Ethics at the Edge: Bioethics, AI, and the Courage to Lead with Arthur Caplan, PhD

Mike Tsakopoulos: Welcome to Soundpractice, the business podcast for physicians and healthcare leaders, hosted by Mike Tsakopoulos and produced by the American association for Physician Leadership. Ethics is knowing the difference between what you have a right to do and what is right to do. Associate Justice Potter Stewart. The field of bioethics has never been busier. Advancements in biology, medicine and the emergence of generative AI continually raise new questions for bioethicists. My guest today is a national expert in the field of bioethics. He will guide us through bioethics today, next on Soundpractice. My guest today is Arthur Caplan. Dr. Kaplan is the doctors William F. And Virginia Conley Mitte professor and founding head of the Division of Medical Ethics at New York University's Grossman School of Medicine's Department of Population Health. Professor Kaplan is a leading bioethicist, having authored dozens of books and hundreds of peer reviewed journal articles. Arthur Caplan, welcome to Soundpractice.

Arthur Caplan: Thank you for having me.

Mike Tsakopoulos: It is my absolute pleasure. Professor, you've been at the forefront of bioethics for decades. Can you describe your career trajectory and uh, what initially interested you about the field of bioethics?

Arthur Caplan: Sure. I'm one of the last people in America, if not the world, to have had polio. I had it when I was six. Uh, still have some post polio use, a walker sometimes. I went into, I grew up in Boston and went, uh, into the Mass General Hospital, probably, I'm guessing 1956 or 7. And obviously they didn't know what to do with polio. I just missed getting the polio vaccine by months. Uh, probably one of the last cases, there was a Boston outbreak that I was, uh, part of, uh, in the hospital. I think the experience got me thinking a lot about how patients were treated. Even as a little kid, we had very restricted visiting hours. Uh, we basically had a pretty regimented, uh, existence. Remember we didn't have much except, uh, a little bit of TV and uh, it was boring. And so we did a lot of talking, uh, amongst ourselves, um, and we also had kids who were very sick and clearly disappeared. And they lied to us about what happened to them. They said they went home. They didn't go, um, home. We knew they were dying and we knew they were, uh, they didn't make it. Uh, I'd also heard about, although I wasn't on the floor where the iron lungs were, but I knew that there were people in those and they wouldn't let us down there. Long story short. Well, I wouldn't claim much sophistication from that experience. It got me oriented toward uh, how do we deal with people in hospitals telling the truth, allowing them to see family members, um, dealing with the boredom that can happen with a chronic illness if you're in a nursing home or long term care facility, which is similar. Later I went to rehab, uh, and learned to uh, regained some uh, physical function, legs. I did not get paralyzed in my diaphragm or chest, but my neck in any event. So I went to rehab for years and learned about that culture. Which also raises interesting ethics questions. Are you motivated properly? There's this notion that the patient has to really be pulling to want to get better. Kind of what you see in drug treatment a little bit. And you sort of like hey, I'm like 10, I'm not motivated to do much of anything. I'm motivated to watch tv. I don't know what are you bothering me here? I don't think people knew how to deal with that gap between wanting you to do your exercises and be compliant and be a good patient, quote unquote, or virtuous and what you know, young kids even to teenage level are going to be like, which is very uh, self centered and often uncertain. So ultimately I wound up going to Brandeis for college. And uh, all I'll say about that was this great experience not far again from where I grew up, uh, the school. But it was at a time when there was a lot of discussion out of the classroom about ethics, civil rights, Vietnam War, gay rights, women's rights. And I got caught up in those debates. I always laugh and say was the campus conservative because I liked Hubert Humphrey and wanted people to vote for the Democratic Party instead of just killing everybody, which was the sort of alternative party line at the time. And uh, nonetheless I enjoyed uh, getting into these arguments and debates, um, very intellectually lively climate. People who were at the school when I was there, Herbert Marcuse, Abby Hoffman, Angela Davis, Kathy Power. Later in my career I went and was invited to give a speech, ah to a uh, meeting of FBI leaders and uh, military leaders at Quantico. And when I came in the building I looked up at the 10 most wanted list of the FBI and I think I knew four of the people on the list. And I told the audience, I said this is first speaker you've had, I think, who knows, more people on the 10 most wanted list than those in the audience. They were like, they thought that was pretty amusing. But that got me interested in um, philosophical questions. Decided to try med school. Went to Columbia, uh, went there two Years, and while I was there, observed all kinds of interesting ethics issues on the floors. To give it one example out of many, we had, uh, guy run down the hall, uh, getting screamed at by another guy in a very long white coat. The longer your coat, the more senior you are. This guy was pretty senior. And, uh, he was telling the junior guy that he couldn't do this experiment here in his lab, uh, which was in obgyn. And, uh, for listeners with a long memory, the guy yelling was Raymond Vanderweel, chair of OB GYN at Columbia. Pretty famous. And the guy he was chasing was named Landrum Shuttles, who was a basic science guy who was trying to do the first in vitro fertilization, making test tube baby a dish they didn't need permission. There wasn't anybody to get permission from. At that time. We're talking 79 or so. Um, but the chair of the department certainly could say, you're not doing that here. And what he did was he flushed shuttles, uh, whatever was in his dish down the drain. So that was an example of an ethics thing that I saw hide in, get involved in it. I just observed it. I was a little junior nobody. But, uh, it got me thinking. When do we talk about these ethics questions? Especially with these new technologies like IVF or transplant or kidney dialysis or ICUs emerging for the, uh, more commonly with a lot of, uh, ventilators and artificial feeding and this sort of stuff. Long story short, I decided I'm going to go get, uh, master's degree in philosophy from the Columbia philosophy department. I show up there and I'll get through this bio soon. Um, and they say, oh, we don't do that kind of ethics. We're interested in whether ethics is possible. And we certainly don't do the ethics of plumbers, meaning doctors. Like what? You know, what do they do? It's like that we don't. That's.

