Teaching Ethics in High School and Middle School

I'm in Vermont at the Bread Loaf School of English, a Middlebury College program in which the students, primarily high school and middle school English teachers, can get a Master's degree in the course of five summers. My wife has been teaching here every summer since 1992 and I've been enjoying the potential for (a) telecommuting and (b) swimming and hiking in Vermont.

This year the Bread Loaf program has a new format for elective workshops, and I'm doing one next Friday on teaching ethics in high school and middle school. I've never taught at that level, but I've taught medical ethics at Harvard Medical School for many years, and I wanted to see whether and how that experience could be extended to pre-college English classes. I hope the participants learn as much as I have in preparing for the workshop.

Since the content of the medical school course isn't relevant for pre-college English classes, I dissected out the underlying goals I have for the medical students. I identified five:

1. Strengthen ability to identify ethical issues, ideally combined with a zest for tackling these issues – a capacity that can be called “moral imagination” or “moral sensitivity.”
2. Impart systematic approaches to resolving ethical questions – approaches, not answers.
3. Enhance skills and attitudes that promote considering the views of others in a respectful manner – listening to those we’re talking with and, imaginatively, to the views of other stakeholders to the issue. 
4. Cultivate the habit of using our own "gut" reactions as “data” for ethical reflection, not necessarily as “truth.” This doesn’t come naturally to most adults, and is even more challenging for adolescents. 
5. Enhance capacity to reason to a justifiable conclusion and articulate the rationale for our conclusions.

In preparing for the workshop I came upon the work of Tom Wartenberg, Professor of philosophy at Mount Holyoke college, who teaches a course in which undergraduates (a) examine children's books through the lens of articulating the implicit philosophical content of the stories and (b) train to lead discussions for fifth graders at a nearby charter school. (The website is very worth a visit.) In an interview he described his objectives for elementary school children as essentially the same as my objectives for Harvard Medical students. His aim is to teach children how to "philosophize," not about the content of philosophy per se. The children dove into the discussions with the same gusto that makes teaching the course to medical students such  a privilege and pleasure.

Apart from the specific content focus of ethics education, the attitudes and skills required for reasoning about ethical issues are the fundamental requirements for democratic participation. I'll depend on the teachers who participate in the workshop for ideas on whether and how including ethics in high school and middle school English classes is (or is not) a promising practice in an era dominated by standardized testing.

Sexual Intimacy in the Nursing Home

The most recent issue of the Journal of Medical Ethics has an excellent article from the Centre for Evidence-Based Aged Care in Australia - "Dementia, sexuality and consent in residential aged care facilities."

The authors' argue that "while we must abide by laws regarding consent and coercion, in general we [in the West] expect to be able to engage in sexual behaviour whenever, and with whomever, we choose." In their view, nursing homes should allow for sexual intimacy and interfere only for clearly defined reasons, rather than treating sexuality as a special privilege that must be earned by requiring both parties to "prove" decisional competence, and, often, to require permission from families.

The authors are drawing on the concept of "dignity of risk." Meaningful life entails taking risks. If we agree with John Stuart Mill that as long as individuals are (a) not causing harm to others and (b) understand the nature and consequences of their proposed actions ("decisional competence"), then(c) their liberty should not be constrained. The authors recognize, but do not discuss in depth, the challenge of assessing "competence" in the presence of dementia. To my reading they underestimate the potential risks, as when one party erroneously believes that the other is their spouse or partner. But they're right that we tend towards excessive prudishness with regard to sexuality in our parents and grandparents.

This was the explicit focus of teaching when I was a medical student. We were in our 20s, so patients in their 70s and 80s were the age of our grandparents. When teaching us how to take a medical history our instructors warned us that we might feel uncomfortable asking about sex with patients in that age range. They reminded us that we were doctors-in-training learning a medical role, not prurient children or grandchildren peeking through keyholes into a bedroom.

