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Academic Freedom in Medicine: Ethics and the Training of Sovereign Professionals · 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
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the Health Ethics Podcast. I am Brian Pilkington, Professor Bioethics at the Hackensack
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Meritan School of Medicine. Today I have the great pleasure of speaking with doctor
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David S. Gorton. Doctor Gordon is President and CEO of the Association of
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American Medical Colleges, which represents the nation's medical schools, teaching hospitals and health
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systems, and academic societies. Doctor Gorton began his leadership at the WMC in
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July of twenty nineteen after a distinguished career in government, higher ed and medicine.
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Previously, he served as the thirteenth Secretary of the Smithsonian Institution, where
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he oversaw nineteen museums, twenty one libraries, the National Zoo, numerous research
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centers, and education programs. Doctors Gordon, I might have to ask you
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some zoo questions for my daughters. Prior to that, he served as president
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of two universities, Cornell and the University of Iowa, where he also served
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on the faculty for twenty six years and specialized in the treatment of adolescents and
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adults with congenital heart disease. A pioneer of cardiac imaging and computer processing techniques,
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he was co director and co founder of the University of Iowa Adolescent and
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Adult Congenital Heart Disease Clinic. A distinguished professor at Georgetown University, doctor Gorton
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is an elected member of the National Academy of Medicine, the American Academy of
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Arts and Sciences, and the American Philosophical Society, as well as a lifetime
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member of the Council on Foreign Relations and a Fellow of the American Association for
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the Advancement of Science. He earned a BA and MD. Both BA and
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MD degrees from Northwestern University, Go Wildcats. I believe he completed his medical
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residency and fellowship in cardiology and was chief Medical Resident at the University of California,
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Los Angeles. Doctor Gorton, Welcome. We're discussing medical education, medicine
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and academic freedom, and so I'm curious in your view, what is academic
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freedom. Is it important and if so? Wa Brian, it's a pleasure
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to be on the podcast. Congratulations on a podcast. It's really cool and
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I'm glad to see you doing it. Before you answer your question, I
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just want to tell you about one book that I'm recommending to people who are
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interested in this area, and it's called Free Speech. The subtitle is a
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history from Socrates to Social Media, and it's written by Yakob mitching Gama,
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who is the head of a think tank in Copenhagen called Justicia and also now
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has a branch or an annex or whatever the right term is at Vanderbilt.
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And I found this very complete history which includes, but it's not limited,
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two academic freedom issues. That we may be discussing today. So just a
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reference for those who maybe want to understand some of where I'm coming from.
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Some of it is from my own experience, and I learned a lot from
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this book I read just several months ago. So you asked what it is
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I think and is it important? So there are formal definitions of academic freedom,
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and some of them come from the American Association of University Professors in nineteen
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fifteen, nineteen fifteen, and even though they look like it, I actually
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wasn't there when this happened. The AAUP was founded and they wanted to define
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academic freedom, and the current definition of the AAUP in answer your question,
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what is it is that and I'm quoting this now the freedom of a teacher
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or researcher in higher education to investigate and discuss the issues in his or her
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academic field, and to teach or publish findings without interference from political figures,
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boards of trustees, donors, or other entities. And then it goes on
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to say that this concept of academic freedom protects the right of a faculty member
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to speak freely when participating in institutional governance, as well as to speak freely
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as a citizen. So four elements. One is teaching, one is research,
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you know, investigation, a third is the faculty voice and institutional governance
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or shared governance. And the fourth, which can be confusing, is reiterating
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the right to speak freely as a citizen. Of course, in the United
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States, all of us have this right constitutionally, but it also indicates that
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because someone has the professional right of academic freedom doesn't take doesn't take away their
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personal citizenship right of First Amend meant First Amendment right. So that's that's the
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formal definition. I think about it in that in that way because I've been
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in academia for a long time and and have you know, utilized the AAUP
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and other organizations that are based on a up definitions to to think about it
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and is it important? I think it's wildly important, and uh, it's
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been important for a very very long time. The book I mentioned to you
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takes us back to medieval times and even earlier, where challenges to the whatever
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the current orthodoxy was, and I don't don't use that only in a religious
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sense, was uh, someone who challenged the orthodoxy could be in real trouble
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in academia and beyond academia. And so the idea is that higher education writ
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large is a place where we want to explore new ideas, not only for
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broadening the horizons of our learners, but keeping our own horizons broad And just
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because one gets an appointment as a professor doesn't mean that that learning and broadening
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is over. That would be terrible, because we need to always be broadening
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our horizons. So I think it's very very important and very important for all
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of us, the faculty, the learners, others to have their right to
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speak out. And I think that a review of the history is in that
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book and elsewhere to me reveals a very strong message that in general, it's
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a very broad generalization. In any situation, the more open speech and open
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exchange the better, and attempts to limit open exchange, even in the interest
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of something that may seem at the moment a good idea, can often backfire
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and lead to problems. So I'm on the side of thinking it's very important.
