Title:Finding the ‘right and good healing acts’

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.”

Sheehan works alongside Sulmasy and Sotomayor in the Ethics Consultation Service, which employs what they call the Pellegrino ethics workup, grounded in Pellegrino’s fundamental question: What is the right and good healing act for this patient?

“So we first consider the right thing to do,” Sotomayor says. “What is the treatment option that in clinical judgment of the physician is most likely to benefit the patient?

“Then what is the good?” she continues. “Dr. Pellegrino explained to us that there were four levels of good that we have to look for when we’re caring for the patient. At the lowest level, we have the biomedical good.

“The second level is what the patient considers to be good for him or her. In this level, you take into consideration important things such as the cultural background and the family of the patient. As a patient, you bring a lot of yourself to the table, who you are and what you believe,” Sotomayor says.

“Then you have the third level, which is the protection of the dignity of the human person. And then the fourth level would be seeing the patient as a transcendental being. We think that spirituality plays a role in making these decisions.

“When we use these tenets, it is easier for us to discern what is fair and what is just.”

Preparing the next generation

The Pellegrino Center provides a wide range of programs for students and the broader community, including offerings in Catholic clinical education and neuroethics. In addition, it sponsors the annual Pellegrino Symposium and the Harvey Lecture, endowed in honor of John Collins Harvey, a founding member of the center and close colleague of Pellegrino.

The center also is responsible for bioethics education at Georgetown University School of Medicine and in the residency programs at MedStar Georgetown University Hospital in addition to publishing a monthly newsletter for hospital staff, covering topical issues.

In 2019, the center established the Pellegrino Student Scholar program, an initiative designed to carry forward Pellegrino’s legacy to the next generation of health care providers. The program includes both medical and nursing students.

“One medical student and one nursing student would pair up each week to lead a discussion on different ethical problems, such as futility of care and end-of-life issues,” says Casey Haldeman (G’21), who was a Pellegrino Scholar while enrolled in the Clinical Nurse Leader program at the School of Nursing. “I spoke about how clinical ethics apply to all different kinds of health providers.”

Haldeman cites the issue of informed consent as an example. “What is the nurse’s responsibility in regards to consent? We’re witnessing what the doctor is telling the patient, and making sure that the patient understands what they’re consenting to. So there are two different roles there.”

For her culminating project, Haldeman worked with Sarah Vittone, an associate professor in the School of Nursing and member of the Ethics Consultation Service. “I did a reflection on clinical and nursing ethics through the pandemic, comparing and contrasting Dr. Pellegrino’s philosophy with Dr. Patricia Benner’s nursing theories—looking at the fact of illness, the trust of the patient, and the virtue of the provider.

“For the two years of the pandemic, nurses were the superheroes,” Haldeman said. “How do we lean into this new value in the nurse? How does trust in the physician translate into nursing? What kind of virtues make a good provider?”

Now a labor and delivery nurse at MedStar Harbor Hospital in Baltimore, Haldeman continues to use the knowledge she gained as a Pellegrino Scholar in her practice. “It comes through in something as simple as a birth plan,” she says. “If a mom wants a more natural birth, it may conflict with certain standards of care in the labor and delivery unit. So balancing the mom’s request with the plan of care that the doctor is prescribing can be a difficult area to navigate.

“I care for a very vulnerable population, so I make sure that the patient feels understood and that I’m advocating for them.

Theory and practice

Especially because it is a relatively new field, the discipline of bioethics continues to evolve through the interplay of theory and practice.

Daniel Sulmasy, for example, recently conducted a series of studies on surrogacy with colleagues from Johns Hopkins University in what they called “the bioethics version of The Newlywed Game.”

“Theory predicts that when a patient can’t speak for himself or herself, and we still want to recognize the patient’s autonomy, that we would ask a surrogate decision-maker what they think the patient would have wanted,” he says. “That leads to an empirically testable question.”

The researchers asked individuals acting as patients what treatment they would prefer, then asked their surrogates to predict their decision. Their predictions were correct in two-thirds of the cases.

