The future of clinical bioethics
Prior to becoming an anesthesiologist, Alyssa Burgart trained in bioethics.
She now counts herself among a growing number of certified clinical bioethicists who help doctors, nurses, patients, and their families handle ethically complex medical decisions at the bedside. Bioethicists are critical to care, Burgart argues, helping patients facing difficult choices to clarify personal values and weigh a complex array of risks and benefits, as well as emotions and familial, cultural, and religious norms. While much of her work is in pediatrics and maternal-fetal cases, she also studies how moral distress and moral injury impact clinicians, contributing to burnout among doctors and nurses. Having a strong ethical community brings resilience to these challenging environments, Burgart tells host Russ Altman in this episode of Stanford Engineering’s The Future of Everything podcast.
Transcript
[00:00:00] Russ Altman: This is Stanford Engineering's The Future of Everything, and I'm your host, Russ Altman. Since we started this show eight years ago, it's become an archive of amazing and impactful work by my Stanford colleagues. Research is not something that just happens in the lab, and as you'll hear on this show, the research at Stanford can impact areas like health, technology, law, and business, and many other topics that can affect everyday life.
[00:00:23] We hope you'll tune in to learn more about how research has the potential to help your life and to help the lives of people you care about and your family and your community.
[00:00:32] Alyssa Burgart: When we talk about bioethics, we're talking about what are the values that are driving the decisions that we're making? So whether you're a patient and you're going to see your doctor or a nurse practitioner and you're trying to get some health information, you're trying to get some care, there's a lot of ethical issues that come up there.
[00:00:47] What are the risks and benefits of the medication that you're considering taking? What are the treatments that you're considering, and how do those fit within the things that matter to you in your life?
[00:01:03] Russ Altman: This is Stanford Engineering's The Future of Everything, and I'm your host, Russ Altman. I just wanna remind you that you should follow the show, press that button so that you get notified of all the new episodes the moment they come out.
[00:01:14] Today, Alyssa Burgart will tell us that bioethics is an important component of medical care. This is a specialty where people can help make tough decisions, end of life decisions. Should I get that procedure? I can't agree with my spouse or my family about how to proceed with my medical care. These are all questions that are not just medical, they're ethical as well. It's the future of clinical bioethics.
[00:01:38] Today, we're continuing our feature, The Future in a Minute. At the end of my conversation with Alyssa, I'll ask her some rapid fire questions, and she'll give me some rapid fire answers. And before we get started, please remember to follow the show. Press that button so you get alerted and you never miss The Future of Anything
[00:02:00] So when we go to a hospital, we expect medical professionals who have deep expertise in medicine, expertise about how to make treatments, how to do diagnosis, how to understand how a disease is likely to progress. But that's not the only kind of information we need. Sometimes in the hospital, we get difficult ethical and moral decisions.
[00:02:22] What do I do about my loved one who's in a coma and who doesn't look like they're gonna come out of it ever? What about my loved one or myself who is experiencing incredible pain that can't be controlled with any pain medication? Or there's a new procedure. Should I try it, or is it too risky? These are ethical questions.
[00:02:40] It's not just about medical knowledge. And guess what? There are trained professionals who are experts in what's called bioethics or biomedical ethics. How do we look at a situation medically, and how do we help a patient and their providers make the best decisions? Well, Alyssa Burkhart is a professor of anesthesiology and perioperative pain, and she is an expert on bioethics in addition to being a clinical anesthesiologist.
[00:03:06] She'll tell us how they run a consult service to help physicians who are in the middle of difficult situations and difficult decisions, how they make those decisions.
[00:03:16] Alyssa, you're an anesthesiologist. You practice anesthesiology, and yet a lot of your work is in the area of bioethics. How did that happen?
[00:03:25] Alyssa Burgart: Yeah, thanks for asking. I'm sort of a weirdo in bioethics in that I was a bioethicist before I decided to become a physician, which is not typical. And so my undergraduate degree is in bioethics, and I worked as a clinical ethicist at Cedar Sinai after college. And then I worked at UCSF to, in the, institutional review board doing a bunch of research ethics, and then I went to medical school.
[00:03:49] And while I was in medical school, I also got a degree in bioethics and health policy because I'm a masochist, and I didn't think that one degree was enough.
[00:03:56] Russ Altman: As a bioethicist, how the heck did you choose anesthesiology?
