(00:00:00) And the time is 12 o'clock that afternoon Dan Olsen in the Twin Cities and we've been Welcome to our guest Arthur Caplan PhD in Philosophy from Columbia University. He is currently director of the center for biomedical ethics and professor of philosophy and surgery at the University of Minnesota in Minneapolis. And thanks to office staff Julie lift over providing those documents so we can get a little background on Art. Formerly. The associate director of the Hastings Center and is also taught at Columbia's Columbia University's College of Physicians and surgeons at the University of Pittsburgh. So welcome and what a what a day for weather in Minnesota quite Minnesota, and I'm glad your car started so you could get here to our Saint Paul Studio Art. What is the center for biomedical ethics? (00:00:47) Well, the center was set up Dan about a year ago and I actually came to it in September. It is an interesting approach to the study of Ethics because it's interdisciplinary. We basically are a unit of the University of Minnesota. We're not part of the medical school or the nursing school. We have a small group of four. We have two philosophers one lawyer and we have one nurse working on the staff now and the mission of the center is basically to do four things first. We are there to teach and we are currently teaching courses on ethics in the medical school for the staff of the University of Minnesota hospitals. We're doing teaching in the nursing school and we're doing work with the schools of Pharmacy as well as a School of Public Health. We are not yet engaged in undergraduate teaching. Although I think will expand in that area shortly right now. We're primarily at The Graduate level of Professional School level. The second thing we do at the center is original research, which we do Under the auspices of the center that involves people beyond the four staff members. We're going to be it to problems this year which we hope to have reports out on one on the use of fetal tissue in healthcare as some of the listeners may be aware the progress in the field of transplantation has moved to the point where there's some hope that for diseases like diabetes or Parkinson's disease perhaps Alzheimer's perhaps AIDS one might be able to use material from fetuses to transplant cells that would repair some of the damage in these diseases obviously there's some important ethical questions there because one it has to ask where is this material to come from is it to come from those who have abortions is it to come from spontaneous abort us' would we allow someone to get pregnant knowing that what they intend to do is abort the baby and Transplant tissue back to themselves or to a loved one and I could tell you we've already had a case like that come up with the you or someone is actually appeared saying I have diabetes I have no Owner no one is available to give me a pancreas. I have no family. What if I got pregnant? Could I transplant tissue back to myself? So it's not it sounds science fiction, but it's actually come to the point where at least people are beginning to think about it. I will tell you that to my knowledge there have only been two instances in which fetal tissue has been used one was Chernobyl where dr. Gale after that disaster arrived and did attempt 6 bone marrow transplants using fetal tissue on those Russian Soviet workers, they all died but it was difficult to know whether they died because they've been so injured because of the explosion or whether the transplant itself fail, but that was done last year and there's been a series of 18 attempts using what are called islet cells, which is basically the business end of the pancreas the part that makes insulin in Colorado at a children's hospital out there. So they've been two uses of fetal material and what we're going to take a look at is the whole range of issues around that we hope to have a report out. Awful solve it, but at least we'll lay out what some of the problems are. This is not only a national issue has International Dimensions. You can imagine it's somewhat frightening to imagine but there's a possibility for a market in this kind of tissue. You could have people going to a Bangladesh or a chador an El Salvador and saying I'll pay you $100. Let me have the fetal remains. We're going to throw they have to have both National and international agreements. If this is going to happen the other are we going to take a look at is peculiarly Minnesotan. I didn't realize how interested Healthcare Providers Patients Hospital administrators. The citizens of Minnesota were in the problems raised by what I call the new forms of delivering and paying for Health Care. Minnesota is a leader in pioneering both prepaid medicine and the delivery of medicine in group settings are PHP. In our group health approach the various prepaid plans that Now operate in the state the question that confronts both patients and Healthcare Providers is whether the old tradition of medical ethics is adequate to the new setting and new forms of payment for care and I can illustrate that very simply in the old days whatever the problems that existed between doctor and patient one at least knew that if you hired the doctor you paid his fee the doctor was going to go to bat for you and that was his primary concern was to get you what you needed from the doctor's point of view. There was also a belief that more was probably better than less from the patient's point of view that seem comfortable enough so that if we were in a situation where someone said, well, I need at a store. I want a procedure as long as you had the money to pay for it assumedly you and the doctor on the same side of things when you have prepaid medicine which reimburses at a fixed rate. It says you get a hundred dollars to take care of your acne and you come to the physician and the physician says Let me see if I'm going to make money on this particular care. I have to balance off giving you various tests and procedures with the fact that my income is derived from the difference that's left over after the fee is paid you kind of have to worry if the old ethic of truth-telling of privacy of an alliance between the doctor and the patient is going to hold up another way to put this is all we hear about these days our Cost Containment concerns relative to health care. What does that do to the Doctor Who now comes up to the bedside of a critically ill person and has to think well, I could keep this person in the hospital another day, but after all the gross national product of the United States in the budget of vastly out of whack maybe what I should do is save us all some money in Dish discharge this patient today. So it's that kind of tension. That is the other area. We're going to take a look at this year. I don't think we'll solve it. But I think well at least be able to open up the fact that we've got some ethical conundrums there that that really are new and Challenging and as I say there peculiarly Minnesotan because we do more of that here than anywhere else in the country. We have more prepaid medical practice. We have more reimbursement by fixed fee. We are kind of leading the we're on The Cutting Edge of how health care is delivered under these new modes the other two things we do briefly we are