Day 2 Plenary Paper Presentations : Ethics of Death, Dying, and Moral Challenges in Surgery

uh Dr. Megan Applewhite, who is uh professor of surgery and uh also an associate director of the MacLean Center, um who will moderate this next session. So, Megan. >> All right, thank you. Um uh this is going to be a great lineup. Our first uh speaker is Dr. Kristo Laszlo Lazaridis. Um he's a professor of neurology and neurocritical care at the University of Chicago. And he is faculty at the MacLean Center for Clinical Medical Ethics. His neuroethics work focuses on ethical and conceptual problems in acute brain injury, including disorders of consciousness and determination of death. Welcome. >> Hi. Thank you very much. Um Okay, let's get started. I'm going to keep my own clock here so I don't go over this. Uh okay, so I'm going to be talking about um I would I would making the case that uh the dead need protection, too. Um and I will argue for how potentially to do that. And I'm going to be specifically talking about a category of being called a physiologically maintained disease. Uh I have no disclosures. Okay. So, here So, here is what I'm going to be talking about and everything is on this slide, the entire presentation, really. Um but I'm going to say what is a physiologically maintained disease. There are two types. One is kind of a short-term PMD, which is encountered in a normothermic regional perfusion after DCD. And then, there's a long-term PMD, which is a brain-dead individual who is physiologically maintained for potentially days, weeks, or months for discovery research purposes. Um so, I'm going to ask the question, why would we need to protect PMDs if they are dead? Seems to be a very natural question. Um and the answer to this is that we have to take precaution precautions against the reemergence of consciousness. Uh I'm going to say a word about how we can protect them which is ensuring brain circulatory arrest. And then finally I'm just going to say a couple of words and potentially you know hopefully we'll have a discussion uh about the implications of thinking about this and taking it seriously. Okay, what is a physiologically maintained diseased? Um So it is a patient who has been determined and declared to be dead according to established medical criteria and according to the UDDA in the United States uh who remains on artificial ventilatory and circulatory support which is the case classically for death after neurologic criteria or brain death. Uh or uh there is a this patient is then uh um actually has reinstitution of artificial ventilatory and circulatory support and this is what happens in the case of donation after circulatory death and specifically NRP. Okay, let's start with NRP which is the more common thing and probably larger issue. Um so this is just a graph showing you the standard process for uh donation after circulatory determination of death. So there is withdrawal of treatments as an independent decision. We observe the patient for an hour or two for circulatory arrest. When that happens then there is a 5-minute hands-off period to make sure there is no um auto resuscitation and then death is declared based on circulatory criteria. So standard DCD organs are either explanted and uh directly uh implanted or they are ex ex situ um you know subjected to ex situ machine perfusion. Uh NRP changes a little the uh the game. Uh The first thing that happens is that after the declaration of death, the uh arch vessels from the aortic arch to the brain are surgically excluded. They're ligated. And one once that is completed, then the NRP circuit, which is basically an ECMO pump, reperfuses the thoracoabdominal cavities. Uh, just for visuals on the procedure, that's that's how the patient looks after sternotomy and after um as you see the arch arteries are ligated. And so there is no conduit, right, from the thorax to um to the brain. Uh, why I mean there there are many This is a complex uh and interesting ethical topic. Um, but but what but but you know, I'm uh in the middle of all this controversy, why why is this very popular and why do the transplant community why does the transplant community wants to really do this? Uh, and there are good reasons. Uh, so all organs um are perfused with one machine, so there is a significant reduction of warm ischemic time. Uh, there is immediate functional assessment of the organs. Actually, you can actually have native cardiac function restart, right, and have uh direct functional assessment of the heart. Uh, there is higher organ yield and there is early empirical data suggesting better recipient outcomes. Now, um we have argued here we have argued here um that um uh surgical exclusion of the vessels is not sufficient. You actually have to make sure that there is no blood flow entering the brain after you restart the NRP circuit. But this is also debatable and not entirely acceptable from the transplant surgeons. Okay, now why is this the what what's the point of this talk? What are we want to protect uh against? So, we want to prevent reanimation of the brain and arguably of the patient, right? Um and so, this is not going to look like the donor wakes up uh in the on the table like in the movies. Uh but um what may happen what what's within the within the uh sphere of possible is that you may have re- If there's brain reperfusion, there could be some reemergence of even rudimentary consciousness. Um and you would you wouldn't even know, right? If you don't have any neuro- even if you have neuro monitoring actually, you wouldn't know that the patient actually recovers some potential raw phenomenal consciousness, right? So, there is a risk for experiential harm here. Now, when you talk about consciousness, it's the same about talking about death. We don't really know what we're talking about. Um but uh but but but in a very basic level, um the neuroanatomy of consciousness is is is more or less established in the sense that there are you know there is a subcortical brainstem component that mediates arousal and there is a cortical component that mediates awareness and this is a very old model for decades. Um but uh but the point here is that there are um there are um theories about So, the question is what would be the minimal neuronatomical substrate for consciousness? How much brain do you have to have alive or reperfused to think that there could be some emergence of consciousness, right? Um and this is the not an established question, but the safest the safest answer when you're doing things like uh organ donation or discovery research with brain dead patients, the the the safest answer is that you really want zero flow into the brain. No not a little bit, not a few cc's per per millimeter per gram tissue. You you really want to have zero reperfusion of the brain. Okay? To avoid from this um you know, any kind of reanimation to occur. And these are just images from you know, brain dead patients, what it looks like to have a cerebral angiogram with an empty skull, and then you see a spec blood flow study with again an empty skull uh suggesting that there is no reperfusion to There is There is no brain blood flow, better to say. Uh and these are So, when you do this testing you see these images, these are diagnostic for brain circulatory arrest. Okay, let me let me uh switch now to the the second topic. The So, that was the short-term PMD because NRP takes an hour, 2 hours that this patient is subjected to this procedure. Um but um but but this longer-term PMD um is a is somebody who has been declared brain dead, and then um they are subjected to discovery research practices. Like for example, the the the most um publicized um uh use for that was in NYU Langone where they had a brain dead PMD uh maintained for 2 months. They implanted a pig kidney, and then they were studying immunological reactions, transplant reactions, uh and studying the the science of xenotransplantation, right? Um and uh a very nice summary of where to read where the where is what is the state of this kind of research was published in Science by Padel. That's the paper I have up there. Um where they argue about the many many scientifical benefits and breakthroughs that could be facilitated by discovery research. You could do like phase one trials uh that cannot be done in, you know, they have higher risk of complications or side effects with life patients. So, scientifically and medically and clinically, there's good reason to take this seriously. Now, El País, the the Spanish newspaper, had this very interesting title in English. Said, "Using brain dead people for medical experiments, the new debate at the frontier of bioethics." And probably you cannot read the fine print, but they say four US experts propose using still breathing still breathing humans to advance drug research. Which is um which is not a which is not a good way to talk about um a brain dead individual, okay? That's the problem with newspapers. Okay, so but I I I want to uh seriously ask can consciousness reemerge in a PMD? Uh and if the answer is we are 100% certain that this cannot occur, uh then I think the argument easily follows that we do need to take precautionary measures to protect these donors. Uh and I think the answer about NRP is widely accepted. Everybody accepts that you need to exclude the circulation to the brain. Um uh pro and anti-NRP crowd, I think they all agree on that point. Uh they disagree on everything else, but but but on that, I think there's agreement that you you cannot absolutely categorically cannot do this procedure without surgical ex- exclusion of the brain. Uh and again, the the reason you're doing that is to ensure the permanent loss of the capacity for consciousness. Um and uh so the additional question I have is, you know, should we doing this in patients who are subjected to this discovery research purposes PMD brain death. Um and in the science paper I showed you the authors, they don't consider this, right? They actually say they have this claim that PMDs do not have cerebral perfusion and so that is not an issue. Um but I would I would I would gently disagree here and for the following reasons and I do think these patients also need precautionary measures to be taken. So the first thing to say is that brain death is a clinical diagnosis. So it doesn't require demonstration of brain circulatory arrest and thus the prevalence of preservation of blood flow in brain death is uh more or less unknown. The second thing is that isn't is entirely unknown, entirely unknown scientifically, what happens to a brain dead individual who is physiologically optimized for weeks and months. In fact, uh a proposed use for PMD research is using neurotherapeutics, right? So we have no idea uh how this kind of interventions could potentially uh both uh um um reestablish or change flow dynamics, but also neuronal cell viability. And then finally, the lower threshold of the studies we're using, so for example SPECT for diagnosis of brain death, um we don't really know what is the lower threshold flow detection for those studies, okay? Uh and there's an old theory going back