[00:04:00] Alyssa Burgart: I, I have thought, I thought in medical school about being lots of different things. I started off thinking maybe I'll be a palliative care doctor or I'll be an oncologist or I don't know. I was very, very close to applying to be a surgeon because I loved the operating room, and then I did an anesthesia rotation, like, on a lark. And very last minute, I'm talking like weeks before you had to submit your applications for residency, I switched because I had a, a wonderful, person who ended up becoming a mentor who was like, "Nope, you're one of us," and really taught me how.
[00:04:39] People joke that like, "Oh, all of our patients are asleep, so anesthesiologists don't like to talk to people." but I love, I get to have a first impression like multiple times a day. I get to meet people who are strangers. I call it talkesthesia. I get to talk to people and before I give them any medicines, I get to learn about them and, and, try to help provide a, a safe environment for them because I am a stranger when they meet me, and I need to not be a stranger, especially for people who are handing me literally their children.
[00:05:07] So yeah, it's, it's a wonderful job. I love the operating room. I it's like, I get to work with the coolest people and I meet lots of wonderful patients.
[00:05:18] Russ Altman: Okay, great. How can you give someone who doesn't think about bioethics all the time, can you give us a working understanding of what it means? Even ethics might be a little bit tricky for people to get their arms around, but certainly bioethics. So what are we talking about when we talk about bioethics?
[00:05:34] Alyssa Burgart: When we talk about bioethics, we're talking about sort of the, what are the values that are driving the decisions that we're making? So whether you're a patient and you're going to see your doctor or a nurse practitioner, and you're trying to get some health information, you're trying to get some care, there's a lot of ethical issues that come up there.
[00:05:50] What are the risks and benefits of the medication that, you're considering taking? What are the treatments that you're considering, and how do those fit within the things that matter to you in your life?
[00:06:00] Clinicians are also dealing with these issues where they're weighing the risks and benefits of treatment. And as I mentioned, I worked in research ethics before, and so when we're work-- much of bioethics, much of modern bioethics actually comes out of the origins of research ethics because human beings who are engaging in research deserve special protections, and there's a lot of ethical issues that come up there as well.
[00:06:22] So, you know, in a-- there are people in the hospital who say, like, I'm their, I'm their walking conscience, that they can, you know, reach out to me when they're struggling with a difficult decision that relates to the values that they're, they're trying to connect with, with the integrity of being a caregiver or with a family who's dealing with difficult decisions.
[00:06:41] And so, you know, in its most basic thing, if you imagine like, you know, the cartoons where you've got like the good character and the bad character, I'm trying to actually present both views and try to help people understand what are the complex trade-offs involved when you're
[00:06:56] Russ Altman: So you're both the angel and the devil.
[00:06:58] Alyssa Burgart: Yeah. That's my goal. To really try to present both.
[00:07:03] Russ Altman: Now, now you said that, you know, you said something about your colleagues think of you as like their their conscience, but now you certainly don't want physicians to outsource- their own ethical thinking. So how do you, so how do you manage that where you, you can be and you have skills and thoughtfulness about all of these issues, and yet you certainly wanna help your colleagues, like, raise their level. So how do you do that balance?
[00:07:25] Alyssa Burgart: Yeah. It's one of the things that's really fun about being a clinical ethicist is that, you know, when somebody reaches out to me, a lot of times they're, they're in some sort of a state of overwhelm. They're dealing with an issue that they've never dealt with before. It's something that's very complex.
[00:07:38] And one of the things that our ethics service does and that I've learned to do is how do I help take that complex thing that seems very unmanageable and help this person to articulate, like, kind of what boxes do each of these things fit in? Because some of it's, like, not a problem. You're doing a great job.
[00:07:54] You you should keep doing whatever you're doing. But then when there's areas where they're really trying to weigh how should they respond as an ethical physician, as an ethical nurse, as an ethical leader, how is it that I can help them to identify the values that are most important to them?
[00:08:12] How can they stay in alignment with their integrity while providing excellent care? And so certainly the goal is never to let people I don't wanna be, like, doing everyone's decisions for them. That would
[00:08:23] Russ Altman: Right
[00:08:23] Alyssa Burgart: ... very dysfunctional. But I do really enjoy working with, you know, people who are really deeply connected with how do I do the right thing when all the choices seem bad?
