Thursday, July 12, 2018

Ethics education and democratic values in high school and middle school

Every summer since 2012 I've taught at least one workshop on "making ethics part of high school and middle school English class" at the Bread Loaf School of English, a Middlebury College program in which the students, mostly teachers, can get a Masters degree in English in the course of 4-5 summers. I've written a series of posts on what I've learned in the workshops (see here, here, here, here and here if you're interested.)

I build the workshops around the issues the teacher-students bring to it. This year several teachers brought up the question of how best to deal with students who assert views the teachers regard as morally repugnant. They don't want to let the repugnant views go unchallenged but at the same time they don't want to put down the student.To squelch the student goes against the goal of fostering a classroom atmosphere of respectful deliberation, but to let the repugnant view stand can be seen as enabling.

The National Conference of Teachers of English (NCTE) statement on Academic Freedom urges teachers to cultivate democratic values in the classroom as a central objective:
NCTE maintains that students have the right to materials and educational experiences that promote open inquiry, critical thinking, diversity in thought and expression, and respect for others.
At the same time, the NCTE directs teachers not to proselytize or preach to their students:   

Educators and educational institutions must not require or coerce students to modify their beliefs or values. Efforts to convince students to modify their beliefs or values must be academically justifiable.
As I saw it, the teachers are in a difficult bind. They want to encourage  "diversity of thought," but human nature (and adolescence) being what it is, diversity can include prejudice, bias, and hate - the opposite of the "respect for others" NCTE calls for!

The teachers in the workshop asked each other - "how can we best deal with this dilemma?" Three examples illustrate the kinds of strategies they suggested:
  •  After a hurricane, a  student said "why should we spend money helping people from XYZ?" This touched a very personal nerve - XYZ was where the teacher came from. The teacher kept anger in check and asked the class "does anyone have ideas about why we might want to spend money helping XYZ?" The question led to a thoughtful discussion. 
  • A student called a classmate "you bitch." The teacher used a jiu jitsu-like approach: "thank you for bringing that up - it lets us discuss the implications of the language we use..."
  • Another teacher described how she used "kindness" in dealing with cruel comments: "that might be hurtful...let's put it aside."
In medical practice and medical education we pay tremendous attention to the doctor/patient relationship. For teachers, "classroom management" has the same prominence. But the challenges I've faced over the years in relating to patients strike me as much easier than the challenges the teachers I've come to know at Bread Loaf have to deal with. 

As physicians, we're largely in 1:1 interactions, except for pediatricians, who deal with parents as well as the child, and geriatricians, who often deal with their patient's caretakers as well as the patient. Our field of action is less complex than a classroom that could have as many as 30 youngsters. And teachers typically must consider the expectations of principals and other administrators, parents and the school board in addition to dealing with a classroom full of bumptious students.

At the end of the workshop, I asked if the participants could help me pull together the wide-ranging discussion. The final comment, coming from an ex-teacher, was especially useful. He pointed out how much students learn from the way we comport ourselves and relate to them. Whatever the problematic situation we're dealing with, fairness, thoughtfulness and compassion will always convey "good lessons."

Recalling his comments put me in mind of Francis Peabody's 1927 address to Harvard Medical Students on "The Care of the Patient" that was given to us in a thin red booklet on our first day of medical school in 1960. Peabody's unforgettable final line rings true 91 years later. I expect the same will be said in 2118 and 2218: 
One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.

Tuesday, July 3, 2018

Transmission of Values within a Profession

Last night I had the pleasure and privilege of having an extended conversation about medical ethics with Laurie Patton, president of Middlebury College. I was surprised when Laurie expressed great interest in my experience teaching medical ethics. Was she just being polite? It turned out to be much more than that.

Laurie explained that two months ago she’d invoked the Hippocratic oath and the influence of her surgeon father in an essay titled “Our Moral Directive,” in which she argued that “a Middlebury education should be accessible to all, regardless of financial means.” Here’s the opening paragraph:

My father is a retired cardiovascular thoracic surgeon. My childhood memories are punctuated with instances of him being called away from home for emergency surgeries. On those days, and many others over his long career, he never questioned whether the patients whose lives he was trying to save were able to pay for his services. He had taken the [Hippocratic] oath to heal to the best of his ability all those who presented themselves—and he spent his career doing so…In higher education, we don’t—yet—have our own official version of the Hippocratic oath. But at Middlebury, we do have a mission that serves as our moral directive… 

Our conversation and her essay conveyed a crucial insight into what it means to be part of a profession. As professionals we profess values imbibed from our teachers. Laurie invokes two - her father and Hippocrates. She treasures stories her father told about nurses in the operating room who saved him from making mistakes. From those stories she took lessons about respect for competent women, humility about one’s own expertise, and teamwork to serve patients.

