Notes in the Margin - 4 December 2024
Time-limited trials, writing, harm, and more
Notes from a Family Meeting is a newsletter where I hope to join the curious conversations that hang about the intersections of health and the human condition. Poems and medical journals alike will join us in our explorations. If you want to come along with me, subscribe and every new edition of the newsletter goes directly to your inbox.
Every so often, I’ll share things I’ve been reading with a few words of mine scribbled in the margins. If you have something to share, please do! The comment section is open.
We Have All the Time in the World: The Law and Ethics of Time-limited Interventions in Clinical Care
A partial review of the (American) law of end of life decision-making, providing justification for the more frequent use of time-limited trials. In fact, the authors argue that any life-sustaining therapy should be offered only a time-limited basis. I do wish the authors explored the legal and ethical landscape of what to do at the end of a time-limited trial when patients or surrogates choose not to honor it. The authors don’t really address what happens at an impasse with a medically therapy that isn’t absolutely “futile.”
The Hippocratic Society Podcast: What It Means to Be Human with Carter Snead
John Rhee and Michael Egan engage a conversation with law professor and bioethicist, Carter Snead, about what it means to be human. What kinds of value judgments are we making when we behold someone with severe dementia and claim they “died long ago?” What are we saying when we affirm someone’s evaluation of their own life that they’re “better off dead?” Is it true that the barest unit of what it means to be human is the individual will?
observes that “to the writer, writing matters, which makes it more difficult.” Writing is a “productive struggle” as the writer grapples with all aspects of bringing some thought in their mind onto the page in a clear, concise, compelling way. Writing really is thinking. I wish more clinicians would write outside patients’ charts, because that form of writing is itself formative of a particular kind of thinking (and many clinicians’ documentation practices are abysmal, supporting Warner’s point). Clinicians can do hard things. Writing should be one of them.Clinical ethics consultation faces some problems - and not just the kind it’s intended to face. Matthew Shea distinguishes “real ethics” (the pursuit of what is believed to be objective moral truth) and “conventional ethics” (the adherence to norms bound by consensus). Current clinical ethics consultation depends on conventional ethics. However, it still faces the same challenges in a morally pluralistic environment while leaving important moral questions unaddressed and really doesn’t meaningfully help people.
Can AI Make Medicine More Human?
Adam Rodman traces an abbreviated path through the history of how clinicians have used technology to help with their decision-making, leading us to this moment with artificial intelligence (AI). He’s got mixed feelings: “Large language models are not a panacea for medicine. In fact, I’m pessimistic about how some of these technologies are currently being rolled out. And these models will not fix larger problems, such as the cost of care or access for vulnerable populations. But never before have I been so hopeful about a future where technology truly helps me be a better human being instead of trying to convert me into a data entry clerk whose primary job is to collect information.” I doubt very much that AI can help us be better humans because there’s nothing inherent in the technology itself to help guide us in that direction, and we won’t drift in that direction on our own.
Abram Brummett argues that mere concerns about harm are insufficient to overrule a parent’s refusal of treatment for their child, the classic example being the refusal of a Jehovah’s Witness for their child to receive a life-saving blood transfusion. Admittedly, I don’t know the exact spiritual concern Jehovah’s Witnesses have with blood transfusions, but Brummett poses it as if it’s a matter of eternal salvation. Thus, it certainly sounds more harmful to lose one’s eternal salvation than to die, but the state, in allowing hospitals to overrule parents on this issue, makes not just an ethical judgment, but a metaphysical judgment (i.e., receiving a blood transfusion won’t cause you spiritual harm). This touches on a long-running debate among clinical ethicists as to whether they are moral experts or not. The American Society for Bioethics and Humanities (ASBH) argues they are not; clinical ethicists should focus on process (I previously addressed this concern). But if that’s the case, they should also pursue metaphysical neutrality and allow the children of Jehovah’s Witnesses to come to easily preventable (physical) harm. Brummett agrees this is an odious conclusion, and encourages ethicists to reach some consensus about their metaphysical commitments. There’s more to be said on that, as I think consensus about metaphysical commitments will be just as hard, if not harder, to reach than consensus on ethically fraught issues, but Brummett does highlight a substantial bind for modern clinical ethics.
From the Archives
Here's something, only a little dusty, that new readers may not have seen.
As I’ve traveled through my career in medicine, I’ve met clinicians who have twenty years of experience, and other clinicians who have had one year of experience twenty times over. One of the differences between the two, it seems to me, is wisdom. Simply sticking around is no guarantee that one will accrue wisdom, because experience and wisdom aren’t synonymous. What does it mean for a clinician to be “wise?” How does wisdom relate to the goals and limits of medicine?
