August 15, 2023 • 59 mins
This episode of ReligionWise features Dr. Bob Machamer who teaches courses on Health Care Ethics at the Pennsylvania College of Health Sciences. In this conversation we consider both the historical context for considering healthcare ethics and the changing dynamics of the field, particularly as it addresses the implications of a more diverse patient population. As a teacher, counselor, and pastor, Dr. Machamer brings a multifaceted approach to these questions; this discussion deals primarily with the practical considerations and implications that he deals with in his wide experience with students and clients.
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Chip Gruen (00:03):
Welcome to ReligionWise the podcast where
we feature educators,researchers and other
professionals discussing topicson religion and their relevance
to the public conversation. Myname is Chip Gruen. I'm the
director of the Institute forReligious and Cultural
Understanding at MuhlenbergCollege, and I will be the host
for this podcast. In this seasontwo of ReligionWise, we will
(00:24):
continue to consider a broadvariety of religious and
cultural beliefs and practices,and try to understand their
place in the contemporaryconversation. If you like what
you hear, I encourage you toexplore the 12 episodes from
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we would love to hear from youwith your questions, comments,
or suggestions for futureepisodes. To reach us, please
(00:48):
visit our website atreligionandculture.com. There
you will find our contactinformation and also have the
opportunity to support thispodcast and the work of the
Institute. Today's guest is Dr.
Bob Machamer adjunct faculty atthe Pennsylvania College of
Health Sciences, who teaches acourse entitled Ethical Issues
in Health Care to undergraduatestudents studying to become
(01:10):
healthcare professionals in anumber of different capacities.
Dr. Machamer, who is also alicensed Marriage and Family
Therapist, and an ordainedminister in the ELCA Lutheran
tradition serves as the seniorpastor at St. John's Lutheran
Church in Boyertown,Pennsylvania. So today's episode
features a conversation thatI've been really curious about
and interested in for a longtime. Here at Muhlenberg
(01:32):
College, I served on the PreHealth Advisory Committee. And
one of the things that we did iswe designed a program called the
Shankweiler Scholars Programthat is interested in
cultivating those interested inmedical professions in academic
interests other than biology andchemistry, of course, biology
(01:53):
and chemistry being important tothe study of medicine. But the
argument goes that so are otherthings, whether that be history,
philosophy, the study ofreligion, or things in the
social sciences, psychology, andsociology, etc. And as part of
that program, I've had theprivilege of talking to students
about the confluence ofreligious traditions and our
(02:16):
pluralistic society in whichpeople might come with a number
of different worldviews into amedical facility, and the
provisions of health care thatthey find there. One of the ways
that I talk about this, is thatI say that it's important that
medical professionals realizethat providing health care to a
(02:38):
human is not like a mechanicfixing a car, there's a lot more
to it, it is not simply a matterof replacing the oil, or
switching out the carburetor,the person who's coming into
that office is coming withpotentially very different ways
of understanding the world,understanding their body,
(02:59):
understanding the nature of lifeand death, then we can assume
the practitioner has right thatthere is a very different,
potentially very differentworldviews that are operating in
that office simultaneously. Now,of course, the hospital
facilities in particular, havechaplains offices over the last
(03:20):
few decades, those chaplainsoffices have become increasingly
literate and competent todealing with people who are
outside of their own tradition.
So a Catholic chaplain might beable to deal with issues from a
Jewish patient or a Muslimpatient cetera. But as we move
(03:44):
forward, it seems to me that notjust in the chaplains office,
but also within the healthcareprofessionals themselves.
Knowing how the treatment ofpatients and ethics around
patient care might be affected,if someone coming in is a Hindu
or a Buddhist or a secularHumanist, for that matter, that
(04:08):
the way that care is deliveredmight be very different,
depending on how that personagain, understands their body
understands the nature of lifeand death, understands the
procedures and the ethics ofthose procedures. The other part
of this that I think is reallyinteresting is the confluence of
ethics, and morality, legality,and patient autonomy. We as a
(04:33):
21st century American societywith a particularly capitalist
and materialist worldview arereally interested in what is
legal to do. And so sometimesthere is a conflict between
ethics and legality and theindividual beliefs practices of
both the practitioner and thepatient themselves. Dr. Machamer
(04:55):
comes in as somebody who isresponsible for talking to
students headed into health careabout some of these issues and
to make them aware. And so withthat, I welcome Dr. Machamer to
the program. Dr. Bob Machamer,thank you for coming on
ReligionWise.
Bob Machamer (05:13):
Chip I'm excited to be here with you and to
continue the conversations thatwe started just a few weeks ago.
Chip Gruen (05:20):
All right, so let's jump right into it. So I'd like
to start our conversation byhaving you introduce yourself
and the trajectory of yourprofessional life. Your training
is really wide. It's bothscholastic as well as clinical
and practical. Can you tell us alittle bit about your biography
and background that led you tothe place now where you teach
ethical issues in healthcare?
Bob Machamer (05:40):
Surely, coming out of Grove City College as a
psychology major, I found myselfin seminary in Boston, exposed
to all kinds of traditionsdiversity that I never
experienced growing up inLebanon County or in Grove City.
That was the challenging partfor me, learning not only the
(06:01):
academics at Grove City, andGordon Conwell putting together
my organizing principles oftheology, but then trying to
figure out how to, in apractical way to relate to God's
creation. In my firstcongregation, I realized that my
training was pretty inadequate,when it came to the problems
(06:24):
that people would come into myoffice and want to discuss, and
the field of ethics opened upright there, because I think the
field of ethics is aboutpractical decision making. And I
think that the principles andthe theories that we talked
about when studying ethics areincredibly helpful. The theories
of course, the decision makingmodels that we use with them,
(06:46):
and then the principles thatfocus specifically on the
individual, are they upheld,arethey violated. My work at the
college as an adjunct hasexposed me to health care
workers, those in training,those that had been there for
20, 30 years, but came back toget their BSN, the bachelor's in
nursing, and that was amarvelous experience, because
(07:09):
they already knew 20 times morethan I knew. And then they would
put it into their case studies.
And it started my thinking ofhow can we help? And how can we
be a people who regard eachother with respect? How can we
uphold these things that wetalked about in the textbook?
How can we do that for and withone another? I think simply at
the end of the day, it'll boildown to what kind of person do
(07:32):
we want to be?
Chip Gruen (07:37):
So in our preliminary conversations,
leading up to this discussion,we were both really rather
insistent that we get practical,and we'll deal with case studies
later. But I think it'simportant to consider, at least
in brief, a little background,the method of the field, that
this you know, ethics isn'tsitting around in a circle and
(07:59):
talking about our feelings, itis grounded in a very old
discipline. So can you give usthe one foot version, the brief
version of the intellectualtradition that sits behind the
way that you teach this topic?
Bob Machamer (08:12):
Absolutely. Our first class, the first hour and
a half of teaching the classthat I teach, and it's generally
an intensive it's a five weekprogram. We talked about Western
world, of course, and it's, it'straced back to the ancient roots
with the Greeks, the School ofHippocrates, and all of the work
(08:32):
that they put out. I mean, backthen you have physicians who are
both healers and executioner'sthey supported euthanasia. So
coming out of that tradition andshifting that through the years,
and that's BC, that's 300 yearsbefore. And and if ethics is the
practice of decision making, ifit's if it's to be practical,
(08:55):
and it's problem solving, thosekey components that were put
forth by people like Aristotle,that pursuit of excellence for
Aristotle, being a virtuousperson, what does it mean to be
a virtuous person, and the wordthat he used Eudaimonia it's not
(09:17):
just happiness, it's not justflourishing, we don't have a
synonym for it in our language.
It's, it's it's engaging,virtuous character. And I think
beyond Aristotle, in moving moretoward Aquinas, 1500 years
later, as a philosopher as atheologian, I think that Aquinas
(09:37):
brings both the head and theheart puts together right action
and right thinking in terms ofgood and evil of course, during
that time of history, virtues,the preservation of life, the
preservation of the species, thepursuit of truth, which kind of
sounds like something that inour country was written right
(10:02):
about the time of theDeclaration of Independence. So
we talk about that, yeah, we getwe, we spend a little bit of
time in Aristotle, we move toAquinas. And then we get into
where we are today, and thechallenges of what it means to
be one who is in healthcare as aprofessional, not just
physicians, but everyone inhealthcare.
Chip Gruen (10:25):
So I think we'll get the opportunity to talk about
this more, but I just want toput a marker here and get some
preliminary comments on the waysin which this intellectual
tradition that we're, you know,that are the background of the
class, Aristotle, Aquinas, etc,are the Western intellectual
tradition. And not only theWestern intellectual tradition,
(10:48):
but then the Catholic scholastictradition as well. And I think
it from my perspective, it lookslike, particularly the Catholic
piece, the Christianintellectual history piece of
that can sometimes be occludedwhen we have these
conversations. It's not frontedright, that ethics is imagined
(11:09):
as secular. But it seems likelooking at this, the
contemporary at conversation andethics is rooted in a particular
background.
Bob Machamer (11:17):
Absolutely. It's hardly secular. I mean, we could
make believe that it is so butit's not. The traditions of
faith, Judeo Christian, are sodeeply embedded in ethics, our
traditions have something tosay, when people come in to ask
questions, they're looking forguidance, they're looking for a
(11:40):
direction to go. And I believethe combination of the two,
provide us with thosepossibilities in Judaism, of
course, tradition has somethingto say about life life, before
it comes out of the womb lifeafter it comes out of the womb,
a sense of community, perhapsdifferent than we've experienced
in the Catholic Church or theProtestant church, it's vital
(12:02):
that we find a way to have thosediscussions and continue to have
those discussions not in alegalistic way. But in the
methods of discovery of wherehumanity share a common good,
share a common good end commonperhaps, if I can say, a common
not so good or evil, to identifythat, and then to operate out of
(12:24):
that in the way we provide carefor one another.
Chip Gruen (12:28):
So your background is one that is I mean, you've
mentioned your seminarytraining, that, you know, the
way that you practice isinformed clearly, by the
religious intellectual traditionas well. But at the same time,
and this is one of the things Ireally want to get across in
this conversation, that thattradition, as you understand it,
(12:49):
is very progressive and veryinclusive. And so I wonder about
how, again, that intellectualtradition within Catholicism and
then moving moving forward intime, is that a barrier, you
know, to that kind of inclusive,multicultural, you know, world
(13:14):
and context in which you'reliving in or do you recognize
that and then move on? How Howdoes the coloring of that
religious tradition affect thepractice and understanding of
contemporary ethics for a peoplewho is not necessarily lockstep
on the same page for those sortsof spiritual or theological...