Mike Tsakopoulos: That was an unkind comment, was.

Arthur Caplan: It was. They don't do deep things. And I'm like, yeah, we do. We make life and we're killing people and things are. Babies are deformed. We have to decide what to do with them. And it's very deep. But in any event, I got my degree. Turned out they didn't give master's degrees. You had to get a PhD. Master's degrees were for dropouts. But I got interested in what's called the philosophy of science and wrote a dissertation not on something in medicine or ethics, but actually about evolution and whether creationism was scientific and what should you teach in the schools about evolution or not. Uh, later in my career I was asked to testify in Pennsylvania at a key trial in Dover, uh, Pennsylvania, which was kind of the modern day Scopes trial. And uh, it was decided that creationism could be taught but not a science, which was, I agree with that. Teaches religion, teach it. You can even teach it in public school if you want as part of what do religions think about creation or why animals are the way they are or why we are the way we are. I have no issue with that. But it's not science. So what makes something science became the big uh, issue there. But again was interested in an ethics controversy that was kind of public and engaging wider voices. All those factors shaped my career. When I finally got back to Columbia, I started a medical ethics course. And I'll tell you at 100 students, first years and uh, I think at the end of the course there were six people left, none of whom had English as a first language. They didn't really know, they didn't have to go or be there. It was like an elective. It's a horrible course. And I taught it as a philosophy course from what I had learned. And I went back to the dean, said this didn't work. And he said, yeah, I know, I hear about it a lot that you stink. But um, he said you're doing it wrong. Remember from med school we teach by cases, kind of like law. And uh, you have to have a case based course. They're not going to want to know theories and the history of ethics and all that. They don't care. I switched it, succeeded, took off. And that's sort of where I got rolling in terms of the bioethics side of the career.

Mike Tsakopoulos: Very, very interesting. Tell me a little bit about the difference between your students in bioethics and in the um, in the PhD program. Because it seems to me that it must attract, although potentially equally intelligent, different types of people. Is that fair?

Arthur Caplan: 100%. So a lot of the people who wind up in your PhD program say in philosophy. They're there partly because they really don't like the real world. And some of them are seeking to find answers to questions in a more, I'll call it idealistic, theoretical, abstract kind of a situation. Uh, think, uh, it has an analogy. Think in biology when someone says, I'm going to study a lake. There are two ways to do it. One is you go to the lake and you sample the creatures and the plants and the dirt and the soil and the sediments and sort of say this is how the lake works. The other approach is to say, I'm going to do a mathematical model based on some variables that I see exist in the lake. But the lake is too complicated. I can't understand it. It's too changes in the seasons and there's differences in temperature. I can't monitor all this. I'll have a cleaner version and that will let me understand better. That's the Ph.D. student. Whether it's understanding human nature or being abstract about ethics, the common technique and um, PhD land is what would abstract beings who are rational decide to have for rules just if they were disembodied and didn't have a particular self interest. That would be the road to saying, well that's the right ethical theory. Bioethics starts down in the lake. It wants to know what's going on, what's all the variables, what's the craziness here? And if somebody said, but you'll never get to the ultimate principle, the bioethics crowd will say, we don't care. We just need to get enough consensus to solve this problem today. Maybe we don't have an ultimate theory of right and wrong, but if everybody agrees that you want to protect your right to consent to be treated or not treated, that it's your body and you should control it, and that's fine. Our work is done so very, very different. Very different.