trying to be responsive to the community the center since I've been there has received I would say we've had about 300 calls from the media. They've come from Japan Norway England all around the United States. We try to respond to them because in a way our mandate from the university is to not just be there for the faculty or the students or the staff of the you it is to really serve the citizens of Minnesota. And one of the ways we can do that is by appearing on programs like this. We try to highlight issues before they take place. We try to respond when different news organizations have questions about issues. The last area of our work basically is community outreach. We do put on lots of educational programs give you one example, we're going to sponsor meeting on April 15th at the University on issues surrounding assisted reproduction in vitro fertilization surrogate mothering who what ought to be done in this area. Should we Outlaw the notion of paying someone to be a surrogate who should have access to in vitro fertilization. Should it be limited to those who are sterile who can't have children or should we allow people to use those techniques for reasons of convenience or Aesthetics? So we do try to put on public programs. We do try to put on community forums and I think those who are interested in that can certainly get in touch with a with us at the center will be happy to let them know what we're doing. So we're busy (00:08:44) aren't the colors are already lining up. We haven't even gotten the phone number out and let's do that right now. If you have a question for our guest, dr. Arthur Caplan the director of the center for biomedical ethics at the University of Minnesota. Give us a call at 2:00 to 7:00. Some to 276 thousand and outside the Twin Cities area call us toll-free with in Minnesota one 865 to 9701 865 to 9700. And of course you can call us anywhere you can hear us at area code six one two, two two seven six thousand and I think we have a caller on the line. So let's take the first question. Hello. We're listening for you your guests already mentioned PHP and as a physician my experience with them has been less than ideal. I joined immediately and then dropped out and then had to join up again. And when I discovered this this funds that they were withholding each year. They weren't returning so that it didn't cover the cost of operation of the hospital are of my practice and then When I tried to get figures out of them I go round and round from one office to another to another somebody's in meeting. Somebody will return your call all of this kind of stuff and they won't even provide the figures on which they made their determination and for listeners who don't know the history of it. Then there was a sort of a revolt and now there are new Physicians involved that with Burke having one foot in each pie. Then he had to leave the administration part of it and how much they were paying for those kind of services. All right, let's give dr. Kaplan a chance to respond to what is clearly an issue involving new sense of operation for healthcare providers and you spoke to a little bit (00:10:44) already. Well look the color points out some of the real thorny dilemmas that that face Physicians today who are either coming into practice or having to adjust Us to this this New Economic and I would add sociological climate the PHP plan not to pick on it, but it's a visible illustration of these problems. I think many Physicians came into medicine in part because they enjoyed the notion of being autonomous not to use a philosophy buzzword, but basically being able to run their own Affairs run their own business not have people looking over their shoulder and second-guessing them and not having to spend a lot of time pushing paper around sort of explaining what they did to others the collar points out. That's not true in a large plan like PHP one has many people looking over your shoulder from administrators to peers to accountants to lawyers to God Only Knows philosophers, but the fact remains the freedom of the physician in that kind of a practice is very difficult to preserve the Physicians ability to sort of say look. I want to advocate for my patients I want to do what's best for them. I can't have a bottom line mentality. Ready when I come to my office or when I come to the bedside. I think we have to do something about the these sorts of pressures. We can't lie. We simply can't sort of direct our physicians to a do everything you can make sure that everyone gets treated maximally and be tell them at the same time. Well do it cheaply. I mean that's where the tension Lies We have this desire in the United States and it's evident in Minnesota to go out and say look we want everything done for (00:12:23) everybody. The ethical dilemmas apparently do not disappear with a nationalized health system. You'll certainly correct me if I'm wrong, but I think if you live in Great Britain and if you need kidney dialysis, and if you're over the age of is it 50 or 55? You might not get (00:12:36) it. Well, I think in many parts of the world there are social policies and in some cases physician driven policies the British kidney dialysis policy is one where you wind up instead of having the public decide how much it wants to spend the Simply says look, here's what you've got to spend figure it out physician and what the Physicians do is they come up with different ways to triage or ration scarce resources in Britain age counts. I'll tell you some other factors that are used in Britain. One of the things I did about two years ago is take a trip there and visit the dialysis units and I found out something interesting people who didn't speak English. We're less likely to be dialyzed than people who did that didn't make any sense to me. I could understand in one sense people saying well you're older maybe you won't do as well. But speaking English or what I found out was that the British in an attempt to cope with scarce resources have basically moved to home dialysis where we do all of our dialysis with these machines that cleanse the blood in hospitals or in clinics. They give them to the patient to take home. If you have to teach someone to do that. It takes a lot of time to teach someone who doesn't speak English to run their dialysis machine. So they basically triage out those who are difficult to teach these kinds of Psychosocial factors. They age or speaking English or mental ability or what have you are ever present in the Health Care system. I don't think we're going to do away with that. What I do believe is Center like ours should be trying to to reinforce public awareness of where the value choices are being made. Let them be reviewed and let them be commented on so that at least we have social consensus about what's being done. I'm not saying we can't necessarily stop building bombs and aircraft carriers and tanks and live in a world where everybody has everything they want in health care. It doesn't seem the American public want that they want defense they want education they want agriculture. They want many things. So we are going to have to make some choices, but we can be of assistance to The Physician who called and others simply because it's our responsibility. It won't do this say oh go ahead doc you