The future of clinical bioethics

0:00Alyssa Burgart:This is Stanford Engineering's The Future of Everything, and I'm your host, Russ Altman. Since we started this show eight years ago, it's become an archive of amazing and impactful work by my Stanford colleagues. Research is not something that just happens in the lab, and as you'll hear on this show, the research at Stanford can impact areas like health, technology, law, and business, and many other topics that can affect everyday life. We hope you'll tune in to learn more about how research has the potential to help your life and to help the lives of people you care about in your family and your community.

0:32When we talk about bioethics, we're talking about what are the values that are driving the decisions that we're making. So whether you're a patient and you're going to see your doctor or a nurse practitioner and you're trying to get some health information, you're trying to get some care, there's a lot of ethical issues that come up there. What are the risks and benefits of the medication that you're considering taking? What are the treatments that you're considering and how do those fit within the things that matter to you in your life?

1:03Alyssa Burgart:This is Stanford Engineering's The Future of Everything, and I'm your host, Russ Altman. I just want to remind you that you should follow the show, press that button, so that you get notified of all the new episodes the moment they come out. Today, Alyssa Burgart will tell us that bioethics is an important component of medical care. This is a specialty where people can help make tough decisions, end-of-life decisions. should I get that procedure? I can't agree with my spouse or my family about how to proceed with my medical care. These are all questions that are not just medical, they're ethical as well.

1:35Alyssa Burgart:It's the future of clinical bioethics. Today we're continuing our feature, The Future in a Minute. At the end of my conversation with Alyssa, I'll ask her some rapid-fire questions and she'll give me some rapid-fire answers. And before we get started, please remember to follow the show, press that button so you get alerted and you never miss the future of anything.

2:00Alyssa Burgart:So when we go to a hospital, we expect medical professionals who have deep expertise in medicine, expertise about how to make treatments, how to do diagnosis, how to understand how a disease is likely to progress. But that's not the only kind of information we need. Sometimes in the hospital, we get difficult ethical and moral decisions. What do I do about my loved one who's in a coma and who doesn't look like they're going to come out of it ever? What about my loved one or myself who is experiencing incredible pain that can't be controlled with any pain medication? Or there's a new procedure.

2:36Alyssa Burgart:Should I try it or is it too risky? These are ethical questions. It's not just about medical knowledge. And guess what? There are trained professionals who are experts in what's called bioethics or biomedical ethics. How do we look at a situation medically and how do we help a patient and their providers make the best decisions? Well, Alyssa Burkhardt is a professor of anesthesiology and perioperative pain, and she is an expert on bioethics in addition to being a clinical anesthesiologist. She'll tell us how they run a consult service to help physicians who are in the middle of difficult situations and difficult decisions, how they make those decisions.

3:16Alyssa Burgart:Alyssa, you're an anesthesiologist, you practice anesthesiology, and yet a lot of your work is in the area of bioethics. How did that happen? Yeah, thanks for asking. I'm sort of a weirdo in bioethics in that I was a bioethicist before I decided to become a physician, which is not typical. And so my undergraduate degree is in bioethics, and I worked as a clinical ethicist at Cedars-Sinai after college. And then I worked at UCSF in the institutional review board doing a bunch of research ethics. And then I went to medical school. And while I was in medical school, I also got a degree in bioethics and health policy because I'm a masochist and I didn't think that one degree was enough.

3:56Alyssa Burgart:As a bioethicist, how the heck did you choose anesthesiology? I have thought, I thought in medical school about being lots of different things. I started off thinking maybe I'll be a palliative care doctor or I'll be an oncologist or I don't know. I was very, very close to applying to be a surgeon because I loved the operating room. And then I did an anesthesia rotation like on a lark and very last minute, I'm talking like weeks before you had to submit your applications for residency, I switched because I had a wonderful person who ended up becoming a mentor who was like, no, you're one of us.

4:35and really taught me how people joke that like, oh, all of our patients are asleep. So anesthesiologists don't like to talk to people, but I love, I get to have a first impression, like multiple times a day. I get to meet people who are strangers. I call it talkesthesia. I get to talk to people and before I give them any medicines, I get to learn about them and, and, uh, try to help provide a, a safe environment for them because I am a stranger when they meet me and I need to not be a stranger, especially for people who are handing me literally their children. So yeah, it's a wonderful job. I love the operating room.

5:11It's like I get to work with the coolest people and I meet lots of wonderful patients.

