Medical Ethics Louisiana-Style

Are our medical schools doing enough?

JEFFERY JOHNSTON PHOTOGRAPH

Sally Knight is a lady with a mission. Armed with a doctorate in public health, she helped shape the Tulane School of Public Health and Tropical Medicine during a turbulent era in the 1960s and ’70s.

Now she’s fighting from the sidelines. She believes medical ethics should be part of the medical school curriculum on equal footing with anatomy, biochemistry and the other basic and clinical sciences. Knight put money where her mouth is.

She spearheaded a fundraising campaign to fund an endowed chair at Tulane devoted to the teaching ethics to medical students during their four-year metamorphosis into physicians. Raising more than the $1 million necessary to endow a university chair was the easy part. Getting a physician named to that chair has been the hard part.

The James A. Knight M.D. Chair of Humanities and Ethics in Medicine honors her late husband, a renowned psychiatrist and medical educator who diversified the student body at Tulane Medical School as the hands-on dean of admission for over a decade. Then as now most medical schools delegated the day-to-day operation of medical school admissions to non-physicians. The first class he admitted was dubbed “Knight’s Folly,” a moniker they proudly carry. Sally Knight and her family made the first donation to establish a chair to support those ideals held dear by Dr. Knight. Those who still call themselves Knight’s Folly were next.

A graduating senior medical student once said about Dr. Knight: “He taught us that the Krebs cycle wasn’t nearly as important as truly listening to and empathizing with our patients. He taught us to examine our own beliefs and how they would influence the ethical decisions we must make in our practice.” He continues, “But probably the most important thing he taught us was that while a tough exterior is necessary to deal with the tragedies of our profession, we should always leave a part of us vulnerable, so as to know the gravity of our work and the ethical responsibility of our profession.”

The money for the endowed chair languished in a Tulane bank account from 1999 to 2002 while the university decided how to proceed.

Finally they hired a former emergency room physician with an interest in history. It was a poor fit for both that ended when Tulane reorganized after Hurricane Katrina.

The Rev. Dr. Don Owens currently holds the Knight Chair, and its funding now flows through the Office of Student Affairs. Father Don, as the students affectionately call him, has been the chaplain and a student favorite at the medical school since 2000. His duties have multiplied like the fish and loaves of bread Jesus fed the masses. In addition to chaplaincy duties, he interviews prospective medical students, counsels premedical and medical students and lectures about such issues as death and dying. Father Don retires in 2015.

“I think we had ethics lectures in our foundation in medicine courses,” said a 2014 Tulane Medical School graduate I interviewed for his reflections, “but there isn’t much I can remember during our last two years. The only lectures I recall were from Father Don.”

Medical schools in surrounding states pay more attention to medical ethics. To our west is Texas A&M, which has had a full fledged department called Humanities in Medicine since its inception to coordinate core courses and seminars devoted to medical ethics. A student organized Medical Ethics Club meets at lunch to stimulate discussions about ethical challenges facing physicians.

To our north and over a bit, we have Vanderbilt University. Their Center for Biomedical Ethics and Society with a fulltime staff of four physicians and five Ph.Ds is a beehive of teaching, research and publishing. To our east we have the University of Mississippi Medical School in Jackson. A physician directs their Center for Bioethics and Medical Humanities consisting of a fulltime core faculty of five physicians and one attorney.

And back in New Orleans a recent LSU medical student describes her recollections: “I don’t remember medical ethics being taught during our first two years. In our senior year, an older female attorney gave us three or four lectures that touched on medical ethics. We also had small group discussions in one of our clinical rotations, but nothing pertaining to our patients or LSU. I can’t remember any of the topics.”

Certainly the award for most improvement in addressing medical ethics goes to LSU. Prior to Hurricane Katrina LSU held an occasional lunchtime ethics seminar. It was run by a now departed professor who asked tobacco companies for money to support research that Cajun genetics rather than smoking was reason behind high lung cancer rates in Louisiana. Those letters are easily accessed through the Legacy Tobacco Documents Library on the Internet.

New Orleans and Louisiana have no scarcity of home-based inspired medical topics to illustrate the need for more attention to medical ethics and professionalism. Medical students should be stimulated with case histories leading to discussions that are remembered (see box).

As for Tulane, many of those former graduates who helped establish the Knight Chair are concerned that the medical school didn’t use their contributions as seed monies to expand an emphasis on medical ethics. Original contributors have high hopes that Tulane will recruit a physician with the credentials to carry on in Dr. Knight’s tradition. But a one-person program lacking departmental status with no direct university financial support for staff and supplies is a hard sell for a really qualified prospective applicant.


A Sampling of Louisiana-Inspired Medical Dilemmas

• You receive a call from a friend. She is very upset that a neurosurgeon has shot dozens of cats in a medical school lab. The army paid $2 million hoping his research would help treat brain-wounded soldiers. “That’s all old stuff. All those studies were done at Duke years ago. He isn’t finding out anything new or helpful. He is just shooting cats and collecting government money,” said a neurosurgical colleague later that day in the medical lounge. The next week you receive a telephone call from the researcher’s wife asking you to sign a petition in support of her husband’s research. How do you respond?

• You are Ms. X’s internist who just had surgery for breast cancer. An oncologist told her that she needed a bone marrow transplant. You know that the hospital administrator established a “profit center” to perform these expensive procedures generating more than $100,000 per transplant in hospital revenue after factoring in all the complications. You also know that this procedure popped out of nowhere supported by what later turned out to be falsified data from South Africa. Yet, the oncologist on the payroll of the hospital administrator told her that his success rate was 100 percent. Ms. X wants your advice. How do you handle this situation?

• You are the chief of medicine at a hospital when a hurricane strikes. Power fails and the surrounding neighborhood floods. The local, state and federal governments are paralyzed. Resources for evacuations are problematic. How do you decide who evacuates first? Women and children first as on sinking ships? The sickest first? What about otherwise stable patients with Do Not Resuscitate medical wills? Should they go to the end of the line and be the last to leave a flooded hospital?

• You are a medical school junior faculty member and receive salary support from that same hospital impacted by a hurricane. You reported for hurricane duty and initially cared for your own patients. You are summoned by a hospital administrator and told that resources for evacuations are problematic, and some patients on an upper floor will probably not make it out alive. You are asked “to make them comfortable if you know what we mean.” How do you respond? What do you do?

•You and about 20 percent of your freshman medial school class failed biochemistry. The “flunker” was a seasonally paid junior faculty member who needed summer supplemental income and signed a contract with another school to teach remedial biochemistry. A medical student “leaks” that the highest fail rate at any medical school in the country occurred in New Orleans, and an interested reporter calls the teacher and school administration with questions they don’t want to answer What ethical and reality issues are at play here?

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