Your patient has been diagnosed with breast cancer but her family requests that you tell her she has a rare blood disease; they worry that she will not be able to cope psychologically with a cancer diagnosis. The patient, however, is fully lucid and functional. What, as a physician, should you do? Where does your responsibility lie?
Dr. Tia Powell You have been tasked with managing a government-subsidized healthcare program with a strictly limited budget. There is a patient who requires an expensive, but effective chemotherapy treatment. With thousands of other patients who need care, do you approve the treatment? How do you decide?
Dilemmas and questions like these confront medical professionals, lawyers and policymakers, every day. The academic discipline dedicated to tackling these complex, multidimensional issues is known as bioethics. The dynamic field brings together the fields of medicine and law, while promoting and teaching ethical awareness, sensitivity to narrative, and critical reasoning to provide guidance on challenging healthcare decisions.
In 1978, internationally renowned bioethics expert and attorney Nancy Dubler, established one of the country’s first bioethics consultation services at Montefiore Medical Center, the University Hospital for Einstein. Such services allow a patient, family member, or any member of the healthcare team to request help in assessing the ethical aspects of medical decision making. Trained consultants help build consensus among all concerned toward an ethically, legally and clinically acceptable plan.
In 1995, in response to the growing demand for professionals trained in bioethics, Ms. Dubler created the Certificate Program in Bioethics and Medical Humanities, a year-long, interdisciplinary program that has provided hundreds of professionals with rigorous instruction and hands-on experience in bioethics. Now, in partnership with the Benjamin Cardozo School of Law, Einstein has developed a full-fledged Einstein-Cardozo Master of Science in Bioethics that builds on the tested foundation of the certificate program. Einstein and Cardozo are the medical and law schools affiliated with Yeshiva University.
“What we’re trying to focus on is how bioethics can help people live longer or have less pain or feel more satisfied with their healthcare,” explains Dr. Powell, who once served as executive director of the New York State Task Force on Life and the Law.
She counsels students to avoid two classic errors in bioethics. First, that “there is one right answer, and it is mine. We focus on the notion that you are, as a bioethicist, mediating among people; you are building collaboration and consensus. That takes both critical reasoning and clinical humility.”
The second classic error is that there are no wrong answers. “There are some wrong answers. In clinical medicine, in bioethics, you can really do some things that are wrong. If you’re a practitioner, it’s up to you to know what the law says and what’s hailed as best practice in your field. If you disagree with the established practice, you have to be able to know what it is, critique it and show why you think something else is better.”
What makes the Einstein-Cardozo master’s unique, Dr. Powell explains, is that it grows from a true collaboration among Einstein, Cardozo and Montefiore. The program’s inspiration and focus arise in important ways from the clinical wisdom of developing bioethics consultation at Montefiore over the last 30 years. The program takes that knowledge and combines it with the scholarship of Einstein as an academic medical center and Cardozo as a premier law school. This blend brings together academic and clinical strengths in a unique way.
Dr. Elizabeth KitsisMoreover, Dr. Powell notes that the program fills an unsettling void. “It’s quite disturbing that a lot of people who do bioethics consultation have little or no training in clinical bioethics.” Given the weight of decisions consultants face, she says, “It is concerning that people are providing bioethics consultation when they don’t know the basics.”
The master’s program attracts a diverse group of students from social workers, lawyers, members of the clergy, including rabbis, and mid-career doctors and nurses. The diversity of student backgrounds allows for a variety of perspectives to be shared. "For the healthcare professional, it’s a real mind-opener to read through a Supreme Court case and understand more about how law is made,” Dr. Powell says, “For the attorneys, the surprise comes in learning that not only argument but also clinical data and clinical uncertainty need to play a role in shaping health policy.”
“This is a unique program, which applies the distinct disciplines of law and medicine to critical ethical questions,” explains Ed Stein, vice dean and professor of law at Cardozo. “The program combines rigorous legal theory with its real-world application with the goal of positively impacting people’s lives – a hallmark of Cardozo. Health law is a growing legal field and the bioethics degree gives lawyers new problem-solving skills and a strong foundation for confronting complex ethical issues in all arenas.”