[00:08:33] Russ Altman: Now, you said ethical service, and I know a little bit about this, and people may be surprised. If I'm not mistaken, you actually are, like, a consultant. Like, when, you people know that we're in the hospital, and if you get, like, a fever, then your doctor might call the infectious disease expert to come in and write a note and evaluate the.
[00:08:50] And, and if I am understanding it, it's a very similar situation for ethics where they say it's not an infection, it's a hard problem where they feel this, this sense of, being overwhelmed. So could you walk me through, like, how do you get consulted, and then how does it work? do you, do you speak with the patient as well as the physician?
[00:09:07] It just sounds like a very interesting thing that I think would surprise many people.
[00:09:12] Alyssa Burgart: Yeah. That's, I think you've done a great job explaining, which good job. And we, we have a pager service, so we actually have people who are assigned to be the person you can reach if you are in a situation where you think there are complex ethical trade-offs. And so, we have services for both our adult hospital and our children's hospital, and so, I work on both of those, both of those services.
[00:09:38] And so, you know, for example, a clinician might send us a, a page or a message on our secure app saying, "Hey, I wanna talk to you about this particular patient's situation," and they do exactly the thing that they would do if they were consulting, let's say, a cardiologist or that infectious disease doctor.
[00:09:55] Russ Altman: Right.
[00:09:55] Alyssa Burgart: The person who calls us gives us a presentation about, you know, this is this patient, these are the conditions that, they currently are facing, and these are some of the things that we're struggling with in terms of how do we help guide decision-making, how do we help determine, how to, how to work with this patient or with this family in order to help them decide what's best for that patient.
[00:10:17] Russ Altman: Yes, yes. that really is great. And and is that routinely available in most hospitals, or is it kind of an optional thing that some hospitals do, some don't?
[00:10:25] Alyssa Burgart: It's interesting. There's a lack of uniformity, certainly across the United States. Stanford has been very, ahead in terms of being available to clinicians regularly.
[00:10:39] And we also, for example, document in the patient's chart. So we, you know, we meet with families, we meet with clinicians, we meet with administrators, and we actually document our recommendations in the chart, which also serves as education for people who weren't necessarily in those conversations directly.
[00:10:56] So for other parts of the country, different hospitals have different features. And in even the 20-plus years that I've been doing clinical ethics consultation, clinical ethics has gone through a big round of professionalization.
[00:11:10] So, just in the past few years, there's become a a national certification, for example, to be a healthcare ethicist. The Joint Commission, which is a accrediting body for a lot of, hospitals, requires that there be some mechanism to deal with ethics issues in a hospital. But in a lot of hospitals, it's sort of like a nice person who's willing to help have those conversations, and they might have a committee. We are very fortunate at Stanford that we have a, two very robust systems that are robustly supported by the hospitals because they recognize that there is a real value in helping folks to address the significant moral distress and moral injury that can come from being in these situations without support.
[00:11:53] Russ Altman: Yeah, that, that makes really good sense, and it's exciting to know that there's, like, a move towards a, a, a certification and making sure that the quality is quite good. Now, I know, of course, you can't talk about specific cases in detail and, give, giving names and addresses, but I would love to have, have a few example, consultations that you might get.
[00:12:13] Either ones that are kind of very illustrative or, or recently that, that they're on your mind, just so people can get a feel for the kinds of questions you get asked. They might be surprised.
[00:12:23] Alyssa Burgart: In my work at the children's hospital, it's always fascinating 'cause I love working with kids. I never thought I was gonna do pediatric ethics, by the way.
[00:12:31] When my very first job when I was at Cedars-Sinai, I thought that the, the, the ethics issues related to children were, like, the most tender. They were the most painful. You're, like, working with families of, of dying children, and I just thought, "Oh, I am never gonna do that." And then here I am running this clinical ethics program.
[00:12:51] Russ Altman: It's a specialty.
[00:12:51] Alyssa Burgart: Yeah, and I became a pediatric anesthesiologist after become... You know, I was an adult anesthesiologist, and I specialize in pediatrics. I love having those relationships with families. And, I don't know, there's, like, a special kind of person who's willing and not afraid to work so closely with families.
[00:13:06] Russ Altman: Yeah.
