Health Sciences Report Spring 2005


Medical Ethics Discussions Go Beyond Black and White

By Susan Sample

Photos by Tim Kelly

Talk may be cheap, but if it's in the form of a true discussion - with divergent opinions considered and argued - it can provide valuable, as well as affordable, immunity. Take it from infectious disease specialist Jay A. Jacobson, M.D.

In late 1986, he was confronted not only with a largely unknown virus - Human Immunodeficiency Virus (HIV) - but concerns from many physicians. "My residents were asking me why they needed to take care of HIV patients," said Jacobson, professor of internal medicine in the Division of Infectious Diseases, who chaired a housestaff education committee at the time. "AIDS [Acquired Immune Deficiency Syndrome] was a new and unexpected threat. We had crude tools and crude drugs. We were managing fear as much as disease.

On the ethics side, it was just as puzzling. They were closing bath houses in San Francisco. It looked as if the disease was confined to a male homosexual population, which raised ethical questions. The most compelling was: "Is this disease a responsibility for physicians?" The surgeons would tell me, "It's okay for you to say yes, but you don't get stuck with needles and contaminated blood."They were right," acknowledged Jacobson. "I was struggling. Infectious disease was the genesis of their questions about ethics, but I was under-prepared.

That's when notice of a new fellowship in clinical ethics at the University of Chicago School of Medicine caught Jacobson's attention. With support from both the U medical school and LDS Hospital, where he practices, Jacobson was given a sabbatical in 1988 to complete the fellowship. As part of the agreement, the University of Chicago would contribute one-third of the physician's salary for the next three years-if the returning fellow would establish an ethics program at his or her medical school.

I was really excited about it. I did have to make an argument for it," recalled Jacobson of the "cleverly funded" program. But he readily garnered funds and, in 1989, founded and was named chief of the Division of Medical Ethics.

A mainstay of the division the past 15 years has been the Evening Ethics Discussions, a series of monthly multidisciplinary meetings where health-care professionals and community members consider timely and challenging medical ethics questions: Is the sale of kidneys a solution to the mismatch between the number of patients with end-stage organ disease and available organs? Who decides what is the best medical treatment for children-parents or the state? When it comes to dangerous and highly communicable infectious diseases, have we answered the ethical questions yet?

To the latter, Jacobson might reply, "Not entirely." But, at least, he's helped immunize Utah's health-care community against what philosophers have called "the Virus of Mani": infectious thinking that reduces answers to complex moral dilemmas to either yes or no, right or wrong, black or white. For his efforts, Jacobson was recognized last December by the American Medical Association with its highest honor in the field: the Isaac Hays, M.D., and John Bell, M.D., Award for Leadership in Medical Ethics and Professionalism.

To my knowledge, Dr. Jacobson is the first physician in the entire state of Utah who has shown an interest in and dedicated his professional life to medical ethics," said William L. Hamilton, M.D., LDS Hospital medical director, who nominated Jacobson for the award.

Jay Jacobson is an incredible resource for both University and LDS hospitals," said A. Lorris Betz, M.D., Ph.D., U senior vice president for health sciences and executive dean of the School of Medicine. "Ethics is a critical consideration at modern academic medical centers because of the complex dilemmas we face. We're fortunate to have Jay leading our efforts. It's unusual to have someone who does it so well.

Medical ethics may be one of the few areas in the medical school where the content of the subject matter has influenced the form of the division. From abstract questions that address the greater good-What constitutes moral standards? What are appropriate codes of behavior?-has arisen a healthy partnership between the University of Utah and Intermountain Health Care. The Division of Medical Ethics is funded by and serves the departments of Internal Medicine at both the U medical school and LDS Hospital.

We've never felt we are exclusively in the business of internal medicine," noted Jacobson, however. "We always wanted to serve people in surgery, obstetrics, pediatrics.

This interdisciplinary perspective had been fostered at the University of Chicago, which broadened its reach beyond philosophers and lawyers traditionally involved in ethics to physicians active in medical schools. The emphasis in the fellowship program was on "clinical" ethics, reflecting new issues that health-care professionals had to grapple with in the 1980s-among them, genetic experiments and informed consent-along with life-supportive technology and end-of-life questions that had been raised in the 1970s.

Once back in Utah, Jacobson "built on the strengths of the University" by recruiting faculty members who already were working in ethics for the new division. Margaret P. Battin, Ph.D., now distinguished professor of philosophy, and Leslie P. Francis, Ph.D., J.D., chair of the philosophy department and the Alfred C. Emery Professor of Law, were the first to join. The late David Green, M.D., a U pediatrician who had completed a certificate in bioethics from the U philosophy department, also was enlisted.

Three additional faculty members from the School of Medicine and U College of Nursing now round out the division, along with a "second circle of contributors": program associates and facilitators from various departments in the College of Humanities, notably English, Russian literature, and the Honors College. "They're a wonderful bridge between the different parts of campus," said Jacobson. From the beginning, "I think there was a shared vision. We all had responsibility for medical ethics."

Goodwill continues to characterize the division. "It's gone on for so long: the time, insight, money contributed. Everyone does it on top of what they do anyway," said Jacobson of the associates, who often receive no compensation for teaching. "A medical school without a lot of financial support has to look to creative solutions. There's been a lot of opportunism-if I can use that word without negative connotations. We've literally taken advantage of opportunities. That's how we've grown."