Mike Tsakopoulos: Well, Professor Kaplan, let's go to the lake. It's my impression that ethics committees are underused in many health systems. What does an effective ethics infrastructure look like and what roles should medical leaders play in developing it?

Arthur Caplan: Well, first, medical leaders should be sure that they have the basics that would be both in hospitals but also m nursing homes and long term care. Uh, an ethics committee. Secondly, they should be sure that it's meeting, that it has, uh, keeping its minutes. They should be sure that it liaisons with their attorneys. Uh, whatever else ethics committees do, they should know what the law is. And if they don't know what the law is, they should be able to find out quickly by asking, uh, the legal staff of the institution or whoever they're using. I think it's very important next that in addition to the ethics committee, there is an ethics community. And what I mean by that is what's going on educationally. Do we have ethics rounds? Are we involving nurses, social workers, uh, patient, the people we use sometimes as patient advocates or representatives? When someone comes into the hospital, they should all be wired into regular ethics education about what, uh, areas of consensus there are, what areas where they Might need to develop a policy if they don't have one, that sort of thing. Also checking to make sure that your policies are known. A lot of hospitals adopt things about what to do if say, a parent, um, refuses care for a child that is necessary. There should be a policy on that and people should know what it is. One of the things I strive to do when at nyu, but in other places that I've worked too, is to make myself not needed. That is to say, let the palliative care people manage end of life care. If they're properly trained. I don't want to hear from them unless it's a really weird, strange case. They should be able to handle that. One other thing I think leaders could do is occasionally hold a fire drill, say X has happened, I'm calling you up. What are we doing? Even if X didn't happen. But see what the response is. Who gets involved, what the people do all the way up to pr and uh, uh, what's the public position of the institution going to be? You know, you want to test your systems and I don't think people do that enough.

Mike Tsakopoulos: I agree with you. Um, I'm interested. What are the, in your opinion, the defining bioethical challenges we're going to experience in the next decade?