[00:13:06] Alyssa Burgart: And so in working with, with kids, we really get to see people from, I'm, I'm embedded in our maternal fetal medicine program. So for example, we hear about cases where a baby hasn't even been born yet, and there's families who are facing ethical questions about what treatments are not to pursue after a baby is born, for example.
[00:13:27] And then through the lifespan, and I really love, helping guide clinicians and families through how do we make developmentally appropriate decisions for these kids, and how do we include patients as they age in ways that empower them and to help them with their developing autonomy and so that they can have, be participants in their healthcare to the degree that they're, that they're ready to.
[00:13:52] And to also help support parents who are also... you know, parenthood, it's like the ultimate amateur hour, and then you add critical illness on top of that. You have families that are going through just incredibly intense experiences. And so I really appreciate, I especially love working with teenagers. I really like the opportunity to both empower teenagers to express themselves, as well as having their parents, kind of learn to help those teenagers really take the lead, especially when they're facing a complex illness.
[00:14:22] Russ Altman: Yeah, you know, I always, I always stalk my guests before I speak with them, and I know that you wrote a paper about a, I think it was like a, a pregnancy decision where the parents and the, and the, and the, and the I guess the new mom was, were at odds about how to manage the delivery and, and, that was very interesting.
[00:14:38] Alyssa Burgart: Yeah. It's, we're so lucky. Like, I, it's... I, I think when I tell people outside of medicine what I do or, you know, you're like in the neighborhood, it sounds terrifying I think to most people. Like, not only do I do this pediatric anesthesia thing, which also sounds scary, but the fact that we're the kind of people who really lean into that discomfort and lean into conflict rather than avoiding it.
[00:15:05] And for me, it's something that it gives me great meaning in my life, but it also really, I find it really empowering to be able to partner with patients, families, and clinicians who are just struggling with some terrible decisions.
[00:15:17] What treatment do I have after my baby's born? I didn't expect that I was gonna have to deal with this particular topic, and now I've gotta make life-altering decisions that are gonna completely change our family's lives. Working with families of, whether they're children or adults who, who are dying. How do I, how do I help highlight the agency of the person who's involved and really elevate the, the human dignity of every single person that we care for?
[00:15:45] Russ Altman: So, that's very important. And I wanted to ask you specifically about how, cultural differences factor into your practice. So as you approach a situation with a family, maybe they have a very strong faith, maybe they have cultural expectations or cultural beliefs about the role of medicine or pills in their lives.
[00:16:05] How do you navigate that? And, and, and I guess you're trying to help them make the best decisions, and, while also kind of, I guess, factoring in these kinds of considerations
[00:16:17] Alyssa Burgart: Yeah. It's, I always like to lead from a place of curiosity, and that's a skill that I have had to... Like, I am a know-it-all by my nature. Like, I am a know-it-all. That's why, like, I've made lots of decisions in my life. And so, I have really had to consciously, as a, as a communicator, be like, "Wow, you gotta tone that down." Yeah. And so I'm, I've really spent so much time, and we work with so many of our consultants to be like, "Okay, but, like, what if it wasn't about you?"
[00:16:44] And we work about that with, we work on that with clinicians as well to be like, okay, just let's be as absolutely curious as possible at, rather than judgmental. And I think that, you know, medicine, there's lots of think pieces right now about how medicine is in a crisis of trust, and there are many very important reasons why people don't necessarily trust doctors and nurses the way that they did in the past. And I think that it's so important that we lead by being trustworthy and by showing trustworthiness through our actions.
[00:17:15] And so, for example, you know, I kind of love it if somebody has really specific beliefs and they're willing to share them with me. One, it's, it's an honor for people to share the things that are absolutely most important to them in their lives and how it is that they're thinking about their decision-making.
[00:17:33] And it's also this, this dance of like, "Okay, I'm hearing that this is your value. How do I share this other information, or how do I facilitate a conversation with you and your clinicians who are coming from very different places? And how is it that we can try to really lean into that relationship rather than try to do what I think medicine has had a tendency to do, which is to, dominate?"
[00:17:57] Russ Altman: Yes. You know, I, I, I have training in as an internal medicine doctor and, and, and, and I remember, especially in the hospital, that, you know, the very difficult cases are often when the family itself can't agree on, on how to go forward. And so, maybe the patient is involved, maybe not, but it almost doesn't matter. They can, there can be siblings and parents and spouses and children.
