Why Bioethics Matters | Robert Klitzman, M.D. | Talks@Columbia

Summary

Highlights

• Dr. Klitzman introduces us to the significance of bioethics in everyday life. 🎙️
• He recounts living with a Stone Age tribe studying a disease similar to mad cow disease. 🌿
• Explores how sorcery and science collided in New Guinea over disease beliefs. 🧙
• Shares poignant personal stories illustrating the clash between medical ethics and real-life decisions. 🏥
• Dr. Klitzman emphasizes understanding the patient's perspective and broader healthcare issues. 👥
• Discusses critical bioethical topics, including autonomy, justice, and the controversy of organ donation. ⚖️
• Highlights the ethical challenges in the rapidly advancing field of genetic engineering. 🧬
• Calls for increased bioethics training in medical education to improve patient care! 🎓

Key Takeaways

• Explore the fascinating intersection of medicine and ethics with Dr. Klitzman! 🌟
• Bioethics isn't just for doctors; it impacts patients, voters, and taxpayers alike! 🗳️
• Dive into real-world dilemmas like genetic testing, organ donation, and patient autonomy. 🧬
• Discover how bioethics helps us critically analyze our assumptions in healthcare! 🤔
• Learn from history's mistakes to build a more ethical medical future. 📜

Overview

Chapters

• 00:00 - 00:30: Introduction of Dr. Robert Klitzman This chapter introduces Dr. Robert Klitzman, highlighting his academic roles as a Professor of Psychiatry at the College of Physicians and Surgeons and the Mailman School of Public Health at Columbia University. He is also recognized as the Director of the Bioethics Masters Program at the School of Professional Studies and a co-founder of the Columbia University Center for Bioethics. The discussion will focus on bioethics, emphasizing the critical challenges and dilemmas, including topics like engineering embryos.
• 00:30 - 01:00: Topics in Bioethics This chapter, titled 'Topics in Bioethics,' explores several relevant and impactful subjects within the field of bioethics. It covers the ethical considerations surrounding designing babies through genetic modification and the implications of genetic testing. The chapter also delves into public health concerns, using the examples of epidemics like SARS, Ebola, and Zika to highlight challenges and responses. Further, it examines the potential over-medication of children and the ethical dilemmas surrounding end-of-life decisions, specifically when to withdraw life support. The Affordable Care Act is also discussed in terms of its ongoing controversies and debates. Dr. Klitzman presents these topics to demonstrate their significance to patients, healthcare providers, and voters, emphasizing their widespread impact on society.
• 01:00 - 03:00: Experience in Papua New Guinea The chapter titled 'Experience in Papua New Guinea' describes the author's experience living with a Stone Age tribe in Papua New Guinea. The author studied the tribe's cannibalistic rituals, which were linked to the spread of a brain disease called Kuru. This disease was later discovered to be the same as mad cow disease, although this was not known at the time of the study. The geographical context of Papua New Guinea is also provided, noting its location north of Australia and east of Indonesia.
• 03:00 - 06:00: Medical Training and Ethical Reflections The initial portion of the chapter discusses the misconception before World War II that central New Guinea was uninhabited due to its challenging geography, steep mountains, deep valleys, and widespread malaria. However, during World War II, the Japanese intended to invade New Guinea as a strategic move to approach Australia. This led to the discovery, via aerial surveys, that approximately three million people lived in New Guinea's jungles, following Stone Age lifestyles. In 1956, Carleton Gajdusek began his work in the region, which becomes a focal point for discussions in this chapter.
• 06:00 - 06:30: Introduction to Bioethics The chapter 'Introduction to Bioethics' explores the discovery of fascinating diseases found in primitive tribes, with a focus on the disease kuru. Kuru was significantly impacting tribal populations, particularly women, affecting up to 90% of them. It is revealed that kuru was caused by prions, which was unknown at the time, and linked to cannibalistic practices. The study of such diseases highlights the intersections of culture, disease, and emerging scientific understanding, framing key ethical considerations in bioethics.
• 06:30 - 09:30: Challenges in Healthcare and Ethical Questions The chapter discusses the intersection of healthcare challenges with local beliefs and ethical questions. The narrator describes a situation where they were tasked to observe dietary habits and their correlation with longevity. However, the predominant belief among the local people was that illnesses were caused by sorcery and could be cured by the same means. This led to significant debates, as the people believed sorcerers used personal belongings in rituals to cast spells, illustrating a clash between traditional beliefs and modern healthcare practices.
• 09:30 - 12:30: Ethical Principles of Bioethics The chapter delves into the ethical principles that guide bioethics, using a narrative to illustrate the challenges and skepticism faced when explaining scientific phenomena to those unfamiliar with scientific methodologies. The story underscores the importance of understanding and empathy when communicating complex scientific ideas, as exemplified by the narrator's interaction with individuals struggling to accept the scientific explanation for kuru, a disease they attributed to supernatural causes. Despite attempts to explain kuru as a disease caused by a prion (something akin to an organism but not visible without special equipment), local beliefs and traditional explanations prevailed, highlighting the ethical dimensions of respecting cultural beliefs while advocating scientific understanding.
• 12:30 - 18:50: Importance of Bioethics Education The chapter 'Importance of Bioethics Education' highlights the challenges of convincing people about evidence-based medicine in regions with strong beliefs in traditional healers. The narrator encounters resistance from individuals who believe in healers that can 'cure sorcery.' A dialogue reveals skepticism towards these healers, who claim success by pointing to those they purportedly cured while ignoring failures. The narrative underlines the necessity of bioethics education to bridge the gap between traditional beliefs and modern medical practices. It emphasizes the importance of informed decision-making in health treatments and understanding the ethical implications of various cultural practices.
• 21:00 - 21:30: Conclusion The narrator discusses an experience with a patient who became ill because they did not follow medical treatment properly. Reflecting on this, the narrator shares insights from their later training as a psychiatrist, where they encountered a medical student patient who was experiencing significant stress due to pressure from their parents to pursue a medical career, despite not wanting to.