Arthur Caplan: Well, there should be jobs for bioethicists in the next decade. Uh, a lot of issues still rattling around. The obvious big thousand pound gorilla in the room is AI. So AI is sweeping into health care. It's there already in a big way, but it is raising questions that have not been addressed by legislation or regulation. And so that's where ethics usually comes in. Tries to come up with the answers. And then maybe those get put into legislation or legal policies. Everything from when do you have to tell the patient that you're using AI? When do you say that AI is sufficiently, uh, competent to take on certain tasks? What's our liability if we use an AI program and an error occurs? Are we liable? Are the programmers liable? Is everybody? I mean, I know what the legal profession will do. They'll sue everybody and let the court figure out who's responsible. But it still might be useful to have some idea of internally what we think. Many questions about handling privacy, confidentiality of data, systems being protected from hacking or leaks, you know, the regulations we have, hipaa, uh, most of that was written before there was even the Internet. So you need to be thinking hard about what are we doing internally and what are we doing, you know, with our, uh, professional groups and societies to set out requirements for Privacy, confidentiality, disclosure, second party use resale Partnering with private entities with our health Information for profit frequently we're going to sell you this data and you can make a monitor or a Fitbit or an advanced form of surveillance to help advance people's health. I think that area is going to be huge and I'm just skimming the surface of AI there, uh, other big areas, um, neurology, the study of the brain is starting to catch up to genetics and obviously the brain, uh, modifying it, whether it is to use virtual reality implants into the brain, deciding what, uh, drugs are working well because you can monitor their impact on the brain, uh, with better uh, scanning and so forth. So this area also raises questions about who keeps the images. Who, uh, is going to say that uh, a diagnosis can be made based on scanning, not just symptoms. Uh, what are you going to do if somebody says you put this implant in my head and you promised me I could see again or you promised me my anxiety would go away, but it didn't and now what and how are you taking it out safely Research to get to these places? Many questions coming up there. So neuroscience, neurology, study of the brain I would flag as a major area. Third one is definitely going to be cost and rationing. We still have a system that can't, uh, figure out how to drive its prices down. And I don't know that we ever will. Uh, you know, there are a lot of people making money off of the current system and sort of changing the direction of that aircraft carrier's part. But it still means that tough choices are going to have to be made. You have therapies appearing, cost $2 million to do a gene therapy, or prices that are clearly beyond the means of nearly everybody. Are we going to have a two class system? Will there be access only to the richest? Can the richest pay for and buy things at your institution that no one else could get? Um, are we going to be in a situation also where we have systematic rationing of things? Uh, because we want to make sure that quality care goes to the most people possible. How do we make sure that happens in our institutions? What rules are guiding what's in our formulary, what drugs we have available? Whether we approve of a new device and make it available to our ortho guys or whoever it might be, leadership really has to grapple with guidance, uh, making sure not just that decisions are made, but the process is fair, that the process is evidence based, that we're not just rewarding the most productive surgeon around because that's what he likes or she likes, that sort of thing. And I'll mention one more area that, uh, I think is stirring up, uh, challenges for leaders. And that still remains, if you will, the, um, study of research ethics. I mean, a lot of places say they do research. Uh, many don't. But a lot of them still are tied in or feeders for research. We have an ethic that historically, uh, has been very protective of people in research because of abuses. Nazi experiments in camps, Tuskegee study, Willowbrook. There's a long parade of these things. From the 40s, 50s, 60s, 70s, we built a set of research ethics principles. Informed consent, IRB review committee review by peers of research, conflict of interest management. They're great. They're also going out of date. Today's person who's very sick. Today's person who has a very sick kid is not as concerned about protection from abuse as they are access to research. They want to go faster, they want to get in. I think we're going to see a revamping of, uh, research ethics rules to allow more risk, to allow less evidence to have something approved or certified as a vaccine, drug or device. By the way, we saw it in Covid with warp speed and the COVID vaccine. But it also led to trouble because people wind up not trusting things. They said, you went too fast, maybe you didn't have enough evidence, that sort of thing. Or maybe it was just companies looking to make sales or whatever their objections were. Still, I see speed and access is starting to drive research ethics. Uh, I don't see many people coming up to me today who are subjects or prospective subjects and saying, please protect me from researchers. What they say is, I want to write, to try. I want the ability to get in there and see if my kid is going to die, whether something might help him or her. I trust the research more. I think that breakthroughs might be possible. We may even see shifts in where the line is drawn in terms of traditional FDA oversight and rules about how much evidence is needed to approve something that poses leadership challenges to make sure that the ethics are understood, that the shift that I predict is coming is implemented, but also cost, because you're going to be spending more on things that may not be as proven. So are you in a registry? Are you monitoring what happens? Can you collaborate with other places and collect data, uh, in the real world now, as things get approved earlier to either pull them if they don't work or they have adverse events? In other words, I think we'll be looking and need a System that looks retrospectively post approval of things to see if there's problems as opposed to trying to manage risk before things get approved.

Mike Tsakopoulos: So that, I think leads us directly into, uh, compassionate use. And you've co chaired compassionate use advisory committees for Johnson and Johnson. What should physician leaders know about navigating patient requests for unproven therapies as, um, so many of these seem to come, uh, filter through social media?

