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Spheres of Morality: The Ethical Codes of the Medical Profession · Health Ethics Podcast

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Welcome to Health Ethics, a series of conversations with leading experts about ethical considerations
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associated with health and healthcare, both locally and globally. I am Brian Pilkington,
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Professor of Bioethics in the Department of Medical Sciences at the Hackensack Meridan School
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of Medicine. This series, like its predecessor, which focused on the COVID
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nineteen pandemic, relies on the idea that challenging ethical issues are best addressed by
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folks from diverse backgrounds practically reasoning together, and complements the Health Ethics series with
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its panel of leading experts from medicine, nursing, politics, economics, philosophy
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and the law. Thank you and enjoy the episode. Welcome everyone to the
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Health Ethics Podcast. I am Brian Pilkington, Professor of Bioethics at the Hackensack
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Gradian School of Medicine. Is my great pleasure today to speak with doctor Sam
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Dornberg and doctor Bob Truge. Doctor Dornberg is an internal medicine resident at Brighaman
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Women's Hospital. A graduate of Harvard Medical School, he studied philosophy as an
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undergrad and completed a fellowship in the Department of Bioethics at the NIH. He
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denucts research on physician role morality, among other topics, and his work has
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been published in jama The Analyst of Internal Medicine, and the American Journal Bioethics.
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He plans to pursue a career as an academic clinician. Sam Welcome.
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Bob Truge needs very very little introduction, at least very little introduction for those
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of us in bioethics circles. Doctor Robert Trugue is Director Emeritus of the Harvard
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Medical School Center for Bioethics. He is the Francis Glessner Lead Distinguished Professor of
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Medical Ethics and Esthesia Pediatrics in the Department of Global Health and Medicine at HMMs.
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He also has a position in the Department of Anesthesiology, Critical Care and
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Pain Medicine Boston Children's Hospital. Those of us in bioethics have read some of
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Professor Trug's I think over three or four hundred publications. He's been amazingly influential
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in the field, especially around pediatric intensive care and ethics. Has done some
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really interesting work from my own perspective on medical error. We'll leave the introduction
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there because I can go on forever. It's wonderful to have you. Thank
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you for joining the podcast. You recently published in an article in the American
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Journal Bioethics titled Spheres of Morality, the Ethical Codes of the Medical Profession.
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Phenomenal piece. I've spent many times reading it, my students have been reading
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it, and so we really wanted to delve into sort of what brought about
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the writing and the paper, the main claims of the paper, and think
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about the topics more generally. So let's start, just in case some of
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the listeners haven't had a chance to read it. What do you take in
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sort of quick summary to be the main claims of the paper, So a
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brief overview of the paper. Basically a paper on role morality and medicine.
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And we start from the idea that there are distinct roles that people occupy in
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medicine. If you're a student training to be a doctor, you're looking at
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a career where you're going going to be in a clinical role. You're going
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to be taking care of patients, and there are certain responsibilities that are attached
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to that role. You have to put the interest of your patients first above
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many if not all other things very often, and those are the ethical responsibilities
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that are incumbent upon you. But the responsibilities that you have to follow for
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any particular role in medicine are a little different, and there are different roles.
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And so we lay out five different roles within the entire medical profession,
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public health, clinical research, science, and sort of the market or a
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business sphere. And we say that each of these spheres, each of these
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roles has a different specific morality. So there are somewhat different responsibilities and obligations
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that are attached to each of these roles. And this does a couple things.
