Finding the conjunction of good medicine and sound ethics | Features

Kabasenche designs, oversees, and delivers the ethics component of university medical curriculum. “I might come in and do an afternoon on end-of-life decision-making for patients with cardiovascular disease,” he says, describing how he weaves ethics topics in varied medical classes. “It’s very hard to make ethical judgements in the abstract. But depending on the context, the details of a particular case or a situation, then the students and I would be thinking together about what would be good or best or right.”

Asked about his talk’s question about whether or not an unethical doctor can be effective, Kabasenche has a ready answer. “In some cases there is a close alignment between being effective and being ethical,” he says. “We could say if someone’s being ineffective in certain domains, that means they’re also being unethical. And then in those same domains, if they’re being unethical, that also means they’re being ineffective.

“One way I could know I’m dealing with an unethical provider is if the care they give is not going to be effective in one respect or another. To use one example, if a provider had financial conflicts of interest that led them to make judgments about what was best, for instance, what’s the best medication for me to take? Did the financial conflict of interest affect their judgment and lead them to, say, want to prescribe a medication from a company from which they’ve received money in the past? Then the drugs being a poor fit for me could be a strong indicator that something ethically problematic was going on. One really striking example is that there’s research showing a clear overlap between the places where pharmaceutical companies invested a lot of money to encourage doctors to prescribe opioids like Oxycontin. Take a map of places where a lot of money was put into encouraging physician prescription writing, and then overlay that with a map of where a lot of opioid addiction and deaths occurred. Unfortunately, those maps line up really well. That’s an example of a place where there’s a close connection between ethics and effectiveness.”

Kabesenche states there is a database that lists medical professionals and facilities and what payments they receive from drug and medical devices companies (it’s openpaymentsdata.cms.gov/search.) “And there’s a separate database where you can find out what drugs in general they have prescribed over the past year,” he says. “Investigative researchers have gone in and basically combined these two databases, and they show what, by this point, we should expect. And that is that when doctors take money from drug companies, they tend to write prescriptions for the products of the companies from which they take money.”

Knowing this happens clearly is of benefit to patients. Are there other useful pointers a person coming to the presentation Monday can expect to gain?

“When you’re near the end of your life, either you or someone on your behalf will be making really big decisions,” Kabasenche points out. “For instance, whether to continue treatment, what kinds of treatments to pursue. In a very real way, this affects the quality of a person’s death. There’s research that shows that patients who have not given much thought to how they would like to die, what a good death would look like, their default is that they’re going to be given a lot of interventions. There’s other research that shows the more intervention that is done to you at the end of life, generally speaking, would match with what most people describe as a low-quality death.” Research shows the more consideration given to how one dies is directly proportional to the quality of passing. Then there are issues such as physician-assisted suicide, abortion, and performance enhancement, among many others.

“Part of the talk [Monday] will be where medicine and ethics are relatively less controversial partners. But there are other areas of medicine and ethics where it’s not at all uncontroversial. There’s a lot of controversy. And so another part of my talk will be inviting the audience to think with me about how we can address those especially contentious issues. There are some ways in which ethics is built right into the core aims of healthcare. The stakes are very real. It’s not just an academic debate; it very much affects the quality of people’s lives, the integrity of the practice of healthcare providers, and all kinds of related matters.”

Then there’s that reference in the presentation description about “good” help. What is “good?” That, after all, is a topic of philosophic debate for millennia. Kabasenche immediately talks about a Harvard Medical Center study of the effects of placebos.

“There may be a placebo effect just from the kind of confidence that a patient places in a doctor,” he states. “It’s how a doctor elicits by how they present themselves to patients.

We have a course in our medical curriculum at WSU that’s called the Art and Practice of Medicine. And that’s because it really is an art; it really is something you practice at. It’s not just a matter of taking hard science and applying it algorithmically to patients who could be replaced by numbers. You have to engage with a real person. You have to treat a whole person. You don’t just treat a cancerous organ or a broken body part or a failing organ system. You treat a person. Treating a person requires the provider to also be a person and to engage at a level of humanity and decency that is going to meet the patient where they are. It’s eliciting a sense of confidence from the patient that, ‘I’m here to help you. I’m committed to helping you. The reason that I get up and put on my white coat in the morning, because I want to help patients.’ Some bioethicists have likened this to a covenantal relationship. It’s not a contract. If it’s a contract, you and I make a contract, maybe I’m going to sell you my car. We agree to terms: you’re going to give me a bunch of money, and I’m going to give you a car. Each of us comes away with something that we want, but those things are unrelated to one another.

“In a covenant, what we share in common is literally shared in common. Sometimes people will liken a marriage to a covenant relationship in the sense that the good of the marriage is a thing that is shared between the parties. So if you think of a provider-patient relationship as a covenantal relationship, then it’s defined by the good of the relationship, and the good of the relationship is promoting the wellbeing of the patient. That’s why both the patient and the provider are in the room. They’re both there for the same reason, which is to promote the wellbeing of the patient. There is a kind of ethical responsibility if you’re entering into this profession. You need to recognize that you are there to treat patients, real human beings. And that will require you to engage with them as a real human being. And that will include among other things, that you are presenting to them a kind of confidence that you will not abandon them.”

Kabasenche is being brought to Goldendale by Klickitat Valley Health (KVH). KVH’s Director of Support Services Jonathan Lewis explains why the hospital had a special interest in creating this event. “I met Bill at a conference on ‘The Anatomy of the Soul’ in Walla Walla,” he says. “He told me about his relationship with Humanities Washington and how his department has been giving talks in rural communities around eastern Washington. I asked more about how it worked and then pitched the idea to the senior leaders at KVH.

“I was mainly intrigued by his ability to address very hard questions without being divisive. We also had a very interesting discussion about the importance of rural communities taking control of our own healthcare needs.”

Lewis believes the event will be of interest to a wide range of people. “People who are interested in healthcare and its hard questions should attend,” he adds. “We have sent out special invitations to the medical providers at KVH, Skyline, and MCMC [Mid Columbia Medical Center, now called Adventist Health Columbia Gorge]. I’d especially encourage people who have deep problems with the current state of healthcare—maybe even people who have some trauma related to a healthcare experience—to engage and help us have a civil conversation about those concerns. The more we share together and work on the difficult questions, the more we will be able to leave the next generation with more humane systems and solutions.”

Kabasenche says he’s looking forward to being here and putting his hard-earned education to work. His PhD is in Philosophy. “I went to a graduate program at the University of Tennessee that at the time had a very strong focus within the philosophy department on biomedical ethics,” he states. “I picked that program because one of the components of the curriculum I did there was six months of rotations through the University of Tennessee Medical Center, so I could see how ethics plays out in actual clinical settings. I had a friend once who joked that I’m a blue-collar philosopher, in the sense that I care about philosophy as it shows up in our everyday lives, not just sort of abstract, ivory-tower kind of theoretical thing. I do a lot of theoretical work but always with an eye toward how this matters in real lives.”

So kids, when you tell your parents you’re going to major in Philosophy and they ask you how you expect to make a living with that, now you know what to tell them.