Arthur Caplan: Well, first leaders must be sure that their IRBs, Research Ethics Committees have a policy about requests for unapproved drugs, unapproved devices. You could in theory soon get them for unapproved vaccines, because we're seeing a lot of cancer vaccines begin to emerge that look good but aren't through their tests and trials yet. The sort of thing that helped Jimmy Carter with his melanoma as an early unapproved, uh, cancer vaccine. So, um, when we, uh, look at requests, the first thing is, are, uh, we set up to say we don't do them here or we don't honor them, or if we're going to honor them, you have to come in with a doctor's request, not just a patient. You've got to convince a physician to make that request. And if they come to my committee, I want that reviewed by our human experimentation committee with their opinion. You may want to get legal into that too, uh, just for issues about who's paying and liability and what happens if somebody dies. Absolutely. Pr. There's no worse headline than little Johnny died getting an unproven thing at Hospital X. Uh, you don't really want that on your blotter. So, uh, having a setup that's ready to manage, you also need to know what the world is out there for handling this. I set up the first effort to have a committee of independent people review requests, but that was oriented toward industry, not so much hospitals. Industry was getting a lot of requests for their drugs and then, uh, trying to figure out should they honor them and then partner with doctors at various hospitals to give them out. But the initial requests often come to, uh, Johnson and Johnson or Merck, but they can come to little startup companies too, that you have new drugs. Those, all of those companies didn't want to deal with these patients. A variety of reasons, and they weren't doing much. And I said that's wrong. Sometimes we should honor these requests. And sometimes, even if the supply is scarce, we should allow some people to have access to new things, even if not all can. So the compassionate use advisory committee model I set up was basically to advise industry when it got Requests from physicians at different hospitals and long story short, made up an international committee because requests come from around the world, hospitals everywhere, for drugs for cancer, sickle cell, Alzheimer's, you name it, something that's in the pipeline. And we met and set out rules and tried to understand what would be fair and tried to be transparent and involve patients and patient advocates in the committees. Long story short, we've wound up giving out, uh, many, many more drugs than have actually been in clinical trials of these drugs, probably four or five times as much as people are getting by being in studies. We don't want to undermine the studies. You have to get the studies done. But sometimes there's enough drug or product around that they can do a little more. For some people, that world is an example of bioethics solving a problem. Not just whining about a problem, but actually implementing, ah, a structure that has now been emulated by many companies around the world. So leaders need to know, requests come in, what's the drug? What's the company? Does the company have a compassionate use advisory committee? Can we liaison there? The leader doesn't have to work it all through, but they need to know where are the resources that could help. And I think again, that's a nice one. For a fire drill, you get a request for a weird drug, it comes in to the hospital administrator. That's likely who the patient's going to call. What happens then? Where do they go? Who do you draw in? What questions do you ask? So, uh, time and again you know, the wife of the senator, the local, uh, congressman, some prominent business person, My kid's sick, I'm calling up Mary whoever who runs the Ninth Adventist Hospital of Waco. And I want access. That's what you need to be ready

Mike Tsakopoulos: to manage for fire drills. Are there organizations that have a tabletop exercise that uh, facility could, could borrow or use? Because it seems to me that, um, how the, how the question is crafted and how it works through makes a big difference on how your fire drill ends. And are there places people can go for help to learn, um, if they really want to implement a fire drill.

Arthur Caplan: Some of the fire drill stuff people are used to as leaders because they know that say, hospital accreditation is coming and they have to get ready to be asked a lot of hard questions. And they do do practice runs. And I know that it turns out my wife, now retired, was a former CEO of the Bronx va. I know what a fire drill looks like, uh, firsthand inside a big hospital, a, uh, va, but nonetheless a place that needs to get accredited to. So uh, it's not so alien to them. But I'll answer the question by saying not enough places have things in the boutique spaces. We do it a little bit for compassionate use and uh, requests for early access, pre approval access. I'm sure there are others who are doing it, uh, in other spaces. But generally speaking, it's been hospital accreditation that drives the practice fire drill. And I can tell you occasionally I've had the honor or misery of serving as an expert witness in lawsuits about things. Adequate informed consent, off label use, violation of privacy, variety of things. And uh, you can see that you wish they tried some fire drills there because they weren't. You know, you give doctors a lot of leeway to prescribe approved drugs for non approved uses. That's great. But then if something goes wrong and they haven't really told the patient that this is an off label use, and lawyers are swarming to say, you know, what's the policy of the institution, an off label use? And don't you have guidelines about, uh, making sure that appropriate consent to an off label use is given? Sometimes they try to leave the doctor out there to hang, but oftentimes, you know, everybody in the institution is getting swept up in this thing. So again, I like practice. I do. I think that helps. And it's not. You ask your hospital attorney to make up the two or three scenarios that scare them the most. They'll do it

Mike Tsakopoulos: in about 24 hours. Professor Mark Twain famously said, a lie can travel halfway around the world while the truth is putting on its shoes. Um, when health misinformation, including from political figures, is actively shaping patients beliefs, how should physician leaders rethink their approach to informed consent?

