Bioethics for the People

In this episode, Darian Goldin Stahl delves in the wild west of eating your placenta!

Transcript

0:05 

Welcome to this episode of Bioethics for the People.I'm joined by my Co host Tyler Gibb, who according to his students, is best described as the goat of bioethics.My Co host is Devin Stahl, who, according to a previous student, should be cloned and teach all of the bioethics courses. 

0:28 

All right, Tyler.It's another one of our special episodes.I love Halloween episodes, particularly because we get to have a repeat visit by the other Doctor Stall, The spookier, prettier, and all around smarter Doctor Stall. 

0:48 

Dr. Darian Golden Stall.I couldn't agree more.It's lovely to be here with you both.For our special spooky tales of medicine, ethics, and and maybe a little bit of art.Excellent. 

1:04 

Well, because now we're videoing this.Folks can watch the YouTube and actually see the art if you want to share it, Darian.Oh.Well, I wasn't told about that, so OK, I don't have it ready, but we can upload some pictures later.OK, we'll we'll upload pictures to the website. 

1:20 

Perfect.It might also be commentary about how much you 2 resemble each other.I don't know if anybody's ever seen.I feel like I have the pale power of living in Canada right now and Devin looks tan and Texas.Girl, the climate really changes you. 

1:39 

I've heard that about Texas.Mm hmm.We just get prettier in Tanner here.Just all around sweatier.Darian, what do you have for us?So this year's topic, you know, I I've heard it in the zeitgeist and I wanted to dig into it a little bit more. 

1:57 

And wouldn't you know, there's a lot of weird medical and ethical considerations around this serious, dynamic and temporary bodily organ, the placenta.Oh no, we just were joking about this and hopefully it doesn't. 

2:18 

You don't get mad, but I brought it up in a previous episode.So tell us about your placenta.Or just the placenta.Before we start, before we start, I am repulsed by the placenta.It is the.It creeps me out more than anything else in the. 

2:36 

In the body.Wait, yeah, I thought you were a feminist.I I can be a feminist and also be have some thoughts about placentas be repulsed by women's bodies.I love women, but not their bodies. 

2:51 

Their bodies.All right, well, this is this is really fun so far.I I feel like the placenta is finally getting it to do.Like more studies around it are popping up.I've heard different podcast episodes about the placenta.It's it's a remarkable organ both in what it does. 

3:10 

Inside the body and potentially what it can do outside the body.OK.OK.I want to hear all about it.So as an artist, I'm interested in these medical topics, as you know, and as a person who herself grew a placenta. 

3:32 

I wondered if this organ could have some more potential after its main job of sustaining life for a fetus, and it turns out there's a lot of nifty ideas out there.According to such esteemed outlets like parents.com, one might consider inking up that bad boy and stamping it onto a T-shirt or your baby's onesie, which could be considered baby's first print. 

4:02 

So as a printmaker, that one really resonated with me.You could also, if if that's not quite your style, make a cast of it in plaster and frame it alongside of your baby's footprints.Crafty.Or better yet, you might consider drying it out and carving a little space out of the middle of it for a picture of your baby. 

4:28 

So making a placenta photo frame?Oh no, that's too much.With that space that you've carved out, you can't let that go to waste.So consider suspending it in resin and making like a beautiful brooch or some beads that could go on a bracelet. 

4:49 

No, like bodily organ jewelry is where I draw the line well.Don't get me started on what you can do with that little cord stump.Oh, I bet.Oh.It's a lot of beautiful pendants. 

5:07 

So, Devin and Tyler, do any of those sound appealing or do you have a suggestion for another crafty item?No, you could throw it right in the garbage.Or have somebody else throw it into the garbage.Even better, it's medical waste. 

5:23 

Darian, how do people even get their placenta?Maybe I'll get into this, but like, I don't remember the doctor being like, you want this and then me being like, Nah and him throwing it away.How do people even procure their own placenta?Is this like just for home birth kind of stuff?Is it?Is it a particular market that can do this? 

5:40 

Luckily for you all, I have been researching this topic and we will get into it, but I want to frame our discussion in placenta.Frame it in placenta, our discussion of placenta before we go too much further. 

5:57 

And I I want to spend the rest of our time today talking about another fun thing that we can do with a placenta, which may be the one that you all have encountered the most eating them.Some people bury them, right? 

6:14 

Yeah, like being buried like at the foot of a tree or something like that.And then the tree.Like, I don't know there's some sort of special connection to the child, but eating it?I don't know.There's a lot of organs that we have that we don't eat.So why are we Are there many that we expel? 

6:32 

That's true.That's true.Tyler.How often are you expelling organs?Well, I don't think that whether or not I'm expelling the organ makes it more palatable.Usually things that come out of your body should not go back into your body.That's like my general rule.That's what I try to tell my kids when they eat boogers is like, just just don't. 

6:50 

Just like if it's coming out, let it be out.If it wanted to be in, it would have stayed in so.Auto Placentophagy Oh no, that's that's not the name, but it's not really the.Name that is actually the name Auto Placentophagy. 

7:06 

The practice of eating one's own placenta is a sub category, yes.That would imply that there's non auto placenta placenta, right?Yeah, that's right. 

7:22 

That's right.So other other peoples, No, that's that is way worse.OK, we're interrupting.Go ahead, Gary.Tell us what we don't know about this.Yeah, you know we're we're going to get into it.Auto plus entophagy might be known as a subcategory of auto sarcophagy or self cannibalism. 

7:44 

And I I feel like I've gotten a little bit of a reaction so far, but I would.What?What is your initial gut reaction to this, To this practice of eating one's own placenta?Devin and Tyler, I mean, whatever makes you feel good. 

8:01 

It doesn't.It didn't.It didn't appeal to me as somebody who gave birth.That was not something I wanted to do.I mean, I think, like the way I've heard it done is a little less kind of, like visceral than maybe what people might initially imagine like it being expelled. 

8:16 

And you just like taking a big bite of it is repulsive.But maybe there's like other things you could do, I don't know.That face tells me that that's just the norm.We're just like expelling and chomping.That's kind of gross to.Me.I mean, if you're trying to get the nutrients, is that the best way it's? 

8:33 

Got to be the best way, like Bear Grylls style Game of Thrones eating that horse heart.It's like bloody mess.Tyler, have you have you known anyone to eat their own placenta?I don't.I think that I do.I can't think of anybody off the top of my head that I know personally. 

8:49 

Yes, you do, Tyler.Yes, you do.She's on the video right now.Oh, it's me.No.Twist Gotcha.The reveal.All right.Tell us more. 

9:05 

I ate my own placenta.But don't let that stop you from being very critical of this practice.It's totally OK with me.I won't take it personally.Yeah, sure, sure.So the practice of eating one's own placenta actually pretty much started in the US in the 1970s, with proponents stemming from midwives to the alternative health community. 

9:30 

And advocates for this practice report The Naturalness.Citing the fact that most placental mammals eat their own placentas after birth, either to hide the evidence of their vulnerable newborns or just as a nutritious snack. 

9:48 

Now pregnancy takes a lot out of you, and why let that go to waste?But for humans, there is actually not a lot of strong evidence that ancient civilizations practice auto plasentophagy.But.There is a 16th century Chinese medical text, The Compendium of Matira Medica. 

10:10 

I'm guessing that's a translation.Does describe does describe the practice of preparing placenta to feed other members of the family well?This is the placentophagy part, not the auto placentophagy and. 

10:33 

This seems to be a more actually common practice than eating one's own placenta is to kind of have it as a medicinal community banquet snack.Can you imagine bringing that to the potluck? 

10:49 

So wait a second.Oh my gosh.So it was eaten in like a ceremonial like, we're celebrating the birth of this child.Or like, here's some extra protein and iron.To supplement our otherwise normal day diet. 

11:05 

I think it's a celebration and also in like medicine.So drying it out and having it be kind of in the pharmaceutical cabinet for people later, that's really interesting.Darian, I would have thought it was like eating your own would have been some sort of ancient thing, but so I'm surprised to learn it was just a bunch of hippies in the 1970s. 

11:23 

Yeah, I was surprised too.I I thought.But that's a fallacy, right?Like that it has some tie to an ancient practice.But it really doesn't seem to at all OK.But Speaking of which, let's bring it back to this contemporary US context where auto placentology is most likely to occur in the world today. 

11:44 

Wow.In the USI am shocked by this.We are weirdos, aren't we?Well, we love freedom.We love freedom.This.There's nothing more free than eating your own placenta.I I think I saw that on a bumper sticker once. 

12:01 

But that's my right.You can't tell me I can't eat my own placenta.Well, we'll get into that.Oh, OK.The University of Nevada, Las Vegas conducted a survey in 2013 of 189 women who had eaten their placenta with a 95% rating of the experience as positive or extremely positive and overwhelmingly reported that they would do it again. 

12:29 

Yeah, well, I mean, you're not going to do it and then be like, Nah, it wasn't for me.Yeah, there's some sampling bias there.People who eat their placentas are not going to be like, I don't want it, No, they've committed.Yeah, they should do a controlled trial and have people eat them without knowing it and then tell them later. 

12:48 

Get that through your IRB.We're going to slip it in to protein shakes.Go, Darian.The the the reason they're reporting that it was such a positive experience.Is that they reported higher lactation levels, more energy and better mood? 

13:06 

I don't know.I'm dubious, right?Like, how do you like they weren't lactating much and then they took the placenta and then they were lactating more and that wasn't due to like anything else that was happening in their lives.Just how do they how do they know it was the placenta pill, I think.You can know for sure, yeah.I don't think you can know either. 

13:21 

Self-reports about health benefits are dubious.And you're getting into the ethics.But but you know, the self reporting is not all.Healthcare advocates also claim that hormones and nutrients including estrogen, progesterone, lactogen, iron, endorphins and oxytocin are retained through the preparation and consumption of placentas. 

13:46 

It is also said to reduce postpartum bleeding, speed up uterine recovery, enhance maternal bonding and boost the immune system.That does sound amazing and not like any of it was made-up at all by the people trying to sell you your own placenta. 

14:02 

Why?Don't everyone eat their own placenta?Let's do it.Why?Why not?With all these benefits, yeah, if those were real proven benefits, I might have eaten my placenta.Devin and Tyler, let's go ahead and put on your medical ethics hats now and could you maybe put forward a couple reasons why this practice is deemed controversial? 

14:25 

There might be risks, like who's doing it?It's some, like midwife.Is she, like, trained to do this in a Safeway?Like this?Isn't a pharmacy compounding medicine?This is like some woman in her apartment just encapsulating. 

14:42 

Well, you can talk about, like, how you actually prepare it, but I don't know that it's being prepared in like a Safeway.I don't know really know.It's my placenta.I don't know.What if there are actual health risks that were not being reported?Tyler.We have a process of dealing with bodily waste, which I understand that we're not deeming this as waste, but bodily material in a way that is safe, right? 

15:05 

I mean we deal with blood products and parts of other parts of bodies in a way that is safe and.Handled in very particular ways.I guess I don't my concern would be that we're not that there's potential for for risk or infection or something. 

15:21 

I don't know.It's obviously not a well researched area.So there's concerns about whether there's actual benefit or not.There's a significant yuck factor.I'm going to go on record and say ethics is mostly about yuck factor. 

15:39 

So he feels like he's something must be wrong.No.But I mean yeah, like there there just seem like some potential risks.Also, if we haven't been doing this, women have had successful burrs and postpartum experiences without this for Millennium. 

15:55 

So like why do we need this?Not to say like just because it's new, it's bad, it's new, it's not well researched.I'm I'm skeptical.I think all of those are very valid points.Let's start with the health risks.So what?What are the safety concerns?When?Eating one's own placenta. 

16:12 

Some providers of placenta preparation do adhere to Occupational Safety and Health Administration regulations, OSHA, but it is truly the Wild West out there.There's a lot of information and recipes on non medical or government regulated websites on how to prepare your own placenta for consumption, so it's a lot of just sharing information with each other on the Internet. 

16:39 

And given that the placenta can be a hotbed of bacteria and viruses as the filtration organ for a developing fetus, proper preparation should be given actually quite a lot of attention.Yeah, I didn't even think of that.What is its function in the body? 

16:56 

Is like Probably pretty important to like what it it consists of, yeah?A lot of bacteria and viruses, Yeah.So you're eating a lot of your own bacteria and viruses.Maybe.You know, we probably do that anyway.It's not a strong argument, Darian. 

17:13 

It's not a strong argument.I have young children.I probably am accidentally consuming a lot of viruses and bacteria.That's right and and actually I could only find.Evidence for one confirmed case of an infant needing hospitalization due to a strep B blood infection tied to their mother's consumption of the placenta. 

17:35 

So I think if it were super risky, we'd probably hear more about these cases.Fair not to say that they're not happening, but it doesn't seem to be an an overwhelming consequence of the millions of women eating their own placenta.That's. 

17:53 

Right, you said recipes, which has me concerned because when I thought I thought you were talking about drying it out and like encapsulating it, but.Oh, Tyler.Oh, no.Simple, simple Tyler.I feel like you're going to ruin my day, Darien. 

18:12 

Yeah, I just, you know, I hope you've already eaten breakfast.OK.I think the next point y'all brought up was the efficacy.Does it actually do the things that placenta eating advocates say?Well, there haven't been a ton of studies to begin with and the ones that have been done don't find a lot of strong evidence. 

18:33 

I could really only find 1 double-blind test around eating ones on placenta, and it had to do with measuring the iron levels.Of people eating and not eating their own placentas.Since pregnancy does leave a lot of people iron deficient and low iron is a known cause of like low mood. 

18:57 

So it could be that the iron rich placenta is one of these mood boosting factors of eating of eating it.But the study found actually no difference in iron levels for people who had eaten their placentas and those who had not after three weeks time. 

19:16 

So you might have had like an initial boost, but really no market difference after three weeks, OK.So it's not, it's not helping you recover iron, it's.Not the iron, but that's about it.There are really no other blind case studies to measure what the placenta is doing. 

19:35 

I think that there's a lot of momentum now, but the results haven't been published.I mean, a double-blind insinuates that they encapsulated something and put it in a pill and it's like it could be your placenta, it might not be, might be dirt.Yeah, that's what they did. 

19:52 

I what what they're like, kind of like brownish Gray, right?Yeah, they look like little dried mushroom bits.It's kind of chunky.So in my my when my wife gave birth, I don't remember like seeing the like.There's a lot of other things going on in the room, but I I have this vague memory of like a melon sized like gooey scab. 

20:16 

That's my impression of a scab.I mean honestly that's that's an accurate right assessment.So, so we're we're on the same page.So you're telling me that at some point somebody looked at that after having just witnessed birth, which is its own type of miracle. 

20:35 

Miracle.That's the word I was looking for.And then they said, I wonder what it tastes like.And then they ate it that IA.Bunch of hippies in the 70s, That's hard for me.You know, hippies.You know those hippies?You know, curious folk. 

20:51 

What does a placenta look like inside the body?Is it beautiful, Darien?It's a pancake.It's like a big bloody vanny pancake.Yeah.Well, that sounds more appetizing.Yeah.And one thing that you're alluding to, Tyler, that maybe we haven't touched on yet is the medical burden. 

21:14 

So there is an extra step if you know that the person giving birth wants to eat their placenta and that kind of falls to the medical and nursing staff to take it and leave it somewhere sanitary so that you can take it home. 

21:30 

And in the pregnancy books that I read, I was suggested to bring a big old Ziploc bag and a cooler filled with ice.Oh.My gosh, bring your old Ziploc bag to your.Birth to your birth if if you know that you want that because you really can't rely on the medical staff to do anything. 

21:50 

To have a biohazard bag, I mean, I'm just going to tell you that's like messed up because there's lots of those.Like they have special bags.But maybe bring your own, just in case.Maybe they just, like, plop it in the garbage right away.And he said no, no, no, put it in this bag.Did you did you go out and buy Ziploc gallon sized bags and have it in your like your go bag in preparation for giving birth? 

22:11 

So here's what happened to me.I had a doula who I had pre arranged for her to gather my placenta.But during my birth, things went South.And I had to have an emergency C-section. 

22:26 

So they wheeled me into the operating room, which is a space where only my husband could come with me.So the doula was not allowed in the operating room.And there is a flurry of activity going on.And honestly, the last thing on my mind was, wait, wait, wait, my placenta. 

22:42 

Like, what's going to happen here?But you know, to their credit, I have a picture from the nursing staff.Of, you know, a nurse holding my naked screaming baby next to a screen that has her weight and inches height on it. 

23:00 

And in the corner of the photo is a big clear plastic bag with my placenta in it.Nice.And it's like, oh, this is like they got it and they put it in a bag.My baby and my baby's former home, yeah.Well, did you tell them ahead of time though, like or the doula was like at the door knocking with the bag going. 

23:21 

Don't forget about the placenta.I have no idea.Maybe my doula had talked to them.I don't remember really talking about it.I I was in a different world, which I I think is fair.It was really far away from my mind. 

23:37 

Yeah, that seems fair.Well, good.Good on your doula, because she clearly was the one.I doubt it was your husband.No.No.He wasn't doing anything.Yeah.Like, literally nothing.But he was there.In the room.He.Was there, I guess. 

23:53 

He was actually texting me, so he wasn't doing nothing.That's true.He was buying toys off of Facebook Marketplace that I was making him purchase a giant rocking squirrel.For the baby.For the baby, you You have your placenta in a plastic bag, but you don't. 

24:12 

It's not like you, you know, give birth and jump up and go home.So did your husband have to, like, carry it, take it home and put it in the fridge?Or like what happened?So I think what happened was the nursing staff put it in a refrigerator and then my doula picked it up from the refrigerator and took it away and did whatever she does with them. 

24:37 

It's best to not ask questions.I don't know.She showed up at my house three days later with a bunch of pills.It's a real Jesus moment.It was taken away and who knows?It seemed dead.But then three days later, it came back.It gave.You life.And it gave you life. 

24:53 

Nice.Yes.And I would say, OK, the next kind of squishy medical ethics that Tyler, you're focused on, I think is to question, is this Wellness culture run amok, You know, what's the deal here? 

25:12 

Who are these people?And I think those who are skeptical of this practice also cite the trendiness of it and potentially A widespread placebo effect of these amazing benefits to eating one's own placenta. 

25:29 

Sure, now this is a practice grown from a niche Wellness community with big celebrity endorsements today, like January Jones, who cites eating her own placenta as the reason why she was able to go back to the set of Mad Men only six weeks postpartum. 

25:45 

Six weeks?Yikes.Oh, poor lady.Why just stay home?To stay home and you know, Khloe Kardashian posted her placenta pills on her Instagram, which is a huge get for the placenta eating community. 

26:06 

The PE CS, AS I like to be called.Yeah.So what's the volume?How many pills are we talking about?I mean, is it like a thought?Like, yeah, like a kilo of.I'm envisioning like your doula coming in having like a, you know, a duct taped kilo like a drug dealer. 

26:22 

So it depends how big your own placenta is, because they vary in size.But.In general, in general.For me, I had four placenta pills a day for 30 days. 

26:41 

That's a good amount, so. 120 pills?Did you eat all of them?Oh yeah.Except the ones that I ate.Just kidding, I didn't do that.I was.I did see them when I was visiting and I considered putting them in my coffee in the morning. 

26:57 

But I in your coffee.Oh.Yeah, like the salt.Like open it, open the capsule.And it's like on the top of the latte.Oh yeah, Yeah.Gosh.Devin, I have a question for you.OK, what do you think the demographic breakdown is for people who eat white women? 

27:18 

It's all white women.Anything else?Nope.Just just white women of a certain age, of a certain age up.Upper middle class, educated.Yeah, this is a like a wealthier white lady thing to do. 

27:34 

Is that right?That is absolutely right.Of course, because you have to, like, pay someone to do it.Yeah, and it's weird.It's not cheap.Oh, we haven't even talked about the cost.What is?What is it?If you don't mind us asking Darian, how much in Canadian dollars did you have to pay to get your placenta encapsulated I? 

27:52 

Don't remember.I think it was like 250 bucks.Oh, OK, that's not nothing.Yeah, it didn't seem outrageous either.It seemed like just on the cusp of like, OK, well I'm not paying free because I live in.Canada.Yeah, that's true. 

28:07 

That's true.It's going to say not because you're not paying for your delivery or the healthcare at all, then seems like a drop in the bucket.We call those co-pays in America.Yeah.That's one ibuprofen in the emergency room.So there's there's a lot of mass media outlets like the Times running headlines like after birth. 

28:30 

It's what's for dinner.No, that's a good one.I like it.So popular culture has kind of sensationalized its reporting, and it could be providing this practice with more credence than than maybe it deserves. 

28:48 

The mass media would never do that, but.But I also put this on its head, Devin and Tyler.Is this another case of white lady mass hysteria, or would this be a case of medicine disregarding what women are reporting about their own bodies? 

29:06 

Sure.Good question.Good question.Well, the fact that so many are doing it and there's been so little research is kind of like in and of itself, like a woman bias, probably.Because even if even if it does nothing, and there's no research to show it does, if that many people are doing it, we should probably do some research to make sure it's not risky or that it actually is doing something all right. 

29:29 

So the fact that there's been like, one study is embarrassing.So that's that's kind of the ethical portion of this practice.But I want to get down to the brass tacks of the lawfulness of this practice.Yeah, this is where this is the stuff that actually matters, not that squishy ethics. 

29:47 

Agreed finally, finally the real stuff.Just tell me what to do and maybe.This is a question for Tyler.What do you think are some legal barriers that people might face if they want to take home and eat their placenta?Boy, this is not something I've thought about before. 

30:07 

I wonder if it would be regulated under something along the same lines that we regulate how to handle corpses.Like I wonder if it's some sort of like like municipal public health codes or something like that would be involved.Can you sell it? 

30:25 

Is it a commercial product?Well, it's an organ, so no right?Can you sell your You can't sell your own organs.I could sell my fingernails.Oh, I mean, I guess you could.That's a good point.Yeah.Is a placenta more like an an appendix or is it more like a fingernail? 

30:42 

I mean, you probably couldn't just sell your appendix, right?So I had.I had my tonsils taken out when I was actually just after law school, and I thought about getting them lacquered and made into earrings.How are you so quick about what we're talking about? 

30:57 

And then admit that, drop that bombshell into this conversation like you're so much higher and mightier than us.And then he wanted to wear his tonsils as earrings.Yeah, I wanted to.I wanted to.I wanted to give them as as earrings, as a gift and not tell anybody what they actually were. 

31:15 

That's the troll move, yeah, but they said no.They said I couldn't.I couldn't have them.Oh, OK.They like threw them away and burned them.Yeah, 'cause it's it's a biohazard, right?It's bio waste.So it's unsafe to just like, let people have stuff we take out of them potentially. 

31:31 

Wait, why is?Why are Placentas different then?This is a great question and Darian teach us.Yeah, so this is a real patchwork of specific hospital policy, city and statewide laws, And many hospitals do consider the placenta to be medical waste. 

31:52 

So either they flat out refuse to give it to you, they make you sign a liability waiver to take it away, or you must obtain a court order ahead of time.For you to be able to take your own placenta, which is what one woman did in Mississippi Jordan Tearing, and it cost her nearly $1000 on top of the fees of actually encapsulating your placenta in order to take it away from the hospital. 

32:20 

She really wanted that placenta.Really wanted it.But if she had lived in other states, she would have the legal right.To take home her placenta.So actually written into the laws of three states is the right to have your placenta. 

