Ethics Takes Root at HMS
By Lynn Peterson, MD
After 2 years studying moral philosophy at Oxford, I returned to HMS in 1985 as an Assistant Professor of Medical Ethics in the Dept. of Social Medicine and Assistant Professor in the Department of Surgery. I had trained and then practiced general surgery at the Brigham for 18 years and taught at HMS for 10 of those years. I chose to go to Oxford based on discussions with a number of people including Sisela Bok, Ed Pelligrino and Ed Hundert. When I left in 1983 there were elective courses in medical ethics at HMS but no appointments in ethics; my task upon returning was to build something more substantive.
Leon Eisenberg, Chairman of Social Medicine at the time, was very supportive in my returning to HMS and in creating space and support. Deans Tosteson, Adelstein and Federman were also helpful in many ways.
One of my first charges was to create a course in medical ethics that would fulfill 2 of the 10 credits in social medicine and biostatistics required for graduation from HMS. A course that fulfilled the graduation requirement was a major step in recognizing the importance of the subject matter in the education of a physician. Such courses were precious symbols that departments and faculty valued highly. To receive this distinction the proposer had to appear before a committee of senior professors. With support from Leon, I put together a course outline and syllabus and was invited to appear before the Committee.
I will never forget that interview; I gave a brief discussion of the material and how the class would be organized, etc. Then the senior faculty asked questions. One of the first questions asked by one of the most revered senior faculty was “How can you teach something like “ethics”?; there’s NO TRUTH IN THERE.” he proclaimed. Obviously there is something about “ethics” that involves values and principles often regarded as distinct from factual, empirical truth. On the other hand, which I tried to address in my answer, there are many lessons or approaches to ethical issues, historical examples and legal precedents which are important insights. Fortunately the chair of the committee, Miles Shore, was an ally and the committee approved the course.
A couple of years later, Harvard created a University-wide program in professional ethics with the title of Program in Ethics and the Professions headed by Dennis Thompson. While Dennis’s appointment was in the Kennedy School, he was a great supporter of ethics in the medical school as well as elsewhere at Harvard. I became the medical school’s representative to the Program and served in that role for the next 15 years. The first group of Fellows included Ezekiel Emmanuel an HMS graduate who has getting a PhD degree in politics with Michael Sandel at the time.
Soon after creation of the Program in the Kennedy School, work was begun to create a Division of Medical Ethics at HMS. A Division was felt to be necessary in order to bring together a number of people working in ethics in the hospitals as well as many who would not be members of the Department of Social Medicine but be members of other Departments often working in the teaching hospitals. Precedent Divisions were the Division on Aging and the Division of Primary Care. Senior faculty who helped create the Division were Ken Ryan, Leon Eisenberg, John Stoeckle and Dennis Thompson.
Ken’s unwavering support was especially important because he was Chair of Ob/Gyn and a highly successful researcher. Most important, he had been head of the landmark, national medical ethics commission which produced the Belmont Report in 1982. This Report addressed major issues in medical ethics on a national scale. In the early discussion of the Division, a question was raised as to where its office would be located and Ken offered to have it in the new building dedicated to research in Ob/Gyn. Upon further discussion however, it seemed more appropriate to have the Division’s headquarters in Social Medicine for more collegial connections and efficiency.
The Division was launched with a day-long program on medical ethics in 1989 with Dan Brock as one of the major speakers. The Division’s Executive Counsel included Linda and Ezekiel Emanuel, Troy Brennan, Alan Brett, Lachlan Forrow, Ruth Fischbach, Ed Hundert, Martha Montello, Jim Sabin and Bob Truog. With the help of Dennis Thompson and the central office of the University, the Division received a grant of $1.2 million over 5 years from the DeCamp Foundation headquartered in New York City. This grant went to support education, research and further training in ethics for physicians, nurses, lawyers, etc in the medical school. After a positive review by the Foundation, the grant was extended for an additional 2 years.
In 1996, seven years after the Division began, the Dean created an outside review panel to visit HMS and assess what had been accomplished and make recommendations for the future. Dan Callahan from the Hastings Institute, Ed Pellegrino a physician from Georgetown’s Kennedy Institute and Rebecca Dresser a lawyer-ethicist at Case Western Reserve comprised the evaluation team. The panel was very impressed with what we had accomplished; a meeting with a group of medical students, for instance, was particularly laudatory.
The Visiting Committee however felt the Division needed to grow. Arthur Kleinman was the Chairman of the Department of Social Medicine and agreed with the need for the Division to grow and I was asked to lead a major increase in teaching, research and ethics programs. This would mean becoming full time in the School. I had been practicing surgery half time ever since returning to HMS and enjoyed clinical work. Indeed, for me ethics was anchored in the patienbt-doctor encounter and the life of a physician. I always had patients come to some classes with students to discuss things like informed consent, substituted judgment and end of life care.
After much thought and discussion, I decided to step down as the Director of the Division. Allan Brandt took over as Director. At the same time in 1997 the Brigham decided to have an Ethics Service and I was invited to be its Director. This was a perfect solution for me to remain active in ethics and continue practicing surgery. As a co-investigator in the Robert Woods Johnson SUPPORT Study, I had realized the importance of an ethics function in hospitals; it provided an opportunity for patients and families to deal with complicated, serious life threatening decisions with support in individual and family meetings. We hired a nurse ethicist and an administrative assistant. As a result we increased consultations from 25 to more than 100/year, organized and supported Schwartz (compassionate care) Rounds, organized ethics training for Partners hospitals, held annual reviews with an outside ethicist, twice monthly ethics committee meetings, surveyed practices of cardiopulmonary resuscitation and the use of Advance Directives in hospitalized patients.
While ethics has been an integral part of medicine, especially for doctors, since Hippocrates’s Oath, it has waxed and waned as a formal part of medical practice and teaching. In the 20th century advances in biological science, chemistry and physics made medical education ever more deeply anchored in basic sciences. Indeed people with MD degrees were making discoveries in basic science and PhDs in chemistry were discovering things directly relevant to medical practice. Since then medical education has continued to advance by making bridges between practice and basic science.
As a result curriculum and learning exercises of the 60’s and 70’s were filled with the roots of medical science leaving little room to formally address the human needs in clinical practice. While clinical courses often included instruction in polite, appropriate behavior there was little formal study of the sensitive ‘emotive’ issues confronting clinicians. Communication, Team-based care and Patient-Centered Care, now standard topics, were not in the curriculum.
By the late ‘70’s ethics began to take root in medical education. A number of events led to this: the controversial Karen Quinlan case, increasing worry over clinical trials, litigation over the standards of informed consent and public battles over abortion and organ donation were some of the key issues.
Over the past 10 years serving on two ethics committees, teaching at Dartmouth, Medical School, doing ethics-related clinical research and serving on several health care boards, I believe ethics has the role of deeply humanizing medical care. It liberalizes health care by giving legitimacy to the narratives that form the basis of the doctor-patient relation. It makes it appropriate for students to express their fears and anxieties and it promotes team-based care integrating nurses, physician assistants and social workers to make effective health care interventions.