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It's important for all of us to broaden our horizons, to actually discover
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new things, and not just to be hardened in our own conceptions of what's
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right or wrong. What's accurate or inaccurate, and that that journey should never
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end for any of us. I mean, a great answer and our great
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starting point to the conversation. And I really appreciate the focus on sort of
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the lifelong learning right of faculty members and the realization that we're all on a
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journey a quest of sorts. I mean, I think that's a really nice
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image or a nice metaphor for thinking about the importance of academic freedom. So
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you lead the Double AMC, and the Double AMC has joined other institutions in
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signing statements affirming the values associated with academic freedom, sometimes highlighting the importance of
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open academic inquiry and vigorous debate, which I think, folks, maybe tell
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why given the answer you just gave, But why as an institution does the
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Double AMC find academic freedom and important? That's a great question. Thanks,
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Thanks Brian. So we're here to lead and serve the world of academic medicine.
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But the real strength of our organization is in the members themselves. The
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one hundred and fifty eight m D granting medical schools in the US, some
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in Canada, the roughly four hundred teaching health systems, and hospitals and so
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on. That's where this interchange is really happening. Of course, we have
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interchange here at the campus, the mother ship, but really we're here to
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serve as this broad, broad community, which itself is a subset of the
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broader community of higher ed. And because of that, because we are a
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subset of the broader community of higher ed, if it's important to have academic
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freedom and higher education, then therefore, by definition, it's important to have
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it in medical education. Now, it's a complicated world, and some of
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our medical schools are tightly linked to a parent university, others less so.
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Some of the faculty members who teach and deliver clinical care are in the traditional
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mold of academia, doing a broad range of activities, others not so much.
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May be very predominantly oriented toward toward clinical care, which is hugely important
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because everything we're doing helping aspiring positions to walk through that pathway through the continue
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of medad is ultimately for the good of the country by improving the health of
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the of the of the populace in general. And so because we're part of
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that larger ecosystem, I think that we should follow the same basic rules and
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approaches, even though there's something very different about the world of academic medicine than
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some other not all literary, but some other areas because the very very large
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service function that are served in there. But that's not enough of a difference
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to in any way go back on the importance of academic freedom. And we
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have signed statements not only because of the general importance of it, but because
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some of that is is under siege and under attack. And I believe that
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that is because we're in a fractious culture at a difficult, fragmented time in
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our country. Not the only time and not the only place in the world,
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but sure is happening right now, and so it's not surprising that the
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cultures inside our institutions are affected by that fractious culture and even sometimes partake in
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that fractious culture, maybe not on purpose. And so for all those reasons,
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I think it's really important for us to keep talking about the importance of
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debate, of listening to each other, of having open minds, the Zen
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Buddhist concept of beginner's mind. There's a phrase from Srian I mispronounced that Suzuki,
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and the phrase goes something like in the expert's mind, there are few
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possibilities. In the beginner's mind, there are many, and we want to
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maintain in my view, beginner's minds all the time throughout academia because the knowledge
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base is increasing, Our understanding of the world is increasing, and nowhere is
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that more evident than in medicine or our understanding of how should I put it
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of life? In health and disease changes all the time. We want it
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to change. We want to do better, We want to understand all the
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elements that pertain and contribute to health. So that's along we did answer to
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a short question. It's why it's important for us to maintain and join with
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others who want to maintain values associated, as you put it, with academic
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freedom. I want to pick up on thinking about medical education and medical institutions,
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which you touched on early in that answer. How do you conceptualize medical