Bob Machamer (13:35):
It smacks us in the face, you think about the
Hippocratic Oath, hundreds ofyears before Christ walked the
planet. Then you see theinfluences by the Middle Ages
where Islamic communities alsoaccept the Hippocratic Oath. And
it goes right down the line. Nowwe have, we're not we're the
traditions, the religion that wehave, what we've been taught,
(13:58):
didn't know the internet wasgoing to arrive. They didn't
know that we would havereproductive technologies for in
vitro fertilization. They didn'tknow that there will be non
blood products available forblood transfusions. So for us in
my area in this Lehigh County,born and raised in Lebanon
(14:22):
County and close to LancasterCounty, Amish population and
Jehovah's Witness, they now haveavailable to them the blood
products that their religion andtheir hierarchical structures
would have said, You areprohibited from receiving that
except in the case of a minorthat's, that's a whole other
legal issue. But I think thoseare the things that are in
(14:44):
current medical practice, nowbeing questioned and being
discussed and I'd see lots ofdiscussions going on around the
country. Our large major healthcare systems are now extended
programs 3, 4, 5 sessions 3, 4,5 weeks to time, exposing their
healthcare practitioners, theirnursing staffs their, their
(15:06):
radiologists it's all coming toa beautiful head, I think. And I
see it as a positive experiencehaving circumstances that were
never questioned in the past.
Now we're saying, wait a minute,I'm grateful for that. I'm
grateful that I'm at thebeginning of learning about it.
I don't, I don't know all ofthis. I know that I need to know
(15:28):
more.
Chip Gruen (15:32):
So one more question on context. And then we'll start
jumping more into the practicalthe case studies the where the
rubber hits the road. Whenyou're introducing these topics
to students, it's myunderstanding that you give them
a few broad categories, orprinciples to anchor their
thinking in the field. Can youtell us a little bit about that
basic schema, even if it's justto give us the vocabulary that
(15:57):
we need in order to understandthe conversation or the field?
Bob Machamer (16:02):
Sure, the the first day of class, they're
handed two pieces of paper onthe one, they have the
definitions of the four ethicalprinciples that I use in class
autonomy, everyone has the rightto decide for oneself. The
danger, of course in modernmedicine is paternalism, doctor
(16:25):
knows best. Beneficence is thesecond ethical principle to do
well to do a kindness to do goodand, and to not do harm.
Nonmaleficence is to do no harm,or the way I teach it is to do
no further harm, harm probablyhas already happened. And then
justice, to be fair, to behonest, those four ethical
(16:46):
principles are at the root ofmedicine for centuries. But in
recent years, they've becomeeven more important to the
conversation of how do we decideyou have ethical theories. So
you have the theory in and ofitself, and then you have meta
ethics, which is the questioningabout those particular stated
theories. So for us, we startwith those four words. And I
(17:09):
tell them at the end of thefirst class, please learn these
words, learn learn what theyare, because you're going to use
them and ethical principles arealways about the individual.
They're never about thehealthcare system. They're never
about the family in the room.
They're always and only aboutthe individual. So autonomy can
either be upheld or violated onbehalf of the person.
Beneficence can neither beupheld or violated justice can
(17:31):
either be upheld or violated.
And sometimes it's really hardto distinguish which way to go,
the ethical theories ofconsequentialism, where the
outcome is more important thanthe intent, where the the the
overall consequence, what dowhat's more morally right. And,
(17:54):
and seek to do the greatest goodfor all people, it's not just
the greatest good for thepatient is the greatest good, it
has to be a larger number to beunderstood as consequentialism.
Deontology is always duty based.
And I laugh, because this is theexample that we use is one that
is familiar to those who arenurses in the profession of
(18:15):
nursing, they will invariably bewith a patient and they're,
they're cleaning a line orthey're working with the patient
or they're, they're changing adressing, and an x ray
technician might show up and thex ray technician is there to
simply do their duty. And theirjob is get the job done and get
the x ray. So in the middle ofthings, they're ready to move on
(18:37):
to the next patient, they haveanother patient that they've got
to get their equipment to. Andthe nurse then is in conflict
with their own healthcare team.
So we have those deontologicalconflicts. Again, it's theory,
virtue ethics, probably where wecould spend the most of our time
(18:59):
because I am one that believesin virtue ethics. So at the end
of the day, what kind of Pastordo I want to be? What kind of
therapist do I want to be? Whatkind of husband do I want to be?
What kind of human do I want tobe? What kind of advocate do I
want to be for marginalizedgroups? I think modern
healthcare is going to belooking at that. I think modern
healthcare has to be looking ateveryone who is marginalized. If
(19:22):
50% of the research is correct,that 50% of physicians,
prescriptions that are handed toa patient are that they go
unfilled, primarily because thephysician didn't ask or they
didn't know they can't affordit. So 50% of prescriptions go
unfilled, or they go to the backshelf of the pharmacy at Wegmans
(19:46):
and no one picks them up. It'sbecause they can't afford it. So
healthcare has to get way pastpatient as client, they have to
be patients as people. Those arethe challenges that I talk about
with with my class, and then ofcourse, authority based
religious ethics, in the Amishpopulation, your Bishop comes
(20:07):
into the hospital and helps youand if not helps you makes the
decision on your behalf that canhappen with Jehovah's Witness at
well, my Bishop has never beenin my office never been in my
hospital room to tell me what mynext procedure is going to be.
And I'm grateful for that,because I'm not sure my Bishop
would know any better than Iwould. So.
Chip Gruen (20:28):
So I want to push on this a little because you you
mentioned, right, you give thisframework you give these ways of
understanding. I've noticed andI've had the privilege to talk
to, you know, first yearstudents who are interested in
studying health care that I'vehad the privilege to have the
(20:50):
humans are not carsconversation, like how can we
think about religious andcultural backgrounds? As a as
one of the, you know, theprimary context for delivering
care. And one of the things thatI've noticed in those
conversations is that they'rereally interested in thinking
about what's legal. And thenthey have a hard time separating
(21:12):
the con... the conversationabout what's legal, from what
ethical. Do you see a similarpropensity here? Is that the way
your conversations go?
Bob Machamer (21:21):
I can't I don't have a conversation, I may be
speaking hyperbolically but Irarely have conversation where
that does not enter in. Andthat's why the class that I
teach always has a legalcomponent and most healthcare
institutions or health careoriented programs, college
programs, at the undergraduatelevel, in their very first
(21:43):
class, there is always the legaldimension. Frequently, it's
discussed by using case studies,case studies such as Tuskegee
Airmen, and and how they werenever. Their consent was never,
it wasn't even known to them.
They didn't have any option toconsent to the study on syphilis
and all that longitudinal workthat was done. Henrietta Lacks,
(22:08):
there was no awareness. And infact, there was a blatant, her
husband said, No, you may not.
And yet her genetic material hasbeen purchased. And it's
probably in most labs around theworld to think that we could
have had people of faith basedbackgrounds promote promoting,
(22:33):
advocating for necessarilyhiding that, that now is in the
front of 18, 19, 20 year olds,when they're sitting at an
undergraduate class, and they'resaying, how could that have
happened? That's good question.
What we do in that it didhappen? I think is the question
that we want to be responding toand making sure that in the
(22:55):
future, those things don'thappen. Informed consent is a
big one. Implied Consent is bigfor folks, seemingly smaller,
but not so much. So what doesone do when an attorney comes in
a prominent attorney, and thestaff are preparing the
paperwork and the doctor and theattorney are talking and the
(23:17):
doctor knows that the paperworkis only good for 30 days, and
the surgery is scheduled now for35 days? And the attorney says
yeah, but I'll sign it now. Thatpaper is illegitimate. It's,
it's and it would be wrong toproceed. What does the nurse
what does the lower level on thehierarchical chain do? How do
(23:41):
they confront? How do theyuphold the patient's right to
making an informed decision,however, holding Upholding
justice for the organization andits documents? I have folks
writing practice dilemmas. Forthe five weeks. I have hundreds
(24:02):
and hundreds. In fact, I havesome with me right now, of
healthcare staff that had beenput in positions where they're
in direct violation of not onlythe regulations of the hospital,
but also of general practice oflaw.
Chip Gruen (24:20):
Yeah, the case that sort of sticks out to me and I
don't have the details at myfingertips, but it was someone
who served as an EMT, and thatthe EMTs are sort of both on the
frontline and with relativelyminimal training to do what
they're being asked to do. Butit was a blood transfusion case.
(24:43):
And I think that they had beeninstructed that well long as the
person's unconscious. It doesn'tmatter. Like legally, you can do
whatever you need to do, andyou're you're protected. You're
covered. And it was it was very,it's very odd conversation
because it felt I mean, it feltvery pragmatic, it felt very
(25:05):
practical. But the values of theof the system were values at
life at any cost, as opposed tofollowing the wishes of the of
the patient, even if those areknown and sort of the legal
maneuvering, right, or the legalways of getting around that, it
was a little surprising to me.
Bob Machamer (25:27):
There are lots of cases of record about that, if
it's known, and their agentmajority if they're adults, and
they say I do not want a bloodproduct that is honored. In most
cases. Sometimes injunctions arebrought in court systems people
(25:47):
are rbrought in. If they're aminor, all bets are off. And
again, I'm not an attorney. Butfrom the studies that we've used
in class, the case studies thatwe've, we've read together as a
class, and we've discussed as aclass. And they are concerned
about that they're alwayslooking for good up to date
(26:09):
medical records. Now that's onthe patient. So if my chart, and
if I were in an accident, when Ileave here, the healthcare
people that are arriving in thatambulance can pull up my
records, because I'm in that bigsystem, so whether I'm
transported to Lehigh ValleyHealth Network or St. Luke's
they'll have my chart andthey'll know all those things
(26:31):
right at the top. He may he doesnot he wills he does. All of
that is right there. So we livein a great age, to be able to
create that environment ofconsent. But what about the
rural areas? And what aboutwhere that technology doesn't
exist to the degree that we havehere in the Lehigh Valley, we do
(26:55):
talk about that we do talk aboutthe religious orders that we may
or may not know, because thatmay not be on the chart. That's
what confronts the students inLancaster. They're not always
sure what to do. When a patientcomes in, and a person comes in,
and they are Amish, they don'talways know what to do. But that
(27:18):
I know, the hospital system hasworked very, very hard to work
with those denominations andthose particular religious
groups to talk about the law andthe medical practice before we
arrive at the need for that totake place. Those discussions I
know are going on in Lancaster.
So I've got to believe they'regoing on all across the country,
or at least I hope so. And ifnot, we need to advocate for
(27:40):
that to happen. Let's have theconversation before we are in
that last minute where we needthose life saving measures. Now
those are my words. Because forthe person who is Amish, it
might not be life saving at allit because it might be an
affront to what they believe tobe the will of God. For me, my
body. And maybe this helps withthe legal question. For me, I
(28:04):
have an obligation to take careof my body, I believe that God
gave me this body. So if I were,if I were renting or leasing an
apartment from you, I havecertain obligations to not
destroy it, I have certainobligations do not leave the
water running and that the floodpours out over the window sills.