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And in addition to sort of trying to clarify this conceptual space we try
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to achieve with this paper is we think that having this framework for understanding the
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moral landscape helps to clarify some of these conflicts. Oftentimes, you'll be in
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clinical practice, you'll be thinking about an ethical question to say, why,
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you know, how did this person who's supposed to be doing this thing for
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patients end up doing this other thing that we think is actually against the interests
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of patients and is for some other end. And so there are a number
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of ethical conflicts that come up in medicine that we go through in the paper
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to show how this is a lens for understanding ethical conflicts, how role morality
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can be a useful way of understanding what is really at stake when there are
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a number of different ethical conflicts in medicine. So we think it helps to
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think through these conflicts and to hopefully tempt to resolve them. Excellent sam,
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really helpful framing in the paper without getting too far in the detail tales,
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because folks are going to read the paper. Were there any of those examples
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that you just mentioned which were especially a illustrative or interesting or sort of rang
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true to you, the sort of examples that highlighted a potential tension between spheres
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given the different roles. And we picked them because they are such important issues
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in bioethics and because I thought that, you know, taking the spheres approach
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really helped to clarify them. So, you know, I had spent you
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know, my formative years and the build of bioethics that the extend you can
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say that, you know, in my stage of a career learning about equipoise
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and therapeutic misconception and all of the issues that come up in clinical research with
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human subjects, and then thinking about it from this perspective, I felt like
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I had clarity about why these these ethical questions were so challenging all of a
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sudden. It's that they there is this conflict between the clinical role and the
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research we do that involves people. And by looking at it through this lens,
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I could understand and make sense of all of the issues that pretty much
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all of the issues that relate to human subjects research and the conflicts that exist
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there By thinking about it in this way, the very idea of role morality,
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I think can be challenging for people. It's like, I'm a human
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being, and as a human being, I have ethical commitments and I want
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to live an ethical life, and that's really, you know, all you
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need to know. And what was helpful for me in thinking about the concept
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of role morality was really the legal profession, where you know, you think
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about a lawyer who's let's say, you know, defending somebody who's been accused
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of a serious crime and on balance, you think the person probably committed that
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prime. You know, you've looked at the evidence and she's pretty persuasive that
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the person is in fact guilty. And yet in our system, they deserve
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the best possible defense they can get. And so, you know, as
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an attorney, then your job is to put aside that kind of all things
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considered, I'm a good person hat and really the best job you can to
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have that person to quit it. And you know, I think for some
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people that may just be like counterintuitive and and well it's counterintuitive to me,
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but it shows that there are I think, ethical commitments that we take on
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purely because of the roles that we have in life, and that being able
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to see that they are associated with a particular role can be helpful in terms
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of figuring out what the right thing to do is. I noticed one of
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the one of the commentaries that accompanied our paper was harshly critical of the whole
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idea basically just said, you know, when I mean the paraphrase it in
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a sentence, when faced with a problem, just do the right thing.
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And I thought, an incredibly naive way of looking at it. But I
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think also maybe also captured one, you know, one view, which is
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that parsing it out as Sam and I have done creates these sort of artificial
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standards that really are misleading to us. I disagree with that, but you
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know, I think that some people might look at it that way, Bobby.
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That's helpful both the legal lens but also sort of the general consideration and
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explanation of role morality. And I'm curious if if we asked folks sort of
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outside of thinking about just the medical professional, even health professions, do you
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think that certain professions might have norms associated with the roles which folks who aren't
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in those professions have And my guess is that they're do the right thing,
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although because I think I'm with you here might change. I mean, an
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off duty firefighter, the usual example, may have obligations to run into a
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burning building even though she's off duty. I don't know if you want me
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running into the burning building. That might complicate things. So I think that
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there's I think there's something really there. And the example that Sam Ray's is
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the one that I talked most about with students, both because of therapeutic misconception
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connection, but also because many of them have interest in being physician scientists and
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thinking about aims of generalizable knowledge in one space and helping the patient right in
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front in another space raise some of these tensions, and that's why I think
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that's one of the reasons I think the papers so help anything that in particular
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that motivated you to do this specific work other than your sort of early studies
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in bioethics, Like what drew you to thinking about these tensions? I think
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one of the things that made it certainly resonate the most for me is having
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the experience of being a medical trainee and sort of having a framework for doing
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what I thought was, you know, quote unquote the right thing, and
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getting into medical school and clinical practice and realizing that there were all of these
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things that happen in the hospital, in medicine more broadly to my patients that
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I might not necessarily think of as me doing the right thing, but they
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might have been right for someone else to do. Thinking about big part of
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this paper was written during COVID in the early days of the COVID pandemic,
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and thinking about, well, you know, how do we square the obligations
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that individual physicians have to their patients with the questions about limited number of events
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and allocating scarce resources that those same physicians were also dealing with, and thinking
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about, how do we you know, is there is it one person who
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should be making the same decision in all of these cases or is it something
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that should be divided up into different roles? And I was trying to envision
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if I were in those shoes, how would I be able to make both
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of those decisions, because they seemed to rely on such different ways of thinking
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and such different approaches. And that was one of the ways that it really
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hit home from early on. Yeah, I build on that. I was
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part of the task force in Massachusetts that created our ventilator allocation guidelines during the
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pandemic. So we developed these scoring systems to basically, you know, decide
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who would get a ventilator or not. And one of the things we built
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into it was that the people that were generating the scores and determining the priorities
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should be separate from the people that were actually taking care of the patients.