in the '90s that, you know, there is some degree of global ischemic penumbra in these patients. So this is flow that's not detectable by conventional studies. Um and uh and so, you know, you diagnose brain circulatory arrest, but indeed there is some residual flow that with optimization could actually reach levels that lead to reperfusion and potentially reemergence of functions. Okay, so two more slides. So take stock here. What What am I What am I saying? So I'm arguing that PMDs both short and long require protection. Real precautionary measures. And the reason they need protection is because we have to ensure that indeed the loss of the capacity for consciousness is permanently lost. Now the determination of death determination of death both for neuro and circulatory criteria based on permanence and not irreversibility. That's kind of tangential but related because there are legal issues here. How they contradict the language in UDDA. Capacity for consciousness emerges as a grounding biological function for the determination of human death. We have to ensure permanence. The The only safe proof way to do this is surgical exclusion. Um and then monitoring that actually confirmation that this has been done properly. And so there is there is an implication here that if you're saying that you know people who have been declared dead they potentially retain some degree or at chance for recovery of consciousness. What exactly are you saying? What what are the implications for how we understand determining and declaring death in the medical legal context. And so and and this one slide doesn't this probably is going to come out confused because I have done an entire talk on this on this issue and my colleagues in the McLean are sick and tired of of hearing me talking talking about different paradigms of death. But what I just want to point out here is that it's impossible to discuss this coherently by accepting that very traditional biological paradigm of death that rests upon um the irreversible loss of homeostatic integration of the organism as a whole. Um um we have to revise this uh foundational principle of death. Uh instead, we have to focus uh the target concept of the determination should be the permanent cessation of the capacity for consciousness. So, we have to follow a unified brain-based determination of death. Unified because um both set of criteria are grounded by the same concept, which is a unified brain-based one. So, all death is about brain death, basically. Uh the dead donor rule can remain in effect, but we we have to change the paradigm. Otherwise, it's clearly contradicted. So, so if the if if death is based on loss of homeostatic integration, then routinely every day organ donation, both circulatory and neurological, violates the DDR. Uh NRP is permissible if and only if the brain circulation is properly excluded, and there's solid confirmation for that. Uh and then I have argued that PMDs, so brain-dead individuals subjected to research or maintained for research purposes, need to have a similar procedure that makes the the possibility of consciousness re-emergence really zero. Um and then uh because these issues are complex, they need uh they they need public deliberation, right? Uh and I think they need serious informed consent. Um uh instead of talking about uh carrying over authorization the same way we do standard DCD or standard brain dead donation, I think we actually need an explicit disclosure of exactly what is done in these procedures, what are the risks done, and uh obtain proper consent to to go forward. Thank you very much. >> Two minutes to ask your question. >> Okay, I'll try to be fast. Hi Kristo. So, um I know I've said this to you already in person. So, I apologize for asking again. But, I I think your target concept is going to have problems of permanent brain death, right? I mean, I I do think there is a biological definition of death that's consistent and that's total cellular death. That's when the body is a bunch of bones and has decayed. You know, and all these other definitions are going to fall apart at some point. So, I liked your idea of focusing on the death behaviors that are ethically permissible and making arguments that uh research on the recently deceased on PMDs uh may be ethical be because we are guiding the dying process, but we're not actually declaring anybody re- No one's really dead from a true in a true consistent fashion until they are have experienced their body has experienced total cellular death and is decayed um you know, beyond any question of a doubt. So, curious >> What what's the No, I I I I I I agree with I think everything you said. Where where is the Is there a disagreement somewhere or a or a >> You you you described a target concept of >> Yeah. >> permanent brain death. >> Right. >> Which I think will have the same problems as everything else. >> Okay, good. >> Yeah. Yeah, I'm sorry. That's that's that's a that's a great point. Um you see um the the issue is that I don't think uh I I I the problem is that it's it's unavoidable. We have to construct um uh we we need to accept a certain concept that we have to define death and then, you know, derive criteria from there uh in order to perform the activities we are performing. Meaning, if you go that every single cell has to be dead, uh you basically killing off uh all organ donation. >> Yeah, exactly. >> Or or you have to get rid of the DDR, for example. >> Yeah, exactly. I just think you Right. So, I think the DDR's got to go. I you know, all these things have to go. Like, the only thing That's That's I So, I'm I guess my concept is is quite radical. It's is is that we move the definition of death to make it consistent. The only thing that's consistent would be total cellular death. And then instead work on the ethics of what dying processes are Yeah. legal and ethical and permissible. And organ donation, yeah, I think is a moral ethical way to die. Um but it's a way to die. You are not dead before you donate organs. The only consistent idea of death is total cellular death. But, I guess that's a a very radical position given what the UDDA says. And but I think, you know, it's just gymnastics otherwise, but >> Yeah. I I think politically both of our suggestions are difficult to get through, but uh Yeah, please go ahead. >> Chris, it's good to see you again. Um I'm going to ask you to to uh do a thought experiment, pun intended, about BrainEx. Right? So, the idea here cuz implicit here is that we can do research on uh a bodies that's brains disconnected, you know, physiologically and and and by by the procedures that you're mentioning. So, what about the 2019 thing about BrainEx, which showed that you could reestablish cellular activities on the prick brain if you preserved them for at least they did it for 6 hours, right? But, the NIH had a big issue about it What What was that going to look like? Um would that research be ethical here now? Because you could potentially then disconnect the brain, yes, physiologically, no circulation, put it have it reanimated by or at least have cellular uh activities restarted with Brain X or Brain X 2. And now, what do you do there, right? Cuz you said for a moment it was, but still not permanent, right? Cuz that would now call into question the permanence thing. >> Yeah. Uh nice to see you as well, Les In, and uh this is a very good question. Can we go for 30 minutes? No, okay. Okay. Okay, but but Brain X is an experiment where uh done in Yale, right? They took four head big heads uh several hours postmortem, right? And reperfused them with this magical liquid of goodness or something. I don't know what it was in there. And then you have some cellular functions coming alive, right? So, actually that connects very nicely. Actually, that's a great answer to Will's question, right? That it's not about cells um or even organs. I mean, we have to draw the line in some kind of principled manner uh thinking about what func- what biological func- functions actually matter, right? And I'm siding with people who are saying, "Listen, uh a function that clearly clearly matters is the capacity for consciousness. And then from there, think, "Okay, what follows? What kind of medical criteria? How rigorous can have to be?" Um and then public deliberation because this is a neurocentric approach, right? But not everybody agrees. Thank you very much. >> That's great. Thank you. I don't think anyone in the MacLean Center gets tired of hearing Kristo's talk. We're lucky to have you. Um our next speaker is Julie Campbell. Um she's an assistant professor of law at the Brandeis School of Law, University of Louisville. Her scholarship examines the intersection of health law, medical ethics, and administrative regulation with a particular focus on informed consent, end-of-life decision-making, physician accountability. Her current work explores legislative and policy mechanisms to align clinical decision making with patients' rights to self-determination. She'll speak today on a topic entitled When Silence Harms: Misconceptions about CPR and a legislative path forward. >> Thanks. >> Good afternoon and thank you for having me here today. It's really a privilege as a former fellow to be able to speak to you all. I'm going to forewarn you that I don't normally read a script, but what I have presented here is actually the law review spin-off of the empirical study I did with a fellow fellow, Gina Piscatello, and this is 65 pages long and getting it into 15 minutes is really hard. So, I did this so I can make sure I'm not rambling. So, let's start with this premise. When a patient's heart stops, we treat CPR as a default. But, most patients have no idea what that actually means for their chances of survival or the life they might or actually return to. So, today I want to explore what that gap in understanding means for autonomy and how we might address it. I have no disclosures. We know that patients significantly overestimate the effectiveness of CPR. In our study, only about 10% of the population correctly understood that survival to discharge after in-hospital cardiac arrest is roughly between 10 to 20%. Meanwhile, over 70 70% of our study surveyed believed survival exceeds 50% and a third believed it it was as high as 70 to 80%. And when we asked why they demand CPR even when informed it will not work, two common themes that were troubling to me emerged. One was there was no downside to CPR, and the other was that they don't want to decide to forego a potentially life-saving intervention for their loved one. So when patients say they are Sorry. Um they want CPR, they are often that decision based on a fundamentally inaccurate understanding of what CPR can actually achieve. Am I not hitting this? There we go. So there are several reasons for this. Um media depictions dramatically overestimate the survival rates. Although I do want to give a shout out to the show The Pit. I think they actually do a really great job. And if you haven't caught that, you really should catch that show. Um but on top of that, the CPR courses focus on technique, not outcomes. I went