My father was something of a ladies man. He outlived three wives and, over the years, I was aware of a number of his girlfriends. In the final months of his life he suffered from dementia and heart failure, along with blindness, and was in a nursing home. On a visit that turned out to be just two days before his death, we returned to his room to find an elderly woman lying on his bed. I said in what must have been a saccharine-toned voice "this is my father's bed." She responded, with a mischievous smile and a twinkle in her eye, "I know."

Knowing that flirtation was alive and well so near the end of my father's life is a happy memory for me!

(The full article is only available by purchase, but a free abstract is available here.)

Teacher/student sex

I spent four happy years (9th to 12th grades) at the Horace Mann School in New York, and was startled by a New York Times article in June titled - "Prep School Predators: The Horace Mann School's Secret History of Sexual Abuse." The author, Amos Kamil, had researched the piece for more than a year and had interviewed more the 100 former students and teachers.

The article describes how several teachers in the 1980s and 1990s were well known for "hitting" on students. The article discusses in detail three who preyed on boys. One, possibly two, committed suicide after finally being dismissed. But the sexual exploitation had gone on for many years. It's hard to believe that the administration was unaware of what was happening. The author himself was invited to the home of Inslee Clark, the head of school, and, although underage, was given alcohol, at a small dinner that included one of the teachers known for hitting on boys.

In the world of organizational ethics there's a saying: if the CEO isn't "chief ethics officer" as well as "chief executive officer," don't waste your time on organizational ethics. Leaders set the moral tone of organizations by what they practice, not what they preach. Clark's alcohol-laced dinner suggests that he was setting an atmosphere that tolerated what in the medical world is called "boundary violations."

There's a structural similarity between the doctor/patient relationship and the teacher/student relationship. We give doctors and teachers authority and respect for helping us cultivate our capacities for health and wisdom. We expect them to focus on the needs of their patients and students, and to put their own private desires into the background. Sexual interest isn't a violation of that trust. Overt behavior is.

Neither I nor my best friends from high school had any knowledge of teacher/student sexual relationships, but we were at Horace Mann 25 years before the period the article discusses. But Tek Young Lin, a new teacher in our days, now 88, acknowledged that he had sexual relationships with students in the 1960s and 1970s. Tek was a Buddhist and a beloved English teacher. I remember him as a charismatic, profoundly educative person. The candor I remember him for was reflected in the interview he did with the New York Times:

 "in those days, it was very spontaneous and casual, and it did not seem really wrong...if I had in any way harmed them, hurt them, I am truly, truly sorry. I hope if they have been hurt, they will overcome that hurt, and I should be very happy to help in any way I can." 

 The fact that a beloved teacher could also be an exploiter is consistent with comments made on this blog by former patients of physicians who'd lost their licenses for boundary violations. It's clear that teachers, like doctors, who violate boundaries with some, may provide superb education to others.

An article in yesterday's New York Times reports that alumni are unhappy with what to them seems like a "cold" reaction on the part of current leadership. I'd felt the same way. The disappointing public comments probably reflect the misguided legal advice the school administration was given - to say nothing that could be used against the school in court. This is what lawyers used to advise physicians in situations of bad outcomes. That defensive approach is now seen to be (a) inhumane and (b) bad strategy for preventing malpractice litigation.

I take three lessons from these unhappy stories about my high school. First, we humans are open to a wide range of feelings and fantasies. In relationships like teacher/student and doctor/patient we should expect that the full range of emotions can enter in (on both sides). Professional education should help us become better self-observers and self-managers, so that we can govern ourselves in accord with our professional responsibilities. Second, leadership matters. Inslee Clark set a permissive example. Likewise, in years past, leaders in medicine did the same. Medical leaders hushed up allegations against colleagues, just as bishops did with offending priests. Finally, when a problem hits the fan, respond as Tek Young Lin did, not as past medical leaders and bishops did - take responsibility for the situation, apologize, and make amends when possible.