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Now, both groups would be clinicians, you know, physicians, nurses,
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et cetera. And it didn't mean that you were exclusively in that role.
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I mean, one one day, I might be the physician in the ICU
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taking care of the patients, you know, the next week I might be
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on the allocation committee and I would have no direct contact with any patients.
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I would be just you know, generating the priority list, you know,
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and I don't. This was before we were actually thinking about the you know,
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the whole paper on on spheres, but I think it was an example
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of how we kind of intuitively realized that these roles need to be separated.
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That even though you might imagine some one person being able to do both and
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being able to somehow separate out the issues in their own mind, that it
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would probably lead to a lot of internal conflict, it could, you know,
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I think I think it could lead to a lot of moral distress for
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a person, and that this was really a way of both maintaining for everybody
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to maintain their own integrity and yet still do a job that needed to be
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done. Bob, I really appreciate the way you frame that issue because there's
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the the also the objectivity component. I mean, you could imagine that people
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would say there's a conflict of interest here if you're one person of both of
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those roles, and then you know, thinking about it from that you question
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from a from a spher's perspective. I mean, if you're the clinician,
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you're supposed to do everything you possibly can to take care of your patients,
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and you might it might be unnatural for you to accept some limitations that are
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imposed by a separate group of physicians who say this is how this. You
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know, we've made a decision that your patient is or is not going to
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receive a ventilator treatment. But the ability that you have that that affords you
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to do as much as you possibly can for your patient, I think allows
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you to stay true to the morality that you have in that role. But
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I think it also raises an interesting question of where exactly are the bad boundaries
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of these when there are conflicts which sphere, which role takes precedence and under
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what circumstances, Because I don't think it's not as though we say a rational
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sphere of public health allocation sphere that that always takes priority over a clinical sphere.
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And so where exactly those those spheres bump up against each other and how
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we navigate those conflicts. I think it's also felt Perry Germaine. Over the
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last few years, we've got the paper on the table, we've got sort
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of how the paper came about, which is always terrifically interesting, and Bob
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mentioned some of the critical comments on the paper that came out in those a
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job, but commentaries. One of your commenters raised questions about whether we might
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really think that a particular sphere should take priority. Isn't there something about being
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a physician that pushes you into that clinical space for most I hear I read
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that, you know, physicians contribute in all different kinds of ways, but
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aren't clinicians sort of at first clinicians? I think, you know, there's
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an example that I've I think it's an important critique and it's one that we
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thought about the fair amount when when writing this. You know, is there
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you know, if there is sort of one and one t lose of being
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a physician, it could can we say that there is one end and that
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that supersedes all of the other spheres and all of the other things that medicine
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tries to accomplish. One example that has been relevant recently is consider a chief
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medical officer of a large academic institution. You know, they are trained as
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a physician. You might say that they have a responsibility, no matter what
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stage of life or role they're in, to put the anticipations first. But
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if they are you know, thinking about the you know, the hospital finances
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and the way to make the you know, the system run for everybody,
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for hundreds of thousands or millions of patients who are you know, under their
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purview. Sometimes they may have to make decisions from the framework of what is
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best for the organization and what is best for sort of a global population approach
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that may result in some some worse outcomes for a certain select group of patients,
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and they you know, you might say that they wouldn't be able to
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do that if they were operating only in a clinical role, but you know
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the fact that they are a physician, that they have that training. I
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think, you know, sometimes I think hospital administrators get a lot of flack
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for exactly this, like how could you ever do something that goes against the
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interests of patients? But I think that there's another there's another perspective on this.