decide whether it's age or mental handicap or ability to speak English or media? Janessa T the ability to go on and Lobby loudly on a radio station to get an organ or money to pay for a It's plan. It's our problem and we can't kind of dump it off on the hospital administrator or the physician. So that's that's certainly one of the things that we want to be alert to here is that this is everyone's problem. And we've got as a center kind of drive home that (00:15:08) point. All right, we'll take another caller and we have one on the line. Hello art Caplan is listening for your question. Yes. Mr. Kaplan. I was just listening to her last comments there and I guess my question sort of comes around that when we're talking about the ethics and developing certain practices that are going to be acceptable or a norm whose ethics are the ethics that become those that are practiced or the norm. It seems that it's going to be those who do speak up and unfortunately, it seems that those who speak up are often very well represented by the lobbyists of the insurance companies or the American Medical Association both of whom have a seat. Namik interest rather than what I might consider to be more moral and ethical in the judeo Christian ethic principles. (00:16:06) That's a very interesting question. It's one that is tempting to me to spend the rest of our time discussing as a philosopher because you're asking sort of one of the foundations for doing ethics and I might even put a Twist on your question say look, how do you do ethics in a pluralistic society? Because we have people who are Jews and moslems and all variants of Christianity plus a few secular humanist atheists agnostics and and indifference running around on our streets to how do we kind of do all this? I guess I would answer your question without taking rest of the hour and two ways first there has been and continues to be a medical ethic the appearance of art Caplan at somebody's bed side is not the first time that ethics makes it a kind of show. In organized medicine, I might like to think that philosophers are the place to turn for wisdom about moral matters, but the fact is Physicians have had to Grapple with these problems for many hundreds of years nurses dentists Public Health officials have traditions and customs and practices where you start is by trying to ascertain. What are the existing Norms did Physicians believe they have a duty to treat and in fact the answer to that is no unless it's an emergency. There is no tradition of a duty to treat in the United States unless one makes a kind of contractual arrangement with a patient that may be different in other nations. It's not true in ours to Physicians have they historically believe they have an obligation to tell the truth. No, they haven't in fact for therapeutic purposes historically, they've believed that sometimes withholding a diagnosis or withholding the prognosis from a patient is a good thing to do who want to be in charge of one's care historically at least back in the 19th century paternalism reigned in how Physicians approach the patient they What was best for the patient it was up to the physician to determine the course of care? Well, clearly, we don't believe that any of the things I've just said are true today. We've changed our thinking about truth-telling we've changed our thinking about paternalism. We have a very autonomy driven patient-centered approach to healthcare. We ought to determine each one of us when treatment will start if we will be a patient. If on religious grounds, we don't want blood transfusions if we don't want respirators or what have you in the process of are dying will be in control of that. We got their first by understanding what the existing ethic was. So that's what we have to do first is kind of the Anthropologist and and figure out what is it that people believe. What is the Legacy the history bring us? Sometimes it's fine. Sometimes it's important simply articulated and understand it and reinforce it. Sometimes it's not and that leads us to the second question. Well, how do you get prescriptive? How do you become normative? How do you tell people what they ought to do? I guess I turn to a variety of sources in my own work in trying. To find ways to to prescribe values. The first is to the law one wants to know what the law has said about many things. For example, the law tells us we ought not discriminate in this country against people on grounds of age. Now if that's routinely happening in the allocation of resources say we were giving out dialysis or organs for transplant on the basis of age if we said you're too young or too old and that's the only reason you won't get a liver transplant or a heart transplant. We'd be inconsistent with legal consensus. So that's one tradition a second is to go to theological tradition while theological Traditions don't always agree many times. They do we have a great deal of agreement for example on thinking about equity and Justice and fairness in all Catholic Protestant and Jewish Traditions, there are points of Confluence about how to approach these things and with a don't it's interesting to see where one can find the best arguments from those Traditions about how things might move the third place ones turns is actually to what I would call. The philosophical and ethical tradition and of itself. Not only is there a long Legacy of thinking about ethical problems in western civilization? We actually now have a body of literature in medical ethics than one can go and look at and see whether by case reasoning or by analogy one can move from one sort of problem to another sort of problem. And I think that's the way you kind of do Ethics in a secular world or as I call it sometimes doing Ethics in the street. It's not easy. You don't always get agreement sometimes what you have to settle for then is agreement on a procedure. If we don't get substantive agreement sometimes what we have to do is decide. Well, let's do it by a committee or let's do it with a decision that's under review. Maybe we'll have different outcomes for different patients, but we'll all agree in a procedure that at least be fair (00:20:43) other callers with questions and we'll get to the next one right now. We're about a fourth of the way through our conversation with. Dr. Arthur Caplan who is director of the center for biomedical ethics and a professor of philosophy in surgery at the Receive Minnesota in Minneapolis. Hello. We're listening for your question. My husband and I are considering having a child and because of our age amniocentesis is advised does your organization or can you recommend an organization who we could talk to for counseling on whether or not to abort if there is a problem. (00:21:14) Well, actually anyone older than age 35 a woman older than age 35 and actually the summit data that for men to who are over the age of 35. It is important to get genetics counseling to seek out information both amniocentesis and there are some other tests now that can be done involving testing of by ultrasound of fetal development. There are many problems and difficulties that can come up in pregnancy with couples who are older. I don't want to scare you. I think relatively speaking they're still very rare the kinds of things were talking about