Ethical dimensions of enhancement technologies

Q & A: A retrospective on a career in bioethics

This is Ben Rich’s last regular column before retiring as the Alumni Association Endowed Chair for Bioethics — and as a columnist for UC Davis Medicine.

Rich came to UC Davis in 2000 as an associate professor of bioethics and advanced to become the chair of bioethics in 2007. He has published extensively in medical, legal, and bioethics journals and texts on topics ranging from informed consent and advance directives to pain management and end-of-life care. For many years, our readers have benefited from his insightful commentaries on current debates about pressing ethical issues in health care and health care policy. Now a retrospective, in his own words:

Q: Why and how did you get involved in the field of bioethics?

A: I was teaching a course in health care law at the University of Colorado School of Law in Boulder while I was the general counsel for the University of Colorado system. Making a move from university administration to the academic side appealed to me, but being “just a lawyer” in the eyes of the faculty, I felt the need to “rehabilitate” myself academically in order to successfully migrate to full-time teaching. For me, the most engaging material in the course I taught was in the domain of bioethics, so with the strong support of my wife Kathleen I entered the philosophy Ph.D. program at CU-Boulder. Upon graduation I was extremely fortunate to immediately join the faculty of the bioethics program at the University of Colorado Health Sciences Center in Denver.

Q: What was the field (and health care in general) like then, and how has it changed over the course of two decades?

A: I entered the world of bioethics just about the time it was really taking off. You could see this in the exponential increase in the number of attendees at the annual national bioethics conference as well as the proliferation of bioethics programs at academic medical centers. This period also marked the rise of the human genome project, the new reproductive technologies, and stem cell research, all of which generated a host of new and complicated issues in bioethics.

Q: Along the way, what topics or themes have interested you the most and why?

A: Early in my second career in academic bioethics I developed a strong interest in the management of pain and suffering in the clinical setting. It struck me as quite remarkable, particularly as a former attorney with knowledge and experience in health care law, that although data had emerged indicating the existence of an epidemic of undertreated pain in America, there was no evidence that these clinical deficiencies had resulted in either medical board sanction or medical liability claims. Indeed, medical boards were still obsessively focused on the small number of physicians who were viewed as over-prescribers. My early work was an effort to mobilize the resources of bioethics and law to make the case that the relief of pain and suffering is a fundamental obligation of health care professionals, and that there should be consequences for those who fail or refuse to do so.

Q: Bioethicists touch all areas of health care and a varied list of issues that runs “from A to Z,” with new issues arising constantly in step with advances in research and practice. How does one keep abreast of developments across such a wide range of topics?

A: Your point is well taken. When I was counsel to the University of Colorado system, there was a saying among those in such positions that a university counsel’s knowledge base is “like the Platte River in Nebraska — a mile wide and an inch deep.” The situation is somewhat similar in bioethics. My colleagues in academic philosophy, on their curriculum vitae, identify both their “areas of specialization” and their “areas of competence.” Here again, there is something of an analogy with bioethics. One cannot be an expert on everything, but one needs some level of minimal competence, or the capacity to get up-to-speed quickly on a topic, in order to meet the expectations others have for those of us in this field. The challenge is that because bioethics is by its very nature interdisciplinary, keeping abreast of current issues requires being conversant not only with recent publications in bioethics journals, but also those in medicine, law, and the social sciences.

Q: What’s it like to be an academic bioethicist in the capital of California, this trend-setting, melting pot of a nation-state?

A: The diversity of racial, ethnic, religious and political perspectives in California has a number of salutary features. Unlike parts of the country which lack this diversity, we are in a sense insulated from one-dimensional thinking about major issues in health care policy and ethics. We have no choice but to take an eclectic, pluralistic, and tolerant approach to differences in perspective on the part of our citizens and policy makers. I have learned a lot from my opportunities to engage with the legislative process in Sacramento, and also in Colorado. It is a different world in many ways, but everyone benefits when there is regular interaction between the political and academic domains.

Q: What kind of impact is the UC Davis Bioethics Program having on the field and on health care as a whole?

A: It is challenging to objectively identify and document the “impact factor” of our program, which has always been and continues to be quite small compared to some of our counterparts in academic medicine. An esteemed clinical colleague of mine at UC Davis suggested, when I assumed the position of the Alumni Association Endowed Chair of Bioethics in 2007, that I was in all likelihood facing the choice of building a highly visible and influential program at UC Davis or solidifying my position among bioethicists nationally. While I respected that individual’s insight and perspective, I really felt that I had no choice but to endeavor to pursue both.

What I, and my faculty colleague Mark Yarborough with his recruitment to UC Davis in 2010, as well as our associate faculty in bioethics, have sought to do wherever and whenever possible is to make clear the significance of bioethical considerations in all aspects of clinical practice and research. We do this in a variety of ways, such as courses and guest lectures, departmental grand rounds, interaction with various fellowship and residency programs, collaboration on clinical research initiatives, and our Distinguished Bioethics Lecture Series.

Q: What are your proudest accomplishments (don’t be humble!)?