Why Bioethics Matters | Robert Klitzman, M.D. | Talks@Columbia Transcription

• 00:00 - 00:30 I would like to introduce Dr. Robert Klitzman. Dr. Klitzman is Professor of Psychiatry at the College of Physicians and Surgeons in the Mailman School of Public Health at Columbia University. He is also the Director of the Bioethics Masters Program at the School of Professional Studies and co-founder of the Columbia University Center for Bioethics. Dr. Klitzman is joining us to discuss bioethics and the critical challenges and dilemmas we face. These dilemmas include engineering embryos
• 00:30 - 01:00 and designing babies, genetic testing, epidemics of SARS, Ebola, and Zika, the possible over-medication of children, questions of when to turn off life support machines, and ongoing controversies about the Affordable Care Act. Dr. Klitzman will explain how as patients, health care providers, or voters these crucial questions affect us all. Please join me in welcoming Dr. Robert Klitzman. [APPLAUSE]
• 01:00 - 01:30 Several years ago, I had the privilege of living in a Stone Age tribe in Papua New Guinea studying cannibalistic rituals that had led to the spread of a disease called Kuru. It's a brain disease. And that we found several years later was the same as mad cow disease but we didn't know that at the time. This is before mad cow disease existed. This is Papua New Guinea. It's located north of Australia, just to the east of Indonesia
• 01:30 - 02:00 and south of the Philippines. Up into World War II, the center of New Guinea was thought to be uninhabited because no one had ever been there. There are very steep mountains and deep valleys with malaria. And during World War II, the Japanese decided they wanted to take New Guinea to get to Australia and suddenly there was a lot of warfare, planes flew overhead and found that there were three million people living in the jungle of New Guinea living in the Stone Age. And in 1956, Carleton Gajdusek, here,
• 02:00 - 02:30 decided that there are probably interesting diseases in primitive tribes around the world and started to go and look for them and study them. And the most famous one ended up being kuru. It was affecting up to 90% of the women in the tribe, 2/3 of the population. And he studied it and found that it was caused by what we now know are prions. But, again, we didn't know that at the time. What we did know is that it turned out to be traced to cannibalistic feasts.
• 02:30 - 03:00 And so he sent me to study who ate and how long it took for them to die. But what interested me most was that the people believed that the disease was caused by sorcery and could be cured by sorcery. And I got into long debates with them. They believed that a sorcerer would take your clothing or something that belonged to you and bury it. And they would wrap it around a stone. And they would put the stone the ground, cast a spell on the stone, and they dig up stones.
• 03:00 - 03:30 And they say, see this stone here, this is the stone that killed my mother. And I'd say, no, no, no, kuru is caused by a little thing like an insect. It's sort of alive. And they said, really? well, show it to us. And I said, well, you need a special machine to see it. And they'd say, well, what does it look like? And I'd say, well, we don't know. We hadn't yet identified it. And they'd say, well, have you seen it? And I'd say, no. And they said, that's just magic. It's a stone that killed my mother.
• 03:30 - 04:00 And I was unable to convince them. Similarly, they thought that they had healers who could cure the sorcery. And I'd say, well, who have you cured? And he'd say, well, all these guys I cured. And I'd say, well, anyone you didn't cure? And he'd say, yeah, that guy over there. And that guy was the one guy who I thought had the disease. These other people look normal to me. And I'd say, well, what's the treatment? And they said, well, for two weeks I say that you're not allowed to drink water or eat salt or touch a member of the opposite sex.
• 04:00 - 04:30 And I give the person some herbs. And I cast a spell on them. And I thought, well, should I stump them? I'd say, oh, well, why did anyone get sick? And he said, very simple. He didn't follow the treatment. He was not a good patient. I thought about these issues a few years later, however, when I was trained to be a psychiatrist. And I had a medical student at one point as a patient, who was very stressed out by being in med school. She really didn't want to be there. Her parents had wanted her to be a doctor. And she would talk about how stressed out
• 04:30 - 05:00 she was but wouldn't think very deeply about a lot of these issues. And I had a strict Freudian supervisor who said, say nothing to her. Get her to free associate. So I said nothing to her. And she started to come late. She started to sessions. And my supervisor said, she's a no-goodnik. She's failed the treatment. End the treatment. And I felt that, again, it was the same kind of thinking that I had seen in New Guinea. And it made me wonder about how do we deal with failure when we as physicians or as healers don't succeed in treating
• 05:00 - 05:30 a patient and how it's easy to blame the patient rather than look at the larger issues of what we're doing. And I became interested in trying to understand the underlying assumptions that we make and to think critically about them in terms of why we do what we do and how we look at it. Similarly when I trained in medicine on my first day as an intern, I was given a list of patients. And I walked in the door to see the first one. And it was a woman who was sitting eating her breakfast,