[00:18:21] And so, it can be a huge orchestrated conversation, and I'm assuming that, one of your skills is doing all of that orchestration of the family and the patient, of course. And then there's all the caregivers who have their own set of, of opinions.
[00:18:35] And, and I, and I know from your writing that you actually consider all these perspectives as an important integration. So, like, how do you do that? Like, these are and they're also very often time-critical decisions. It's not like we seven weeks to to make this decision. So, how do you approach these consultations? And it, it must be, exhausting.
[00:18:55] Alyssa Burgart: it's, it's invigorating sometimes and I've, I've had to learn to, I always joke there's like an emotional hangover after you've done a really good job.
[00:19:03] Russ Altman: Yes.
[00:19:03] Alyssa Burgart: And, you know, being attentive to that. But one of the things that you just said, for example, like as being, an internist, I think it's funny that people who, who are afraid of taking care of children for whatever reason, they're like, "That's not my jam. I don't wanna deal with like kids." But it's these skills actually about family communication that I have found are the most transferable to adult care and can be such a powerful addition.
[00:19:28] Russ Altman: Wow.
[00:19:28] Alyssa Burgart: And it's part of actually why we've, really pushed all of our consultants to learn how to do consults across the age spectrum because families are part of these decisions in almost every aspect of life.
[00:19:41] We certainly have some patients who are estranged from their families or don't have, a lot of people to support them, in which case, the ethics committee steps in to try to act, act on those people's behalf. But when we're dealing with a family that has a lot of different opinions and let's say the patient's voice is not quite as, present because they're in a coma or they have a severe neurologic disorder or there's something else physiologically going on that prevents them from participating, we really try to again lean into that curiosity with these families of like, well first of all, who knows this person really well? And who can give us the most information on what this person might have wanted for themselves if they could tell us what they wanted?
[00:20:21] Russ Altman: Yeah.
[00:20:21] Alyssa Burgart: What do you think they would tell us? And, and tell us all about that.
[00:20:24] And I remember even from my very earliest experiences, you know, in, right out of college, helping to facilitate some of these conversations with a much more senior ethicist, that, you know, there's just families come in all shapes and sizes, and, you know, there's a lot of dysfunction that shows up when people are stressed, and they're someone that they love and care about presumably is the person who's in the hospital. And, like, we meet people on their worst days, and so I feel like the best that we can do, oftentimes when, when, as ethics consultants we're stepping into that conflict space, is, like, how do I stay emotionally regulated to hold the conflict that is happening here. And try to help people find the areas where, wow, you guys heard the same stories from this person. Let's talk about what that might look like in reality. And how do we make it so that we can really honor, again, the inherent human dignity of this person who's suffering, whether it's from a recoverable illness or not? How is it that we can walk that together?
[00:21:32] Russ Altman: You're listening to The Future of Everything. I'm Russ Altman, and I'm speaking with Alyssa Burgart. Don't forget, at the end of the episode, we'll have The Future in a Minute, where I'll ask Alyssa some rapid-fire questions and give, she'll give me some quick answers.
[00:21:43] We've been talking about bioethics and how it manifests in the hospital and in the clinic, and what the issues are that come up, and I wanted to move to, a little bit of more focus on clinicians.
[00:21:55] So, you write about something called moral distress and moral injury in clinicians. So can you unpack that? What, what is that, and why is that a topic of concern?
[00:22:05] Alyssa Burgart: Sure. I'll address, I'll actually talk about moral injury first just 'cause it's an older, it's an older concept. Really came out of military veterans and the fact that, you know, these people were coming back from war zones and had a lot of psychological symptoms that, you know, we talk a lot about PTSD now, post-traumatic stress syndrome, but what really pioneering psychiatrists and psychologists and chaplains who are working with veterans really saw, like, wow, people are having. They're actually having existential crises about who they are and where are they situated in the world in terms of their integrity having been exposed to war.
[00:22:43] Russ Altman: Huh.
[00:22:43] Alyssa Burgart: And so that's where the term moral injury comes from. And I think that in, you know, especially the, especially COVID is really where people started talking about moral injury more amongst clinicians.
[00:22:53] Russ Altman: So it's kind of an injury to their moral, kind
[00:22:57] Alyssa Burgart: Yeah ...
[00:22:57] Russ Altman: of network and system
[00:22:58] Alyssa Burgart: Like your, like
[00:22:58] Russ Altman: way of thinking ...
