Here’s to Your Health
Although we are not related, I wish that we were. Dr. Jay Jacobson is an extraordinary individual. He is Professor of Internal Medicine and Infectious Diseases and Chief of the Division of Medical Ethics at LDS Hospital, and the University of Utah School of Medicine. He received his medical degree and residency training in internal medicine at the University of Florida. He did special training in epidemiology and infectious diseases at the Centers for Disease Control and the University of Utah, where he joined the medical faculty in 1978 in the Division of Infectious Diseases.
In 1988, he became involved in the emerging discipline of medical ethics. To this end, he studied at the University of Chicago Center for Clinical Medical Ethics. Returning to Utah, he established a new Division of Medical Ethics with colleagues from the University of Utah College of Law, College of Humanities and the School of Medicine. Later, he served on the American Medical Association’s Council on Ethical and Judicial Affairs, American Medical Association’s Council on Ethical and Judicial Affairs, the American College of Physician’s Council on Ethical and Judicial Affairs and the American College of Physician’s Ethics and Human Rights Committee. He is known in the community for participating in local hospitals’ ethics committees and chairing the School of Medicine Institutional Review Board.
For four years, this extraordinary man directed a Robert Wood Johnson Foundation project to improve End-of-Life Care and, in 2004, he was awarded the Isaac Hays and John Bell Award for Leadership in Medical Ethics. In 2006, Dr. Jacobson received one of the highest honors possible in the profession when his medical students nominated him for the American Association of Medical Colleges Humanism in Medicine Award.
Dr. Jacobson holds forth in the newly built Health Sciences building, which houses classrooms and laboratories for the medical, nursing, pharmacy and allied health sciences. The teaching is under the auspices of the Division of Medical Ethics, Medical Humanities, Department of Internal Medicine and Medical Humanities. The classrooms in the new building are all wired for students to take notes and to respond to their professors on their computers during class. This allows the students to interact with the professors in a non-threatening environment to questions that may be sensitive. The result is the teaching, not only compassionate, but also competent. Sometimes in medicine there is no time for compassion, but we must value both. Compassion can be taught as part of competence in medical education and all of the health sciences as well.
The doctor contends that disease of any kind influences the individual. We in the medical community need to know about that impact so that we can provide respectful and humane care. In addition, it is important to engage all care providers, patients and families to resolve their ethical conflicts in care. Each party may have differences, and we must communicate with them to understand all of the facts. It is then the explanation and methods of care can proceed in an ethical manner. Sometimes we may find that reasoning can be enhanced with literature, film drama, and art. All of the team must be informed regarding ethical issues so that the medical staff can be prepared to communicate compassionately, and with empathy. Medical students and other health care providers must be educated to learn "detached concern" because we are so close to the problem. We must not "internalize" because we would lose our ability to treat the patients because of our internal angst. This isn’t general knowledge and is important so that physicians and others can better understand the problems objectively, and imagine the other side of the problem with objectivity. Becoming emotionally attached will lessen the need for objective decisions by the health care providers. Furthermore, we must be prepared for anger in patients and their families when decisions must be made for the patient’s good. By having an objective perspective, caregivers will be able to get past rejection when a patient refuses care.
Moral reasoning is also explored. The Ten Commandments tell us not to lie. Discourse with the students is promoted and theories of ethics are discussed. Jacobson says that it is important to help the student to gain insight into the doctor/patient relationship. It is important to learn social history, cultural experiences to understand how people react. For example, when mistakes are made disclosure is essential. Feelings of inadequacy are present when mistakes are made, and one must "read between the lines. Hope is life extension while death is considered a failure." Our society is diverse and we must be able to understand and empathize with different cultures. Social workers may also be brought in to explain diversity and how to deal with the immigrant population, for instance.
Jacobson spoke of the use of literature, poetry and film to assist students in understanding their patients and their needs. He mentioned one film, "A Beautiful Mind," that gives us a great example of schizophrenia and its treatment. Books such as "On Doctoring," by Richard Reynolds and "How Doctors Think," by Jerry Groutman are also suggested.
Internal medicine residents, nurses and other hospital personnel are also encouraged to participate in these discussions. Colleagues in the rest of the medical community and hospital personnel are also invited to the ethics lectures at the University of Utah.
Other discussions relating to medical ethics are related to events that are timely, such as a family’s right to refuse medical treatment. An advance directive in a patient’s will, and right to privacy laws are also included in the discussions that are held amongst the students and the community at large.
Assisted suicide is another issue discussed. It is legalized in the Netherlands. Oregon is the only state in the United States where suicide is permitted, however it requires a sustained wish for over two weeks. Following the two weeks, a physician is allowed to prescribe oral medications that will assist in the termination of life. The "wish" is also reviewed by other physicians who review the medical records. It is interesting that minorities are under-represented. Psychiatric, suicidal and depressed individuals are often those who might choose to end their lives. Those with chronic and painful diseases may also choose to end their lives. A patient must make his or her own decision. Even so, the practice in Oregon is not that prevalent with only a fraction of the state’s patient population choosing assisted suicide. In the Netherlands the large percentage of those who engage in the practice are the elderly and mentally demented if the families choose. This is not the case in Oregon.
Jacobson explains a recent Roberts Wood Johnson Grant for research specifically for the ethical approach to end-of-life care. Living wills are being studied to provide a humane end to a terminally and persistent vegetative state. No heroic measures are allowed and only medications for pain are included in the advanced directives being studied.
It is of interest to note that when the emergency medical technicians and their ambulances are called, a will is irrelevant. Their charter requires medical attention. Sometimes it might be better to let the patient die peacefully at home if the condition is known to be terminal.
On the other hand, "Durable Power of Attorney" says what, who, and when a patient does not need to be treated if in the last stages of life. The family member who is delegated to have the power makes the decision.
A recently enacted Utah law is deemed to be better than a living will. This law allows each individual to instruct his loved ones on his or her wishes at the end of life. This discussion is between spouses, or close relative. There are no conditions, and you or a loved one can express his or her desires on a specified form. Then the family will be able to proceed based on the deceased wishes. It appears that the more you talk about the issues, the better it will be for the family left behind. They will not have to feel guilty because they might go against other family members,’ or those of the diseased.
This discussion on medical ethics affects all of us at one time in our lives or another. It makes for safer patient care because we can be assured that the issue of ethical care is being addressed. Most important, it helps all of us when we meet with serious medical conditions. It will enlighten us to make the right choices by making us feel that we have done all that was possible.
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