Out of curiosity I Googled “Dr Patton cardiovascular surgeon.” What I found reinforced the lesson about transmission of values within a profession. In college Dr. Patton broke his collar bone playing hockey. Two of his moral influences were the surgeons who took care of him – their empathy, competence, positive attitude and the pleasure they took in their work. And in an essay of his own, Dr. Patton tells the story of Dr. Daniel Fiske Jones, a noted surgeon who graduated from Harvard Medical School 62 years before Dr. Patton did. The subtext of the story is that Dr. Patton is guided by the same values that guided Dr. Jones.

In my first year of medical school I experienced the process of value transmission directly. I was in a tutorial group that met with Dr. William Castle, a distinguished hematologist. Dr. Castle, who was 63 at the time, described the following dialogue from when he interned at the Massachusetts General Hospital in the early 1920s:
Teacher: Dr. Castle, if you had a patient with pneumonia, and you did ABCD, but the patient died, how would you feel?
Dr. Castle: I would feel terrible!
Teacher: Dr. Castle - if you persist in feeling that way, you will have to leave medicine. You would have done everything that we are able to do at this time. You will have to learn to govern your emotions! (reconstructed from my memory)

Dr. Castle was a gentle, compassionate man who I admired. Over the years his story has led me to reflect on the challenge of how to be close enough to our patients to feel love for them, and at the same time to have enough internal "insulation" to maintain our own stability when our patients do not do well.

Laurie Patton is applying the values professed by her surgeon father. I reflect with my own students about the values Dr. Castle's teachers tried to pass on to him almost 100 years ago. 

That's a large element of what professions are all about!

Friday, June 29, 2018

How not to handle conscientious objection

On the evening of June 21, Nicole Mone Arteaga went to Walgreen's Pharmacy in Peoria, Arizona (a suburb of Phoenix) to fill a prescription for misoprostol. The 9 week fetus in her longed-for pregnancy had no heartbeat, and the pregnancy would end in a miscarriage. She chose a medical rather than surgical removal of the non-viable fetal tissue.

When she arrived at the pharmacy, staff pharmacist Brian Hreniuc asked if she was pregnant. On hearing the answer he told her his "ethical beliefs" forbade him from filling the prescription. According to Ms. Arteaga's Facebook post her 7 year old and five customers could hear the exchange. The result: "I left Walgreens in tears, ashamed and feeling humiliated by a man who knows nothing of my struggles but feels it is his right to deny medication prescribed to me by my doctor."

Next day Ms. Arteaga was able to fill the prescription at another branch of Walgreen's. 

Arizona law allows pharmacists to exercise conscience as Mr. Hreniuc did. And while reflective individuals differ on whether professional responsibility to serve one's patients or individual conscience should rule in situations like this, my Catholic friends have helped me understand how for Mr. Hreniuc, filling the prescription could make him feel complicit in what he might see as a mortal sin. But as experienced by Ms. Arteaga, he did not communicate in the right way.

Here's what needed to be done. (1) "I'm so sorry for what you are going through." (2) "I have to refer you to another pharmacy/pharmacist." (3) "I want to wish you the best for the future." The conversation should have been private, not audible to others. The tone should be warm, caring and apologetic, not self-righteous. Ideally, Walgreen’s would have systems in place so that patients would not encounter pharmacists who were not willing to fill their prescriptions. And for those like Mr. Hreniuc, there should be rigorous training in how to communicate in a manner that respects the needs of patients as well as the conscience claims of the staff.

It's not impossible that Mr. Hreniuc conducted himself this way. The pain of the situation could have prevented Ms. Arteaga from experiencing an effort at compassion. I know from experience that this can happen. Many years ago I came upon a distraught couple at the health center where I worked. They had just received bad news. The husband had cancer. I had recently taken a course on dealing with bad news. I sat down with the couple and spoke with them. I'm reasonably confident that a videotape would have shown that I applied what I had learned.

A week or two later a letter of complaint came to the administrator of the health center (me) from the couple. The letter described the cold, cruel person they had encountered (me). For me it was a chastening lesson in the potential difference between what is intended and said by the clinician and heard by the patient.

Arizona state Sen. John Kavanagh, co-sponsor of the 2009 law that allows pharmacists to refuse to fill abortion or emergency-contraceptive prescriptions based on moral or religious beliefs, showed a shameful defensiveness and lack of empathy in his comments on Ms. Arteaga's experience:

He said he was surprised that Arteaga wasn't more sympathetic with the pharmacist, given that she eventually was able to get the medicine from another Walgreen's location. "What's the problem?" he said. "She got what she wanted. The pharmacist complied with the law. I don't see why she doesn't respect the pharmacist's right to not do this," he said.
In her Facebook post Ms. Arteaga shows an admirable understanding of the situation: "I get it, we all have our beliefs." She appears to accept the issue of conscience but rightfully does not accept the way the conscience exception was carried out. In her response - a public post and a complaint to Walgreen's management - she is being an ideal advocate. Her complaint gives Walgreen's, and  professionals who might invoke conscience in not offering a medically indicated legal service, guidance in how to conduct themselves in a more ethically admirable manner.