32:35 

Let's guess which ones.California.No, I I bet it's not Texas.Oregon.Oregon.That doesn't surprise me.Yeah, Washington.Washington Nope.Oh, what are the other hippie states? 

32:51 

It.Is the.Hippie One.Hippies.New Hampshire.No.Where are Ben and Jerry from?Vermont.Vermont.No.Yeah.All right.Tell us where.Hawaii.Hawaii, of course.And then the third one, which state has the most freedom? 

33:09 

It's not Texas, is it Texas.It's.Texas, you didn't take advantage of your freedom.That's right.Wow, I feel like such a sucker now.Come to Texas where you can get a tan and eat your placenta.Barbecue placenta, like placenta tacos. 

33:27 

Less than Papos.So there's there's also super helpful hospitals like Mass General in Boston that will test the placenta for pathogens and package it up for you to take home.So really, other hospitals are going above and beyond to make this process easy and safer for new parents. 

33:48 

Yeah, they're probably like, if these women are going to do it anyway, we might as well try to make it safe for them.That's fascinating because as a hospital, like getting a hospital to do something that doesn't have some sort of evidence behind it, I mean, that's hard, right?Just so someone can say, oh, I'm going to eat my placenta based upon no published data about the benefits or risks, really. 

34:10 

And the hospital is going to do it for you?I don't know.That seems strange to me.I can see the hospital saying if you want to take it, that's fine.We don't want anything to do with it.Yeah, the liability, that's that's how risk typically works.They're like, all right, sign a waiver.I guess whatever you want to do on your own time is fine.But the hospital going through and like processing and redistributing it, that's interesting to me. 

34:30 

It's harm reduction.It's a public health thing, right?Good for them.So, and another layer to the legality of this issue are the businesses that are.Processing your placenta and then selling it back to you and the state laws regulating these businesses are incredibly strict, proactive and really keep the mother's health at the forefront. 

34:56 

Good, good, good.Just kidding.Oh, yeah, of course not.You mean they're more probusiness than pro woman?That there just are no laws at all.It's it's a total free for all.Parents bear the burden of sleuthing out their provider and making sure that they have some kind of licensing or sanitary practices. 

35:18 

But you can give it to like anyone, and then they'll just do something and bring it back to you for money.There's, there's no regulations there.So Darian, based upon the our conversations from a couple of seasons ago when you were talking about the lack of regulation on what we do with dead bodies, it's not surprising that we have zero laws about placental remains, how we deal placental handling I guess. 

35:45 

Right.And then I have to question because I saw this debate like do we really want governmental bodies to be regulating this business?So the the United States Food and Drug Administration does not currently regulate encapsulating placentas. 

36:02 

And while it might.Seem like a good idea for the FDA to put forth some standards for selling placenta prep services.These are almost exclusively women owned cottage industries who could definitely not afford to have any kind of industrial equipment to process placentas, which is probably what the FDA would would demand. 

36:26 

So a lot of providers then would shutter.We want that.Would such regulation over protect women to their own health detriment?Well, I mean, that presumes there's some health benefit, but OK. 

36:41 

I think it also presumes that there's a lot of risk, and that hasn't been shown to be the case either.Like I can trade cookies and sell people cookies.Yeah, same thing.It's a great analogy.It's.Not, not, not so different maybe. 

36:58 

Well, we I think maybe a better analogy would be like all these women who sell their breast milk.Oh, that's a whole other thing because because that's raw, you don't pasteurize it.That seems more dangerous than the placenta, I think, because at least the placenta might get like cooked or dried to mitigate some of the bacteria, whereas the milk is raw. 

37:17 

I think this is the first time in all the seasons we've been doing Darien's special episodes that I saw Darien have a yuck reaction to something and it was breast milk.Yeah, Darian, what do you hate women's bodies?So, Darian, why did you do it? 

37:34 

I thought if any of it could be true, then why not?Like I didn't see the risks posing that much of A risk and the benefits seem to be plentiful.And there's a lot of anecdotal evidence out there because there just are no scientific double-blind case studies to back up those anecdotes. 

37:55 

But.My doula, who's doula D for decades and has hundreds and hundreds of people eating their placenta under her belt.She really advocated for it, though.She's also selling it to me.As you say.Oh, you mean the woman who charged you $250 to do it thought that it was good? 

38:13 

I.Don't know.So yeah, this is fascinating.So, Darian, when you first thought of this, at what point in your commitment to doing this did you bring your partner into the conversation?You know, he's pretty open minded and I've done a lot of weird stuff to our house in the pursuit of making art and he's always been very generous for that. 

38:38 

So I I brought it up kind of right away and he was like, whatever you want.Uh huh.Which is perfect.Yeah, it's the right answer from a from a spouse.Yeah.But he wasn't also like, yeah, let I'll take, I'll take 2 pills a day.You take 2 pills a day and we'll.Yeah, Why would he take them? 

38:55 

That's they're for me.I mean, apparently it's good for iron and.Not iron.That's the only thing we do know.It's not iron.OK, you're right.I can't think of any reason why he would do it.You know the, so we're getting back to the the efficacy here and I think another question we could ask is, is this a case for the consumer protection agency? 

39:22 

You know, we are being sold a product that purportedly has all these benefits.But what if there's no benefits at all and we're all getting scammed?That's true.So it could be more like the the the dietary supplement industry rather than the Pharmaceutical industry. 

39:39 

Absolutely.A classically well regulated industry supplements.Yeah, but also, I mean, it's the same debate there.Like, do these pills actually have what they have in them on the label?Does it have these benefits?Are we being scammed? 

39:54 

Yeah, it seems to me like they've only gotten in trouble when they don't actually contain the thing they say they're containing, but they haven't really gotten in trouble for claiming that supplements do something that they probably don't really do.Isn't that right?Yeah, I think that's right.So if you found out that your doula gave you placenta pills that were full of chalk, then we should report her to the Better Business. 

40:16 

Bureau.Yeah, I'd be bummed.So that's that's kind of what I have today.And I I wanted to know after this conversation, Devin and Tyler, do you have some concluding thoughts on the rights, ethics, potential regulations or permission? 

40:35 

Yeah, we've touched on a lot of these things.So another question for you Darian, when you had, so you you had all 30 days, 4 you said 4 pills a day, 30 days.When you were taking your last dose, what were your thoughts and emotions taking the last dose or was it a non event for you? 

40:52 

Here's what I'll say.What what I'm about to say should not be taken as medical advice or opinion, but I think everyone should eat their placenta.It was awesome.There were there was like a three day gap.Between having my baby and the placenta bills being processed and delivered to my home, those three days were horrible. 

41:15 

I was like constantly crying, could not stop weeping 24 hours a day.The day after I started taking my pills, it was like a light switch flicked on and I was so much more in control of my emotions. 

41:33 

It was really like this night and day difference.I couldn't believe it because I was fairly skeptical.I was interested in like, oh, maybe, you know, these will have some benefits, but it was so dramatic.And maybe that third day would have been the turning point anyway.It's impossible to know, but I guess I like to think that the pills had something to do with it. 

41:53 

And if it was just a placebo, then what a hell of a placebo?Like, I'd paid money for that placebo.It worked.And I was very sad.At the end of those 30 days and a little bit scared like, Oh no, I wonder if I'll go back to being super sad and weepy. 

42:10 

I didn't.But yeah, I was in the 95% of people that had an overwhelmingly positive experience and I would do it again.Extremely positive experience.Well, that's enough for me.So do it.I don't have that many ethical concerns. 

42:27 

I mean the the yuck factor is high in this one I think but but now that but as we think through it a little bit and Darien's glowing review of of her experience, I think I'm softening.Well, get ready to be grossed out again, because we've made it to the parts of our placenta discussion where I'm going to give you some suggestions on how to eat it. 

42:51 

All right, so not encapsulation.I guess that's what you did, but there are other options.There are other options because.If you know you're wanting to keep all those nutrients, you don't want any of the hormones or whatever being baked away, then eating it raw might be the choice for you. 

43:10 

You can dig in.You know, the original recipe.Chicken Choppy the way Kentucky Fried Chicken?No.No, no, The way the way nature intended.Right the way Nature intended.Just naman. 

43:26 

Yeah, but if that's a little too visceral for you, you can, like, pack off chunks and pop them into your smoothie in the morning.You know, make little ice cubes out of your placenta and and blend them up.Or you can cook it up.You know, like a steak with a little side of vegetables. 

43:44 

For extra, You know, rounding out your nutritional plate, you can mince it up.As the protein option in such things as lasagna or chili or placenta pie.Oh.No. 

44:00 

Placenta pie?Oh.But I like this placenta Taco.Placenta tacos.That's a great suggestion that I didn't see, but I'm like, why not?But if these if these savory options you know aren't for you, you're more of a dessert girl then. 

44:19 

If you can satisfy that sweet tooth after it's been dried and pulverized by dusting it into your favorite truffle recipe, just roll it in there.Yum.I like it.The idea of it being like the cenery nugget in a chocolate. 

44:37 

Oh, that's creative.Yeah, go for that.But even like this is the drying and pulverizing.You can judge that up a little bit.How?Tell us how.Well, your placenta can be first steamed in an herb bath with traditional Chinese medicine recipes before placed in the dehydrator and pulverizer, which is what my doula did. 

45:02 

Still seems dehydrated by the end of it, but OK it was.Steamed with medicines.Steamed with medicines.I didn't ask any more.Questions after that.Best not to.So my my yuck factor is rebounding.Yeah, we're we're back. 

45:19 

So Darian, if you had the opportunity to eat another placenta, would you do it?And how would you consume it?I guess my instinct is like, why?If I were going through a depressive episode, then yes, I think that I might try eating someone's placenta again. 

45:43 

I don't suffer generally from depression or anxiety, so I'm like, I don't think I have a hormone imbalance.I would rather somebody else, you know, because it's a precious thing.Save it for somebody that needs it.I mean like there are other drugs for those conditions that I might recommend first, but. 

45:59 

Will those have consequences too, Devin?Yeah.Well, thanks for coming along on this cannibal adjacent spooky gross episode of Auto Plus Antopagy.Such a fun word.Such a fun word that I will not say right now because I'm afraid of messing it up. 

46:16 

Say it one more time, I.Practiced it auto plus antopagy.Thanks, Darian.Happy Halloween.Happy Halloween.Thanks for listening to this episode of Bioethics for the People. 

46:35 

We can't do this podcast by ourselves.We've tried and it's not pretty.Our team includes our research interns, Michaela Kim, Madison Foley and Macy Hutto.Special thanks to Helen Webster for social media and production support.Our theme music was created and performed by the talented Chris Wright, friend to all, dad to two and husband to 1. 

46:54 

Podcast art was created by Darian Goldenstall.You can find more of her work at dariangoldenstall.com.You can find more information about this episode and all of our previous seasons at bioethicsforthepeople.com.We love to connect with our listeners.All of our episodes can be found wherever you listen to podcasts. 

47:12 

Please like, subscribe and share and connect on social media. 

Tyler (the leading expert on the Schiavo case) and Devan discuss the life and death of Terri Schiavo.

Transcript

0:03 

Come to another episode of Bioethics for the People.I'm joined by my Co host Doctor Devin Stahl, who according to her student reviews should be cloned and teach all of the bioethics.And he's Tyler Gibb, who, according to his students, is best described as the goat of bioethics. 

0:28 

All right.Tyler, it's your turn today.What do you have for us?All right, all right.I got a case that I think that I've read more about this case than anybody has read about any case in the history of bioethics.That is quite the the feat, yeah, the claim. 

0:45 

Why have you read so much about this case?Right, so this case the the Terri Schiavo case is what it's come to me known as is actually the the central topic of my dissertation.So it was a labor of love I guess. 

1:02 

So I've read at that time.I'm sure the other things have been published, but at the time that I finished writing my dissertation, I was confident that I had read everything written about Terri Schiavo books, blogs, miniseries, like everything. 

1:18 

Like I had consumed everything about.Wow.And this.So this would have been eight years ago. 810 years ago, yeah.So yeah, I finished it in 2015.And so that was when, yeah, I even dusted off.I don't know if you do this very often, but I actually dusted off my my actually bound published dissertation. 

1:37 

What?I never had my dissertation bound.That is beautiful.I yeah, really?Yeah.I I had it bound and I got a bound copy for a couple of advisors and gave him to him as gifts.I'm sure that they are sitting on their shelves and never being read either. 

1:54 

I hope you signed them with love.Oh, I don't.I think I did sign them.You better.Have anyway.Well, I did publish my dissertation, so I guess I sort of got it bound.Yeah.Eventually, yeah, I I I pulled the classic grad school grad student move where I thought, I'm gonna publish this, this is brilliant. 

2:11 

And then it sat on my shelf for a year and a half and I picked it up and I was like, maybe it's not as brilliant as it felt at the.Time.Well, today is your redemption.Today is the day where all that labor is worth it.That's right, I it's gonna make it all worth it. 

2:28 

All of those years of toil.OK so Terry Schiavo, this case fascinates me obviously because it is really complicated and has a a cast of characters involved that makes it more complicated. 

2:44 

That I think is just mostly unknown.I think some of the people who play a role in this case are well known outside of this case.So but we'll we'll we'll get to that.So Terri Schiavo, what, how, what do you know about Terri Schiavo?Not to put you on the spot, but putting you on the spot. 

3:01 

A little bit only because it comes up as one of those right to die cases.So typically, I'll teach it in conjunction with a couple other cases, but we just do really bare bones.So she's a one of those 3 pretty young white women, which I think is, I say was sort of just, but also in seriousness, like, the public cares a lot about a particular kind of person when these cases make headlines, because she's certainly not the first person that's ever happened to. 

3:29 

So why was she the one?And I'm sure you have lots of explanations for that, but she gets seriously hurt.Her husband wants to take her off life support, her parents object.And so it creates this huge what isn't necessarily uncommon. 

3:44 

I'm sure you've seen cases like this in the hospital.There's a intera family fight about what should be done.What's unique about this is it gets politicized in a really outrageous way.And so politicians are involved, the media is involved, and it's this fight about what ought to be done for this woman and. 

4:02 

What the burden of proof for convincing us that she would or wouldn't have wanted to live in this way in a what we then might have called a vegetative state?And maybe we have better words for now.I wish we did have better words.We just abbreviate.It makes it go away. 

4:17 

We just don't say the words.OK, yeah, So Terry Schiavo was born in 1963 in Pennsylvania, actually.And so most of this case takes place in Florida.And after a couple of things to note about her as we kind of set the stage is that when she was younger she had a, she struggled with her weight and her body image and was bullied and picked on like through middle school and high school and was quite heavy at the end of high school moving into kind of her college years, late teenage years. 

4:52 

She went on a couple of really extreme diets and lost a ton of weight and got a lot of social you know, positive feedback started going out with boys and started getting more socially outgoing and kind of changed her life in a in a meaningful way for the benefit, for the for the good. 

5:14 

And she was able.I mean she went to Community College and met this a guy named Michael, Mike Schiavo, Michael Schiavo.And they started dating and everyone seemed to like them.And you know, it's kind of a a really happy time in their lives.At some, at a point maybe late 1980s, nineteen 90 ish, they moved down to Florida where her parents had retired to. 

5:37 

And they wanted to be in the Tampa area so they could be close to her retired parents while they were continuing school and stuff like that.So newlyweds moved to be closer to her retired parents in Florida.OK, all right.So she continued to have. 

5:53 

And some of this is speculation.And so I kind of have to go out and say that at the beginning is that there are vastly different accounts depending on whose perspective you're taking here.But at some point during the late 1980s like 8889, Michael and Terry Schivo, she became interested in having children and she started to go to a fertility clinic. 

6:18 

And because she was continuing to have a really kind of extreme diets, weight loss, protocol regimen that she was going through, she was having fertility issues.OK, so crash diets tend to not produce healthy outcomes is just what I know, right? 

6:36 

Yeah, there are other ways to accomplish the same goal, but she was having trouble having regular periods and stuff like that, and so she was having a hard time getting getting pregnant.She was allegedly, apparently reportedly drinking massive amounts of iced tea and so like 5 gallons a day or something like that, like like an outrageous amount of iced tea in order to continue to maintain her weight and stuff like that. 

7:06 

So through the process of that, it seems in retrospect that she was, her malnutrition was an issue as as well as her electrolytes were kind of all out of whack because of this massive amount of iced tea that she was drinking.There were reports in the in the media that she was anorexic or that she had an eating disorder, but that may or may not be true. 

7:29 

It's hard to really tell, but she was definitely very concerned about her weight and also the diet was was kind of wacky as well.So all of that is and back story. 01 more caveat before we get too far into this.Sorry.Caveat upon caveat, there's a little bit of disagreement between the family members and people who are close to her about actually what we call her so. 

7:52 

Like her name?Her name?Yeah, so.So Terry is short for Teresa and apparent some reports say that Terry was just almost like a like a diminutive nickname that her family would use like really close intimate friends. 

8:10 

And the family has bristled a little bit that everyone is calling calls her Terry now because it was, it feels too familiar for people who didn't know her and so they would prefer her name her to be referred to as Teresa, which makes sense.But everyone else calls her Terry. 

8:27 

So that's just the terminology we use.And also her last name Shivo is how it's commonly pronounced in the media and and and amongst people who study or read about this.But apparently the pronunciation, the Italian pronunciation of her last name is something closer to like Schiavo or something like something more like that. 

8:46 

Not even close.So we really butchered it like the media totally butchered it.Yeah, butchered her first and last name.Which I mean, if this is, if this is your family member who you care about, who's in vulnerable situation, like at least let's get her name right, But so here we are. 

9:02 

Well, So what are you going to say?Are you going to say, I'll say, I'll say Terry Schiavo, just because, I mean it's kind of the way that everyone does it, but but it's.Wrong.And and you should and our listeners know, OK, yeah.So at some time during the night in February of 1990, so I'm going to give a lot of dates and so I'll I'll try to keep these in sequential order because it it, it's important later. 

9:27 

So in February of 1990, where were, what were you doing in February of 1990?Oh, so I had just turned 5.Yeah.So I don't know.I don't know. 

9:42 

I don't know either.I was 9.So February of 1990, Michael Schiavo was working a late shift and came home.His wife was already in bed, Terry was already in bed, and at some point during the night, according to his account, he hears A thump and he understands that to her, her having collapsed in the hallway. 

10:04 

So the story is that he comes to bed late, she gets up to use the bathroom or something and passes out in their hallway.And so he gets up and tries to revive her, is unsuccessful, calls 911 and starts doing chest compressions there in the hallway. 

10:21 

Oh, so her heart stopped.So she right, stopped breathing.No, no heart rate.And after the fact it seems like this is related to her electrolyte issues and and the other things going on.No suspicion at this time of any type of foul play or malicious intent or anything like that. 

10:40 

From from Michael, over the course of the next 20 minutes to 30 minutes, the EMS folks show up, they end up shocking her heart.I think they they reportedly shocked her seven different times.So 7 rounds of very, very aggressive CPR even in the terms of your CPR is often aggressive chest compressions. 

11:02 

Eventually they're able to get her heart restarted and she is able to maintain her heart rate.So return of spontaneous circulation.However, during that interim when the heart isn't beating, the blood isn't flowing, the oxygen isn't circulating, she suffers massive irrecoverable A neurological injury. 

11:27 

So brain damage, because of a lack of oxygen, she gets transferred to the hospital and then eventually she stabilizes and is kind of in a an equilibrium where she's not getting worse but she's definitely not getting better.And in a condition that later becomes known as the persistent vegetative state or permanent vegetative state, the terminology again is a little squishy. 

11:51 

So what that means, basically is that everything above her brain stem has been significantly damaged.And so she will have so people it.Lots of individuals in persistent vegetative states will have spontaneous respiration. 

12:08 

They'll have reflexes.Really basic brain functions that maintain their life will maintain their, you know, blood pressure and core temperature and stuff like that, respond to pain in some ways, but not consistently, but definitely no interaction. 

12:24 

She's not opening her eyes.She's not appreciating anything going on around.Her No consciousness.No consciousness.So some of the old literature refers to this type of condition as wakefulness without awareness.It's funny you say that just because I was thinking sometimes people will want to say instead of PBS because vegetative sounds a little dehumanizing. 

12:44 

Unresponsive wakefulness syndrome or something along those lines which actually sounds similar to maybe an older terminology.And the idea being, you still have sleep, wake cycles, but there's no consciousness at all, right?No consciousness and no perception of what's going on around you, right? 

13:01 

And so when somebody walks in the room, there's no response, right?If someone pops a balloon, there's no response, right?There's no interactivity with the outside world.What the individual is experiencing is unknown.Like we don't.We don't know what what it's like to be in that condition because by definition, nobody ever recovers from that definite that condition. 

13:21 

It's a it's a permanent or persistent situation based upon the level of injury and the location of the injury.Injury from lack of oxygen.So yeah, so not the same.Sometimes people recover from coma.This is not that, right?And usually it's the case that people, when they have significant brain injuries that they will be in a coma for a period of time. 

13:44 

But being in a coma, the way that we commonly understand it is really a transitory state where people will either get better and they'll, quote, UN quote, progress into a persistent vegetative state or maybe a minimally conscious state, or they'll recover or they will deteriorate and they'll pass away, they'll die. 

14:03 

And so it's unusual to be in that that kind of coma state without any type of movement.And so that's where she was initially, but then progressed, quote UN quote, progressed into a persistent vegetative state or PVS.So at this time, Michael. 

14:18 

So the main characters at this point are Michael, her husband and her parents Bob and Mary.Terry's maiden name is Schindler and so Bob and Mary Schindler are on and Michael Schivo are the the main people in her life right now at this time they are very united. 

14:35 

They are very concerned about their daughter.Michael actually gives up his apartment which was further away from the rehab center where she was transferred to moves in with his in laws in order to be closer to provide good care.All indication is that there's a really a cohesive unit really trying hard for her to get better. 

14:56 

That's what you want.Yeah, exactly.And they are pushing for a very aggressive treatments.They are exploring experimental therapies.At one point she was even taken to University of California, San Francisco, which has an excellent state-of-the-art Medical Center. 

15:16 

There to do procedure call.It was some sort of stimulator they put inside of her brain to see if it would like re reanimate Some of the electrical stuff.A thalamic thalamic stimulator was implanted experimentally that ended up not working, and so during this time up until about 1992 ish. 

15:36 

So for several years the family was united and very aggressively trying to get her better.At one point, Terry's parents and Michael joined together to sue her primary care doctor and her obstetrician, claiming that they, those doctors either knew or should have known her malnutrition, her other issues going on that precipitated this and they didn't treat her for it. 

16:01 

So it's kind of a little bit of a stretchy malpractice claim, but but there was a claim there and actually it went forward and one of the doctors settled for his policy limits, which was about $250,000.And then the other doctor ended up settling after some other litigation back and forth for close to let's see. 

16:25 

So the second malpractice case, Michael received about $300,000 as compensation and for for that as of the Exeter of or the guardian of Terry Schiavo and then about $750,000. 

16:41 

So 3/4 of $1,000,000 was put into a trust to take specifically for the use of her for medical complications and treatment ongoing.Right.Which might have gone through pretty quickly.I mean, the state she's in is a very expensive sort of condition to have, and so my guess is that money didn't pay for even everything. 

17:02 

I don't know.Yeah, not, not a lot, right.And so that came about in about 1993, so kind of the end of 92, beginning of 93 and in February actually on Valentine's Day of 1993.At their multiple accounts of of this interaction, Bob Schindler and Michael Schiavo had an explosive disagreement about who and how this money was being used. 

