Institute Brings Moral Dimension to Healthcare Policy


Mike Field
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Staff Writer


     A 22-year-old mother of three is admitted to the hospital
ready to deliver her fourth child. During admissions she insists
that, for  religious reasons, she will not accept blood or blood
products, even to save her life. The attending physician,
however, is no less determined to do whatever it takes--including
blood transfusions--to prevent the patient from dying and leaving
three young children at home without a mother.

     If the patient's delivery had turned into a crisis situation
(in this case it did not), who would make the ultimate decision?
Is it ethical for a physician to let otherwise healthy young
patients die simply because they object to certain treatments on
religious grounds?

     Ethical conflicts are nothing new to the medical profession,
where decisions are frequently of a life and death nature.  

     "Medical ethics has been around as long as there's been
medicine," said Ruth Faden, professor of health policy and
management in the School of Public Health. "What is different now
is that previously, most of the discussion took place between
doctors among themselves."

     All that has changed in the last two decades, Faden said, as
the concept of patient's rights was born amid the technological
revolution of modern medicine. 

     In this time period medical technology made dramatic
advances, often without serious consideration being given to the
ethical ramifications of each new procedure or discovery.

     "Organ transplants are a perfect example," Faden said.
"Suddenly the technology was there without any social consensus
as to who would go first. There is a very limited supply of
available organs. How do we decide who should get them, and in
what order?"

     Organ transplants can become a difficult and even
controversial subject, as the recent media attention surrounding
baseball Hall-of-Famer Mickey Mantle's liver transplant made
clear. And, say medical ethicists, organ transplants are just one
example of a broad array of issues that cannot be decided without
some reference to a system of ethical beliefs.

     Should fetal tissue be used to develop new treatments for
devastating illnesses? Under what conditions should trials of new
vaccines against HIV be allowed? May organs be harvested from
people who are not "brain dead" but stand no chance of recovery?
How should information about genetic predisposition to disease be
used?

     The range and complexity of issues is as broad as the
medical profession itself.

     In order to bring the moral dimensions of health policy and
medical care to the forefront of scholarship and practice, the
university has created the Bioethics Institute of The Johns
Hopkins University. Announced last month at a special ceremony on
the East Baltimore campus, the new institute will draw together
faculty from across the university to study the moral and ethical
questions arising in the medical, biological, public health and
social sciences. It will be led by Faden, who has gained national
prominence as a medical ethicist for her work as chair of a
presidential panel investigating Cold War-era radiation
experiments on unsuspecting human subjects.

      "Historically, the term medical ethics was used to describe
ethical issues that were directly related to the medical or
nursing professions," Faden said. Issues such as "right to die"
cases and quality of life decisions typically fall within this
category.

     Now however, with the tremendous advances of molecular
biology and the simultaneous changes in health care delivery,
ethical issues often transcend simple medical decisions.

     "We have called it the Bioethics Institute in order to
include medical ethics and go beyond," said Faden. "Every new
advance seems to come with a host of ethical issues. For
instance, the Human Genome Project will identify every human
gene. But what are we going to do with this information? Is there
a right to genetic privacy? Already we are seeing the language of
genetic discrimination begin to emerge."

     Faden's designation as director of the Bioethics Institute
included appointment as the first Wagley Professor of Biomedical
Ethics. 

     The newly endowed chair was named in honor of Philip F.
Wagley, associate professor emeritus in the School of Medicine,
who is widely remembered for having delivered the first lecture
in medical ethics at the School of Medicine nearly 20 years ago.
He subsequently co-directed the school's first course in medical
ethics until his retirement in 1987. 

     As director of the institute, Faden will report directly to
university provost Joseph Cooper. Currently located on the fifth
floor of Hampton House on the East Baltimore campus, the
institute plans to include faculty with appointments in the
schools of Arts and Sciences, Medicine, Nursing and Public Health
as funding becomes available. The intent, said Faden, is to make
the institute a truly university-wide resource that can provide
an integrated intellectual base for students, faculty and
researchers in all relevant divisions.

     "Hopkins is uniquely well-balanced, with considerable talent
in ethics, health policy, nursing, medicine and public health,"
she said. "I believe we have a duty to use our resources to help
develop new concepts in bioethics. If we don't do it, we are
failing to live up to our obligations as a teaching institution."


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Bioethics Institute to 
Address Medical Values

     The creation of the Bioethics Institute represents the
culmination of an ongoing effort to address ethical issues in
medicine and health care on a systematic basis at both the
university and the hospital.

     For more than a decade the hospital has had an ethics
committee and consultation service composed of physicians,
nurses, social workers, chaplains and others. 

     "Physicians are trained to perceive themselves as
individuals who do whatever is in their patients' best medical
interest," said committee chair Peter Terry, professor of
medicine in pulmonary and critical care medicine. "Sometimes the
treatment prescribed by the physician can be in conflict with the
values of the patient or the patient's family. In that situation
the ethics committee will try to advise parties on how to think
about problems. Our role is not to give them facts. Our role is
to lead them through a way of thinking about ethical dilemmas so
they can arrive at their own decision."

     In addition to serving as an on-call consultation service 24
hours a day, 365 days a year, the committee also publishes a
quarterly medical ethics newsletter distributed to more than
5,000 nurses, physicians and others in the hospital system.

     Occasionally, the committee will play an advisory role in
formulating ethical guidelines and policy. One example of this
concerns the refusal of members of some religious groups to
accept blood as a life-saving measure. In an emergency situation,
advises hospital policy, if a physician was unwilling to let the
patient die and there was no other physician available, blood may
be administered against a patient's wishes.

     The ethics committee also sponsors the annual Shallenberger
Medical Ethics Lecture. On June 13, at 5 p.m. in Hurd Hall,
Dartmouth School of Medicine professor Joanne Lynn will talk
about opportunities for excellence in care of the dying. 

     "The one major success of modern medicine is the creation of
long, slow dying," Lynn said. "What we haven't done is learned to
find ways of making the process free from pain and degradation. I
will be speaking about what can be done to improve the quality of
life at the end of life."

     The Shallenberger Lecture is free and open to the public. A
reception will follow in the Doctor's Dining Room.
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