Arthur Caplan: I'm going to say something pretty, uh, controversial here. I don't think they're exercising leadership today enough courage. There's too much misinformation that goes unrebutted. A lot of places are duck and cover. I don't want to get on the wrong side of the administration or by the way, the state officials, they are powerful in many states where a lot of misinformation is flying around. I'll mention Florida as an example, uh, where I think leadership, Governor, surgeon general of the state have put forward bad policies based on misinformation. I understand the power issues. I understand the need to protect the institution from backlash, whether it's cuts in research grants or just uh, having people all of a sudden show up to audit everything all day or whatever penalties government may exercise. Still, I don't think we in the long run, do better by not challenging misinformation. I think it undercuts the credibility and trust that people have in mainstream medicine. If you let, uh, misinformation flourish, then eventually somebody's going to say, I don't need to go to your institution. I'm going to the Wellness Clinic or Mr. Whoever on online and buying their pills through AI, which I can get delivered to me in a brown paper wrapper at my house. I don't need to show up and have anything happen in, uh, these big facilities or small hospitals. I don't need them anymore. The ability to do healthcare in the US relies on the lubricant of trust. People don't think they can trust the institution. They won't go to the institution. And I think allowing misinformation to fester and flourish. And it is, I mean it's everywhere. It's all over the Internet. It's not just government officials, uh, espousing oftentimes nonsense, say, vaccines and autism. But I could easily, within 10 seconds, produce 100 websites that are full of bunk. Some systematic effort to support, uh, faculty or staff or doctors and nurses who also want to go out and talk in the community. I like programs that get voices out in front of high schools, 4H clubs, boy scouts, junior league, uh, churches, synagogues, whatever. Um, I don't think we come out to the community enough and send out spokespeople enough to talk about these things. And by the way, also reward it when people do it. Say, not only will you get money if you up your efficiency and seeing patients, um, in gastroenterology and colonoscopy, but if you go out and give a talk about anything in a high school, we have a little incentive for you to do that. Let's do more grassroots stuff. That's where the know nothings and the, uh, misinformers are. They're frequently in those places and I think we can engage there too. Leadership should be leading that the more courageous. It doesn't mean that the CEO has to be the voice of correction, but somebody who wants to correct. They need some support, not just tone it down or shut up because we don't want to bring any, uh, attention to ourselves. Now I say that a little bit as somebody who's always trying to mouth off. So I have a vested interest in them.

Mike Tsakopoulos: Um, well, it strikes me that some physicians, maybe not from a lack of courage, but from a position of not wanting to offend or alienate certain patients, take a, um, a quiet approach, um, maybe not supporting what they believe is inaccurate, but not refuting it either.

Arthur Caplan: Uh, well, I'll tell you one. I'll give you a concrete example. I can't find a cancer center in the US that doesn't have reiki aromatherapy, other not well proven or nonsense type interventions on the menu at the cancer center. And it seems to me we tell our students, I do, that we're evidence based and yet we are selling massages and things, uh, aromatherapy and things that, uh, are not proven, they're not evidence based to help, uh, patients. So I think we can look inside our own operations frequently and say, what are we offering? Why are we doing it? How do we explain it? I mean, a massage can make you feel nicer. I don't think it's going to help your cancer, but if it makes you feel better, okay, but then let's make sure that's how we're billing it when we have it on the menu of things that, ah, are available to people getting cancer care here. So, you know, there are even internal places where we don't want to lose the market or there is a market and the, um, intervention is being offered even though it is not evidence based.

Mike Tsakopoulos: Let's shift gears to a topic you brought up a little bit earlier. Um, from organ allocation to ICU beds during COVID rationing decisions expose some deep inequities in our system. What principles should guide physician leaders when they are the ones making those hard decisions?