through my husband, he's an emergency medicine physician. I went through his advanced cardiac life support training book. 183 pages. One sentence that talked about the low efficacy of CPR. Right? And these training programs are not just for medical professionals. They're for the lay people. They're for our future surrogate decision makers. On top of that, our institutional defaults. Our legal system, the policies you have in your hospitals, the ones that say you have to do CPR unless there's uh active do not resuscitate or do not attempt resuscitation order in the patient's chart. These signal to the public that these are the recommendations, that this is beneficial treatment. So patients are not just uninformed, they're being guided by a system that implicitly signals that CPR is almost always beneficial. This causes conflict. And it's significant. So, we have this information asymmetry. Physicians know better. Patients don't know enough. For the patient, they experience CPR as a positive, right? Something they are entitled to. On the other hand, the physician experiences CPR at a negative rate, something that they have the right to avoid if the harms are more severe than the benefits. For a patient, when you tell them in the dire moment that you don't recommend CPR, it creates distrust in the medical recommendation because their entire experience before that was that CPR was beneficial and it would save their life. For the medical professional who is forced or obligated to do CPR on a patient that they don't believe would actually benefit, it creates moral distress. Sorry. So, what is the real reality of CPR? I'm sure most of you know this in this audience. If I was to tell this to a law audience, they would be shocked at this point and they have been. The reality is that CPR is both ineffective and harmful than more harmful than patients realize. Survival to discharge is already low and that drops further when you factor in underlying disease. And the harms are significant. You have broken ribs, you have neurologic deficits, and you have something called CPR induced consciousness, which really dovetails nicely off of your talk. Um all of the literature on that event, that's when CPR is actually perfusing the brain and the patient becomes conscious again. And every single instance of this, the patient has had to be restrained either chemically or physically because they are trying to push people away. And they are saying, "Stop." So, my slides are a little off, but okay. Um so, what is the problem here? Why is CPR so different? And the problem is that there's a legal gap, right? Typically, from the legal perspective, we have informed consent that's supposed to protect patients from interventions that the harms greatly outweigh the benefits, right? We're supposed to tell them what the risks and benefits and alternatives are. But CPR is treated as the exception, right? So, they are never fully informed as to what the the intervention they're going to be receiving. So, really we have we've created a system that effectively defaults patients into CPR without ensuring they understand what it entails. So, my argument is that emergency exception should not excuse the failure to inform patients before emergencies occur. If we take informed consent seriously, then we need to rethink how and when we provide this information. And this isn't a new problem. The original creators and the ad hoc committee asked to actually establish these um guidelines when CPR first came out in the 1960s, both concluded that CPR was not designed for the severely ill or terminal patient. It was designed for the patient with an acute injury or an acute insult like surgical anesthetic problems or electric shock or drowning. And the medical community has known this reality for years, in fact, over 50 years. And they have tried several things to overcome this. They have tried the unilateral DNR order. Although this is extremely controversial because it's very subjective on how we define futile or nowadays medically inappropriate. They've tried slow codes or show codes, which also are a deceptive practice and there's mixed reviews as to whether that can ethically ever ethically be done on a patient. Um they've tried conversations with terminal patients. The SUPPORT study in 1995 involved this these conversations. And the researchers said, "It's just these conversations are happening too late." When you when you wait to have the conversation when the patient is in crisis, they go through Elizabeth Kubler-Ross's five stages of grief. Denial is first followed by anger. Okay. And my study along with Gina Pizziello follows in the line of trying to rename the do not resuscitate order. So we've seen several iterations of this: do not attempt resuscitation, allow natural death. And we tested beneficial care only. But unfortunately, all of these have failed because they don't really address the core problem, the information asymmetry. And that's because again, these conversations happen too late. And that is usually as a result of both parties waiting or physician discomfort in having this conversation. Or there might be training gaps for physicians. And the fear that maybe if I have this conversation with the patient, that they will give up hope. In terms of the framing effect, it's common knowledge that I found out after our study resulted in a null um result, um that framing is only effective if it aligns with the the subjects experience, intention, and most importantly knowledge. So, what are we trying or what am I trying to argue in this is that we need to align the patient's expectations of, you know, how effective CPR will be with for them with their current medical condition. So, this is actually taken from Michelle Bedduli. She's a Swiss researcher and she nicely put in these three categories of potential patients. Okay, so obviously for that young healthy that did have that acute insult, CPR would be the normal recommendation. For the mild chronic disease, the equippoise patient, which I'm hoping all of us probably are in this room, this you would let it be the patient's informed choice, right? And then finally for that severe disease, death is imminent patient, DNR is the recommendation. So, we need to get the patients or just lay people to start understanding that the default does not maintain its beneficial status through the course of your life. It shifts as your health shifts. So, when patients are informed of these choices, we actually find that they make different decisions. So, in 2015 Elwyn Chuang did a study where he used video decision aids to show patients what CPR really is. They included the harms of CPR and the likely outcomes, which included the neurologic deficits. And the results were pretty impressive. They saw a shift from 3% that were 3% willing to do a DNR to 38%. And they found that there was no increased anxiety. Christopher Becker did a 2025 study and he was testing the impact of code status discussions at hospital admission on non-critical patients, so the equipoise patient. These are terrible slides, I'm sorry. And they found that um with these, you know, visual decision aids and conversations at hospital admission, that patients actually shifted to agreeing to a DNR status. So, I think there was from like a 37% to 50%. And mind you, these are patients that are otherwise healthy. Um and also they found there was no increased anxiety. So, how do we get this? How do we implement these two studies into a decisional framework today? And that's where I am proposing this modified prompted choice. This is based off of choice architecture. Um if you know uh Richard Thaler or Cass Sunstein, they came up with four different choice architect choice architectures, presumed consent, explicit consent, mandatory consent, and prompted choice. I'm creating a hybrid, so I'm taking prompted presumed consent and I'm adding prompted choice to it. And I'm doing this because the current four don't really address our situation. So, in this one we're going to retain CPR as the default, but we're going to mandate the El-Jawahri CPR video decision aid be provided at at hospital admission, as well as the Christopher Becker admission conversations, in which they do patient-specific survival data and at admission, potential harms from CPR, including the neurologic deficit, and the iterative provider-patient discussions. On top of that, I want to include public education campaigns. In the United States, 48 states either mandate or recommend that high school students receive CPR training in their high school curriculum. This would be a wonderful place to actually educate future surrogate decision-makers. Um as well as senior centers. So, how what can we use to implement this legislative nudge? The Patient Self-Determination Act. And why do we want to use that? Because it has a national scope. It already applies to all Medicare and Medicaid facilities, and that includes hospitals, nursing homes, and home health agencies. It already has a built-in compliance mechanism. So, the Joint Commission monitors uh facilities compliance, as well as CMS monitors the compliance through state um auditors. And it has a proven track record of success. So, when the government agencies go in and look at how well the PSDA in terms of advance directives, they found that in under 2 years there was a 21% increase in patient knowledge. And that after 5 years, nearly all providers were informing patients about advance directives. Now, there are possible limitations to this. Um some argue that you're just, you know, these disclosures at hospital admission will lead to the patients making, you know, involuntary or unreasoned decisions. Um or that patients may feel a huge like as though the hospital is trying to tell them they were doing something wrong, or they were going to they were going to die. But I think I've shown you that the two studies, the El-Jawahri and the Becker study, both showed that there was no additional anxiety in having these conversations. And in fact, the Becker study found that the the individuals had felt more comfortable with their decisions after the the information was disclosed. The other argument is the expense, right? The staff time, the need to educate and train staff, the need to engage in community education efforts. But I argue if you have specifically trained, maybe you know, advanced practice providers uh that can have these conversations with patients at hospital admission, that that wouldn't actually burden the physicians additionally, right? And in fact, if you think about it, 40% of all ethics consults have some relation to the CPR conflict at the end of life. What I'm arguing is let's front-load those conversations and spend our time and money there so that we don't have to do them at the back end where you most parties don't leave happy, right? And why do we need to do this? Well, first of all, CPR was never designed to be utilized on the terminally ill. Um the original creators and ad hoc committee specifically said do not use it on this patient population. This universal application really violates beneficence and