[00:22:59] Alyssa Burgart: like your deepest sense of who you are as a person
[00:23:02] Russ Altman: Wow. Okay
[00:23:02] Alyssa Burgart: ... and, and who you are in the world. And, moral injury can be caused by, you know, an action that I take. So, you know, and I'm certainly not gonna say that being a physician is the same as being in a war zone. I'm, I'm not saying that. But what we do have is, you know, do I have an experience if I make a medical error, how do I know how to trust myself again?
[00:23:24] Russ Altman: Yeah ...
[00:23:25] Alyssa Burgart: After I've made an error? And these are these deep sort of existential moral elements about who do I believe myself to be, and how, and where is the, is there a gap between who I desire to be, who I wish to be, and how I have shown up in a particular situation.
[00:23:41] And it may be that it's also from witnessing an event. You know, I witness someone being harassed. We, in, in healthcare, we witness a lot of violence. We witness the, you know, I I trained in, Chicago in an area where there was a, a lot of very violent injuries where we cared for people. And so, even just witnessing those things can be, can, can be beyond the fact that it's a very stressful experience. It can also be very, It can really disorder our sense
[00:24:12] Russ Altman: Yes
[00:24:12] Alyssa Burgart: ... of who we are.
[00:24:14] Russ Altman: Yes.
[00:24:14] Alyssa Burgart: And so I'm, I'm deeply committed to, as I've, as I've mentioned previously about when we're working with patients and we're working with clinicians about what are the values that are showing up?
[00:24:24] What, you know, is it, is it honesty? Is it, you know, safety? Are we trying to connect with, tradition, you know, in the in the sense of, of, for example, religious beliefs. So how is it that we connect those things that are most valuable to a patient and help them use those to reconnect to those, values when those values have been threatened or harmed because of an experience that someone has had?
[00:24:52] Institutional betrayal is a, is a major thing that can happen where, you know, if you feel that the, the organization of your hospital or your whatever the situation is, there's a policy or there's
[00:25:06] Russ Altman: Yeah, yeah
[00:25:06] Alyssa Burgart: ... a, a law. We have so many laws right now that the government is imposing that really impact how you can practice healthcare.
[00:25:14] You think about laws that have been, imposed that limit abortion care. You think about gender affirming care. People who are working, vaccines. I know that,
[00:25:23] Russ Altman: Yeah
[00:25:23] Alyssa Burgart: ... you've spoken, previously about vaccines on this show. So for clinicians who are working in these areas that can be very intense, and there's laws and, social movements that are really interfacing with what does it mean to be a clinician-
[00:25:40] Russ Altman: Yeah
[00:25:40] Alyssa Burgart: ...trying to provide excellent care. You can really have your, your morals and your, the, the deepest aspects of who you are challenged.
[00:25:48] Russ Altman: You know, one of the moral microinjuries that I that is, that I'm sure many clinicians would relate to and that I remember vividly are prior authorizations. When, when prior authorizations are denied by insurance companies because you've talked about it with the patient, you've kind of gotten the patient excited about this opportunity.
[00:26:06] You have think that you have an ironclad reason to get authorization for this test or procedure or whatever, and then the, the, the powers that be come back and say no. That really can be a, a, a punch to the gut. and when it happens constantly, it really can lead to all these manifestations that you described about, like questioning why am I doing what I'm doing? Am I being effective? You know, where, where is my, why is my worldview so at odds with, with, with these, the, these other folks?
[00:26:37] Alyssa Burgart: Yeah.
[00:26:37] Russ Altman: So what about distress?
[00:26:39] Alyssa Burgart: So moral distress, and this comes out of the nursing literature, in the early 1980s, and it's really interesting 'cause, the moral distress is this idea that I know the right thing to do, but there are barriers to me being able to do it. And again, that may be a policy, it may be it, that they might be external things. It's a law, it's a policy, but I'm trying to figure out how to overcome that.
[00:27:01] When it first, was described, it was really this idea from, from nurses, like, "Well, I've been, I've received a physician order that I feel is in conflict with this, this aspect of care that I think is really important."
[00:27:13] And it's really come to be, you know, expanded beyond that, where it's is it the organization? Is it something internally, like I'm not sure that I'm psychologically safe to be courageous in this, morally courageous in a particular space, and so how is it that we can help navigate that? So that's really, I think of it as a, a precursor to moral injury.