17:35 

And so they both accused each other of promises being made and assurances and and commitments that have been broken.And prior to this, Michael Schiavo had been appointed through the normal process as the guardian of Terry, and so he was empowered, without opposition by the Schindler's, to make all, any and all medical and financial decisions on her behalf. 

17:59 

Once that kind of blew up, though, that relationship was irretrievably fractured.They it was high animosity from that point on, So 1993 on.So money and my guess is it's just stressful right? 

18:15 

It's special living with your in laws but also well just maybe in general.I don't know.I've never done that but but having to care for somebody who's so in such a grave position and and my guess is hope for her recovery is dwindling as years go on. 

18:32 

So Michael has come to the conclusion that further aggressive treatment is not going to help that that this is the state that she's in.And so he, it seems like from the literature that he is more resigned to this is going to be a long term chronic care type of situation instead of we're going to get her the best treatment, she's going to recover and we're going to move on with our lives. 

18:54 

So this is 3 years in.So three years in.This isn't, this isn't going to end, all right, but the parents are holding out hope.Yeah.Neurological injuries, as you know, are really difficult to prognosticate, meaning that it's really hard to see an injury, particularly a recent injury, and have a really good idea of what that is going to look like long term. 

19:18 

And the longer it goes, the better information we have about what the prognosis is going to be.And definitely after three years aggressive treatments tried and failed, it's pretty clear that this is kind of her status quo.All right, Michael obviously moves out with from the Schindler's and then later that summer Bob and Mary Schindler write a letter to Michael and this is what it says. 

19:42 

Let me just read.So it's it's it's very long.But here's the important point.So the letter said on a long term basis, we would like you to consider giving Terry back to us so we can give her the love and care she deserves logistically and realistically. 

19:59 

You have a life ahead of you.Give this some thought.Are you ready to dedicate the rest of your life to Terry?We are, so let us know your feelings.So, so basically inviting him to recuse himself as a decision maker and let the family take over and make decisions. 

20:16 

Yeah, 'cause he's a young guy, he's in his 20s, he has his whole.I mean, it's sort of, that's sort of a gracious thing that they're doing.It is, yeah.The rest of the letter wasn't quite as gracious.OK that was kind of the the kind part So after that and and Michael it seems he perceived that as a veiled threat. 

20:37 

It did not.It was not received well and after that point the relationship continued to be really tough.I I specifically they they started getting lawyers involved and so the family wanted Michael to not be the guardian anymore. 

20:55 

They wanted to make decisions because they they had a suspicion.They had an inkling that he was going to make decisions that would limit aggressive treatment and they wanted more aggressive treatment and so they wanted to remove him and then jump back and continue the aggressive treatment. 

21:13 

He Michael felt like he had made a commitment to Terry and that he knew what she wanted and it was the case that she wouldn't want to live like this and so he was confident and comfortable making end of life decisions with that understanding the family Bob and Mary and all. 

21:31 

There's a brother and a sister actually involved in the the Schindler's as well and the brother has gone on to have quite a important reputation and role in end of life issues.His name's Bobby Schindler, he's created a foundation in Terry's name and stuff subsequently, but they all believe that #1 Michael was a suspicious or unreliable decision maker and #2 Terry never would have said that because of the way that she was raised. 

21:59 

She was raised as a a devout Roman Catholic and based upon the the Roman Catholic Church's teachings about end of life and sanctity of life and and all of those things, they believe that Terry number one didn't believe that and #2 probably never said that either. 

22:15 

OK, so so Michael's saying she told me she would never want to live like this.They're saying there's no way, given our family beliefs around this, Catholics don't.Well, they might have thought that it's not a rule that Roman Catholics think that all people in PBS have to stay in that state permanently. 

22:31 

But OK, we'll leave that for another podcast, right?Yeah, we can talk about that.OK, So what?What happened?So the interesting point in the case right now are two questions.Number one, does a surrogate have the authority to make an end of life decision for their loved one? 

22:47 

And #2 what's the quality of evidence necessary in order to make that decision?Yeah.Hadn't we settled this by 1990?Yes, we had.So the first question gets got answered in the 1970s.OK, so a case about a woman named Karen Ann Quinlan, Is that ringing a bell? 

23:09 

It is the the other, that's the this is the trifecta of of young white women who who helped us figure out end of life law.Exactly right.So we got three of them.We got Terry Schiavo or Teresa Schiavo, depending on how you want to pronounce it.We have Karen Ann Quinlan, the 1970s and then in the early mid 80s, Ish. 

23:31 

We have another case.Nancy Cruzan was in the 80s and 90s and then Terry Schiavo was later.So the first case, Karen Quinlan was, like you said, a young woman who also ended up in a persistent vegetative state after actually, I think it was a car accident in Missouri. 

23:50 

Is that where we're at?No, this was in New Jersey.As you say, you're thinking of the next case, yeah, Cruzan was in Missouri, so Karen Ann Quinlan is in a an accident, maybe involving drugs and alcohol, maybe not.Not relevant, but she ends up in a persistent vegetative state, similar to Terri Schiavo, but she is ventilator dependent. 

24:15 

OK, so so her location and severity of her injuries made it so that she wasn't able to breathe spontaneously on her own and she was hooked up to a ventilator.After a number of years, the family decided, you know, she really wouldn't want to be hooked up to a machine like this and then requested the the doctors to stop that. 

24:36 

And this was kind of the first, the first time that the family requested a withdrawal of life sustaining treatment and the families request was resisted by the hospital.So the hospital said, wait a second, is that something that we can really do? 

24:52 

Yeah.Is that killing, right?To remove this, knowing that she would die, Is that a form of killing?So they're nervous, understandably, because this had really been the case before.Yeah, exactly.And recently in I think it was in Connecticut. 

25:07 

So a a neighboring state or a close by state in that area, there had been a lawsuit, a really public lawsuit about a doctor being sued or a hospital being sued.That kind of put a chill into the the environment, right.So everyone's a little bit more cautious than maybe they were. 

25:23 

Normally that goes up to the the New Jersey Supreme Court and the hospital actually wasn't saying no, we're not going to do this.They were saying we need someone else to look at this to make sure we're doing the right thing before we.Do it.Get legal involved, get legal right.We need some legal advice. 

25:40 

So after some back and forth, and because the doctors and the family weren't necessarily in conflict about this decision, just who and how the decision was being made, eventually it was removed, the ventilator was was stopped and removed, and Karen Quinlan ended up living for about 10 more years. 

25:58 

Yeah, they didn't realize, and because this is early ventilator practice, right, that even if she wasn't spontaneously breathing initially, the vent being hooked up for so long, when they withdrew it, she did start spontaneously breathing at that point. 

26:14 

They and they didn't really think that that would be a possibility.Now we know.Now we know, and the family was actually very happy because the family didn't want her to die necessarily, but they wanted her to be more comfortable.And so the family's goals were achieved, the hospital was satisfied, and she ended up living a fairly stable life and persistent vegetative state PBS for almost 10 more years before she died of pneumonia, which is one of the primary ways in which people with these types of injuries will pass away. 

26:46 

But the Quinlan case established the idea that surrogates can make withdrawal withholding decisions on behalf of somebody else.So the first.So the first question in the in the Schiavo case was answered by Quinlan that #1 Michael Schiavo does have the authority to make this end of life decision for somebody else. 

27:06 

To free her from the ventilator.But she's not on a ventilator, right?Terry's not.Yeah, that's an interesting point.So what else would you relieve her from?So Terri Schiavo was the the medical intervention that was keeping her alive was artificial nutrition and dehydration. 

27:22 

So she had a feeding tube.Can you remove the feeding tube?That's an interesting question.Is a ventilator the same as a feeding tube?Are they both medical interventions?Are they not?Are they different in some ways?Is there some reason why a surrogate could make the decision for a ventilator but not the feeding tube? 

27:42 

Those, those are the questions that we're, we're struggling with early in the Schiavo case.So the second question as how, how good of evidence is necessary in order for the surrogate to do that?Does it have to be written down?Does it have to be notarized?Does it have to be witnessed?All of those questions about the quality of the evidence? 

28:00 

And that was answered in the Nancy Cruzan case.So Nancy Cruzan in the 1980s was in a car accident and ended up in a persistent vegetative state, and her family asked that she be removed from the ventilator to be allowed to die. 

28:18 

The difference in that case or the the the new wrinkle in that case was that the state got involved.Missouri is traditionally a much more conservative, politically conservative state than New Jersey.The attorney general got involved and said no, we're not going to allow this because it's basically hearsay. 

28:38 

Like there's nothing written down.We don't really know that this is what Nancy would have wanted.Because we're expecting.So we let surrogates make those decisions, but we let them make those decisions as if they were acting like the patient.So, so the idea being that we need some sort of evidence that the patient would have wanted this, not that it's just what the surrogate wants. 

28:57 

And so they're saying there's a burden of proof.Then you have to convince us that the patient really wouldn't have wanted this treatment, right?And so I I misspoke.So in the Cruzan case, it was a feeding tube as well.And so Quinlan was about a ventilator, Cruzan is about a feeding tube, Shire was about a feeding tube. 

29:16 

So in Cruzan, the judge, it went all the way up to the US Supreme Court, so all the way to the top.And they issued a state, an order.And they said that the state can require that the family or the surrogate they have, they have to provide clear and convincing evidence of the patient's wishes. 

29:36 

Yeah, that's a high bar.It is a high bar.And it's also wasn't clarified exactly what is clear and convincing.A lot of Supreme Court cases get all the way to the top orders.Decisions are are issued and then there's still a lot of questions afterwards like they don't we actually apply this. 

29:54 

Right, right.They're just saying what the ruling is and then states have to then actually apply the ruling and so like make a form.And I remember this because we went to school in Missouri and advanced directives have a special box for feeding tubes, right.So in a lot of states feeding tubes get counted as any other life sustaining treatment. 

30:14 

But in Missouri and a couple other places, you actually have to specifically say and a feeding tube because it some people think it's slightly different than other end of life treatments.Exactly.And eventually the family in Cruzan were able to provide enough information that the state felt like it was clear and convincing evidence of Cruzan's wishes, of Nancy's wishes and it was removed and she passed away. 

30:37 

Whether or not a feeding tube is a medical intervention.And so the the, the ruling that came out of the the idea, the legal norm or legal principle that comes out of Quinlan and Cruzan is that #1 surrogates can make decisions if they have clear and convincing evidence and also that medical interventions can be refused. 

31:01 

And so that that becomes an interesting question because whether or not so it's pretty clear that a ventilator is a medical intervention, like you said, it's less clear that feeding tube is a medical intervention.But in the state of Florida in 1990, when Shiva was happening, they had legislatively or by statute defined artificial nutrition, dehydration as a medical intervention. 

31:24 

Well, that seems to settle it then, right?So and then everything went smoothly after that.Yes, no issues.End of story.All right, that was a quick one.It's probably worth mentioning, right?Like Quinlan and Cruzan also introduced the ideas of advanced directives, so one way to have clear and convincing evidence is you yourself. 

31:43 

Write it down.So if all of this totally freaks you out, you don't think you'd want to live, or you would want to live in a persistent vegetative state, you should write that down.Either way, right?I wouldn't.Or I would.You should write that down in your state's legal form and hand it to your doctor and ethics committees, right. 

31:59 

So the other thing is that the Supreme Court is, was it the court that said you should have some sort of mechanism to handle this in house and stop bringing it before judges And so the thus the invention of ethics committees.Yeah.In hospitals.Yep.Exactly.All of that stuff kind of percolates out of Quinlan, Cruzan and then eventually Schiavo as well. 

32:18 

So.Right.No, there.That did not answer all of the questions.So this case continues and continues.And what is really, I think frustrating and inspiring is the dedication of Bob and Mary and also their children, Bobby. 

32:38 

And there's a daughter who's who's involved a little bit as well, their absolute dedication to what they believe.Terry wanted and what was in her best interest, and eventually there are 17 different court hearings about different questions in this case, and the and the Schindler's lose almost every single one of them. 

33:02 

But they continue to bring up these cases.And at one point they were filing petitions to get Michael removed as a surrogate because he had.They accused him of abuse, they accused him of causing the injury.In the beginning. 

33:19 

They accused him of, well, he actually did begin a romantic relationship with somebody else.And so they said, oh, he's moved on from Terry Now we are the, the, the people who are best able to speak on on her behalf.And so at every one of those junctures, they would file a motion to the judge as, OK, now this is the reason why Michael should be removed. 

33:42 

And now this is the reason why Michael should be removed.And every time that that happens, the court system because of due process, because of the the way in which we try to be fair in the way that our society deals with disputes, the judge is obligated to say, OK, we're going to pause everything that's going to go on and we're going to investigate this claim. 

34:01 

Right.Because if if Michael gets his way, then Terry will die and that's irreversible.So you have to pause that every time they file a claim and that's that's hard for both parties, right?So Michael wants, if he really genuinely thinks she wouldn't want this, then seeing her in this state prolonged because her family won't like let him do what he thinks is right is also probably really hard on him. 

34:24 

Yeah, absolutely.And it's hard on the caregivers, the people who take care of, who get to take care of her every single day.And so Michael at this point has decided she would not, would not want to live this way.I'm the decision maker that is a medical intervention that I can refuse. 

34:41 

I'm going to refuse that.And then the the Bob and Mary and their representatives would file motions in order to stop that.And also the the judge whose lap this landed on.His name is Judge Greer in Florida. 

34:56 

And he really was really inspiring, I think, especially from someone from a a lawyer's perspective.I rarely ever hear that.I know, right?He this this man, I I don't know much about him because after all of this publicity he's really kind of. 

35:14 

I'm actually not even sure that he's still alive.I, I, I I hope he is and and he's well.But he is very, very consistent in his application of Florida law and he's at least all the published writings and stuff that that have come during the case and afterwards. 

35:32 

Just I think that he actually personally disagreed with Michael Schiavo.I think that he, because of his religious background, believed that nutrition hydration was essential and that the the stopping of it was morally questionable at least. 

35:50 

But he was able to put that aside and make rulings based upon the law.And he was consistent.And over the course of what turned into about 15 years of litigation, he was he was not overruled a single time on any point of law. 

36:07 

And so he was really consistent and good about that.And over 1993 ish is when this all kind of started bubbling up.And then in 1998 is when Michael actually got through all of the the initial litigation maneuverings and asked Judge Greer to approve the removal of the the artificial nutrition and hydration with the expectation that she would die shortly after that. 

36:35 

That sparked off obviously that then it becomes an emergency right and then petitions are being filed and and other people are getting involved like 199819992000 and there are bench trials and all of these different allegations and back and forth.It's as the the stack of legal documents is enormous that was. 

36:57 

Generally, like in this case, I love it.So many legal documents, so many legal documents, and we're not even to the good part yet.Oh.Jeez, because I remember this because when you said, we said what were you doing in 1990 and I'm like, I'm five, but I remember this on the news.So this went on for a really long time. 

37:14 

Yeah, so it didn't end in did so.Spoiler alert Terry Schiavo died in 2005.That is such a long time, such a long time to be in this you know this back and forth conflict with these you know people your in laws basically over the question of whether or not this this woman should live or die. 

37:37 

In March of 2001, it got to the point where Judge Greer had gone through all of the the mechanisms, legal mechanisms, and then ordered that the feeding tube be removed.And so in in April, after some more back and forth, he the feeding tube was removed. 

37:58 

That sparked off obviously another round of intense legal maneuverings, petitions all the way up to the Supreme Court.Judge Greer was asked you know motions to recuse himself all kinds of different stuff.And then at at some point they stopped making claims in state court or at the same time they were making claims or asking for relief by the federal court system. 

38:25 

And so that kind of put a pause on everything and and one of the federal court judges said, well with all of these new hearings, all of these new issues, new questions, new motions, I'm going to put an injunction and require that the the nursing home at this time put reinsert the feeding tube in order for us to work through this. 

38:44 

Those poor nurses.Oh yes.I can just imagine like what stress this is on the healthcare team too.Yeah.At this time the claims against Michael escalated as well.I mean now there are claims of abuse, there are claims of financial misappropriation really. 

39:04 

Like not just like we disagree with him, it's like he is now a bad person doing bad things and these have to be investigated as well.And so this continues until, I think the next big point is 2003. 

39:22 

So in 2003, October of 2003.So this is like 18 months later, right, Still going back and forth and she still is consistently being maintained.So Terri Schiavo is very, very stable.That's amazing throughout all this time, which speaks I think to the excellent nursing care that she got. 

39:43 

And so in October of 2003, the federal court dismissed basically one of the last claims that the Schindler's had about jurisdiction and about other things.The governor at the time, do you know the governor in 2003 of Florida? 

40:01 

I do.That would be Jeb Bush, right?Jeb Bush, right?Everyone knows that, right?Yeah, the little brother of the sitting president of the United States.So.Jeb Bush gets involved in October of 2003.So the the federal government is involved and at that point the interest by outside parties exploded. 

40:23 

So in 2003 there was it's kind of the beginning of what has come to be known as like culture wars or these really big social political issues that.Are generating a massive amount of public interest. 

40:42 

There's a guy named Randall Terry who organizes.It's the leader of a group called Operation Rescue which is primarily a pro-life, anti abortion activist group network that is very large throughout the country.They would organize civil disobedience they against or abortion providers they would block. 

41:04 

Access.And so a lot of the laws that we have now about abortion providers who protesters can't like block the doors, they have to be off the sidewalk.And all of those rules were generated because of not exclusively, but because of Randall Terry's organization doing those things and then getting sued for it and making these laws. 

41:22 

OK.So in October.Terry Randall's group gets involved.Another appeal by the Schindler's gets refused and then in mid-october 2003, Terry Schiavo's feeding tube gets removed again.Wow, so it is like media mayhem at this point, right? 

41:41 

So.Media, they're they're protesting outside of the hospital.It's all over the news, Jeb's.Getting involved.Jesse Jackson comes down and has a press conference in front.And yeah, so, you know, civil rights activist and it's at this point from kind of a biopolitical like social commentary perspective that Terry Schiavo really becomes less important than the idea of who Terry Schiavo is becomes important. 

42:11 

So disability rights groups start getting involved.Randall Terry's group of that primarily looks at anti abortion action is now clasping on to Terry Schiavo's quote fight for life and and appropriating that for their own good. 

42:27 

And it what matters to Terry my Co, the Schindler's really becomes kind of a secondary issue to all of these other groups and activists who latch on to the case and use it for their own benefit.One thing that I found in my research, and I don't know if this is published someplace else, but the the there's one person we can track this back to and it's gonna surprise you. 

42:53 

I think so.Oh please.This is like a bioethics, so that people explain this.Yeah.So in Florida at the at that time in night in 2001, 2002, 2003, there was a drive time radio host. 

43:10 

Who was kind of a a middling.The host wasn't super popular, wasn't unpopular, was in the Tampa Bay area in a couple of other markets, wasn't widely syndicated.But he was contacted by somebody associated or connected with this issue, and he became passionate about fighting for Terry, his name. 

43:33 

Was Glenn Beck.Oh, I knew it.Oh, I did.I've never heard that before.Yeah, so Glenn Beck was a drive time radio host in Florida got aware of this and started talking about not only this, but all of kind of this, this political issues and that really sparked his popularity. 

43:52 

And so people in that area had started tuning in, not just for his drivetime radio banter, but also because he would have kind of these hot takes about politically charged issues.Terry Schiavo was one that he consistently hammered on as he became more popular.In 2002, 2003 his syndication expanded and then in 2003, end of 2003, he went nationwide. 

44:16 

And was being broadcast you know coast to coast got a huge contract from headline news and one thing that he was consistent in was advocating on behalf of Terry's parents.So really hammering this issue and took it from kind of a local regional issue that may or may not be interesting to a lot of people nationwide and he started talking about Terry Schiavo and the right to life and what these. 

44:44 

The opponents or Michael Schiavo's folks, people who are supporting him, how they were undermining all of these other like core values of America, kind of like what Glenn Beck did at that time.So is this the first time?I've never thought about this?Because I think of like pro-life organizations are often we are used to them advocating for certain things at the legislative level today that have a lot to do with end of life cases, whereas I think maybe the public thinks of them as more like beginning of life sort of abortion. 

45:15 

Is this really the first time that those like kind of anti abortion groups are like moving into the area of end of life for people like Terri Schiavo?You think this is like kind of where it starts?I think so and and and kind of the the the group of people involved would be Glenn Beck being the the the spokesperson for so the advocate the mouthpiece for this. 

45:37 

Randall Terry, whose organization really kind of got The Who had the experience of of organizing and mobilizing people around these socially hot button issues.And then Bob, Bob and Mary Schindler's consistent advocation for this point.And so let pro-life, anti abortion folks got involved. 

45:55 

Disability rights folks got involved.Bodily autonomy, pro-choice folks got involved.I mentioned earlier Jesse Jackson was involved because it was portrayed to him as.The the government taking over the rights of parents and so a lot of really awkward bedfellows in this. 

46:15 

So Jesse Jackson is advocating on behalf of the Schindler's.The Schindler's Yeah, super interesting.There's a picture that I found of Bob and Mary Schindler, Jesse Jackson and Terry Randall Terry all on like the stage together. 

46:33 

And after that point, I think when Jesse Jackson and his folks, people who work with his team, got there and saw the parties, the the players that they kind of.Backed off a little bit, like she was sending it to the bushes a little bit.Exactly.Yeah.A little bit like, wait a second. 

46:49 

This isn't exactly how it was pitched to me.Yeah, interesting.Unsurprisingly, there was another injunction issued and Terry's feeding tube was reinserted again.And so this is now the second time that court ordered removal of the feeding tube.During this time, Jeb Bush is not backing down and he calls a special session of the Florida legislature and. 

47:13 

Kind of Rams through a law called Terry's Law into Florida.It's always best to make laws for particular people.Yes, specifically and this again, I mean this is like an entire part of my dissertation is looking at the legislation because it's really unusual for legislative tools to be used to benefit one person. 

47:32 

It has.I mean, one of the principles of legislation is it has to be applicable to the more than a group of people, at least at least more than one, yeah.And so this law being crafted in a way that doesn't only apply to Terry, but the set of circumstances in which it applies are so narrow that it only applies to Terry is really interesting. 

47:57 

And you have to be 29 years old at this particular time and in this county.And so all of these caveats.Eventually that law was deemed to be unconstitutional because it was so narrow.But that.Because there was a law, it delayed the entire process again, right. 

48:20 

So that law eventually becomes deemed unconstitutional.Lots of back and forth about that.It goes up to the Supreme Court because, you know, if there's a challenge against state laws, the the court of last resort is the Supreme Court. 

48:35 

And so the Supreme Court said.No that's unconstitutional.Smacks it down.There was action among Republican conservative members of the the US legislation.So the US Congress gets involved. 

48:51 

They start drafting.They have hearings about this all about this one case and the just reams and reams and reams of decisions and motions and and stuff back and forth and the Schindler's and Michael Schiavo like you mentioned earlier the. 

49:08 

The money from the malpractice claim was what was kind of fueling this until about 1998, two thousand, and particularly when Terry Randall as kind of the poster boy for all of the other advocate groups getting involved, then the coffers are basically unlimited. 

49:27 

There are there's so much money being important to this, there's no limit to the number of motions and lawsuits and and claims that can be filed back and forth.All right, Fast forward spring of 2005. 

49:43 

OK, so spring of 2005.The Supreme Court has weighed in twice now.The federal law never, never was put into the books.It was passed and then found to be unconstitutional.The Florida State law was found to be unconstitutional. 

