Friday, October 24th

Z. Smith Reynolds Library Auditorium

CLE Credits:

5.5 hours General

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Please REGISTER today to help us accommodate all of our guests for parking and CLE credit.

Directions to the Z. Smith Reynolds Library Auditorium can be found here.  For the most convenient parking, please use Lot S and Lot E, as designated on the parking map.

Please direct any questions to Kenny Cushing at cushka12@wfu.edu.

Description

The Wake Forest Law Review will host its Fall 2014 symposium, “Relationship-Centered Health Care: Implications for Law and Ethics,” on Friday, October 24th at the Z. Smith Reynolds Library Auditorium.  The symposium is co-sponsored by the Wake Forest Center for Bioethics, Health and Society.

Viewing health care delivery as fundamentally relational—rather than as a series of discrete transactions between provider and patient—provides a psychological and sociological lens to evaluate its contemporary legal and ethical dimensions. Larry Churchill, the co-author of two acclaimed books on this emerging topic—Healers: Extraordinary Clinicians at Work (2011) and What Patients Teach: The Everyday Ethics of Health Care (2013)—will be the featured keynote speaker, along with co-authors David Schenck and Joseph Fanning.

In their first book, Healers, the authors use empirical observation, as well as philosophical, anthropological and psychological perspectives, to analyze the ritual structure and spiritual meaning of healing skills. In What Patients Teach, the authors examine the dynamic of “doubled-agency” between doctors and patients, which is based in patients’ vulnerabilities and gives rise to a set of special responsibilities.

A distinguished group of legal, medical, and ethics scholars will respond to the ideas raised by these authors and explore their own work as it relates to the web of critical relationships within health care delivery.

Schedule

 8:30 Continental Breakfast
 9:00 Patient-Centered Health Care (Keynote Speaker)
Larry Churchill, Ph.D. Professor of Medicine, Ann Geddes Stahlman Chair in Medical Ethics, Vanderbilt University Toward an Ethic of Patient-Centered Health Care
Joseph Fanning Assistant Professor of Medicine, Vanderbilt University
David Schenck Assistant Professor of Medicine, Vanderbilt University
 10:30 The Phenomenology of Being a Patient, Physician, or Research Subject
Mary Catherine Beach, M.D., MPH Associate Professor, Department of Medicine, John Hopkins University Clinician Emotions and Values: Risks and Benefits of Relationship-Centered,Care
Lois Shepherd, J.D. Peter A. Wallenborn, Jr. and Dolly F. Wallenborn Professor of Biomedical Ethics, Professor Public Health Sciences, Professor of Law, University of Virginia Welcome, Responsibility and Healing Skills
Mark Hall, J.D. Fred D. & Elizabeth L. Turnage Professor of Law, Wake Forest University Physicians as Placebos: The Law and Ethics of Healing Relationships
Rebecca Dresser, M.S., J.D. Daniel Noyes Kirby Professor of Law, Professor of Ethics in Medicine, Washington University What Subjects Teach: The Everyday Ethics of Human Research
 12:00 Lunch (click here to see on-campus dining options)
 1:30 Computers and Physical Space: The Architecture of Clinical Encounters
Pat Ober, M.D. Professor, Wake Forest University The Electronic Medical Record: Treating Our
Fellow Creature as Corn and Coal
Christine Coughlin, J.D. Director, Legal Analysis, Research & Writing, Professor of Legal Writing, Wake Forest University iConsent: The Doctrine of Informed Consent in the Electronic Age
Elizabeth Pendo, J.D. Vice Dean, Professor of Law, St. Louis University Caring for Patients with Disabilities
 2:45 How Doctors and Patients Communicate
Arthur R. Derse, M.D., J.D. Julia and David Uihlein Professor of Medical Humanities and Professor of Bioethics and Emergency Medicine, Medical College of Wisconsin Three Generations of the Objective Patient
Standard is Enough!: The Evolution of Informed
Consent in Wisconsin and its Implications for the Physician-Patient Relationship
Nancy King, J.D. Professor, Wake Forest University The Reasonable Patient and the Healer
Chris Robertson, J.D., Ph.D., M.A. Associate Professor of Law, University of Arizona Should Patient Responsibility for Costs Change the Doctor-Patient Relationship?
 3:45 Adjourn

