the deceased person's wishes. When I left the Netherlands we talked a lot about Spain, and the success of Spain. And since then, a lot of, a lot more countries in Europe have adopted the opt-out system. And what is interesting to note is that back in the days we always said, actually the success of the Spain model depends on these coordinators and these communicators. And actually empirically that has been shown to be the case. So in some countries, and I cannot completely remember which one, but I think, and these are not European, but Chile and Brazil chose to go to an opt-out system and then actually there was no increase in organs because of the family vetoes. And I think there is a couple of countries in Europe too that decided to go for an opt-out system, but didn't have these communicators, these navigators, and therefore it didn't lead to an increase in available organs. So it's interesting to think that it seems not the opt-out system that leads to an increase therefore, it seems that the communicators and these bedside navigators lead to the actual increase in organs. So in return, coming back to our question at the outset, will an opt-out system lead to more available organs, if it purely depends on these communicators, then why can you not have these communicators in an opt-in system? Like at the bedside. And I'm wondering what you think about that?

LF: That, I, you're probably right about that, and that that's the most critical element in securing an increased supply of transplantable organs. There are some other options though, and since we're talking about other countries in the world I did want to mention Israel did one thing that I thought was kind of interesting, and I'd actually be inclined to endorse it, I don't know if you would endorse it. But what Israel decided to say was that if you wanted to be considered for an organ transplant, should that need arise at some future point in your life—ten years from now, twenty years from now, thirty years from now—then, it had to be the case that you agreed ahead of time that you would also be willing to be an organ donor. Otherwise, and the whole idea is, you know, this is what reciprocity is all about. This is what fair treatment. If I expect you to donate the organs of your loved one to save my life, then I ought to be willing to either make my own organs available for donation or to agree to donate the organs of a loved one for the same purpose. And so that seems like something that is morally reasonable. The result was, and this was very widely publicized, and of course Israel is a small country, but within ten weeks they had increased by seven or eightfold, the number of individuals who signed up be organ donors. So that seemed like a very effective way, and again that's respectful of autonomy, it's, and it seems like it's also it's more just, more fair than the alternative. Though I realize there would be a kind of awkwardness associated with someone actually having a need for an organ transplant and checking to find that they had never agreed to be an organ donor. And having in effect to say to them, well we're just going to let you die then. Now it doesn't actually work that way in Israel, but the way it actually works is that if two people are equally available to be an organ recipient, and one of them in the past has agreed to be an organ donor, they would get priority over an individual who had not agreed in the past to be an organ donor.

ME: And in a way, when you're alluding to that, I'm thinking about the example that I read a couple, may a year ago or two years ago, about, here in the U.S., a grandfather signing up to give an organ because his grandson needed a kidney in the future. So, there are variations of those systems available. And I'm, I probably should have looked it up, but, so there are systems of paired and chain donation available in the U.S. I believe that the system is somewhat problematic because some individuals for their religious or cultural beliefs cannot sign up, right, to be an organ donor. Does this exclude this from receiving an organ donor. And then, in the paired and the chain donation, it always depends on your social connectedness, right? And so it would exclude a hermit that doesn't have any relatives to sign up for, right. And so I think both these systems, you know, suppose some homogeneity of individuals, some reciprocity that basically on which the organ systems, you know, shouldn't fully rely. So I'm not sure that these system are, are as unproblematic as you say, because they make certain moral presumptions, and they make certain personal assumptions on your personal things. But then-- okay, you want to say something.

LF: Okay, so maybe what we have to say is that, we can't hope for something like perfect justice or perfect respect for autonomy. We have to settle for non-ideal justice or imperfect justice, and, um, a bit of a compromise with respect to personal autonomy and so on. But that's the price we may have to pay in order to secure an increase in the number of organs that are available for transplant purposes in order to save the lives of individuals that in fact are salvageable.

ME: Let me, let me put you a little bit more on the spot here, Len. So if we're talking about, you know, we want to achieve a system that generates more organs and a system that is based on somewhat of an autonomy, so how, what do you think about the sales of organs then?

LF: Oh, well actually I would be opposed to the sale of organs. I'd be opposed primarily for moral reasons. The individuals who would be motivated to sell a kidney or to sell a portion of their liver and to risk the surgery, the morbidity, and risk the mortality associated with that are individuals who would be relatively poor, less well-off, and so they'd be vulnerable to exploitation. In general, it shouldn't be the case that those who are financially well-off would be able in effect to buy an organ to gain additional life, when it would be the case that an individual who is less financially well-off who had an equal medical need would not have the ability to obtain an organ in that way. Would have to rely upon some less reliable system.