Arthur Caplan: I think it's very important again to set the tone as leaders about what values drive, uh, the delivery of care. So I'm a little proud. At nyu, we have a, uh, fancy hospital with nice sheets and good meals, uh, where richer people go. But we also run Bellevue where poor people go. And every poor person gets the same care because they're the same doctors and the same, I don't know, equipment, facility, whatever. Uh, they're not getting private rooms and no gourmet chef comes to cook, uh, them up a meal. But the care is not different. So equal care, equal quality care for all. I think that's something we should strive for. I understand we can't always, uh, fulfill that totally, but it's what we at least aspire to. Even with the limits on cost and problems of people who have no insurance and people who are overwhelmed by drugs or homelessness, uh, and so on. We try still to give them the same quality of care regardless of who they are and background. Secondly, we want to be evidence based. And so we are trying very hard to make sure we're giving Things that we know work. Now we can argue about what work means. One in a hundred, one in a thousand, 50% of the time. I think, again, maximizing m the availability of things that work the best is a pretty good principle. So it may not be that everybody gets, I don't know, the new drug that has just been tried on animals, but that's okay with me because maybe we're making sure that everybody's getting the drug that helps preserve kidney function at a very high success rate. So I like trying to maximize, uh, efficacy. And a last principle is that I think everybody should be treated with dignity and respect. And that is important to set as a tone throughout the workforce. By the way, the weekend staff, the evening shift, the vacation people. It isn't just running a program about what is compassionate care, empathy, or how do you do consent properly, or how do you address patients in the day. You got to make sure you pick up everybody who is working at your place. I can tell you that patients, uh, don't really know who's the night shift and who's the day shift. And if they pick up something that they don't like from a temporary person, it can be very damaging to, uh, their, uh, satisfaction. So I do think, uh, setting a tone and making sure that that's emphasized and being a good example of the same is very important for leadership. Treating, uh, all of our, uh, patients and family members or friends, whoever they are, whether we agree with their lifestyle or their religion or whatever it is,

Mike Tsakopoulos: uh, respectfully is, our time together comes to an end. I'd like to think about the next generation of physician leaders. How is bioethics currently being handled in medical schools and in training?

Arthur Caplan: Until recently, it was, uh, strong, getting a little weaker because, uh, things are changing in the external world at the medical school level in terms of grant support. So less money is coming in, overhead rates are dropping, and some places, a lot of the bioethics was paid for out of the overhead rates. You didn't see it directly, but it was, it was spillover support. And that's drying up pretty quick. So bioethics, in a way, is starting to have to depend on its own ability to fund itself in order to survive. And a lot of places can't do that. There's not that many grants. There's not that much philanthropy that goes in that direction. So as essential as I think it is, it's a little bit more in trouble these days. That said, I think there are also some hopeful signs. We do see better, uh, uh, training, moving out I think everybody focuses on what's happened to the med students, but for bioethics, it's the residents and the fellows. That's where it ought to be. Not exclusively, but it ought to be there. That's where young doctors form their values. That's where they really, uh, are paying attention as in charge of patient care, seeing, uh, the choices that they have, the limits that they face. They find out that not every patient is wonderful and not every family is a total delight. And not every request they have to get something is going to get honored. And that's where you really form your ethics chops. So some programs and ethics are expanding. We are trying to do that at NYU into those settings because I think that's of crucial importance. The other thing I think is hopeful is there still remains a lot of continuing education. So we do see a lot of places offering online degrees in bioethics. And some leaders do that. We see people offering short courses. We do that, for example, in a variety of fields online, where you could take a course in transplant ethics or genetics and ethics, vaccine ethics, but even soon to come hospital leadership, kinds of oriented ethics stuff. And we're not the only ones. I'm just mentioning the ones mine because I know them, but they're all around the country and I think continuing education, using real world experience with real practitioners, real leaders, that is a very rich future source of training the next generation of leaders.

Mike Tsakopoulos: My guest has been Arthur Kaplan. Professor Kaplan, thank you so much for being on Soundpractice. This has been absolutely fabulous.

Arthur Caplan: Uh, great. Thank you again for having me.

Mike Tsakopoulos: My thanks to Arthur Kaplan for his time and expertise. Dr. Kaplan has spent a career promoting the safety and integrity of health care. My thanks also to the American association for Physician Leadership for making this podcast possible. Please join me next time on Soundpractice. We release a new episode every other Wednesday. You've been listening to Soundpractice, the business podcast for physicians and health care leaders. Check out the show notes for this episode@soundpractice.com if you have any suggestions for future episodes, we'd love to hear them. Email us@infoooundpractice.com subscribe to SoundPractice wherever you listen to podcasts so you can automatically receive our episodes and please rate us and comment on the podcast in itunes and Google Play. Soundpractice is presented and produced by the team at American association for Physician Leadership. We are the world's premier organization organization for all aspects of physician leadership in every sector of healthcare. Learn more@physicianleaders.org.

Arthur Caplan: Robin ritual capal.