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NEW DEAN of the School of Public Health Harvey V. Fineberg '67 has been grappling with questions about medical ethics and decision-making throughout his versatile career. As a member last year of the state appointed Task Force on Liver Transplantation, Fineberg helped evaluate a proposal to create a pioneering consortium of four Boston area hospitals that could perform liver transplants. The author of several books, he has also written articles addressing such issues as rising costs of technology and the inadequacy of traditional ethical standards in evaluating such procedures as organ transplants.
Recently, Fineberg criticized the decision to perform the second-ever artificial heart implant, at Humana Hospital in Kentucky last month, because the procedure is still highly experimental and the hospital's resources could have been used for more established procedures such as valve replacements.
In his recent article in Technology Review, Fineberg discusses one of the most important and difficult issues facing the medical profession and the public today: how to balance the possibilities new technologies present for saving lives with the need to contain costs and the realities of drastically limited resources.
The dean proposes a number of suggestions for those both within and outside the medical profession, aimed at forcing all groups to rethink their priorities as individuals in a responsible society. To counter the drastically low rate of organ donation, one of the most serious constraints on transplants, he suggests that the United States follow the lead of many European countries and make organ donation more like the donation of blood: an act expected of all who are capable of doing so.
The question of reimbursement of hospitals for costly procedures is dealt with differently in many states, and while there are some national guidelines for such underwriters as Blue Cross-Blue Shield, there remains a gray area between "established," or reimbursable procedures, and those which are still "experimental" and therefore not funded by insurance. Fineberg has proposed that procedures such as heart and liver transplants, which today fall somewhere between the two traditional categories, be given a label of their own--he calls it "investigational." Whether or not and to what degree these oprations would be underwritten, and how they would receive priority in various scenarios would be determined by a national commission including health professional, policymakers and consumers. This suggestion stands in stark contrast to calls to leave such decisions strictly under the aegis of doctors.
Recently Fineberg discussed with The Crimson some of the questions raised by the speed of new discoveries, the inadequate ethical guidelines that now exist, and the prospects for overcoming the difficulties presented by current medical dilemmas. Following are excerpts from the interview.
Crimson: People speak of technology outstripping our ability to evaluate it, outdating our ethics before we can determine them. Is there any way to "slow down" this phenomenon? Who should be primarily responsible for reforming our standards?
Fineberg: At one level, the problems of ethics imposed by technology have to do with life-sustaining methods in cases where life isn't really what we'd call "living," when it's not even in the patient's best interest. On another level, which is harder to evaluate, are the societal ethical questions. For example, there are too-expensive technologies which could create a system of multi-class care which is undesirable. Or, some issues carry ethically-charged questions like the right to life, such as decision-making about life-support systems. It's the latter group [societal vs. individual questions] that we are even less able to evaluate.
We need both national and local bodies, in particular hospitals, involving community members, people with not only a medical perspective. Those decisions are not fundamentally medical--they're "social-ethical." Hospitals and states should set up groups such as the Task Force [on Liver Transplantation], with representatives from a cross-section of the public: clergy, clinicians, lawyers, ethical experts, and community residents.
President Bok's annual report last year addressed medical education, specifically urging medical schools to incorporate the touching of ethics into their curricula. How can the schools achieve this? Is this sufficient preparation for the decisions doctors will face?
This kind of training and sensitivity shouldn't start in medical school: I think it should start sooner. It should be part of a liberal education, where people are forced to confront these questions, and understand historically the philosophical and ethical positions. That means undergraduate training.
In addition, it's desirable to take advantage of medical education as an arena where problems get applied--not so much as solving questions, but having students recognize what their roles will be as physicians. Emphasis medical training has been on the profession in particular. We should stop looking at decisions as only "medical decisions" and make doctors appreciate their part of this total process.
Although you're not advocating "presumed consent," in which the organs of an individual who dies are presumed available for donation unless he or she has forbidden it, you do support stronger measures to ensure more donation. What would these involve?
There's an intermediate ground between presumed consent and complete dependence--you could call it "required request." It would oblige physicians to ask [next of kin for permission to harvest organs]. With this sanction, that the doctors will always ask, it would overcome doctors' reluctance to do so, and reduce the trauma of the families. It would be a sanctioned part of social discourse which is something which, to me, we clearly should do.
What of your definition of "investigational" procedures, as the gray area between "experimental" and "established"? Has there been talk of adopting such a category?
The specifics haven't been widely discussed, but the issue has been. Part of what we're trying to do is provide a language for talking in a more fitting way about the state of technologies. The problem now is that we have a kind of "go-no go" mentality. We need a transmission with several gears.
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