“Sensitivity to narrative is also essential,” says Dr. Alvan Ikoku, assistant professor of epidemiology & population health at Einstein and the program’s associate director for graduate studies. A graduate of Harvard’s medical and Columbia’s literature programs, Ikoku is an expert in narrative, and his work explores the ways in which medical stories shape and inform practice.
“Clinical practice involves several stories being told,” Dr. Ikoku explains. “There are the stories patients tell their doctors, about their illness and personal lives.” There are also the abbreviated stories shared between practitioners, one physician talking to another about a patient, or a nurse discussing a case with a social worker. “In my medical training, I found that this aspect was really not examined closely enough. For example, what effect could one have by shortening a patient’s story, trying to translate a complicated narrative into a few sentences for a physician? The way we re-represent patients to other caregivers can affect their care.”
The program’s faculty includes Dr. Elizabeth Kitsis, assistant professor of epidemiology & population health and of medicine at Einstein, as well as a former vice president at pharmaceutical giant Pfizer. This year, she will be teaching a course called Pharmaceutical Ethics, having directed similar seminars at Pfizer.
In the private sector, she was responsible for the design of human clinical trials. “I was responsible for the safety of millions of patients who happened to be taking the drugs that I was supervising,” Dr. Kitsis says. “Bioethics became a great concern and interest of mine.”
Dr. Kitsis’ published academic work aims to challenge what is often reductive criticism of the pharmaceutical industry by re-evaluating its contributions and receptivity to bioethical reform. She explains, “When I left Pfizer I decided that I could use my experience in the pharmaceutical industry, learn even more about ethics, and combine those two to determine how the pharmaceutical industry could collaborate with academia and others to develop drugs in a way that was ethically sound.”
Student Michelle GoldsammlerMichelle Goldsammler, an intern with the Montefiore-Einstein Center for Bioethics and an Einstein student, strongly believes that these perspectives will have a direct impact on the quality of care she will deliver to her patients once she graduates from both the M.D. and master's program simultaneously in spring 2012. “Being able to look at a patient – not just their illness or what their medical issue is – but looking at the whole picture and all aspects of what they’re feeling – I think that having that kind of background will make me a better physician,” the 25-year-old says with confidence. Ms. Goldsammler plans to pursue a residency in obstetrics and gynecology and is enrolled full time. The program is designed to also accommodate professionals with full-time work commitments; many classes are once-weekly seminars held in the late afternoon.
Dr. Melissa Epstein, a recent graduate from the Einstein-Cardozo Certificate Program in Bioethics and Medical Humanities, is now enrolled part-time in the master's program. She says the curriculum and personal interactions have expanded her knowledge, skills and professionally opportunities – even though she already had extensive work experience in the field of bioethics.
After receiving her doctorate in linguistics, Dr. Epstein worked with an Institutional Review Board, conducting regulatory oversight over human subject research at the former St. Vincent’s Hospital, in Manhattan. She was expected to learn the intricacies of the position “on the go” without formal training. She first sought out the certificate program before deciding to pursue her master's in bioethics.
“For me, it was an opportunity to step out from behind the everyday paperwork and think about the ethics that were involved and also about the larger issues in bioethics besides my small little corner,” she says. Dr. Epstein is now asked to guest lecture on research ethics at Hofstra University – invited by a fellow program graduate who also is a law professor there.
Dr. Epstein is not shy about sharing the impact the program has had on her personally and professionally. “It been absolutely extraordinary,” she says. “The faculty is incredible – attentive, thoughtful, and outstanding in every way.”
“There are quite a number of people who have told us that this program was a critical turning point for them,” says Dr. Powell, “that it really changed the way they thought about the profession and changed the kind of work that they do.”
To learn more about the Einstein-Cardozo Master of Science in Bioethics and Certificate Program in Bioethics and Medical Humanities visit: http://www.einstein.yu.edu/masters-in-bioethics/home.aspx
Posted on: Tuesday, October 11, 2011