5:18Alyssa Burgart:Okay, great. How can you give someone who doesn't think about bioethics all the time, can you give us a working understanding of what it means? Even ethics might be a little bit tricky for people to get their arms around, but certainly bioethics. So what are we talking about when we talk about bioethics? When we talk about bioethics, we're talking about sort of the, what are the values that are driving the decisions that we're making? So whether you're a patient and you're going to see your doctor or a nurse practitioner, and you're trying to get some health information, you're trying to get some care, there's a lot of ethical issues that come up there.

5:50What are the risks and benefits of the medication that you're considering taking? What are the treatments that you're considering and how do those fit within the things that matter to you in your life. Clinicians are also dealing with these issues where they're weighing the risks and benefits of treatment. And as I mentioned, I worked in research ethics before. And so when we're working, much of bioethics, much of modern bioethics actually comes out of the origins of research ethics because human beings who are engaging in research deserve special protections. And there's a lot of ethical issues that come up there as well.

6:22So, you know, in a, there are people in the hospital who say like, I'm their, I'm their walking conscience that they can, you know, reach out to me when they're struggling with a difficult decision that relates to the values that they're, they're trying to connect with, with the integrity of being a caregiver or with a family who's dealing with difficult decisions. And so, um, you know, in its most basic thing, if you imagine like, you know, the cartoons where you've got like the good character and the bad character, I'm trying to actually present both views and try to help people understand what are the complex trade-offs involved.

6:56Alyssa Burgart:So you're both the angel and the devil. Yeah, that's my goal, is to really try to present both. Now, you said that, you know, you said something about your colleagues think of you as like their conscience, but now you certainly don't want physicians to outsource their own ethical thinking. So how do you manage that where you can be and you have skills and thoughtfulness about all of these issues, and yet you certainly want to help your colleagues like raise their level. So how do you do that balance? Yeah, it's one of the things that's really fun about being a clinical ethicist is that, you know, when somebody reaches out to me, a lot of times they're in some sort of a state of overwhelm.

7:34They're dealing with an issue that they've never dealt with before. It's something that's very complex. And one of the things that our ethics service does and that I've learned to do is how do I help take that complex thing that seems very unmanageable and help this person to articulate like kind of what boxes do each of these things fit in? Because some of it's like not a problem. You're doing a great job. You should keep doing whatever you're doing. But then when there's areas where they're really trying to weigh how should they respond as an ethical physician, as an ethical nurse, as an ethical leader, how is it that I can help them to identify the values that are most important to them?

8:12How can they stay in alignment with their integrity while providing excellent care. And so certainly the goal is never to let people out. I don't want to be like doing everyone's decisions for them. That would be very dysfunctional. But I do really enjoy working with, you know, people who are really deeply connected with how do I do the right thing when all the choices seem bad.

8:32Alyssa Burgart:Now, you said ethical service, and I know a little bit about this and people may be surprised. If I'm not mistaken, you actually are like a consultant, Like when people know that we're in the hospital and if you get like a fever, then your doctor might call the infectious disease expert to come in and write a note and evaluate. And if I'm understanding it, it's a very similar situation for ethics where they say it's not an infection. It's a hard problem where they feel this sense of being overwhelmed. So could you walk me through like how do you get consulted and then how does it work? Do you speak with the patient as well as the physician?

9:07Alyssa Burgart:It just sounds like a very interesting thing that I think would surprise many people. Yeah, I think you've done a great job explaining it, which good job. And we have a pager service. So we actually have people who are assigned to be the person you can reach if you are in a situation where you think there are complex ethical tradeoffs. And so we have services for both our adult hospital and our children's hospital. And so I work on both of those services. And so, for example, a clinician might send us a page or a message on our secure app saying, hey, I want to talk to you about this particular patient situation.

9:48And they do exactly the thing that they would do if they were consulting, let's say, a cardiologist or that infectious disease doctor. The person who calls us gives us a presentation about, you know, this is this patient. These are the conditions that they currently are facing. And these are some of the things that we're struggling with in terms of how do we help guide decision making? How do we help determine how to how to work with this patient or with this family in order to help them decide what's best for that patient?

10:17Alyssa Burgart:Yes, yes. That really is great. And is that routinely available in most hospitals or is it kind of an optional thing that some hospitals do, some don't? It's interesting. There's a lack of uniformity, certainly, across the United States. Stanford has been very ahead in terms of being available to clinicians regularly. And we also, for example, document in the patient's chart. So we meet with families, we meet with clinicians, we meet with administrators, and we actually document our recommendations in the chart, which also serves as education for people who weren't necessarily in those conversations directly.

