♪ ♪ ♪ ♪ WHEN FACED WITH AN ILLNESS, DO YOU WANT NUANCES OR ABSOLUTES WHEN DECIDING A COURSE OF TREATMENT?

STAY WITH US AS WE TALK WITH ETHICIST Dr. AVERY KOLERS ABOUT MEDICAL ETHICS NEXT ON "KENTUCKY HEALTH."

>> "KENTUCKY HEALTH" IS FUNDED IN PART BY A GRANT FROM THE FOUNDATION FOR A HEALTHY KENTUCKY.

>> A FORMER MENTOR OF MINE WAS FOND OF SAYING TECHNICAL FEASIBILITY IS NOT AN INDICATION FOR SURGERY.

JUST BECAUSE WE CAN DO SOMETHING DOES NOT IN ALL SITUATIONS MEAN THAT WE SHOULD DO SOMETHING.

THAT IS A DIFFICULT CONCEPT FOR MANY OF US IN HEALTHCARE TO GRASP AND AN EVEN HARDER ONE FOR THE LAY PUBLIC.

THE COMPLEXITIES OF MANY TREATMENTS DEMAND THAT THERE BE FULL BUY-IN BY PATIENTS, THEIR FAMILIES AND CAREGIVERS AND THE HEALTHCARE TEAM.

ADMITTEDLY ONE SIDE IS PRESUMED TO HAVE A BETTER GRASP ON THE SCIENCE WHILE THE OTHER KNOWS THE LIMITATIONS OF THE FINANCIAL PHYSICAL, SPIRITUAL RESOURCES TO ACHIEVE A FAVORABLE OUTCOME IT IS REQUIRED THAT THERE BE AN UNDERSTANDING REBOUNDING ANYTHINGS AND APPRECIATION OF EVERYONE'S PERSPECTIVES.

UNFORTUNATELY, TOO OFTEN WE ARE NOT ALL ON THE SAME PAGE AND THIS CAN LEAD TO CONFLICTS AND LESS THAN IDEAL OUTCOMES.

TO DISCUSS THE ESDZ IX OF HEALTHCARE AND THE DECISIONS WE MUST ALL MAKE WE HAVE AS OUR GUEST Dr. AVERY COALERS.

Dr. COALERS IS A CANADIAN BY BIRTH AND I WON'T HOLD THAT AGAINST HIM AND HE EARNED HIS BA.

AT BROWN UNIVERSITY IN PROVIDENCE, RHODE ISLAND AND Ph.D. FROM 9 UNIVERSITY OF ARIZONA IN TUSCON.

Dr. KOHLER IS CO-EDITOR OF JOURNAL OF APPLIED PHILOSOPHY AND PUBLISHED TWO BOOKS, LAND, CONFLICT AND JUSTICE, A POLITICAL THEORY OF TERRITORY.

AND A MORAL THEORY OF SOLIDARITY, BOTH OF WHICH WERE HONORED WITH THE CANADIAN PHILOSOPHICAL BIENYELL BOOK PRIZE.

HE IS THE CHAIR AND PROFESSOR OF PHILOSOPHY AT THE UNIVERSITY OF LOUISVILLE.

THANK YOU VERY MUCH FOR BEING WITH US.

>> THANKS FOR HAVING ME.

>> I THINK THIS IS A FIRST FOR US, HAVING A PHILOSOPHER ON.

>> HOPEFULLY IT WON'T BE THE LAST.

>> I DON'T KNOW, WE HAVE TO WEIGH ALL THE OPTIONS AT ITS HEART, WHAT IS ETHNICS?

WE ALL HAVE A CONCEPT.

WHAT DOES AN ETHICIST THINK ETHICS IS.

>> WHEN WE ACT WE HAVE A SET OF AIMS WE ARE TRYING TO ACCOMPLISH AND SET OF RESTRICTIONS ON WHAT WE CAN DO TO ACCOMPLISH THOSE AIMS.

THE SOURCE OF THE RESTRICTIONS IS OFTEN GOING TO BE SORT OF BASED ON UNTHOUGHT THROUGH VALUES OR NORMS.

AND THINKING THOSE THROUGH IS THE BEGINNING OF ETHICS.

SO, FOR INSTANCE, HISTORICALLY THERE HAVE BEEN ALL SORTS OF CONSTRAINTS THAT PEOPLE FELT ABOUT THEIR BEHAVIOR WITH RESPECT TO TABOOS, ACROSS GENDER LINES, RACIAL LINES, NATIONAL LINES.

THINKING ABOUT WHETHER THOSE ARE GOOD RESTRICTIONS TO ADHERE TO, THAT'S AN ETHICAL-- THAT GETS YOU STARTED ON DOING ETHICS.