In addition to the Evening Ethics Discussions, the faculty conducts monthly ethics conferences for internal medicine residents at University Hospital, LDS Hospital, and the George E. Wahler Veterans Affairs Medical Center in Salt Lake City; a two-week medical ethics course for senior medical students; and scientific integrity seminars required by the National Institutes of Health for grant awardees.

From across the country, scholars are brought in by the division for the annual Cowan Memorial Lectureship and David Green Memorial Lectureship. The monthly newsletter, Medical Ethics in Utah, is mailed to readers throughout the region. In June, the division will sponsor its 15th annual Intermountain Medical Ethics Conference with this year's focus on the use of mediation to solve ethical conflicts.

For three years, the division was involved in the Robert Wood Johnson Foundation's Partnership to Improve End-of-Life Care. Jacobson was Utah's project director and involved communities, businesses, churches, and hospitals throughout the state. Although the project ended in 2002, the Utah Department of Health just last year implemented a major policy promoted by the partnership: a portable order for life-sustaining treatment.

Two monthly Literature and Medicine Discussion Groups-one for medical students; the other for physicians and health-care professionals-are popular division courses. Jacobson was inspired to initiate them in Utah after attending a literature program at a hospital in Evanston, Ill., during his fellowship.

That program was a gem," he recalled. "Literature is a much more appealing tool to teach medical ethics." Great Dialogues of Plato; Ian McEwan's contemporary novel Atonement; May Swenson's poetry, May Out West: the range of works discussed offers endless opportunities.

Not all of us remember where we learned something," said Jacobson of the impact of medical ethics. "It's indirect. It percolates through issues. But it's certainly my hope that the nurses who work on the floors who have been to our programs, or the residents at our conferences, reflect what we're teaching."

We've arrived at a time when we have to learn how to manage our miracles, which causes us to learn a whole new system of ethics," said Chase N. Peterson, M.D., professor of family and preventive medicine, who, with his wife, Grethe, is a member of the division's Development Advisory Board. "Imagine the loss, or tragedy, if all of the miracles that surround medicine fail to penetrate that final common moment of doing right by the patient in all the meanings of the word right?

One of Jay's contributions,"continued the former U president, "has been to bring people together to create a mosaic of ideas on this subject."

That's not usually on the syllabus in medical school. Yet, when he looks back, Jacobson finds connections. "Medicine and philosophy share problem-solving. For me, those two go together."

Growing up in Miami in the 1960s, he was encouraged, as were many boys, to pursue problem-solving as an engineer. He earned a scholarship to the University of Michigan, where he soon realized he was "terribly mismatched": "Engineering was too removed from personal interaction with people."

So he transferred into the College of Literature, Science, and the Arts. "I was thrilled!" said Jacobson. Not only did his new major-chemistry-"take science and turn it into something that helps people," but just as important, "the college was a great place to see how science and the arts connect.

In medical school at the University of Florida, he was drawn to the study of infectious diseases in part for "the detective work" involved. "You can solve problems through analysis and thought. It's incredibly gratifying, too," he explained. "There are limited areas in clinical medicine where cures are possible.

While serving a fellowship as an epidemic intelligence officer in the Centers for Disease Control and Prevention (CDC) in Atlanta, Jacobson continued to be awed by "how dramatic the field can be. A sick child can be totally restored to health with years of life ahead. That's a very big deal.

Mentors also played a significant role in shaping Jacobson's career. While on a CDC assignment to Utah, he met the late Lowell Glasgow, a U pediatrician Jacobson described as "a wise and capable figure," who convinced the native Floridian and his wife, Julie, to head west in 1978. Not only did Glasgow convey a sense of adventure and excitement, but also offered the opportunity for Jacobson, as an infectious diseases specialist, to care for both adults and children.

It was an eye-opening experience," said Jacobson of the move to Utah. "We had to reconfigure our definition of mountains when we got here, and we got excited about the desert.

In what he describes as a "nice rhythm," Jacobson has reconnected with Charles B. Smith, M.D., associate professor emeritus of internal medicine, who left the U not long after strongly encouraging Jacobson to join the faculty. Smith returned to Utah after retiring and co-teaches medical ethics with Jacobson."It's incredible how these people shape us: admirable, well-rounded, fine people," he mused. "Mentoring is like modeling. It's a blend of personal and professional-something I've tried to do.

Though he claims to know "nothing" about managing, Jacobson clearly has demonstrated his strength as a leader. "Leadership is making change happen in an organization; changing the culture of organizations," he said. "I don't know if I've done that.

One of the lessons I have learned has been how slowly change happens. I always have to re-learn that. And I've learned new vocabulary and how to see things differently," he added. "I feel very lucky.

That phrase, which Jacobson uses liberally yet sincerely, perhaps best sums up the culture he's built in medical ethics. He may not have, as division chief, a burgeoning budget, but there's no limit to the gratitude and opportunities he extends to all involved. And when the topic of discussion is the greater good, gratitude counts.

To learn more about activities and programs in the Division of Medical Ethics, go to: uuhsc.utah.edu/ethics/

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