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It says, actually, oftentimes people are acting in ways that are appropriate
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to the requirements of their role, even if that means that, you know,
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health and promoting health is still an active interest of any large medical center,
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of course, but sometimes it may take a relative backseat in certain cases
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and certain decisions. And that doesn't mean that administrators aren't living up to their
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ideals. I think you're maybe tapping into someative feelings of that being a physician
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is not a role but actually an identity. It is who you become as
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a person. You know, And I'm thinking of like the white coat ceremonies
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that have become so popular. You put on that white coat and it changes
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who you fundamentally are. I mean, I love it, and I you
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know, as I think of myself, I do think of my identity as
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being a physician. But I think there's real dangers in that because I mean,
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I think, as Sam, as Sam was putting putting forward, there
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there are times where the idea that you know, all I care about is
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the patient in front of me, is going to lead to bad choices on
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ethical choices, and so, you know, as romantic as it is to
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think about the hollowed nature of the medical profession, I think that the various
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fears that we have put out and maybe they need to be modified, maybe
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there's more, maybe they can can be less. But I think that general
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approach is actually very important to maintaining our pegrity as we move through the various
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things that that we all do, whether you know, it's the bench science,
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whether it's our role as a public health administrator or our role in actually
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taking care of patients in the clinic. Two great answers. Yeah to a
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tricky question, Bob, you hit the nail on the head with what brought
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the question on. It's the professional identity formation physicians as an identity as opposed
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to filling the you know, a particular body of knowledge, a set of
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skills, and sort of what that might mean. And I asked this question
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and with probably a great deal of bias, because I'm not a doc.
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I mean, I'm pg philosopher who just spends a lot of time with super
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great and interesting physicians, And so I'm watching it from the outside a bit
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and sort of seeing how some of these things play out. Also wonder if
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that this reflects a shift in the way that the medical profession has been conceptualized,
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both internally and externally. That in the past, the kind of the
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physician was often viewed as kind of a journalistic, sort of all powerful within
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their domain, type of person who had a lot of leeway to make a
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wide variety of clinical decisions without a lot of influence from anywhere else external to
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the physician of medicine. And I think that that has also changed and the
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locus of where medical decisions are made has shifted somewhat. There are now many
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more formal guidelines. There are now insurance companies and pharmaceutical companies that have influence
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over what medications are available and who can afford to pay for them and under
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what circumstances, and questions of rationing have become more paramount and less reliant.
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We now have less of a paradigm of the individual physician who is doing bedside
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rationing and more of a systematic approach, and I think that that has also
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I think informed this question and this issue that you're both raising of the identity
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of the physician has also itself changed. What that means and what that looks
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like has maybe also changed over time. So I'm thinking about the normative conceptual
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overlap across the spheres and sort of whether there's a concept we might appeal to
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in one sphere which could have implications for another sphere, so for example,
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upholding the dignity of research participants and that as opposed to patients, and whether
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that suggests that there's something about bioethical concepts or norms that might not be captured
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by the spheres. View, Are there important ethical concepts, which some folks
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would want to say, well, no, we're talking about autonomy here and
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there and there, and might that suggest maybe the spheres are a little closer.
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Do we have to have autonomy one, two, and three versions sort
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of? Could you talk the audience through maybe some sort of how to think
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about some conceptual overlap. Brian, you said something that actually I hadn't thought
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about, but I think could be very helpful here is that what maybe ties
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it all together is that all of the sphere are in a broad sense focused
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on the health and well being, which you know, if you look at
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like World World Health Association or World Health Organization statements, you know about what
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is it all about. It's about the health and well being of people.