50:01 

The 11th Circuit found that.Judge Greer had not had not violated any of his rules or or obligations and so eventually every single legal Ave. was closed off and in 2005 in March of 2005 the IT goes gets remanded back to Judge Greer in Pinellas County, Florida, this local probate court judge and he says again. 

50:31 

The feeding tube should be removed because Michael's the appropriate decision maker.The decision is appropriate and there's clear and convincing evidence.So it kind of meets all those standards, the same standards that were in place and which he had met almost 8-9 years previously.So it gets removed and then basically everybody is just on death watch, basically just waiting for her. 

50:54 

She's getting again, excellent healthcare.Nursing care Around the clock in this nursing home, of course, because of the media sensation that that this had all created.There were protests and vigils outside the hospital.There were armed security details transferring the families into and out of for visiting hours. 

51:15 

Glenn Beck actually put his his nationwide TV show on hiatus or on sabbatical or whatever, and started broadcasting from a conference room across the.The street from the nursing home, it would. 

51:31 

I mean, it was bananas.That's so sad.I mean, ultimately so sad for this family.Regardless of like sort of how you think this should have gone, this is not how it should have ended.No.Eventually, after almost two weeks, she does pass away. 

51:49 

She dies from, you know, the typical ways people die from not having a sufficient nutrition and hydration and.She died in March of 2005.So that's 15 years almost, you know, to the month of when she first had her injury. 

52:09 

Yeah.Wow, that is wild.I don't think I really fully appreciated how long that went on and how involved.I didn't realize it went to the Supreme Court twice.I did know about, like Terry's Law.I remember that just cause I've it's so like outrageous man. 

52:26 

Yeah, that is has do you think there's ever been a single case like this that has created such a legal and media sensation?I I don't.I think it I think it is kind of the pinnacle of public interest in a highly controversial kind of end of life bioethics case. 

52:46 

The the only other ones that I think and these are more recent examples and so maybe there's some bias there, but there's one in.The UK about a little boy named Charlie Guard recently, that was really kind of a media media storm.Jihai Mcmath is one that we're going to talk about in a different And then also Jack Vorkian before this. 

53:09 

Yeah, yeah.And that's more of a course the doctor than the patient.But yeah, he becomes such a sensation.But and and legislatively has to also get worked out if what he's doing is legal or not.But but this seems I mean and in Charlie Guard you're right was also a immediate sensation so was Johnny Macbeth but like the the amount of like legal maneuvering seems pretty extraordinary in shivo and and the longevity of it. 

53:35 

Yeah, the the duration of this case is just it it it's shocking really that this is able to continue.But yeah, so at the what the leg in Tyler, what's the legacy?Yeah.The legacy is that it's. 

53:52 

It's really complicated, right?Even though these decisions, these issues had been settled before Michael Schivo and the Schindler's were in conflict, it's it was able to persist and it was able to continue through the legislative process, through the judicial process, through the media. 

54:12 

And it it just speaks in my mind and this is kind of, you know.A little bit of a spoiler alert because I know everyone's going to run out and buy my dissertation and and read it now.Yeah, yeah, you can get on Proquest.I might be able to upload APDF someplace, I don't know. 

54:28 

Oh, we'll, we'll put it on the website.No, no, we're not.It's that at that in 2003 when Randall Terry, who I put a lot of blame on in my in my research, it becomes not about Terry anymore. 

54:44 

And I think that's what's different is that.Jehi Mcmath, Charlie Guard, some of the other kind of well known named cases that we talked about in Bioethics.At the end of the day, they're mostly still about the person and they have broader implications. 

55:01 

But Terry became almost an afterthought by the end of her life and it's really sad in my mind that the family was not able to come to some sort of.Mutually agreeable conclusion well before it became out of their control and because once it gets into like this, like social, you know, social justice, public policy, are you pro-life? 

55:30 

Are you pro-choice type of debates?Then Terry, is is not the most important person in the conversation anymore.Yeah, that's a sad legacy.I mean, I think it's not, it's it's interesting how it how it became so popularized. 

55:47 

But these are things that happen all the time.I mean, I'll say I've been a part of many clinical ethics cases where the person who has the authority to make the decision makes a decision other family members don't like and we have a care conference about it and we try to get everyone on the same page.And sometimes we can and sometimes we can't and we just do the thing that the surrogate, the authorized surrogate tells us to do and it it doesn't, it's not a 15 year battle. 

56:13 

It might be a 15 day battle or a 15 month battle, but it's all internal to the hospital.It rarely gets outside of that.So it's it's just interesting that this case got so outside of kind of the mechanism and in early 2000s it's not like everyone had a like super functional Ethics Committee or even ethics consultation. 

56:33 

But just to say, I think I don't know if it would turn out differently today, but I see it all the time.So this isn't, it's not an unusual case in and of itself.It's just unusual, the way it became so expansive.Yeah.So just kind of wrapping up, I I want to read to you what I think. 

56:50 

So before we get there, one other issue is that Bob Schindler and Michael Schiavo were some of the most stubborn.Is that the word?They they were committed to their positions and they they would not be moved from those. 

57:07 

And those two personalities I think drove this initially quite a bit as well.And I don't, I don't know who is right.I mean I don't know that Terri Schiavo and Michael Schiavo had those conversations.I don't know what her upbringing was.So at the end of the day, there's still some open questions.Like I said earlier, Bobby Bobby Schindler, who is Terri Schiavo's brother, I don't know if he's older or younger. 

57:29 

I think younger he has founded a created a foundation and continues to be very active in end of life.Type of conversations and advocacy and support.So Michael Schiavo buried Terri Schiavo after her death. 

57:46 

And the the headstone is really interesting.It says Schiavo Teresa Marie Beloved wife, No mention of daughter, no mention of anything else.Born December 3rd, 1963.Departed this Earth February 25th, 1990. 

58:07 

At Peace, March 31st, 2005, I kept my promise at the very bottom.Yeah.So depending on what side you you fall on, that could be either really, really touching, really a final tribute, or it could be the last middle finger to the in laws. 

58:25 

Yeah, it kind of feels like that last one.She didn't die in 1990.I, just like by any definition of death, was not dead.Right, so, he said.Maybe socially, but.Departed this Earth February 25th, 1990.What does that mean? 

58:41 

That's.I don't know.That seems like aggressive, like a like a passive aggressive slight at her parents.That's that's too bad.And maybe not so passive, maybe it seems like maybe like a an aggressive, aggressive, yeah.And it's unusual and this just speaks to the the, the animosity, right, That I think was still really visceral. 

59:02 

I mean it's, I think it's unusual.I've never seen a gravestone like that.Yeah, to kind of have your last, you know, thumb in your eye to somebody being the gravestone you put on.Yikes.So anyway, so that's a quick and dirty Terry Teresa Marie Schiavo. 

59:21 

Thanks for listening to this episode of Bioethics for the People.We can't do this podcast by ourselves.We've tried, and it's not pretty.Our team includes our research interns Michaela Kim, Madison Foley and Macy Hutto.Special thanks to Helen Webster for social media and production support. 

59:37 

Our theme music was created and performed by the talented Chris Wright, friend to all, dad to two and husband to one.Podcast art was created by Darian Goldenstall.You can find more of her work at dariangoldenstall.com.You can find more information about this episode and all of our previous seasons at bioethicsforthepeople.com. 

59:57 

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Tyler and Devan discuss their worst reviews, their favorite published sentences, and what’s to come on this season of Bioethics for the People.

In this mini-sode, Tyler and Devan discuss the various court rulings about the drug Mifepristone and the recent decision by the Fifth Circuit regarding its status.

Read more on the developing situation here:

• Background information on the FDA approval of Mifepristone 23 years ago.

• Read about the two cases that led to the DOJ asking the Supreme Court to restore access to Mifepristone.

• Opinion letters reflecting views of people across the country.

• Key points and take-aways of the various lawsuits.

• How this ended up at the Supreme Court.

• The consequences of banning Mifepristone.

• How the Texas ruling might impact health and science.

• Information on the Texas ruling and how it changes access to Mifepristone.

Transcript

0:18 

So, Tyler I know the answer to this, but for the rest of the podcast listeners, what have you been obsessed?With, not just this week but the last three weeks?Well, I think unsurprisingly, there's been a bunch of legal.I don't know. 

0:33 

Shenanigans, is that the right word?So, there's been lots of legal activity about this.One particular medication that I thought it would be really helpful if we kind of talked through a little bit.And so the drug is Is he ready for it? 

0:51 

Yes, we say that the same time, when I you say it, and I'll say, if I think that that's the right way to say it, okay?One, two, three cocaine.No, it's my Presto own if a presto, okay, that's right.If the priest own, right. 

1:09 

So, mifeprex town is this medication.That is the heart of a bunch of legal activity, and political maneuvering and man, Just really is a it's all over the news right now.That's right. 

1:25 

So I think maybe we should just start off with like, what we know about mifeprex tone as a drug, right?So it's it's being called an abortion drug.We know it's about 50 percent of abortions are medical abortions.Used this drug in combination with another drug, but we also know that it is used for a few other things, some off label things, it's also used for miscarriage. 

1:50 

So it's not as if it's only used for medication.Ian, but that is seemingly the biggest use of this drug.And so, it's being targeted, given our sort of post-ops world as another access to abortion, that some states would like to restrict is that, is that fair? 

2:10 

Yeah, I think that's, that's, that's right.Usually, when we think about abortions, I think that most people in their mind think of surgical abortions, which there's a large number of abortions.And when we're talking about abortions, I think it's important.And to highlight that we're talking about both wanted and unwanted terminations of pregnancy, right? 

2:31 

So some people very genuinely, do not.They want a child, the pregnancy is intended and they want to have the baby but for whatever reason sometimes it's medical that they decide to not go forward with that with the pregnancy and sometimes that requires surgical intervention and sometimes the pregnancy is not far enough is far is early enough that medications can do the same function, right? 

3:01 

So there's two drugs that are used in tandem one like you said is myth oppressed Stone and the other one is called misoprostol and again, like we're not real doctors, so the pronunciation of these is probably a little bit different. 

3:17 

But so yes, if a stone is used to actually it, Sir, interacts with the hormones of the woman and if that gets interrupted, then the next drug is used to contract the the uterus and actually expel the uterine context, right? 

3:37 

So it's kind of a two-step process and mifeprex stone is being targeted as the kind of the first step in that in that two-step process.And after Dobbs which for those of you who are keeping up on the Cream court rulings. 

3:56 

Recently Dobbs is the case that overturned the Protections in row row row versus weight.So row allowed a nationwide access to abortion and it didn't specify surgical or medical abortions and then so that was 1972 ish. 

4:22 

And then What was it?Almost two years ago.That Dobbs was overturned.It was it just last year.Oh man, I can't even remember.Hey, you're the legal expert?Tyler supposed to do these things.I know.It's been a it's been a year.But so Dobbs is the name of the case that went to the Supreme Court and the Supreme Court said this right to abortions underneath the, the Privacy protections of the Constitution, doesn't make sense anymore or never did make sense actually And therefore States should have the power to regulate how. 

5:00 

And if and when and what Manner, abortions can take place in their states, then as predicted all of the states, then create their own rules about whether or not abortions are available.And then also how abortions and when abortions can take place. 

5:16 

So that's kind of big picture where the legal landscape is states that have the goal.I would I'd say the interest in reducing the number or the type of abortions performed in their state have taken a couple of different approaches to how to limit the number of abortions. 

5:34 

And that's how we get laws about certain timing of when abortions can or can't take place.So, six weeks, 10 weeks, 14 weeks, 22 weeks.Sometimes there's cut offs and then there's also reasons for the abortion. 

5:49 

And so, this is something that gets brought up all the time, is there If abortions are prohibited within the state are there exceptions, whether it's a medical exception or whether it's because the the pregnancy was the result of a rape or incest or something like that, the health of the mother is at risk. 

6:12 

So so there's all these different exceptions that may or may not be created within the states to actually either limit or put some sort of rules on abortions.Good.That's like a really good overview.I'm glad that you are our legal expert if you're not our timeline expert. 

6:31 

Okay, so something really big then happened.It's about been about 3 weeks.Now in the Glorious state of Texas, a judge made a pretty controversial ruling Texas already has now, three laws about abortion that have restricted abortion, but this was I think in some ways unexpected what he said about mifeprex tone, so can you walk us through? 

6:58 

Kind of what the judge in Texas said initially.Yeah.So I think before we get to what he exactly said, I think it's important to highlight the ways in which laws get created in our country.So the if you'll remember the how does a bill become a law school of rock video. 

7:19 

So the one way that law is get Didn't this is true for States, it's true for the federal government.So a legislator, someone in the legislative, branch can propose a bill.It gets debated and then either gets written into law signed into law or not.There's a lot more that goes into it. 

7:35 

Another way in which laws or public policy gets enacted in the United States is through the judicial branch.So a judge can say, this is the law or this is the way the law is going to be interpreted, or this is the way it's going to be applied. 

7:52 

And for Public Policy or changes in kind of social policy that are really problematic to get through the legislative branch.So say that there aren't enough votes or whatever in the in the legislature to actually change laws. 

8:08 

That may actually be really harmful.Sometimes the best way to change.Those laws is to go through the judicial branch and so a good example of this is Brown versus the Board of Education.That's a classic case where the It, the state laws and the about this notion of separate, but equal education in the United States, it was going to be really hard to get that change through the legislative branch. 

8:35 

So, actually a change in the statute, but instead, they went through the judicial process and had that law or that portion of that law, declared to be unconstitutional.And so people who are interested in equality and interested in equal access Us education and stuff like that. 

8:54 

Went through that process to the judicial activist litigation is, is one of the terms.It's used to describe it.They are able to change the laws and so that's what's happening.That's what happened here.Is that instead of going through the legislative process, they went through the judicial review, and a group of people organized themselves in a jurisdiction in Texas that they thought, Got it again. 

9:23 

We're kind of, I think we're kind of armchair quarterbacking this a little bit trying to read into them, into their intentions, a little bit from just, what's publicly available information.But regardless of what their true intentions were they, deliberately, they intentionally organize themselves within a jurisdiction that had what was known to be publicly known to be a very conservative, a judge, who had a very conservative interpretation of abortion. 

9:50 

Abortion, rights, and abortion access.And filed a lawsuit, claiming that mifeprex stone was actually, should not actually be legally permissible to distribute or to use or to order prescribed within the United States.Yeah, I don't think it's too much of a stretch to say this National group of Physicians Incorporated. 

10:12 

In a part of Texas that only has one judge that they knew they would draw for this case so it doesn't, you know, Maybe where it's just conjecture.But why would they have chosen Amarillo as the place to incorporate? 

10:28 

It's pretty transparent.What their objective was is we talked about this sometimes with like, oh, it's so hard to know people's intentions.When you talk about in medicine like well double effect, who knows what somebody's intention is and my response is always, nope.You know, by their actions. 

10:44 

All right, you can kind of you.Often can tell people's Intentions by the thing that they do.Right?Maybe it's a little bit of mind reading.But if that Wasn't their intention.It's quite the coincidence.Yes.All right, I think that's fair.Maybe I was trying to be too dainty to politic being to magnanimous with my interpretations, but I think that that's probably not think that's true. 

11:10 

So this group filed, this lawsuit in court in the court where they knew that the judge was going to at least their suspicion.Was that he had this particular view because he had Published about he'd written about it.It was very open about not just the issue of abortion but also other other kind of social policy type of issues. 

11:31 

So they filed this lawsuit, claiming that mifeprex stone was and when you file a lawsuit, you know, this that that you can file multiple claims at the same time, right?It's not just a this is my claim.Decide this mr. 

11:49 

Judge it is here's a whole list of claims that I'm making all the same time and you can kind of rule on each one of those as it as you want.And so this this judge was presented with the case that their mifeprex Stone specifically was unsafe and it was ineffective in doing its job and and that is exactly what medications are intended to do and that's what The FDA process of approval is intended to decide, is it safe? 

12:22 

And is it effective?It's pretty bold claim, right?That that these doctors are going to, you know, they're their authorities on medicine and so they might have evidence that this is unsafe but really the it's the job of the FDA to decide if something is safe and effective. 

12:39 

And they this has been FDA-approved whatsoever 23 years.It was approved in 2000.So it's a pretty Bold claim right to say, I don't know, maybe the FDA didn't do its job or there's been more recent evidence that the FDA is not looking at that.We have that this huge group of scientists has been ignoring. 

12:58 

Yeah, that's right.That is literally, the fda's job is to look at the look at the science.Look at the studies that are presented and to make a determination on efficacy and safety.And yes, twin 20 in 2000 year 2000. 

13:15 

So it's been 23 years, 20, And a half years since this was approved, it's really hard.If you take away the political aspect of it it's really hard to wrap your mind around.Why now for this case and there hadn't been new studies. 

13:32 

There haven't been, there's not new science that undermines this.This this drug so.So that's what their claim was.Number one, it's ineffective.It shouldn't have been approved will because it's ineffective.Because it's unsafe. 

13:47 

There's also a third claim which we'll talk about in just a minute which has to do with an old law from the Civil War era that will talking always good to bring up.Yeah.The Civil War was a great time for making laws and so it seems super relevant to today so I'm anxious to hear about that, you know?It's surprising how often that's coming up. 

14:05 

Isn't it that these yes current laws are being under you know, removed from the books and then all of a sudden we've got a law from 1873 that we're trying to apply to Current times itself.All right.So the judge ruled in Texas ruled that while he basically, he bought their, the argument of these Physicians and whether or not he actually, there was actually standing, which means that in the United States legal system in order to file a claim, you have to have been the one that was harmed. 

14:38 

So if you are in a car accident, I can't sue somebody on your behalf because I'm really upset that you were hard And in this car accident, right?I have to be the one who is harmed and that's called standing I.So I have to have standing in front of the before the court, in order to file a lawsuit and the standing claim that these in that this group made is a little, I don't know. 

15:03 

Squishy.Is that except the right word?I, I think.So what I heard it, I was surprised that they could have standing because what they claimed was, as far as I understand it, that there are Men who come in after using the first time because they're concerned about excess bleeding. 

15:23 

And I think that that's fair, right?Any sort of miscarriage or abortion can have a lot of, a lot of bleeding in it.Understandably, freaks people out or they could have some sort of complication with are claiming lots of complications from this drug which are pretty suspect, but they are afraid that a woman would come to them with this urgent need and that they would have to treat her because emtala says that we have to treat people in a medical crisis. 

15:49 

We can't turn them away but and not only with this e unfair to these Physicians who think that abortion is wrong.So it would be sort of a you know, they'd be treating somebody against their conscience but also that would take up time and energy, they could have spent with other patients that needed their care. 

16:07 

So it is distracted from the job they want to do because women would hypothetically come to them with this need Right.That's how I understand it as well.And that, I mean, I am not their lawyer. 

16:23 

I've not anybody's lawyer, but gosh.That's a it's, a will say, creative claim for standing, but judge bought it.And that's and, you know, the a good legal argument is validated when a judge says, okay, I'll buy it, so he granted standing whether or not that holds up is, that's a different story. 

16:44 

But so they're standing and then the judge ruled that Basically, you know, he, he bought all of their arguments and wrote a really long opinion, and it says that number one, it is unsafe. 

17:03 

And number two, it's either not effective or not as effective as other interventions.And so then we get to the third claim that they made, which is that if it's not safe and effective and also because it is deals with abortions, Civic leaders in 1873 law called The Comstock law, which prohibits the u.s. mail system from Distributing quote indecent or other material. 

17:34 

That is against, you know, public policy or against basically, you can't send, you can't use the u.s. mail system to distribute things that should not be distributed upsetted. 

17:51 

Jean material, indecent material, the word lewd, and lascivious or used, which are two of my favorite word's.Great words.Great words.Yeah.So then the judge said, because of the Comstock law, prohibits prohibits the distribution of this stuff, then it has to. 

18:11 

What follows from that is that a nationwide ban on distribution of this medication, which puts All types of non surgical abortions at risk because this is the drug.This two-step drug process is the standard of care. 

18:29 

It's the safest most effective way to accomplish the medical goal.Yeah, so a combination of really interesting rulings, but he says in his wisdom, would this make sense this won't go into effect immediately? 

18:47 

Let's wait to see if this gets a peeled up.The line to the fifth circuit.So let's give it seven days to see if there's an appeal process that needs to go through recognizing that this would probably be a controversial ruling.Yeah.So I think the smartest thing that he ever liked The most correct accurate thing that he said in his opinion was this may be controversial and up for appeal, right? 

19:14 

And I mean the same day, there was a similar case different, a little bit different legal argument in a different jurisdiction in the United States up in Washington.That came to a different conclusion.So you have these two courts in two different parts of the country. 

19:30 

Make making or issuing rulings that are Seem to be at odds with each other.So there's a conflict between them and when that's the case in the Federal Judicial System, that is almost an immediate appeal to the United States, Supreme Court to figure out that the circuit split or the difference within this federals because we can't have inconsistent laws in the federal system, right? 

19:58 

That's the that's the reason for the review.So, So I tell it, I wonder if it's worth mentioning and maybe you'll get to this, but we'll post a bunch of links on the website.But is there any good scientific evidence to say that if a person really is unsafe, the ineffective claim is odd. 

20:21 

It only makes sense.If you say that, surgical abortions are more effective and more safe, I think that that's the effective sort of side of it, but the unsafe is really what got a lot of attention because I looked up all the studies, there's I've been a meta-analysis of a lot of these studies of thousands of patients. 

20:39 

And really, it seems very safe which isn't to say that there are never adverse effects.There's never sort of risk.Every medication has risk, of course, but there's been a lot of claims in the media and by groups that have supported the initial ruling that this really is unsafe. 

20:55 

So, what do we know about safety?I-i've been reading the same stuff that you could reading.It's, I, I don't, I don't see it.But again, like they're, there are other smart people involved that are making this claim. 

21:11 

But I there are definitely more risky, drugs, more dangerous drugs on the, on the market that are used routinely.And if, if if that's the case, then it's really hard to draw the Illusion that this is anything other than an over attempt to limit abortions for other reasons. 

21:35 

It's hard not to draw that conclusion.So we'll put the studies up on the site.But I looked, I mean, there are a couple studies that showed some some level of risk and it's it's just up to thousands of people.I mean, this is, it's such a low percentage, it's such a safe drug. 

21:53 

I don't see the evidence for it.So we'll put those up and let people decide for themselves, but I've looked at the studies, I can't make sense of this claim, unless you think that anyone getting hurt from a drug ever, should make the drug unlike unavailable to anybody, in which case we have to withdraw, almost every drug on the market. 

22:13 

It just can't be the way we go about doing this because there's always some level of risk in any medication that you'll ever take.Yeah.We that's your talent all bottle is a lot of risk.Exactly.And that's setting aside the whole issue of whether or not abortion Options should be permissible or not and right. 

22:31 

And you, we can have very different opinions about whether abortions are morally or ethically, permissible, and under what circumstances, they might be, but what concerns me about this case.In the way that this is progressing is that it's giving a federal judge. 

22:47 

An unelected federal judge, the power to undermine the entire FDA process and the process.I mean medications in the United States.Pharmaceuticals are expensive because and we always we hear this all the time that because of the research and development is so expensive. 

23:05 

Right?And the research and development is expensive because of all of the studies and all of the steps and all of the Hoops that have to be jumped through in order to get FDA approval to Market in to sell it at actually make money off of it.So it has to be proven to be safe and effective and go through all this process and this judge, you know, with a stroke of his pen has undermined that whole process. 