[00:27:32] Russ Altman: Yeah.
[00:27:32] Alyssa Burgart: And so, when we have opportunities to really give people the language around these topics, to be able to identify that they're not, like, this thing is really happening to them. You know?
[00:27:43] Russ Altman: Right.
[00:27:43] Alyssa Burgart: It has physical manifestations, it's existential manifestations. You know, your, your stomach might hurt because you're in this situation, and that these are all expected consequences of not being in alignment with who you're, the, the ethical being that you are intending to be.
[00:28:00] And so, when you talk, for example, about prior authorizations, and of course, this has only gotten worse and worse and
[00:28:06] Russ Altman: Yeah
[00:28:06] Alyssa Burgart: ... every single year. And so, you know, maybe, you know, you get through the first prior authorization and you're like, "Wow, that was, that was terrible and offensive, and I'm supposed to have this relationship with the patient, but it turns out there's this like multi, you know, conglomerate in between us." And that there's some peer on the phone who's telling, you know,
[00:28:26] Russ Altman: Somebody in a room somewhere
[00:28:28] Alyssa Burgart: Somebody decided that I, I cannot give them this clear medication that I should be able to give them. But when you go through that again and again and again, there's something called moral residue, where it's like you haven't quite recovered from the first one.
[00:28:42] Russ Altman: Whoa.
[00:28:42] Alyssa Burgart: No. And then it happens again.
[00:28:44] Russ Altman: Yeah, yeah.
[00:28:44] Alyssa Burgart: And there's this concept that was described by, Beth Epstein and, Ann Hamrick, who are both pioneers in this area, who call it the crescendo effect. That, like, it just keeps getting these, the, the, the residual experiences keep adding up. And, you know, we have been trained...
[00:29:03] I used to joke, I, I don't know, 10 years ago, I'd be like, "Oh, doctors are talking about burnout, nurses are talking about moral distress," But those are actually a big Venn diagram. And it took a long time for the literature to really demonstrate that. But I think there's so many things where it's like, listen, vacation, having some time away is not gonna fix the fact that the moment that you come back, you will continue to be assaulted by all of these things that actually get in the way of you being a great clinician. To the people that you care about the most.
[00:29:33] Russ Altman: So, you, have you found ways to help these providers deal? Because what you've described is, I think everybody can understand it. It, it's very easy to understand that, but addressing it, treating it, so to speak, doesn't sound trivial to me.
[00:29:48] Alyssa Burgart: It's not trivial, and I think we're all still trying to figure it out.
[00:29:52] Russ Altman: Yeah.
[00:29:52] Alyssa Burgart: And, you know, moral distress and moral injury, this is part of being a human being. This is not something that we are going to, like, obliterate or, you know, if you just had, like, the right framework, this would never happen. I don't think that that's realistic.
[00:30:09] I do think that this is part of if we're trying to develop moral community and we want to be able to support clinicians in having the moral resilience to be able to go back and do this work again and again, we do need to find ways to really offload that distress, to really help people to work through it.
[00:30:30] And certainly, many clinicians can benefit from things like psychotherapy, but that's also a very individual response. Whereas, I think the work we're trying to do, at least in the children's hospital, we run something called moral distress rounds, where we actually routinely work with people in our ICUs, and you try to get people actually in a group.
[00:30:49] And so moral distress, for example, a very common way that people describe it is that they feel helpless. They feel like, "I know what needs to happen, but I am helpless to accomplish it." And so, we try to actually help people take that helplessness and find what are actions that can be taken, whether it is as individuals or as a group. Or what actions can they demand or request from their managers, from the organization, to help try to correct-
[00:31:19] Russ Altman: Yeah
[00:31:19] Alyssa Burgart: ...some of these places where these alignments are actually based in a system that didn't anticipate this outcome.
[00:31:25] Russ Altman: It's also my impression that even by just giving it a name and acknowledging that it exists, you know, we know that sometimes even when somebody has a terrible diagnosis, being able to give them the diagnosis and some closure about what's actually happening helps them kind of think about their situation and how they wanna respond.
[00:31:42] And so I, I had never heard, of some of these terms, and it, I think it would be... it's useful for a practitioner just to know that they're not alone, that there's, that this is something that's been observed before, and that we know a little bit about it, and that, and there are things that we can do to help them deal with it. So I, I think just naming it is actually a big step forward.