(For the initial article about "Prep School Predators" see here. For the article about my teacher Tek Young Lin, see here. For yesterday's article about alumni reaction to how the school is handling the situation, see here.)

Paranoid Style in the ACA Dissent

My wife and I are in Vermont with two of our grandchildren visiting, so I've only just now finished reading the 193 page Supreme Court decision about the ACA.

Throughout the health reform process I've tried to understand the virulent opposition to the ACA in terms other than "stupidity" and "demagoguery." Stupidity is real, as when Senator Breaux's constituent pleaded "don't you let the government get hold of my Medicare." And demaguguery is all too real, as in Sarah Palin's death panel lies and Mitt Romney's sucking up to the Tea Party and running away from his constructive role in Massachusetts health reform. But the dissent written by Justices Scalia, Kennedy, Thomas, and Alito (that's the sequence of their names on the dissent) offers a uniquely clear insight into hatred of the ACA.

I'm not a scholar of constitutional law, but I found Justice Ginsburg's argument that the individual mandate was constitutionally justified under the Commerce Clause persuasive. But I also found Justices Scalia, Kennedy, Thomas, and Alito's argument that the Commerce Clause does not justify the mandate strong in logic.

It may be the psychiatrist in me, but I believe the conclusion the four dissenters reached (and the virulent hatred of the ACA that some of its opponents express) reflect the dissenter's fear of a slippery slope more than the nuances of interpretation of precedents. The dissent has a framework of logic, but the driving force is emotion. I've highlighted the emotional content of three representative excerpts from the dissent:

...to say the failure to grow wheat (which is not an economic activity, or any activity at all) nonetheless affects commerce and therefore can be federally regulated, is to make mere breathing in and out the basis for federal prescription and to extend federal power to virtually all human activity. (p 129)

...If congress can reach out and command even those furthest removed from an interstate market to participate in the market, then the Commerce Clause becomes a font of unlimited power, or in Hamilton's words, "the hideous monster whose devouring jaws spare neither sex nor age, nor high nor low, nor sacred nor profane." (p 134)

But if every person comes within the Commerce Clause power of Congress to regulate by the simple reason that he will one day engage in commerce, the idea of a limited Government power is at an end. (p 138)

The dissenters see the ACA as unleashing a hideous devouring monster. Their outlook reflects what historian Richard Hofstadter called the paranoid style in American politics. Here's the essence of Hofstadter's analysis:

I believe there is a style of mind that is far from new and that is not necessarily right wing. I call it the paranoid style simply because no other word adequately evokes the sense of heated exaggeration, suspiciousness, and conspiratorial fantasy I have in mind. I am not speaking in a clinical sense...It is the use of paranoid modes of expression by more or less normal people that makes the phenomenon significant.

...As a member of the avant-garde who is capable of perceiving the conspiracy before it is fully obvious to an as yet unaroused public, the paranoid is a militant leader. He does not see social conflict as something to be mediated and compromised, in the manner of the working politician. Since what is at stake is always a conflict between absolute good and absolute evil, what is necessary is not compromise but the will to fight things out to a finish. Since the enemy is thought of as being totally evil and totally unappeasable, he must be totally eliminated—if not from the world, at least from the theatre of operations to which the paranoid directs his attention.

The dissenters see the ACA through the lens of the paranoid style. This is what leads them to the crucial slippery slope argument - that if we allow the individual mandate we allow the government unlimited power to coerce us. The end result is the image of the body politic as an infant, being forced to eat broccoli by a controlling mother:

All of us consume food...But the mere fact that we all consume food and are thus, sooner or later, participants in the "market" for food, does not empower the Government to say when and what we will buy. That is essentially what this Act seeks to do with respect to the purchase of health care. (p 139)

The slippery slope argument - from the health insurance mandate to total government control and forced feeding with broccoli - depends on the emotion, not logic. Justice Ginsburg makes a powerful argument that health care, representing more than one sixth of our national economy, is a distinctive case, not just one stop on a slope leading to broccoli. But from the perspective of the paranoid style, giving an inch is giving a mile.