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schools or rejected if the question is not well posed, But we might think
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about them as primarily training institutions, and then certain sorts of norms. Right,
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You and other physicians as members of a profession, might owe certain kinds
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of things. We might think of them as parts of larger institutions when they
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are or we might think of them as any other kind of institution of higher
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education really seeking to instill the values of inquiry and curiosity in members of their
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communities. Does any of that resonate? Can you sort of help us think
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through the category of medical schools? So if it was a multiple choice exam
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instead of a podcast interview, Brian, are they a I'm getting you right
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here. Training institutions for future members of a profession be part of larger institutions
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where for whom academic creedem is important. See institutions that seek to instill values
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of curiosity or d all the above, And it's all the above. And
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actually it's perfect that an ethicist and a social scientist is quizzing me on this,
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because the field of health, not just healthcare, but health is moving
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more and more and more to understand that we're not going to solve our thornist
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issues in medicine any more than we're going to solve our thorniist issues in society
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by science by stem alone. STEM hugely, hugely important. My own specialty
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has been in the care of young people. In my practice was age twelve,
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then teenagers, and adults who were born with heart disease con general heart
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disease. The year that I was born nineteen forty nine, If you can
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imagine such a thing, roughly eighty percent of the babies born with an inborn
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heart disorder would not live to adulthood, would die before adulthood. Eighty percent
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would not live. Now ninety percent plus are living to adulthood, a complete
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reversal of prognosis. That's because of the stem disciplines. That's because of advances
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in surgery, anesthesia, diagnosis, imaging, interventional procedures, and understanding of
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the course of the disorders. But as we understand the broader, broader palette
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of what affects health, we're learning that things that are really more the purview
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have been war a purview of the social sciences and even the humanities are very
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very important contributors, sometimes referred to as social determinants of health or vital conditions
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for health, and in fact, quite a bit of research suggests that they
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are in the aggregate. The largest single a determinant of health is the aggregation
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of all these factors. Does one have a secure place to live, a
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roof over one's head, Is there nourishing and safe food, Is the environment
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safe in terms of violence? And many many other things. Does one have
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the financial wherewithal and other wherewithal to get to a physician's appointment, to follow
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up, to buy the medications to continue? And so I think that we
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are part of the broader society and therefore all the things that you mentioned are
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relevant. Let's take a one by one real quickly. So definitely, training
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institutions for future members of a profession very very important. And there's many aspects
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of medical education that have that professional cachet. We even have a physician's pledge,
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you know, derive from the hippocratic pledge that we are doing. Some
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have the right honor to do some commencement speeches this time of year, and
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they tend at the end of the medical school commencement after the people have been
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declared mds in those schools that we all take the ones who just graduated and
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the ones who are in the audience again take take the physician's pledge. So
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all those fit with the professional aspect that you mentioned. The second larger institutions,
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academic freedom is important. Even if they're freestanding, to use your term,
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they're still part of the broader the broader community, the broader ecosystem of
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education, so I think that's important. And thirdly, wanting to instill values
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of increy and curiosity won't be it to our profession if we stopped being curious
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the day we got our medical licenses and all of our undergraduate graduate medication training
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was over. I still have an active medical license. I need to take
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courses every year. I learn every year, and even a course with the
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same name two years in a row, I'm learning something I didn't learn the
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year before. And so either that sort of narrow formalism of inquiry or the
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broader idea of understanding. As I mentioned, health and life rather than health
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and disease all require inquiry. So it really is everything that you mentioned.