[00:32:03] Alyssa Burgart: Yeah. I I talk about, when I lecture on this topic, I talk a lot about the power of expanding our moral vocabulary because of exactly that factor. Where people are like, "Oh my gosh, I have been berating myself for the fact that I literally feel ill, and I cannot sleep because of these experiences that haunt me. That are actually about what are your deepest values and how is it that we can help you reconnect with those.
[00:32:28] And I will say, like, having done, you know, sessions with groups of people who have been involved in some sort of an outcome that was, tragic. Being able to help people identify, like, you're having these emotions, and we can tie them to who is it that you were trying to be when you showed up to this case.
[00:32:50] Russ Altman: Yeah.
[00:32:51] Alyssa Burgart: And, and how is it that you're feeling disconnected from that? And, and how can we help you to see that that person who showed up isn't gone. That person who showed up is worthy of, of care and love and dignity just as much as you tried to provide all of those things, to that patient in that moment.
[00:33:08] And so, helping with that vocabulary, vocabulary I do think is really powerful. And I also feel that there's some aspects of this that I am able to do because I am a clinician 'cause I have been there. You know, I, in my work as an anesthesiologist, I am in some of these cases or I am, doing work that is, that is very adjacent to the things that happen.
[00:33:30] And there's something about telling your story to a person who has earned the right to hear it. Which is very different from, like, trauma dumping on your neighbor who, like, doesn't know anything about your job.
[00:33:40] Russ Altman: Right. Fantastic. Well, well I, I... we're gonna have to stop there. but, but that was a great way to end because these are important concepts that, again, I hopefully we've expanded everybody's moral vocabulary. I think that's, that's one of our goals in life.
[00:33:54] But before we finish, I wanted to ask if you're ready for, the Future in a Minute segment. Let's do it. Where I'll ask you some questions and you'll give me some answers. Okay.
[00:34:04] What is one thing that gives you the most hope about the future?
[00:34:08] Alyssa Burgart: There is a generation of people entering clinical practice that are just as deeply committed to patients, and they are also, like, they're like really aware of the ways in which the systems of medicine have not served patients or themselves.
[00:34:24] And I think that having a group of clinicians coming of age who are saying, "We deserve better. Patients deserve better, and we can have a system of education that is less toxic. We can have care where we, we prioritize dignity of patients over profits," is huge. That gives me hope for the future.
[00:34:45] Russ Altman: What's one thing you want people to walk away from this episode remembering?
[00:34:49] Alyssa Burgart: Ethics is embedded in absolutely every aspect of healthcare, and you should think about, I hope you'll take the opportunity to think about the things that you value most and try to tie those to care. And from a policy level to your appointments with your clinicians.
[00:35:05] Russ Altman: Aside from money, what is one thing you need to succeed in your work?
[00:35:10] Alyssa Burgart: A deep commitment to human dignity, an abundance of intellectual and I would say cultural curiosity. Like I follow the news because I need to because it's so attached to everything that's happening in the hospital. So, I think being willing to lean into those things and, pull those cross-disciplinary aspects together is part of what makes a great clinical ethicist.
[00:35:36] Russ Altman: If all goes well, what does the future look like?
[00:35:38] Alyssa Burgart: Everybody has access to healthcare. We manage to reign in healthcare costs without compromising patient safety and dignity.
[00:35:46] Russ Altman: And if you were starting all over again and you needed to get your degree or certification in a different discipline, what would that be?
[00:35:53] Alyssa Burgart: I would play a lot more music. I, I love playing guitar. I love, I love singing. And I think everything I'm, I, I'm also really into languages. I think I'm really into listening. We've talked a lot about communication. I'm an anesthesiologist, so my hearing is all about like beeps and boops and what do they sound like. And, so I think more music, more languages.
[00:36:15] Russ Altman: Thanks to Alyssa Burgart. That was the future of clinical bioethics. Thank you for listening to this episode. Don't forget we have more than 300 in our back catalog and you can spend all day listening to the future of pretty much anything. You can connect with me on many social media such as LinkedIn, Threads, Bluesky, and Mastodon where I'm @RussBAltman or @RBAltman.
[00:36:35] You can follow the Stanford School of Engineering @StanfordSchoolOfEngineering or @StanfordENG.