ME: So I think that, I hope you don't mind me challenging you here, that that presumes a certain system of, an unregulated sale of organs. While, for example, in Iran, I alluded to that, there is a regulated system of organ sales. So, you know what you're gonna get, you know, for example, $3000 for an organ, and it's actually the government who sells, who can then redistribute them. The organ is just, you know, you just pay $3000, basically anyone can purchase it because it doesn't, it's not that $10,000 will offer you a better kidney than a $3000 one.

LF: Would there be some individuals who could not afford the $3000?

ME: That’s-

LF: I mean given, I assume if you're using a number there relative to the standard to living in Iran, would be equivalent to $30,000 or something in the United States. Or maybe that's too high.

ME: Yeah, you're catching me in something that I'm not even fully aware of. I don't know what the regulated market means. And if in Iran, for example, individuals have for healthcare insurance, for example. Because, I mean, we, I named the money $3000 for a kidney, but basically here in the system, probably a kidney costs $3000, right. If you look at the value of it. But it's just being taken care of by insurance. So it's paid for by insurance. Imagine that in Iran the people have healthcare insurance that can pay $3000, you know. If it just about the availability of organs, yeah, if people are willing to give up this organ, for example, in restitution for some financial compensation, you now, I don't know if there is, if it's very different. If we're basing our argument around autonomy.

LF: You know, who are the people who are willing to give up an organ for any kind of financial compensation? I wouldn't. In part because I'm very securely in the middle-class and so I would not want to have to take on the medical risk associated with surgery like that for purposes of making a few dollars that wouldn't mean that much to me. It would be different if it was somebody that I cared a lot about, and who was desperate and for whom I could provide that organ. Then I'd be willing to take the risk, but not for money. I just...

ME: Right. And as we're talking I realize we're actually confusing multiple systems. So an opt-out and an opt-in system refers to, you know, when we're talking about that, refers to deceased donation. While we are talking about living kidney donation, right.

LF: Yes.

ME: And who is willing to give that up. So in a system of, you know, an opt-out system, or even in an opt-in system, I would not give up my organs while being alive. So, I think it's necessary to distinguish that. So the argument about, you know, who would sell their organs, and, maybe I'm poor, but I can gain money, right? You know, why should I not be allowed to get some extra money from this extra kidney that I don't need. Right? Which is the idea of, you know, privileged people say that I'm being exploited when I'm selling my kidney, well I just want to give some money, right? I just want to get some money, why should I not be allowed to sell my body. Right? So, um, so that's an argument against, you know, or to counter your concern about who would give up their organs, it's just the people who are vulnerable. Maybe, but then, why not, if I have a spare one, right. But I think maybe we should go back to the system after, you know, after death, and, you know, what happens there? And if, if that's, you know, vulnerable to exploitation, etc. Yeah.

LF: That would probably be less vulnerable to exploitation, and a number of policy makers in the United States have suggested that state governments or the federal government could provide tax incentives of one kind or another to encourage donation. And, uh, and this is donating the organs of somebody who is, who has already been declared dead. And so there is, the issue of exploitation then seems to go away. I probably would have less in the way of objection to that sort of system. We could ask other questions about whether that's a good use of resources and so on. One of the problems that, we can't really go into any detail on this, but the basic issue is if we were to get in the United States, say, 8,000 more organs in a year, would we have then saved all the lives that needed to be saved? And the short answer is no. Because we right now control access to the list of individuals who are put, who are available or who are in need of having a major organ transplantation. If we were more liberal in allowing individuals to access that list, then the need would obviously increase. And so the actual need for hearts, and livers, and so on is many, many times greater than the simple loss of those 8,000 lives that I mentioned at the beginning of this discussion.

ME: Um, I don't know how to wrap it up, Len. It sounds like there is many argument that we could use, you know, to support an opt-out system. And also to use against an opt-out system and for an opt-in system. And these arguments, you know, range from have we tried everything, what are good-- what are some other means to increase the available organ. And does it mean that, a presumption that your organs are, you know, should automatically go to other people in case they haven't opted out. Is that really, should that be the presumption. Which is something that I struggle with. To really maybe wrap it up is one last thing that I want to say. Um, our organ donation debate is surrounded by language, even, you know, referencing donation, etc. It's a very fluffy wonderful language. And I, I do think that we are in some way persuaded by the language of gift and the language of donation. And the language of wonderfulness. And to me, that is somewhat interesting. Um, when I'm reading again the parliamentary history up to the change in legislation in the Netherlands, it is all about donation. And when I studied a little bit cross-culturally, you see that the language of donation and gift is very much tied to some Christian Western values. And, for example, some other cultures and religions you don't speak of organ donation, you speak of organ harvesting. And these are very harsh terms that we don't like to embrace. And, yeah, I'm just thinking that we haven't really explored all the arguments around, or all the arguments and the language around organ donation yet. I think it's a fascinating discussion that we can continue to have.