autonomy. CPR is not always beneficial and quite frankly, how we're using it in today's society, it's more often not beneficial. And this transparency, this disclosure of information, it's the way that we truly create an autonomous autonomous choice in our patients. You know, as our forefathers of bioethics have said, you know, one must be adequately informed to have an autonomous choice. So in conclusion, really silence harms in this context and if we have informed choice, it will heal. Thank you. >> So So I guess my question, uh thank you, very nice talk. This is a difficult topic and one that affects all of us who practice. I guess my question is is why focus on CPR rather than advanced directives or living wills? There's a hospital system in La Crosse, Wisconsin that just standardly, when you come in for to the hospital, will say, "Do you have an advanced directive? Can you fill it out?" Why not focus on advanced directives, which are broader potentially for patient desires than just CPR specifically? >> The reason I don't focus on advanced directives is cuz they don't actually educate them on the efficacy of the interventions that are being labeled in the advanced directive, right? So, if our population, 90% of them believe CPR is going to be effective, they're going to just do an advanced directive that says to CPR on me, right? So, until we address the knowledge gap, um they're not actually doing even the advanced directives being currently filled out are questionably autonomous because they're being filled out in a in an environment of complete misinformation. >> Wonderful talk, very courageous. Um my question for you is has this been has CPR education been tested in the setting of a effectiveness implementation trial in a large-scale healthcare system? Has that happened at any point? >> The Christopher Becker study in 2025 was published in New England Journal of Medicine that took place in six hospitals and you know, across the board. And again, I think what's so persuasive about that study was these were not critically ill patients. These were not patients at the end of life. These were us, the equapoise patients. And they saw a significant shift in the people that before the conversations were, you know, CPR all the way, to after the conversations filling out DNRs. >> Hi, thank you so much for your talk. I really enjoyed it. Um, I have a question about um, like the general education on like DNR DNI orders. Um, and I was curious if like um, so your approach has a lot of um, explaining and and educating the patient on the negatives of CPR which is really good, I think. Um, but I wonder about like how we might talk to patients about like the potential benefits and like how to set you up for success if we do have to do CPR. I'm thinking specifically of the patients who sign um, CPR but DNI. Um, and like maybe tell them about the like the intubation aspect of it if they if maybe there'd be like a holistic approach to this or um, what you might think about that. >> You know, from the research that I did, when you have CPR but you don't have DNI, you're really doing like a show code, right? Because there's no possibility of reanimation or ROSC in that situation. So, I think that's deceptive in itself. So, if you're going to you know, even think about entering that order, I I I probably have a problem with that from an ethical standpoint. And I think it needs to be explained to them that really we can't achieve ROSC if we don't have the ability to do a D like to actually intubate at the same time. Right. Thank you. >> Thank you so much. Our third speaker is Dr. Timothy Murphy. Um, he's a professor of philosophy and biomedical sciences at the University of Illinois College of Medicine. He holds a doctorate in philosophy from Boston College and conducts research on ethical aspects of genetic research, fertility medicine, and biomedical research especially as these affect sex and gender minorities. He is the author or editor of 10 books and the author of more than 125 peer-reviewed articles that appear in such journals as the Journal of Medicine and Philosophy, Bioethics, Hastings Center Report, Journal of Medical Ethics. He has been on editorial boards of the American Journal of Bioethics, Bioethics and Reproductive Biomedicine and has been a visiting scholar at the Institute for Ethics of the American Medical Association. Welcome. >> Good afternoon. I I think the first thing I want to say is that my CPR training occurred when I was a Boy Scout camp a long time ago. So, I hope nobody needs to rely on me for that. Um but I'm happy today uh to talk about uh a topic that's of perennial interest uh to uh medical ethics, to clinical ethics, and that is to say physician-assisted suicide. I have no uh disclosures to make in this regard. Uh what I do want to today do today is to um introduce, for those of you unfamiliar, to the AMA ethics opinions regarding physician-assisted suicide and the exercise of conscience. In order to talk about its limitations and to make a recommendation for a shift in the position that it currently holds um with respect to this topic. All right. So, um in the totality, uh the code of method medical ethics consists of these things, and this is what the AMA says, not my making this up. The code consists of the principles of medical ethics, which is a short list, uh its opinions, which are ethical advisories on specific topics, and also the supporting reports that come out of the Council on Ethical and Judicial Affairs um that justify the opinions that they offer on particular topics like uh abortion and physician-assisted suicide and sundry other things. So, when you sort of just as a layman look up to see what the AMA has to say about physician-assisted suicide, it says this. Um after defining the term and acknowledging that some people might decide death is preferable life, it says pretty boldly, "Permitting physicians to engage in assisted suicide would ultimately cause more harm than good. Physician-assisted suicide is fundamentally incompatible with a physician's role as healer, would be difficult or impossible to control, and would pose serious social risks." All right. >> [sighs] >> So, that looked pretty definitive, uh but that's not the whole story. Um in 2019, the AMA was aware that the world was changing around it with the legalization of medical assistance in dying in some states. So, it convened a review of its uh opinion and advisory about uh physician-assisted suicide, and it asked itself whether they should change the opinion or not. And the answer was no. All right. Uh and the reason for that is because despite the condemnation of physician-assisted suicide, provisions regarding the exercise of conscience make room for physicians engaged in the practice. All right. Uh I'm going to explain a little bit more about what this means in particular. All right. So, um to get at the totality of the story about physician-assisted suicide, you also have to take into account the exercise of conscience clause. Um and this is this is a text-heavy slide. I apologize for that. Um we're doing a little kind of textual analysis here. Um the declaration here is that the opinion here is that physicians are moral agents in their own right and are informed by and committed to diverse cultural, religious, and philosophical traditions and beliefs. For some physicians, their professional calling is imbued with their foundational beliefs as persons, and at times the expectation that physicians will put patients' needs and preference first may be in tension with the need to sustain moral integrity and continuity across both personal and professional life. Um the upshot of this is um in so far as physicians are not interchangeable replicas of one another, are the physicians should have considerable latitude to practice in accord with well-considered, deeply held beliefs that are central to their self-identities. And it's here that the door opens to the prospect of participation in physician-assisted suicide as a matter of the exercise of conscience. It also uh allows physicians to opt out of participation in philosophical in physician-assisted suicide for the same reason. Uh I should mention I'm going back and forth between the language of medical assistance in dying, which is typically the statutory language used, and physician-assisted suicide. The AMA wants to put um use that language to put the physician at the center of the analysis, rather than to make it an institutional or legal practice. All right? So, in a master stroke of diplomatic language, uh in this report, the AMA came to the conclusion, weighing all these factors, uh it said, "In the existing opinions on physician-assisted suicide and the exercise of conscience, the code offers guidance to support physicians and the patients they serve in making well-considered, mutually respectful decisions about legally available options for care at the end of life." All right. All right. Uh as I read this, what the the is saying here, uh it indirectly permits physician participation in medical assistance in dying while the same time as an institution formally condemning the practice. Right? So, now the AMA is sort of aware of what it's doing here. It call it says calls the conflict between the pro and con views about MAID, medical assistance in dying, an irreducible moral tension. All right. Um are we stuck here? Um well, let's look at the again the the legal landscape. Uh the world is changing around uh the question of medical assistance in dying in the United States. I think this is right the last time I looked or at least time I uh uh prepared the slide, uh a significant number of uh states uh already allow physician-assisted suicide. Uh New York comes online in a few weeks. Uh by my philosophical ac- account, some 82, 83, 84 million people live in a state uh where physician-assisted suicide is legal and in some cases uh more In principle, everyone in the United States have access to this because at least two jurisdictions do not enforce residency requirements. So, if you're healthy enough to go to Vermont and seek uh help there, you can do it. All right. Um now, I'm going to sort of segue through uh a prior conflict that the AMA has gone through um in terms of um how to balance opposition with uh inclusion of a of a disputed practice. And that has to do with abortion. And I want to suggest that it's the AMA's change over time offers a model for change uh in its uh physician-assisted suicide uh thinking. Uh specifically, um uh historically, I'd say, uh the AMA was a leading, if not the leading force in the United States for the criminalization of abortion in the in this country beginning in the 18 late 1800s. Um the historian James Mohr called the 19th century efforts the AMA's crusade against abortion. Now the resistance to abortion was not absolute. Um the AMA did carve out possible exceptions, but in general the default was set against abortion. And and quite plainly so. Uh so I'll pull out an example from 1967. The policy was that, quote, where there is documented evidence of a threat to the health or life of a woman, and when