23:27 

Is in a way that's never been hacked never happened before.This has never been the case in the United States.That a federal judge has unilaterally, or on his own authority said that a specific drug ought not to have been approved and should be with removed from the market. 

23:46 

Yep.I agree.I think there's lots of good debate to happen about the ethics of abortion, but that this particular drug is unsafe.Doesn't seem to be to be the strongest claim.If you are somebody, who's taking a pro-life position that it shouldn't be available in which case maybe resorting to The Comstock tact makes more sense. 

24:08 

Yeah.So you know that that's what that's what's going on with those two rulings and then the Supreme Court, it gets fast track to the Supreme Court where because of the the previous administration had the power of appointing three. 

24:26 

Judges to the Supreme Court.There is a conservative bias of bias or leaning towards the Supreme Court in the Supreme Court right now.And so they have the opportunity to make this ruling.It's going to be really interesting to see what happens in the Supreme Court. 

24:44 

And so what happened a week or two ago is that the Supreme Court Judge Justice alito's?The one who's kind of been to spokesperson from the supreme court site about what about this case?Case initially said, we'll have a ruling by the timber 17th or 18th of April that time came. 

25:03 

And then he's reissued or extended this day and stay is just a fancy legal term for a pause on the impact of a decision to be to be put into effect or to be activated. 

25:20 

All right, so what should we be looking for?So it makes sense.So they're going to Who knows what's going to happen, right?But didn't didn't say.It needs to be pulled off the market right now.So, good news for some people.Bad news for other people, but will rule presumably on whether there is sufficient evidence to say that this is a not safe drug and might rule on these other issues that we didn't get so much into about, whether it can be mailed, whether the drug. 

25:48 

So a few years back was it 2018 the FDA extended some of the use of this drug to a little bit further?Into pregnancy and said, it could be mailed and that will become, presumably an issue as well.So this increased access over the last few years might become restricted. 

26:07 

Again, might be pulled off the market altogether.I hear states are hoarding the medication.So worried that the Supreme Court will say, no have been stockpiling the medication.There might even be worries that the manufacturer will stop making so much because they, if they anticipate that it'll not Not be approved anymore. 

26:28 

What else should we be worried about?Yeah, those are the big issues so think about a pharmacy or pharmaceutical manufacturing like the pipeline right there is this has caused disruption throughout that process. 

26:45 

So there are their pharmacies in hospitals and in communities that have this medication on, it's shelves right now.It's not used very commonly.I mean it's not like You know, don't like antibiotics that are constantly being.Prescribed an administrative used up so it's imagine a pharmacy at a small, local hospital in Texas that has this medication. 

27:09 

Then all of a sudden this judge says, Thou shalt not administer this medication.Do they go into there and pull it off their shelves?If it's already if there's already a prescription for it, do they do they cancel that prescription and how do they order more? 

27:25 

And when and it just is hugely disruptive to the The to the whole process of the FDA approval and provision of these medications.And so I think that's going to be something that the Supreme Court has to deal with is what do we do? 

27:44 

If they decide that it should be taken off, which is going to disrupt all kinds of things in the FDA approval process.And I'm not an FDA lawyer and we don't spend a lot of time talking about the FDA approval process and there are people way smarter and way more involved in that process. 

28:00 

But one of the things that is most important about our legal system, is the predictability of it and the regulatory system like we have to be able to predict how things are going to progress in order to make plans and develop new drugs and stuff, like stuff like that. 

28:16 

And, and this undermines that in a really, I think, harmful way if the FDA approval process needed to be redone.That's fine.Let's have that conversation.But going through it through the judicial.Process.I think is something that the Supreme Court needs to figure out and need to needs to rule on. 

28:35 

So that one and then the that's the availability issue and then access States administering or stockpiling or hoarding this medication in ways that may impact the availability of it in other states or what happens when somebody's state says you can't administer this if that's if that's the outcome of this. 

29:00 

Is it okay for them to cross state lines to go to a different state that has it?If the Comstock ruling is stands up, then you can't mail it.So what if you transport it on your person?Like I mean there's just a whole bunch of other issues that come out of this but and which is interesting from a from a lawyer's perspective because of the process and how it messes up the is impact in the process. 

29:25 

But you know, that's setting aside the whole ginormous issue of Of should abortions be available at all?Which I think most people are focusing on and not focusing on the, the implications of what this type of really, what happened, right? 

29:42 

We're here to bring you the B-side of other horrifying things, this might my Endeavor in the future.So we'll just have to see and hopefully we'll have an update later next month when we know more but this is kind of what we know so far. 

30:00 

Far and that apocalyptic at all.Tyler's just saying that maybe the FDA won't exist in the future.That it'll just be up to judges to say whether things are safer.Yeah.Yeah.Can you imagine that?If the process was, you have to convince one judge that your medication is safe and effective and they have the ability to say yes or no. 

30:24 

Whether you can my gosh.Craziness.Okay, so that's what I'm obsessed with before, Prestone and the mostly, I mean, abortion is interesting topic.It's something that I think is endlessly debated endlessly discussed, not only in the public, but also in in bioethics Worlds, but all of the legal maneuvering and implications, I think is that's what I've been obsessed with this week. 

30:53 

Good.Well, thanks for the primer on how to understand the legal system, Tyler.I bet that's well, it was helpful for me to hear Sure, it's helpful for lots of our listeners.Sure, it's helpful for lots of our listeners. 

This week, Tyler and Devan discuss prolonged emergency department stays for children coming to the ER for a mental health visit, also known as “psych boarding.”

You can read more about psych boarding here or read about an observational study describing the rise of this phenomenon here.

Transcript

0:47 

All right.So Tyler.What are you obsessed with this week?All right.Well, I'm obsessed with this specific topic that I've been doing some little bit of research and reading about, and actually, in the process of writing a A with two of my favorite colleagues and I have a surprise for you. 

1:04 

Okay, the surprise is I brought in a guest who knows way more about this than I do.Alright, so who is it?All right, so this is dr.Catherine Kate reading, ER, who is an emergency medicine doc here at Western Michigan. 

1:24 

And also she is the assistant Dean for tell me again.Clinical application clinical applications.So basically the third and fourth year of medical school, okay?So and you may know her as the spouse of one of our dear friends, Mike reading here. 

1:42 

Never heard of them.Yeah, just kidding.The Bears and the podcast.So he, oh, yeah, he doesn't listen to the podcast so we can say whatever you want to about him.Okay cool.Okay, so well.Hey thank you, thanks for having me. 

1:59 

Yeah, so dr.Kate tell us about psychiatric boarding in emergency departments.What is that?Yeah.So psychiatric boarding is probably something that a lot of people would know about or think about For emergency physicians, it's become kind of a Mainstay of our day-to-day. 

2:19 

So boarding itself in the emergency department is not exclusive to psychiatric patients, but it happens when a patient will come in and they have been seen and treated and stabilized by the Emergency Physician, but there's essentially no room at the end. 

2:36 

There's nowhere for them to go.So they physically stay in the emergency department room.And it has a lot of negative safety issues, overall care.It's pretty distressing for the Emergency Physicians involved, because that room is being tied up and it's less room for new patients to come in. 

3:01 

So the waiting room will fill up.So it's a, it's a big problem for us nationally, but lately because of the reduced psychiatric beds.We've had a real increase in the number of mental health patients who are essentially living sometimes for days to months in our emergency department months. 

3:23 

Oh my gosh, I I mean, I don't know what the emergency department at your hospital looks like, but ours doesn't even have like walls.It's like curtains.So how could you possibly live there for months?Yeah, it's a huge problem.So emergency departments in general, like we barge designed and built on efficiency, See and getting people in and out quickly and and to where they need to be. 

3:48 

And so a lot of our metrics are based around the idea that our average length of stay is less than three hours.So they're not built for people to stay a long period of time.So like you said, sometimes it'll have walls, they don't have Windows, most emergency departments, don't have windows. 

4:04 

So a lot of times we have patients, who have literally not seen the light of day for four weeks.So just so I'm clear that they Patients who are experiencing a mental health crisis.They come through the emergency department because that's typically where you go or they're being referred there, but there's no psychiatric beds for them and so they just but we can't ask them to leave because they're in a crisis and we have this emtala law that says we have to stabilize people, but we can't stabilize them because the emergency department isn't set up to stabilize people in a mental health crisis. 

4:39 

And so they just end up staying in the emergency.Apartment.And then we don't know what to do with them.I mean this is the sounds terrible.Yeah, and for me personally, you know, obviously being married to an ethicist in a psychiatrist. 

4:56 

We talked about this a lot, it contributes to this idea of burnout and what some people refer to more as like moral distress of the physician.Right?You come in and you want to take care of patients.But then you actually wonder if you're like, you're able to do that. 

5:14 

To the best of your ability and whether their rights are being violated because you're not able to provide the care that you want to, but you also have a duty to them that you, they have a reasonably safe discharge plan, so if they're not able to go home back to that environment safely, then you do have to keep them. 

5:32 

So, yeah, we have a, I have a lot of different examples of how this plays out of the ethical and kind of legal challenges.So so so Say that I am experiencing or one of my loved ones is experiencing a mental health crisis. 

5:48 

Say, somebody is suicidal or they're psychotic.Obviously I want them to get the care that they need.So I'm going to take them to the emergency department of my local hospital and when I do that they get admitted, they enter the healthcare infrastructure and They get stuck in limbo, in the emergency department is that? 

6:12 

What's happening?Yes, that's exactly what could happen.If you're not at a facility that is adequately resource.With enough psychiatrists, and specifically psychiatric beds, a lot of times they end up being held in a limbo status and for a lot of patients, I think in the general population, they think when they come in, just through the front door of the hospital to the emergency department that they've somehow like been admitted to the hospital. 

6:38 

But it's way more complicated than that.They're still technically like, in an outpatient state in the emergency department and so until someone officially, like, accepts them to an inpatient bed, they're kind of in a limbo State.And so if there's not a psychiatric unit in that particular Hospital, what happens. 

6:59 

So, we have to look for the nearest safe discharge plan that we can come up with.So here we're in Southwest Michigan.Michigan will start contacting Regional hospitals, nearby Grand Rapids Battle Creek, will reach out to Detroit, sometimes Saginaw. 

7:19 

And then if we can't find anything in the state of Michigan, will start contacting States outside of Michigan.Indiana, tends to have some availability for us.So, yeah, you could come in and end up being transferred Far Far Away into another state. 

7:38 

So across the state or even to a different state and it seems to me and I get like I'm not a psychiatrist or an you know, medical doctor at all.So my loved one gets brought to the hospital there in a psychiatric distress, Mental Health crisis and they have to stay in the Ed, the emergency department until they get transferred to a place and that could be across the state. 

8:05 

It could be through a different state and it's not like that.Happens quickly, right?So they could have.It could be like, you said days weeks.Sometimes extreme cases.Maybe even several many weeks.What is happening to the patient while they're in this limbo status? 

8:22 

Are they being treated appropriately?So that's a great question and for a lot of us, we try really hard now to put processes in place that weren't typical of our emergency department setting and care to try to make sure we're addressing the problem as it as it grows. 

8:43 

Emergency physicians usually work in 8 to 12 hour shifts.So there's a lot of transitions of care and that has always been a place of significant.Patient safety, when we're in transitioning over, who's taking care of a patient. 

9:00 

And for someone whose total length of stay is now, an excess of 1,000 hours, you can only imagine how many handoffs and transitions of care that they've had.And that has to impact the care that they're receiving. 

9:15 

Because there's just no way to have that continuity.We're just not built for long-term care in that setting.So, and in other things that just basically, Means I have to remind myself like when I go in to see patients.Now I often have to make sure that I run through a mental checklist. 

9:33 

Like are you hungry?When was the last time you've eaten?Because I'm going to order a diet order, I don't normally order food for my patients.The cafeteria doesn't even come to the emergency department, sometimes because most people coming in that we're seeing, we don't let them eat for those three hours because they might need surgery or they're going to go home soon. 

9:52 

But patients, that might be living there.We don't have showers.An emergency department.So we have to think about how to get them.Bathed and clothed children who come in those are our most vulnerable patients, the children because there's far less fewer number of psychiatric beds available for children. 

10:12 

They end up with the longest length of stays, and those are the ones that, you know, break my heart, because they can't go outside, they're not going to school with.There's basically living in an Environment that it's not meant, not meant for children. 

10:29 

That can't be, I would think beneficial to their long-term mental health.It has to be a traumatic environment for them.So, what do we do?Can you dr.Redinger fix it for us, please. 

10:45 

What this sounds?The sounds terrible and I just was reading studies on how Windows help outcomes.And like the Arches you department is just not a place to stay.It's They going to be traumatic.So what should we be doing?And I think what also makes this heartbreaking is that everyone? 

11:04 

So the patient, if they brought themselves in or the family members, they're doing exactly what we would hope they do, they recognize the Mental Health crisis.They go and seek appropriate care and then they're being stuck in this, you know, terrible hole in the healthcare system. 

11:20 

So what do we do?So I think there's kind of two ways that you can look at this from from a societal standpoint.What do we do?Well, and like many things it comes down to funding, we need more funding for mental health. 

11:37 

We need more psychiatric beds for the patients to go and offload, the emergency departments.And that that's going to help in some we probably also need some funding to help with education and maybe restructuring the way that our emergency departments look. 

11:55 

So that we have here at Borgess, we've actually had some improvements made to our emergency department over the last several years to create basically like eight psychiatric, observation beds, if you will that have showers. 

12:14 

They're quieter.So they're away from the traumas that are coming in.They have their built kind of with more of a psychiatric unit in mind, but they still don't have.Toes but it's an improvement.So so those things can help from day-to-day standpoint though. 

12:34 

I think we also need to address it as the individual Physicians coming in.How do you best?Make sure that you're taking care of the patient in front of you and that's going to be a little bit different than there are typical emergency medicine mindset when we're taking care of a long-term patient. 

12:53 

So and I think we need to so, be mindful that Situations change.And so each day that we come in, we need to make sure that we're seeing those patients that are boarding.We need to re-evaluate the situation and if there is a different safe, discharge plan, make those changes and and come up with an alternative making sure that they're getting access to the food and water and showers that they need. 

13:20 

It's multifactorial problem, is there anything.So I'd hate for X2 think it would be worse to take somebody to the emergency department if they were in a crisis.Although for some of these patients that might be worse to exist in that limbo State than to have, maybe not taken them. 

13:42 

I don't know if I had a family member who I can imagine this happening to, what should I do?Should I drive them to a place where there's a psychiatric hospital nearby or what could I possibly do in a situation like this?Yeah so I mean with anything We all were the open doors of the hospital. 

14:01 

We want everyone to feel like the emergency department is the safety, net of the community.And that if you need help or you feel unsafe, we want you to come through our doors still.I think in an acute crisis, it is better to come in, then to try to go at it alone that that's not what we want for our patients. 

14:25 

So we do want them to still come in. and be seen, but I think it's also being proactive on the outpatient side.So maybe from a family standpoint, not waiting till the very end moment of Crisis. 

14:45 

But talking with primary care.Physicians may be getting in touch with mental health resources in the community sooner just broadening your network of resources.So that the emergency department is kind of more of a last resort option. 

15:03 

We have a really well connected.Wonderful group of people in our community that other hospitals don't have.So we're doing a lot here to make this more Equitable Fair solution for our mental health patients. 

15:23 

But it's even here it's a problem.So it's going to be a long roll dr.Iyengar, do you have potentially a case that illuminate?Some of this or illustrate, some points that you think are important from an Ethics perspective?Yeah, absolutely. 

15:39 

So a lot of this to comes down to the state that you practice in and live in because a lot of our mental health code is regulated, At a state level.And so here in Michigan, you can be admitted on a voluntary basis. 

15:55 

So basically, you are coming in but you're signing yourself into the hospital.For psychiatric treatment or you can be admitted on an involuntary basis.And the general thought is that we want our patients to maintain their autonomy as much as possible and participate in treatment, that that's a better outcome for them. 

16:16 

So we prefer if it's safe If they have the capacity to do so that they come in on a voluntary basis where this gets kind of tricky from an ethical standpoint is let's say a patient comes in their cooperative and they're on a voluntary basis and they're seeking admission because they're feeling suicidal and they're at a point where they're finally wanting to come to care there, haven't really told their family members this but it's pretty serious. 

16:47 

And they outline a Pretty active plan and your concerns, your glad that they're coming in, but you're concerned about their safety.In that case, I would want the patient to sign in, on a voluntary basis, because right now, they're Cooperative, they have capacity. 

17:04 

But I would feel unsafe based on all the information they told me about their detailed plan.Just letting them go if they change their mind.Well, what happens now is they get seen.Maybe the psychiatry With the social workers kind of sees them as well agrees. 

17:22 

And we start the process of trying to find a bed.If there's a delay, they often change their mind, I'll come back later or there's no beds available.I'll be okay.I really have this important appointment. 

17:38 

I can't miss.And then we get into a really tricky situation of whether I should hold them involuntarily based on the statements that they had made prior.Or let them go.And sometimes, again remember our ships are only 8 hours. 

17:59 

So if this whole process takes beyond that the next Doctor is having to deal with this conversation of this was not the change of plan.This was not what the first doctor told me and it becomes really ethically challenging on what to do. 

18:17 

The.Involuntary holds future.When you are saying they have the capacity to sign themselves in.You're also saying that they have the capacity to change their mind.And so that becomes really difficult when when they they don't, they feel the delay is causing a change in their and their willingness to seek treatment. 

18:45 

That that sounds really tricky.So are there.Rules of thumb?Is there a kind of statement that you have to take more seriously than another kind of statement?I mean, is it just a I feel in my gut, like this person really could hurt themselves or somebody else. 

19:00 

If I let them leave, like how do you negotiate then when it's appropriate to allow somebody who came in voluntarily to then voluntarily leave or when you need to make an involuntary?Hold, yeah, I mean, I don't know if there's a hard and fast rule.This is Where I think it's really helpful to go back and then like take a fresh look and redo the evaluation at that moment. 

19:26 

I always try to eight lean toward making sure that the patient is safe and being open to Alternative, safe discharge plans.So in that case, if the patient had a family member, they could contact. 

19:45 

And perhaps if the plan involved, specific weapon or something, if those have been removed from the house and we can get a follow-up appointment with the family doctor or Community, Mental Health provider in the next 24 to 48 hours, those sometimes can be alternatives to kind of activating an involuntary. 

20:12 

Hold.But ultimately It kind of comes down to whether you feel that that patient is able to keep themselves safe.So there are situations where the patient will come in voluntarily seeking help and they've said the right things are said the wrong things and you have concerns about them and then they try to change their mind and leave and you involuntarily hold them in and then they get stuck in this limbo. 

20:44 

So, They came in voluntarily.And then are stuck in this situation where they can't be transferred and they're being boarded in the emergency department for days weeks.Sometimes and that just sounds absolutely terrible for a lot of different reasons. 

21:05 

Yeah.And if we retired mom voluntary but patients who come in on an involuntary basis.So they've been petitioned by someone in the community, someone in the family and then we We do certify that.Yeah, we don't think they have capacity or they're acutely. 

21:22 

Dangerous.So we do go through that process in Michigan.That is supposed to trigger, basically a 72-hour, hold that.Within 72 hours, they can go and have their case heard before mental health court, be admitted to a psychiatric unit. 

21:39 

And have, you know, another evaluation done to kind of confirm, whether they still need to be admitted.And when we get past, Past those 72 hours, still in the emergency department without a hearing without a second psychiatrist evaluation, that's another kind of timeframe that it feels like that due process is being violated. 

22:03 

And and you want to get them to what they need, but it becomes prolonged.And this isn't just a problem in Southwest Michigan or Michigan or in the midwest.I mean, this is Nationwide.Yeah, and how I said the state's usually determined the individual laws for the mental health code, a lot of states have tried to address this for many years and have various proposed solutions that in theory sound great. 

22:37 

But again, if they don't come with the necessary funding to back them, don't work, for example, Virginia had this problem.And they proposed a law in which if at basically The 8 Hour Mark, if you hadn't find a found a bed State Hospital would have to take them. 

22:57 

Well, the state hospital is essentially got overrun because they weren't adequately resource and staffed and funded and it didn't really it just kind of pushed the burden from the emergency department to the state psychiatric hospitals.You could also the look at potential Solutions, Then but you're just ended up kind of Shifting the deck chairs. 

23:20 

If you just admitted them all to like an observation unit and a medical floor, you really have again.Haven't gotten them to the care.They needed their just shifted again out of your emergency department, but now it's the internal medicine departments problem. 

23:39 

Wow.Wow, any optimism, can we end up Nah, only do, I think with all ethical problems, the first start is awareness.So this is definitely on the radar of the National Emergency societies. 

24:01 

It's a big part of what we're advocating for at a state and National level with our with our lawmakers to get improved access to care.So I think that's really helpful.And then I also think that we're going to have to have a shift in education in general with in our Emergency Department training programs that we don't typically have much training in mental health. 

24:31 

It's not part of our typical board requirements but lately it seems that it's become a huge part of our jobs that you know, on any given day, I could actually have more psychiatric patients that I see car accidents.Broken arms.You know Stitches the typical bread and butter things, you think go to the emergency department just it's a much larger proportion of what we do. 

24:55 

Yeah.Well, we appreciate you talking about the topic and appreciate what.I'm sure is good advocacy and patient care.On this front.It sounds.It sounds tough.Yeah.So that's what that's what we're obsessed about this week. 

25:11 

The last several weeks. 

In this mini-sode, Devan and Tyler discuss palliative terminal sedation. What is it, who can get it, and what are the rules around it?

Transcript

0:46 

All right, Devin we are going to do another mini episode about something that we're obsessed with this week.Hmm.Yeah, so what are you obsessed with this week?All right, so I have had this one in my back pocket so maybe not this week but I've been thinking about it for a few weeks because I was advising our staff on an issue, a little while back and it made me think gosh I really need to like write this stuff down. 

1:13 

I was surprised that I couldn't find.In the literature on this topic, I actually find that a lot in clinical ethics.Like there's a kind of Gap in what I think, most people would agree on as good practice and actually it that good practice being documented and published in the literature. 

1:31 

So yeah, I agree.Yeah, it happens so often.Especially we in clinical ethics.We kind of get maybe like rules of thumb or like best practices that everyone kind of agrees upon, but they're not published anywhere.Where? 

1:46 

Yeah, so Shape Up clinical offices.Start publishing this work because it's important I say to myself as I have this document in front of me that has a bunch of rules that I think are important but I've never seen written down.Okay, huh.So the topic that was brought up, was palliative, sedation. 

2:04 

So, have you ever heard of palliative, sedation?I have but palliative means symptom management, right?Right.And sedation means going to sleep, right?Good, so we can deduce from that.So you're so we're putting people to sleep to make them feel better, right? 

2:23 

Typically.So there's we want to be really precise palliative, sedation in general would just mean that sometimes we need to sedate patients in order to treat their symptoms.So if they're so agitated or they're in so much pain that they were having a hard time, treating them, sometimes the treatment that we give can also see Date and then can be to the point of unconsciousness. 

2:49 

Sometimes there's also terminal palliative, sedation and this just like it sounds means sometimes at the end of life pain is so intolerable that there's almost no way to treat it or really no other way to treat it. 

3:05 

Excuse me.There's no other way to treat it then completely sedating the patient to unconsciousness so that they can die more peacefully.Okay.So for example, we have somebody who has I don't know what's a really painful condition like bone cancer. 