AND THEN COMING UP WITH A SET OF CRITERIA THAT YOU CAN PROJECT FORWARD INTO FUTURE ACTIONS BOTH IN THE CHOICE OF YOUR IDEALS AND YOUR AIMS, AND IN THE CHOICE OF THE CONSTRAINTS ON THE MEANS YOU CHOOSE, WHAT WE WOULD HOPE TO ACCOMPLISH, WHEN WE ARE DOING ETHICS IS SOME KIND OF SYSTEMATIC ACCOUNT THAT WILL HELP US IN EVERYDAY SITUATIONS SET AIMS FOR OURSELVES THAT ARE GOING TO BE AIMS THAT ARE WORTHY OF PURSUIT AND ALSO ACCEPT CONSTRAINTS ON OUR PURSUITS OF THOSE AIMS THAT ARE GOING TO BE ABLE TO HELP US AFFIRM THE VALUE AND SIGNIFICANCE OF OTHER PEOPLE AND OTHER VALUES THAT ARE AROUND US.

>> THAT SOUNDS MORE LIKE A TRANSACTIONAL EXCHANGE TO ME THAN ANYTHING ELSE.

THERE IS NO REAL RIGHT OR WRONG.

BUT IT'S FLUID.

>> WELL, I WOULD SAY BOTH.

THERE IS RIGHT AND WRONG OR THERE IS AT LEAST BETTER AND WORSE BUT IT IS ALSO FLUID.

SO THE WAY A LOT OF PHILOSOPHERS THINK OF ETHICAL REASONING, THERE IS SORT OF A SYSTEM THAT PEOPLE CALL REFLECTIVE EQUILIBRIUM.

WHAT THAT IS YOU TAKE A CORE JUDGMENT ABOUT A PARTICULAR CASE THAT YOU PLIGHT WANT TO MAKE.

AND IF YOU ARE REALLY COMMITTED TO THE TRUTH OR THE VALUE OF THAT JUDGE MANY, THE RIGHTNESS OF THAT JUDGE MANY, THEN YOU TRY TO ASCEND FROM THERE AND ASK, WELL, WHAT GENERAL PRINCIPLES WOULD EXPLAIN THAT JUDGMENT?

AND THEN ONCE YOU SEE THAT GENERAL PRINCIPLE, YOU CAN DESCEND BACK TO OTHER JUDGMENTS FROM THAT GENERAL PRINCIPLE AND ASK, DOES IT GIVE ME THE RIGHT ANSWER FOR OTHER SPECIFIC CASES?

AND IF IT DOESN'T, THEN YOU MIGHT GO BACK AND REVISE THE GENERAL PRINCIPLE.

IF IT DOES, THEN YOU CAN APPLY IT TO FUTURE GENERAL PRINCIPLES.

SO, FOR INSTANCE, IF YOU LOOK AT A CLASSIC ONE NOW, FORTUNATELY, SLAVERY IS WRONG, RIGHT?

SO I DON'T NEED A GENERAL MORAL THEORY TO KNOW THAT.

SO I'M 100% CONFIDENCE CONFIDENT IN THE TRUTH OF THAT JUDGMENT.

NOW I CAN ASK WHAT MAKES THAT WRONG?

THAT WILL MAKE IT ASCEND TO THE LEVEL OF GENERAL PRINCIPLE.

IF I WERE LIVING 3,000 YEARS AGO, I MIGHT SAY WELL MA MAKES IT WRONG IS I DON'T LIKE IT WHEN PEOPLE LIKE ME ARE ENSLAVED.

AND THAT WOULD GET ME NOT VERY FAR, RIGHT?

BECAUSE IT WOULD LEAD ME IN OR TOWARDS A PRINCIPLE THAT IS ONLY GOING TO FAVOR MY PARTICULAR GROUP.

UNFORTUNATELY, I'M NOT GOING TO GO THAT WAY NOW.

WHAT I WOULD SAY IS WHAT MAKES SLAVERY WRONG?

WELL, IT'S PROBABLY EXPLAINED BY THE EQUAL WORTH OF ALL PERSONS.

THE FACT THAT PERSONS HAVE AN INHERENT DIGNITY AND AUTONOMY SO I'M GOING TO AFFIRM THAT AS A GENERAL PRINCIPLE.

AND THEN IT WILL ASK, WHAT DOES THAT IMPLY FOR, LET'S SAY, THE JUSTICE OF LABOR RELATIONS POST-13th AMENDMENT.