the child may be born with incapacitating physical deformity or mental deficiency, or when a pregnancy results from legally established or forcible rape or incest, this was an allowable abortion as a matter of medical ethics. Right? But otherwise, the default was set against abortion uh as a matter of uh defensible clinical ethical practice. Right? This opinion came under challenge as United as US society changed. Uh briefly I want to mention Roe v. Wade and Doe v. Bolton, uh which put sent put physicians at the center of decision-making for abortion. In some ways, I read these documents as not conferring on women the right to have an abortion, but conferring on physicians the right to practice an abortion. Right? Um the the physician is center square in these cases. Uh the physician has specific responsibilities in con- consultation, determining the stage of fetal development, and discretion over the technique to be used. Uh Roe even specifically authorized states to limit the practice of abortion to licensed physicians if they wished. Right? Okay. Um now, having set the default against abortion, Roe and Doe come along, the AMA has to do something. This is what it did. Uh its declaration its ethics opinion at the time was the principles of medical ethics do not prohibit a physician from performing an abortion that is performed in accordance with good medical practice and under circumstances that do not violate the law. All right, note that well. Do not violate the law. Because along comes Actually, I'm going to uh skip this. Skip this one. Along comes Dobbs versus Jackson. Right? Um which denied any constitutional right to practice abortion and conferred all decision-making on states and uh territorial jurisdictions. So, now many states, as you know, prohibit abortion. Um but the AMA is stuck with its advisory saying that physicians are entitled to practice abortion unless it violates the laws of the community. All right? So, in this case, the guidance would uh the AMA the guidance from the AMA would confer decision-making authority over abortion on the legislature rather than on physicians. So, uh and this puts physicians in peril. I'll mention this one example from Alabama. Um it's unlawful for any person to intentionally perform an attempt or attempt to perform an abortion except for medical emergencies. Uh the attempt at an abortion is a class C felony subject to 1 to 10 years imprisonment. And the the actual abortion a law unlawful abortion is class A felony subject to 10 to 99 years imprisonment. Uh and I thought this was curious until I looked up this is the standard imprisonment for a murder of a person. Okay. So, the AMA had to change its rule after Dobbs, and what it did here um it said uh the the the the the I'm going to skip the the first part of it and go to the bottom. The principles of medical ethics of the AMA permit physicians to perform abortion in keeping with good medical practice. There's no reference to the law here anymore. Okay. So, to contrast this uh before um Dobbs, we have the the law being uh held in place. After Dobbs, medical practice is the guidance standard. All right? Now, to come to this opinion, the AMA had to do these things. It had to overcome the internal dissonance of its membership. It had to enfold practice within the medicine practice of medicine. It had to commit to the morality of the practice despite its being illegal in the jurisdictions. And it declined to endorse the claim that abortion constitutes wrongful killing. All of these things bear on physician-assisted suicide in their own way. So, the abortion opinion grants physician choice. The AMA might do the same thing with respect to medical assistance in dying. Secondly, uh the AMA situates the practice of abortion with within the remit of medicine no matter that the practice is criminalized in a number of states and heavily penalized. All right? So, this is the kind of questions I'm leading down the path toward. Why should the criminality of MAID in some states pose any obstacle to accepting it as a matter of medical good medical ethics? Um the third point, again, um the AMA endorses abortion in the face of objection that involves the wrongful killing of a person arguably. All right? By contrast, MAID is not vulnerable to this criticism. All right? Um because people are offered a lethal dose to to adults with decision-making capacity. MAID is comparatively easier to defend as a medical practice because it involves no involuntary death. All right. So, um I think what the AMA might do in light of its what it has done with respect to abortion is start to think along the same lines and um enfold the practice of made within medical medicine and uh model a judgment on medical assistance in dying in the same way it has done on with respect to abortion. Namely, the principles of medical ethics permit physicians to participate in medical assistance in dying in keeping with good medical practice. And there are more reasons for this. Um I first of all, to say that it's defensible does not mean anything goes. I think there should still be a standard of care. We should still think about that the practice of it that way. Um but I do want to move to these conclusions. Um the AMA ethics opinions um always reflect the divergent views of their membership. All right. Uh in this particular case, their opinion now is that they both permit and def- and and um disallow the practice of medical assistance in dying. All right. But if you read it closely, um they do give um philos- they give physicians a way to practice med- um physician assistance in doing not in dying in good medical practice through the exercise of their conscience. All right. Um over time, the ethics opinions have not been static. Um the AMA has moved from staunch opposition, a word dropped out here, uh to abortion to indirect acceptance. Um is formal acceptance ahead for physician-assisted suicide? I think it should be. Ethics opinions are an outworking of the theories of medicine and nature and identity. Um the AMA has moved from a staunch opposition to abortion to a guided guarded acceptance to formal inclusion uh despite the debate about the morality of abortion and its relationship to medicine. All right. The AMA right now is not very far from a formal inclusion of MAID within the practice of medicine. All right. It declares the practice is contrary to the nature of the profession, but it also opens the door through the exercise of conscience. Uh the bottom line I'll draw your attention to um every physician right now could invoke the free exercise of conscience to justify their participation in MAID. And when I say every physician um I mean every physician. I know this is doesn't map onto reality, uh but this is the way philosophers think. Uh in principle anyone could invoke this and say uh I can I I all physicians could do this and say I'm entitled to do this and I want to do this. All right. So I think the AMA should ultimately do for uh medical assistance in dying for what it has done for abortion, to accept the practice while excusing physicians who don't want to engage in this behavior. So we have something like this. Again, the principles of medical ethics of the AMA permit physicians to engage in assisted dying in keeping with good medical practice. Um in doing so, at the very least, uh the AMA would acknowledge the practice of MAID openly. We have a big swaths of the country where this is going on. Uh in any particular jurisdiction, it's always a minority of physicians who participate in this. Nevertheless, um it is a part of the legal and ethical landscape. Um it also would make the position clearer to the public of what it does actually allow and disallow. Um and I think this is an important, too. Um it it aligns his ethics opinion with his own recognition that some patients in extreme distress may come to decide that death is preferable to life. If that's true, then why not align the ethics with it? Um and then therefore we would be a better able to achieve the aspirational goal that every patient come to the end of life as free as possible from suffering that does not serve the patient's deepest self-defining beliefs. These are AMA statements. With that, I think I'm done. Those are my sources. Thank you. If you like the slides, let me know. And I'm sure there will be questions and comments. Or maybe not. >> Uh do you know how the uh ethical guidelines for the AMA are created? Do they survey their membership? Does someone draft it and they send it out for approval from the membership? Or is it sort of a unilateral um sort of ethics committee within the AMA that decides it? >> Yeah, it is a uh the opinions are uh the work from the Council on Ethical and Judicial Affairs, and they go through an approval process above that. So the uh Council on Ethical and Judicial Affairs will prepare a report, and then it will be approved by the Board of Trustees of the AMA, and the the opinion uh is put in place that way. >> And you mentioned um everyone points sort of uh conflict or internal sort of tensions from the membership. Do they get feedback? Yeah, or is that how that sort of play like how does that play out? >> to to uh I don't know that they conduct surveys per se. Uh I think the conflict comes from the nature of the AMA. Um most physicians as room I guess not belong to the AMA. So the AMA um is dependent on its membership, which tends to be to come from particular regions uh of the country. It's not representative of the country physician physicianship as a whole. But there are, you know, there is deeply embedded, and I recognize this, deeply embedded views within medicine that physician-assisted suicide does not belong to the nature of the practice per se. Right? >> We do these two quick and then >> I don't I don't know. You're You're here. Sure, we'll go with you. >> I Arthur Singson, Medical College Wisconsin. Tim, nice to see you. Um So, you said for abortion, this is, you know, an issue about maybe the intentionally ending a life. Uh and in medical aid in dying, it's the same. Um but what about the folks who say abortion is different because we don't think that that is intentionally ending a person's life? And yet, for aid in dying, that is the goal. Everyone's on on board that at least the goal is intentionally ending a person's life. So, for those who don't accept that abortion is in that same category, uh does that give you any pause? >> I I will I will take your your your comments as a as a um as a remark that I probably should have been a little bit clearer about what I was doing. Um so, um an abortion and some some views is the involuntary killing of another person. Right? Medical medical assistance in dying is not that because it's a voluntary. It's not the It's There's no involuntary killing. Now, um now there are There's also the camps that abortion is not the killing of an individual, and in that case, um you wouldn't have the same carryover value for my argument from that position. >> Yeah, thank you cuz I do think that that's an important Yeah. aspect. >> Yep. Thank you. >> Um so, one line of uh one line of criticism