National Cancer Prevention Campaign Discussed

In this second portion of a two-part interview, Linda L. Emanuel, MD, PhD, discusses the future of bioethics. Part I highlighted end-of-life care and physician-assisted suicide, while part II focuses on organizational ethics and future issues in bioethics.

Dr. Emanuel is Buehler Professor of Aging and director of the Buehler Center on Aging, Northwestern University Medical School. She was formerly vice president for ethics standards at the American Medical Association (AMA).

Dr. Emanuel has written and lectured widely on bioethics, including editing the book Regulating How We Die: The Ethical, Medical, and Legal Issues Surrounding Physician-Assisted Suicide (Harvard University Press, 1998).

Oncology News International: What areas in the medical field are particularly lacking bioethics research?

Dr. Emanuel: Bioethics needs more empirical research in most of its areas. Facts matter in bioethics. There really isn’t a field in ethics that has a very strong body of research of an empirical nature. End-of-life care is the area in ethics that has the strongest empirical research. There are aspects of policy that are supported by decent survey research, and some that are empirical.

There is beginning to be some ethics research on aspects of clinical practice that are directed by ethics concepts. There is beginning to be some empirical work on research integrity, but most of the research is of a scholarly nature, and there is just so much to be done. Organizational ethics has a small amount of empirical research, but this is even more embryonic.

ONI: How do you perceive the role of bio-ethicists and bioethics committees in medicine in general? Do you think this field is going to continue to be more and more integrated into clinical care? Will it ultimately change the way that clinical care is aproached and delivered?

Dr. Emanuel: I think it has already had a significant influence and will continue to do so. We’re seeing a larger role for ethics committees. The IRBs [Institutional Review Boards] actually came out as an early product of the ethics efforts, and ethics were integral to the end-of-life care field in its early days.

We’ve seen a lot of impact. Now we’re seeing organizational ethics take off, and we’re going to see more of that. I think there’s going to be a very interesting place for ethics in the corporate environment and in the medical environment.

Education in Ethics

We’re seeing more and more people with clinical degrees get ethics qualifications. I think we’ll see integration, with clinicians graduating with a decent education in ethics as part of their professional education. I think it will continue to grow.

What will be interesting will be the tussle between different components of ethics. Is this going to be something that moral philosophy dominates? Is it going to be more derived from religious ethics or from virtue ethics? What about political science and economics?

All of these are legitimate components of ethics, so what will comprise the authentic blend that will be defined as clinical ethics?

ONI: In what way was working on ethical issues from an organizational perspective, as in your work at the AMA, different from working on ethics from an academic position?

Dr. Emanuel: Very different. The AMA has a national and political role that academic organizations don’t have. Thus, the perspective and the forces that are brought to bear are very different.

The AMA has some unique organizational ethics demands that are essentially a blend of organizational ethics, professional ethics, and political ethics.

Although evidence suggests that most people don’t really understand this, the AMA is an organization that is designed as a federation with a structure that mirrors our national government’s federation structure.

Initially, the AMA was a state-by-state coalescence of organizations that was later organized into a federated structure to facilitate a geographically based form of democratic representation.

As the specialties began to form their own societies, these, too, were included in the federated structure, each represented by delegates to the AMA’s House of Delegates.

The structure is a democratic representation based on numbers, just like any other representative democracy. There are organizational ethics issues related to that, which are also matters of political theory.

Staff Structure

In addition to the representational structure of the AMA, there is a staff structure. The AMA staff was at about 1,000 people when I was there. It’s a large incorporated structure, so corporate ethics needs to be considered.

On top of these complications, the AMA is supposed to be a professional representative to the nation.

On the one hand, the AMA is supposed to be an organization that ad-vances professional needs, which are largely patient care and public health. On the other hand, it is supposed to be an organization that represents the needs of the workforce (ie, physicians), and that responsibility tips very readily into physician self-interest.

The latter factor makes the AMA a special interest lobbying group, a role that is mutually incompatible with the professionalism that is supposed to subjugate self-interest. It’s on the horns of that dilemma that the reputation of the AMA has swung from very good to very bad during its history.

But it is important to remember that the AMA’s reputation is the collective responsibility of all physicians, since it legitimately represents about 98% of physicians through the delegates, and the staff is accountable to the elected officials from the House of Delegates.

The dilemma of how to deal with the needs of a professional workforce presents itself differently depending on the nature of the medical community in a given country. Some countries, for example, have a separate physician-lobbying group. In Canada and Britain, professional organizations are separate from physician unions. We don’t have that. In the United States, both of those interests come together in one organization.

To successfully handle the two interests, you can either have two separate physician organizations or you can have different departments within the same organization. But different departments within the same organization can hold hands too closely. If that is the case, you don’t have the arms-length separation needed to avoid a conflict of interest.

So, as you can see, there are all kinds of organizational ethics issues at the AMA that are fascinating, urgent, and have a major impact on the medical policy of the country and the efficacy of its medical profession.

These ethical issues are not well understood by practicing professionals and are completely different from academic medical ethics issues.

ONI: What new directions do you see the field of bioethics taking in the future?

Dr. Emanuel: Genetic medicine is going to transform bioethics, and organizational ethics is going to become very important.

This country has the luxury of supporting a profession of bioethics, and the source of much of that luxury is the biomedical corporate world. Much of medical monies come from the biomedical industry, which raises a number of ethics issues.

The corporate industry in medicine has a lot of very smart, well-intentioned people in it who feel they are doing good and want to continue to do good with the help of bioethics. Then there are also those who are more cynical. They want the blessing of the bioethics community so they can keep doing what is profitable for them.

Either way, there is a motivation for the bioethics community to get involved in the biomedical industry. Bioethics is cheap to support by all standards of research and development. Bioethics will get more and more involved where there is money to support it, and many biotech industries have that money.

Ms. Ali, Ms. Witlen, and Ms. Tomori are project managers, Northwestern University Medical School. Dr. Bennett is professor of medicine, Northwestern University Medical School, Robert H. Lurie Comprehensive Cancer Center, and director of HSR&D, VA Chicago Health Care System—Lakeside Division.