WHAT DO WE INFER ABOUT HOW PEOPLE SHOULD BE TREATED ON THE JOB, LET'S SAY, WHEN SLAVERY ISN'T AN ISSUE, BUT HIGHER ARCTICAL LABOR RELATIONS CONTINUE TO BE AN ISSUE.

>> THAT MAKES THE ASCUPTION THAT ALL PEOPLE ARE THE SAME IRRESPECTIVE OF WHERE THEY COME OR WHAT THEY LOOK LIKE.

UNFORTUNATELY WE CAN JUSES PHI AND SAY THEY DON'T LOOK LIKE US AND WEEK DO THAT.

THAT WOULD MAKE FOR AN INTERESTING-- BUT IN HEALTHCARE, WE FACE THIS KIND OF A PROBLEM WHERE WE RECOGNIZE A THEM-US AND A CERTAIN THING IN THE PAST WE HAVE SAID WELL WE CAN DO CERTAIN THINGS TO DO GROUP BECAUSE WE DON'T DEEM THEM TO BE...

SO HOW DO YOU-- GREATEST EXAMPLE IS THE UNITED STATES STUDY IN UNTREATED SYPHILIS IN TUSKEGEE.

HOW DO WE NOW, IN MEDICINE IN CERTAIN POPULATIONS SAY WAIT A MINUTE, YOU HAVE DONE THIS BEFORE.

HOW DO I KNOW YOU ARE NOT GOING TO DO SOMETHING LIKE THIS TO ME AGAIN?

WHAT ARE THE ETHICAL CONSTRAINTS.

WHAT ARE THE GUARD RAILS?

WHAT DO THEY LOOK LIKE?

>> THAT STUDY OR SO CALLED STUDY, SINCE IT WAS-- THEY ALREADY KNEW HOW TO TREAT SYPHILIS AND IT WAS JUST AN ABUSE OF PATIENT RIGHTS THAT STUDY LED TO THE PRESIDENT'S COMMISSION THROUGH WHICH THE BELMONT REPORT WAS CREATED AND THAT ESTABLISHED PRINCIPLES THAT HAVE COME DOWN TO US AS THE FOUR MOST COMMONLY AFFIRMED PRINCIPLES OF BIO MEDICAL ETHICS, WHICH ARE JUSTICE, RESPECT FOR AUTONOMY, BENEVOLENCE AND NON-MA LEAF SENSE.

AND THE AFFIRMATION OF THE EQUAL WORTH OF PERSONS AND THE CRUCIAL WITHIN VIEMENTED IN TUSK KEY TUSKEGEE IS INFORMED APPROVAL.

BENEFITING PEOPLE IS BENEFITING PEOPLE AND NOT DOING HARM.

SO THOSE FOUR PRINCIPLES, THEY'RE NOT ALL BIO MEDICAL ETHICS BUT THEY HELP ASK THE CORE QUESTIONS THAT CLINICIANS AND RESEARCHERS NEED TO ASK BEFORE THEY DO ANYTHING TO A PATIENT.

>> SO, ALONG THAT SAME LINE THEN, LET'S TAKE A LOOK AT, WE JUST CAME OUT OF A PUBLIC HEALTH CRISIS CAUSED BY AN INFECTIOUS DISEASE COVID.

THIS WAS SUDDENLY POLITICIZED IN SAYING WHERE IT ORIGINATED.

BUT HOW DID WE GET TO A POSITION WHERE THE SCIENCE IS NOW BEING QUESTIONED AND WE ARE SAYING THAT THERE ARE INEQUITIES IN THE DISTRIBUTION OF TESTING, INEQUITIES OF HOW THE TREATMENT IS GOING TO GO.

THIS LEVEL OF MISTRUST HOW DO WE GAIN THIS THING BACK AGAIN OR THE GENIE OUT OF THE BOTTLE?

>> THERE ARE TWO QUESTIONS THERE.

THE HISTORICAL QUESTION.

HOW DID IT COME TO BE THAT INSTITUTIONS LOST THE MEDICAL INSTITUTIONS AND MEDICAL PROFESSIONALS LOST THE TRUST OF THE PUBLIC?

ON THAT I'M NOT EXPERT.

YOU MAY KNOW AT LEAST AS ELWELL AS I DO.

THE HISTORY THERE IN THE LAST 50 YEARS SINCE VIETNAM AND WATERGATE THERE HAS BEEN A DECLINE IN TRUST OR DROPPING OFF THE TABLE OF TRUST, SOCIAL TRUST IN INSTITUTIONS IN THE UNITED STATES.

AND SO YOU SEE THAT ACADEMIA, YOU SEE THAT IN GOVERNMENT.

YOU SEE THAT IN THE CHURCH.

YOU SEE THAT IN THE MEDIA.

AND NOW YOU SEE IT IN MEDICINE.