3:23 

Yeah but the first thing I thought of to.Yep.Yeah so bone cancer is really, really painful and the normal pain medication isn't working is that the but the situation is, right?So it's actually not all that common.We can typically relieve pain symptoms at the end of life but there are some conditions that are just so painful that there's no way you Could give the amount of appropriate pain medication, without accidentally killing them, or hastening their death or putting them into an unconscious state. 

3:54 

So we want to be really careful when we do this, but there are times in which that is really the only way to manage symptoms is to sedate somebody so heavily that they become unconscious before they die.So so most hospitals will have some sort of policy on when this is acceptable and when it's not acceptable. 

4:14 

So we had a Question from staff about a patient who had come in with, that's a moderate dementia, but this was his only condition.This is his only illness, and he was getting a little aggressive with staff and he was in, he kind of chronic pain condition as well. 

4:36 

And we were palliating, the chronic pain condition, but his aggressive behavior was pretty intolerable to the staff of the time and to his wife.And she asked us to give him terminal, palliative, sedation, mmm. 

4:53 

So it's one thing I love about clinical ethics is that the layers?Just keep going and going, right?So we've got palliative, sedation.We were laying on Terminal, palliative, sedation, and then we're laying layering on Terminal palliative, sedation for a psychiatric condition. 

5:15 

Right?So dementia and then we're laying layering on palliative, see terminal palliative, sedation for a psychiatric problem, being requested by a surrogate.All right.Yes. 

5:31 

So you can maybe imagine why this made staff uncomfortable?Yeah, cuz so dementia is technically a terminal illness but you are not Terminal in the terminal phase until we project. 

5:49 

You have approximately six months of life or less.So in the state of Texas and in most places, this is the requirement.We can't call you terminal until you reach a state where Physicians would say it is predictable that you would die within the next six months. 

6:07 

So and how good our doctors about predicting whether there's six months left.Well, it sort of depends on the condition.So in general, not great, but not so far off.Its, it's not typical that a doctor would say. 

6:23 

Yeah, it makes sense to me, that you die in the next six months and then you live, 20 more years.That's pretty rare.Are they perfect or exact with this?I mean, six months is sort of an arbitrary line except that it counts for hospice.And it counts for the Addition of terminal. 

6:40 

So you are eligible for hospice.If doctors say, they think you only have six months or less to live or in the state of Texas.And in many other states, your living will or mpo, a, your medical power of attorney.Only kicks in when you are in the terminal phase of an illness. 

6:59 

So that's six months really matters legally.Even if we recognize that it can be a little squishy around the edges.So It's a best prediction.But dementia is really hard in that. 

7:15 

It's so hard to say with dementia exactly how much time somebody might have left.So there are stages of dementia that we associate with the sort of terminal phase.But this patient has what I would call moderate dementia and is probably not at the end stage of life, okay? 

7:34 

So maybe not terminal in the way that you described it, probably not.So the first question, It is, you know, so our Hospital only will do this under that condition.So and that I've never seen a hospital policy that didn't say that.So if you're going to give terminal sedation, it has to be in the terminal phase of an illness. 

7:52 

So that's sort of the first question is, you know, is he in the terminal phase of this illness?And what I'm hearing from staff is like, probably not, you know, he, he has had to mention for some time but we don't think he's at end-stage, dementia quite yet. 

8:08 

Gotcha.Okay.But despite that, his wife is requesting this sedation, right?And so this is, and this is not something we hear very often, right?So, typically, family members and less there in the medical field themselves, wouldn't just know what palliative sedation was so my very smart intern. 

8:31 

Googled just Googled palliative, sedation because she was also unfamiliar I think and she said, did you know, dr.Stall, I make her call me Doc, I'm just kidding.But I think she does call me back so she says dr.Saul did you know when you Google palliative sedation?One of the first things that comes up is a right to die website, that advocates for physician-assisted, death and says on that website. 

8:56 

That if you live in a state that doesn't allow for physician 8 and dying or Medical Aid in dying that you can instead request palliative, terminal sedation, Interesting.This reminds me of other topic.We covered in a previous episode about voluntary, stop V said, voluntary, stopping eating and drinking. 

9:17 

As another way of controlling end of Life Institute in places where physician-assisted, suicide, or physician Aid in dying is not legal in that jurisdiction.So, this is a different work around well, so this would be similar. 

9:35 

And, and remember in that Episode.We talked about the sort of again the staff being more or less comfortable with the idea of like aiding somebody and dying by relieving pain symptoms associated with stopping eating and drinking.So one difference there is that it's typically patient initiated. 

9:53 

So the patient him or herself says I want to stop eating and drinking so that I can die this case with palliative terminal.Sedation would be like that in that we would what was being requested was that we stopped feeding Seeing this patient so that he could die. 

10:10 

But in the meantime to sedate him.So that he wouldn't experience any of the associated pain or discomfort with stopping eating and drinking, okay?Interesting.And so, in the way that I understand V said or voluntary stopping eating and drinking is that the patient themselves is making that choice to not eat, right? 

10:32 

But in this situation, what you're describing is that we Care providers are sedating.The patient to the point that they're asleep, basically.And when you're asleep, you can't eat or drink and that will be actually the modality of their death. 

10:48 

So that's correct.So this makes it's one thing for a patient to ask for this.It still makes a lot of stuff uncomfortable, it's still more uncomfortable, that this is being requested by his wife.So then the question is, do you think that the patient would have wanted this? 

11:04 

And the staff is generally agreeing know No.I mean he has some pain issues, but now that were medicating him properly, they seem to be relieved.He was pretty agitated but we've been able to relieve that as well.So we're not really sure.Now that we've been able to relieve his pain and distress, there seems to be no reason to go this extra step, but she's requesting it and saying that, this is what she thinks he would want, or he would have wanted in a state in which he was not demented. 

11:33 

Hmm.Yeah.So if the condition and that justifies, Today's palliative sedation is intractable or uncontrollable pain.This, the case that you're presenting is that that condition doesn't apply and therefore, maybe palliative, sedation in general wouldn't even be appropriate exactly. 

11:54 

So we get to rule number one of O.R.These stalls rules.These are stalls rules for terminal sedation.We remember one, the patient must be experiencing uncontrollable.The or refractory symptoms, despite optimal treatment strategies. 

12:13 

So this is a treatment of Last Resort.You only give terminal palliative sedation if there's no other way to relieve the symptoms of pain and distress at the end of life.Yeah.Okay I can get on board with that first one.Does it require stalls rules? 

12:31 

Number one you've had a sedation.Does that require that all other treatment options have been exhausted and proved to fail.Well, yes and no.All other reasonable treatment options that the physician thinks would potentially work, so it's not any and everything. 

12:50 

You're not, you know, giving things for the sake of giving them, but the Physicians need to agree.Basically, we've tried everything that makes sense.In this particular case.Yeah, everything that's reasonable.Okay, great.Okay, so rule number two and I know people are going to slam you on this because I know people hate this phrase is is we have to follow the rule of double effect, okay? 

13:15 

But or I'll rephrase because it's only actually applicable to a couple of the double effect rules.We cannot give terminal palliative, sedation with the intent of causing the patient's death.Okay, so are the intent of palliative, terminal sedation should be to relieve the symptoms of pain. 

13:37 

All right, so this is why we sedate people is because that's the only thing that's going to help relieve their pain symptoms or their distress symptoms, but we can't be doing it with the intention of killing them, right?Okay.So are you okay with that particular?Yeah?Yeah, yeah, I'm on board with we do what we ought not to Color patients, right? 

13:57 

Yeah, and I get so we should have a whole episode on double effect because it's it's more complicated than that.And I know people are going to give me a push back on this, but in general we this is not what we're trying to do.The intent of the of the sedation is to relieve pain. 

14:13 

Sometimes not to hasten the death of the patient.And in this case, it's pretty clear that the wife of this patient.Her goal is actually to end the patient's life in a more controlled and peaceful way and that's not a bad idea.Intention, it's just that that's not what we do in the state of Texas or in most other states, particularly those that don't allow physician-assisted suicide. 

14:35 

That's right.So there's only a handful of those.So in every other state you have to mind this rule.Yeah.So intentions matter I'm on board with that one.Okay.All right.Rule number three is I'm calling proportionality.Okay, it's related but slightly differently. 

14:52 

Articulated in that.I want to say the level of sedation That should be as little as needed to relieve the patient's symptoms.So we're not maxing out pain medication simply for the fact for the goal of putting him under or making him unconscious, we level up, right? 

15:11 

So we try typically at a palliative care team will do this.I'll get this to a second, but you give what you think would be an adequate.You don't want to start too low, because a lot of these drugs take a while to kick in.So you don't want to, you know, start so low that It's not going to do anything and you can't actually get them pain relief for several days that would be bad but you don't want to Max it out first go you want to give what you think is reasonable and then ratcheted up. 

15:37 

If that's not working, you don't want to immediately sort of just knock them out unconscious giving pain relief, right?And so the the phrase that we hear all the time in the hospitals that they titrate, right?That they are titrating the medication to the the symptoms. 

15:54 

Okay.All right, I'm on board with that one, too.This one also isn't working for us in this case because it seems like the goal, even if the goal is not to hasten death, the goal shouldn't be simply to induce coma or deep sleep, but it should again be to relieve symptoms.So, we need to make sure that we're doing that appropriately. 

16:11 

All right.Rule number four.I'm calling terminology and we sort of already hit on this but you need to have consensus that the patient is in a terminal phase of their illness.Okay?So that rule of six months again.And actually for palliative, sedation, or terminal palliative, sedation, most agree that the patient should actually be imminently dying like even more so than six months they need. 

16:36 

If you're going to stop feeding them or giving them hydration and nutrition, they need to be pretty close to death.Probably even closer than six months.So this is kind of debated but I think actually, it shouldn't merely be six months.It might it should be more like days to weeks at best, okay? 

16:54 

Because, because it, Well, actually potentially be, the not feeding them that will be the cause of their death.And we don't want that to be the case, right?Okay.So again, we ought not to kill our patient, a lot of these sort of hit on this.All right, the rule number five is we need to get appropriate consent. 

17:15 

So the patient or their legal representative has to be aware of a few things.So this, the kind of components of informed consent that the patient does have an irreversible illness.That the patient could die in this unconscious State while sedated and that palliative sedation is the sort of root we're going. 

17:34 

So this isn't necessarily a problem in this case but there is some worry in the literature that I found that you know we might be not well explaining what the goals of palliative sedation are.So we want to make sure that that's the case and in any case and as maybe especially this case, we'd want to check in about why the legal representative, why the surrogate is choosing this? 

17:55 

All right, so what are the motivations?What are the intentions?What do they think?The patient him or herself would have wanted?And we should do a whole episode about this because I think it's really fascinating, but in a case like with this patient, where he actually seems to have, no intent to die.But his surrogate. 

18:11 

His wife is saying, if he prior to his dementia, he would have said, this was an intolerable state, but in his demented State, he's saying no, I'm fine.Which, which person the before person or the current person wins out in the That debate. 

18:28 

Yeah, that's that.That needs to be a whole different because, yeah, that gets really complicated really quickly.When you start talking about, current persons versus past persons in terms of wishes and interests and that's tough though. 

18:43 

Yeah, interesting, but so rule number of what do we want to rule number five, Sol's rules, and number five.So this one is basically that this, that this decision to pursue palliative, sedation is okay, for a surrogate to Quest.If these conditions are met right. 

19:00 

Yep.And then number six, the final rule, I like calling them rules, okay?Because it sounds very legal and mandatory is that you need to support, you need to consult supportive and palliative care.So, most most hospitals will have a team. 

19:17 

Gosh, I hope so.I know they don't all but hopefully you have a supportive and palliative, care team, whose job it is to think about appropriate levels of pain medication.Ian support people with gold making at the end of their lives.Like these sorts of things, they are the best team to administer palliative, terminal sedation, but also to work with families about whether this is appropriate or not for the patient. 

19:43 

Yeah, so one of the hospitals that I do Consulting with actually renamed their palliative care, team to the advanced illness management team.So interesting, I kind of liked.Yeah.Because part of what we think about with palliative care, is that provision that they're working with serious illness conversations, right? 

20:01 

Right?Yeah.Well, good.Alright.So those six rules answer the questions presented in your case, well, so in our case, at least as it was initially presented to me, almost None of these conditions had been met.Okay, so the patient we didn't think was terminal. 

20:18 

We thought the intent was to end his life.We thought it wasn't, we weren't at that proportional stage yet where we had actually tried things that were working.And so we didn't need to ratchet them up.There was consent, although I will say and this is sort of, I think unfortunate when it was brought to the wife's attention that ethics was reviewing the case, she immediately kind of retracted her Request and said, oh no, never mind. 

20:46 

I don't like as if we were the ethics beliefs, or she was somehow going to get in trouble, and that's to me and unfortunate reaction because I think it says something about about how people think about ethics, but I do know.What do you think?Yeah, I present ethics specially in the clinical setting. 

21:02 

When people are like well who are you and what are you doing?I just generally described it as we're here.Our team is here to help make difficult decisions and so yeah.Yeah, we often get that that misconception that we're there as the police or tell people what is right and wrong, which really, is not the role of clinical ethics. 

21:22 

Yeah.Or to somehow, like, get people in trouble for asking for things, there is no, so it kept people kept asking me, is it okay for her to ask, this asked for this?And I kept saying she can ask for anything, right?It's our job to say whether she can receive have it or not, right? 

21:38 

Have it or not if we want to fulfill that request, but you should never feel like you're going to Trouble for asking, for something for your, loved one or yourself, while in the hospital.All right?You know, there are some Physicians who are like, oh gosh, they, you know, went on dr.Google. 

21:53 

And now there, but I actually think that's a minority of people.We want people to be involved and to ask questions.That's appropriate.So what she asked for?Wasn't something we could do, but it wasn't an appropriate question.Yeah.Yeah, good.Yeah.What an interesting topic. 

22:09 

I bet there's going to be a lot of comments and Feedback about stalls rules.Well, I hope so.And actually can I throw out one more thing that actually I realized after the case.Yeah, resolved that I didn't quite think about. 

22:26 

I realized that there is a big debate about whether existential suffering.Counts in these cases.Yeah, that's actually I've been involved in cases where that was the case and maybe that's a topic for another episode as well. 

22:44 

This idea of existential suffering terminal existential suffering, right?So just a, just a tease, the listeners.It's, I think most people would agree that if somebody was at the end of their life and they were experiencing just unbearable intractable suffering, I don't think there are many people who would say it's not. 

23:03 

Okay, to sedate them to the point where they're they fall asleep, so they don't experience that pain.All right, that'd be weird to demand.Somebody experienced horrible pain.At the end of their lives.But what is much more debated is whether existential suffering by? 

23:19 

Which we mean they're just like kind of experiencing such mental anguish, right?It maybe isn't physical but it is so existential so destructive cycle, like psychologically and emotionally.Yeah.And usually that's about the fear of death or it might be about just other life circumstances, it does that count. 

23:38 

Cuz they're pretty distressed and and often very anxious and we can control some of those symptoms.But you know sometimes not all of our suffering is physiological pain suffering, right?We all recognize that we can be in terrible suffering that isn't necessarily biologically-based, although, maybe I'll get pushed back on that to maybe it's all somehow biologically-based, but should that also be should people like that. 

24:03 

Also be potentially receiving palliative, sedation.And I think some people will say No and some people will say yes.So that's that's a debatable topic.Yeah, great topic.I thanks big fan of stalls rules.Thanks cool. 

Picture source.

In this mini-sode, Tyler and Devan discuss the Biden administration's proposal to break up UNOS' monopoly on organs for transplantation.

Read more on the background of this topic here and an opinion piece here.

Transcript

0:23 

All right.Tyler, what are you obsessed with this week?Devin, this one has been driving me, crazy all week long.So this is a great, great thing to get off my chest and to talk about.Okay, great.So so David, I was recently reading about a report that was talking about the really big problems in the organ donation process, okay? 

0:48 

And I ran across this article that said that there are are thousands of individuals waiting on the the wait list.And there are also a huge number of individuals who are dying without getting an organ transplant, right? 

1:06 

So in the order of tens of thousands of people and recently there was a congressional hearing.So this article that I was reading is talking about the Congressional hearings that recently happened.You heard about this?No, I haven't go on, okay.Alright. 

1:22 

So this article that I was reading is talking about these Congressional hearings and there's going to be some changes to the process, but the article that I was reading was from 1986.Well, okay, so but we've like improved a bunch since then, right? 

1:41 

No.Yeah.So the It was interesting because this article was talking about this, these hearings that were held up hitting in 19, in the mid-80s about the inequality, and the inefficiencies in the organ allocation system. 

1:58 

And so, in the United States, there are there's one organization.It's a not-for-profit organization called United Network ordering sharing, What is it like company?I don't know.Hold on a sec.No, no, just the United Network for organ. 

2:15 

Sharing for organ sharing.Yeah, so it's this organization is nonprofit organization that has an exclusive contract with the United States government to not only run the the matching system but also to be involved in how these organs are being distributed. 

2:36 

And Dave recently come under some I would say very pointed criticisms, right?So, you know, this is this like, massive, you know, they call it almost like a quasi-governmental agency because it has this exclusive contract. 

2:52 

It has what some people are now calling a monopoly, right?So it shouldn't be the case that one company has the, the only access to this like huge resource that, you know?And if they were like, really good at running it, maybe we'd look the other way, but apparently, they're not great at running it or, at least. 

3:10 

There are massive inefficiencies and lots of people who could whose lives could have been saved.If only the program have been run better and that's pretty daunting, right?And so recently there's been some about a year ago.There were some Congressional hearings mostly LED out of seven. 

3:29 

Senator Warren.From Massachusetts, has been at the Forefront of looking into reforming at least examining shedding some light on the organ.Allocation and transplantation process. 

3:45 

And recently they just made it.So just in the past week there was a change in the policy or in the process that would allow other organizations.Besides you knows to basically step up and say wait a second, maybe we can run this whole system better than you. 

4:05 

Nose has been running it which seems like a good idea to me, right?Yeah.Competition being being what drives Innovation.I feel like that's kind of like the American capitalist ideal, right?Yeah.Would it surprise you to learn that you? 

4:20 

Nose has been the only organization to have this contract with the government to run this?It's a nationwide contract and they've had exclusivity for over 40 years since the process since the system was established. 

4:37 

It's not surprising.Given what I know about health care but It should be right like we all know that like there's like these three organizations that run all of the electronic Healthcare records.I always think about and I how bad they are and how slow they are to adjust.And like what an absolute pain it is to like change the system in any way. 

4:56 

Like we just have these massive companies running really important stuff and they're not like hooked up to the latest it.I remember it was it last year.You knows the system went down for like 40 minutes and it just created and absolute chaos. 

5:12 

So your whole system can't just crash that meant that like people didn't know where the organs were going for 40 minutes and that might not seem like a long time, but that meant that people died who could have received organs And that crash got a lot of media attention, but it's apparently not the first time or the most significant time that this process is system has failed. 

5:36 

And like you said, it's based upon technology.So it's very technologically, their algorithms on the allocation and how they are being distributed.Even within smaller markets, a small Regional areas, but the technology is so important to so many people particularly people. 

5:54 

Who are waiting for these organs and the in efficiencies and the failures.In the breakdowns in the system are absolutely mind-boggling.There is one statistic that was shared that it that the organ procurement organizations or you knows which operates our overseas. 

6:14 

The, the organ procurement organizations that the, it's something like five times more likely to lose or damage a human organ in transit.Then An airline is to lose or damage a piece of luggage. 

6:29 

Well, that is totally mind-boggling because I feel like I have to buy a new suitcase every time I travel because of the ways that it's handled like, it just like is falling apart by the time I get it on the other end.So if like, airlines are better at this than the people who are in charge and it's not the people's problem, I'm sure. 

6:45 

But like the sort of system in which, you know, these organs are so fragile and delicate and nobody doesn't understand that.So, is it just that there?Going too far.Is it right?Like how they traveling too far?Like, what is the problem?I think it's so complicated that there isn't one problem that's able to be fixed, right? 

7:05 

So it's not just a transportation issue, it's not a logistical issue.It's also a question about how we decide we being, you knows how you knows decides who gets, which organ and the organs are all treated differently because there are different processes and different statistics and data and Technologies involved in. 

7:30 

H-how organs, like for example, and a heart is treated differently than a kidney is treated differently than a set of lungs or a pancreas or something like that.So the way in which its allocated, it's really complicated but also people on the waiting list all have different medical needs. 

7:47 

They all live in different places.They all live different distances from the transplantation centers.So all of these things and they're and those issues are those characteristics of the patient who Who needs the organ can be constantly changing as well. 

8:02 

They're not, you know, they could be getting sicker and sicker and sicker, as they're waiting, which most people do.And then they would, if we were allocating the organs based upon who needs it, the most, which is one model of allocating, scarce resources, whoever needs it. 

8:22 

The most that person as they continue to get sicker would, theoretically, move up the line.And Beast and be higher on the list, right?I mean that seems so tight.It's complicated Ikat is you know, snow minute by minute.So some of the patients that we see are just can crash really quickly and so they move from like definitely needs an organ but not now to needing it right now within the course of maybe an hour. 

8:49 

And how do you communicate that with a giant organization that then is trying to find those organs?It just seems if what you're doing is basing it on On sickness and not on geography that the Acuity of the illness.Seems really complicated. 

9:07 

Yeah, it is and it's always changing and it is dependent upon how sick the patient is in all other aspects of their lives, right?So the term we use is comorbidities so if I have if I'm in liver failure, it's not just my liver that's going to be a problem, it's going to be everything that kind of Of stems or falls out of that liver failure. 

9:31 

Could be my heart.Could be infections.It could be, you know, problems with the wit no delirium.And all these other issues that also complicate the assessment of whether or not.I am the best person to get this.And, you know, if we want to make this even more complicated, or try to unpack it a little bit more the way in which the United States Healthcare System is structured favors. 

9:58 

Who are the most vulnerable?Oh geez.People who need it?No, so if it's not the most vulnerable at least not really the sickest always write such a really person who needs it. 

10:17 

The most is it.The people who have the most money I'm afraid it is no, no.And it's not just like an Will being able to go out and purchase a kidney, right?It's not just because there are some really strict rules about compensation, and you can't buy and sell human organs in the United States. 

10:39 

It's illegal.So, the people who have access to resources in particular, people who have access to massive amount of resources are able to game the system in a way that benefits them to the detriment of everybody else does this sound familiar in any way? 

10:57 

I mean, Does but I guess, I guess, I don't understand how that works.Tyler, because part of the reasoning behind not being able to buy and sell organs, is that it would disproportionately hurt the poor and it's one way of trying to level the field.So, how is it that rich people are still gaming. 

11:15 

The system to get organs over people who are poor?So here's one of the most popular examples that people look to to illustrate.This problem is Steve Jobs, so I found her you've heard of him, founder of Apple and he was, I think he had pancreatic cancer, so he was looking for a donation for a, he needed an pancreas donation and what he was able to do. 

11:47 

So what are the requirements of getting?An organ is you have to live within a certain distance of a transplantation Center and also you have to be listed in that either state or regions list of people who need the organ. 

12:04 

So you have to get on the wait list.And so what Steve Jobs was able to do and there's that there's some disagreement about whether how factual all of these little points are because a lot of the records are sealed or confidential or people don't really know exactly. 