10:55And so for other parts of the country, different hospitals have different features. And in even the 20 plus years that I've been doing clinical ethics consultation, clinical ethics has gone through a big round of professionalization. So just in the past few years, there's become a national certification, for example, to be a health care ethicist. The Joint Commission, which is a accrediting body for a lot of hospitals, requires that there be some mechanism to deal with ethics issues in a hospital. But in a lot of hospitals, it's sort of like a nice person who's willing to help have those conversations and they might have a committee.

11:34We are very fortunate at Stanford that we have two very robust systems that are robustly supported by the hospitals because they recognize that there is a real value in helping folks to address the significant moral distress and moral injury that can come from being in these situations without support.

11:53Alyssa Burgart:Yeah, that makes really good sense. And it's exciting to know that there's like a move towards certification and making sure that the quality is quite good. Now, I know, of course, you can't talk about specific cases in detail and giving names and addresses, but I would love to have a few example consultations that you might get, either ones that are kind of very illustrative or recently that they're on your mind, just so people can get a feel for the kinds of questions you get asked. They might be surprised. In my work at the children's hospital, it's always fascinating because I love working with kids.

12:29I never thought I was going to do pediatric ethics, by the way. When my very first job, when I was at Cedars-Sinai, I thought that the ethics issues related to children were like the most tender. They were the most painful. You're like working with families of dying children. And I just thought, oh, I am never going to do that. And then here I am running this clinical ethics program. Yeah. And I became a pediatric anesthesiologist after become, you know, I was an adult anesthesiologist and I specialize in pediatrics. I love having those relationships with families. And, um, I don't know, there's like a special kind of person who's willing and not afraid to work so closely with families.

13:06And so in working with, with kids, we really get to see people from, I'm embedded in our maternal fetal medicine program. So for example, we hear about cases where a baby hasn't even been born yet, and there's families who are facing ethical questions about what treatments are not to pursue after a baby is born, for example. And then through the lifespan, and I really love helping guide clinicians and families through how do we make developmentally appropriate decisions for these kids, and how do we include patients as they age in ways that empower them and to help them with their developing autonomy.

13:45And so that they can have, um, be participants in their healthcare to the degree that they're, that they're ready to, and to also help support parents who are also, you know, parenthood, it's like the ultimate amateur hour. And then you add critical illness on top of that. You have families that are going through just incredibly intense experiences. And so I really appreciate, um, I especially love working with teenagers. I really like the opportunity to both empower teenagers to express themselves as well as having their parents kind of learn to help those teenagers really take the lead, especially when they're facing a complex illness.

14:22Alyssa Burgart:Yeah, you know, I always I always stalk my guests before I speak with them. And I know that you wrote a paper about a I think it was like a pregnancy decision where the parents and the and the and the I guess the new mom was were at odds about how to manage the delivery. And that was very interesting. Yeah, it's, we're so lucky. Like, I think when I tell people outside of medicine what I do, or, you know, you're like in the neighborhood, it sounds terrifying, I think, to most people. Like, not only do I do this pediatric anesthesia thing, which also sounds scary, but the fact that we're the kind of people who really lean into that discomfort and lean into conflict rather than avoiding it.

15:04And for me, it's something that it gives me great meaning in my life, but it also really, I find it really empowering to be able to partner with patients, families, and clinicians who are just struggling with some terrible decisions. What treatment do I have after my baby's born? I didn't expect that I was going to have to deal with this particular topic. And now I've got to make life altering decisions that are going to completely change our family's lives. Working with families of whether they're children or adults who are dying, How do I help highlight the agency of the person who's involved and really elevate the human dignity of every single person that we care for?

15:46Alyssa Burgart:So that's very important. And I wanted to ask you specifically about how cultural differences factor into your practice. So as you approach a situation with a family, maybe they have a very strong faith. Maybe they have cultural expectations or cultural beliefs about the role of medicine or pills in their lives. How do you navigate that? And I guess you're trying to help them make the best decisions while also kind of, I guess, factoring in these kinds of considerations. Yeah, it's I always like to lead from a place of curiosity. And that's a skill that I have had to like, I am a know it all by my nature.

16:24Like I am a know it all. That's why like, I've made lots of decisions in my life. And so I have really had to consciously as a as a communicator, be like, wow, you got to tone that down. And so I'm, I've really spent so much time and we work with so many of our consultants to be like, okay, but like, what if it wasn't about you? And we work about that with clinicians, we work on that with clinicians as well, to be like, okay, just let's be as absolutely curious as possible rather than judgmental. And I think that medicine, there's lots of think pieces right now about how medicine is in a crisis of trust.