Abstracts

Churchill

Despite the profound changes in medical ethics over the past 50 years, medicine’s codes, oaths, and principles remain steadfastly centered on the professional. This Article explores how pervasive this professional orientation is and the shortcoming and distortions that result. By adopting and incorporating many of the bioethical formulations for good doctoring, medicine has largely substituted norms inspired by political ideals and an economic model of consumer rights to replace the defunct paternalistic norms. A genuinely patient-centered ethic begins with patients, with patients’ understanding of the moral features of clinical encounters, and a reworking of the moral tools essential to practice effectively.   Read PDF of article online.

Coughlin

The recent introduction of electronics within the doctor-patient relationship—specifically the use of computers and tablets—will affect the quality of that relationship, as well as the patient’s understanding of the clinical encounter. This presentation and Article looks at that effect by examining the use of computers and tablets in the informed consent process.

Many physicians and health care entities use general informed consent forms to document a patient’s consent. Indeed, various state laws provide physicians some protections from litigation if an informed consent form is used. In reality, many of these informed consent forms, while arguably consistent with the law, are inconsistent with the goals of informed consent because they are not focused on the patient as an individual and they are written above the recommended grade level reading target. Recent research, moreover, regarding reading comprehension on computers and tablets versus hard copies suggests that reading on tablets and other types of computers promotes “skimming” and likely decreases reading comprehension overall.

The advent of electronics used to obtain informed consent and other information, while efficient, may decrease the understanding and comprehension of the risks and benefits of the proposed treatment. Appropriate precautions must be instilled not only to obtain meaningful informed consent but also to preserve trust in the doctor-patient relationship. As electronics become an integral part of patients’ clinical experience, best practices should be implemented so the focus is not only avoiding possible litigation. Rather, best practices should be implemented in a manner consistent with Dr. Churchill’s and his colleagues’ focus on the patients’ understanding of the various dimensions of clinical encounters.  Read PDF of article online.

Derse

The Wisconsin Supreme Court in 1975 adopted the objective patient standard for material information that must be disclosed to a patient by a physician for adequate informed consent. The court significantly expanded the standard’s reach by including these elements as material to an objective patient 1) information about the health care facility’s level of expertise, 2) the experience of the physician, if substantially different from an average practitioner, 3) all viable alternative options for treatment including means of diagnostic measures and followup and 4) a duty to disclose all viable alternative diagnoses considered before arriving at a final diagnosis, as well as the diagnostic tests that would rule out those alternate diagnoses. In response to claims of judicial overreach, the Wisconsin legislature amended the state’s informed consent statute to return the state to a professional standard of material information and excluded the requirement to disclose alternative modes of treatment for other diagnoses considered. The saga of the establishment and expansion of the standard, as well as the recent legislation, will be reviewed, and implications for physician-patient communication will be discussed.

Dresser

In What Patients Teach: The Everyday Ethics of Health Care, Dr. Larry Churchill, Joseph Fanning, and David Schenck offer a critique of conventional medical ethics. They contend that ethical codes and principles neglect patients’ experiences and rely too heavily on what professionals, rather than patients, see as ethical care. I believe that many of the points Churchill and his colleagues make about medical ethics apply equally to research ethics.

For the most part, research ethics has developed without serious attention to the views of people who know what it is like to be a research subject. Rather than relying on speculation about the research participant experience, research ethics and oversight ought to rely on what actual participants say about their experiences. Research ethics, as well as regulations intended to promote ethical conduct, should be based on evidence. Ethical and regulatory decisions should take into account participants’ knowledge, as well as their positions on ethical issues in research.  Read PDF of article online.