I have legal obligations also tomaintain it so that it doesn't
(28:32):
become infested with bugs,health care professionals today
are being confronted with all ofthat, in an environment where
patients can be seen as clients,and that people in an
environment where physiciansaren't just medical
practitioners. They're in anindustry, they're they're joined
(28:52):
to a business contract. And whenwe sign all those sheets of
paper, I do not read all ofthose sheets of paper word for
word. But I was shocked I was ata doctor appointment not too
long ago. And on the desk, itsaid if you have ever or plan to
or think you might want to filean action against us, we will
(29:14):
not see you as a patient. I havenever seen that in a major
health care system right here inthe southeastern part of
Pennsylvania. And I asked theperson at the desk. Can you
explain this? And they said no,you have to talk to your doctor
about that. When I asked mydoctor about it. They said we
just don't have the time tospend in the courtroom. So we
you're vetted. We already knewthat you haven't filed any legal
(29:39):
action.
Chip Gruen (29:41):
Wow.
Bob Machamer (29:42):
Patient care, patient autonomy, justice, all
that's on the table right nowand the laws are being rewritten
and debated all the time.
Chip Gruen (29:50):
Well, and it's interesting. I mean, given your
your roots where you teach andwhere you have been a therapist
the examples that you bring upare good ones as a Jehovah's
Witness and Amish. But I'll justsort of say, you know, one of
the goals of the Institute is toget people broadly literate
(30:11):
across all kinds of religiousdifference in that one of the
examples that I bring up and itmight sound very small to to
people, but the prohibitionagainst cutting hair in Sikh or
Sikh communities. And so youthink somebody comes in for an
emergency surgery, and you haveno idea why that person wears
that turban, right, much lessanything else, or that there are
(30:33):
particular undergarments thatmarried individuals don't take
off in that community, right,and you cut those things off, or
you cut the you shave an areafor surgery, or whatever, and
you have just committed a majorviolation of that person. And so
and that's one of the examplesthat I know about. But as our as
our world, I won't say becomesmore multicultural pluralistic,
(30:56):
but as we're recognizing thatpluralism and multiculturalism
and religious difference moreand more and more, I've got to
think the numbers of those kindsof literacy issues, right, that
people need to be aware of isjust going to grow and grow and
grow and grow. And I hope ourhealthcare system is up to that
challenge.
Bob Machamer (31:13):
I think that what you're talking about is exciting
for some, and I think it'sfrightening for others. And I
believe that many people wouldsay, Gosh, how much time is it
going to take to train thatnumber of people. And the
reality is, we're going to haveto take the time. So programs
may need to be lengthened,rather than abbreviated. What
(31:34):
once took four years to receiveyour degree. Now, one can do in
18 months or 24 months, to savemoney and to create money for
institutions, we may have tobackpedal and prioritize people
over dollars, medical treatmentis big business. That is not
(31:55):
something said lightly. Becauseit should be about people. And I
believe in general, I meet veryfew, I can't say that any of my
family's physicians treat uslike we are widgets. I really
can't. Now we we're carefulabout where we go. And we have
met physicians, and we've said,No, thank you, and we move on,
(32:18):
and we find the next person,because we look for people who
treat us as people. Now, when itcomes to the variety, the
pluralistic society that we havebeen for decades, we can't
ignore that any longer. I thinkthat will happen through
conversations like this one. Andyou'll have people on that are
far more knowledgeable than Iam. And that's the benefit.
(32:41):
Because I'll listen to the nextconversation, not one that I'm
on with you. But I'll listen tothe next person. This is a great
opportunity, I think, to openpeople's eyes to diversity, to
equity, to inclusivity. To, toreligions that they've never
heard of. And to do it in a waythat perhaps doesn't engender
(33:06):
fear or threat, like around9/11. Oh, my goodness sakes. And
for Asian Americans, oh, mygoodness sakes. Health care has
to be aware of that when aprisoner is brought in when
somebody in an orange jumpsuitis brought into the hospital,
and they are in line to receivetreatment. And people are
(33:26):
screaming in the waiting room?
Why does that person get toreceive treatment over my child
who is crying and in pain?
There's a reason because they'retreated as humans, regardless of
what their resume says somethinghas happened in their life
that's put them in that orangejumpsuit, law and health care.
(33:50):
It's wide open now. And we wantto participate in it. Thanks for
asking that question. Inparticular, because of all the
things that we've talked aboutso far, I think I could probably
talk about the principles and Icould talk about the theories
and I can speak about it withsome fact based confidence. But
you're asking questions, that itseems to me, we don't have good
(34:13):
answers. But I appreciate thegood questions. And I hope that
the listeners are hearing thatgood questions might just be
more important right now thanthe good answers.
Chip Gruen (34:26):
When we think about something like religious
literacy, for example, culturalliteracy, and we think about how
is it that we deal with that inthe medical training of
individuals? Well, those peoplewho are trained to be doctors or
nurses or whatever in themedical field, have been to an
(34:47):
undergraduate institution. Andhere's my soapbox moment, is
that the humanities right andteaching about, about difference
and about ways of being in theworld and about meaning and
Those sorts of things that Ithink informed this conversation
don't have to wait until you getto medical school, right that if
you were having a, a aneducation that prioritizes
(35:10):
thinking about, about differencein people and, and maybe not
even all the details of that.
But that there are differentways of being in the world and
the way that you are in theworld, then you're already sort
of a step ahead for thatconversation when it happens
professionally later in life.
Bob Machamer (35:27):
I think it's a mandate. I have the privilege of
teaching at Pennsylvania Collegeof Health Sciences, they receive
an undergraduate degree. And assuch, there's a general
education component the nursesthat I've had the privilege of
working with throughout my 12,13, 14 years of being an
adjunct, those who have 20, 30years of experience as RNs in
(35:50):
the hospital. They are theybring massive experience,
massive knowledge, massiveheart. They just didn't bring
the piece of paper. And theywould say, Yeah, but why do we
need the piece of paper becausethat general education component
is critical. Yes, you do writein a chart, and it's
(36:11):
abbreviated. It's important toknow that a subject and a verb
are a part of every sentence.
And I'm saying that playfully,of course, and not meant to be
harmful in any way. In thegeneral education experience,
you're going to learn more aboutthe influence of religion,
you're going to learn more aboutand have much more taught around
that the theories and theprinciples of ethics in modern
(36:33):
medicine, we can't short sheetthose discussions any longer.
Chip Gruen (36:42):
All right. So let's talk about the practical
implications. We've, we've sortof hit around the edges of this
a little bit. But I know thatone of your key pedagogical
tools for discussing thesetopics is the introduction of
case studies that exploreparticular fault lines and
dilemmas that might beencountered in the healthcare
field for the next part of theconversation. It would be great
(37:03):
if we could just if you couldgive us a few of the examples
that you'd like to introduce tostudents to get the conversation
going. Do you have any good casestudies sort of ready for us?
Bob Machamer (37:13):
I think so. I think one is what I kind of
touched on earlier, a doctorpresented they were doing the
prep work for a surgery that wasgoing to take place outside the
30 day informed consent formsignature requirement, and the
surgery was going to be 35 days.
And the person who is taking thenotes was hesitant, they didn't
(37:34):
want to approach the physicianand say we can't do that they
didn't want to get yelled at,they didn't want to be scolded.
doctor knows best. All of thatis still embedded in our
healthcare system. But in fact,by pushing that paperwork
through, while the patient doeshave a right to self
determination, they don't have aright to falsify documents, nor
(37:57):
does the physician. And justbecause they are the physician,
they have to maintain, they haveto uphold the ethical principle
of autonomy by making sure thatthe documents are in compliance.
Justice was clearly violated. Itwas not upheld for the patient.
Even though the patient colludedin the violation of falsifying
(38:23):
that document. That happens morefrequently than not, we're doing
a lot in recent years to cleanit up. And there are flags, even
in the programs, the softwarepackages that will flag it if
it's outside the rubric of thetimeline. So with technology, we
have the benefit of ofreinforcing, informed consent,
(38:43):
we have the benefit of nowsoftware packages that won't let
us step out of the law. When Ithink about Henrietta Lacks.
That really touches me, Iremember that picture. And maybe
you do too, back in scienceclasses. And I remember that
picture and thinking, what'sthat story all about? And now
(39:06):
that I'm much older than when Iwas reading that little science
book, way back when in highschool, it's somewhat
infuriating to believe and toknow, that her person was
violated, she her body had died,but she hadn't died in the heart
and mind of her husband, whoclearly declined, that her body
(39:27):
be touched. I think about thetroubles in when an EMT or an
ambulance shows up in a home. Dothey know if the patient has an
advanced directive that says DoNot Resuscitate once they start
they can't stop and they'retrained both in curative and to
(39:48):
provide any success ofmaintaining that life. But
everyone that I know that runson an ambulance they also know
there's a difference betweencuring a patient and healing a
patient, even if that healingcomes in death. For me, as as a
Christian, I believe that lifedoesn't end when my heart stops
(40:12):
beating. I believe that my lifecontinues on in whatever way God
chooses. Those are case studiesthat are before courts
constantly. And we have, we haveindividuals, because Muslim
population, it doesn't take buta 10 second Google search to see
dozens of cases where theirreligious beliefs and rights
(40:37):
were violated over and over andover again, we see major chains
CVS, we see major healthcaresystems saying, you may not do
this, the doctor, you may notprovide alternative reproductive
treatments for a certainpopulation for certain I know of
(40:59):
a hospital where a doctordecades ago, would give the
young woman money to go toanother hospital where they had
the option to terminate thepregnancy. But the hospital
system that she came tooriginally would have never done
(41:20):
that. There would have beenshame there would have been
blame, there would have been onealternative. I believe that we
do much better today. But I knowthat there are still cases like
this in the faces of theattorneys. I spoke last week
with an attorney with a localhealth care network. And I asked
specifically, what are the majorissues between ethics,
(41:43):
healthcare and religion. Andthey said, it's almost always in
consent. When a person does notconsent to treatment because of
their, their, their beliefs. Theyoung boy that was in the car
accident, and said to theambulance, I am Jehovah's
Witness, I am not to have ablood product was taken to the
(42:06):
hospital. His decision washonored. The first day the
bloodwork came back, and we sawas the levels were going down,
and then the next day evenfurther. And finally, the
hospital said this can betreated and it's not a difficult
treatment. And they requestedand received an injunction. They
(42:27):
gave this young man a bloodinfusion. And he survived. And
after he survived, they sued thehospital. And it was upheld in
the court that the injunctionwas upheld. And, and they didn't
lose the case for trying to tocure this young man. But even so
was this young man's autonomyviolated, even though he is
(42:50):
alive, well part of this youngman will now for the rest of
this years struggle with maybeit was God's will for me to die,
and that my life isn't to behere but to be with God. Those
are the kinds of things that arepresenting in 2023. These issues
aren't solved yet. But thesediscussions I think are helpful.
(43:14):
If we could have theconversations before we get to
the hospital. Is it unethicalfor a human being to not have an
Advanced Directive? I think it'scruel and unusual punishment for
someone to not have an AdvancedDirective, and for their family
to not specifically know inwriting what their wishes are. I
think it's as equally cruel tohave an Advanced Directive but
(43:35):
to not have shared that. I thinkit's equally cruel. When a
patient says Please don't tellmy husband that I'm going to die
in three days. I'd rather havethem stay with me until I die.
And the doctor is required tohonor the patient's request.