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And you know, whether that's through the development of new drugs, or taking
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care of populations, or making sure that scientific research is done with integrity and
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respect for the participants in that research, all of those things do kind of
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fit with that theme. I say this with some hesitation because really, until
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you said that, Brian, I hadn't kind of had that thought. I
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hadn't really thought about the ways in which the spheres all fit together. And
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so this maybe isn't you know, maybe not the best idea, but at
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least that's what occurred to me, And you know, I think there might
20:48
be something there. I think that the sort of focus on health and well
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being gives us, or would give me whatever conceptual content I want, and
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picking out a physician as opposed to someone engage in another profession, and it
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may be that that does the relevant work. And there are cluster of ethical
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concepts realized in different kinds of ways which inform sort of how we understand health
21:08
and well being. So I think that's right. And one reply you might
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give to this annoying commentator is that he has sort of misplaced considerations of precision,
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and we just don't need to sort of parse out particular interpretations of autonomy
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in this sphere or in that sphere as a whole. It actually happens within
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those spheres. I really appreciate the question of you know, are there some
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overarching values or moral principles that are relevant to all of the spheres. I
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think the answer is yes. I mean, I think respect for persons,
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integrity, trust, these are sort of universal moral values that apply to all
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people, regardless of their profession or role. We're talking about identity a few
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minutes ago. I mean, regardless of your role, whether that's your identity
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or you have your own personal morality, those universal values still apply, and
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then how exactly they're specified in different contexts. To use Henry Richardson's phrase,
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that looks a little different, but I think the same. I mean,
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you know, you could say that truth telling and importance of trust is the
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same for the doctor patient relationship. You know, it looks a little different
22:19
in a clinical research context, but you still want to be very upfront with
22:23
the people you're involving in your study. And I think those are just specifications
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of a universal morality. The common thread here, as Bob was saying,
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is that they all relate to health. Sorry, I couldn't help myself from
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getting into the Philosophy Club for a minute. It's it's nice to have the
22:37
opportunity. The members of the Philosophy Club are always welcome to appeal to it.
22:41
So this is this is good, and that's that's helpful because you've also
22:45
again with this sort of overarching principle language I think helped clarify, especially for
22:49
our listeners, whether they're internship, out of the club, sort of that
22:53
general idea of values crossing over different spheres, which motivated the question. So
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I want I'm move now. So we got a good explanation of the paper,
23:03
some sort of critical feedback and responses back and forth about these ideas,
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and I know, you know, folks, if they haven't already once a
23:10
year the podcast, they're going to go pick up the paper. So I
23:11
want to sort of shift the question a little bit, given sort of the
23:15
multiple roles that both of you inhabit, if you have any advice for future
23:19
physicians, and I have thinking of particular medical students of mine who are really
23:25
interested in sort of what could become dual roles. So some who are very
23:30
interested in research, especially ethics research. Some we have a big research enterprise
23:34
here too, who are really interested in becoming physicians scientists. Any recommendations not
23:40
from the sort of fighting about the finer philosophical points of the paper, but
23:44
sort of human advice for future folks or folks who wish to enter your profession.
23:49
I can give the end of one answer. Bob can give the thirty
23:53
thousand foot wisdom answer. I have a couple pieces of advice. Pay attention
23:59
to moments where you question what exactly is going on from an ethical standpoint when
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suddenly doesn't feel quite right, when you're left a little unsettled by a conversation
24:07
or some interaction about a patient's care, pay attention to those moments because those
24:12
are I think I've always found them particularly important in recognizing ethical issues that come
24:19
up if you're interested in ethics. And I think if you're a physician,
24:23
it's hard not to be interested in ethics because it's all around you. I
24:26
would say read, read broadly, and read deeply in whatever area you find
24:33
most In a area of ethics you find most interesting, you know, pick
24:37
something you've seen clinically and you're passionate about and just really dive in. And
24:42
I think having a broad way of thinking about these things. It sounds like,
24:48
Brian, this is what you do when you teach medical students that you
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you know, you get to offer these ways of thinking deeply and encourage people
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to think through some of the more abstract shoes outside of clinical practice of medicine.