are down syndrome, which is associated with severe to moderate forms of retardation. Spina bifida, which are neural tube defects that can lead to paralysis and loss of bowel and bladder control and then a host of other congenital defects of varying degrees. I don't think there's a correct answer on when one ought to have an abortion or if abortion is an option. What I do believe is that information ought besought any large Hospital in the state of Minnesota will have a genetic screening and counseling service the University of Minnesota certainly does all of the hospitals in the Twin Cities do one merely has to call and ask for information on genetic screening and counseling and make an appointment to see that counselor and I think you'll get the kind of information on testing and the kind of information about risk that that are encountered in a late pregnancy that you want. (00:22:43) I want to jump to another item our Kaplan to bring us back in time to a few weeks ago when the item was in the news about the woman in California who was in a hospital waiting for the birth. For baby who was to be born without most of its brain and she had tried unsuccessfully apparently to interest a number of hospitals in accepting the organs from that child. It was expected to not live very long after it was born but the hospital's apparently had turned her down citing legal and ethical questions. What's going on in this case? (00:23:16) Well, then I have to tell you I want to be upfront with the listeners on this. I have a position here. I've been a proponent of allowing public policy law and medical morality to use babies who are born with the condition known as anencephaly. So I'm not personally neutral about this. I guess I've written most of the existing literature on this subject which sounds like an impressive claim except I think that boils down to two articles and to op-ed pieces. It's a new issue. It's a new issue because historically nothing's been able to be done for these children about 2,500 babies are born each year in North America. They're cortex missing. They simply have brain stem. The brain stem is the oldest part of the brain. It's a small nub of brain tissue located above the spinal cord and it controls reflexes. It allows you to breathe. It controls your heartbeat and a day like today. It reminds us that controls thermal regulation as well shivering and those sorts of responses. These babies can't live there is nothing that can be done to cure them 60% of them are born stillborn another 30% of them are dead within one day after birth and the remainder except for a handful of exceptions are dead within a week. So they are born dying the problem that hospitals have had when approached by Family such as the winner family in California is to utilize these babies as organ donors one has to have heartbeat and respiration present. If you don't have that you damage the organs that you're trying to procure to give to other children or in some cases adults. Problem is really threefold first. Would you put a baby like this on a respirator when it was born knowing that the only reason you're going to put in on a respirator is to enable you to harvest organs a lot of Physicians have problems with that because it's not being done for the benefit of the baby indeed both the parents and in almost every case. I can think of the providers are hoping for a quick and easy death for this baby second. If you do do such a thing as put the child on a respirator, when would you do the actual organ procurement? What would Death be? What is the time of death and a child like this a very contentious question historically, we've thought that when your heart and lungs stopped beating that's when you're dead. Obviously we have machines today that can duplicate those functions. So we've shifted our understanding of when death occurs and we talk now about brain death. Some people have proposed that these babies be considered at Birth dead, even though they do have this brain stem activity. I think that proposal is wrong. These kids are clearly alive. If you look at them, they move they are born in at Terrible and devastating condition but there's clearly life present. Then the question becomes. All right. Well, maybe you could use some other measure to fulfill the brain death criteria because the problem is without having most of the brain there. It's very difficult to measure its activity reliably. So what signs and symptoms of death should you use the third problem is if you're going to use these children, I think this was another reason the hospital's had difficulty in accepting this voluntourism. Will it work? We don't know exactly what the organs and tissues are like from these babies. We haven't transplanted all that many infants there have been eleven infant heart transplants tried at Loma Linda Aid of the babies are alive, but the series has only lasted a year. None have been done at the University of Minnesota. I think many of my surgical colleagues over there a little bit skeptical of the ability to transplant organs in infants. Do you want to put a family through this kind of things you want to put an infant through this kind of thing be at a decerebrate one knowing that you're at the Experimental end of the spectrum relative to the transplants now my answer to that just so the listeners know has been yes and my answer to the question of does it demean or is it undignified to put a child on a respirator at Birth knowing that you're doing? So in order to harvest organs is no it isn't. In fact, we do do that today with adult donors. We actually keep them on respirators. Keep them on heart-lung machines solely to take organs and tissues not everyone wants it. But nonetheless we do do it and I don't think it is somehow disrespectful to the person to put them in a state where by their heart is still beating their lungs are still beating albeit mechanically supported knowing that the only reason that goes on is because we want to harvest organs and tissues for others. (00:27:39) I want to make sure we talk more about that issue of the organ shortage and other procedures in the hospital, but let's pick her to see to the telephone callers who have been waiting and get back to the telephone right now. Thanks for standing by. Hello. We're listening for your question. Hi, I will commit a quick comment and then I would like to hear Fonts to my comment and I will hang up then after I get the comment down so I can listen on the radio. I am a nurse and Central Minnesota and I have worked under drgs and also under the system we had before that where the physician would have the patient in the hospital and then they would be reimbursed for whatever they did and I'm a firm believer in the fact that they medical system must be monitored by someone besides the Physicians. I have seen abuses of the system people being able to stay in the hospital longer than was necessary for their treatment. I don't want to say the physician wanted the money, but when a person is well, they said go home. They shouldn't rest in the hospital for several days. I would like to hear comments on that. Thank you. (00:28:47) Well, I'll give you three comments on that the the system of payment that the nurse was referring to drgs is called diagnostic related groups for