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“Medical advances can often stir up ethical issues, which ripple into two courts: the court of law and the court of public opinion. These news articles described a public relations nightmare brewing at the National Pituitary Agency (NPA), which operated with NIH funding. Founded in 1963, the NPA had been collecting 72,000 cadaver pituitary glands annually for research purposes. The intent was noble.”
Alfred Sadler is a physician. Blair Sadler is an attorney. They are authors of the book, Pluck: Lessons We Learned for Improving Healthcare and the World.
They share their stories and discuss their KevinMD article, “Medical advances can often stir up ethical issues.”
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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at kevinmd.com/rate. Subscribe at kevinmd.com/follow.
Today we have Alfred and Blair Sadler. Alfred is a physician, Blair is an attorney, and together they are authors of the book “Pluck: Lessons We Learned for Improving Healthcare and the World.” They have an excerpt from that book on KevinMD titled “Medical advances can often stir up ethical issues.” I’m going to ask each of you just to briefly share your story and journey to where you are today. Alfred, why did you go first?
Alfred Sadler: When we were in Philadelphia, me finishing up my surgical residency and internship and Blair his law school and a subsequent clerkship, we got in touch with each other a lot and talked about health law problems. One of them was the Good Samaritan question about stopping at the scene of an accident. One thing led to another, and we were fortunate enough to end up at the National Institutes of Health in July of 1967, with the help of Dr. Luther Terry, who had left his position as surgeon general and become vice president for health affairs at Penn. We submitted a list of medical-legal subjects, from the use of human beings in research, to the definition of death, to genetic engineering, to death-and-dying kinds of issues, to him. He thought it would be very good to have a lawyer in the Public Health Service, which had never happened before. So we went to the NIH as a medical-legal team to address whatever they wanted us to choose.
The first thing they asked us to look at in the NIH director’s office was this question of getting human tissue, in this case pituitary glands, to get human growth hormone from cadavers. There are some legal issues related there too, which, if we had a longer time, we could go into. It’s a fascinating story. One thing led to another. Five months after we were there and researching all the laws in the states relating to dead bodies, of which there are basically four groups, Christiaan Barnard did his first human heart transplant in Cape Town, South Africa. That was December of ’67, and all of a sudden this niche little area of ours was front-page news every day. Christiaan Barnard, for example, became man of the year by Time magazine.
The ethical issues related to the law that we helped write, because we worked with a group called the National Conference of Commissioners on Uniform State Laws, now called the Uniform Law Commission, so it’s not quite so many words to deal with. They write model state laws every year, one or two or three, where the Constitution says this is an area of state law, but thoughtful people, starting in 1892, which was the first time they got into this business, would benefit by having all state laws be the same, whether it’s interstate commerce or, in this case, organ transplantation. What we came up with, with the Commissioners on Uniform State Laws, in July of 1968, was the Uniform Anatomical Gift Act, and that’s still in place today with some minor modifications. It was adopted in all states plus the District of Columbia in three years, which none of their laws has ever done.
I think the reason it went so quickly related very much to your question of ethical issues. We felt that this should be a donation statute, where we as individual citizens have the right to donate if we want to, and then if we don’t make a statement, our next of kin can make a statement: “Yes, Fred wanted to donate his organs.” And the specified order of priority in that law. Other important issues: separate the transplant team of physicians from the recipient team of physicians, and therefore avoid conflict of interest.
The other approach was, let’s make everybody an organ donor. It’s called opting out, or presumed, that unless you object. So the obligation was on me or you as a citizen to object, and we felt that that was not in consonance with the United States principles of autonomy, altruism, and trust. Those were the three key things that we went with. So we were very involved in bioethics from the very beginning as it related to this issue and several others. We were involved in the human experimentation issues.
Then we discovered a year later, in 1969, that there was a group of people meeting in New York who were setting up something that was later called the Hastings Center, the Hastings institute on bioethics. We went up and met with them and were two of the 17 founding fellows of this group. The whole point was to do an analysis of bioethical issues. Henry Beecher’s article had come out in 1966 about some questionable practices relating to government-supported research: Were the normal volunteers being told effectively of the risks? And then in 1972, of course, the Tuskegee experiment hit the press, and that has been a stain on our ethics in research. There have been others, but that’s been the most important.