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But I think taking time to do that is is hugely beneficial. Listening
25:07
to Sam and thinking about my own career, it reminded me of I think
25:11
one of the formative moments for me early on when I was a pediatric resident
25:17
in Denver and working in one of the hospital emergency rooms, and we were
25:26
told by the hospital administration that because of financial constraints, that if patients came
25:32
to the emergency room who were not known patients of the hospital, we should
25:38
refer them to the city hospital that was about a mile away and not see
25:44
them and not take care of them. And you know, maybe gets a
25:48
little bit to like how we think about roles and the role of a resident.
25:53
Wasn't my place to go making hospital policy. That was up to the
25:56
hospital administrators. And you know, now, much to my shame, I
26:03
I look back, you know, I did that there would be children who
26:07
would come in that really needed care, and I would say, you know,
26:10
we'll call a we'll call a cab for you, and they're going to
26:12
take you down to the to the city hospital, the general hospital down the
26:15
street. Shortly thereafter, Congress enacted uh the Emergency Medical Treatment and Active Labor
26:22
Act, the MTALA Medicine Legislation, which made what I was doing illegal that
26:27
you know, it was dumping and that's what it was, and you can't
26:32
do that anymore. But why didn't I see the ethics of that? Why
26:36
you know, where do you where do you step out of you know,
26:38
your your sort of pigeonholed role and and say that, uh, you know
26:45
this is wrong and I'm not going to do it. So it doesn't really
26:48
answer your question except to say that maybe you know some of these formative moments
26:52
that are happening for your for the medical students now or people a little bit
26:56
further along in training, is to pay attention to them, because I think
26:59
that not dismiss them, and recognize that sometimes people at lower levels of the
27:06
pyramid can see things more clearly than those at the top. And so that
27:10
was a formative moment for me. One more advice question or advice solicitation.
27:15
So any advice for the students done, any advice for medical educators who might
27:22
find themselves in situations where they feel a conflict or attention around their roles as
27:27
healthcare professionals and their roles as a teacher. So for folks like me and
27:34
Samuel alluded to, I mean, it is enjoyable, it's challenging at some
27:38
points, but I have the luxury in some ways the deficit, but the
27:42
luxury in some ways of not being a physician. When I'm teaching students the
27:48
sort of things I can do space, I can move obligations that I may
27:52
not incur, but I have, you know, physician colleagues and friends or
27:56
also teachers, and sort of run into this tension where the thing thinking about
28:00
the health of the public and the future and also thinking about obligations to particular
28:04
students. Do you notice a tension between these two things? Do you not?
28:10
If you do, any suggestions on navigating this. It's a great question,
28:18
And as someone who is at a stage of training where I both am
28:22
responsible for other people and also have people who are responsible for me, I
28:27
think about it all the time. There is in theory a conflict between taking
28:36
care of patients and teaching the next generation and perfect you know, ideal theory
28:42
patient care might be. I don't want to call it perfect because I don't
28:47
think that's necessarily accurate, but an ideal theory of patient care would be that
28:51
the most experienced person does every procedure with to ensure the lowest possible complication rate,
28:57
but when that person retires, no one else knows how to do the
29:02
procedure, and so there's a there's a need, there's a necessity to train
29:04
the next generation. And this is a conflict people come across all the time,
29:10
and I think what I've come to learn about it is that the way
29:15
to do it is to make sure that there's appropriate supervision that you you know,
29:22
there's someone looking over your shoulder, you know, making sure that you're
29:26
doing whatever procedure or having whatever conversation in the right way or in an acceptable
29:33
way that both allows you to learn and make sure the patient has an appropriate
29:37
clinical outcome. The adage in medicine is see one, do one, teach
29:42
one. I think it usually needs a few more than one to feel completely
29:47
comfortable. You know that you've learned and got into a stage where you're comfortable
29:53
to be taking on those responsibilities yourself. But absolutely, you know, one
29:57
of the challenging questions, particularly I used to do anesthesiology, and I would
30:03
take care patients in the operating room and preoperatively parents would pay to me,
30:07
you know, doctor Kruge, I just want to make really sure that it
30:11
is going to be you who is taking care of my child. They're one
30:15
hundred percent of the time, especially you know, at the critical times putting
30:18
in the end of tray kiel tube, all that sort of thing. I
30:19
want to make sure that it's you who's going to be doing that. And
30:23
you know, I had to tell them factually that's not going to be the
30:26
case, that this was a teaching hospital, that the trainees would be doing
30:30
the procedure. They didn't want that they would have to go someplace else,
30:33
and you know, this was a very hard conversation to have. I never
30:36
had anybody like actually leave, but I did have some very unhappy parents who
30:41
couldn't understand why I wouldn't agree to do that in just the way Sam said,
30:45
I mean, everybody wants the most talented person in the room doing the
30:49
procedures on them, or somebody that they that they care about, and so
30:52
I don't think we can we can completely sweep the issue under the rug.