12:19 

How it happened, but the story is that he was able to, not only did he have access to a, you know, Gulfstream Jet private jet that could get him anywhere that he needed to go within an hour or two in the United States, but he was able to purchase property and establish legal residency in various States close to transplantation centers. 

12:42 

So, for example, one of the biggest ones in the midwest is in, in Nashville, like, at Vanderbilt, Example.So, for example, if I'm trying to optimize the opportunities that I have to get an organ is particularly an organ is, is quite scarce and there's a lot of people on the waiting list, if I buy a house next door, to the transplant center outside of Detroit at Henry, Ford and one outside of Nashville near Vanderbilt and one outside of Houston at MD Anderson, these big transplantation Senators, then You know, I can get on multiple lists and up the chances that I'm going to be able to get access to an organ. 

13:27 

Yeah, way.It's like going out to dinner and everything is really booked and you put your name on the waitlist for a table at five different restaurants.Whichever one comes up first, that's where you decide to go to dinner.Well, in this is really just the, it's not like, you know, the kind of rich and the middle class and the poor. 

13:43 

This is like the mega Rich because not many people can just buy a home in multiple locations.Transplant centers are at least not many people like right?Right.Yeah.So it's a very small subset of the country that are able to do this but it also trickles down to other issues of access. 

14:07 

It's particularly access with when Health when finances are the driving force.So for example, if I am somebody who is financially Lee struggling getting access to preventive care and getting access to diagnostic care and taking time off of work to go to all of these appointments and being able to navigate the healthcare system. 

14:33 

And being able to physically get to my appointments, these are huge burdens for individuals.And at any point if I not diligent, or I miss an appointment or something gets rescheduled, It just throws a wrench into the entire process and and it just slows down the ways in which people can get access to these life-saving. 

14:59 

And, and often it's not just, this is going to improve your life.It's like you get this organ or you die, right?These, the stakes could not be higher, right?And I haven't done a ton of work with our hospitals on, you know, allocating organs it. 

15:18 

Something actually I just signed up to do because I'm really curious about this topic but it also seems to me that there's this question of like adherence and are they going to is this individual going to preserve this organ in a responsible way?And so if you're constantly missing appointments because you don't have good transportation that might look on the healthcare end like you're just not adherent to the medical regimen and maybe you're not a person. 

15:42 

We want to give an organ to because we could give it to somebody who would take care of it better and it would preserve their life longer.So these are other ways.As in which being poor and having Health, disparities trickles down the way to you know being a responsible person that we would want to give an organ to and it shouldn't be that way. 

15:58 

And hopefully most of our hospitals are thinking about the bigger picture and and helping people to get access to healthcare.But I can see how, you know, being poor and not having access to other kinds of resources, makes you less liable to get an organ to save your life.So those are the issues on the receiving end, right? 

16:18 

So the people who are wanting to receive an organ, some of the same issues are at play and maybe even more.So at play on the supply side of this, okay?So people of color, or people who are underrepresented in medicine, folks, from those communities are less likely to be organ donors as well because of all of the systemic inequalities and inefficiency. 

16:43 

These and issues that go into it.So the supply of organs that are most appropriate for people of color, for example, are significantly underrepresented in the supply and that leads to worse outcomes on the other end as well. 

17:02 

Oh yeah.I remember we, this got brought up when we were talking about the prison issue where prisoners are more likely to be people of color and so wouldn't they be better?Organ, donors.So shouldn't we pay them by reducing their sentences?Alright.So that was the kind of the logic there.So it is true that there's an not enough organs for people of color and that people of color are less likely to donate, and they would be better matches. 

17:23 

I still contend that the way to solve this isn't to pay prisoners, but it's a broader issue of supply and demand and how we're meeting that.So what's the solution?So, the solution that the government is taking up, is to open up the competition. 

17:43 

Basically the Contracting process taking away this exclusive Monopoly from you knows who not only has been the primary overseer and organization since the Inception in the early 80s.But they've actually from what the reports that I've read that they've actually never had it a competitive bidding process for these contracts. 

18:06 

So nobody is never stepped up and been able given the opportunity to say a different organization to say, you know what, we can do it better, here's how we can can do it.And so these these contracts are were going to be these bids.These proposals are going to be accepted over the next several months and the Department of Health and Human Services is going to pick one or maybe several to try to organize this. 

18:32 

What's scary about that.Number one, I think breaking up the Monopoly at We'll have good.Good outcomes.I am of the belief in general, that competition breeds Innovation, and it's going to improve it in some meaningful way. 

18:48 

Not all the time there, but this is similar to basically overhauling the Air Traffic Control process in the United States.All at the same time, it's not the case that we can, it's not the case that we can take six months and figure out how to do it. 

19:07 

Son.Sunset one organization on board.A new organization, they have new ideas, new infrastructure and then they get going.It has to happen.Like you said, a 40-minute delay in the process or a breakdown in the system leads to people's death.And so this is a process that not only it has to be efficient, but it has to be efficient immediately and having worked in big organizations of various Stripes. 

19:33 

It does not seem like it's a recipe for a smooth transition.Well hopefully they've somebody's thought of that if you and I have thought of it.Somebody else.Somebody else has that.It's true.That's true.Yeah but if they if you know you guys want to call me it's a Biden. 

19:50 

Ministration wants to call Tyler, and I and ask for some suggestions for willing to give them Yeah, I have some thoughts.Yeah, Joe doesn't joke, all you fairly regularly.I mean, he calls me about all sorts of stuff.We haven't talked about organs, but maybe I'll bring it up in our next conversation. 

20:07 

But put that on your weekly agenda for the B Administration.So, lots of like you said, lots of smart people are working on this and it's a process.Like the I think the comparison to the air traffic control is is useful in this situation because it's a process. 

20:25 

And a system.And and a way that Healthcare is delivered that has to work.It's not like we can abandon organ transplantation, and try to figure out a different way or, you know, we have to make this work in in order for people's lives to be saved and lives to be improved. 

20:44 

So that's what I'm obsessed about this week organ, allocation process, all right?And we'll post a bunch of links to articles about what the proposal is and what the end efficiencies are and why Steve Jobs shouldn't be able to buy multiple homes and get an organ over somebody else. 

Understanding embryo grading. Utah Fertility Center.

In this mini-sode, Tyler and Devan discuss a recent court case where a judge partially relied on a 19th century law that treated humans as property in order to rule on whether an embryo should be considered property.

Read about the court’s use of this law here. This story was originally reported in the New York Times.

Transcript

0:31 

All right, Tyler.I came across a news story that a friend sent me this past week that I think is going to be really interesting for you.All right?Bring it on.Okay, so before I get to the news story itself, I want to just ask you kind of a background question.Have you thought, you know as as somebody who studied the law about what an embryo is, what an embryo is I I have in my mind, a working definition of what an embryo is, but since you phrase it like that, I'm going to say maybe I haven't thought about it enough. 

1:09 

Okay, well maybe so medically like what is an embryo?Right.So it is a group of cluster of cells that have been fertilized and are kind of in kind of a limbo State before progressing into growing into a human. 

1:31 

Hmm.Sure.That sounds good enough to me, okay, right of the scientific kind of answer and of course so we have something like a million embryos in storage right now because of the process of IVF.So in vitro fertilization, you create that embryo outside of the womb and they the hope is that they get implanted. 

1:53 

But often people will create more of these embryos and they actually even want implanted because maybe not all of them fertilized correctly and so you do a few more and then you can store the extras.So millions of embryos being stored in the u.s. right now and of course there's lots of ethical questions about this, right? 

2:11 

So what jumps into your mind is sort of the The ethics of embryo storage.So there are questions about whether we should be doing this at all.Sure yep.So there are certain religious Traditions that have questions about the creation of potential life outside of marriage and that type of thing. 

2:36 

So there's a fundamental question of should we be doing this at all?But then there are I see a couple of Of other further.Questions number one, being if these are not humans and I don't think that we under the law, treat them as humans, the embryos individual embryos, they are potential humans. 

2:56 

So what types of Rights or duties?Do we have towards them, you know, in order to kind of magnify their dignity and stuff like that?I think that would be a question.Also who is controlling these who's in charge? 

3:13 

Hmm, is it, the is it that people who, who, Who provided the gametes that created the embryo?Is it the facility that actually houses?The, the embryos is, it may be the physician or the technician that created them, do they have some sort of say in it? 

3:32 

So I think there's all, I mean, that's just off the top of my head, but I think there's a lot.Oh yeah, lots of issues, right?So even if you think that their persons all Of issues with like them being created at all.Like, what does it mean to store a person in a freezer? 

3:50 

What would it mean to destroy them?So let's say you didn't want the embryos.You either didn't want to proceed with IVF, or you did have a child and you don't want any more children, is it okay to destroy them.I actually ran across a clinical Ephesus recently who was talking about how in Texas. 

4:06 

There's all these embryos that are stored that we can't trace back to the people that created them like the We've sort of for whatever reason, lost the thread and but the hospital's don't even know what to do with them.Wait, so the people whose genetic material was used to create the embryo, we've lost their cell phone number or something. 

4:29 

Yeah.Yeah.Like they were maybe created a while ago and we've just lost the connection.But so, then, is it, are you allowed to destroy them?If you don't get the consent of the the persons whose genetic material there?So also, The questions there.And of course even maybe even more important is like what would it mean to the hospital? 

4:49 

Like would it be bad PR if we destroyed a bunch of embryos in a place like Texas, where maybe a lot of people do think that their persons or can we do research on them?So those are kind of the oh he's the present questions about embryos and IVF, there's another kind of legal question that comes up though, and it came up in this case. 

5:06 

And I talked about it with my students sometimes is like, who owns them and you've sort of suggested this, but I doubt many people would say, oh, the physician who created the embryo, they own them, that would be weird, right?Probably the people who donated their genetic material to create the embryo own as a weird word, but have kind of Rights over this embryo. 

5:29 

But what if those and it's, you know, those two people.What if those people disagree about, then what should be done with the embryo?Yeah, I think I remember reading a case about this in law school.Facts are a little bit different. 

5:44 

But yeah, what if the parents for lack of a better term?The the donors of the material.If they say, they were married, when these were created, then they get divorced.Yep.Wow, yeah.And I mean so that's usually the case that we think about is they were in the process of IVF, maybe they tried implantation before. 

6:06 

Maybe they even had children, but there are still these extra embryos, they get divorced and either one of the parties wants to Use the embryo, like wants to implant it either in, you know, the woman herself or if a man were to get remarried and it's the embryo is half of his genetic material. 

6:23 

Could he use that embryo in a new partner?Would that be ethical Wow, it feels like kind of sci-fi Brave New World.Yeah, but I mean what? 

6:38 

So what would be your gut impulse?So let's say the easier cases, maybe, you know, that it was a married couple and they get divorced, but the wife the woman, the ex-wife still wants to implant that embryo.Do you think she has the right to do that?And so, just for clarification, the, let's say, the husband or the ex-husband is in disagreement with that. 

7:03 

Can she make that decision against his in contradiction to his decisions?That is that kind of what you're asking, right?Right.So if they agreed, then, maybe there's no ethical question there.But let's say they disagree.So say he says, Nope, I have as much right over. 

7:19 

This embryo as she does, I don't want another child.And I don't want her to implant this embryo.Does he does his right to not have children supersede her right to have children.Boy that is a super interesting question because there are very few. 

7:39 

So let's just assume let's look at this as if those embryos are property and which again like is kind of an uncomfortable way of looking at it.But so if Another piece of property.Might be a couch right.It's so say super similar. 

7:55 

Yep.Go on.Yeah.So let's say let's say this married couple bought a couch from Ikea used equal amounts of their own money to purchase this couch, but it hasn't been assembled yet.And for some reason, it's a unique couch and they split up the the marriage relationship dissolves and one person wants to create the couch. 

8:19 

The other says, no, I don't want that couch to ever see the light of day.Uh-huh.I have no idea what the law would do.Yeah.I know, I would be really surprised if the law has specifically looked at this.I mean, state by state jurisdictions, obviously, but yeah, I don't know. 

8:38 

Yeah, I mean, it's so I would say, sort of my impulse in these cases is that in the sounds really strange but they're the right to not have children.Me super seats, the right to have children, you know, and I'd have to think more about this, but I think if you don't want that embryo to be implanted, that's a pretty strong, right? 

9:05 

Right.So we talked about procreative Liberty and you know that our government should not prevent people from having children.Again, we talked about this in a previous episode, our government did that for a long time, with Eugenics, sort of forcibly sterilizing people, we think that that's wrong.So I Don't think the government should be able to step in and prevent people from having children. 

9:24 

But at the same time, I think the right to not have children is also really strong and that if you are it is weird to talk about an embryo as property, but if it's half of your material and that potential child is your child. 

9:42 

You have a pretty strong right?Not to bring that child into the world, if you don't want to be a parent.All right?So we also want to Serve those rights.So it's this complicated like whose rights supersede, but I think to not bring the child into the world, seems to me like a stronger, right? 

9:59 

But I think the law is pretty unclear about this.And so, I there's been cases in different states where this has come up.So here we finally 10 minutes into this, I'm going to get to the case itself because this is the question.So, in Virginia last week, this was the case. 

10:16 

So I husband and wife get divorced.They had been going through IVF She, the wife wants to implant the embryo.They had had actually, apparently this is pretty common.These days is that you sign an agreement about what would happen if this if divorce were to happen and they had said that either, a Court ruling would determine who has the rights over the embryo or they'd have to agree. 

10:40 

So the idea is, and this would, of course, be the what you would want, you'd want both parties to agree.So, you do some sort of mediation.Just like you would in any divorce proceeding.To decide how to delineate property.That'd be the best case scenario, right?Or you enforce the prior agreement, of course, this prior agreement was that a court order? 

11:00 

Could overrule one of the parties.So this is where we're at.They can't agree.You got it, do this and so it's going before a judge and the ex-husband is saying, no way.I don't want this embryo to be implanted.I have I have rights to, she can't do it and she's saying, you know, this is my last chance. 

11:19 

She has a very sad story.Rory of going through chemotherapy and being infertile and this is her only shot at having biological children.And so who is he to prevent her from doing that?Simply because he doesn't want to have a child with her, right?So what is, what do you think? 

11:36 

What do you think the judge says, in this case, what would be great?Let's say you're the judge, you're the Virginia judge.You know, what are you, what kind of precedent are you going to draw on or what kind of old old timey, laws are going to kind of maybe apply to this case.Oh boy.I hope that there are no old timey laws that get brought into this because it's, it's a, it's a Fool's errand. 

11:58 

I think to try to apply historical laws to these really new technologically, interesting questions.I think that there is some precedent in regards to like gestational surrogacy.So when somebody would a woman, somebody a person with a fetus or not, if he has a person with a uterus, this is impregnated implanted with through the IVF process, with somebody else's embryo that. 

12:30 

So the carrier, the the person who is using their uterus, is the way to say it, but cool.Yeah, I got halfway.Yeah, he's right.I got halfway to that sentence and it just kept getting more awkward.So anyway, so the person who is Carrying the child. 

12:51 

And, you know, obviously it's growing in them.There have been situations.They've been case law where that individual tries to assert some sort of parental rights over the, the fetus or the newborn.And then it gets.I think there's a couple of California cases that talk about that. 

13:09 

So that's as close as I think that the laws.Been to my knowledge but I'm sure yeah, I'm sure others.No more and our listeners are going to correct me.Like they they seem to enjoy to do that.I do.They do please, correct.Tyler at all points of what you just said, you know, the woman with the uterus. 

13:28 

So, so, that's right.So there have been these interesting cases and honestly like state law on this is so wild.I show this chart to my students all the time where it's like, what with surrogacy, what those state laws are and they are really variable.So in some states The woman who gives birth to the child is the legal mother until she forfeits those rights. 

13:48 

So even if she were just the gestational carrier meeting like she's not genetically related, she could in some places get parental rights that would be if it gets strange and it doesn't typically happen but that it's there's some wild coincidences in the law and they're pretty different.But this is a slightly different than that in that. 

14:07 

You know who gets to own.This embryo is a somewhat different question and what kind of precedent You draw on unfortunately.The judge in this case did drawn an old-timey law, the worst kind of old-timey law. 

14:23 

Oh no slaves, as property laws, wait wait, no, he did.So he referred to an 18-49 code that categorize slaves as property, that could be divided and sold as precedent for thinking about embryos as 30 to be sold. 

14:48 

That seems like a not a great, even if the idea behind it would make sense like citing slavery laws in any regard right now.Seems like a really bad move seems like a bad but like even if it's expeditious to get the outcome that you think is fair, don't just don't slack site, Slave Code. 

15:09 

Like just seems like a big really.There's nothing else in the law that you could think about.I mean, even if you think of Rio's is property one of the best.So as I was reading this article when people on the far left and the far right, both agree, that the thing you just did is really bad. 

15:26 

That's a fun coincidence, right?So, it was, you know, they're, they're quoting people from like the Southern Baptist convention, who think that embryos are persons, who are like, no, don't cite Slave Code and then you have people who are all for kind of reproductive Liberty.And choice also saying like, nope don't cite slave codes, so he's so A bad way to maybe get to the outcome. 

15:48 

And so and this decision that he wrote up, merely means that now the ex-wife can go to trial to try to get rights over the embryo.But yeah.So I said I got this article sent to me.I was like, oh my gosh, what are like what would a bioethicist? 

16:05 

Think my hope.And I think I'm fairly confident in this is that no bioethicist thought that this was a good idea.Yeah.At least the way he got to this decision.I think that there might be a, I mean, most judges a lot of Judges have either the law students or recent law grads as clerks. 

16:26 

And so maybe this one just got slipped through the editing revising process.But right, so I think regardless of whether you think of embryos as persons or potential persons, yeah, I just don't want to invoke legalized slavery as A way to talk about who gets to own the embryo. 

16:49 

Yeah, I agree.And that is that is my legal opinion.Write that one down.Don't slight site Slave Code.Yep.Yep.It's a good.That's a good like bioethical.Principle like don't call their people Nazis and less like they're actually not cease. 

17:06 

This is a good one in bioethics and don't cite Slave Code period.Actually there's no there's no second part of that.Yeah.There's no second part of that, that sentence.That is necessary.Yeah, so it'll be interesting to see kind of what the backlash is against this. 

17:25 

Or if this gets taken up by other judges, just can't imagine what he was thinking because it seems to me.And you're the lawyer, you know, you know better than I do.There must be a better analogy.The IKEA sofa seems not like a equally bad analogy, a very poor one, but still better than Slave Code but you know, the surrogacy Eli's makes sense is kind of some sort of precedent or even like organs. 

17:52 

I mean it's weird because an embryo isn't an organ either but we do still have regulations about like who owns organs and whether they can be bought and sold, maybe that's a better analogy.There does seem to be like no great analogy here, but possibly picked the worst one to set a precedent for, right? 

18:10 

And I think that we just need to rely upon the, the stall principle.Hmm.Which Has don't slight don't site Slave Code period. 

In this mini-sode, Tyler and Devan discuss match day; when fourth year medical students find out if and where they’ve matched for their residency years. It is one of the most intense, significant days in the life of aspiring physicians.

Transcript

0:26 

All right, Tyler.We just had a really big event in the medical world happen.What was it?So, last week March, I guess it was on st.Patrick's Day, March 17th.All of the current fourth year medical students.Across the country found out if and where they were going to be spending their residency years, Yay. 

0:51 

Yeah, mostly, yay, mostly.Yeah.Well I like everything else that has to do with Healthcare it's way more complicated than I think a lot of people recognize her a lot of people even appreciate the complexity of it. 

1:06 

So let me walk you through the match process and then we can talk about some of the reasons why I'm currently obsessed with all the inner workings of the match.Okay, cool.So during the fourth year of medical school, so the medical school in the United States obviously has four years. 

1:24 

And then during the fourth year, students submit applications to residency programs.So postgraduate training in the specialty of their choice.There are dozens of not dozens, but many, many different types of residency programs so students can go into Internal Medicine which is kind of the most General, they Pediatrics will Be kind, they can go into surgeries and so they get an opportunity to kind of distinguish between the different sub practices of medicine. 

1:56 

What type of physician they want to be alright.So far so good.Yeah.And so they apply to all these different programs, different places across the country and residency.Programs are not necessarily tied to medical schools and so you could go to like a community-based Residency program. 

2:16 

So, say that I was Sitting practicing rural family medicine, for example, and I applied to a hospital or a hospital system in South Dakota, for example, that has a Residency program and I could go and do my training there and, you know, get very well trained to be a family physician in kind of a rural setting. 

2:39 

Yep.My whole family's from South Dakota so we get it.It's Paradise.So super competitive, right?Super competitive.Everyone's trying to get to South Dakota for the residency.Programs.But so previous tip covid students would have to apply to these programs receive an offer for an interview and then fly out to sometimes 10, 15, 20 different. 

3:04 

Oh my gosh, 20 different interviews.Well how can they who's paying for that?Well, that's a great question.The residency programs are not paying for it.Medical school is not paying for it, so it lands on the student.Oh no.So can be hugely Expensive disruptive to the fourth year of medical school. 

3:26 

And some students who don't have the financial resources or are wisely not willing to add that to their already.Massive student loans have to be really strategic about who they interview with and where they apply for, hmm. 

3:43 

And there's a lot of count coaching and counseling that goes in on the front end of this, from the medical school perspective, where you were looking at their grades, or Looking at their letters of recommendation and scores on certain really important tests to help coach them into what type of residencies, they would be competitive for regardless of whether they're interested or not. 

4:07 

So some of the really high profile really lucrative but also really good.Lifestyle types of medicine tend to be more competitive.So explain what what those would be I think I know.But what do you think?So some of them you would Assume based upon kind of The Prestige and the difficulty of getting into them. 

4:26 

So for example, neurosurgery for example or plastic surgery, those would traditionally very competitive also ones that you might not think about like Ophthalmology and dermatology and Urology. 

4:42 

Some of these a little bit more specific types of subspecialties are, can be really, really, really competitive to get into, is it?Because those Schulte's don't have like as much on call.You're not working 80 hours a week because there aren't like Dermatological emergencies. 

5:00 

Yeah, I think that's basically the, that's how I understand it.Some of them have our procedure based and so you're doing maybe minor surgeries in the office outpatient, maybe some inpatient surgical procedures and they're not a lot of call. 

5:17 

It's there's not a lot of emergencies, a lot of Independence.So those tend to have really good lifestyle and the pay is really high, even relative to other physician types of practice, interesting? 

5:32 

Okay?So all of the students who are currently fourth year, students in the United States.Plus, all of the graduating International medical students can apply to be part of what is referred to as the match.The match. 

5:48 

Oh, I like the sounds like a TV show.It's probably not as enjoyable as a TV show if you're in it, okay?Okay.So with a couple of Exceptions there a couple residency programs that do an early match and so if you're going into I can't remember all of the top of my head I think you're ology Ophthalmology and maybe another one, they do their match ahead of time and also if you're involved in the military so if you're matching into a military residency then those happen previously. 

6:19 

But for the vast majority of students who are graduating Fourth year they last week on Monday they got an email from the National Organization that runs it that tells them whether or not they matched into a Residency program. 

6:35 

Okay.So they have previously submitted a ranked list of all the programs that they would like to go to.And it can be as long as I think it can be, as long as they want, you know, up to 20, 25 30 programs, if they wanted to rank all of them and then the program. 

6:51 

So the residency Programs have interviewed hundreds sometimes dozens and dozens of students from across the country and internationally, and they have a massive list of ranking as well.So, both of these ranked lists, from the programs, and the students, in all of the Specialties goes into this algorithm and I love it, that this seems like the right way to do it, right? 