Hofstadter is clear that the paranoid style doesn't mean that the views being asserted are wrong. In my view the dissenters make cogent arguments about Commerce Clause precedents but, again in my view, the arguments don't trump those advanced by Justice Ginsburg. But for those who see the world through the paranoid style lens, the associated emotions add the necessary weight to arguments that in themselves are not decisive. 

The paranoid style isn't a logical conclusion - it's an emotional predisposition. As a result, logic won't alter it. Between now and November we'll see how the Republicans will seek to fan paranoid style flames and how the Democrats will seek to counter it. Stay tuned!

(The full Supreme Court decision is available here. And for a strong argument as to why the health sector is distinctive and the slippery slope argument fails, see health law professors the amicus brief from 104 health lawyers here.)

Praying for health

When I learned last week that a friend, who is also a colleague I admire, is having major surgery today, I included this sentence in the note I sent him: "Although I don't literally "pray," the phrase "you will be in my prayers feels true - and you will be next Tuesday."

He wrote back: "Technically, I do not "pray" either. However, I find that I have a strong faith in universal purpose, the importance of helping others, and that one's contributions profoundly matter in some way."

By chance on the same day I sent my email, another colleague wrote to me this way about our shared interest and pleasure in Vermont, where I am now: "We are so blessed living in New England!"

What's going on with non-praying prayers, universal purpose, and blessedness?

My love of religious language is not rooted in a theology. When I'm forced to explicate my religious position I define myself as "a religiously minded Jewish atheist." As an atheist, I don't participate in a congregation or community that calls itself religious. But here I was, on the same day, telling my friend that he would be in my prayers, hearing back from him about universal purpose, and hearing from another friend and colleague that we were blessed.

I do feel blessed to be part of a set of overlapping communities committed to health and health care - clinicians, researchers, and folks involved with health care ethics. An anthropologist studying us would say that these communities are like religious communities in (1) sharing values and (2) regularly talking about ("professing") those values while (3) maintaining recurrent, long term contact with each other. For me, and for folks like the two colleagues I exchanged messages with, these moral communities have the same valence that an organized religion can have for someone for whom the religion as a living experience, not a dutiful routine.

Referring to "prayer," "blessedness" and "universal purpose" uses terms that have been developed in the context of religious commitment and theological belief to affirm and reinforce the commitment that my friends/colleagues share. The religious terms carry a distinctive weight. They help to convey that health care can be a "vocation" and "calling," not a job.

I haven't been down on my knees today, but my friend is definitely in my prayers!

Bereavement, Depression and DSM-V

In January I criticized the American Psychiatric Association (APA) for planning to drop the "bereavement exclusion" from the definition of major depressive disorder in the forthcoming new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Under the exclusion, the diagnosis of depression is not made if:

The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

In a recent issue of the New England Journal of Medicine, Richard Friedman, a distinguished psychiatrist at Cornell who writes excellent New York Times columns for general readers, adds to the voices criticizing the APA for medicalizing normal grief (see here). Here's the essence of Friedman's argument:

In removing the so-called bereavement exclusion, the DSM-5 would encourage clinicians to diagnose major depression in persons with normal bereavement after only 2 weeks of mild depressive symptoms. Unfortunately, the effect of this proposed change would be to medicalize normal grief and erroneously label healthy people with a psychiatric diagnosis. And it will no doubt be a boon to the pharmaceutical industry, because it will encourage unnecessary treatment with antidepressants and antipsychotics, both of which are increasingly used to treat depression and anxiety...The medical profession should normalize, not medicalize, grief.