all the talk about transplants and artificial hearts and AIDS the biggest revolution in the Health Care system has been in our Medicare program what we did, although I'll be at quietly and oddly enough under the Reagan Administration in the name of competition was to shift from a system of payment at the federal Level under Medicare where you paid by procedure for what the doctor did to one in which you pay on the basis of the diagnosis of fixed fee. The reason I laugh and and say that that was done in the name of competition is it's basically price fixing it simply saying we pay fixed rates you Physicians you nurses you hospitals figure out how to deliver the care within the boundaries of what the fixed reimbursement rate is that we set I agree strongly with the suggestion that we do need supervision. What I think we're doing in the Health Care system is we're trying to achieve Cost Containment. But what we haven't done unfortunately, I haven't asked of our medical system and what organized medicine hasn't been willing to do to itself is to determine what interventions it has that are efficacious. In other words the way I would look at the system as this I don't think the answer lies in fooling around with financial incentives and trying to put economic motivations in the path of the hospital or the healthcare provider. I actually think that's fooling with danger because you set up the kind of situation the nurses talking about were fiscal considerations get tested on or keep a person in a hospital longer or get them denied access to a neonatal unit because they can't pass a wallet biopsy when they get into the hospital admissions unit. The problem becomes not so much monkeying with things economically and I have to confess if Economists listening to us. I apologize, but I think we go too fast to the economic solution. What I think we have to do is say look, we've got to figure out what it is in our 450 billion dollar expenditure on Health Care 11 percent of the gross national product. What is it? That works what makes people better? What makes people healthier? What is useless? What is dangerous? If you look at the statistics on how much we spend to assess medical procedures and interventions and I'm talking about surgery. I'm talking about nursing interventions. I'm talking about occupational therapy. I'm talking about stroke rehab psychological mental health interventions from A to Z. We spend about 1/100 of 1% of the 450 billion dollars trying to figure out what works. So in that sense, I am a keen and vociferous supporter of more efficacy assessment by Third parties be they Physicians reviewing other Physicians be they the federal government monitoring more. Trials and assessments of things like tonsillectomies or adenoidectomy knees or the artificial heart or pancreas transplants. Whatever it's going to be the harsh reality is we spend a ton of money on things that were not sure work. And what we're trying to do is Jimmy the financial incentives of the system to save money, but we're not sure we're doing is saving money on procedures that are helpful to people while we still let people march around having things done to them that we're not sure work not may turn out that it all works. I doubt that will be true. And I think there's evidence in the history of medicine recently to show that there are a lot of things out there that have been fabulously adopted that haven't been of much use the collars other point in addition to trying to figure out who should supervise we have another problem in this country. We sometimes for scare on people when they don't want it and that takes us into the realm of how we deal with the dying Cost Containment has led the way in discussions of the termination of treatment recently. All the listeners will be familiar with the famous, brouhaha. That came up over Governor Lambs statement the ex governor of Colorado who said the elderly have a duty to die. So that more resources will be available for the young well after some contemplation of that statement in a few efforts to retract it. I guess he's backed off from that kind of public pronouncement, but it certainly set the stage for discussions of what we do with the terminally ill and the elderly by Leading with Cost Containment. I think that's backwards. I believe there's a problem there and I think the governor was in Surge of it, but I don't think they got it quite the problem is this there are many people in there dying. There are many people in there who are elderly in nursing homes or in hospitals who say I don't want everything done. I don't choose to die with tubes coming into me force fed on a respirator. I don't even choose to die in an Institutional setting we might take an AIDS patient as an example that I want to die at home or surrounded by friends. Well, I certainly don't want to be in the business of seeing medicine imprison people in our Holes in nursing homes or do things in there? They don't want now may happen that we could save some money to buy finding out whether people actually want things done to them and what it is that they do want their many people out there who want everything there are others who don't unfortunately the system right now. It's ethos is to respond full-bore with everything for everybody. It's very hard not to have things done to you. So I think what we have to do there is think a little bit more about how we can have patience indicate their wishes and desires so that perhaps we can have treatment be more appropriate with what individual patient values are (00:34:17) back to the telephone for more comment from dr. Arthur Caplan Our Guest today on midday and we'll take your question right now. Hello. Hello. I wanted to get back to the question of the organs from the babies. I'm a little bit confused upon where you know where the line is being drawn with I guess he's babies. Our blind some of them with 9/10 their brain missing a you know, and they're dying. Now I've heard of a case that one lasted for about a year here in the Twin Cities. And so I'm wondering you know, where where is the line drawn when you measure a prediction of the the amount of time this baby is going to live and compared with condition. I mean, how do you make a distinction between giving care and love to that baby as opposed to giving care and love to another baby who may die within you know a week the transplant anyway, and you know is in our purpose in life to to give nurturing and love to the people around us no matter what their condition. (00:35:31) Well, I think there are a number of points that the caller makes that Merit comment. The first is one of these babies capable of doing what what what is their mental and cognitive life? Like the defect of anencephaly is a clear and distinct category of baby. It is not sort of a slippery slope from these children down to those with retardation or those who have mental illness of those who have other birth defects. It's a very precise diagnostic category and I guess what I'd say about what characterizes these babies are they are dying and they are born without the ability to think feel or suffer. They do have reflexes. And if you put a very painful stimulus next to them, they will withdraw but in fact that is a function not so much of mental life as it is what