Please don't tell my husband,that I am pregnant with another
(43:58):
person's child. Don't allow thatto be revealed. Please don't put
in my chart. These fears. I'vecome to you for answers to
questions. I need peace. I needcomfort. That's where the
healing for these people isexperienced. Please don't tell
anyone else. So now we bring inthe therapists hopefully, the
(44:20):
emotional therapist, because ifwe're talking about healthcare,
we can't just talk about thephysical body. We have to talk
about the spiritual and theemotional bodies as well. I
think hospitals are doing a muchbetter job at that. Note that
the first person that's calledin an ethics question in a
hospital is the chaplain now Ifind that unbelievably
(44:40):
intriguing. Not the attorney,legal counsel for a local
hospital network but thechaplain is called. So think
about how that chaplain has toknow about Roman Catholicism has
to know about Judaism has toknow about Protestantism has to
know about Muslim, Hindu,everything that's available in
(45:04):
their potential service area.
They've got to know that. Well,thank God we have that person on
staff. I feel really good aboutall that. Reproductive
technology, what does one do ifthe doctor doesn't believe in a
male that shows up to theurologist and says, I'd like to
(45:27):
have a vasectomy. But I don'twant my wife to know, how are
you going to do that? Well,she's going to be way on
vacation. Okay, well, why do youwant this? Well, because there's
someone else that I want to bephysically intimate with. I was
privileged to have that, as acircumstance show up in one of
(45:47):
my practice dilemmas with astudent. And that student
handled it remarkably, becausethey didn't impose they're very
conservative, very conservative,evangelical, I can use those
terms very broadly, conservativeevangelical beliefs with their
patient.
Chip Gruen (46:06):
So you're in thinking about some of these
case studies and thinking abouteverything that we've been
talking about one of the thingsthat occurs to me, and I will
sort of admit to personalexperiences where the
complicatedness of our medicalsystem is very frustrating.
Right, that one hand doesn'tknow what the other is doing,
(46:27):
particularly around issues of,of mental health now of ethics,
of end of life of elder care,that there is this very
complicated. So we've talkedabout doctors, we've talked
about hospital systems, evenwithin those hospital systems,
we can think about the chaplain,right, we can think about
insurance companies, we can callthink about legal
(46:48):
representation. Thinking abouteven if our best minds, right,
our best ethical minds can getin a room and imagine the world
that we would want that valuesautonomy, and beneficence and
justice. How does that becomeaffected by the complicated
(47:12):
structures that I think arethese organic, nobody would
design the system the way thatit is now, right? That it sort
of organically grown up to havethese a million appendages that
don't always know what they'redoing? How does even if we can
make really good decisions? Howdoes that? How's that affected
by this complicated system, thenthat we're confronted with?
Bob Machamer (47:32):
I understand what you're asking I think about my
field exegesis, taking a passageand tearing it apart to try and
understand it, not just thewords, but the historical
context at cetera. I thinkhealthcare is more like
eisegesis, we take ourtraditions and our past, and we
try and find ways to insert itinto current dynamic, and that's
(47:55):
where we end up in trouble. Whenwe take that which is old, and
it doesn't fit. So we jam it inthere, we force it, rather than
allowing the flexibility ofthese conversations. I love my
favorite symposiums that I go toare when they're opposing views.
And then someone steps in andsays, But you know, they
(48:16):
actually are less in opposition.
When we add these principles,they are no longer, completely
oppositional. Think about, thinkabout double effect. I think
that's Thomas Aquinas. If aperson receives morphine for
pain, and the intention wasn'tthat they die, but they die,
that's okay. That's acceptable.
(48:37):
I shouldn't say okay, that'sacceptable. But if we just
simply euthanize them, that isnot okay. except in a few
states, where physician assistedsuicide is permitted under very,
very, very strict standards. Sopeople think, well, you can go
there and Oh, my goodness sakesno, there's a ton of paperwork
(48:58):
and a ton of really important,because we do as a society, we
Chip Gruen (49:00):
Well, let me follow up. And maybe this will clarify
really, really, really, reallyvalue this physical life, this
physical body, this physicalbeing. I think if that's
something that we can moveforward then but can you imagine
who will make the final decisionwith that? Legislators. How do
you get in their ears? And howdo you teach them? Do we send
(49:23):
them back to school? Aren't wegoing to have to? We've got to
have people this is a time forreally serious people, serious
learners, serious thinkers, andnot just the academics of
course, but the people that arewith it, you have to be willing
to my opinion, you have tolisten to the people that are in
(49:44):
the stories. For me, the LGBTQI+has been perhaps one of the best
things that ever happened to mein the last decade of my life.
In health care. I've experiencedrepeatedly, folks will go to
their doctors, and they wouldwant to talk about what they
were feeling, what they wereexperiencing what they knew to
(50:05):
be their truth. And the doctorjust did not know what to do
with transgender people. AndI've experienced close friends,
that it was almost an abusivepain to go to someone that they,
they had to have trust, becausethey needed to know. But they
would be brushed off mostlybecause the person didn't have
(50:26):
any idea. I don't know if Ianswered your question.
a little bit. You say this is atime for serious people, right
for people to engage with theseissues. And I think that we can
look around here in 2023 and wecan see that in some ways we've
(50:49):
taken we've made forwardprogress, right in valuing
identity in valuing individualin letting people tell their own
stories to express their ownworldview. Yet, in many ways, we
are seeing some of that progresstaken away, as well, because of
(51:11):
the nature of the conversationin public life.
Bob Machamer (51:13):
With regard to women's health, and and choice.
I don't even know if I can sayon the recording, I it's painful
to think about the women that Iknow. And it's painful to go
backward.
Chip Gruen (51:31):
I think and this gets back to my previous
question. I think where I sit inthis conversation right now, and
maybe I'm just a little more ofa pessimistic person than you
are, but I talk to you and youhave hope, right? That systems
can do better, that thatlearning is possible, that we
(51:55):
can in the light of ethicalreasoning get to places where
the individual is valued. And Ilook around not as an ethics
specialist, but but justsomebody who looks around and is
curious about the world. And Isee the complicatedness of
political conversations oflegislators who will end up
(52:18):
being responsible for this, ofthe stock options and
shareholders that are involvedin these health care systems,
with people who might mean well,but nurses and doctors and other
health care providers who thinkvery differently about all a
host of issues. And I justthink, Oh, my goodness, this is
(52:40):
a mess. I know we can do better,I have hoped that we can do
better, but I'm not sure that Isee the way forward.
Bob Machamer (52:45):
I think the way forward is to continue the
conversation, I think the wayforward is to invite people to
sit around a table with a cup ofcoffee, a cup of tea, a beer,
and to find a direction, acommon direction. And to mull it
over together, and then to getout and add to the numbers of
(53:08):
those for whom it could behelpful. We teach this at the
college because the collegebelieves not just to check up a
box for their licensure. But weactually believe that the person
who enters into that room whilethere's virtue ethics, I mean,
it just it's going to stick upall the time. We want I want my
(53:30):
students to walk into a room andhave a patient say, you're
really good at this. What areyou good at? I I want them to
listen to the person in that bedand to not see patient only but
a person who has a story whosespouse might be at home, and
(53:54):
they want so desperately to beat home with them because they
are that spouse's primarycaregiver. And, and to recognize
that you have a whole personthere, what brought you here,
what keeps you here? What areyou going to do when you get out
of here? I want to happen atevery level. And I know I've
seen the software packages thatsay you've got 17 minutes to see
(54:16):
this patient. And then you'vegot to move on because we have
to keep a certain dollar amountin the practice. I think it's
going to take people saying No,I won't do that, and to probably
reform and maybe even recreateand start fresh in a new way of
(54:37):
doing and being Catholicinstitutions are all around the
world. Right? They I saw them inAfrica, in Tanzania. I saw the
remarkable work that they did.
remarkable work that they did.
Some of it harmful of course,but by and large, the people who
serve there who could have beenserving here, they brought their
(54:58):
whole self to that position,that I guess my hope is because
I wouldn't know what to do if Ididn't have hope. And I do
believe in God. And I believethat God does have a plan. And I
believe that God wants us to doexactly what Aristotle said,
(55:20):
Seek the highest fulfillment,through virtuous living, I
think, I think that's critical.
I think sometimes we just haveto keep reminding people, that
they matter what they do, whatthey would what they do matters.
That's the heartbreaking thing.
In health care. I see healthcare workers, I see public
(55:41):
educators, I don't know how theydo it. Remember what it was 35
years, and hey, you have yoursummers off, and you're retiring
at 55. I don't know how manypeople stay till their 35 any
longer. I don't have a lot ofanswers Chip. But I do want to
stay in the game. And I do wantto continue to have the
conversations.
Chip Gruen (56:00):
So one of the there are a couple questions that I
like to finish off with, and I'mgonna give you one version of
those. And it it really modelssomething that I think is very
important that that we allrealize our own myopia on these,
in these conversations, thisisn't something that I spend 40
hours a week thinking about thisisn't something that I've read
(56:22):
as deeply as many people andcertainly anybody in the field
has. So what am I missing? Youknow, I've come up with we've
had this conversation, I've comeup with a list of questions,
I've sort of probed the thingsthat are on the top of my mind.
But what is it that I'm missing,that you see from your
perspective, or that we mightsee if we were on site and a
(56:43):
healthcare facility that isreally, really important about
this conversation that we cantake away?
Bob Machamer (56:48):
The vast majority of folks that I meet in a
healthcare system want to dowhat matters. And I think the
thing that we can miss is anopportunity to thank them, I
think that we can miss engagingthem at a personal level in the
midst of doing their job andreminding them that we
appreciate that they are doingtheir absolute best on our
(57:10):
behalf. But they're doing itbecause internally, they really
want to. And if we in the publiccan help them remove the
barriers to providing that kindof loving care. I think that we
can go a long way. I think thatfor me as a Christian man I
believe that we're to love Godand to love all people. And I
(57:33):
really mean all people, whichmeans respecting some of the
labels that are out there thatthey exist, but not allowing
them to shape and determine theway we relate to one another. So
for me, I think that when wehave an opportunity to see
somebody in healthcare, when wehave an opportunity to see
(57:54):
someone that's an ethicist,whether they're an academic or
they're practical, like I wouldconsider myself to be just, I
get to teach. But I'm not a fulltime ethicist. I wouldn't call
myself an expert in ethics, Iwould call myself parish pastor,
who happens to be a therapist,who happens to really, really
(58:15):
believe that health care can bemore than just a machine, but it
can be people, loving peoplewith certain skill sets, certain
gifts, certain talents. Thatwould be the only thing because
I think you're asking the rightquestions. I think that you like
all of us don't have a lot ofanswers. But if you're not at
(58:37):
least asking the questions.
Well, then I don't think thereis hope.
Chip Gruen (58:42):
All right, well, I think that is where we're going
to leave it for now. And thankyou very much, Dr. Bob Machaer,
for being with us onReligionWise.
Bob Machamer (58:50):
Thanks, Chip.
Thanks very much for having me.
Chip Gruen (58:55):
This has been ReligionWise a podcast produced
by the Institute for Religiousand Cultural Understanding of
Muhlenberg College ReligionWiseis produced and directed by
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(59:16):
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We look forward to seeing younext time.
