One Rutgers, A World of Discovery: This story is part of an ongoing Rutgers Today series looking at emerging collaborations, across a wide range of disciplines, at the new Rutgers.
A 92-year-old hospital patient with a serious blood infection is unable to communicate. She has no advance directives and her only relative declines to make decisions about her care saying, “It is up to the Lord.”*
The medical staff is seeking guidance from the hospital ethics committee: Should doctors place limits on therapies that cause pain and suffering? How do they determine the goals of care when the patient cannot make decisions and a surrogate won’t participate?
Medical professionals wrestle with these questions every day. The difference here at Robert Wood Johnson University Hospital is that Rutgers undergraduates are sitting at the table.
Eric Singer, a urologic surgeon at Rutgers Cancer Institute of New Jersey and a faculty adviser to the Rutgers Bioethics Society, an undergraduate student club, is inviting students to these monthly meetings to observe and to learn – part of a new initiative to raise awareness of bioethical issues across Rutgers and make ethics education available to a wider variety of disciplines at the undergraduate, graduate and professional levels.
“It's critical for students, especially for those who are thinking about the health professions, to see the ethical dimensions of clinical decision making – and the problems that come up routinely at a large university hospital,” says Singer, who is also an assistant professor of surgery at Rutgers Robert Wood Johnson Medical School. “There is a big difference between reading a textbook and seeing a health care team struggle with the facts of a case and make a recommendation or decision that will have real consequences.”A few miles away, Francis Barchi, an assistant professor in the School of Social Work, is meeting with first- and second-year medical students. They are gathering over pizza to discuss a real-world case in which a medical team in a third-world country has only enough medicine for a portion of a village being decimated by an infectious disease.
Barchi, who teaches an undergraduate course on global health at Rutgers and a doctoral course on research ethics and integrity in the social sciences, has led this exercise many times. She says it never fails to unnerve first-timers. “The case forces students to put a value on different categories of people, like women, children and old people,” says Barchi, who is the wife of Rutgers President Robert Barchi. “For the first time, one of the students stopped and said, ‘I’m not comfortable with this.’ That’s what you hope for – to make students aware of a moral imperative they’ll have to grapple with as health care providers. It’s part of the learning process.”
An Integrated Approach
Singer and Francis Barchi, who both arrived at the university during the summer of 2012 as Rutgers was preparing to integrate with the former University of Medicine and Dentistry of New Jersey (UMDNJ), come from different backgrounds. He is a surgeon with an interest in clinical bioethics; she researches women’s health in southern Africa and is interested in ethical challenges in global health training and responsible conduct in research. They have a common goal: to expand bioethics education at Rutgers and build an integrated approach to ethics at the university from which all disciplines would benefit.
The university is meeting the requirements in research ethics, they agree. As mandated by federal law, Rutgers has an Institutional Review Board charged with ensuring ethical conduct for research involving human subjects and protecting their rights and welfare.
But, they say, they’d like to see Rutgers, which turns out undergraduates for its own medical, public health and nursing schools, go well beyond compliance.
The field of bioethics – which took off in the 1970s as society began to wrestle with issues like stem cell research and end-of-life care – is multidisciplinary, incorporating principles from diverse disciplines.
“We have to expand what we think of as medical to include cognitive science, clinical psychology, philosophy, theology, social work, nursing, pharmacy and genetics – any discipline involved in research,” says Barchi, who like Singer has a master's in bioethics. “We have a world-class philosophy department that thinks about ethical issues, but not in an applied way, and a new partner that has to make ethical decisions every day. The possibility of putting these things together is huge."
A Health Sciences Working Group
Barchi and Singer have spent the last year identifying opportunities to support the teaching of bioethical ideas, principles and theories at all levels, from undergraduate studies and continuing education to consult services for faculty and working health professionals.
The first step was the creation of the Ethics in the Health Sciences Working Group, a loose confederation of faculty drawn from the humanities, social sciences, life sciences and the health professions gathered under the umbrella of Rutgers’ Institute for Health, Health Care Policy and Aging Research. The group, comprising about 15 members, including Singer and Barchi, is exploring ideas that could lead to a fully integrated, universitywide program in ethics education, research and practice in the health sciences at Rutgers.
“We have an opportunity to reach students early and have a greater impact on how medical students, residents, fellows, nurses and clinicians approach their work,” Singer says.
The group’s early efforts are focused on developing innovative curricula in ethics education in the health sciences at the university, building on new synergies created by the integration of UMDNJ and Rutgers. Members are asking questions like: What are the attributes of an ethical practitioner? What is being done at Rutgers Biomedical and Health Sciences (RBHS) and elsewhere at Rutgers to enhance these attributes in students and trainees? What opportunities could be made readily available by capitalizing on new relationships made possible by integration? What might an ideal ethics education platform look like and what resources would it require?
Once fully constituted, the group will include faculty from all the schools within RBHS, the Edward J. Bloustein School of Planning and Public Policy, the Graduate School of Applied and Professional Psychology, the School of Arts and Sciences, the School of Engineering and the School of Social Work. A preliminary report is expected later this year.
Part of an Arts and Sciences Education
Matt Matsuda, dean of the honors program in the School of Arts and Sciences at Rutgers, believes the vision of an integrated approach to ethics education reflects the recommendations of the Presidential Commission for the Study of Bioethical Issues created by President Obama in 2009, which views a foundation in bioethics as an integral part of a liberal arts and sciences education.
As a faculty adviser to the Rutgers Bioethics Society for the past three years, Matsuda has seen a growth in diversity of members’ disciplines – with majors ranging from science and engineering to philosophy, law, psychology and the humanities. The society, a group of about 40 undergraduates, publishes an academic journal and hosts a spring symposium, examining such topics as face transplantation and the future of end-of-life issues.
Today, with the increasing complexity of medical care and technology – and confusion about how institutions, practitioners and patients should interact to benefit all parties – Rutgers is playing a strong role in developing ethical foundations for students and trainees to think sensibly about issues that don’t have just one answer. “We need voices from all sectors,” Matsuda says. “The students are united in their understanding that cross-disciplinary knowledge and skills will be essential to address the complex bioethical decisions of the future.”
Danika Paulo, a second-year student at Robert Wood Johnson Medical School who co-directs the international health interest group, has spent summers as a volunteer at a hospital in Trujillo, Peru, and as part of a medical team in the Himalayan region of India setting up health clinics in remote villages.
Paulo would like to see more coursework at Rutgers to help clinicians-in-training navigate ethical quandaries, including electives in global health training. “In unfamiliar cultures the challenges are even more complex," she says. "For example, whose cultural norms should guide decisions about health care and treatment plans?"
Until participating in the case studies with Barchi, Paulo had little exposure to ethics discussions. Some concepts were introduced in a “Patient-Centered Medicine” course focusing on improving patient-physician interaction, but bioethical issues weren’t touched upon in lectures or discussions.
“The way Dr. Barchi’s sessions work is that we discuss a hypothetical case, divide into small groups, come up with solutions and then compare and contrast answers. It’s difficult, intense and stimulating but a great learning experience,” Paulo says. “It’s through discussions like these that we develop the kind of critical thinking that is key to being a good doctor.”
*The facts of this case have been changed to protect patient confidentiality.
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