the spinal cord and reflexes will do with painful stimuli, but I don't think the Can think or feel it is true that some of these children have lived more than a couple of weeks. I know of one documented instance of an and cephalic baby living for five months. That baby was however, given respiratory support and was fed artificially and given fluids intravenously so that you can't have the baby live unless you kind of assisted in its living. What's interesting here is that the listener and others may know we had a huge controversy in this country about the treatment of babies born with congenital defects the so-called dispute about baby doe and we have a federal law that mandates that when newborns are born. They get maximal care the one exception to that is the and cephalic baby so that even public policy in this country makes an exception right now for the medical treatment of these children. I think the moral question then becomes a final point. Is it right to kill someone or hasten their death? If your goal is to try and get tissues or organs for others? I don't want to deny the fact that some have said these kids are so severely defective that we are treat them as dead and simply proceed. I don't agree with that point. I think where we draw the line is we don't allow anyone to hasten death. We don't allow anyone to kill another human even one with this devastating defect. What we do is attempt to determine in good faith when that child has died. What's interesting is if you put that baby on a respirator at Birth the worst that can happen is the baby will prove you wrong and continue to breathe if you take the respirator away. I don't think you're going to violate anything about the child. If you take the respirator way in the baby cannot breathe. I think you can to say at that point. This child can't breathe spontaneously if the other signs and symptoms clinical signs and symptoms of death are there that's the time to declare death and go on with the organ (00:38:18) procurement of a number of other callers waiting to ask Of Our Guest dr. Art Caplan will get to you momentarily. I do want to ask our to comment for just a minute at the most two on a slightly larger question related to organ transplantation. How serious is the shortage of organs donated organs in this country for transplantation purposes (00:38:41) timely question and has a Minnesota twist as a matter of fact, which I'll get to in one second the shortage of severe there are approximately 50,000 people who die each year under circumstances that will allow them to be an organ donor that is to say they died in car accidents motorcycle accidents head trauma. They suffer brain death of that number about 15% actually wind up being an organ donor every year I would say well the easiest way to capture the shortages that every day at least one child dies for want of an organ donor. There are probably right now in the United States seven to ten thousand people awaiting a kidney transplant. I would guess they're at 500 on waiting list for a heart transplant at least 500 for livers and an assorted unknown numbers easily in the thousands waiting for other kinds of organs and tissues a severe shortage. The problem is really twofold I think. While people want to help they are concerned about the fact that maybe if they identify themselves as organ donors, they're not going to receive aggressive treatment in the hospital. I think this problem of trust. I've talked to lots of people about why it is that they do or don't carry a donor card or do a don't check off their Minnesota driver's license saying donor which one can do and I'm told time and again, I'm worried about that movie Coma where they kept people going just to get their parts or G with all this talk about Cost Containment. If I get injured, I don't want to go in the hospital kind of having this donor status stenciled on my head. Maybe they're going to try and get parts for someone else. Well, in fact the medical system doesn't work that way and the listeners will already know. I'm quick to criticize it when I think it has a problem. But in this case, there's a clear separation between people who care for you if you get sick or injured and those who come around asking about organ donation after your death the people who determine death and who determine the care of the critically ill and terminally ill are not connected to the transplant team and I think that line is Clear and it ought to be clear but it's the one that ought to make us feel secure about organ donation in terms of identifying ourselves as donors. (00:40:47) Should we have a stronger state law perhaps a stronger federal law regarding hospitals Hospital Personnel medical personnel coming to the family and saying will you agree to have the organs of your family member donated? (00:41:02) Well, that actually leads me to the second part in the Minnesota twist. We do have these laws in the past year. We have enacted both a federal law and 40 state laws. Minnesota's just being past two months ago, which mandate that when someone is pronounced dead in the hospital next of kin be approached about the prospect of organ donation. The reason that law exists is because if you look closely at the organ transplant situation, you learn one other fact in addition to distrust on the part of patients and the general public about will I get aggressive care nurses and doctors are reluctant to Approach family members about donation even if you carry a card, if no one asks, if no one remembers if no one considers it a high priority at the hospital which are taken to inquire about this. The card is useless if it's in a purse if it's in your wallet, if it doesn't come with you to the hospital if your family doesn't know your desires nothing is going to happen so that we have to ensure that people are given the opportunity and I am a strong proponent of the right of every individual to at least be given the opportunity to be altruistic to others. That doesn't say they must do it, but they ought to be given the chance to have that gift be made if doctors and nurses don't do this if they don't come and ask when a death has occurred then organ donation rates will suffer in those states that passed those laws. Earliest New York is one that I'm familiar with Arizona's another there have been very impressive increases in the rates at which organ donation and tissue donation. Take place something on the order of 200 to 300 percent increases for example in cornea is available to the blind for transplant. What you learn is that most people most of the time will give if they get asked if no one asks, nothing happens, we better be careful in Minnesota to make sure that our hospitals are doing what the law ask them to do in terms of approaching families. It's one thing to enact a law if you've been around this racket a while. You also learn that you've got to make sure that it gets complied with I'm not persuaded yet that the citizens of Minnesota are being served by their medical and nursing Personnel by their hospitals in the sense in which they are zealously trying to comply with the existing state law in this one. So that's something I think we ought to be keeping an eye on during the next few months during the next year or two to make sure that people get the