From Codes to No Codes: Loma Linda University Alumni Postgraduate Convention Wrestles with Bioethical Themes and Cases
David R. Larson
Bronwen F. Larson
Ronald R. Garet, a professor at the University of Southern California School of Law, launched an entire morning devoted to a consideration of themes and cases in bioethics by delivering the Jack W. Provonsha Lecture at the Loma Linda University School of Medicine Alumni Postgraduate Convention on Friday, March 7, 2014.
The Center for Christian Bioethics and the Clinical Ethics Consultation Service at Loma Linda University organized the event. Roy Branson, Associate Dean of the School of Religion, is the Center’s Director and Alice Kong is its Coodinator. Gina Mohr, a doctor who specializes in palliative care at the Loma Linda University Medical Center, is the Director of the Consultation Service. Donna Carlson-Reeves, a doctor and lawyer who studied with Professor Garet at USC, helped arrange his visit to LLU.
The title of Professor Garet’s Lecture, which he selected from Abraham Lincoln’s First Inaugural Speech as President of the United States, was “My Ancient Faith.” By his own account, Garet “held a mirror” to LLU’s School of Medicine by thoroughly and appreciatively commenting on its Physician’s Oath.
He pondered other oaths as well. These included medieval and more recent wedding vows, the oath for the California Bar, and an oath required of prosecutors in the state of Tennessee. In addition, he commented on the Provisions of the United States Constitution, the Oath taken by the all nation’s presidents and a speech Lincoln gave at Peoria, Illinois on October 16, 1854.
Garet’s presentation, which was almost an hour long, was aesthetically and intellectually rich. As Roy Branson and others observed, it was more like a religious meditation on sacred texts than a typical academic lecture.
Although professionals have many different callings, Garet contended that they are all summoned to greater faith/faithfulness/fidelity. In the written version of his speech, he separated these words with forward slashes rather than spaces in order to emphasize that he was using them as synonyms that point to the same thing. This one thing is understanding and being shaped by fidelity to one’s commitments, especially when they are executed with oaths.
Garet recalled Lincoln’s appeal to the unity that prevailed among the states that eventually became a single nation before they had a formal constitution. This “ancient faith,” Lincoln held, should guide the nation when its Constitution did not fully answer all of its questions. Garet held that in a similar way we should be guided by our “ancient faith” when we face new and perplexing legal and ethical challenges.
Roy Branson led a panel discussion in response to Garet’s presentation. Brian Bull, a pathologist who has served as Dean of the School of Medicine, reviewed the development of the current LLU Physician’s Oath.
David Larson, a professor in the School of Religion and one of this report’s authors, incrementally moved backward in time from what “fidelity” often means in popular culture today to the theme of “loyalty” as God’s faithfulness or steadfast love in the Bible.
Among other things, Michael Orlich, a doctor and researcher at the School of Public Health, reflected on the moral ambiguity of taking oaths and why those in Biblical times viewed them in different ways, some positive and some negative.
Donna Carlson-Reeves, the doctor and lawyer who helped arrange Garet’s lecture, commented on the experiential significance in her life of taking the oaths of both professions. She also addressed what seemed to be a major concern of many in the audience. This is the tension doctors increasingly feel between their responsibilities to their patients, on the one hand, and their obligations to employers, insurers, government policies and so forth, on the other.
In the second session, Gina Mohr led a panel of doctors who work under her leadership in the LLU Clinical Ethics Consulting Service. These were Tae Kim, Marquelle Klooster, Grace Oie and Karja Ruh.
“C.P.R: Right or Rite?” was this panel’s theme. Its members discussed several cases that differed in their clinical details but posed the same ethical question. This was: “What should doctors do when patients, or more frequently their loved ones, demand interventions like Cardio-Pulmonary-Resuscitation when it is virtually certain that these efforts will not succeed?”
In addition to tracing the history of resuscitation efforts and their relatively recent success, the panelists reviewed the statements of professional societies which indicate that such interventions should be used only in acute cases when it is likely that they will succeed in returning the patient to his or her former life, or at least something acceptably proximate to it. They should not be used in chronic cases, especially when terminally ill patients cannot benefit from them.
The panelists emphasized that doctors should recover the power that they have been losing to patients and their loved ones. They called for a partial return from the principle of respect for each person’s autonomy toward a modified or chastened form of medical paternalism. One panelist bemoaned the fact that now “we sometimes allow patients to dictate what will be done.”
The panelists observed that many issues that are thought to be ethical are actually clinical. A Do Not Attempt Resuscitation order is a “package deal” they pointed out. This means that patients cannot choose some components of them but not others as though they were making selections from a food menu.
They held that doctors should not wholly place the burden of making difficult decisions on the moral backs of patients and their loved ones; rather, because they are more knowledgeable and experienced, doctors should make clear and strong recommendations, calling upon the Ethics Consultation Service, if necessary, when patients object.
In at least one of the cases that the panelists approvingly discussed, a doctor unilaterally wrote a Do Not Attempt Resuscitation Order contrary to a relative’s wishes and the patient died. This probably clarified who had the most power. Or did it?
Answers to this question depend on our answers to a prior one: Coercion or persuasion: Which is the most powerful? If the ability to force people is the measure, orchestrating the time and manner of patient's death by unilaterally writing a Do Not Attempt Resuscitation Order is impressive. But If it takes more power to persuade people than to compel them, it isn't.
Perhaps like everyone else, doctors are strongest when they patiently work with others until they achieve consensus about what should be done instead of abbreviating this process by unilaterally doing what they think best. Although coercive power is sometimes necessary, it mght also be a sign of weakness.
The panelists would probably agree with this suggestion because their overall point was that dying patients or their loved ones now have too much power and doctors don't have enough. Having said that, we have to brace ourselves for the possibility that not everyone feels sorry for doctors. Not even all doctors.
Tae Kim, an emergency room doctor on the panel, took a somewhat different approach. Although he, too, regretted how much power he had sometimes “accidentally given” to the families of patients, he lingered with the idea that for many people drastic interventions like C.P.R. are more like “rites” than “rights.” In my words, they are “rituals” which are akin to the ancient Christian sacrament of “extreme unction,” and similar formalities in other cultures, in that they “liturgically” mark a person’s passage from “here” to “the hereafter.”
Kim’s way of thinking about these things, informed as he said it is from his study of literature and cultural anthropology, has several advantages. One of them is that provides an alternative to distilling these difficult cases to power struggles between doctors and patients. Another is that it encourages doctors to probe more deeply into why patients or their loved ones are making their demands. Kim made this point himself when he said that doctors would do well to spend more time listening to patients and their loved ones in hopes of becoming better acquainted with the “narratives” of their lives. This, in turn, would seem to provide yet another opportunity. This is the option of developing different “rites” that are culturally satisfying but medically more appropriate.
No one explored any possible relationships between the presentation on “faith/faithfulness/fidelity” in the morning’s first session and the discussion of “C.P.R.: Right or Rite” in its second. This was disappointing. Constructing conceptual bridges between what the professor said about “codes” and what the panelists said about “no codes” would have been enjoyable and useful!