to MAID that I hear that I find more more compelling than others is um you know, that that basically uh medical practice is ableist and so uh um uh expanding access to MAID or even uh endorsing MAID uh will not will not sort of justly or or uniformly uh increase access to MAID for everyone. It'll particularly increase access to MAID for a population of patients like you know, patients living with disability, um particularly visible disabilities, uh who whose lives you know, we are sort of implying have less inherent worth, right? And they will be uh the fear is that there will be greater pressure. Um so so to that line of criticism, how you know, do you do you find that as reason that the AMA maybe shouldn't, right? Or or would be more morally consistent to not endorse MAID along that kind of uh criticism? >> So this is the uh is there some reason to be cautious about this because of this kind of slippery slope argument? Uh that the vulnerable be um more likely to be as part of the informed consent process brought into medical assistance dying. I think the same kind of slippery slope argument did not stand in the way of the AMA coming to its conclusion about the practice of abortion where similar sorts of views uh were brought forward that the practice of abortion would necessarily lead to uh uh uh actions against the disabled um in in in in intent and in in fact. >> Thank you. >> I'm done. >> All right, our next speaker is Ursula Francis. Uh she is uh a full-time clinical ethics fellow at the MacLean Center for clinical medical ethics. She earned her PhD in classics from Columbia University, a law degree from the University of Chicago where she was also an undergraduate, and a masters in bioethics from Harvard. Her current research interests include the relationship between emotions and medical professionalism, the impact of AI on humanity and medicine, and the temporal dimensions of illness experience, caregiving, and in the clinical space. Today she will talk about a case for catharsis, surgical M&M, and the emotions. >> All right, and now for something completely different. I have no disclosures, but as John Donne once said, no man is an island, and I'd like to acknowledge the following people for their support. Doctors Mitch Posner and Jeff Matthews and the general surgery community for allowing me to sit in and observe their M&M conference for several months. My surgeon mentors in this and other projects, Doctors Peter Angelos, Sparta Shockley, Sean Wightman, Megan Applewhite, and Jason Sulkowski. My fellow McLean fellows, especially my surgeon colleagues, Dana and Song Greg, who were so generous in sharing their thoughts on this project. And of course the administrative staff who are foundational to the life and logistics of the McLean Center and this conference. All right, so I'd like to set the stage for this talk with a brief overview of surgery and the emotions. The practice of surgery imposes unique psychic demands on surgeons who often feel adverse outcomes to be a matter of personal responsibility. As Charles Bosk wrote in his seminal monograph, Forgive and Remember, when the patient of an internist dies, the natural question his colleagues ask is what happened. When the patient of a surgeon dies, his colleagues ask, "What did you do?" As one might imagine, the weight of this responsibility exacts a substantial emotional toll. Surgeons experience high rates of anxiety and depression and have some of the highest rates of suicidal ideation among medical specialties. Rates of burnout, defined by emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment range from 30 to 38% among surgeons. And indeed, there's a strong empirical association between these psychological vagaries of surgery and the incidence and experience of adverse events. In a Boston-area survey of 281 surgeons, 90% reported experiencing an intraoperative AE during their career with 71% recalling at least one event within the past year. 84% experienced significant emotional turmoil after such an event, including anxiety, sadness, guilt, and shame. In another study that assessed 47 surgeons with the Impact Event Scale, roughly a third demonstrated acute traumatic stress that breached a threshold of clinical concern 1 month after an AE. Reporting a medical error in the prior 3 months has a statistically significant adverse relationship with mental quality of life, burnout, and depression. Burnout and depression, in turn, are independent predictors of reporting a major medical error. In a national cross-sectional survey of US surgeons, roughly one in five indicated that they considered taking a break after a patient death. And one in 10 thought that they would abandon their surgical careers. These statistics raise the question of collateral effects on professionalism and patient care. In a 2024 study, Cooper and colleagues determined that surgeons were more likely to have at least one CORS report of unprofessional behavior and more likely to have patterns of such reports than other fields. It is possible that surgeons practice in more stressful environments than other specialties, they suggest, resulting in interactions during high stake events that increase the likelihood of a co-worker reporting a concern. They follow this up with some speculation about how the personalities of surgeons might also contribute to these rates, a subject over which I will pass in silence. I'm just kidding. But on the subject of the surgical personality, on which there is in fact a robust literature, sorry. Uh Surgeons as a group have a statistically higher score on the neuroticism scale of the big five personality profile, which is often associated with greater susceptibility and sensitivity to negative emotions. Yet the realities of frequent exposure to significant morbidity and mortality prompt emotional desensitization for effective medical management. And the culture of surgery has historically lionized stoicism and self-reliance. Surgeons also have demonstrably low rates of self-help help-seeking behavior when it comes to mental health. All of this suggests that while characterologically prone and circumstantially goaded to negative emotions, the surgeon's professional ecology offers little recognition or outlet for affect. As one surgeon put it, we all hide our grief, suffer in silence. The pain can be close to debilitating. An emerging body of scholarship has posited potential remedial measures, including education on positive psychological coping skills, organizational and institutional support for personal wellness and life balance, and institutionalizing mentorship and peer support groups to address second victim syndrome. However, as Dr. Shaksheer and Weitman point to in a recent invited commentary, moving from theory to practice remains a challenge. Further, implementation of resources may be necessary but insufficient in the context of of poor help-seeking behaviors and cultural premium on self-containment. Indeed, one cardiothoracic surgeon described this challenge as follows. It is ironic, he writes, given the similar high-stakes nature that unlike the military and aviation, our specialty offers virtually no education on how to manage ourselves and support our colleagues in such trying times. Instead, we are handed, either overtly or subliminally, assimilated scripts from residency and our culture to do what the retired Navy SEAL Jocko Willink recommends. Get up, dust off, reload, and reengage. An algorithm that works well in many circumstances, but is at odds with current best practices for healing from and growing after major psychological trauma. Having set the surgical stage thus, I'd like to spend a few minutes talking about the concept of catharsis, which I will operationalize with respect to a veteran institution in surgery, the M&M conference, in the third movement of this talk. I will discuss four types of catharsis, taking an interdisciplinary approach to this concept. The first is the Aristotelian theory that tragedy is a medium for the catharsis of pity and fear. The second is the Freudian model positing that psychic healing occurs through bringing traumatic events to conscious awareness and giving them expression. The third is the idea that modes of social purgation, especially scapegoating, are means of restoring social order and reinforcing social norms. And finally, the idea of collective catharsis through a mode of exchange, whereby mutual sharing and support are means of shoring up group solidarity. Let's turn to the origination of the concept in Aristotle's Poetics, where he writes, "Tragedy then is the imitation of an action that is serious, complete, and of a certain magnitude with incidents arousing pity and fear affecting a catharsis of such emotions. In fact, Aristotle imported the term catharsis from ancient medical literature where it refers to the evacuation of bodily humors, which is kind of a an interesting point. Uh so, some scholars have interpreted this passage along those lines arguing that catharsis is the expulsion of negative emotions. Others suggest that catharsis is rather a process of purification restoring emotional and moral equilibrium. Others still suggest that this is a process of intellectual clarification that attends emotional catharsis giving us rational governance over our emotions, a richer understandings of the vicissitudes of life as represented in tragedy, and facilitating learning and inference, a subject to which we will return. This process of emotional release is taken up and reimagined by Sigmund Freud and Josef Breuer as a process of reducing or eliminating a complex by recalling it to conscious awareness and allowing it to be expressed. A process they saw as essential to the remediation of neurosis through the talking cure. Catharsis has also been imported into the context of sociology in two important ways. First, in reference to social purgation or scapegoating. Here, when a piacular event, that is a moment of moral crisis, occurs within a community and threatens the collective conscience, that is, a shared set of norms and values, the majority assigns blame to a disempowered individual within that community. This individual is publicly pilloried and or ostracized, and this process is a mechanism for explaining chance or systemic failures and misdeeds while retaining positive collective self-image, reaffirming shared values, and maintaining social cohesion. A second sociological model of catharsis is that of social sharing. The idea that a collective catharsis takes place when individuals in a community engage in a mode of exchange. This has been articulated by social psychologist Bernard Rimé as follows. Emotion opened up a process that can enhance social integration and social cohesion within the larger community. He writes. By the same token, emotion appears to open up a communal spreading of emotional episodes through which individuals have lived as well as of related questioning and searching for meaning. Emotions experienced by individuals are not only instruments at the service of individual adaptation. They are also major tools serving the adaptation of