A: In all sincerity, I cannot identify a single “accomplishment” in bioethics that is attributable to me alone. I am proud of the work I have been able to do in the ethical and legal dimensions of pain management, but at least since 2001, much of that work both at UC Davis and nationally has been enhanced substantially through the support and major influence of faculty colleague Scott Fishman, Chief of Pain Medicine at UC Davis.

Similarly, after much time and effort, we now have a required ethics course in the second-year curriculum of the medical school (with the ultimate objective of a four-year linear and integrated curriculum), but this accomplishment was the work product of a core group of faculty: myself, Nathan Fairman, Hendry Ton, and Mark Yarborough.

In critical care medicine, we have instituted twice-monthly ethics and palliative care rounds in the MICU to address the most challenging cases. But this would not have been possible without the initiative and support of Hugh Black, Jack MacMillan, and their colleagues in pulmonary and critical care medicine and the palliative care service.

Finally, through the Distinguished Bioethics Lecture Series, we have been able to bring to UC Davis over the last eight years many major figures in American bioethics, not only to present formal lectures, but also to engage with medical students, residents, and faculty in small-group settings. This would not have been possible had we not been able to draw upon funds from the Herlan and Marjorie Loyd Endowment in honor of former medical school dean Hibbard Williams.

Q: How do you feel bioethics should be integrated into medical school curriculum in the U.S.?

A: The integration of bioethics into the medical school curriculum is a work in progress and a very important ultimate objective. That progress is essential because no physician, or health care professional of any kind for that matter, can claim to be competent to practice or conduct clinical research without a basic grounding in ethics and professionalism. This has been recognized by both the Liaison Committee on Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME).

A linear, integrated ethics curriculum across all four years of medical school is viewed by the best minds in medical education to be the optimal means of imparting the requisite ethical knowledge, skills, and attitudes to medical students in an incremental fashion which implicitly conveys the important message that ethics is integral to all aspects of patient care and human subjects research. Ideally, whenever possible, teams that will be caring for patients together would also be learning together, i.e., physicians, nurses, pharmacists, clinical psychologists, social and clinical pastoral services professionals.

Q: What’s on the minds of your students these days?

A: Broad generalizations are difficult and often misleading. Our students are, almost without exception, serious and highly motivated to become competent and caring physicians. They are challenged to master an immense amount of highly technical information, but not, in the process, to lose sight of what motivated them to pursue medicine as a career. Students want and need guidance and support in learning how to navigate the many conflicts and challenges encountered in diverse health care settings and systems that at times do not necessarily support optimal patient care. They are naturally concerned about the legal and regulatory aspects of clinical practice and research, and desperately need accurate and up-to-date information of this type so as to not be influenced by the persistent and pervasive myths about what the law requires or does not permit.

Q: Do you have advice for current or future front-line providers who navigate complex bioethical issues on a tactical or daily basis? How can they establish and defend a sustainable bioethic in such a dynamic environment?

A: Do not allow peer or systemic pressures to unduly influence or diminish your sense of duty to your patients or your professional standards. There will be instances in your medical career, perhaps more than there should be, in which you will be called upon to engage in acts of moral courage so as to not compromise your professional integrity and core values. Being able to handle these situations effectively may well depend upon your ability to thoroughly analyze the relevant ethical principles and arrive at a position which you can justify and defend against countervailing views or systemic forces. This is why those of us who teach bioethics acknowledge that the value of the knowledge we seek to impart to medical students may not be apparent to them or fully appreciated until years after they embark upon the practice of medicine.

Q:What does the future hold for the field? Advice for budding bioethicists?

A: Some of the most contentious issues in bioethics, e.g., abortion, euthanasia, brain death, never seem to be resolved, even after they have been the focus of U.S. Supreme Court decisions. They simply go through permutations. Other issues arise with the development and implementation of scientific and technological discoveries and innovations. The importance and relevance of bioethics should no longer be seriously questioned. Nevertheless, I think those who choose to work in this field should expect to have to prove to others, day in and day out, that their voice should be heard and their insights can advance the role and mission of medical science and patient care.

My advice would be to avoid developing too narrow a focus in your field. Pursuing a particularly passionate interest is good up to a certain point, but at the price of being able to function effectively in other areas in which bioethics expertise is required. Also, always be open to the insights that other professions and disciplines bring to complex issues.

Q: Retirement plans?

A: It is a familiar cliché among those leaving positions, usually when under some sort of duress, that one wishes to spend more time with family. Fortunately for me, I am retiring simply by virtue of personal choice, and indeed spending more time with my loving wife Kathleen is a vital part of my retirement plans. I will continue to teach selectively when opportunities present themselves, to write and lecture on the topics and issues that most excite me, and to be open to new pursuits and opportunities when they present themselves.

Q: Any parting words?

A: I want to express my appreciation to the Alumni Association of the School of Medicine, which twenty years ago had the vision and determination to create the Endowed Chair of Bioethics at UC Davis. The creation of that position lead to the development of the current program and the important place of bioethics in the institutional culture. The school and the health system, during the transition to a new holder of the chair, will be soliciting advice and counsel from many stakeholders about the future role, mission, level and sources of support for bioethics. This is as it should be. I wish everyone involved a smooth transition and a bright future.