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I want to pick up on a couple of those themes social determinants of health
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and also sort of the kinds of medical professionals that are being formed through medical
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schools curious in light of the expanding notion of health and all the information in
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the training that students may now need, some of these topics were not on
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their highs in five, ten, twenty fifty years ago. Is there a
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risk that instead of helping to form excellent physicians, we're forming wonderful global citizens,
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intellectually, rigorous and curious persons. This is great, but is it
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possible that aim is slightly different? And so one way of framing this is
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it's pushing back on the d answer and saying, maybe there's a bit of
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attention. You can't be both a training institution and also create wonderful, well
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rounded hole people. Well, you and I are becoming friends in this interview,
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but we can't agree on everything, and I would say that not only
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should we we have to we have to develop global citizens. Now you could
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argue with this next point I'm going to make, but didn't COVID teach us
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that lesson. Did something start on the other side of the world all of
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a sudden, you know, affected millions of lives, cause depth here and
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around the world, and reminded us that we need to understand global health.
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And even though that's still within the scientific, the stem purview of medicine,
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it also takes into account a lot of other things, the changes in the
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world because of air travel, and again the political realm, and how much
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can we suggest or recommend things, how much can we insist how much should
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the government, by decree or legislation, you know, limit people's prerogatives.
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All of those things are things that physicians have to think about. Not only
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the physicians who are in positions of responsibility the state surgeons general and so on,
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or the heads of health departments and those in the public health domain,
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but all of us have to be thinking about that. So a patient comes
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to the office and as a fever and a cough, and we ask have
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you been traveling? We also ask a lot of other things that we ask
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have you been traveling, where were you traveling, how long ago? Things
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like that, And so it doesn't exactly answer your question because that's still in
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the realm of scientific inquiry for that patient, but it immediately gets us out
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of the idea that all we have to do is think about the person as
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he or she is sitting right in front of us now. And so I
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think that it's very, very important that we do develop You use the term
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I believe global citizens, which is a broader concept that I think brings into
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such things as climate change and other sorts of things. And hey, guess
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what we're now. We now have a major initiative with a national Academy of
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Medicine to make sure that climate change is also part of the curriculum, part
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of the things that we need to understand, because as the planet warms up,
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there's a change in the proliferation of vectors insects that can carry disease,
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lethal disease, and so all of a sudden we have to have these disciplines.
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The tension, and use the word tension, it's a very apropos term.
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Is the concept that people are trying to convince me that there's twenty four
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hours in the day. I'm not sure about that, but all the everything,
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my Apple watch, everything seems to convince me that there are only twenty
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four And in that context, you can't do everything with everybody all the time.
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And so the pressure on the faculty in medical schools is enormous. How
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do they incorporate what's one of the newest things that AI. How do they
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incorporate an appreciation of AI, urine, ephesis to ethics related to AI,
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all of those things, will equity be served or harmed by AI? All
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those things? How do you put that into a curriculum already boiling over with
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the thing we just talked about and what's the next thing that's going to come
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after AI. I'm not smart enough to know, but we have to figure
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out a way to do it. And this is a moment for a tip
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of the hat to the medical faculty, because the faculty is where the curriculum
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is and should be developed. There's commonalities, but each school has a certain
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orientation, certain specific mission, and the faculty voice should be paramount in that.
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And faculty are under enormous, enormous pressure to respond to these needs.
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Some of them, by the way, don't come from outside. Some of
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them come from the students. The students want us to teach about climate change.
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The students lead us, as they do in so many parts of society,
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and so it's hard, but we have to do it. And I
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can't praise enough medical faculty around the world. Right now we're talking about in
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our country here that they have found a way and are continuously finding a way
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to a corporate the things that are new and different while not giving up the
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basic foundations that really don't change. How do we evaluate a patient, the
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person to person interactions, the basic sciences that helps us understand what is going
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on literally beneath the surface, and so it's tough, but it's something we
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just have to do. Is there too much that we're asking of physicians?
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Have we the non physicians, violated the social contract in some way by keeping
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this much on medical students? You know, I'm not smart enough to answer
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that question. I think it really feels that way to a lot of faculty
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members. I feel that way. I don't teach anymore, but I feel
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that way by proxy by listening to colleagues around the country and elsewhere in the
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world. I believe that we're asking almost the impossible. And the only reason
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I say almost the impossible is that they get it done. And again,
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I don't mean for this to be a cheering session for faculty, but faculty
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are finding a way. In general, there's always exceptions, there's always problems,
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there's always things that happen that we wish could be, you know,
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even better or different. But taking the input from others in their field advancing
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knowledge, each taking actually not only pressure but knowledge and information from the students.
