Max, a 72-year-old patient dying of severe congestive heart failure, asks his physician to turn off his left ventricular assist device (LVAD) because his quality of life has diminished considerably since the device was implanted months earlier. The device has caused a painful infection, and he is in such a fragile state that the LVAD cannot be removed or replaced.
The attending cardiologist objects, knowing that if the request is granted it is likely to end Max’s life in a matter of minutes. The physician, citing his religious views, says turning off the device is akin to killing the patient. The issue at hand is one of professional conscience. The question: When is a health professional obliged to perform a medical task if it violates their deeply held view of right and wrong?
It is a question without an easy answer, making it perfect fodder for the “Hard Call” podcast, an example of the way the increasingly popular medium of podcasting is being used to help engage medical students, physicians and the broader public about the often trying decisions faced by patients and health professionals.
“Hard Call” is just one podcast produced to help advance medical ethics education. Produced monthly, “Ethics Talk” explores ethical and professional challenges that are confronted by medical students, physicians and other health professionals.
Issues explored in “Ethics Talk,” which is produced by the AMA Journal of Ethics® and available on iTunes, hew closely to the theme of that month’s issue of the journal. Recent episodes have focused on topics such as clinician responsibilities toward incarcerated patients, communicating iatrogenic outcomes in pediatrics, and creating social connections for people with dementia.
The producers of the “Ethics Talk” podcast also make a concerted effort to include the perspectives of patients and the public. The recent episode on correctional health care, for example, includes the voice of Troy Williams, who served 18 years at San Quentin Prison and discussed his experience seeking medical care behind bars.
Asking the toughest questions
As for “Hard Call,” producers of the serialized podcast strive to take true stories of medical situations—illness, well-being, life and death—and bring them to an audience that extends beyond closed-door meeting among health care professionals.
The podcast—a project produced from the University of Colorado Anschutz Medical Campus and funded by the Colorado Health Foundation and the Community First Foundation—discusses dilemmas confronted by patients, their loved ones and health professionals. In Max’s case, his story is told by a voice actor and done on a first-name only basis to maintain anonymity. In other instances, actual patients voice their stories. At the end of each episode, the audience is presented an ethical dilemma and asked to vote—through the podcast’s website—on what constitutes the correct decision.
“One of the things we try to do with these stories is we take one person’s experience, and the decision they faced, and we try to use it to explore larger ethical themes,” said “Hard Call” co-host Matt Wynia, MD, MPH, who also directs the Center for Bioethics and Humanities at Colorado’s Anschutz Medical Campus.
“This was a real case. It really tore up the [coronary care unit]. The nursing staff was very distraught that the doctor was refusing to turn off the LVAD when the patient asked to have it turned off. The doctor felt like this is tantamount to murder,” Dr. Wynia said. “So that question of, ‘Does a patient have a right to ask you to do something that is contrary to your personal religious beliefs?” is a broader question than one about LVADs.”
New way to present case studies in class
In its initial incarnation, “Hard Call” offered general questions—“Should Max’s doctor be required to turn off the LVAD (or find another doctor to do it) even though he is morally opposed to doing so?”—to general audiences. This coming school year, however, the podcast is being used as a tool for Colorado medical students.
It is Dr. Wynia’s hope that the stories on “Hard Call” will be effective case studies that facilitate dialogue. He and a colleague, Daniel Goldberg, PhD, plan to use episodes of the podcast in Goldberg’s elective med school classes on ethics and stigma.
“The advantage we have here is we are telling real stories and talking to mostly real people who have experienced those kinds of things, so we can be sure that we are going to capture some of the nuanced points that might or might not come up in a small group discussion that is prompted by a bare bones case,” he said. “So we can get a lot more detail, and we are in control of making sure if we haven’t touched on something yet we can go do another interview.”
The podcast medium offers a measure of convenience not available through text, Dr. Wynia said.
“The nice thing about podcasts is they are very suitable for listening on your way to work or while you’re working out,” he said. “I’m hopeful that people will appreciate being able to use these as curricular modules. You can give it as homework, but it allows you to squeeze some homework in when you are doing things that are otherwise enjoyable.”
Operating in the gray area
When asked about the dilemma in Max’s case, the majority of respondents on the “Hard Call” website felt the doctor should be required to turn off the LVAD. The real-life outcome was different. The cardiologist didn’t turn it off, but he was willing to stop Max’s anticoagulation and antibiotics. Max died a few days later, after being transferred to hospice, but with the LVAD still running.
Dr. Wynia believes that these questions are about understanding opposing viewpoints as much as anything, and there are no wrong answers.
“We are leading people to a very difficult decision where both answers could be right,” he said. “We are looking for topics where—if we do this perfectly—by the time we get to the end of the episode, half the audience will vote yes and half the audience will vote no. And some of them will have changed their minds of the course of the episode.”