7:14 

So it matches them to and you may not get your first choice, and the program may not get their first choice, but the algorithm is Up in a way that most people get most of what they want.Okay.So this sounds a lot like speed dating, right? 

7:30 

Like, or do you want to be in a relationship with and do they want to be in a relationship with you?Like basically the same thing, right?Yeah basically and it happens for everybody all at the same time so on Monday they know whether or not they have matched or not.If they don't match we'll talk about that in a second. 

7:47 

If they could email on Monday saying that they did not match but if they got Got a match then they don't find out where their match is so where they're moving to and spending the next, you know, three, four five, seven years of training. 

8:03 

They don't know where that is until Friday at noon.So they have like four days of that's torture wai-wai-wait.I mean, if they matched, don't doesn't the algorithm know where they matched?Yeah, it does.But it keeps Us Secret.Why why? 

8:20 

So, what happens if you get a Email on Monday saying that you didn't match okay so at the same time students are finding out that they are unmatched so they didn't match to a program and also all of the programs that have empty spots, all find out at the same time and then it is really like speed dating for the next two or three days. 

8:41 

All the programs are frantically trying to find people to agree to come into their program and students are frantically trying to to decide where to go.So, there's lots of interviews, there's zoom and kind of the changes in medical education because of the pandemic are really have been really helpful in this way. 

9:03 

Because a lot of The Residency interviews I think, almost all of them are done virtually now.So the cost is lot less for students but still a lot of stress and and then at the end of it, you may not match and then you're kind of in this process where you're scrambling to and that's what it actually used to be called, is the Well they call it this soap now, which stands for, I do remember this verse. 

9:29 

I can't remember the subsequent open, I don't remember.That's basically it's a scramble and then they try to find a spot and then on Friday, at least at our Medical School.The other schools I've been associated with, there's a kind of a big party and ceremony and people will open it and some schools. 

9:51 

Will you get to open it in private and then you find out where you're going?Because it could be really, really good news or it could be really really disappointing news.Absolutely, right.Yeah.If it was the last one on your list or it's really not a specialty that you thought you wanted to go into, you had your heart set on Ophthalmology and suddenly, you have to be a dermatologist, how terrible? 

10:13 

But I mean, where's the, I want, like a cake that when you cut into it, like a gender-reveal party like I I want that kind of level of ceremony, but if you disappear but I guess, you know, those sex reveal parties can also be kind of disappointing depending on, you know, yeah, what you wanted. 

10:31 

So, so you might do it in private.That makes more sense to me, but then there's a big celebration.But how about these people are there?People who don't match?Even after the scramble there are, it's pretty, it's pretty rare, but it does happen to some folks and I think in, so, what I've seen in my experience is often students who are committed. 

10:50 

Is to wanting to be into that.Maybe an ultra competitive specialty will take a year off and maybe do a year of research or maybe a master's degree or something to make them more competitive and then go back into the process again and then try to rematch the next year. 

11:09 

Hmm.Wow so this is just incredibly stressful.You got a match because you have to do a residency.The you can't just even after four years of med school you are then a doctor you're a physician.You Get that degree but you have to do a residency, right?You can't just practice medicine without a residency, right? 

11:26 

You have to get a so doing a board-certified residency is necessary to get a license.I think in almost every state I'd be surprised if there's a state that doesn't allow that or that allows it not to happen.But yeah.So you have to go to a approved Residency program to get trained in the specialty that you are going to practice and some people matching new programs that there. 

11:50 

Not so interested in and they do a residency program and then they sometimes do another Residency program.Well, because they don't want to have their like sort of first real job until they're 40.Is that kind of the deal as two?People have multiple graduate degrees. 

12:06 

We get it friends forever.Yeah just keep going to school but but what so what did it so that happened all last week.So that was really fun.It's exciting.Kind of a big celebration for the students but But what was interesting about the match this year, is that there was one program or one type of residency, that previously had been really quite competitive. 

12:30 

And to the point that some students who didn't have a strong and numbers or whatever work discouraged from a even applying to that Residency program, but those types of programs because of the competitiveness of them.So can you guess what?It was anesthesiology. 

12:48 

No, but not too dissimilar, actually the the, it's emergency medicine, emergency medicine, the really intense one.Yeah.Right.And so it is, it was really interesting because the way that medicine is being practiced from like a business perspective is well, there's a lot of reasons why people are speculating that emergency medicine was very, very much. 

13:18 

Less competitive.Meaning that on that Monday, dozens hundreds of open spots in emergency medicine were unmatched because there weren't enough applicants to do that type of program.And so there's a couple of things that I've talked to people about why emergency medicine had such a hard year and some spots have even after The Scrambled. 

13:42 

The so process are still left unfilled.And I was reading about an I can't Amber where it was maybe in Illinois or Ohio.But there was a residency program in.Emergency medicine program that had let's say four or six open, first year residency spots and didn't fill any of them. 

14:00 

Oh no, yeah, so it's really Uncharted Territory for the for this specialty.Specifically.But all Specialties and there's a couple things that people are thinking about why this how to explain this.And so if you think about over the last couple of years during the Diabetic. 

14:19 

The folks that really bore a lot of the brunt of the uncertainty and the change.In the way that medicine was practiced, was emergency room Doc's.Yeah, that makes sense.That makes sense.Yeah, and so students, one hypothesis that I heard from somebody that I think is really smart and that I trust, she said that students are going in and rotating during their third year and sometimes in their fourth year through these emergency departments and seeing what a A challenging environment. 

14:49 

It is how there's a lot of change in the way that Partnerships and practices are being pot up.Bought up by private equity, and hospitals are cutting staff or asking staff to do jobs, or fulfill rolls out of necessity. 

15:07 

That doesn't really require an MD degree.So a mid-level providers, for example, nurse practitioners and Physicians, assistants are taking More and more responsibilities in the emergency room.And so for a lot of students they had a really, I don't know. 

15:24 

Not, it's hard to say, I haven't really talked to people who have gone through that, who made this decision, but it's it, I think it's plausible to think that such a difficult experience.As a medical student, would be discouraging for folks to go and say, this is what I want my life's work to be. 

15:42 

Absolutely, I would think that, that makes total sense to me.If you had if you went through the Edie as a med student on rotation during the pandemic, you wouldn't want anything to either.You would say this is exactly where I want to be or you could say absolutely not. 

15:59 

Yeah, and I think more people, well apparently our people said absolutely not where people said absolutely not and so therefore there are it really changed.The supply of medical students going into this into the match. 

16:15 

So.Oh goodness.So we does that mean like You know, ten years down the line, we're just going to have an incredible shortage of Emergency Physicians because this year, they just didn't match enough or what's going to happen now.So, this is a really big change for the specialty of emergency medicine previously. 

16:36 

Like I said, it was really competitive and so there was a lot of people being trained in it because it was its shift work, which means that you go in treat, the defeat the patients who are there and then you go home and you don't have Have and I'm on call.You don't have a long-term obligation to any patients. 

16:52 

And so, some people really like that, so it was quite competitive.So the short answer is we don't know what this is going to do for the practice of medicine.Specifically in emergency medicine moving forward, Well, we've got great. 

17:08 

No, terrible.Probably, there will be not good, right.We definitely need emergency medicine.It's super important in our country.I mean, probably every country, but especially a country, where a lot of people use it as like Primary Care.Exactly.And it's really going to be interesting to watch how this type of kind of ripple from the pandemic plays out over there, like you said, many years to come because really a nun. 

17:36 

Charted territory.Hmm.So that's what I'm obsessed about this week.Yeah, that's a good one.Well, congratulations to everyone who matched condolences to those who didn't.But maybe there's a spot for you in emergency medicine, Maybe 

For more information about the match:

• The Match: National Residency Matching Program

• NRMP Match Algorithm Explained (Residency Application Process) (YouTube)

• Joint Statement on the Emergency Medicine 2023 Match Results (March 13, 2023) American College of Emergency Physicians

Permalink

In this mini-sode Tyler and Devan discuss whether it is ethical to turn off a pacemaker if a patient will die without it.

Links:

• What is a pacemaker? (Mayo Clinic)

• Practical and Ethical Considerations in the Management of Pacemaker and Implantable Cardiac Defibrillator Devices in Terminally Ill Patients, by Benjamin & Sorkness (2017)

Transcript

0:23 

So Tyler.I hear that this past week.You had a really good ethics consult.What was it about?Yeah.So super interesting question and it's not a question that's entirely unique, but I think one thing that's really interesting about bioethics and I think that's maybe one of your previous co-workers. 

0:43 

Tom Tomlinson said this, that bioethics is interesting because the issues are cyclical meaning that they come around again and again and again and usually it's technology that drives some of these reexaminations of previous So for example, the technology around Gene editing, for example, is always changing and always getting more precise and advanced. 

1:10 

And so the papers that were all written or the books that were written in the late 90s about Gene editing are being rediscovered or re used sometimes to apply to more contemporary iterations of the same problem. 

1:27 

Anyway so the question was about Pacemakers so an implantable device that helps regulate heartbeat.And the question was about whether or not turning off the pacemaker, either, the patient requesting it, which is really unusual or in the situation where a family is making our surrogate is making decisions. 

1:54 

Is it under what circumstances is it?Okay for a pacemaker to be terminated To be shut off.And part of the, the concern that was raised in this specific question.And also in the literature is is that not more like killing the patient directly, then withdrawing a patient from a ventilator for example, and how do we compare these different technological technologies? 

2:23 

That perpetuate somebody's life.In a way that is different or the same.And so the question came from a cardiologist or somebody working in the College of Cardiology with with a Cardiology service and so a patient was very ill and was unlikely to was was there's no reasonable expectation. 

2:47 

That the patient was going to recover and actually the pacemaker continuing to Fire and the way it was described, as that, the patient basically had no underlying In heart rate are heartbeat and so, all of the cardiac function was being stimulated by the pacemaker. 

3:03 

And so, by turning it off, there was there basically turning off the all cardiac function, which feels a lot different than withdrawing a ventilator and maybe the patient, breathes, maybe they don't, maybe they breathe for a little bit and then pass away peacefully. 

3:20 

So, that's the question, interesting.I mean, my first reaction to it is that it sounds exactly, like the Case of withdrawing a ventilator because you need to breathe.If you don't breathe, you die and if we take out, the means of breathing, we do expect you to die. 

3:39 

I mean, there are cases in which somebody kind of is breathing over the vent and we might anticipate that they could breathe a bit longer, or sometimes, it's apparently a surprise.Like, we didn't think they would continue to breathe, but they do.But the expectation, when you withdraw ventilator is in end-of-life cases, is that they won't breathe. 

3:55 

And and so, then that will lead to their death and And that could take minutes or it could take hours, sometimes it can take a well.I probably not more than a few hours.You can tell me if you have cases if they're not breathing.Alright, it's not going to, but if they do continue to breathe, it could take longer. 

4:11 

But, you know a pacemaker.We can predict that it is keeping cardiac function going and that turning it off.Would you know, your heart would totally stop.Maybe there are cases in which like the event.We didn't expect the heart to keep beating, but it could, and we don't for sure. 

4:28 

But that we do expect it to lead to death.So I guess I'm not sure how they're different.They sound the same to me.So what is the thinking about them being different?And that's really where the so there's a couple of reasons why they may be, they're not actually different, but they feel different particularly to the person who's turning them off. 

4:48 

And one of them is the immediacy of the patient's death, if there's no, underlying cardiac function, right?And in this situation, they were pretty confident that but the cardiologist Just said, it feels different.When I flip the switch or do whatever, and they immediately flatlined like, that feels like I am killing that patient. 

5:08 

And so, that's what.So the immediacy or the lack of uncertainty.So, in some ways that uncertainty provides a little bit of comfort or at least some distance from the action of withdrawing or term or shutting off and the actual patients demise the other question that Gets raised sometimes particularly in the literature is in what way is a pacemaker different than an implanted organ or a transplanted organ? 

5:40 

At what point does something implanted into your body?That is necessary for your biological function?When does it become part of you?So, for example, we don't, you know, turn off or terminate or, you know, shut down anyway. 

5:58 

It, it organs transplanted, organ.So some of these kidney, we're not going out going around turning that off, but it's so, so, I mean, there's definitely some differences, but I think it's it raises some interesting concerns, particularly for people who haven't thought about, who don't deal with the withdrawal or withholding of life-sustaining treatment, as commonly as it is done in like an ICU setting. 

6:22 

So a pulmonologist and I see you pulmonologist is pretty Experienced in with hot withdrawing or withholding a ventilator and seeing how that process plays out.It's less common.I think for a cardiologist to be asked to trot off a pacemaker. 

6:42 

I'm sure that's true, right?We do terminal excavations, quite frequently and it might just be that the cardiologist is Raising this because they're not doing that sort of thing.They're not taking away treatments that lead to death very often at all and so it feels different to them, they haven't gotten used to it. 

6:58 

I mean For Better or Worse, they're just not as experienced with that, but they're you're right about the immediacy.That feels very immediate and so that can feel pretty weird.It can feel like killing even if we might agree, ethically, it's not.I actually, I mean, I just make the case. 

7:14 

I don't think it's ethically, killing.I don't think it's equivalent to killing it.Is the you are actively doing something that cause Ali is associated with the death.But we try to justify these kind of All withdrawals of treatment by saying it's not. 

7:32 

It's the technology that was keeping them alive and we're merely withdrawing the treatment.The question though about the organs is so interesting because of course we would never equate like a human organ transplant with a medical technology that we could just deactivate.And in some ways that's may be merely because it's not something we can easily deactivate. 

7:53 

You'd have to like go in surgically and remove an organ, which is pretty different than like waving a magnet over.A Pacemaker.Isn't that how you deactivate it?I think, I think that's generally.It's some sort of external a wand, or a magnet or something like that.That is programmed to shut off the to shut it off. 

8:11 

Yeah.It's and that's, I mean, there's that movie from, I don't know.Maybe the mid-2000s called Repo Men.Did you ever see that movie?I've never seen it, but I know the movie, right?Yeah.So the idea, you know, just a little bit of background the movie.It's a, it follows these Folks whose job it is to go and reclaim surgically brutally transplanted. 

8:36 

Organs if folks who got the organs are unable to maintain their payments.So if they basically default on their payment for the organ, transplant procedure, then they go into default and just like you would have your car repossessed if you don't pay the loan on it same thing happens. 

8:58 

But so So that's kind of the idea, but if we start thinking about pacemakers and organs is being different, which I, you know, obviously that that is the case.But there are other things that we do medically, that maybe are a little bit in more in between like for example you and I have talked a lot about deep greens, brain stimulation. 

9:18 

So deep brain stimulation is where you go in and put, you know, very precise, electrodes and wires and such an even like a battery pack.Sometimes in implanted and at what point if ever does that device become so integrated into the individual that it becomes part of them such that you can't remove it, right? 

9:43 

Yeah.Well and sometimes deep brain stimulation is called like a brain pacemaker.So because it's firing in ways that may be more like a defibrillator would, but or maybe more like a pacemaker.Actually think it's a better analogy to a pacemaker.I haven't heard people claiming at this point, it may be just because it's pretty new that it's so integrated into your body that it could never be switched off. 

10:06 

But that might be the case, one day, I mean, I feel like I talk to people with various disabilities who use Prosthetics, who do consider those Prosthetics part of their body, like, it wouldn't be something, you could just take away from them.This came up during covid.I remember, when people were very afraid that if they went to the hospital with covid, their Ritual ventilators. 

10:30 

So people who need kind of breathing machines all the time that those would be taken away from them and used on other patients as kind of a triage.If folks thought they they individual wasn't really benefiting from their own breathing machine.And that really scared people and the claim was that it's part of my body. 

10:48 

It's not something you can just take away from me and give to somebody else.And so there is this kind of fine line between just because it's a machine, doesn't mean it's not part of your body.But it does seem like there's something pretty different with a transplanted, organ like ontologically. 

11:07 

Then a pacemaker.It's hard to kind of pinpoint.Maybe somebody at one of our good philosophy.Friends can come up with a schema for us and it can't.But it can't be simply as easy as one is like from a human to human.And the other is a machine like that that won't hold up. 

11:23 

I don't think right because we are you know moving towards a Ality of transplanting, non human organs into individuals, whether they're xenotransplantation, which means from nonhumans into humans like a pig heart, for example, or pig. 

11:39 

Valves, but also like genetically engineered or fully mechanical organs being implanted.And so for example a total artificial heart for that is medical technology that is exists and is available and people receive it. 

11:59 

But the process of doing that is you actually remove the person's disease heart and put in a fully functional mechanical heart, it does that become part of the person to the point that it's you, I don't know. 

12:16 

It just gets it feels very sci-fi sometimes but also maybe we're just overthinking this.Well, that's what we do is bioethicist as we open.That's true thing.That's and then try to come up with simplistic policies that work for everything. 

12:35 

Yeah, yeah.So I don't know where the line is.But so what did you say?Did you say it was permissible to deactivate the pacemaker?Yeah, so that was the recommendation was we talked a lot about the difference between You're actively killing somebody and what that would look like. 

12:53 

And so the clinician who I was talking with, was using some terminology inconsistently or kind of misusing some terminology and unhelpful ways, like physician assisted suicide.For example, thought that he was being asked to help an individual commit suicide, which is a completely different type of issue or that it was euthanasia, some sort of like See Killing. 

13:19 

And that he was his medical expertise was being co-opted in a way that was inappropriate.And so, kind of talk through all of those issues and those topics and I think at the end of the day, he was comfortable doing it.But only because there was still some a little bit and more ambiguity than he, let on it the beginning about whether or not the person had an underlying heart rate. 

13:42 

So it was actually suggesting so because there was the he felt that there was some potential.That when he turned off the pacemaker that it wasn't going to be an immediate Flatline that that ambiguity or that uncertainty was comforting for him. 

13:58 

Hmm I can see that right?It feels a little less like direct killing.Yeah.If you allow sort of the natural process to linger and then happen, what feels like more on its own.Like, it feels less causal.If it doesn't immediately happen and I think again, ethically would say that's that's not important difference. 

14:19 

In theory.But in practice to the person doing it it might feel important.Yeah and oftentimes we're as clinical Ephesus put in a position where we are trying to reassure professionals that what they're doing is okay, right? 

14:35 

That it's not you're not actually killing your patient that here's how you can understand or think through this processor, what's going on in order to give them some comfort.But and I was I think I was successfully able to do that in this particular case.But Man, it's set me down, a couple of different rabbit holes, and I've been annoying my colleagues with wait a second. 

14:56 

What about this?What about this?What about this about this issue of pacemakers?Which it was kind of 2010, 11, 12, there was a kind of a rash of papers talking about this and I don't know, maybe it's time to re address those questions that were raised. 

15:14 

Well, do you think anything new has come of this question?Like is there any reason that it needs to be thought about a new other than it's happening still and and it's still making people uncomfortable or is there something different about Pacemakers in the last 10 years that warrants a new investigation in my mind. 

15:30 

It's not that the pacemaker itself has changed it's that there are so many other technologies that are either more or less like an implanted pacemaker like deep brain stimulation.For example that maybe the whatever framework was used to make it make sense 10 or 15 years ago Maybe we need to readdress that, that maybe there are other things are other ways to look at it. 

15:53 

But yeah.So that's what I'm obsessed about this week.Yeah, that's a good one.I mean, we don't want to let people feel like they're killing their patients, right?And I know that sometimes will use this concept of double effect to talk about it to talk to say, you know, it's not you, that's killing the patient, it's their disease, that's killing them, right? 

16:12 

There's a reason this patients heart stopped actually.The only reason they're still alive at all is because of this technology and that might not be what they would have wanted.And so it's not you doing it, you know, initially when I teach about double effect, my students are often Like that just sounds like a weaselly way to, you know, say what you're doing is actually right when it's actually wrong, but I don't think that's right. 

16:34 

I think that there is an important difference between saying, you know, this thing is killing your patient.Versus you're removing the thing that is, you know, sort of prolonging their death in unreasonable, burden, some ways and you're allowing the disease, the underlying disease to be the thing that allows them to die. 

16:55 

Versus, you know, sort of prolonging that with a technology.So I think it is important to have those differences but at the same time like you said a really important job of the clinical ethicist is talking about moral distress and so insofar as the clinician feels like they're killing someone that obviously is going to lead to some moral distress, if you feel like you're killing your patients unless you're like a sociopath like most Physicians, don't want to kill their patients. 

17:22 

So or you know, unless it's in some parameters.Of Legally acceptable physician Aid in dying but most are not trying to kill their patients.And so they need to like be able to Think Through the differences and that's really important because otherwise we would be vitalists. 

17:37 

Otherwise we'd force all of our patients to remain on all the technology ever to sustain a heartbeat.Simply because we think everything else is killing and I hope we would never get to that point.We need to allow patients to die.It's everybody dies. 

17:53 

And if, you know, we don't want to keep people.In states, where it's just a bunch of machines pushing blood through their bodies.That's not how anybody wants to.That's not really living perhaps.Yeah, and I think from if we're focusing just on the pacemaker issue, there's a difference between turning off a pacemaker that is continually firing with somebody who is otherwise clinically dead, right? 

18:17 

So or so, so far along the pathway towards Death, that the firing of the Pacemakers actually harming them causing harm right perpetuating suffering, so that's kind of one end of the spectrum.The other end of the spectrum might be an otherwise, healthy individual walks into a cardiologists Outpatient Clinic and says, you know what? 

18:40 

I'm just, I just go ahead and shut this off.I'm done, right?So being completely, that's the hard case.Yeah, yeah.And and being, you know, an obvious case and man, the more, I think about it the more I You know, so for me like the one of the analogies that we are thinking through with my, you know, my my colleagues was, what about contact lenses. 

19:04 

Like at what there's like glasses, there's contact lenses.There's surgeries you can do like, at what point does that become?Is it because it's so necessary for me to live in the world being able to see well that those contacts are more part of me than they're not part of me. 

19:22 

Is it something about being inside my eye?Why not?But like on the surface of my eyelid, or My Lens wear glasses and contacts are different in some way or should we think about them the same or I don't know, it's a great ski. 

19:37 

These are great spitting.Great philosophy questions, right?Like, what is your body and it's not as simple as you might think.Like I think the more I think about these things I get in the exact same head space of like well what is my body?What is it my body?Like when I'm pregnant is that is that baby? 

19:54 

My body?Is it not?My body is my yeah my contact lens.What?If it's a surgically implanted contact lens, is that my body now, these are great questions, and does it have to be inside me to be my body?Can it be an Tension of my body.These are these are really good questions. 

20:09 

Yeah.So if I do some body modification and have like no piercings or some sort of implants that change the way my face looks, it does that become part of me?Does it mean?Yeah.And what about like nanotechnology, it's things that like devices that are. 

20:26 

So my very very very small and can like actually go through your circulatory system.Are those Foreign, are they part of you?Does it depend on whether there's an immuno reaction to it?I don't know.I What if and if they're not part of you, then what about our whole microbiome? 

20:44 

Like more of our cells are not human than our human and so if we were to say like nanotechnology is not part of us, then how do we account for all the nonhuman stuff that's already inside of our bodies?Yeah, there is no person.Devon we are, we are, we are So anyway, so that's that's what I'm obsessed about this week. 

21:07 

It's a peacemakers, it's a good one.Let us know what you think, what, what is our body if I would?I put the listeners out there, we know they can give us a good definition.What's part of our body?What's not?What's a machine?