members of a community. With these four models of catharsis in mind, I'd like now to turn a critical eye to surgical M&M. Morbidity and mortality conferences are recurring meetings among clinicians which focus on medical errors and adverse outcomes. During these meetings, clinicians discuss cases from their own practices involving exigent complications which often rouse complex emotions in their presenters and in their audience. Although M&M conferences are ostensibly about quality and safety improvement and are exactingly technocratic in their tone and presentation. I argue that they perform a tacit social function. They are a forum for emotional and collective catharsis providing a safety valve for the release of negative emotions like guilt, shame, fear, and sadness while shoring up group solidarity. This contemporary model of M&M has evolved considerably from the shame and blame model of decades past. Under this previous regime, senior surgeons would famously interrogate and chastise junior trainees excoriating them with sardonic humor, or relentlessly badgering them to explain and account for bad outcomes in which they may have had no hand. A scenario Charles Bosk describes as putting on the hair shirt. Erstwhile M&M dysfunctioned as a performance of scapegoating to establish and uphold professional hierarchies and norms around technical and normative conduct. But Bosk also acknowledges that M&M was a space for grieving and medical error. Indeed, my observations of contemporary M&M bear this out. In presenting difficult cases, there were several occasions on which presenters became visibly emotional and exhibited behavioral indicators of negative emotions, such as weeping, sighing audibly, and avoiding eye contact. There was also a clear, observable, collective response from the audience, an acknowledgement of the emotional salience of the event at hand, both for the presenter and for themselves in their commentary. As one surgeon put it, "M&M is like Catholic confession. You expiate your sins." There were also clear displays of group solidarity in response to emotional cases. One indication of this was the frequent citation of the social prescription against Wednesday morning quarterbacking, an acknowledgement of epistemic humility in contradistinction to the assertion of epistemic authority inherent in the shame and blame model. Surgeons also engaged in informal sidebars with one another and with the case presenter in which they would align themselves empathetically with their colleagues by recalling a similar complex case, adverse outcome, or ethical dilemma. Instead of shaming and blaming, senior surgeons would take a so-called sandwich approach to feedback, offering a positive response, like an expression of empathy or praise, followed by critique, followed by another positive response. Framing bias prompts us to recall the first and last items in a series, indicating that the most vivid exchange here is a showing of support. Overall, there was an ostensible social norm that privileged perspective taking, recognition, and social cohesion, in many ways the inverse of the scapegoating model. The incidental nature of its cathartic func- function raises the question of whether M&M is the optimal modality for confronting the emotional toll of procedural complications on surgeons, given recent calls for targeted interventions to address the psychological vagaries of surgical practice. I do not suggest that it is sufficient to fill this gap. Yet the tacit nature of M&M catharsis may serve individuals who do not acknowledge their need for emotional stewardship, and so do not seek out interventions. This benefit is particularly salient in the context of the American surgeon, who often models him or herself on a strong and silent archetype. The foregoing case for the cathartic function of M&M has implications for surgeon well-being, and relatedly surgical practice, cutting to the heart of the ethics of professional ecologies and downstream consequences for those to whom we owe a duty of care. In the final minutes of this talk, I'd like to connect catharsis to clinical ethics, invoking the cognitivist model of Aristotelian catharsis that links the emotional process he describes to intellectual clarification and moral purification. In a recent publication in JAMA Surgery, Doctors Hanna Phelps, Peter Angelos, Shawn Whitehurst, and Bardar Shah Sheer argue that surgical M&M's focus on personal responsibility is essential to the development of the surgeon's moral character. This defense of traditional M&M comes in the wake of calls to humanize the conference by focusing on positive outcomes or systemic problems that precipitate adverse events, a lighting human fallibility, or to abolish it all together. Calls animated by concern for the emotional sequelae of medical error. Phelps notes that there is a kind of paradox in play here. In an attempt to protect the moral agency of developing surgeons, she writes, "The denigration of M&M has paradoxically caused it to lose its moral purpose." If we take seriously the idea that emotional catharsis attends the process of ethical calculus and moral development by offering a release of the negative emotions that might otherwise confound this process, and allows us to see with clarity the moral lessons to be drawn from cases, there exists a kind of double irony here. Calls for humanization undercut a process that is critical to engagement with fundamental aspects of our humanity. That is, our emotions, our affinities, and the ability to forgive, remember, and forge ahead. Thank you. So, I welcome questions. This is still in the very normative theoretical domain. I'm hoping to follow this up with a companion empirical survey and also a qualitative study. Uh so, I would really be delighted to hear your thoughts, criticisms, especially from the surgeons in the audience. >> Yeah, thanks, Ursula. That was great. Um I I'm I'm sort of curious uh how you think it's uh the process of M&M conference um helps with this finding the middle ground in terms of dealing with a complication. So, I would say, if someone has a bad complication, as a surgeon, if I have a bad complication, I don't feel badly about it, I have a problem. You don't want me to be your surgeon if I actually don't feel badly if I cause you a complication. On the other hand, if I am incapacitated by my feeling badly about the complication that I have caused this patient, then I can't go on and I can't help anyone else. And so so I I guess I'm curious how do we sort of thread the needle? So we have the appropriate amount of yeah, I feel bad, but keep going on. >> Yeah, that is a a great question. I mean, I think that according to my observations, which were kind of just one M&M at one institution at one particular point in time, uh which is a serious limitation of the study cuz I've heard from colleagues that uh things operate quite differently even today at different institutions. Um there was a pretty good balancing of those issues. So on the one hand, I felt like surgeons, senior surgeons in particular, were quite frank in the Chicago style about the problems that they saw in the cases, the personal responsibilities that they attributed to individual junior surgeons who were involved in a complicated case, and did not mince words when it came to that. But I think that they were also very careful to couch that in empathic response and a showing of solidarity in a way that kind of integrated the error into a broader social structure, and also kind of gave the understanding that everyone experienced an error like this, right? That there are no surgeons who are advancing their careers without complications. And so I think that um that kind of weaving back and forth between those approaches was a really effective way of managing these concerns that you've cited, namely wanting to have M&M conference be an effective uh medium for moral development and taking that very seriously, but also having this sort of process of emotional release and social solidarity that kind of moors the surgeon back in the community after a disruptive event and is in a way a kind of expiation of sins. >> Great. Thank you. >> Yes, please. >> Uh thank you. Um very well presented, very well said, very elegant. Um on a kind of similar to that question, actually. So, if a surgeon experiences an event that overwhelms their capacity to um to adapt, overcome, learn from. And there are such events that are kind of seminal and are the beginning of the destruction of a certain physician. This has happened. Physicians commit suicide, etc. So, my question or even recommendation for your study would be can you find measurable ways that actually help rescue that surgeon or particular patterns within M&M that help restore the morality and the the personal sense of morality and self-efficacy of the surgeon? And I'm talking about and not your routine bleeding, leak, etc. I'm talking, let's say, I have an OBGYN, please correct me, guys, if this doesn't give a good example, but if you have an OBGYN who has the unexpected loss of a previously healthy, low-risk pregnancy delivery and the patient dies. Um how can M&M help the recovery of that especially when there doesn't seem to be much to learn? >> Yeah, I think that is a great question because um in my albeit very narrow experience with M&M, there certainly were cases where it feel felt like there was just no um uh no error at hand. It was just an adverse event that was unpreventable. And I think that those are really devastating in different ways. Sort of more of a an existential or cosmological uh traumatic response, right? The idea that things are out of your control, in fact, in a lot of ways. Um I mean, I think the showing of social solidarity and empathy is particularly important in those cases, but I think that um you get to an important point, which is that I think a M&M conference has, you know, maybe in recent history served this function, maybe has a certain particular function for surgeons uh who sort of again as a as a group not you know, in their totality. Uh maybe don't typically engage in overt health help seeking behaviors. Um but I think that one of the points that I want to make really clear is that I don't think that this is a sufficient mechanism for dealing with second victim syndrome. And in fact, one of our follow-up studies is to do uh some unstructured interviews with surgeons and talk in more detail about the relationship between the emotions and professionalism. And I think that that very question is something that we should ask. So, thank you very much. >> Forward to reading your research. Thanks. Thank you. >> All right, I will say um going into this last talk um we following this last talk we'll take a 15-minute break um and then you can come back and we'll um we'll manage our time appropriately thereafter. Our last speaker is Hannah Bents. Uh she is a Master of Science in Bioethics student at Harvard Medical School and holds a BS in Neuroscience, a BS in Microbiology, and minors in Sociology and Chemistry from Indiana University in Bloomington. She is currently a research