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And by the way, the other people in this very complex, multifaceted
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transaction include other health professionals, the staffs in the universities. When I had
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the honor to be college president of you know, both times they reminded me
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that there are many, many more staff than faculty in universities and that we
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wouldn't get anything done without that. But it's not just that they are doing
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the will of the faculty and the student. They're adding enormous value and enormous
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input into these including these very intellectual ideas. So your specific question, which
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I'm dodging, was are we asking too much? And maybe we certainly are
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asking a lot, but I don't see a way to go backwards on that.
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And the very complicated dance that they are doing faculty and the students is
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to find a way to come together around the curriculum as it's decided, while
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paying enough attention to changing and incoming ideas that they neither give short shrift to
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those new ideas nor short shrift to the ideas that have been there for generations
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that still need to be inculcated into, for example, how to do a
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history or physical exam, which doesn't changes as rapidly, although even that changes
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for sure, definitely the history, for sure. And so we're asking a
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lot. I have to say, I don't like to use the phrase too
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much because we have to keep optimizing and optimizing and optimizing, and we have
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to give each other, I guess, the grace to say that we'll do
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our best, and if we don't quite get it right, we have a
27:22
chance to correct and do it. And that's why, as I'm having this
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amazing privilege traveling around, you know, giving some thoughts at commencements, I
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always ask for to the extent that the schedule will permit, ask for some
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time a meal or a little bit of time an hour with local students and
27:41
or residents, because their input is enormous, even though I'm not on the
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local faculty. And one more plug for students and learners is our board.
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The board of the Association of American Medical Colleges always has a voting position for
28:00
undergraduate student met medical undergraduates medical student, and always has a voting board position
28:04
for a resident position. And they're not just window dressing. They they're asking,
28:11
with deference to my colleagues on the board who are very accomplished leaders.
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In my experience working and leading multiple for profits in my time, the learners,
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the people on the way up, ask the hardest questions, most difficult
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not only in content but in refusal to take platitudes as an answer. And
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so I just was at one of our med schools last week and spent some
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time and almost got writers cramp from all the questions, suggestions, constructive criticisms
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that they levied about just a narrow thing, and that is, how can
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the double AMC do a better job of serving them? So long winded way
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of saying, yes, we're asking a lot, but we need to get
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it done. This really helps listeners understand the background and thinking about academic freedom
29:03
as it applies to medical education, and want to pivot back to that a
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little bit more specifically. So, if we have a deep respect for academic
29:11
freedom, does that extend to conceptions of health? For example, how do
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we think in an academic sense about differing epistemologies? We have indigenous ways of
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knowing as opposed to and maybe this is too stark, but certain kind of
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biomedical accounts. We have political and economic social determinants of health. Other kinds
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of factors, say, for example, whether a person owns a gun or
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not, which some academics to pick up that one specifically because I have a
29:38
project with students on that argue has nothing to do with health and others argue
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it significantly impacts health. How do we think about expanding conceptions of health when
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some of these questions are contested and connect up to features of the culture,
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which is fractious. The very good example you asked, should we ask a
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patient if they have a gun, and if they do, should we ask
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how they store the gun? And if we do, should we ask how
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they store the ammunition. It's very important for us to do that. It's
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important for us to ask about other things. Is the is the person we're
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interacting with in a safe situation? Are they concerned about their own safety and
30:25
welfare based on the presence of others or a lack of presence of others?