right to donate organs and tissues if they want to do (00:43:25) that about 15 minutes remain in our conversation with Arthur Caplan and we'll go back to the telephone for more questions. Thank you for waiting. So patiently you're next. Thanks very much. I believe it was dr. Kaplan who wrote a letter to the Minneapolis Tribune this past summer. I believe criticizing a series of hearings on problems and medicine or medical mistakes. I thought that position probably would sit well with the Physicians who works with but seems kind of strange to me for professor of medical ethics. I thought so then I'm wondering if he could comment on whether he believes that people should be have access to information about medical (00:44:03) mistakes. I'm a little low that respond to that question just because it always gets my dander up when people say I'm loathe to go after my doctor friends, I'd beat them up constantly around the you and I know they'll be shocked to hear that I was ever gentle with them. But the collars talking about a problem. That's a very real when it comes back to cost comes back to this business of efficacy assessment. He's talking about what are we going to do with the impaired physician and do existing mechanisms in terms of physician licensure and Medical Board review do the job in terms of weeding out the bad apples in the profession the AMA by its own. Gives out numbers that two to five percent of Physicians are impaired due to senility drug addiction alcohol abuse or simply being out of touch with medical progress in terms of doing a good job as a physician. I think the statistics were last year that we pulled licenses from about one one thousandth of 1% of existing Physicians. So the policing mechanism doesn't seem to be doing the job. There was a hearing held in New York City just before I came out to Minnesota by some New York State officials in which they got themselves worked into a tizzy about this and that's what I was writing a letter to the Tribune about they basically said look we've got to make sure that these boards do their job and toughen up the reviews. I think that the board's aren't going to be able to do the reviews adequately because I think it's very hard for Physicians particularly those in small towns are in communities where they're very few Physicians to kind of police each other. It's a typical thing to do for my own experience if I've come across professors in Universities that I've taught at that I thought were inept or impaired. I find it very hard to go to a Dean or a university president say my colleague is impaired. I think something should be done people would view me as a snitch or a rat or someone. They wouldn't want to work around. It's a tough thing to do. I think the way to go here is not so much reviews. Although I wouldn't do away with them, but I wouldn't put much stock in then I think what we need to do is think about certification and relicense sure. I mean, let's face it. We do a better job with airplane pilots and bus drivers in terms of and ourselves in terms of updating our drivers licenses that we do with our doctors. It doesn't have to be an extensive or cognitively taxing examination my joke used to be if we could simply send out a postcard asking all nurses and doctors to fill out their name address social security number and get it back within two months to the State License Board weed weed out more people that way than by all the reviewing and legal procedures that we now go And I only mean that is half of a (00:46:42) joke. Alright other callers with questions for our guests. Dr. Arthur Caplan and back to the telephone for another one. Hello, you're on the air. I am a nurse in the Twin Cities area currently going to the graduate program in nursing at the you are one of the concerts that I've had is the lack of communication among the graduate programs in health care and actually in the legal profession the area of Ethics strongly impacts on all of us and I think it might make some sense to have folks from who are in school in the various professions to be talking to another one another prior to getting out into the workplace and I'm wondering if there are any plans to try to do that. I've heard of some of the efforts in the past and unfortunately, they very often seem to be kibosh by the medical school, but I was wondering if there's any kind of thing up. What at the you to try to get these folks talking to each other (00:47:44) well in a couple of ways that's going to happen all of the programs that we put on our going to involve persons, you know as appropriate from different parts of the Health Sciences and from other parts of the University when we began the program I pointed out that our Center is administratively a part of the University. It's not part of any school or Department within the universe and that was done intentionally to allow us to do exactly what you're talking about to draw on the resources of the university and indeed the community other hospitals in town and around the state and try and get people talking across Fields And across professions. All of our research groups will be organized that way and if I can really engage in the exercise of total vanity the course, I'm going to teach starting next starting actually this week graduate seminar in medical ethics has the following enrollment it has for Physicians. It has for medical students. It has four nurses two journalism students one Public Health person and one Pharmacy students. Oh, oh and excuse me for philosophers. Forget my own field. So it has a nice mix they're all students assumedly, they'll be able to work off their disciplinary and professional biases upon one another and then we can get down to some real business of doing some ethics but I agree with the collars remark and and the thrust of it in the sense in which this is the area where we really should try to break down some of these professional barriers and let some honest talk go on about intro professional (00:49:04) ethics another caller on the line with the question and we'll have your question answered by Art Caplan. Go ahead. Well, I like to ask how our per capita medical costs Compares with the per capita medical cost of the European economic community and if how ethical questions on per capita and medical costs if how they're resolved in Europe has any influence on how we resolve them here? (00:49:35) Well, we spend the greatest percentage of gross national. On health care of any Western Nation. I don't know what the expenditures are in the Soviet Union or in People's Republic of China, but I do know that we are up at the 11 percent level about it's really about 10.8 the British spend approximately 7% And the rest of the European economic Community is a RAID between seven and nine percent. Roughly Japan I know is spending at about a 9% rate the question. I think that those numbers might lead one to think about is well what really is too much. I mean, we've had a lot of talk saying that it's too much but what does that really mean? Does it mean we're not getting our money's worth doesn't mean that anything that goes over double digits in terms of gross national project is by product is by definition too much an argument could be made that we ought to spend 15% and I might try to make that argument if