SO YOU SEE IT ACROSS THE BOARD AND SO THAT'S-- THE HISTORICAL QUESTION OF WHY THAT HAPPENED WE HAVE TO MAKE REFERENCE TO ABUSE OF TRUST.

DOES KEY TUSES KEY GI STUDY IS NOT IRRATIONAL FOR PEOPLE TO DISRUST INSTITUTIONS THAT HAVE TREATED THEM ARROGANTLY AND SO ON OVER LONG HISTORY.

IT'S MAIN SOURCES ARE FROM POPULATIONS THAT HAVE BEEN ON THE UPSIDE OF THOSE INSTITUTIONS AND SO ONE WOULD WORRY WHAT THE DRIVER OF THAT IS AND WHETHER IT'S THE SAME.

BUT THAT IS SORT OF THE HISTORY OF THAT IS THE FERTILE GROUND IN WHICH THE MISTRUST OF THE SCIENCE TOOK HOLD.

THEN THERE IS THE ETHICAL QUESTION.

WHAT JUSTIFIES THE TRUST THAT WE OUGHT TO HAVE IN HEALTHCARE PROFESSIONALS, IN RESEARCHERS.

THE ETHICAL QUESTION, YOU CAN LEARN SOMETHING FROM THE ETHICAL QUESTION FROM THE HISTORICAL QUESTION FOR GENERATIONS.

FOR PHYSICIANS, MEDICAL PROFESSIONALS HAVE BENEFITED FROM A KIND OF TRUST BASED SOLELY ON THEIR STATUS.

AND THE CAPACITY TO PULL RANK ON PEOPLE.

AND STATUS TRUST, I MEAN, IN A WAY, YOU CAN'T REALLY HAVE INSTITUTIONS THAT FUNCTION WITHOUT IT BECAUSE IT'S A USEFUL SHORTHAND.

WHEN I GO INTO THE DOCTOR, I JUST HAVE TO ASSUME THAT THE DOCTOR WENT TO MED SCHOOL AND PASSED THEIR BOARDS AND ALL THAT, RIGHT?

AND I CAN'T REALLY CHALLENGE IT AT EVERY STEP.

BUT IT NEEDS TO BE BACKED UP WITH MERITED TRUST, WHICH IS THE PHYSICIAN HAS TO EARN THE TRUST OF THE PATIENTS AND HEALTH PROFESSIONALS, RESEARCHERS NEED TO EARN THE TRUST OF THE BROADER PUBLIC.

>> ARE WE EVER GOING TO GET BACK TO THAT POINT WHERE WE CAN EARN, WE IN HEALTHCARE-- I HAVE TO INCLUDE YOU, BECAUSE MY NEXT QUESTION IS GOING TO BE, WE HAVE A TREATMENT THAT IS REQUIRED FOR A PATIENT, BUT THE PATIENT DOESN'T WANT TO SIGN FOR THIS.

OR IT'S FOR AN INDIVIDUAL, THEIR CHILD OR SOMEONE ELSE WHEN THEY ARE RESPONSIBLE.

AND THEY SAY WAIT A MINUTE.

I DON'T WANT TO DO THIS BUT WE ARE SAYING IF YOU DON'T, THERE ARE CONSEQUENCES DOWN THE ROAD.

HOW DO WE ADJUDICATE THAT?

HOW DOES THAT GET HANDLED?

>> AGAIN, I'M SORRY, PHILOSOPHER'S RULE, WHEN IN DOUBT, MAKE A DISTINCTION.

>> AND A SURGEON'S IS WHEN IN DOUBT, CUT IT OUT.

THERE IS THE PRODUCTIVE QUESTION OF HOW THE TRUST IS REBUILT.

THAT CAN ONLY BE DONE THROUGH, I THINK, SHARED DECISION MAKING AND INCLUSION OF ALL AFFECTED REVIEW PANELS AND SERVICE USERS PARTICIPATION IN EVERY INSTITUTION.

IN THE UNIVERSITY WHERE I WORK, IT'S THE SAME GOING THROUGH A PROCESS WHERE STUDENTS ARE BEING ASKED TO HAVE MORE OF A ROLE IN DETERMINING WHAT GETS TAUGHT, FOR INSTANCE, AND THERE ARE GROWING PAINS IN THAT BUT HAVE YOU TO INCLUDE AFFECTED POPULATIONS.

I THINK THE ENVIRONMENTAL JUSTICE MOVEMENT IN THE UNITED STATES HAS BEEN HUGELY IMPORTANT IN PUSHING THE IDEA OF PARTICIPATORY JUSTICE AS AN ESSENTIAL ELEMENT OF JUSTICE AND I THINK A LOT OF INSTITUTIONAL TRUST REBUILDING IS GOING TO REQUIRE THAT.