LF: And it's a discussion that needs to occur in the, with the public. And it's both a moral and public policy discussion. And with that, thank you Marleen for your contributions today.

ME: Thank you Len.

LM: Thank you for joining us today on No Easy Answers in Bioethics. Please visit us online at bioethics.msu.edu, and follow us on Twitter @MSUbioethics. This episode of No Easy Answers in Bioethics was produced and edited by Liz McDaniel.

No Easy Answers in Bioethics Podcast

Medical Workforce Diversity and the Professional Entry Tax: Bogdan-Lovis and Kelly-Blake - Episode 6

February 8, 2018 Libby Bogdan-Lovis photoKaren Kelly-Blake photo

This episode features Libby Bogdan-Lovis, Assistant Director of the Center for Ethics and Humanities in the Life Sciences, and Dr. Karen Kelly-Blake, Assistant Professor in the Center for Ethics and the Department of Medicine at the Michigan State University College of Human Medicine. As leaders of a multi-institutional research team, they were interested in examining strategies and associated rationales for expanding underrepresented minority presence in U.S. undergraduate medical education. In this episode, they provide insight on what their scoping review has revealed, focusing on the notion that underrepresented minorities in medicine are often expected to pursue a service track—an expectation not placed on their white majority peers.

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This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: "While We Walk (2004)" by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License.

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Episode Transcript

Liz McDaniel: Hello and welcome to another episode of No Easy Answers in Bioethics, the podcast from the Center for Ethics and Humanities in the Life Sciences at the Michigan State University College of Human Medicine. Today’s guests are Center Assistant Director Libby Bogdan-Lovis and Center Assistant Professor Dr. Karen Kelly-Blake. A multi-institutional research team led by Dr. Kelly-Blake and Libby Bogdan-Lovis was interested in examining strategies and associated rationales for expanding underrepresented minority presence in U.S. undergraduate medical education. To look at trends over time, their research team undertook a scoping review of the 2000-2015 literature to see what the literature might reveal about those efforts. In this episode, Karen and Libby discuss concerns that emerged from the review regarding covert expectations that underrepresented minority physicians are being trained to meet the medical needs of vulnerable populations.

Libby Bogdan-Lovis: Okay, I'm Libby Bogdan-Lovis, I'm the Assistant Director at the Center for Ethics and Humanities in the Life Sciences in the College of Human Medicine at Michigan State University.

Karen Kelly-Blake: I am Karen Kelly-Blake, I'm an Assistant Professor at the Center for Ethics and Department of Medicine, here at Michigan State University.

LBL: And Karen and I have been working on this project for a number of years now, and we have colleagues in other places. Nanibaa’ Garrison and Faith Fletcher, Nicole Smith and Morgann Brafford and Brittany Ajegba all helped us with this project. We are calling it “A Professional Entry Tax: The Covert Costs of Racial and Ethnic Concordance in the Medical Workforce.” And we should probably start out by explaining our observations regarding the notions of identity matching between physicians and patients. There seems to be some general agreement that it's desirable to have a physician workforce that reflects the race/ethnic composition of the patient population, and in fact we agree that that's the right thing to do. Borrowing from the title of a 2001 I.O.M. report—Institute of Medicine report—on diversity in the health professions. But we also wondered what future costs there might be for underrepresented minority [URM] physicians, who are associated with programs and policies that attempt to expand the numbers of underrepresented minorities in medicine. And most especially when the rationale most commonly mentioned in the literature is that the justification is societal benefits, and by that we mean those benefits that might accrue from the extent to which underrepresented minorities in medicine provide care for vulnerable and historically underserved populations.

KKB: So, having that background, we set out to examine the content of literature over a fifteen year period, 2000 to 2015, to see what it might reveal about trends and programmatic strategies used and the associated policy rationales mentioned for increasing underrepresented minorities in medicine. We wanted to focus on that refrain commonly attached to discussions about increasing URMs in medicine that is, that it enhances access for underserved vulnerable populations. There were around ten major reports issued on increasing health care workforce diversity and all mention the societal benefit of service to the underserved. Many pointed to the notion of benefit derived from doctor patient race/ethnic and concordance. In other words when physicians and the patients they care for share some aspects of that identity, visually through appearance or through language or some measure of culture.