Despite criticism the DSM-V working group has not changed its plan to eliminate the bereavement exclusion, but it has added a footnote that at least acknowledges the challenge of distinguishing normal grief from the illness of depression:

The normal and expected response to an event involving significant loss (e.g, bereavement, financial ruin, natural disaster), including feelings of intense sadness, rumination about the loss, insomnia, poor appetite and weight loss, may resemble a depressive episode. The presence of symptoms such as feelings of worthlessness, suicidal ideas (as distinct from wanting to join a deceased loved one), psychomotor retardation, and severe impairment of overall function suggest the presence of a Major Depressive Episode in addition to the normal response to a significant loss.

I don't know if Dr. Friedman would be mollified by this footnote, but I'm not. For those who want to delve more deeply into the research, the working group presents its rationale here.

To my eye, clinical and epidemiological research relevant to distinguishing the illness of depression from the painful but not unhealthy state of grieving doesn't settle the controversy. The DSM-V working group has chosen to drop the bereavement exclusion out of fear that it might lead to misdiagnosis of some depressive episodes as normal grief. I, along with Dr. Friedman and other critics, see the potential for medicalizing normal grief as a significantly greater danger.

Years ago, when I was teaching a group of primary care physicians about use of antidepressant medication, one of the PCPs commented in the form of a two-line poem:

I know what to do when they're dying,
But not what to do when they're crying.

Between the degree to which harried physicians have become less skilled at dealing with existential concerns like grief and the seductive pharmaceutical marketing that will emerge with the death of the bereavement exclusion, before too long we'll be seeing patients experiencing normal grief being flogged with unwarranted diagnoses and unneeded medication.

Grief typically lifts on its own without medical intervention. Some of these patients and their physicians will conclude that they have been "cured" by the unneeded medication and will remain on it, exposing them to pharmacological side effects. In addition, some will experience an altered self image - "I'm a 'weak' person who got sick when X died and needed medicine to get over it" - rather than "I miss X terribly and experienced severe grief after the death."

The DSM-V working group is factually correct in its belief that loss can trigger the illness of depression and that it's important for clinicians not to miss the diagnosis when this happens. But dropping the bereavement exclusion won't eliminate this risk, and eliminating the exclusion will add to a destructive cultural trend of over-medicalization and excessive use of pharmaceuticals.

Industry, Medicine and Medical Ethics

This morning I co-chaired a meeting of the Massachusetts Association of Health Plans (MAHP) Ethics Forum that used the Massachusetts Gift Ban law as an entry point for discussing the relationship between the medical products industry and the medical profession.

Marcia Hams, program director of the Community Catalyst Prescription Access and Quality Program and Tom Stossel, director of translational medicine at the Brigham & Women's Hospital, kicked off the discussion. Many pharmaceutical companies are affiliate members of MAHP, so participants included pharmaceutical folks as well as health plan medical staff.

What struck me most about the excellent discussion is how the absence of an overall budget for health care has tilted public discourse in a polarized black and white direction. Marcia Hams made a strong, thoughtful advocacy argument that pharmaceutical marketing activities contribute to increased costs and negative impacts on quality. Tom Stossel made a strong, thoughtful advocacy argument that pharmaceutical marketing activities contribute to decreased overall costs and quality improvements.

If we had an overall budget for our health system, or real budgets for components of the system, we'd be having a different set of discussions. Instead of arguing about whether industry influence on medical practice and health care costs is good or bad (it's both), we'd be discussing questions like whether a particular intervention created enough value to justify its use, and how its cost-effectiveness measured up against alternatives.

Many in the policy community argue that the U.S. population is unwilling to recognize and accept limits in health care. In my view, the scattered structure of our health system - most notably, the absence of overall budgets - has made it difficult for us to consider relative value, trade offs, and opportunity costs. By now we're habituated to not thinking about these questions, which makes us progressively immature as a body politic and vulnerable to nonsense like "death panels" and fear that the Affordable Care Act will lead to a government mandate that we all eat broccoli!

(This has been the longest time without a post since I started the blog almost five years ago. I've been unusually busy with teaching activities and a number of projects. It's good to be back!)