• 05:30 - 06:00 cutting her grapefruit I remember, and the sun was streaming in. We had a nice conversation. And then I walked out in the hall. And my supervisor saw me, my resident, and said, what have you been doing so far? And I said, well, I just spoke to Mrs. Jones. He said, she's dead. Don't waste your time with the dead. I said, what do you mean she's dead? I just spoke with her. She's dead. Don't waste your time with the dead. And in his mind, she had terminal cancer. She was labeled do not resuscitate. And it wasn't worth my time wasting my time with her.
• 06:00 - 06:30 And then he turned to me and said, and besides, something just came down into the ER. And we should go down and take a look. Something, a patient presumably, a person. And so I begin to realize how important it was to look at the underlying human side of medicine, not just the science of what we're doing but the assumptions we make and the need to pay closer attention to the larger social, psychological, moral, cultural, and ethical issues involved in what we do in health care. And the field that looks at that is bioethics.
• 06:30 - 07:00 Bioethics is a fairly new field. But it looks at the ethical, legal, social, cultural implications of advances in biotechnology and health care. And of course, there are an increasing number of issues in this area that we're all facing every day, whether we're patients, whether we're family members of patients, or whether we are doctors or nurses or other health care providers, whether we're voters or taxpayers. We spend billions of dollars keeping
• 07:00 - 07:30 people live at the end of life when they have no quality of life. And we only have so much money in the system but we have increasing demands. Health care costs are going up. And we can't afford to give everyone as much health care as they want. And so that leaves to a lot of very difficult questions of who should get what. And underlying those are questions of how people make these decisions and how patients and doctors understand what they're doing in terms of what treatment they're giving to people and how we make sense of that.
• 07:30 - 08:00 These issues came home to me a few years ago when my father was in the hospital. He developed leukemia, rising numbers of certain kinds of white blood cells in his body. And the doctors told us that there was no known proven treatment. That he would die in six months. But he said there was an experimental chemotherapy the we could try as an experiment. And with that, there would be a 50% chance that he could live an additional six months to two years.
• 08:00 - 08:30 My father didn't know what to do. My mother who was very realistic said let nature take its course. I, however, was a young doctor. I just trained in medicine. I was convinced that science had answers for us still. And I encouraged him to try the experimental chemotherapy. And he did. And the last few months of his life were terrible. He was nauseous all the time. He was in pain. He said if this is what life is I don't want it.
• 08:30 - 09:00 And it was a terrible last few months. And when he died and when I went to the hospital, the doctor came up to me in the hall and said the experiment worked. The number of white blood cell counts had gone back to normal. But the patient died. And I was horrified. Had I made the wrong decision? Had I encouraged him to make the wrong decision? Had I pushed him the wrong way? And I suddenly realized what it was like to be on the other side of these decisions, to realize that, again, where as doctors may see
• 09:00 - 09:30 the choices and the science in one way, that for family members and patients it was very difficult to understand all the issues involved. I thought the doctor had been overly optimistic that we didn't really understand and appreciate the risks involved that his life could actually be worse for the next few months as is what happened. So bioethics is the field that looks at these issues, at the ethical, legal, social implications of advances in health care and biotechnology.
• 09:30 - 10:00 And there are four key underlying ethical principles. One is autonomy, respect for the individual. One is beneficence that we should try to do good. One is non-maleficence that we should avoid harming people. And the other is justice, a sense that we should do what equitable for society as a whole. We shouldn't just be helping wealthy people at the expense of poor people, et cetera. And each of these has an interesting history. Autonomy, for instance, really came
• 10:00 - 10:30 to a lot of attention bioethics as a result of what happened with the horrific Nazi experiments during the Second World War. The Nazis, for instance, wanted to see how they could help their soldiers on the Eastern Front survive in the cold. So they decided they wanted to measure how long people could survive in the cold before dying, before freezing to death. And so they took people in concentration camps and put them in the cold and measured how long it took for them to die. No informed consent.