Welcome to ReligionWise the podcast where
we feature educators,researchers and other
professionals discussing topicson religion and their relevance
to the public conversation. Myname is Chip Gruen. I'm the
director of the Institute forReligious and Cultural
Understanding at MuhlenbergCollege, and I will be the host
for this podcast. In this seasontwo of ReligionWise, we will
(00:24):
continue to consider a broadvariety of religious and
cultural beliefs and practices,and try to understand their
place in the contemporaryconversation. If you like what
you hear, I encourage you toexplore the 12 episodes from
season one that are available inyour favorite podcast app. Also,
we would love to hear from youwith your questions, comments,
or suggestions for futureepisodes. To reach us, please
(00:48):
visit our website atreligionandculture.com. There
you will find our contactinformation and also have the
opportunity to support thispodcast and the work of the
Institute. Today's guest is Dr.
Bob Machamer adjunct faculty atthe Pennsylvania College of
Health Sciences, who teaches acourse entitled Ethical Issues
in Health Care to undergraduatestudents studying to become
(01:10):
healthcare professionals in anumber of different capacities.
Dr. Machamer, who is also alicensed Marriage and Family
Therapist, and an ordainedminister in the ELCA Lutheran
tradition serves as the seniorpastor at St. John's Lutheran
Church in Boyertown,Pennsylvania. So today's episode
features a conversation thatI've been really curious about
and interested in for a longtime. Here at Muhlenberg
(01:32):
College, I served on the PreHealth Advisory Committee. And
one of the things that we did iswe designed a program called the
Shankweiler Scholars Programthat is interested in
cultivating those interested inmedical professions in academic
interests other than biology andchemistry, of course, biology
(01:53):
and chemistry being important tothe study of medicine. But the
argument goes that so are otherthings, whether that be history,
philosophy, the study ofreligion, or things in the
social sciences, psychology, andsociology, etc. And as part of
that program, I've had theprivilege of talking to students
about the confluence ofreligious traditions and our
(02:16):
pluralistic society in whichpeople might come with a number
of different worldviews into amedical facility, and the
provisions of health care thatthey find there. One of the ways
that I talk about this, is thatI say that it's important that
medical professionals realizethat providing health care to a
(02:38):
human is not like a mechanicfixing a car, there's a lot more
to it, it is not simply a matterof replacing the oil, or
switching out the carburetor,the person who's coming into
that office is coming withpotentially very different ways
of understanding the world,understanding their body,
(02:59):
understanding the nature of lifeand death, then we can assume
the practitioner has right thatthere is a very different,
potentially very differentworldviews that are operating in
that office simultaneously. Now,of course, the hospital
facilities in particular, havechaplains offices over the last
(03:20):
few decades, those chaplainsoffices have become increasingly
literate and competent todealing with people who are
outside of their own tradition.
So a Catholic chaplain might beable to deal with issues from a
Jewish patient or a Muslimpatient cetera. But as we move
(03:44):
forward, it seems to me that notjust in the chaplains office,
but also within the healthcareprofessionals themselves.
Knowing how the treatment ofpatients and ethics around
patient care might be affected,if someone coming in is a Hindu
or a Buddhist or a secularHumanist, for that matter, that
(04:08):
the way that care is deliveredmight be very different,
depending on how that personagain, understands their body
understands the nature of lifeand death, understands the
procedures and the ethics ofthose procedures. The other part
of this that I think is reallyinteresting is the confluence of
ethics, and morality, legality,and patient autonomy. We as a
(04:33):
21st century American societywith a particularly capitalist
and materialist worldview arereally interested in what is
legal to do. And so sometimesthere is a conflict between
ethics and legality and theindividual beliefs practices of
both the practitioner and thepatient themselves. Dr. Machamer
(04:55):
comes in as somebody who isresponsible for talking to
students headed into health careabout some of these issues and
to make them aware. And so withthat, I welcome Dr. Machamer to
the program. Dr. Bob Machamer,thank you for coming on
ReligionWise.
Bob Machamer (05:13):
Chip I'm excited to be here with you and to
continue the conversations thatwe started just a few weeks ago.
Chip Gruen (05:20):
All right, so let's jump right into it. So I'd like
to start our conversation byhaving you introduce yourself
and the trajectory of yourprofessional life. Your training
is really wide. It's bothscholastic as well as clinical
and practical. Can you tell us alittle bit about your biography
and background that led you tothe place now where you teach
ethical issues in healthcare?
Bob Machamer (05:40):
Surely, coming out of Grove City College as a
psychology major, I found myselfin seminary in Boston, exposed
to all kinds of traditionsdiversity that I never
experienced growing up inLebanon County or in Grove City.
That was the challenging partfor me, learning not only the
(06:01):
academics at Grove City, andGordon Conwell putting together
my organizing principles oftheology, but then trying to
figure out how to, in apractical way to relate to God's
creation. In my firstcongregation, I realized that my
training was pretty inadequate,when it came to the problems
(06:24):
that people would come into myoffice and want to discuss, and
the field of ethics opened upright there, because I think the
field of ethics is aboutpractical decision making. And I
think that the principles andthe theories that we talked
about when studying ethics areincredibly helpful. The theories
of course, the decision makingmodels that we use with them,
(06:46):
and then the principles thatfocus specifically on the
individual, are they upheld,arethey violated. My work at the
college as an adjunct hasexposed me to health care
workers, those in training,those that had been there for
20, 30 years, but came back toget their BSN, the bachelor's in
nursing, and that was amarvelous experience, because
(07:09):
they already knew 20 times morethan I knew. And then they would
put it into their case studies.
And it started my thinking ofhow can we help? And how can we
be a people who regard eachother with respect? How can we
uphold these things that wetalked about in the textbook?
How can we do that for and withone another? I think simply at
the end of the day, it'll boildown to what kind of person do
(07:32):
we want to be?
Chip Gruen (07:37):
So in our preliminary conversations,
leading up to this discussion,we were both really rather
insistent that we get practical,and we'll deal with case studies
later. But I think it'simportant to consider, at least
in brief, a little background,the method of the field, that
this you know, ethics isn'tsitting around in a circle and
(07:59):
talking about our feelings, itis grounded in a very old
discipline. So can you give usthe one foot version, the brief
version of the intellectualtradition that sits behind the
way that you teach this topic?
Bob Machamer (08:12):
Absolutely. Our first class, the first hour and
a half of teaching the classthat I teach, and it's generally
an intensive it's a five weekprogram. We talked about Western
world, of course, and it's, it'straced back to the ancient roots
with the Greeks, the School ofHippocrates, and all of the work
(08:32):
that they put out. I mean, backthen you have physicians who are
both healers and executioner'sthey supported euthanasia. So
coming out of that tradition andshifting that through the years,
and that's BC, that's 300 yearsbefore. And and if ethics is the
practice of decision making, ifit's if it's to be practical,
(08:55):
and it's problem solving, thosekey components that were put
forth by people like Aristotle,that pursuit of excellence for
Aristotle, being a virtuousperson, what does it mean to be
a virtuous person, and the wordthat he used Eudaimonia it's not
(09:17):
just happiness, it's not justflourishing, we don't have a
synonym for it in our language.
It's, it's it's engaging,virtuous character. And I think
beyond Aristotle, in moving moretoward Aquinas, 1500 years
later, as a philosopher as atheologian, I think that Aquinas
(09:37):
brings both the head and theheart puts together right action
and right thinking in terms ofgood and evil of course, during
that time of history, virtues,the preservation of life, the
preservation of the species, thepursuit of truth, which kind of
sounds like something that inour country was written right
(10:02):
about the time of theDeclaration of Independence. So
we talk about that, yeah, we getwe, we spend a little bit of
time in Aristotle, we move toAquinas. And then we get into
where we are today, and thechallenges of what it means to
be one who is in healthcare as aprofessional, not just
physicians, but everyone inhealthcare.
Chip Gruen (10:25):
So I think we'll get the opportunity to talk about
this more, but I just want toput a marker here and get some
preliminary comments on the waysin which this intellectual
tradition that we're, you know,that are the background of the
class, Aristotle, Aquinas, etc,are the Western intellectual
tradition. And not only theWestern intellectual tradition,
(10:48):
but then the Catholic scholastictradition as well. And I think
it from my perspective, it lookslike, particularly the Catholic
piece, the Christianintellectual history piece of
that can sometimes be occludedwhen we have these
conversations. It's not frontedright, that ethics is imagined
(11:09):
as secular. But it seems likelooking at this, the
contemporary at conversation andethics is rooted in a particular
background.
Bob Machamer (11:17):
Absolutely. It's hardly secular. I mean, we could
make believe that it is so butit's not. The traditions of
faith, Judeo Christian, are sodeeply embedded in ethics, our
traditions have something tosay, when people come in to ask
questions, they're looking forguidance, they're looking for a
(11:40):
direction to go. And I believethe combination of the two,
provide us with thosepossibilities in Judaism, of
course, tradition has somethingto say about life life, before
it comes out of the womb lifeafter it comes out of the womb,
a sense of community, perhapsdifferent than we've experienced
in the Catholic Church or theProtestant church, it's vital
(12:02):
that we find a way to have thosediscussions and continue to have
those discussions not in alegalistic way. But in the
methods of discovery of wherehumanity share a common good,
share a common good end commonperhaps, if I can say, a common
not so good or evil, to identifythat, and then to operate out of
(12:24):
that in the way we provide carefor one another.
Chip Gruen (12:28):
So your background is one that is I mean, you've
mentioned your seminarytraining, that, you know, the
way that you practice isinformed clearly, by the
religious intellectual traditionas well. But at the same time,
and this is one of the things Ireally want to get across in
this conversation, that thattradition, as you understand it,
(12:49):
is very progressive and veryinclusive. And so I wonder about
how, again, that intellectualtradition within Catholicism and
then moving moving forward intime, is that a barrier, you
know, to that kind of inclusive,multicultural, you know, world
(13:14):
and context in which you'reliving in or do you recognize
that and then move on? How Howdoes the coloring of that
religious tradition affect thepractice and understanding of
contemporary ethics for a peoplewho is not necessarily lockstep
on the same page for those sortsof spiritual or theological...
Bob Machamer (13:35):
It smacks us in the face, you think about the
Hippocratic Oath, hundreds ofyears before Christ walked the
planet. Then you see theinfluences by the Middle Ages
where Islamic communities alsoaccept the Hippocratic Oath. And
it goes right down the line. Nowwe have, we're not we're the
traditions, the religion that wehave, what we've been taught,
(13:58):
didn't know the internet wasgoing to arrive. They didn't
know that we would havereproductive technologies for in
vitro fertilization. They didn'tknow that there will be non
blood products available forblood transfusions. So for us in
my area in this Lehigh County,born and raised in Lebanon
(14:22):
County and close to LancasterCounty, Amish population and
Jehovah's Witness, they now haveavailable to them the blood
products that their religion andtheir hierarchical structures
would have said, You areprohibited from receiving that
except in the case of a minorthat's, that's a whole other
legal issue. But I think thoseare the things that are in
(14:44):
current medical practice, nowbeing questioned and being
discussed and I'd see lots ofdiscussions going on around the
country. Our large major healthcare systems are now extended
programs 3, 4, 5 sessions 3, 4,5 weeks to time, exposing their
healthcare practitioners, theirnursing staffs their, their
(15:06):
radiologists it's all coming toa beautiful head, I think. And I
see it as a positive experiencehaving circumstances that were
never questioned in the past.