LBL: Yeah, and in fact, for benefits it's true. It's been demonstrated repeatedly that underrepresented minorities in medicine do indeed provide medical care for vulnerable populations, to an extent far greater than their well represented peers. But what got our attention is that there's a paradox here. The same 2001 Institute of Medicine report mentioned earlier had a caution that got our attention, and I'm going to quote here. They said, “We must be vigilant against the potentially pernicious effects of creating the expectation that minority physicians are being trained solely to provide health care services to minority patients.”

KKB: So, I'm going to push back a little bit with Libby, because Libby and I have had this conversation before. She likes to use language “well represented peers” which means absolutely nothing to me.
So what we're talking about are underrepresented minorities, how we're defining that, and we're talking about their white medical student counterparts. That's who we're talking about. The challenge is that underrepresented minorities in medicines are being targeted to serve underserved populations in a way their white peers are not being targeted.

LBL: And in fact, that's one of the reasons we chose to look at African-American and Latino and Native American—American Indian—populations, including Alaskan Natives.

KKB: Correct. So, the concern that we have is that underrepresented minorities in medicine might be viewed as instruments to address failings in our health care system. In such a circumscribed rescue role for the U.S. health care system, URMs then would have delimited professional futures through policies, loan payback programs, and the subtle incentives of positive feedback rewards. URMs essentially would be guided into what in our research we call quote unquote “service” tracks to address the broader societal need to expand care and access for vulnerable populations. What got our attention is that this expectation is in fact quite common, and we found an increase in mention of that particular rationale over a fifteen-year period. The repetition in the discourse in itself might independently amplify the expectation and reinforce strategies. And if I might add before Libby joins further is that we also see the same sort of service track cropping up in admissions decisions, that depending on what university you're applying to, whatever they decide is their mission. If their mission is to provide care to the underserved, which is a very noble laudable mission. If part of that admissions process is to then sort of mainstream pipeline students into those particular tracks as a way for them to achieve admission I think that also is an issue.

LBL: So is it common that admissions look for that commitment?

KKB: I think right now with admissions the idea is to use a holistic approach and part of that holistic approach is to consider people who are coming in from disadvantaged backgrounds, however you want to define that. Socioeconomic, sexual orientation, race, ethnic, rural-urban designation. All those things come into play through a holistic process. I think one of my concerns is whether or not that holistic process amplifies the notion that those people who come from the disadvantaged background are then targeted to physicians’ specialties to focus on serving underserved. It goes to primary care, internal medicine. And those are great specialties, but it should be the choice of the individual, and their future careers should not be delimited in any way by making that choice.

LBL: And tracking them into those specialties means not opening up their future possibilities to others. I guess to illustrate, it seemed to us that well-intended policies and programs might paradoxically be placing sort of an entry tax on underrepresented minorities into the medical profession. And in the long run unfairly curtailing their medical professional possible futures, that those individuals have more restricted options.

KKB: And I was thinking about this earlier, and I should say for the record that Libby really has been the driving force behind this research and she's been doing a fabulous job.

LBL: Thank you.

KKB: This idea of an entry tax, and I was thinking is the tax just, this idea that it's by chance because of the chance of your birth. That just by the chance of your birth you're born with a particular disadvantage. So, you decide that as you’re growing up you want to become a physician, and because of that disadvantage it's seen that if you want to be a physician then maybe you also want to serve the people in your own community. And for many people that is true, they do want to give back. They have this very noble, very deeply held idea that they should give back. But what about those people who don't hold those same sorts of plans and ideas and notions, but maybe feel constrained that they have to present themselves in certain ways in order to get that prize which is entrance into medical school.

LBL: Yeah absolutely.

KKB: So, one might argue that this sort of tracking simply provides another avenue to enhance medical workforce diversity, and that in and of itself another avenue is fair and just to those individuals taking advantage of such a pathway. But that argument would be ignoring the downstream impact on those individuals’ professional future. Devoting their career to service has relatively less remuneration than pursuing high status well-paying residencies and subspecialties. Equally it also requires that they turn away from careers in medical research and medical education.

LBL: Yeah, I agree. And medical education… I remember seeing an article that suggest that medical education, really there's a tension between viewing it as a social good and viewing the education piece as an avenue for people to advance themselves in a particular career. So, it's a social good I guess in educating and training physicians to meet society's healthcare needs, but it's also that recognized professional avenue to advance your own lot in life. To pursue a relatively satisfying career because it's well paying, it includes opportunities for advancement, and through our research we feel that URMs should be afforded those professional perks just the same as their well represented peers, of majority white peers.

