DOWN THE TRUMP RABBIT HOLE – 14 April 2020

Hi. I thought you would be interested in the communication (inserted below) I sent earlier today to the 170+ surgeons (most are faculty members in Departments of Surgery across the country, with a few either surgery residents or non-academic surgeons) who comprise the surgical ethics working group my friend/colleague Dr. Kodner (WashU emeritus colorectal surgery professor) and I have nurtured over the past decade. This communication is #31 in the ‘Surgical Ethics Education Resources’ series I began sending the working group in May 2018. Be safe! And much love! Doug/Dad

[Sent – 14 April 2020 to the 170+ surgeons et al of our Surgical Ethics (Education) Consortium]

Good morning. For ‘Surgical Ethics Education Resources #31’, I am sharing with you an attempt during the COVID-19 pandemic to raise awareness of and to press for insight into the disproportionate risk, suffering, and death faced by vulnerable ethnic populations among our patients. Here in St. Louis, patients residing in predominantly African American sections of the city are tracking toward the worst scenario public health models while the city overall is tracking toward the best scenario public health models as the peak for a COVID-19 surge reaches St. Louis. Not surprisingly, the overall impression absorbs (conceals?) the experience of vulnerable sub-sets of the city’s population. One of our BJC network of hospitals is located in the hardest hit section of the city. For the past decade, I have led the hospital’s ethics consult team and am now assisting the hospital’s recently constituted COVID-19 triage team. Last week I sent to these front-line medical staff and nursing staff leaders (as well as to the hospital’s full ethics committee) links to four recent newspaper articles in the St. Louis American. For more than a century, the St. Louis American has reported local, state, and national news through an African American lens. Issues are published weekly, available throughout the city, and free. I have inserted below the links to these four St. Louis American articles as examples of a way to alert, to remind, and to encourage caregivers to be mindful of those easily overlooked and poorly understood as they make/implement excruciating decisions about (re)distributing severely limited resources. I hope you have a few minutes to take a look. What patient groups in your communities are experiencing disproportionate risk, suffering, and death during the COVID-19 pandemic? I suspect your communities have resources such as the St. Louis American that draw attention to these patient groups (essentially call for ‘respect’, meaning to be seen). How can you use these resources to advocate for those patients too/so easily missed on the margins/periphery of who is included in ‘the public’, ‘the community’, in ‘we/us’? Doug

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http://www.stlamerican.com/news/local_news/black-st-louis-left-behind-in-covid-19-testing-supplies/article_c70a05f4-7451-11ea-8571-832f999891aa.html

http://www.stlamerican.com/news/columnists/guest_columnists/why-north-st-louis-city-needs-a-covid-19-testing-site-now/article_59851be4-7029-11ea-8a47-33453dfbc765.html

http://www.stlamerican.com/news/local_news/covid-19-and-structural-racism/article_65fb3012-79c4-11ea-8cf9-e336755de3ea.html

http://www.stlamerican.com/news/columnists/guest_columnists/now-is-the-time-to-prioritize-older-adults-before-it-s-too-late/article_23c02c8a-72b1-11ea-bb49-8b8e17551334.html

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DOWN THE TRUMP RABBIT HOLE – 29 January 2020

Earlier this week, the 75th anniversary of the 27 January 1945 liberation of Auschwitz was widely recognized. I was reminded of two timely articles re the classic Atlas of Topographical and Applied Human Anatomy that was created by a Viennese anatomy professor (Eduard Pernkopf) and his team during the Nazi years who drew the remarkably detailed illustrations from dissections of victims executed by the Nazis. One article is a personal essay by Susan Mackinnon, MD, published last week in the British Medical Journal. Dr. Mackinnon -- a senior plastic surgery faculty member in our department -- was the lead surgeon in the surgical case that anchors the second article. This second article – published in the journal Surgery last year -- is a comprehensive analysis of the sensitive, complicated, and controversial issues associated with using the Pernkopf atlas in training and in practice. Dr. Mackinnon is the lead author of this second article, with several of us in our department as co-authors. I appreciate the opportunity to have contributed to and to be associated with these two articles. I am inseparably/deeply disturbed by the ironic Nazi echoes/similarities in the dismissive attitudes, ghettoizing policies, and brutalizing tactics by which the government of Israel has for decades -- with the unwavering permission, shielding, and funding of the US government – victimized the Palestinians. I found yesterday’s Trump/Netanyahu announcement especially sickening. Doug/Dad