Now we're saying, wait a minute,I'm grateful for that. I'm
grateful that I'm at thebeginning of learning about it.
I don't, I don't know all ofthis. I know that I need to know
(15:28):
more.
Chip Gruen (15:32):
So one more question on context. And then we'll start
jumping more into the practicalthe case studies the where the
rubber hits the road. Whenyou're introducing these topics
to students, it's myunderstanding that you give them
a few broad categories, orprinciples to anchor their
thinking in the field. Can youtell us a little bit about that
basic schema, even if it's justto give us the vocabulary that
(15:57):
we need in order to understandthe conversation or the field?
Bob Machamer (16:02):
Sure, the the first day of class, they're
handed two pieces of paper onthe one, they have the
definitions of the four ethicalprinciples that I use in class
autonomy, everyone has the rightto decide for oneself. The
danger, of course in modernmedicine is paternalism, doctor
(16:25):
knows best. Beneficence is thesecond ethical principle to do
well to do a kindness to do goodand, and to not do harm.
Nonmaleficence is to do no harm,or the way I teach it is to do
no further harm, harm probablyhas already happened. And then
justice, to be fair, to behonest, those four ethical
(16:46):
principles are at the root ofmedicine for centuries. But in
recent years, they've becomeeven more important to the
conversation of how do we decideyou have ethical theories. So
you have the theory in and ofitself, and then you have meta
ethics, which is the questioningabout those particular stated
theories. So for us, we startwith those four words. And I
(17:09):
tell them at the end of thefirst class, please learn these
words, learn learn what theyare, because you're going to use
them and ethical principles arealways about the individual.
They're never about thehealthcare system. They're never
about the family in the room.
They're always and only aboutthe individual. So autonomy can
either be upheld or violated onbehalf of the person.
Beneficence can neither beupheld or violated justice can
(17:31):
either be upheld or violated.
And sometimes it's really hardto distinguish which way to go,
the ethical theories ofconsequentialism, where the
outcome is more important thanthe intent, where the the the
overall consequence, what dowhat's more morally right. And,
(17:54):
and seek to do the greatest goodfor all people, it's not just
the greatest good for thepatient is the greatest good, it
has to be a larger number to beunderstood as consequentialism.
Deontology is always duty based.
And I laugh, because this is theexample that we use is one that
is familiar to those who arenurses in the profession of
(18:15):
nursing, they will invariably bewith a patient and they're,
they're cleaning a line orthey're working with the patient
or they're, they're changing adressing, and an x ray
technician might show up and thex ray technician is there to
simply do their duty. And theirjob is get the job done and get
the x ray. So in the middle ofthings, they're ready to move on
(18:37):
to the next patient, they haveanother patient that they've got
to get their equipment to. Andthe nurse then is in conflict
with their own healthcare team.
So we have those deontologicalconflicts. Again, it's theory,
virtue ethics, probably where wecould spend the most of our time
(18:59):
because I am one that believesin virtue ethics. So at the end
of the day, what kind of Pastordo I want to be? What kind of
therapist do I want to be? Whatkind of husband do I want to be?
What kind of human do I want tobe? What kind of advocate do I
want to be for marginalizedgroups? I think modern
healthcare is going to belooking at that. I think modern
healthcare has to be looking ateveryone who is marginalized. If
(19:22):
50% of the research is correct,that 50% of physicians,
prescriptions that are handed toa patient are that they go
unfilled, primarily because thephysician didn't ask or they
didn't know they can't affordit. So 50% of prescriptions go
unfilled, or they go to the backshelf of the pharmacy at Wegmans
(19:46):
and no one picks them up. It'sbecause they can't afford it. So
healthcare has to get way pastpatient as client, they have to
be patients as people. Those arethe challenges that I talk about
with with my class, and then ofcourse, authority based
religious ethics, in the Amishpopulation, your Bishop comes
(20:07):
into the hospital and helps youand if not helps you makes the
decision on your behalf that canhappen with Jehovah's Witness at
well, my Bishop has never beenin my office never been in my
hospital room to tell me what mynext procedure is going to be.
And I'm grateful for that,because I'm not sure my Bishop
would know any better than Iwould. So.
Chip Gruen (20:28):
So I want to push on this a little because you you
mentioned, right, you give thisframework you give these ways of
understanding. I've noticed andI've had the privilege to talk
to, you know, first yearstudents who are interested in
studying health care that I'vehad the privilege to have the
(20:50):
humans are not carsconversation, like how can we
think about religious andcultural backgrounds? As a as
one of the, you know, theprimary context for delivering
care. And one of the things thatI've noticed in those
conversations is that they'rereally interested in thinking
about what's legal. And thenthey have a hard time separating
(21:12):
the con... the conversationabout what's legal, from what
ethical. Do you see a similarpropensity here? Is that the way
your conversations go?
Bob Machamer (21:21):
I can't I don't have a conversation, I may be
speaking hyperbolically but Irarely have conversation where
that does not enter in. Andthat's why the class that I
teach always has a legalcomponent and most healthcare
institutions or health careoriented programs, college
programs, at the undergraduatelevel, in their very first
(21:43):
class, there is always the legaldimension. Frequently, it's
discussed by using case studies,case studies such as Tuskegee
Airmen, and and how they werenever. Their consent was never,
it wasn't even known to them.
They didn't have any option toconsent to the study on syphilis
and all that longitudinal workthat was done. Henrietta Lacks,
(22:08):
there was no awareness. And infact, there was a blatant, her
husband said, No, you may not.
And yet her genetic material hasbeen purchased. And it's
probably in most labs around theworld to think that we could
have had people of faith basedbackgrounds promote promoting,
(22:33):
advocating for necessarilyhiding that, that now is in the
front of 18, 19, 20 year olds,when they're sitting at an
undergraduate class, and they'resaying, how could that have
happened? That's good question.
What we do in that it didhappen? I think is the question
that we want to be responding toand making sure that in the
(22:55):
future, those things don'thappen. Informed consent is a
big one. Implied Consent is bigfor folks, seemingly smaller,
but not so much. So what doesone do when an attorney comes in
a prominent attorney, and thestaff are preparing the
paperwork and the doctor and theattorney are talking and the
(23:17):
doctor knows that the paperworkis only good for 30 days, and
the surgery is scheduled now for35 days? And the attorney says
yeah, but I'll sign it now. Thatpaper is illegitimate. It's,
it's and it would be wrong toproceed. What does the nurse
what does the lower level on thehierarchical chain do? How do
(23:41):
they confront? How do theyuphold the patient's right to
making an informed decision,however, holding Upholding
justice for the organization andits documents? I have folks
writing practice dilemmas. Forthe five weeks. I have hundreds
(24:02):
and hundreds. In fact, I havesome with me right now, of
healthcare staff that had beenput in positions where they're
in direct violation of not onlythe regulations of the hospital,
but also of general practice oflaw.
Chip Gruen (24:20):
Yeah, the case that sort of sticks out to me and I
don't have the details at myfingertips, but it was someone
who served as an EMT, and thatthe EMTs are sort of both on the
frontline and with relativelyminimal training to do what
they're being asked to do. Butit was a blood transfusion case.
(24:43):
And I think that they had beeninstructed that well long as the
person's unconscious. It doesn'tmatter. Like legally, you can do
whatever you need to do, andyou're you're protected. You're
covered. And it was it was very,it's very odd conversation
because it felt I mean, it feltvery pragmatic, it felt very
(25:05):
practical. But the values of theof the system were values at
life at any cost, as opposed tofollowing the wishes of the of
the patient, even if those areknown and sort of the legal
maneuvering, right, or the legalways of getting around that, it
was a little surprising to me.
Bob Machamer (25:27):
There are lots of cases of record about that, if
it's known, and their agentmajority if they're adults, and
they say I do not want a bloodproduct that is honored. In most
cases. Sometimes injunctions arebrought in court systems people
(25:47):
are rbrought in. If they're aminor, all bets are off. And
again, I'm not an attorney. Butfrom the studies that we've used
in class, the case studies thatwe've, we've read together as a
class, and we've discussed as aclass. And they are concerned
about that they're alwayslooking for good up to date
(26:09):
medical records. Now that's onthe patient. So if my chart, and
if I were in an accident, when Ileave here, the healthcare
people that are arriving in thatambulance can pull up my
records, because I'm in that bigsystem, so whether I'm
transported to Lehigh ValleyHealth Network or St. Luke's
they'll have my chart andthey'll know all those things
(26:31):
right at the top. He may he doesnot he wills he does. All of
that is right there. So we livein a great age, to be able to
create that environment ofconsent. But what about the
rural areas? And what aboutwhere that technology doesn't
exist to the degree that we havehere in the Lehigh Valley, we do
(26:55):
talk about that we do talk aboutthe religious orders that we may
or may not know, because thatmay not be on the chart. That's
what confronts the students inLancaster. They're not always
sure what to do. When a patientcomes in, and a person comes in,
and they are Amish, they don'talways know what to do. But that
(27:18):
I know, the hospital system hasworked very, very hard to work
with those denominations andthose particular religious
groups to talk about the law andthe medical practice before we
arrive at the need for that totake place. Those discussions I
know are going on in Lancaster.
So I've got to believe they'regoing on all across the country,
or at least I hope so. And ifnot, we need to advocate for
(27:40):
that to happen. Let's have theconversation before we are in
that last minute where we needthose life saving measures. Now
those are my words. Because forthe person who is Amish, it
might not be life saving at allit because it might be an
affront to what they believe tobe the will of God. For me, my
body. And maybe this helps withthe legal question. For me, I
(28:04):
have an obligation to take careof my body, I believe that God
gave me this body. So if I were,if I were renting or leasing an
apartment from you, I havecertain obligations to not
destroy it, I have certainobligations do not leave the
water running and that the floodpours out over the window sills.
I have legal obligations also tomaintain it so that it doesn't
(28:32):
become infested with bugs,health care professionals today
are being confronted with all ofthat, in an environment where
patients can be seen as clients,and that people in an
environment where physiciansaren't just medical
practitioners. They're in anindustry, they're they're joined
(28:52):
to a business contract. And whenwe sign all those sheets of
paper, I do not read all ofthose sheets of paper word for
word. But I was shocked I was ata doctor appointment not too
long ago. And on the desk, itsaid if you have ever or plan to
or think you might want to filean action against us, we will
(29:14):
not see you as a patient. I havenever seen that in a major
health care system right here inthe southeastern part of
Pennsylvania. And I asked theperson at the desk. Can you
explain this? And they said no,you have to talk to your doctor
about that. When I asked mydoctor about it. They said we
just don't have the time tospend in the courtroom. So we
you're vetted. We already knewthat you haven't filed any legal
(29:39):
action.