• 10:30 - 11:00 No respect for the individual having a say over what happens to his or her body. Yet, these concepts can also be quite difficult. So we all believe in justice. And yet people define justice very differently. So there are those who say with Obamacare, for instance, the Affordable Care Act, that justice is that we should give a certain amount of health care to everyone. There are others, however, who oppose that who say justice is if I give more money, put more money into the system, I should get more out.
• 11:00 - 11:30 And if I put less into the system, I should get less out. Others may say that justice is everyone gets the same, whether you need a lot or a little care, you just get the same. Communism. But these principles can also compete. So with autonomy, for instance, there are those who say that we should allow people to buy and sell human organs. That if I have a kidney and I want to earn $20,000, $30,000 dollars by selling my kidney, I should. And if I'm a wealthy person, I want to buy a kidney, I should.
• 11:30 - 12:00 We should let the marketplace rule. However the problem with that is that what may well have happen is that wealthy people may end up buying kidneys from poor people. And unfortunately to sell a kidney may give you $20,000, $30,000 one day, but there are complications that can occur. And we know that a lot of people in other countries when they sell their kidneys, end up being disappointed with their decision when they look back. Somehow what seemed like a lot of money manages to disappear quite quickly.
• 12:00 - 12:30 Unfortunately, medical schools don't have much training in bioethics. They have some and it's increasing but it's still not a lot. I was fortunate to have some wonderful mentors who encouraged me, one was Renee Fox. Renee is a Professor at University of Pennsylvania. And unfortunately when she was in college, she developed polio but became very interested in the sociology of medicine, in how a research ward and other medical wards are organized, what roles people have, what problems they have.
• 12:30 - 13:00 She studied people who survived heart transplants, for instance, in the world of heart transplants. Most recently, she wrote a book about Doctors Without Borders, Medecins Sans Frontieres, or MSF, looking at the kind of moral strains that they face as well. For instance, they may be able to go into a war-torn area but the political leader will say that they could only go in that area to treat patients if they agree not to comment publicly on anything they see
• 13:00 - 13:30 politically, that is if they see genocide, if they see corruption that they are not allowed to speak out about it. And so they face very difficult issues. Should we treat these patients but not be able to talk about the political issues? And they've often decided that as doctors their role is to treat the patients and indeed not comment on the political issues. But these are difficult controversial areas. Having become a patient myself at one point, I became interested in how other doctors look at these issues and how the experience of being a patient,
• 13:30 - 14:00 being on the other side, may open the doctor up to understanding these issues more broadly. And so I ended up writing a book called When Doctors Become Patients for which I interviewed 75 doctors who became patients with serious illness. And what I found surprised me. It gave me a lot of insights into these differences between how doctors and patients look at what they do and how we can make health care better. One surgeon, for instance, said to me that the night before he underwent surgery as a patient,
• 14:00 - 14:30 his surgeon said to him, you know, there's a 5% chance you may die tomorrow in the operating room. And this surgeon said to me, after he said that to me, that night I couldn't sleep. And it's only later that I realized that my surgeon could have said to me instead there's a 95% chance that everything should go OK. And this surgeon looked at me and said, you know, I've been a surgeon for 40 years. And I never realized that those two bits of information
• 14:30 - 15:00 that are statistically the same have such different emotional meanings to a patient. I never knew that he said. I never realized it. That's the kind of stuff we don't teach in med school and need to. Similarly, a lot of these doctor said to me, you know, patients used to say to me, doc, would you pray for me? And I'd go, yeah, yeah. And I'd poo-poo it. And it's only when I became a patient that I realized how important issues of meaning, of spirituality are when you're lying there facing the risk of death, facing your own mortality.
• 15:00 - 15:30 And it wasn't until they became physicians themselves that they realized what it was like to be a patient in these ways. And again, these are kinds of insights that bioethics teachers, that bioethics encourages us to pay attention to in order to train doctors to be more sensitive to what it's like to be a patient and the broader problems that we all face in health care. So bioethics looks at a broad variety of issues. And I've been privileged in the past few years
• 15:30 - 16:00 to have developed and direct a Master's of Bioethics program here at Columbia. And we've broken up the field into several areas that I think illustrates some of the richness and depth and importance of these questions. We look at the history of bioethics. So for instance, even after the Nazi experience that I described, when the Nuremberg tribunal came up with the list of guidelines and ethical principles, they listed informed consent as being extremely important. And yet, the US government in funding the Tuskegee syphilis