Kevin Pho: And Blair, just briefly share your story. I know Alfred talked about some of the ethical issues when it comes to advances, but maybe share some of the other ethical issues that have also come up famously from medical advances.
Blair Sadler: Yeah, I think we took a big bungee jump, as Fred described, at age 26: Could a medical-legal team make a difference? We were very lucky that the opportunity that Fred described had such far-reaching impact, beyond what even the people who asked us to look into it, because it really got to the core of individual autonomy and helping others.
We also moved from the transplant world to the health workforce and the shortage, which you know well and talk about on other aspects of other shows: the shortage of doctors and nurses. We were looking at the fact that well-trained medical corpsmen coming from Vietnam, when they came back to the U.S., had no place to work or to be helpful. So we were very involved in the pioneering physician assistant movement, which started at Duke, in Colorado, and in the state of Washington, and when we were at Yale, we created the fourth physician assistant program in the country.
Some of the ethical questions were: How do we assure that this newly minted person called a physician assistant is really well trained, that they are going to do more help than harm? How do they get credentialed? How do we license them at the state level? How independent can they practice? So the concept of interdependence and working as teams, which you know well as an internist, is invaluable, and it was central to the emergence of, again, changes to state laws, because, as you know well, the licensing of health practitioners is at the state licensure level, besides the national accreditation of programs and certification of individuals.
So what was the way to do that? Working with a couple of other colleagues at Duke, we came up with a straightforward, simple amendment to the existing medical practice act, the physician practice act that applies to you in New Hampshire or in New Jersey or wherever, to simply give authority for physicians to delegate tasks to nurses, nurses’ assistants, and physician assistants, as long as the physician was ultimately responsible and accountable. So, in a very different universe from organ donation: the importance of looking at how the law can be a facilitator and a helper, to make things move more quickly and to make health care better.
Then we got into emergency medical care because of this opportunity to go to Yale and work with Dr. Jack Cole, who had gotten a major grant from the Commonwealth Fund to study how we make the emergency medical care system better. It was really quite shocking. Someone your age probably said, you know, there was a time we had no 911? So let’s take you back to 1970. No single number, no 911. Ambulances were basically hearses or station wagons. There was no EMT. I’ll say that again: There was no EMT, no paramedics. There wasn’t a residency or a specialty in emergency medicine, believe it or not. As we got to meet pioneers in other cities who were experimenting with how to increase the capability of non-physicians, this really then took off.
When we moved to the Robert Wood Johnson Foundation, as it was just getting started as a national foundation in Princeton, the first national program that Robert Wood Johnson ever did was a program for emergency medical communications: to train EMTs, train paramedics, encourage single-digit 911 numbers, and train the dispatchers, who knew how to handle a fire or a police emergency but didn’t know how to deal with the poisoning of a child, for example, and make those universal. That was 44 grants in 32 states, and that helped teach us another thing, about how you take ideas to scale, from a pilot, an idea in one place in Connecticut, to the whole country.
Since then, I’ve been very involved with health care leadership, as president and CEO of the nonprofit Rady Children’s Hospital here in San Diego, where I live, which I did for 26 years. A lot of what comes through in the book are the lessons we learned, those 15 lessons we learned to make a difference, which is what the subtitle of the book is about, and we think they are very relevant today. People might ask, in this polarized world where civility seems to have disappeared, are these lessons valuable today? We believe they are: about finding and developing your voice, just as you have as a facilitator and communicator so effectively. Where can I make a difference? Finding one thing.
I mean, I’m struck by the pediatrician Mona Hanna-Attisha in Flint, Michigan, who four or five years ago, with the lead water crisis, not only was taking care of kids who were affected and poisoned, if you will, but became a real advocate to change the entire legal system. So those are the kinds of inspiring stories we try to weave in, in the concluding chapter of the book, where anyone can find where they want to be and make a difference for one person, one family, one hospital. You can lead, as we say in one of our lessons, from any chair. You don’t have to be the director of the hospital or chairman of the department. You can make a difference at your own level in any way you want.