intern at the Disparities Research Unit at the Mass Mass General Hospital, and a graduate researcher in the Gender Sci Lab at Harvard University. Previously, she worked in a brain aging lab at Harvard's Department of Stem Cell and Regenerative Biology, and a Molecular Neuroscience Lab at Indiana University. She's interested in interdisciplinary approaches that bridge biology and society together. Today, she'll talk about uh Leaving Skin, Taking Choices, Gendered Patterns of Surgical Paternalism. Welcome. >> Thank you so much. I know I'm standing in between you and the snack. So, I will try to make this as efficient as possible. Um and I'm happy to take questions like after we all adjourn and we can just chat. Um Okay. Thank you. Um so I'm so honored to be here and have the opportunity to chat with you about something that's very important to me. Um today I'll be opening a conversation on how surgical practices, particularly skin-sparing mastectomies, can reflect gender assumptions um that shape patient care. I argue that these practices reveal a broader ethical pattern of temporal paternalism in which clinicians privilege a hypothetical future um of uh patient over the patient's present autonomy and expressed will. Um and I would like to introduce this conceptual framework um and and really invite us to think about these issues in a different light. So to begin, I'd like to talk about the broader contextual histories of surgical temporal paternalism. Um so There we go. Um so hysterectomy is um is a great example of have historically been denied to women um who are deemed too young or insufficiently certain um even when valid medical reasoning exists. Um such as endometriosis and cervical cancer. Additionally, in gynecology and obstetrics, um studies show that many women uh undergo procedures such as vaginal examinations um without meaningful consent. Um perhaps the most famous and grotesque example of um an unconsented procedure is um the so-called husband stitch um in which extra sutures are added after childbirth um to tighten the vaginal opening presumably to enhance um the um sexual partner's pleasure. So this stands as a a stark example of intervention justified by patriarchal assumptions rather than medical necessity. So I would like to introduce the skin-sparing mastectomy into this broader continuum um and um uh of gendered uh paternalistic decisions. So in 1991 um surgeons Bryant Toth and Patrick Lapert introduced the skin-sparing mastectomy or SSM as I'll be calling it. Um this technique preserves the breast skin envelope to facilitate immediate reconstruction following mastectomy. Prior to this innovation uh breast reconstruction often required multiple surgeries prolonging recovery and increasing patient burden um and skin-sparing mastectomy was therefore celebrated as a major medical advancement in surgical oncology um offering improved aesthetic outcomes and fewer procedures for patients. Yet beneath this clinical rationale lies a normative assumptions that many patients have experienced that breast reconstruction is expected or preferable um aft an outcome after a mas- a mastectomy. Um and this is from notputtingonashirt.org where there's a huge community of people who have experienced what I'm about to um talk about. So this tension prompts a critical question when does preserving choice become overriding it? So patients who opt for aesthetic flat closures frequently report discovering that large skin flaps as we see on the left here, um were left behind without their explicit consent. And their surgeons have justified this decision as uh beneficent foresight, protecting patients against potential regret during a moment of vulnerability. However, this assumption privileges a hypothetical future self over the patient's present wishes. Rather than preserving autonomy, it renders patients' decisions provisional and subject to revision by clinical judgment. The anticipation of regret becomes a rationale for overriding informed refusal. In this way, the patient's autonomy becomes something to be managed rather than respected. These practices are not ethically neutral. They reflect deeply embedded assumptions of femininity and embodiment. Um breasts have long been culturally associated with womanhood, sexuality, and maternal identity. Um and when surgeons preserve tissue without consent, they implicitly reinforce the belief that a feminine body ought to be restored. For patients who choose not to go undergo reconstruction, unwanted skin flaps can function as a symbolic erasure of their decisions um to live without breasts, which is already a decision that resists conventional ideals of femininity. Um thus, what appears to be to be clinical foresight can operate as a subtle form of gendered paternalism. These assumptions are rooted in broader expectations surrounding heterosexual, reproductive, and aesthetic expectations. Reconstruction is often framed as the natural or desirable trajectory after a mastectomy. Within this framework, choosing to remain flat can be perceived as deviant or incomplete. So, when surgeons leave the skin just in case, they are not merely preserving medical possibility, but that they are inscribing normative expectations onto the body, and the expectations of beauty, desirability, and social belonging. What is preserved, therefore, is not the tissue, but a culturally sanctioned vision of womanhood. These assumptions are reinforced by institutional structures within medicine. Clinical literature emphasizes multidisciplinary teams composed of surgeons, oncologists, and plastic surgeons, yet notably, a lot of this literature um doesn't include the patient from descriptions of the decision-making team. And even when shared decision-making is invoked, discussions tend to focus on surgical timing and risk management rather than patient values, which we've heard a lot of today. Um decision aids frequently highlight um cosmetic outcomes with comparatively little attention given to the option of declining reconstruction altogether. Patients consistently report um feeling under-informed at the time of diagnosis, um sometimes assuming reconstruction is medically necessary. Importantly, breast reconstruction can provide meaningful psychosocial benefits when freely chosen. However, these benefits cannot be ethically realized um without voluntary and informed consent, of course. Thus, when informing becomes directing, autonomy is not protected. It becomes reshaped. Temporal paternalism is a form of anticipatory decision-making in which um clinicians privilege a hypothetical future of patient over the patient's um current autonomy. In these cases, a patient's current refusal is treated not as a legitimate decision, but as a provisional state to be managed, um and the leaving of the skin just in case exemplifies this logic. And this pattern extends beyond oncology to reflect broader history of gendered medical paternalism. This harm is not limited to mastectomies related to breast cancer treatment, but extends to gender-affirming care, particularly when transgender individuals seek chest reconstruction or removal, commonly referred to as top surgery. Um despite broad clinical consensus that gender-affirming surgeries are effective treatment for gender dysphoria, trans and gender-diverse patients routinely encounter barriers to accessing care, including denial, delay, and extensive medical gatekeeping. Studies have shown that many transgender individuals face systemic obstacles such as insurance exclusions, lack of trained providers, um and bias within the medical institution um that restrict access to medically necessary procedures. These barriers are not just institutional, as they're often rooted in assumption about patient capacity and legitimacy. Providers may require psychological evaluation, proof of readiness, or adherence to binary transition narratives before approving surgery. And I'm very happy to talk to you about binary transition narratives um if you would like to know more about that. Um empirical research on access to top industry further and demonstrates the patient experience long wait times, limited availability of affirming surgeons, and prejudice from healthcare providers when non- bi- with non-binary patients beings facing heightened scrutiny when their surgical goals do not conform to binary expectations. Such practices further reflect a form of anticipatory control like the ones we see with SSM cases. Clinicians position themselves as arbiters of the patient's future well-being, delaying or denying surgery on the assumption that the patient may later regret the decision or fail to meet normal standards of gender embodiment. In this way, access to care becomes contingent not simply on informed consent, but the clinician's assessment of whether the patient's desired future is intelligible within existing gender norms. As with just-in-case skin preservation, the logic of protection operates by subordinating subordinating present autonomy as to a medically imagined future. Only here it manifests it manifests not through unwanted intervention, but through the withholding of desired and necessary care. Whether through unwanted intervention or withheld treatment, the same logic persists. Clinicians acting on behalf of a medically imagined future to preserve binary gender norms. What unites these cases is a shared temporal structure of paternalism. The surgeon's hand reaches not only into the patient's body, but also their future, guided by assumptions of regret, femininity, and normative desire. These practices challenge traditional bioethical models that focus solely on the moment of consent. Ethical violations occur even when procedures are framed as preserving options or offering more options. Informed consent requires more than disclosure. It requires epistemic humility, an acknowledgement that patient's decisions are expression of self-determination. For clinical ethics, this case invites reflection on how anticipatory decision-making and protective paternalism persists even in well-intentioned care. Um it calls for expanding the ethics of informed consent to address not only informed disclosure, but also the temporal and gendered assumptions shaping medical judgment. Clinicians must cultivate humility and recognition that respecting autonomy includes honoring refusals and uncertainties as legitimate forms of self-determination. And to address these harms, we must recognize informed consent as an ongoing dialogical process and confront the gendered hierarchies that underlie protective decision-making in medicine. When surgeons leave skin just in case, they claim to preserve possibility. In practice, they preserve the boundaries of gendered medical systems. My argument is not that clinicians act maliciously, but that their decisions are influenced by broader sociocultural norms um embedded within medicine. I have no relevant financial relationships to to disclose. Um thank you so much for your time and attention. I welcome your questions, feedback, criticisms, and curiosities, and I'm very happy to email you my references if you're interested. Thank you.