IN TERMS OF THE-- THAT'S THE PRODUCTIVE QUESTION THEN THE JUSTIFICATION QUESTION OF HOW DO YOU MERIT THAT TRUST?

BUT UNFORTUNATELY, I THINK THEY'RE CONNECTED THAT BEING SEEN TO PARTICIPATE IN COMMUNITY REVIEW AND TO HEAR WHAT PEOPLE'S CONCERNS ARE AND REVISED PROCESSES SO THAT THOSE CONCERNS GET IMPLEMENTED IN SIGNIFICANT WAYS WILL MATTER.

A QUICK EXAMPLE.

THERE IS A-- THE RISE OF RESPECT FOR AUTONOMY IS A SHIFT THAT EMPOWERS PATIENTS TO SOME DEGREE BUT IT'S VERY LIMITED AND ONE OF THE REASONS IT'S VERY LIMITED IS BECAUSE PATIENTS RARELY KNOW VERY MUCH ABOUT WHAT IS GOING TO BENEFIT THEM.

AND THEY TRUST THEIR DOCTORS AND SO THEY WILL OFTEN, RIGHT, TRUST THEIR DOCTORS.

AND IF THE DOCTOR SAYS YOU SHOULD DO THIS, IT'S EXTREMELY LIKELY THE PATIENT WILL SAY YES AND DUE TO COST CUTTING AND VARIOUS OTHER THINGS, IT MIGHT NOT WORK.

SO PATIENTS PUSH BACK.

AND THE PATIENT ADVOCACY HAS MOVED A LOT OF HEALTHCARE INSTITUTIONS IN THE DIRECTION OF SHARED DECISION MAKING.

SO IT'S NOT JUST THAT THE DOCTOR DECIDES WHAT TO DO AND SAYS TO THE PATIENT, IS IT ALL RIGHT IF I DO THIS.

THE PATIENT HAZY, HALF KNOWING, NOT VERY INFORMED, SAYS OKAY.

THE INCORPORATION OF AN EARLIER AGE OF PATIENT VOICES IN DECISION MAKING ABOUT HOW PATIENTS WILL BE TREATED.

>> PERHAPS IT SOUNDS CALLOUS BUT THERE IS THE STATEMENT MY FOUR YEARS OF MEDICAL SCHOOL DOES NOT EQUAL TO YOUR GOOGLE SEARCH.

ALL DATA ISN'T THE SAME.

APPLICATION OF THE DATA REQUIRES A CERTAIN DEGREE OF BACKGROUND BUT HOW DO YOU, AT THE END OF THE DAY, A DECISION HAS TO BE MADE.

AND I DON'T THINK EITHER ONE OF US WANT IT TO BE DO THIS BECAUSE I SAY DO THIS.

NOR ON THE OTHER HAND DO WE WANT THE PERSON TO SAY WELL, I WANT TO THINK ABOUT IT.

I WANT TO THINK ABOUT IT.

SOMETIMES THE CLOCK IS TICKING.

>> RIGHT.

>> HOW DO YOU-- I MEAN AT SOME POINT, A DECISION HAS TO BE MADE.

I KNOW THIS IS THE WORST CASE SCENARIO FOR THE PHILOSOPHER EDS ETHICIST OR IS THE FACT THAT WE ARE NOT DECIDING, IS THAT THE DECIDING?

>> RIGHT, IN A WAY THERE IS NO SUCH THING-- >> I KNEW YOU WERE GOING TO SAY RIGHT.

>> THERE IS NO SUCH THING AS INACTION, RIGHT?

BECAUSE AT SOME POINT NOT MOVING FORWARD IS TAKING AN ACTION.

I GUESS I WOULD-- MY EXPERIENCE WOULD LEAD ME TO SAY THERE IS A SENSE IN WHICH MEDICINE WILL HAVE TO BE KIND OF LIKE TEACHING YOU WANT YOUR PATIENT TO COME OUT OF THE PROCESS, NOT ONLY PHYSICALLY HEALED, BUT BETTER UNDERSTANDING OF HOW TO BE AN ADVOCATE FOR THEIR OWN HEALTH AND HOW TO TAKE CARE OF THEIR OWN HEALTH GOING FORWARD.

JUST, YOU KNOW, TREATING AND DUMPING WOULD BE A TERRIBLE PRACTICE.

AND IT'S LIKELY TO LEAD TO REVOLVING DOORS INTO E.R.s AND SO ON.

SO I'LL GIVE YOU AN EXAMPLE THAT IS NON-MEDICAL.