DOWN THE TRUMP RABBIT HOLE – 20 January 2020

As Martin Luther King, Jr. Day 2020 dawns, I continue to ponder a statement in a brief PBS commentary on today’s commemoration I heard Saturday – i.e., “Dr. King changed the heart and soul of America”. I am saddened/disturbed to disagree. ‘Confronted’, yes. ‘Challenged’, yes. ‘Called for a verdict’, yes. But ‘changed’, no . . . not enough . . . not yet. A decade ago with the energy/anticipation associated with Obama’s 2008 election still invigorating, my reaction to such a celebrating/promising assessment of the struggle King led for expansive civil/human rights would surely have been more affirming. However, the day-after-day-after-day revelations over the past five years re ‘the heart and soul of America’ – e.g., the capacity to fear, to seethe, to bruise/maim/kill recklessly, to disregard the vulnerable, to tolerate poverty, to trivialize truth/facts, to hoard privileges, to idolize capitalism, to demand exceptional treatment in the international community, to . . . – are cause for pause. This darkness in ‘the heart and soul of America’ remains deeply rooted, appears widespread, and now represents (defines?) ‘America’ nationally and internationally. At least for now. The 2020 election in November will reveal for how long. Is there in ‘the heart and soul of America’ the capacity to pivot decisively toward modesty, empathy, sacrifice, welcome, peace, mercy, fairness, integrity, respect, . . . ? toward the image of ‘America’ championed by King and those courageously standing/working in his shadow? I remain hopeful. But we must remain firmly grounded in our core values regardless of the answer/results. Doug/Dad

Surgical Ethics Education Resources #34

[Sent 22 June 2020 to the Surgical Ethics Education working group]

Greetings from St. Louis and WashU.  For ‘Surgical Ethics Education Resources #34’, I am sharing with you (inserted below and also attached) a way to frame surgical ethics with ‘trust’ as the linchpin (i.e., the peg or pin that holds a wheel on an axle, that keeps a wheel from slipping off an axle).  This explanation is the third of seven brief ‘Ethics 101’ promptings I prepared for our surgery clerkship students.   We circulate a prompting every couple of weeks during their 12-week surgery clerkship.  I welcome your feedback about this way to position ‘trust’ in framing the ethical dimension of surgical care.  Doug
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What do we invite patients and their families to trust about us?

Douglas Brown, PhD

Trust is counter-intuitive . . . involves risk . . . is necessary to work . . . requires courage . . . .

‘Fiduciary’ in ancient Roman law denoted the transfer of a right from one person to another person with the recipient’s obligation to return the right either at some future time or on the fulfillment of some condition.  The fiduciary held this right as a trustee with the responsibility to exercise the right on another person’s behalf.  In modern surgery, ‘fiduciary obligation’ refers to the trust patients place in their surgeons to act in their best interests.  The surgeon receives the patient’s trust because the surgeon possesses the special authoritative knowledge and technical skills to which the patient seeks access.  Such knowledge and skills prompt the patient to seek out the surgeon in the first place.  The vulnerability acknowledged by the trusting patient creates a fiduciary obligation for the surgeon who accepts responsibility for the patient’s care.

A relationship this special must be rigorously safeguarded.  Surgeons who prioritize their fiduciary obligation to patients seriously consider conflicts of interest.  Surgeons are among a large and diverse work force that brings to the hospital numerous potentially conflicting priorities.  Many surgeons are engaged in clinical research and in training/education healthcare learners, both being responsibilities that use patients as means to accomplish interests other than the patients’ best interests.  And surgeons have to navigate the availability of commercially-driven surgical innovations that far too often result in eventual injury to surgical patients and even skew professional organization’s technical bulletin guidelines.

Accordingly, the ethical dimensions of patient care can be effectively framed by asking -- “What are we inviting patients and families to trust about their caregivers?”

Each response to this centering question puts into clinically familiar language one of the four basic intentions that are foundational to surgical ethics -- i.e., to avoid adding to the patient’s pain/suffering (non-maleficence), to make a desired difference in the patient’s well-being (beneficence), to align management plans with the patient’s values and goals (self-determination), and to be fair in the use of limited resources (justice).  When surgeons are able to follow through on these four intentions in an integrated way, the ethical dimension of their patients’ care is sound, balanced, in harmony and the surgeons experience what brought them into a surgical career.  For cases in which the ethical dimension of care is shaken or broken, the centering question – “What do we invite patients and families to trust?” -- can be an effective starting point for determining which one or combination of the four intentions has failed to such a degree that respect has given way to loss of confidence, suspicion, adversarial defensiveness.

The trust upon which safe and beneficial care depends is a partnership/collaboration between surgical teams and patients (with their families and friends).  In order for surgeons to follow through on what they invite patients and families to trust, surgeons need their cooperation, their participation, their assistance.  Thus the companion question – “What do surgeons need/expect from patients and families in order to follow through on what they invite patients and families to trust?”  

As surgeons work to avoid harm, they need patients and families to provide complete and reliable information.  As surgeons seek to deliver desired beneficial outcomes, they need patients and families to make a determined effort to adhere to the management plan.  As surgeons establish goals of care that align with patients’ values and preferences, they need patients and families to realize there are limits to what can be achieved.  As surgeons strive to be fair in the utilization of limited resources, they need patients and families to consider the interests of other patients and families.  These clarifications highlight the accountability patients and families bear for following through on the four basic intentions that are foundational to surgical ethics.