Georgetown’s leadership in the complex field of medical ethics
A patient in critical condition refuses treatment, adamant that she be allowed to leave the hospital—even against medical advice. Staff doctors and nurses repeatedly talk with her about the risks. Finally, her attending physician says bluntly, “If you go home, you will die within a week or two.” Still, the woman remains steadfast in her position.
Enter Claudia Sotomayor, chief of the Ethics Consultation Service at the Edmund D. Pellegrino Center for Clinical Bioethics, called in by the patient’s care team. “I don’t come with an agenda,” she says. “I just want to make sure that I listen.”
The consultation service is available to treatment teams and families at MedStar Georgetown University Hospital 24 hours a day at no cost for each consultation.
“It took about 30 minutes for the patient to warm up to me,” recalls Sotomayor, an assistant professor of internal medicine. “After an hour or so, she revealed what was driving her decision.”
The woman, a single mother with two teenage girls, needed to pay her rent that day. If she didn’t deliver the check, she feared her family would be evicted. Sotomayor immediately called the hospital social work department, who contacted the landlord. Assured that her daughters were safe, the patient agreed to the treatment.
Ideas matter
Every day, in clinical settings across the world, health care providers confront similar ethical dilemmas. What if a patient has religious beliefs that preclude a needed blood transfusion? How do you treat an incapacitated patient who lacks a surrogate decision-maker? When a young resident disagrees with an attending physician’s course of treatment, how do you alleviate her moral distress?
For more than 50 years, Georgetown has pioneered the development of an ethical framework to guide practitioners in resolving these kinds of complex questions.
“One of my mantras is that ideas matter and they have concrete implications,” says Daniel Sulmasy (G’95), director of Georgetown’s Kennedy Institute of Ethics (KIE) and Andre Hellegers Professor of Biomedical Ethics.
“There’s more to ethics than just being a practically wise and good person,” says Sulmasy, also a member of the Ethics Consultation Service. “We need those sorts of persons, but it is also helpful to have someone who knows the principles, so they can help clarify others’ thoughts, specify the range of views that might be acceptable or unacceptable—and then, as my mentor Edmund Pellegrino would have said, ask the question, ‘What is the right and the good healing act for this patient in these circumstances?’
“That should be the aim of all the clinicians involved, that should be the aim of the family, and that should be the aim of the ethics consultants.”
Foundational role
Georgetown’s foundational role in medical ethics began with the establishment of the KIE in 1971, through a gift from Rose Fitzgerald Kennedy and Joseph P. Kennedy Sr., that endowed two faculty chairs and provided seed money for KIE’s Bioethics Research Library, which today houses the world’s largest and most comprehensive collection of materials on bioethics.
“The faculty who have been here over the years have done enormous work in establishing the vocabulary of bioethics,” says Sulmasy, noting the publication of seminal textbooks, case studies, and treatises.
Among these are Principles of Biomedical Ethics, first published in 1979 by KIE scholars Tom Beauchamp (now retired) and James Childress (now at the University of Virginia), which introduced the core principles of medical ethics: autonomy, beneficence, non-maleficence, and justice.
“I can tell you that if there’s anything that any medical student in the United States and in many places around the world knows about bioethics, it’s those four words,” Sulmasy says. “And they came from Georgetown.”
The KIE has developed international reach through its annual Intensive Bioethics Course (IBC), established four decades ago. In 2019, the IBC was relaunched in collaboration with the Pellegrino Center, reflecting the course’s greater emphasis on clinical bioethics.
“It’s been remarkable how much impact this course has had,” Sulmasy says. “We’ve trained people who now lead bioethics institutions around the U.S. and overseas as well.
“When I was reviewing its history, I noticed a photograph of a student from the third or fourth year of the course. That person, Mark Siegler, has just retired from directing the MacLean Center for Clinical Medical Ethics at the University of Chicago.”
Dr. Pellegrino’s legacy
In 1983, the KIE welcomed a new director: Edmund Pellegrino, who had previously served as president of Catholic University. Over the course of his 65-year medical career, Pellegrino profoundly influenced the development of clinical bioethics through his scholarship and teaching.
Interested in remaining active in the clinical aspect of ethics, Pellegrino went on to establish the Center for Clinical Bioethics at Georgetown University Medical Center in 1991. In 2013, shortly before his death, Georgetown renamed the center in his honor.
“One very significant part of Dr. Pellegrino’s legacy was his way of looking at ethical situations that were embedded in the doctor-patient relationship,” says Myles N. Sheehan, director of the Pellegrino Center.
“He looked at what he called the internal morality of medicine—meaning that there were goods and ends you wanted to accomplish within that relationship,” says Sheehan, a professor of medicine and the David Lauler Chair in Catholic Health Care Ethics.
“The famous four principles are very important in this, but the most important elements are the recognition of the patient’s vulnerability, the doctor’s commitment to help, and then the process where you try to understand what is the most important healing decision for the patient’s good,” he says.
“So it’s more of a relational issue than a competing principles issue.”