WHEN I TEACH ETHICS, AS I SAID, I THINK THERE ARE BETTER AND WORSE ACCOUNTS OF WHAT IS RIGHT AND WRONG.

I THINK THERE ARE BETTER AND WORSE THEORIES OF WHAT ETHICS, WHAT THE RIGHT ETHICAL ORIENTATION IS.

BUT IF I WALKED INTO CLASS AND I SAID OKAY, CLASS, MEMORIZE THIS, YOU KNOW, UTILITARIANISM IS RIGHT AND DEONTOLOGY IS WRONG.

WHICH I WOULD NEVER DO I SWEAR.

IF I DID THAT, NOBODY WOULD LEARN IN HOW TO LEAD AN ETHICAL LIFE.

I THINK A SIMILAR POINT CAN BE MADE, PHYSICIANS IN A WAY TEACHERS ARE CO-CREATORS OF KNOWLEDGE WITH THEIR PATIENTS.

>> WE ARE GOING-- WHEN YOU COME UP FOR YOUR ANNUAL REVIEW, WE'LL CUT THAT SNIPPET OUT AND TALK ABOUT WHAT YOU DO.

QUESTION THAT REALLY COMES UP A LOT.

A PERSON WHO IS OVERWEIGHT CIGARETTE SMOKER COMES IN FOR-- THEY'VE GOT PLAQUES IN THEIR CORE ROT YOUR CORE ROTTED ARTERY FOR THE THIRD OR FOURTH TIME.

YOU CAN ARGUE THE PROS AND CONS BUT IT IS OUT THERE HOW OFTEN DO WE TREAT SOMEBODY WHO KEEPS COMING BACK IN, DOES NOTHING TO ADJUDICATE THE RISK FACTORS AND COMES BACK IN OVER AND OVER AGAIN.

IS THERE A POINT WHERE SOCIETY SAYS WE SPENT SO MUCH MONEY ON THEM, MAYBE WE OUGHT NOT TO SPEND IT THIS TIME.

>> THE TEMPTATION TO-- I DON'T WANT TO PUT WORDS IN YOUR MOUTH.

BUT THE TEMPTATION TO BLAME INDIVIDUALS FOR THEIR ILL HEALTH IS TOTALLY UNDERSTANDABLE.

AND YET, I THINK IT'S EXTREMELY IMPORTANT TO AVOID THAT, TO RESIST THAT TEMPTATION.

INDIVIDUAL ILL HEALTH HAS ALL SORTS OF SOCIAL DETERMINANTS AND DRIVERS AND ALTHOUGH WE DO WANT PEOPLE TO AFFIRM TO TAKE RESPONSIBILITY FOR THEIR HEALTH GOING FORWARD, HOLDING THEM RESPONSIBLE BY REFUSING TO CARE FOR THEM IS NOT THE WAY TO DO THAT.

SO I JUST-- A MOMENT AGO I SAID SOMETHING ABOUT TREATING AND DUMPING.

IF SOMEBODY IS BACK FOR THE THIRD OR FOURTH TIME, IT'S A GOOD OPPORTUNITY TO ASK, WELL, WHAT DID WE NOT DO LAST TIME THAT WOULD HAVE EMPOWERED THEM, ENABLED THEM TO NOT BE BACK HERE BECAUSE THEY DIDN'T WANT TO BE BACK HERE EITHER.

IT'S NOT AS THOUGH THEY WANTED TO SEE YOU SO BADLY THAT THEY DECIDED TO-- I'M SURE YOU ARE LOVELY BUT THEY DON'T WANT TO COME IN AND BE SICK JUST TO SEE YOU.

>> I AGREE AND I THINK YOU ARE ABSOLUTELY RIGHT ON THAT POINT.

ADDRESS FOR ME-- AND PROBABLY USING THE TERMS WRONGLY, A COMMUNAL SOLIDARITY, IF YOU WILL SO WE RECOGNIZE THAT IN SOME INSTANCES, IN ORDER FOR PROGRESS, AS WE KNOW IT NOW, THEY'RE GOING TO BE BYPRODUCTS, THERE IS AN INDUSTRY THAT GENERATES ELECTRICITY, WE ALL BENEFIT FROM IT BUT SOMEBODY IS GOING TO SUFFER THE POLLUTANTS OF THE TOXINS BEING RELEASED.

HOW DO YOU-- HOW DO WE ARGUE IN THAT GROUP OF PEOPLE WHO ARE RECIPIENTS OF THOSE TOXINS JUST LIKE I SAY, WE CAN'T BLAME AN INDIVIDUAL FOR THEIR PLIGHT, BUT THEY'RE THE ONES THAT ARE GETTING SICK ALL THE TIME.

