Dr. John Lawrence
The moral code of medicine originates in the fact of human illness and in the act of a professional. As a moral enterprise, medicine is grounded in a covenant of trust. The classic clinical encounter of doctor and patient is duplicated around the world: an individual asks for help from a caregiver who professes to be morally and technically competent to help him. That professional then does what he feels is “right” for that patient.
For millennia, the selection of what was ethical and correct care was within the purview of the physician. In the mid-late 20th century the discernment of what was “right” in medical care and ethics began to be challenged. The world and its population were changing.
Following WWII, the rate of medical and technical change greatly accelerated and concurrent societal changes occurred as well. The rights of the individual consumer were increasingly emphasized. Public awareness and education about medical science and health care increased. Resultant change in societal and personal expectations of medical care occurred. Questions raised by individuals, families and an ever-widening group of health care professionals about specific care given to individual patients were vigorously raised and debated.
Over time numerous medical events challenged the “old medicine” to face new dilemmas that modern change had wrought. “New ethics” had to evolve in the right way to meet new medical issues (and their potential unforeseen challenges). Memorable medical issues included:
- The advent of hemodialysis in the 1960s (scarcity, cost and rationing)
- Cardiac transplantation (a new definition of brain death)
- The appearance of deadly HIV/AIDS (1980s) – (professional responsibility to provide care despite personal risk/physician assisted suicide)
- Widely publicized cases of patients with severe, non-resolving neurological injury (futility in care/withdrawal of care)
There was wide societal divergence in the understanding of what would be acceptable ethical determination of decisions made in value-laden areas. There was no ethical structure available on which to answer the questions raised. Forthcoming from scholastic sources were principles on which modern ethical health care (the new field of bioethics) could be consistently applied to individual patients and their specific needs. Widely accepted now are principles that respect and assure individual autonomy, justice (fairness) and good care.
Medicine in Asheville and WNC did not remain immune to the rapid and consequential changes taking place in the rest of the world. Mission’s place as a specialty center and a technologically advanced site placed it at the forefront of need for leadership and change.
To facilitate this change, a physician-led effort to create an institutional program of bioethical education, consultation and hospital-wide cultural change was initiated. Approved by medical staff leadership in late 1990, the Mission Institutional Bioethics Committee was formed in 1991. This institutional entity was strongly supported by the administration and hospital board.
All participants in support of this effort asked this question of themselves: How can we adapt our medical delivery to the values of individual patients and walk together with them as, together, we face the dilemmas confronted in modern medicine?
Critical to committee inception was the selection of a highly respected membership. Personal breadth and depth, as well as societal and professional diversity, were required. Balance within the committee was found in the local community and region as well as within the hospital. The role of members of Mission’s chaplaincy service was critical in application of programmatic function as well as being its face in the hospital on a daily basis.
The program began with efforts to educate committee members about ethical areas of greatest concern (e.g. medical futility and withdrawal of care; informed consent). To facilitate this educational process, a professor of philosophy from a nearby out-of-state university attended and contributed to the depth of our meetings. A consultation service was established and became a capable, readily available resource to all areas of care within Mission. Consultations were reviewed and used as educational tools at regularly scheduled committee meetings. The ultimate goal of every consultation was to enhance communication and maintain the primacy of the spirit of the ethical culture within the hospital.
Based on the great foundational effort in the bioethics program made by many talented, committed individuals, there was strong belief and expectation that the institutional bioethics program would continue to survive, grow and contribute to the health of our community. Mission and its professionals would continue to seek to do what was right for our patients.
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John E. Lawrence, M.D. is a cardiologist and founding Chairman of the Mission Institutional Bioethics Committee
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