“That’s far from perfect,” Sulmasy says. “So the question goes back to theory. There’s an edict derived from the philosopher Immanuel Kant, that ought implies can—if we make an ethical obligation it requires that people are able to carry it out.

“If it turns out that people really can’t do this with such accuracy, the question arises: Do we need to rethink what it is that a surrogate should be doing? Should they be trying to do the ‘Vulcan mind meld’ like Dr. Spock in the old Star Trek TV show, extracting the autonomous preferences in the comatose patient? Or should they in fact be talking with physicians and nurses about the values and preferences of their loved one and then jointly coming up with a plan?”

“So that’s a way in which theory informs practice, practice informs theory and corrects it, and then theory feeds back to informed practice,” Sulmasy says.

Georgetown’s bioethicists are also actively engaged in discussions about the discipline of clinical bioethics itself. “The field is growing, and I think the need for it is becoming more evident as we grow,” Sotomayor says. “There are reports in the literature that an early ethics consultation can reduce hospital length of stay, for example. “The challenge is, how do we make sure that we provide the same level of practice everywhere, not just in academic institutions? How are we going to provide ethics to that rural town in the middle of nowhere?”

The current certification process, a multiple choice exam focused on procedure, is a subject of intense debate, Sotomayor notes. “The process comes with a lot of growing pains. It’s hard to claim that someone is an expert in ethics. In so many different ways, you can’t really standardize it.”

21st-century leadership

A half-century after helping to pioneer the field of bioethics, Georgetown is now poised to assume a new transformative role with the creation of an innovative collaborative structure, the Georgetown Emergent Ethics Network.

“It includes the Pellegrino Center, the Kennedy Institute, the new Environmental Justice Program, and the developing Center for Digital Ethics,” Myles Sheehan says. “Not only are new ethical issues arising in each of these four think tanks, the overlap is surprisingly large.

“If we think about the environment and the carbon footprint of health care, it’s pretty big. What can we do to reduce that?” he says. “And if we look in terms of broad justice, there are people who are suffering health problems because of changes in the environment. These would include things like the development of heat islands in areas of cities where the people are usually poor and lack good air conditioning and green space.”

Sulmasy, who is serving as the first director of the Emergent Ethics Network, points to the COVID-19 pandemic as a prime example of the need for interdisciplinary collaboration to solve contemporary ethical problems. “If you were to think of the three most important issues at the interface between technology, society, and ethics, I think anybody would say they are data, the environment, and biomedicine.

“COVID-19 happened as an environmental problem—how we relate to animals. It was transmitted environmentally through jet travel and spread locally through air conditioning systems,” he says. “And there are data questions. The algorithms we used to predict who should get the last ventilator may in fact be infected with implicit biases we’re not aware of.”

The four centers will collaborate in teaching and research, and plans call for the creation of joint professorships in such areas as medical ethics and environmental justice, as well as shared fellowships. “We’ll work together to try to solve cutting-edge problems in the interdisciplinary way that’s now necessary in the 21st century,” Sulmasy says.

Deep roots

In all aspects of teaching, research, and patient care, Georgetown’s approach to clinical bioethics is reflective of the university’s Catholic, Jesuit heritage. “One of the things I try to emphasize, without being preachy, is that being a Catholic and Jesuit medical center is a way in which the voice of that tradition helps to provide excellent care,” Sheehan says.

“Many things that are forces in contemporary society— the push for justice, equity, and diversity—you can find deeply rooted in Catholic teaching about human dignity,” he continues.

“And so to treat the human being as of exceptional worth is a way in which we can sometimes bridge differences in a pluralistic society, while honoring the tradition that Georgetown was founded in and continues today.”

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The Kennedy Institute of Ethics, Ethics Consultation Service, and Emergent Ethics Network are just a few of the many ways Georgetown is building a stronger, more ethical society, and becoming the university we are called to be. Learn more at calledtobe.georgetown.edu