Hall

Placebos are often denigrated as spurious effects in research, or psychosomatic clinical aberrations, but generations of careful study and reflection reveal that “nonspecific healing” effects are pervasive in medical encounters.  In part, this is because good clinicians, knowingly or subliminally, are able to activate or enhance the body’s own self-healing powers.  Viewed this way, physicians do not so much administer placebos as they themselves are (or can be) a placebo agent—by dealing with patients in ways that make bioactive treatment modalities more effective than if they were administered, say, by a machine.  This is a large part of what we mean when we refer to health care workers as healers and when we emphasize the importance of healing relationships.

            This Article will explain and develop these ideas, drawing on both empirical and conceptual literature.  The Article will then explore whether or not various elements of health care law and ethics are compatible with optimizing the healing aspects of treatment relationships.  Key points of focus will include informed consent doctrine, the ethics of administering placebos, the malpractice standard of care, and managed care patient rights.  Read PDF of article online.

King

This Article’s focus is (1) an examination of the “reasonable person” concept as it applies to disclosure and causation in informed consent, and (2) the application of the reasonable person to the physician-patient relationship, using Alice Trillin’s New Yorker essay “Betting Your Life.” The Article then uses these concepts to discuss healing relationships as described by Dr. Churchill and his colleagues.  Read PDF of article online.

Ober

“The practice of medicine is not a business and can never be one …Our fellow creatures cannot be dealt with as a man deals in corn and coal; the human heart by which we live must control our professional relations.”

[Sir William Osler]

             The introduction of the electronic medical record [EMR] in recent years brought a promise of great potential advantages, especially in the realms of communication, health monitoring, and patient safety. This great potential has fallen by the wayside as the EMR has been subverted for the purpose of business-oriented goals such as more efficient [and, possibly, inflated] billing. Recognition of the ideals of patient individuality and patient-centered healthcare is discouraged by the EMR in its current format. The patient’s unique story is devalued. Patients have become commodities, clinics have become cheerless assembly lines, and the advice of Sir William Osler has been disregarded as the EMR is replacing the traditional patient-oriented focus of medical practice with a business-oriented model.

Pendo

People with disabilities face multiple barriers to adequate health care and report poorer health status than people without disabilities.  The Institute of Medicine and others suggest that lack of physician education and professional training on disability competency issues is one of the most significant barriers to appropriate and effective care.  A related but less-studied barrier is the physical environment of health care, including facilities, examination rooms, and medical and diagnostic equipment.  This presentation will explore the model of relational ethics as illustrated by Dr. Larry Churchill, Joseph Fanning and David Schenck in Healers: Extraordinary Clinicians at Work and What Patients Teach: The Everyday Ethics of Health Care as a framework to acknowledge and address these barriers, and to improve the health and health care experiences of patients with disabilities.  Read PDF of article online.

Robertson

Decades of health policy reforms have caused patients to pay-out-of-pocket greater portions of the cost of their own healthcare.  We know from prior research that some patients are left “underinsured,” which means that the costs of care can undermine adherence, can cause stress, and can cause other risks such as bankruptcy and foreclosure—all of which may worsen the patient’s health. Only recently have scholars begun to ask whether and how physicians should respond.  Do they have a duty to tell their patients about costs of each treatment alternative?  Should they sometimes recommend cheaper healthcare, even if it is inferior?  Do physicians have a more fundamental duty to investigate the real costs of healthcare that will be imposed on patients?  Or, alternatively, are these financial duties better handled by other professionals—such as social workers?   One might cogently argue that treating the whole person includes attention to her pocketbook as well.  These questions are many and difficult, but analysis suggests some paths forward.  Read PDF of article online.

Shepherd

To be successful, all methods of bioethical analysis—whether Principlism or approaches that emphasize care, community, solidarity, or professionalism—rely on the presence of individuals who are radically open to the presence of all others and who are ready, willing, and able to take responsibility for what is going on.  This presentation will explore ideas of welcome and responsibility in the clinical encounter.  In their book Healers, Extraordinary Clinicians at Work, David Schenck and Larry Churchill write that “healing…always has to do with the quality of relationships.”  We often judge clinicians by how responsibly they care for vulnerable patients.  But if relationships are what we seek, then patients must also have responsibilities and physicians must also be vulnerable.  Read PDF of article online.

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