• 16:00 - 16:30 study after that did not follow the principle of informed consent. The Tuskegee syphilis study looked at poor Africa-American men, who were semi-literate in the rural South. They had syphilis. And the point of the experiment was to see how syphilis would slowly take over their bodies. The problem is that after World War II when penicillin became available as an effective treatment for syphilis, the researchers decided not to tell the men about it
• 16:30 - 17:00 or to offer it to them because it would destroy the experiment. And yet one would argue that the men had a right to get the best treatment they can. That the researchers and doctors should have had a commitment to notions of beneficence as well. And so understanding how history has shaped bioethics and how history has created a series of scandals often in which people thought they were doing the right thing and in retrospect were not is very
• 17:00 - 17:30 important for understanding the bioethical issues that we face today. There are also issues with philosophy of bioethics that we look at, for instance. We may say, for instance, that everyone deserves a certain amount of health care. But why do we do that? We don't say everyone deserves to drive a fancy car and the government will give that. We don't say everyone deserves to have a flat screen TV or a iPhone and we'll give everyone that. On the other hand, there are services
• 17:30 - 18:00 where we think the government should provide for everyone. So for instance, if your house is on fire, you don't want to call 911 and have the person at the other end say, well, what's your insurance? We're not going to come and send the fire department over unless we know you could pay for it first. And so we think of health care as being more like that. But why? Again, these are questions about what is health, what responsibility we have to each other. One controversial area in clinical ethics, for instance, concerns definitions of death.
• 18:00 - 18:30 Because there's a shortage of organs to give to people who need them, it was decided that we should change the definition of death to develop brain death criteria, that is if someone's having their heart and lungs working because of machines but their brain is not working, we've decided that we can declare them dead and take out their organs to donate to others. And yet, there are those who argue that because the heart and lungs are working, although with machines, that in fact we're taking organs out
• 18:30 - 19:00 of people who are still alive. Clearly this is a controversial area. Another area is reproductive ethics. So with assisted reproductive technologies, we can now choose embryos. We can say we only want to implant into a woman these embryos that don't have certain mutations and that maybe are only men or only males. And we have now developed so-called CRISPR technology that lets us edit the genes of embryos so in the future people could say,
• 19:00 - 19:30 I want these genes removed from the embryos, I want these ones put in, I want genes perhaps for blond hair, blue eyes, and for height and musical ability. I don't want genes for these diseases there. And of course, this is expensive. And so it may be the case that in the future wealthy people will be able to design babies, whereas poor people won't. And so perhaps in the future, there will be diseases that increasingly will be diseases of the poor rather than affecting everyone. But there are also issues in global bioethics.
• 19:30 - 20:00 At this point, most biomedical research is actually funded by drug companies not by the government and most of that is conducted in the developing world. So just as our cell phones and computers are made in China or India or Malaysia or the Philippines, so too most drug company studies are conducted in these other countries. And yet in these other countries, there may be less regulation. The people may not really understand what they're getting involved in. They may not understand what research is. They may not understand that they can pull out of research
• 20:00 - 20:30 at any point, et cetera. And there are a lot of issues involving ethics in the pharmaceutical industry. Increasingly there are cases where drug companies are trying to charge as much as they can for a drug, often hundreds of thousands of dollars a year per patient. And there are also instances where drug companies are paying doctors to take patients who are doing well on a generic drug to switch the patient to a more expensive new drug that may in the end not be any better, rising the cost for all of us.
• 20:30 - 21:00 So clearly there's a wide range of issues in bioethics that are important for all of us to understand as we move forward into the 21st century because these are issues that ultimately affect all of us, whether we're patients, whether we're doctors, whether we are taxpayers, whether we are voters. And the more we can understand these issues, the more we can understand how health care is not just about science but involves these broader, human, ethical, social issues, the better off all of us will be.
• 21:00 - 21:30 Thank you very much. [APPLAUSE]