Kevin Pho: So your book is titled “Pluck: Lessons We Learned for Improving Healthcare and the World.” Alfred, I have an audience of mainly clinicians, and I’m going to ask both of you the same question. From your book, Alfred, what would you say is the top lesson that you want readers, specifically clinician readers, to come away with after reading your book?
Alfred Sadler: It’s just picking up very much on what Blair was saying. To digress for a moment on the word “pluck” and why we picked that as the title: One of our editors came up with it, and we just went with it, because having pluck, or gumption, or courage, whatever synonym you want to use, is essential. As Congressman John Lewis said, we can’t just believe in democracy; we have to take action to make something happen. Or the quote at the beginning of the book from Teddy Roosevelt, saying that it’s the man in the arena that makes the difference, not the critic on the side.
So having pluck means picking out an area, as Blair suggested, and then maybe asking for help, asking for a mentor, asking for a colleague. Don’t just jump in, but once you decide, pick one area. It can be as simple as helping your next-door neighbor who’s had a stroke. It could be that basic, and that is, for that person, lifesaving or life-helping. Or it can be taking on a broader issue. It can be joining a big organization relating to climate change, for example, or Planned Parenthood. There are lots of ways you can use that pluck.
And then the other thing we like about the word “pluck,” and that’s why we put the P in parentheses, is that that’s the going-action letter of the word, but the rest of it, often, is luck. So when we got to the NIH, for example, and got involved in dead bodies and what parts can be used for what, the fact that the heart transplant came along five months later took the issue we were working on to a worldwide level, and we actually became spokesmen for HEW all around the world, because we had done our homework.
Kevin Pho: All right, Blair, same question to you. For clinician readers who read your book, what’s the top lesson you want them to come away with?
Blair Sadler: I think to pick something you really care about, where you want to make a difference, in addition to your day-to-day clinical practice. So what is the issue? What is the topic, and how can you make a difference? That can be as a leader, a collaborator, a facilitator, and an advocate. But pick something that can make a difference, that gives you satisfaction. Clinical practice is demanding. It can be demoralizing. It can be discouraging. Beyond individual patient care, what’s an area where you can make a difference? And then go for it. Take action.
Kevin Pho: All right, and I’m going to ask both of you for just a take-home message, especially in the current day. I know that you have a lot of historical context in terms of what you’ve seen, drawing from your decades-long experience. Can each of you apply some of those lessons to a current situation today, and perhaps just end it off with a take-home message? So Alfred, I’m going to ask you that. Any historical lessons that can be applied today?
Alfred Sadler: Well, I think we can look all around us and see, with the pandemic, which none of us have ever experienced before, that there are lots of ways we could help out in the pandemic. The vaccine issue comes up, how to wear masks, when to stop. A lot of these issues then became very political, which we didn’t have to deal with so much, although going through our ’67 to ’76 period, there was the Vietnam War, there were the assassinations of Martin Luther King and Bobby Kennedy, and there was the Richard Nixon presidency to deal with. So there were some tumultuous times.
But I think today it’s picking out something related to the pandemic and COVID, and it’s raising its ugly head yet again out here. I don’t know what it’s doing in New Hampshire per se, but we thought we were finally coming to the end of that. And so I would say, pick out what role one could play relating to this COVID. I’m very involved in a PA program right now. We had to change our whole education system, as all medical and nursing schools and PA schools have done, to online, to simulations, lots of change, to go with that flow, and modify people’s job descriptions. So there are lots of possibilities, right under our nose.
Kevin Pho: All right, Blair, last question to you. Historical lessons that you could draw from your experience that could be applied in today’s world?
Blair Sadler: I think two. One would be: Grow and develop your voice. Find out where you can be a most effective advocate and instrument of change. That takes confidence, it takes knowledge, and it takes practice to take that and make a difference. So, developing and growing your voice really well. That can be in writing, that can be in speaking, that can be one person at a time, or it could be a thousand people.
The last one, which I guess we close with, and which I think is very important as a state of mind, is: Dwell in possibility. Live in possibilities. Look for opportunities to improve, and not get discouraged by the challenges all around us and the divisiveness that we’re dealing with.
Kevin Pho: The book is called “Pluck: Lessons We Learned for Improving Healthcare and the World.” We’ve been talking with Alfred and Blair Sadler. Thank you both so much for being on the show and sharing your time and insight.
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