HOW DO WE GO ABOUT THE SHARED RESPONSIBILITY?

HOW DO WE HANDLE THAT BECAUSE THIS IS A HEALTH PROBLEM FOR THIS GROUP?

>> THAT'S A GREAT QUESTION.

THERE IS A MORE STRUCTURAL WAY OF APPROACHING THAT AND MAYBE A MORE INDIVIDUAL WAY OF APPROACHING THAT.

AT THE MORE STRUCTURAL LEVEL, WE CAN DISTINGUISH BETWEEN WHAT SOMETIMES GOES BY THE NAME OF ENVIRONMENTAL EQUITY FROM WHAT GOES BY THE NAME OF ENVIRONMENTAL JUSTICE AND ENVIRONMENTAL EQUITY, THE AIM IS TO ENSURE THAT, WHILE WE HAVE A SOCIETY THAT IS TECHNOLOGICAL AND CREATES A LOT OF WASTE, A LOT OF POLLUTION, AND IN THE PROCESS, THE POLLUTION IS BYPRODUCT OF THINGS THAT WE VALUE, AS YOU SAY.

SO IT'S REALLY IMPORTANT TO ENSURE THAT THERE IS A FAIR DISTRIBUTION, BOTH OF THE VALUABLE THINGS THAT WE PRODUCE AND OF THE DISVALUES THAT ARE BITRUCT-- BYPRODUCTS OF THAT, THE POLLUTION.

SO IF THE PEOPLE IN THE SITUATION YOU ARE DESCRIBING, THE GENERAL CHARACTER IN THE UNITED STATES, UNFORTUNATELY IS THAT THE BENEFITS ARE MAL DISTRIBUTED BECAUSE THEY GO TOWARDS THE TOP, AND THE BURDENS ARE MAL DISTRIBUTED BECAUSE THEY GO TOWARDS THE BOTTOM.

SO ENVIRONMENTAL JUSTICE MOVEMENT PRESSURE TO STOP DUMPING ON PARTICULAR POPULATIONS CAN LEAD TO AN ATTEMPT TO BOTH MORE FAIRLY DISTRIBUTE THE BENEFITS AND MORE FAIRLY DISTRIBUTE THE BURDENS.

I THINK WHAT WE WOULD FIND, IF WE WERE SERIOUSLY ENGAGED IN MORE FAIRLY DISTRIBUTING THE BURDENS IS THAT WE WOULD START BEING PROACTIVE ABOUT NOT CREATING THE BURDENS, FIND ALTERNATIVE WAYS OF PRODUCING BENEFITS OR ASK OURSELVES WHETHER THE BENEFITS ARE SO BENEFICIAL GIVEN THAT WE HAVE TO PAY THE FULL COST.

>> AND THEN NOT GO BACK AND BLAME THE INDIVIDUAL WHEN THEY COME BACK IN WITH A PROBLEM CAUSED BY THESE THINGS.

WHAT IS THE MATTER WITH YOU?

>> EXACTLY.

AND WE ONLY HAVE A COUPLE MINUTES HERE, SO A QUESTION THAT OFTEN TIMES COMES UP.

WE ALL TALK ABOUT EVERYBODY NEEDS TO GET SCREENED FOR CANCERS AND WE KNOW THEY DO A GREAT JOB.

BUT THE QUESTION COMES DOWN, WHEN DO YOU BEGIN AND WHEN DO YOU END?

AND LET'S LOOK AT THE ENDING POINT.

SOMETIMES WE KNOW THAT STATISTICALLY SPEAKING, THERE IS NO FURTHER BENEFIT FOR THE COST PUT IN AND BOY, I HATE TRYING TO EQUATE COST TO SOMEBODY'S LIFE.

EXTREMELY.

SO HOW DO WE CONVEY TO PEOPLE OR DO YOU, WHEN YOU SAY YOU HAVE LIMITED RESOURCES, THIS IS HOW WE ARE GOING TO USE THESE RESOURCES.

AT SOME POINT WE ARE GOING TO SAY HOW ARE WE GOING TO CUT THIS OFF?

HOW DO WE APPROACH THAT DISCUSSION.

>> THERE HAS TO BE A GROUND RULE AND THE GROUND RULE HAS TO BE THAT THE RESULT OF THE SAVINGS IS THAT PROFIT IS PULLED OUT FOR INVESTORS.

IF THE RESULT OF THE SAVINGS IS TO PULL OUT PROFIT FOR INVESTORS, THEN I THINK THAT IS DIRECTLY UNJUST.