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All these things you might think are a little beyond the core history and physical
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that you that you correctly mentioned, but because they do affect health, I
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think they're very, very, very important, and it's important, very important
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as we approach these fractious issues to make sure that we don't become ideologues that
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we base the action or movement into a certain area only on the data suggesting
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or showing that they these factors are contributors to the public health. I think,
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but I'm not mistaken, Brian, that you had what I'm sure if
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it's true, was a joy of interviewing doctor Philip ALBERTI. I did a
31:19
wonderful time. Yes, yeah, And he's my he's my mentor and teacher
31:23
on uh, social determinants of health or vital conditions for health. And I've
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learned a lot from reading things that he's written, and I had the privilege
31:33
of many conversations with him, and so I think that I think that it's
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it's important to two do those do those things move into those lanes, take
31:48
the hits in those areas, but only based on the evidence, not based
31:53
on ideology. If we if we based on ideology and becomes a parent that
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it's ideological, then we're lost, because then we become just part of the
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fractious buzz all around us, as opposed to basing it on evidence that's moving
32:08
us forward. And it's hard to convince people that it's evidence based if they
32:13
see it a different way. And I certainly have failed to convince people in
32:16
that fashion, but I like to keep on to keep on trying. I'm
32:22
glad that you raised the word pistemology and also about indigenous ways on my bookshelf
32:28
right around the corner there there's a Native American health wisdom book and other things.
32:34
And I'm the farthest thing from an expert in things beyond Western medicine,
32:38
but I know that we don't know everything, and perhaps those aspects that we
32:47
have brought to Western medicine, like mindfulness, meditation, taishi people my age,
32:55
including I a little, very very early amateur taichi practitioner, because it
33:01
helps with the balance and it's a meditative practice. I think these things add
33:07
so much because there's a more wisdom in the world that can be contained in
33:13
one slice of global society. But it's hard to become the master of even
33:19
one, let alone a broader a broader field. But I think we do
33:22
have to look broadly because we have such complicated problems to deal with. If
33:29
not solved in our tool belt has to have a lot of loops on it
33:35
that we can put different things on. An excellent metaphor, I think,
33:37
especially for the future physicians who will be listening to this, I'll get you
33:45
out on a bit of shared wisdom. So I know you're a poetry fan,
33:50
any recommendations new classic if medicines are listening to this, they need a
33:55
break from gramming for the next exam, or just they love poetry. What
34:01
any recommendations that you'd share. I'd love to thanks for asking. I think
34:07
the humanities and arts add immeasurably to our lives and to our medical lives.
34:15
At the Double AMC, we have an initiative called the Fundamental Role of Arts
34:19
and Humanities and Medical Education frame of our ahmy, here comes a plug run
34:24
by our fabulous doctor Lisa Howley for busy people. I recommend haiku Japanese of
34:30
poetry form which in the Japanese language was put as a seventeen syllables five and
34:39
then seven and then five. And I'm a very very modest haiku poet in
34:45
English, using those syllable numbers as if that was it. In learning about
34:50
Westerners who have written haiku, I stumbled because somebody told me, not because
34:55
I came across it through my own wisdom. Richard Wright, an author that
35:00
you probably don't think about as haiku, wrote hundreds of Haiku, a great
35:06
book of haiku, and so I recommend get Richard Wrights haiku in some form
35:13
online by the book. It's wonderful. So Westerner's use of this Japanese art
35:20
form. It's compelling. Classic Japanese haiku is very oriented toward nature and Richard
35:29
Wright's Richard Wright's stuff is fabulous. So poetry for a busy person, although
35:37
I have to say a little seventeen syllable poem can keep you busy, thinking
35:44
and feeling for a long time. But that's a suggestion, Richard Wright.
35:49
Check it out. Excellent. Thank you, doctor Gordon David. Thank you
35:52
so much for being here. This was a great conversation. I really learned
35:54
a lot about academic freedom and how the WMC and sort of medicine more worldly
35:59
is thinging about it. You've given me our medical students, of faculty and
36:04
others who listen in a lot to think about. So thank you. I
36:06
really appreciate it. Thanks for having me. It's a pleasure. Congratulations on
36:09
your podcast. I hope it keeps on going and going and going, and
36:14
I really hope our paths cross in person sometimes, so I can, you
36:17
know, shake your hand and thank you for this. Thanks a lot,
36:21
Brian, keep going. Thank you so much. I appreciate it. This
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podcast series is a production of the Health Ethics Lab, and I am grateful
36:28
to colleagues in the Department of Medical Sciences, the IHS Library, and the
36:31
Hackensack I'm ready in the School of Medicine for making this collaboration possible. To
36:36
learn more about our work or to engage with the series content, reach out
36:39
to me Brian Pilkington at Brian dot Pilkington at hmh N dot org.