Institute Brings Moral Dimension to Healthcare Policy Mike Field -------------------- 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." ----------------------------------------------------------------- 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. -----------------------------------------------------------------