SO THE ONLY THING SAY SCREENING OR OTHER ANY MEDICAL PROCEDURE THAT IS HIGHLY EXPENSIVE MAY BE A LAST CHANCE THERAPY THAT IS EXTREMELY EXPENSIVE AND HAS ONLY A SMALL CHANCE OF SUCCEEDING, OR IF BENEFITING THE PATIENT, WE MIGHT WANT TO SAY WE NEED PRINCIPLES FOR JUST DISTRIBUTION OF THOSE.

BUT WHAT THOSE ARE COMPETING AGAINST HAVE TO BE EQUALLY IMPORTANT SOCIETAL NEEDS.

SO SOCIETAL NEEDS LIKE EDUCATION, SOCIETAL NEEDS LIKE BASIC SERVICES THAT GO TO PUBLIC HEALTH LIKE TRASH COLLECTION AND SEWAGE THAT, IF NOT FOR THOSE, A LOT MORE PEOPLE WOULD BE SICK.

AND SO IF WE ARE BALANCING PUBLIC SERVICES AGAINST EACH OTHER, WE CAN HAVE A CONVERSATION HOW MUCH OUGHT TO BE ALLOCATED TO HEALTHCARE AND TO SOMETHING ELSE.

WE NEED AN INCLUSIVE AND COMMUNITY PARTICIPATORY PRACTICE AS POSSIBLE FOR HELP CAN MAKE THOSE DECISIONS.

AND THIS GOES BACK TO THE QUESTION ABOUT THE LOSS OF TRUST IN INSTITUTIONS.

IF I AM TOLD THAT-- IF I'M PART OF AN INSTITUTION THAT IS MAKING HARD CHOICES ABOUT WHAT TO FUND AND WHAT NOT TO FUND AND I'M TOLD AS A RESULT THE THING THAT WOULD BENEFIT ME OR GIVE ME A CHANCE OF A BENEFIT ISN'T FUNDED BECAUSE WE ARE FUNDING SOMETHING THAT IS MUCH MORE BENEFICIAL FOR MANY MORE PEOPLE, I CAN ACCEPT IT BUT IF I'M TOLD THAT FROM ON HIGH, MY NATURAL RESPONSE IS GOING TO BE, WELL WHY SHOULD IT COME DOWN THAT WAY?

SO I NEED TO HAVE BEEN INCLUDED IN THE DECISION.

>> I WANT YOUR 10 SECOND ANSWER ON THIS.

DO MOST HOSPITALS HAVE AN ETHICAL ETHICIST ON BOARD WHERE PEOPLE CAN TALK ABOUT CERTAIN ISSUES LIKE THIS?

>> LARGE ENOUGH HOSPITALS ARE REQUIRED TO HAVE AN ETHICS COMMITTEE AND THEY INCLUDE CHAPLAINS, DOCTORS, PHILOSOPHERS, NURSES.

>> THAT'S GOOD.

SO THERE IS-- I BRING UP SOME TOPICS THAT SOMETIMES ARE A BIT EXTREME BUT I THINK IT IS IMPORTANT THAT WE KNOW THESE THINGS ARE TAKEN SERIOUSLY AND DISCUSSED.

JUST LIKE WE HAVE TUMOR BOARDS WE HAVE ETHICAL BOARDS.

THANK YOU VERY MUCH FOR BEING WITH US TODAY.

I HOPE YOU HAVE OPENED-- YOU HAVE OPENED UP MY EYES AND I HOPE OTHER PEOPLE, TOO.

THANK YOU FOR BEING WITH US TODAY.

I HOPE YOU HAVE A BETTER UNDERSTANDING OF THE COMPLEXITIES AND THE PROCESS THAT IS INVOLVED IN MEDICAL DECISION MAKING.

THE DAYS OF BECAUSE I SAY SO ARE OVER AND WE ALL HAVE A ROLE.

THAT MEANS EACH OF US AS A PATIENT.

IF YOU WISH TO WATCH THIS SHOW AGAIN OR ARCHIVED VERSION OF PAST SHOWS, PLEASE GO TO WWW.ket.org/HEALTH.

IF YOU HAVE A QUESTION ABOUT THIS OR OTHER QUESTIONS, WE CAN BE REACHED AT ket.org.

PLEASE THINK ABOUT THE DECISION MAKING PROCESS WHEN YOU SIT AND TALK TO YOUR PHYSICIAN.

ARE YOU COMING OUT MORE INFORMED OR LESS INFORMED?

IF LESS INFORMED, GO TALK TO SOMEBODY ELSE.

SEE YOU NEXT TIME ON "KENTUCKY HEALTH."

>> "KENTUCKY HEALTH" IS FUNDED IN PART BY A GRANT FROM THE FOUNDATION FOR A HEALTHY KENTUCKY.