Life and Death Choices

Medical ethicist Courtney Campbell deals in thorny questions. If there’s a shortage of chemotherapy drugs, for example, how do you ration them? Who receives a flu vaccine if there isn’t enough to go around? When should medical treatment be stopped and death allowed? Finding answers to these seemingly intractable questions, though, is critical to developing fair medical policies.

Campbell, who is the Hundere Professor in Religion and Culture in the School of History, Philosophy and Religion, has been pursuing these questions since he was in graduate school at the University of Virginia in the late 1980s.

Courtney Campbell

Courtney Campbell helps hospitals decide how to answer challenging questions about medical treatment.

After graduating, he worked for the Hastings Center, a medical ethics think tank in New York, and served as a consultant on ethics committees under both the Clinton and Obama administrations.

In Oregon, Campbell has worked with hospitals and hospices — especially Good Samaritan and Benton Hospice in Corvallis — where issues arise around uninsured patients, as well as patients who don’t have a surrogate to make decisions in case they cannot make decisions themselves. He has also written about Oregon’s Death with Dignity Act and the Oregon Health Plan.

Here, Campbell talks about what an ethicist’s job is, what makes Oregon a fascinating case study and what is the role of social justice in medicine.

How did you become interested in medical ethics?

When I was in graduate school in the 1980s, there was an explosion of interest in medical ethics. It was the era of the first in vitro fertilization and open heart transplants. AIDS had just emerged. There was a public immediacy to these issues.

In Virginia, I was involved in some of the cases that came before the hospital where I volunteered. These weren’t abstract subjects. People were making decisions about whether they should stop medical treatment or whether they should ration intensive medical technology. There was the intellectual fascination, but also I saw that people’s lives were at stake.

I moved to Oregon in the early 1990s because the state was facing some interesting questions, like how to set up a universal health care system, which has not happened, and death with dignity. I sensed that Oregon would be a really good place to go to keep my intellectual interest but also allow me to affect real policy.

How has some of your work in Oregon affected policy?

I am on the ethics committee at Good Samaritan Regional Medical Center here in Corvallis. When the Oregon Death with Dignity Act was finally approved, the hospital system decided it should not be allowed at hospitals, since the law actually says this can’t be carried out in a public setting. But we needed to determine whether our physicians could provide the consultation and write the prescriptions for the drugs. We also needed to determine if they could opt out. We crafted a policy to address those issues.

I’m also on the Ethics Task Force for the Oregon Public Health Division. About four years ago, we took up the issue of a flu pandemic, which was extended to rationing in the event of a big earthquake. What should be the priorities in this catastrophic medical situation? Do we give special consideration to the governor or health care professionals? Do we put all our resources into Portland, or do we send them to the rural parts of the state?

In these cases, our responsibility becomes setting up concrete guidelines and an ethical framework. That’s where I can help out, with a set of values we want to see in practice and then a guide for the heads of practitioner organizations.

What kinds of principles guide you in these situations?

Ethics for me has always been about making sure we’re asking the right questions. Then we work with the principles: respect, justice, non-harm, benefit and professional integrity. We then test the policy with principles of practicality, publicity, collegiality and reversibility.

That means we need to challenge the perceived wisdom we get from political and medical authorities. Ethics is often seen as troubleshooting or problemsolving to find a solution. What are the questions we need to ask a hospital administrator who needs to cut costs, as difficult as those questions may be? What do they need to hear so they don’t lose touch of their ethical bearings? Sometimes we need to ask these questions more than at other times.

What kind of times are we in?

One thing you can’t ignore in the U.S. is that we’re a market-driven economy, and so health care is viewed — wrongly in my perspective — as a commodity. When I first arrived at OSU in 1990, we used to talk about a physician-patient relationship. Now it’s provider-consumer. We’ve set up this basic relationship in medicine as a consumer transaction. It brings in the market as an overarching mechanism to determine how much is going to be paid, what your co-pay is, how long you get to see the doctor for. That’s part of our economy, and I’m not sure if it has to be part of our medical care delivery system.

Most hospital administrators are trained in corporate business, so they approach care from a corporate consumerist model. You’re almost not dealing with the ethics of medicine, but the ethics of business, and there’s not necessarily a code of ethics for business.

Does this disparity cause issues when it comes to treatment?

On many occasions, I think I will have an impact on hospital administrators, but most of the time you’ll have a bigger impact on individual physicians. I think hospitals and medicine have generally tried to make sure to not ration at the bedside, no matter what structural inequities might exist. It would create too much of a conflict of interest for the physician. Largely there’s kind of a buffer, and physicians are not directly confronted with that.

Ethicists help create that buffer. And the role is becoming much more formalized. One of my graduate students just got hired as an ethics consultant. What used to be a volunteer job has now become a formal position in hospitals.

Story by Joe Donovan

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