Chip Gruen (29:41):
Wow.
Bob Machamer (29:42):
Patient care, patient autonomy, justice, all
that's on the table right nowand the laws are being rewritten
and debated all the time.
Chip Gruen (29:50):
Well, and it's interesting. I mean, given your
your roots where you teach andwhere you have been a therapist
the examples that you bring upare good ones as a Jehovah's
Witness and Amish. But I'll justsort of say, you know, one of
the goals of the Institute is toget people broadly literate
(30:11):
across all kinds of religiousdifference in that one of the
examples that I bring up and itmight sound very small to to
people, but the prohibitionagainst cutting hair in Sikh or
Sikh communities. And so youthink somebody comes in for an
emergency surgery, and you haveno idea why that person wears
that turban, right, much lessanything else, or that there are
(30:33):
particular undergarments thatmarried individuals don't take
off in that community, right,and you cut those things off, or
you cut the you shave an areafor surgery, or whatever, and
you have just committed a majorviolation of that person. And so
and that's one of the examplesthat I know about. But as our as
our world, I won't say becomesmore multicultural pluralistic,
(30:56):
but as we're recognizing thatpluralism and multiculturalism
and religious difference moreand more and more, I've got to
think the numbers of those kindsof literacy issues, right, that
people need to be aware of isjust going to grow and grow and
grow and grow. And I hope ourhealthcare system is up to that
challenge.
Bob Machamer (31:13):
I think that what you're talking about is exciting
for some, and I think it'sfrightening for others. And I
believe that many people wouldsay, Gosh, how much time is it
going to take to train thatnumber of people. And the
reality is, we're going to haveto take the time. So programs
may need to be lengthened,rather than abbreviated. What
(31:34):
once took four years to receiveyour degree. Now, one can do in
18 months or 24 months, to savemoney and to create money for
institutions, we may have tobackpedal and prioritize people
over dollars, medical treatmentis big business. That is not
(31:55):
something said lightly. Becauseit should be about people. And I
believe in general, I meet veryfew, I can't say that any of my
family's physicians treat uslike we are widgets. I really
can't. Now we we're carefulabout where we go. And we have
met physicians, and we've said,No, thank you, and we move on,
(32:18):
and we find the next person,because we look for people who
treat us as people. Now, when itcomes to the variety, the
pluralistic society that we havebeen for decades, we can't
ignore that any longer. I thinkthat will happen through
conversations like this one. Andyou'll have people on that are
far more knowledgeable than Iam. And that's the benefit.
(32:41):
Because I'll listen to the nextconversation, not one that I'm
on with you. But I'll listen tothe next person. This is a great
opportunity, I think, to openpeople's eyes to diversity, to
equity, to inclusivity. To, toreligions that they've never
heard of. And to do it in a waythat perhaps doesn't engender
(33:06):
fear or threat, like around9/11. Oh, my goodness sakes. And
for Asian Americans, oh, mygoodness sakes. Health care has
to be aware of that when aprisoner is brought in when
somebody in an orange jumpsuitis brought into the hospital,
and they are in line to receivetreatment. And people are
(33:26):
screaming in the waiting room?
Why does that person get toreceive treatment over my child
who is crying and in pain?
There's a reason because they'retreated as humans, regardless of
what their resume says somethinghas happened in their life
that's put them in that orangejumpsuit, law and health care.
(33:50):
It's wide open now. And we wantto participate in it. Thanks for
asking that question. Inparticular, because of all the
things that we've talked aboutso far, I think I could probably
talk about the principles and Icould talk about the theories
and I can speak about it withsome fact based confidence. But
you're asking questions, that itseems to me, we don't have good
(34:13):
answers. But I appreciate thegood questions. And I hope that
the listeners are hearing thatgood questions might just be
more important right now thanthe good answers.
Chip Gruen (34:26):
When we think about something like religious
literacy, for example, culturalliteracy, and we think about how
is it that we deal with that inthe medical training of
individuals? Well, those peoplewho are trained to be doctors or
nurses or whatever in themedical field, have been to an
(34:47):
undergraduate institution. Andhere's my soapbox moment, is
that the humanities right andteaching about, about difference
and about ways of being in theworld and about meaning and
Those sorts of things that Ithink informed this conversation
don't have to wait until you getto medical school, right that if
you were having a, a aneducation that prioritizes
(35:10):
thinking about, about differencein people and, and maybe not
even all the details of that.
But that there are differentways of being in the world and
the way that you are in theworld, then you're already sort
of a step ahead for thatconversation when it happens
professionally later in life.
Bob Machamer (35:27):
I think it's a mandate. I have the privilege of
teaching at Pennsylvania Collegeof Health Sciences, they receive
an undergraduate degree. And assuch, there's a general
education component the nursesthat I've had the privilege of
working with throughout my 12,13, 14 years of being an
adjunct, those who have 20, 30years of experience as RNs in
(35:50):
the hospital. They are theybring massive experience,
massive knowledge, massiveheart. They just didn't bring
the piece of paper. And theywould say, Yeah, but why do we
need the piece of paper becausethat general education component
is critical. Yes, you do writein a chart, and it's
(36:11):
abbreviated. It's important toknow that a subject and a verb
are a part of every sentence.
And I'm saying that playfully,of course, and not meant to be
harmful in any way. In thegeneral education experience,
you're going to learn more aboutthe influence of religion,
you're going to learn more aboutand have much more taught around
that the theories and theprinciples of ethics in modern
(36:33):
medicine, we can't short sheetthose discussions any longer.
Chip Gruen (36:42):
All right. So let's talk about the practical
implications. We've, we've sortof hit around the edges of this
a little bit. But I know thatone of your key pedagogical
tools for discussing thesetopics is the introduction of
case studies that exploreparticular fault lines and
dilemmas that might beencountered in the healthcare
field for the next part of theconversation. It would be great
(37:03):
if we could just if you couldgive us a few of the examples
that you'd like to introduce tostudents to get the conversation
going. Do you have any good casestudies sort of ready for us?
Bob Machamer (37:13):
I think so. I think one is what I kind of
touched on earlier, a doctorpresented they were doing the
prep work for a surgery that wasgoing to take place outside the
30 day informed consent formsignature requirement, and the
surgery was going to be 35 days.
And the person who is taking thenotes was hesitant, they didn't
(37:34):
want to approach the physicianand say we can't do that they
didn't want to get yelled at,they didn't want to be scolded.
doctor knows best. All of thatis still embedded in our
healthcare system. But in fact,by pushing that paperwork
through, while the patient doeshave a right to self
determination, they don't have aright to falsify documents, nor
(37:57):
does the physician. And justbecause they are the physician,
they have to maintain, they haveto uphold the ethical principle
of autonomy by making sure thatthe documents are in compliance.
Justice was clearly violated. Itwas not upheld for the patient.
Even though the patient colludedin the violation of falsifying
(38:23):
that document. That happens morefrequently than not, we're doing
a lot in recent years to cleanit up. And there are flags, even
in the programs, the softwarepackages that will flag it if
it's outside the rubric of thetimeline. So with technology, we
have the benefit of ofreinforcing, informed consent,
(38:43):
we have the benefit of nowsoftware packages that won't let
us step out of the law. When Ithink about Henrietta Lacks.
That really touches me, Iremember that picture. And maybe
you do too, back in scienceclasses. And I remember that
picture and thinking, what'sthat story all about? And now
(39:06):
that I'm much older than when Iwas reading that little science
book, way back when in highschool, it's somewhat
infuriating to believe and toknow, that her person was
violated, she her body had died,but she hadn't died in the heart
and mind of her husband, whoclearly declined, that her body
(39:27):
be touched. I think about thetroubles in when an EMT or an
ambulance shows up in a home. Dothey know if the patient has an
advanced directive that says DoNot Resuscitate once they start
they can't stop and they'retrained both in curative and to
(39:48):
provide any success ofmaintaining that life. But
everyone that I know that runson an ambulance they also know
there's a difference betweencuring a patient and healing a
patient, even if that healingcomes in death. For me, as as a
Christian, I believe that lifedoesn't end when my heart stops
(40:12):
beating. I believe that my lifecontinues on in whatever way God
chooses. Those are case studiesthat are before courts
constantly. And we have, we haveindividuals, because Muslim
population, it doesn't take buta 10 second Google search to see
dozens of cases where theirreligious beliefs and rights
(40:37):
were violated over and over andover again, we see major chains
CVS, we see major healthcaresystems saying, you may not do
this, the doctor, you may notprovide alternative reproductive
treatments for a certainpopulation for certain I know of
(40:59):
a hospital where a doctordecades ago, would give the
young woman money to go toanother hospital where they had
the option to terminate thepregnancy. But the hospital
system that she came tooriginally would have never done
(41:20):
that. There would have beenshame there would have been
blame, there would have been onealternative. I believe that we
do much better today. But I knowthat there are still cases like
this in the faces of theattorneys. I spoke last week
with an attorney with a localhealth care network. And I asked
specifically, what are the majorissues between ethics,
(41:43):
healthcare and religion. Andthey said, it's almost always in
consent. When a person does notconsent to treatment because of
their, their, their beliefs. Theyoung boy that was in the car
accident, and said to theambulance, I am Jehovah's
Witness, I am not to have ablood product was taken to the
(42:06):
hospital. His decision washonored. The first day the
bloodwork came back, and we sawas the levels were going down,
and then the next day evenfurther. And finally, the
hospital said this can betreated and it's not a difficult
treatment. And they requestedand received an injunction. They
(42:27):
gave this young man a bloodinfusion. And he survived. And
after he survived, they sued thehospital. And it was upheld in
the court that the injunctionwas upheld. And, and they didn't
lose the case for trying to tocure this young man. But even so
was this young man's autonomyviolated, even though he is
(42:50):
alive, well part of this youngman will now for the rest of
this years struggle with maybeit was God's will for me to die,
and that my life isn't to behere but to be with God. Those
are the kinds of things that arepresenting in 2023. These issues
aren't solved yet. But thesediscussions I think are helpful.
(43:14):
If we could have theconversations before we get to
the hospital. Is it unethicalfor a human being to not have an
Advanced Directive? I think it'scruel and unusual punishment for
someone to not have an AdvancedDirective, and for their family
to not specifically know inwriting what their wishes are. I
think it's as equally cruel tohave an Advanced Directive but
(43:35):
to not have shared that. I thinkit's equally cruel. When a
patient says Please don't tellmy husband that I'm going to die
in three days. I'd rather havethem stay with me until I die.
And the doctor is required tohonor the patient's request.