17:01And there are many very important reasons why people don't necessarily trust doctors and nurses the way that they did in the past. And I think that it's so important that we lead by being trustworthy and by showing trustworthiness through our actions. And so, for example, you know, I kind of love it if somebody has really specific beliefs and they're willing to share them with me. One, it's an honor for people to share the things that are absolutely most important to them in their lives and how it is that they're thinking about their decision making. And it's also this dance of like, okay, I'm hearing that this is your value.

17:38How do I share this other information or how do I facilitate a conversation with you and your clinicians who are coming from very different places? And how is it that we can try to really lean into that relationship rather than try to do what I think medicine has had a tendency to do, which is to dominate? Yes.

17:58Alyssa Burgart:You know, I have training as an internal medicine doctor, and I remember, especially in the hospital, that, you know, the very difficult cases are often when the family itself can't agree on how to go forward. And so maybe the patient is involved, maybe not, but it almost doesn't matter. They can there can be siblings and parents and spouses and children. And so it can be a huge orchestrated conversation. And I'm assuming that one of your skills is doing all of that orchestration of the family and the patient, of course. And then there's all the caregivers who have their own set of opinions. And I know from your writing that you actually consider all these perspectives as an important integration.

18:41So like, how do you do that?

18:43Alyssa Burgart:Like these are critical and they're also very often time critical decisions. It's not like we have seven weeks to make this decision. So how do you approach these consultations? And it must be exhausting. It's invigorating sometimes. And I've had to learn to, I always joke, there's like an emotional hangover after you've done a really good job and, you know, being attentive to that. But one of the things that you just said, for example, like as being an internist, I think it's funny that people who are afraid of taking care of children for whatever reason, they're like, that's not my jam. I don't want to deal with like kids.

19:19But it's these skills actually about family communication that I have found are the most transferable to adult care and can be such a powerful addition. And it's part of actually why we've really pushed all of our consultants to learn how to do consults across the age spectrum because families are part of these decisions in almost every aspect of life. We certainly have some patients who are estranged from their families or don't have a lot of people to support them, in which case the ethics committee steps in to try to act on those people's behalf. But when we're dealing with a family that has a lot of different opinions, and let's say the patient's voice is not quite as present because they're in a coma or they have a severe neurologic disorder or there's something else physiologically going on that prevents them from participating, we really try to, again, lean into that curiosity with these families of like, well, first of all, who knows this person really well?

20:14And who can give us the most information on what this person might have wanted for themselves? If they could tell us what they wanted, what do you think they would tell us? And tell us all about that. And I remember even from my very earliest experiences, you know, right out of college, helping to facilitate some of these conversations with a much more senior ethicist, that, you know, there's just families come in all shapes and sizes. and, you know, there's a lot of dysfunction that shows up when people are stressed and they're someone that they love and care about, presumably, is the person who's in the hospital.

20:53And like, we meet people on their worst days. And so I feel like the best that we can do oftentimes when, as ethics consultants, we're stepping into that conflict space is like, how do I stay emotionally regulated to hold the conflict that is happening here and try to help people find the areas where, wow, you guys heard the same stories from this person. Let's talk about what that might look like in reality. And how do we make it so that we can really honor, again, the inherent human dignity of this person who's suffering, whether it's from a recoverable illness or not? How is it that we can walk that together?

21:32Alyssa Burgart:You're listening to The Future of Everything. I'm Russ Altman, and I'm speaking with Alyssa Burgart. Don't forget, at the end of the episode, we'll have The Future in a Minute, where I'll ask Alyssa some rapid-fire questions. And she'll give me some quick answers. We've been talking about bioethics and how it manifests in the hospital and in the clinic and what the issues are that come up. And I wanted to move to a little bit of more focus on clinicians. So you write about something called moral distress and moral injury in clinicians. So can you unpack that? What is that? And why is that a topic of concern?

22:05Sure. I'll address, I'll actually talk about moral injury first, just because it's an older, it's an older concept. really came out of military veterans and the fact that, you know, these people were coming back from war zones and had a lot of psychological symptoms that, you know, we talk a lot about PTSD now, post-traumatic stress syndrome, but what really pioneering psychiatrists and psychologists and chaplains who are working with veterans really saw like, wow, people are having, they're actually having existential crises about who they are and where are they situated in the world in terms of their integrity having been exposed to war.