I was persuaded and maybe the public would be supportive if it were persuaded that what medicine has to offer what health care has to offer really does good if we can't make the case. That expensive interventions that routine care is efficacious. Then I think we're in a tough position trying to justify any budget number. What do we have to learn from the Europeans and others about rationing and allocation a lot of people in medical ethics and a lot of people in health policy think we have a whole lot to learn particular from the British and they keep writing books about how the British have shown courage and gumption and drawing lines like no dialysis over 55 and no neonatal care for most premature babies because they don't build the units and no transplants after all they're probably more transplants done at the University of Minnesota and they were done in all of England, maybe all the United Kingdom. They just they have one liver transplant program and very few other high-tech sexy sorts of medical interventions. I think that we don't have to go there to find out how things will work. I think we can study ourselves. How do we respond to scarcity? Even with this 11% expenditure? Let's not forget. We have 30 million Americans who have no medical insurance. We have a system that basically allocates on the basis of Ability to pay we have a system. Also, if one looks at a feel like transplant that uses Psycho Social as well as economic factors to distribute its resources. So I'm skeptical a little bit of moving across cultures across boundaries National boundaries where you're trying to draw lessons from a Sweden or in England. We've got a pluralistic society. We've got a big Society. We've got a society that's highly mobile. We have a society with a kind of social structure that has a very few analogs around the globe. I guess I'd be interested in what the Canadians do because they look relatively close to us and yet they do seem to be able to deliver to deliver their care sheet more cheaply than we do. But in terms of the European experience, I don't know learning about what eight million swedes do we have the same religion who all look alike who basically can get around their country within you know, 1/2 days travel. I'm not sure that's the the model that we want to use. And of inspire us to think about allocation issues I say that knowing I'm in Minnesota, but I picked it for that reason. (00:52:45) We just have a few minutes left to talk with you Arthur Caplan. I want to throw at you a few other issues that we can only deal with on a fairly superficial level, but get your thoughts on nonetheless euthanasia or allowing people who are ill to die of their own free will if you accept that terminology, where do we stand in Minnesota currently and if there are some national examples which you feel further illustrate where we may be headed in this direction go ahead and mention those (00:53:14) two. We have controversy brewing in Minnesota because we've got a couple of bills coming up in front of the legislature this session on so-called living wills, which are basically directives that people would fill out while competent about the kind of care that they would want. Should they become incompetent and fall into a terminal condition the the points of real tension are those who believe that a person should be able to Reject any and all forms of care anything one can imagine including food and fluid and those who would say look it's one thing to say no to antibiotics. It's one thing to say no to the artificial heart. But when you start saying let people refuse or let food and fluid be taken away from an incompetent person or terminally ill person. You've crossed the line from medicine into the realm of basic human dignity and human relations. So what counts as a treatment is going to be an issue debated in Minnesota's part of those bills. How much autonomy do you want to give to people who whose competency was impaired before they made any statement? That's another confusing area and who should be making the decisions for them committees Physicians family members. What if the family member has an economic interest? That's not Square. Let's say with the patient's Health and Welfare families have been known to come in and say gee that Uncle George is costing us twenty five hundred dollars a day to keep him in that Intensive Care Unit. He's a Years old anyway made it would be better if Uncle George kind of passed on at this point and we kept his resources. So we're going to have to look at that issue National examples. I think the trend has been this in about six court cases and I can almost rattle them off. They become a kind of Liturgy of medical ethics their cases like Bouvier in California their cases such as Conroy in New Jersey Brophy in Massachusetts in the States of Maine and Florida and the Corbett case courts have been coming down pretty firmly on the side of patient control patient autonomy. The answer at the national level to the kinds of questions. I've raised has been people have a right to refuse whatever they want. And whether we agree or disagree about what constitutes a treatment in the end from the American jurisprudential tradition from the American moral tradition, it is personal choice that ought to guide Medical Response to these tough questions. I don't know that's the direction that Minnesota will go in but I think that's The direction that the nation has been moving in at least through its court system in responding to many of these termination of treatment allowing to die kinds of cases if I can to let me add one other issue. We're going to have a discussion soon. That's going to be one. I'd thought we wouldn't get to for 10 years, but there is a push on in California to talk about not withdrawing or withholding things. But to legalize active euthanasia for people who are suffering or for whatever reason say I want to die now there is a push on and I think it's going to get enough signatures to get on as a legislative referendum in California to legalize active killing by physicians. There is one nation that has dabbled with this to some extent and that's been Holland Holland has decriminalized active euthanasia. There are certain steps. That one has to go through not the least of which is getting the consent of the intended recipient of this beneficence, but we're going to have a discussion soon. I think that's going to be quite heated and one that I have some very strong feelings about But the morality of it I'm not a fan of this. I'm not a proponent of it but we are nonetheless going to get into a debate about the legitimacy not simply a passive efforts that is withdrawing and withholding things taking things away, but active steps is it ever ethically and legally legitimate to kill someone using medical (00:56:57) means? All right Arthur Caplan. Thank you very much for coming by and maybe with some luck. We'll get you back into a month / about this stuff. Again. Arthur Caplan is a PhD in Philosophy from Columbia University who is currently director of the center for biomedical ethics and a professor of philosophy in surgery at the University of Minnesota in Minneapolis a job. He has held for several months now, we'll have a minute to check the weather forecast information after this word.