KKB: So, I think one of the questions we can answer for our audience is why do we feel that this research is valuable in today's world. So, we hope it will heighten awareness and open up discussion about the hidden expectations placed on underrepresented minorities in medical education. Expectations that are not placed on their white majority peers.

LBL: Yeah. And there's another, I mean, there are lot of concerns related to our research. A related concern is that other factors might explain the high level of service to vulnerable populations. There is certainly a possibility of institutional racism that might restrict underrepresented minorities’ practice locale. Where can they hang a shingle and have a practice. And it might not be economically or socially tenable for an underrepresented minority physician to set up practice in a white populated community. Another concern is that the notion of concordance could perversely be turned around I guess, to suggest that white patients should be able to see a white doctor and work against underrepresented minority diversity expansion in the workforce.

KKB: And finally there is an admitted risk to drawing attention to the issue. There are those who might say, “Hey, first let us in the door before you go mucking around with these fairness concerns.” But we argue that the societal need to provide care for underserved vulnerable populations is a responsibility, perhaps a burden, that should be equally shared by all in the medical profession. And not have that responsibility shifted to underrepresented minorities in medicine.

LBL: I guess our listening audience might wonder what got us interested in this, and I would credit one particular student who said to his peers, “You know I know when I get selected to show up for some kind of big event where I'm standing in front of the audience. I know what they want me to say, what they want me to say-” and I guess Karen you alluded to this earlier, like with admissions students knowing what's expected of them, “They want me to say that I want to become a physician so that I can go back and take care of my own.” He said that, “In fact I come from a really, really difficult background. I sometimes call it the hood in South Florida.” And he said, “I don't want to go back and have a profession, and have my profession there, and to practice my profession there. I want to go to a city, I want to raise a family in comfortable circumstances, and that wouldn't be back where I was raised, and yet I know that's really not what they want to hear from me.”

KKB: So that sounds like a very enlightened, self-aware student-

LBL: He was, and brave.

KKB: Yes, and brave. To understand what the expectations are, but to say that's not what I want for my own professional life. So, what are our goals for this research? We have embarked really on a preliminary analysis really of what's happening in the literature. I think we've talked about this that maybe some of our future goals is to try to see what current data is available at our own institution here at Michigan State University, College of Human Medicine. I think ideally the idea is to seek and hopefully gain funding to perhaps expand for a statewide assessment. And probably the long-term goal and vision is to really be able to do some sort of nationwide survey, to see what really is happening across the United States. And I think what you've mentioned before is really to maybe try to be able to do a comparison between what's happening internationally and in the U.S., you may want to expand on that Libby.

LBL: Yeah, I think it would be very interesting to open up the conversation to see what other countries are doing to address these issues. As I mentioned to you Karen, when I was in London I was struck by the amazing diversity of their medical workforce, it's phenomenal. I'd like to know if they pay attention to these issues and where they come into play, and if so, how.

KKB: And it might be interesting too, and I don't know if I'm digressing here. But considering your past experience in the UK and this idea that they actually start their students early on within this whole sort of medical school adventure. Can you speak to that at all?

LBL: Yeah so, the students go through a very intensive high school equivalent, high school education, and then take their exams and apply for medical school at that point. So, they come out much younger. They’re done when they're about twenty-six or twenty-seven and entering into the medical workforce at that point.

KKB: So that might be something interesting for us to think about as we're continuing our work. How those sorts of models compare to the model of medical education here in the U.S. What, how do those models impact these sorts of discussions about increasing diversity in the medical workforce?

LBL: The other thing I would like to look at if there were some way to incorporate this is the aspect of intersectional identity. That the professional identity is one of many identities. And there might be sexual orientation, gender issues, locale, whether or not there's a whole issue of foreign born medical practitioners. Who, you know, might by the status accrued with being a physician and perhaps the status they had in the country they were born in, be a higher level than the way they are treated once they get into the United States. So that's another complexity of intersectionality that I think would be really interesting to explore.

KKB: So, it sounds like there are a lot of areas that we can research and really add to this particular research. A lot of ways we can, not necessarily diverge, but how we can really complement what we've already been doing.

LBL: I think so. Yeah, it's opened up a lot of doors, which is what we had hoped to get accomplished with the scoping review.

KKB: So, do we have any final words for the audience?

LBL: I think that’s it.

KKB: Alright, well thank you all very much.

LM: Thank you for joining us today on No Easy Answers in Bioethics. Please visit us online at bioethics.msu.edu, and follow us on Twitter @MSUbioethics. This episode of No Easy Answers in Bioethics was produced and edited by Liz McDaniel.