Please don't tell my husband,that I am pregnant with another
(43:58):
person's child. Don't allow thatto be revealed. Please don't put
in my chart. These fears. I'vecome to you for answers to
questions. I need peace. I needcomfort. That's where the
healing for these people isexperienced. Please don't tell
anyone else. So now we bring inthe therapists hopefully, the
(44:20):
emotional therapist, because ifwe're talking about healthcare,
we can't just talk about thephysical body. We have to talk
about the spiritual and theemotional bodies as well. I
think hospitals are doing a muchbetter job at that. Note that
the first person that's calledin an ethics question in a
hospital is the chaplain now Ifind that unbelievably
(44:40):
intriguing. Not the attorney,legal counsel for a local
hospital network but thechaplain is called. So think
about how that chaplain has toknow about Roman Catholicism has
to know about Judaism has toknow about Protestantism has to
know about Muslim, Hindu,everything that's available in
(45:04):
their potential service area.
They've got to know that. Well,thank God we have that person on
staff. I feel really good aboutall that. Reproductive
technology, what does one do ifthe doctor doesn't believe in a
male that shows up to theurologist and says, I'd like to
(45:27):
have a vasectomy. But I don'twant my wife to know, how are
you going to do that? Well,she's going to be way on
vacation. Okay, well, why do youwant this? Well, because there's
someone else that I want to bephysically intimate with. I was
privileged to have that, as acircumstance show up in one of
(45:47):
my practice dilemmas with astudent. And that student
handled it remarkably, becausethey didn't impose they're very
conservative, very conservative,evangelical, I can use those
terms very broadly, conservativeevangelical beliefs with their
patient.
Chip Gruen (46:06):
So you're in thinking about some of these
case studies and thinking abouteverything that we've been
talking about one of the thingsthat occurs to me, and I will
sort of admit to personalexperiences where the
complicatedness of our medicalsystem is very frustrating.
Right, that one hand doesn'tknow what the other is doing,
(46:27):
particularly around issues of,of mental health now of ethics,
of end of life of elder care,that there is this very
complicated. So we've talkedabout doctors, we've talked
about hospital systems, evenwithin those hospital systems,
we can think about the chaplain,right, we can think about
insurance companies, we can callthink about legal
(46:48):
representation. Thinking abouteven if our best minds, right,
our best ethical minds can getin a room and imagine the world
that we would want that valuesautonomy, and beneficence and
justice. How does that becomeaffected by the complicated
(47:12):
structures that I think arethese organic, nobody would
design the system the way thatit is now, right? That it sort
of organically grown up to havethese a million appendages that
don't always know what they'redoing? How does even if we can
make really good decisions? Howdoes that? How's that affected
by this complicated system, thenthat we're confronted with?
Bob Machamer (47:32):
I understand what you're asking I think about my
field exegesis, taking a passageand tearing it apart to try and
understand it, not just thewords, but the historical
context at cetera. I thinkhealthcare is more like
eisegesis, we take ourtraditions and our past, and we
try and find ways to insert itinto current dynamic, and that's
(47:55):
where we end up in trouble. Whenwe take that which is old, and
it doesn't fit. So we jam it inthere, we force it, rather than
allowing the flexibility ofthese conversations. I love my
favorite symposiums that I go toare when they're opposing views.
And then someone steps in andsays, But you know, they
(48:16):
actually are less in opposition.
When we add these principles,they are no longer, completely
oppositional. Think about, thinkabout double effect. I think
that's Thomas Aquinas. If aperson receives morphine for
pain, and the intention wasn'tthat they die, but they die,
that's okay. That's acceptable.
(48:37):
I shouldn't say okay, that'sacceptable. But if we just
simply euthanize them, that isnot okay. except in a few
states, where physician assistedsuicide is permitted under very,
very, very strict standards. Sopeople think, well, you can go
there and Oh, my goodness sakesno, there's a ton of paperwork
(48:58):
and a ton of really important,because we do as a society, we
Chip Gruen (49:00):
Well, let me follow up. And maybe this will clarify
really, really, really, reallyvalue this physical life, this
physical body, this physicalbeing. I think if that's
something that we can moveforward then but can you imagine
who will make the final decisionwith that? Legislators. How do
you get in their ears? And howdo you teach them? Do we send
(49:23):
them back to school? Aren't wegoing to have to? We've got to
have people this is a time forreally serious people, serious
learners, serious thinkers, andnot just the academics of
course, but the people that arewith it, you have to be willing
to my opinion, you have tolisten to the people that are in
(49:44):
the stories. For me, the LGBTQI+has been perhaps one of the best
things that ever happened to mein the last decade of my life.
In health care. I've experiencedrepeatedly, folks will go to
their doctors, and they wouldwant to talk about what they
were feeling, what they wereexperiencing what they knew to
(50:05):
be their truth. And the doctorjust did not know what to do
with transgender people. AndI've experienced close friends,
that it was almost an abusivepain to go to someone that they,
they had to have trust, becausethey needed to know. But they
would be brushed off mostlybecause the person didn't have
(50:26):
any idea. I don't know if Ianswered your question.
a little bit. You say this is atime for serious people, right
for people to engage with theseissues. And I think that we can
look around here in 2023 and wecan see that in some ways we've
(50:49):
taken we've made forwardprogress, right in valuing
identity in valuing individualin letting people tell their own
stories to express their ownworldview. Yet, in many ways, we
are seeing some of that progresstaken away, as well, because of
(51:11):
the nature of the conversationin public life.
Bob Machamer (51:13):
With regard to women's health, and and choice.
I don't even know if I can sayon the recording, I it's painful
to think about the women that Iknow. And it's painful to go
backward.
Chip Gruen (51:31):
I think and this gets back to my previous
question. I think where I sit inthis conversation right now, and
maybe I'm just a little more ofa pessimistic person than you
are, but I talk to you and youhave hope, right? That systems
can do better, that thatlearning is possible, that we
(51:55):
can in the light of ethicalreasoning get to places where
the individual is valued. And Ilook around not as an ethics
specialist, but but justsomebody who looks around and is
curious about the world. And Isee the complicatedness of
political conversations oflegislators who will end up
(52:18):
being responsible for this, ofthe stock options and
shareholders that are involvedin these health care systems,
with people who might mean well,but nurses and doctors and other
health care providers who thinkvery differently about all a
host of issues. And I justthink, Oh, my goodness, this is
(52:40):
a mess. I know we can do better,I have hoped that we can do
better, but I'm not sure that Isee the way forward.
Bob Machamer (52:45):
I think the way forward is to continue the
conversation, I think the wayforward is to invite people to
sit around a table with a cup ofcoffee, a cup of tea, a beer,
and to find a direction, acommon direction. And to mull it
over together, and then to getout and add to the numbers of
(53:08):
those for whom it could behelpful. We teach this at the
college because the collegebelieves not just to check up a
box for their licensure. But weactually believe that the person
who enters into that room whilethere's virtue ethics, I mean,
it just it's going to stick upall the time. We want I want my
(53:30):
students to walk into a room andhave a patient say, you're
really good at this. What areyou good at? I I want them to
listen to the person in that bedand to not see patient only but
a person who has a story whosespouse might be at home, and
(53:54):
they want so desperately to beat home with them because they
are that spouse's primarycaregiver. And, and to recognize
that you have a whole personthere, what brought you here,
what keeps you here? What areyou going to do when you get out
of here? I want to happen atevery level. And I know I've
seen the software packages thatsay you've got 17 minutes to see
(54:16):
this patient. And then you'vegot to move on because we have
to keep a certain dollar amountin the practice. I think it's
going to take people saying No,I won't do that, and to probably
reform and maybe even recreateand start fresh in a new way of
(54:37):
doing and being Catholicinstitutions are all around the
world. Right? They I saw them inAfrica, in Tanzania. I saw the
remarkable work that they did.
remarkable work that they did.
Some of it harmful of course,but by and large, the people who
serve there who could have beenserving here, they brought their
(54:58):
whole self to that position,that I guess my hope is because
I wouldn't know what to do if Ididn't have hope. And I do
believe in God. And I believethat God does have a plan. And I
believe that God wants us to doexactly what Aristotle said,
(55:20):
Seek the highest fulfillment,through virtuous living, I
think, I think that's critical.
I think sometimes we just haveto keep reminding people, that
they matter what they do, whatthey would what they do matters.
That's the heartbreaking thing.
In health care. I see healthcare workers, I see public
(55:41):
educators, I don't know how theydo it. Remember what it was 35
years, and hey, you have yoursummers off, and you're retiring
at 55. I don't know how manypeople stay till their 35 any
longer. I don't have a lot ofanswers Chip. But I do want to
stay in the game. And I do wantto continue to have the
conversations.
Chip Gruen (56:00):
So one of the there are a couple questions that I
like to finish off with, and I'mgonna give you one version of
those. And it it really modelssomething that I think is very
important that that we allrealize our own myopia on these,
in these conversations, thisisn't something that I spend 40
hours a week thinking about thisisn't something that I've read
(56:22):
as deeply as many people andcertainly anybody in the field
has. So what am I missing? Youknow, I've come up with we've
had this conversation, I've comeup with a list of questions,
I've sort of probed the thingsthat are on the top of my mind.
But what is it that I'm missing,that you see from your
perspective, or that we mightsee if we were on site and a
(56:43):
healthcare facility that isreally, really important about
this conversation that we cantake away?
Bob Machamer (56:48):
The vast majority of folks that I meet in a
healthcare system want to dowhat matters. And I think the
thing that we can miss is anopportunity to thank them, I
think that we can miss engagingthem at a personal level in the
midst of doing their job andreminding them that we
appreciate that they are doingtheir absolute best on our
(57:10):
behalf. But they're doing itbecause internally, they really
want to. And if we in the publiccan help them remove the
barriers to providing that kindof loving care. I think that we
can go a long way. I think thatfor me as a Christian man I
believe that we're to love Godand to love all people. And I
(57:33):
really mean all people, whichmeans respecting some of the
labels that are out there thatthey exist, but not allowing
them to shape and determine theway we relate to one another. So
for me, I think that when wehave an opportunity to see
somebody in healthcare, when wehave an opportunity to see
(57:54):
someone that's an ethicist,whether they're an academic or
they're practical, like I wouldconsider myself to be just, I
get to teach. But I'm not a fulltime ethicist. I wouldn't call
myself an expert in ethics, Iwould call myself parish pastor,
who happens to be a therapist,who happens to really, really
(58:15):
believe that health care can bemore than just a machine, but it
can be people, loving peoplewith certain skill sets, certain
gifts, certain talents. Thatwould be the only thing because
I think you're asking the rightquestions. I think that you like
all of us don't have a lot ofanswers. But if you're not at
(58:37):
least asking the questions.
Well, then I don't think thereis hope.
Chip Gruen (58:42):
All right, well, I think that is where we're going
to leave it for now. And thankyou very much, Dr. Bob Machaer,
for being with us onReligionWise.
Bob Machamer (58:50):
Thanks, Chip.
Thanks very much for having me.
Chip Gruen (58:55):
This has been ReligionWise a podcast produced
by the Institute for Religiousand Cultural Understanding of
Muhlenberg College ReligionWiseis produced and directed by
Christine Flicker. For moreinformation about additional
programming, or to make aninquiry about a speaking
engagement. Please visit ourwebsite at
religionandculture.com. Thereyou'll find our contact
(59:16):
information, links to otherprogramming and have the
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subscribe to ReligionWisewherever you get your podcasts.
We look forward to seeing younext time.
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