30:56
It is a trade off, and as Sam says, it's you know,
30:59
ultimately and it's ultimately necessary because the next generation of people need to be trained
31:04
and there's only one way to do that, and that's that's by allowing them
31:07
to do the procedures. You know, for for you know, I'm thinking
31:11
about medical students or trainees, though there's I think there's also a responsibility on
31:15
their which is to recognize when they're getting in over their head, to recognize
31:22
when the supervision is intadequate, and to make sure that they are adequately supervised,
31:26
and that sort of thing. You know. Sometimes, you know,
31:30
you a student might feel like, well if if I if I say that
31:34
I'm not I haven't put in five arterial lines before. This is my first
31:38
one, and the resident just said, go do it. You've seen how
31:42
it's done. You know, I'm sure you'll be fine. You don't want
31:45
to look like your lack of confidence. Those are this Those are I think
31:49
there are some moments for for trainees where they need to to actually be responsible
31:55
for their lack of experience and make sure that they they're having the supervision in
31:59
the training oversight that they need. Two great answers to I think a tough
32:04
question, and what I really appreciate, Bob, is the point about sort
32:07
of having the challenging conversations. Occasionally you get work in bioethics that suggests sort
32:13
of sweeping in under the rug, or it just kind of happens, let's
32:15
move forward quickly without asking those But as someone who has had some recent experiences
32:21
that put me in these kinds of situations. Having someone straightforward they tell you
32:23
this is how it's going to go. I think only increases trust. Full
32:27
circle to Sam's point about some of those overarching norms that might cover all of
32:31
the different spears relative to trust. I really enjoyed the conversation. But before
32:36
I let you both go, what should the audience be looking to next?
32:39
Because I'm sure they're all going to go if they haven't already and read the
32:44
Spheres paper for an a job. What's next on the research docket for you?
32:49
What can we look forward to reading, hearing about thinking about? Great
32:52
question, Brian. We're always happy to hear from people who have read the
32:54
paper. So if you want to you read it and you agree with us,
32:58
or in the event you disagree with us, even more so we'd love
33:00
to hear from you. You know, we want to engage in conversations about
33:05
this, and that was the purpose of coming on the podcast today, but
33:07
also publishing this paper in a job where the format allows people to write in
33:12
and write peer responses, and so I encourage everyone to read those responses because
33:15
they may contain some very thoughtful insights into how to address these problems, and
33:20
so I always happy to hear from you, encourage you to read the responses.
33:22
I think you know future directions we're thinking about how to tackle more of
33:25
the sphere conflict where they are in medicine, how to identify them, how
33:30
to tackle them in ways that you can imagine that there's much more to say
33:37
beyond what we were able to cover in the one paper about how to address
33:39
these scare conflicts which are deep and you know, deeply rooted in medicine and
33:43
fundamentally affect the lives of physicians. And so's that's where heads are at for
33:47
thinking about the next steps. The audience will of course keep eyes out for
33:51
more research from both of you on these topics. So thank you both very
33:54
much. I appreciate the time. This was great. This podcast series is
34:12
a production of the Health Ethics Lab, and I am grateful to colleagues in
34:15
the Department of Medical Sciences, the IHS Library, and the Hackensack Bridian School
34:20
of Medicine for making this collaboration possible. To learn more about our work or
34:23
to engage with the series content, reach out to me Brian Pilkington at Brian
34:29
dot Pilkington at hmh N dot org.