Religious Diversity, Ethics, and Healthcare - Bob Machamer

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.

Transcript

Chip Gruen: 0:03

Welcome to ReligionWise the podcast where we feature educators, researchers and other professionals discussing topics on religion and their relevance to the public conversation. My name is Chip Gruen. I'm the director of the Institute for Religious and Cultural Understanding at Muhlenberg College, and I will be the host for this podcast. In this season two of ReligionWise, we will continue to consider a broad variety of religious and cultural beliefs and practices, and try to understand their place in the contemporary conversation. If you like what you hear, I encourage you to explore the 12 episodes from season one that are available in your favorite podcast app. Also, we would love to hear from you with your questions, comments, or suggestions for future episodes. To reach us, please visit our website at religionandculture.com. There you will find our contact information and also have the opportunity to support this podcast and the work of the Institute. Today's guest is Dr. Bob Machamer adjunct faculty at the Pennsylvania College of Health Sciences, who teaches a course entitled Ethical Issues in Health Care to undergraduate students studying to become healthcare professionals in a number of different capacities. Dr. Machamer, who is also a licensed Marriage and Family Therapist, and an ordained minister in the ELCA Lutheran tradition serves as the senior pastor at St. John's Lutheran Church in Boyertown, Pennsylvania. So today's episode features a conversation that I've been really curious about and interested in for a long time. Here at Muhlenberg College, I served on the Pre Health Advisory Committee. And one of the things that we did is we designed a program called the Shankweiler Scholars Program that is interested in cultivating those interested in medical professions in academic interests other than biology and chemistry, of course, biology and chemistry being important to the study of medicine. But the argument goes that so are other things, whether that be history, philosophy, the study of religion, or things in the social sciences, psychology, and sociology, etc. And as part of that program, I've had the privilege of talking to students about the confluence of religious traditions and our pluralistic society in which people might come with a number of different worldviews into a medical facility, and the provisions of health care that they find there. One of the ways that I talk about this, is that I say that it's important that medical professionals realize that providing health care to a human is not like a mechanic fixing a car, there's a lot more to it, it is not simply a matter of replacing the oil, or switching out the carburetor, the person who's coming into that office is coming with potentially very different ways of understanding the world, understanding their body, understanding the nature of life and death, then we can assume the practitioner has right that there is a very different, potentially very different worldviews that are operating in that office simultaneously. Now, of course, the hospital facilities in particular, have chaplains offices over the last few decades, those chaplains offices have become increasingly literate and competent to dealing with people who are outside of their own tradition. So a Catholic chaplain might be able to deal with issues from a Jewish patient or a Muslim patient cetera. But as we move forward, it seems to me that not just in the chaplains office, but also within the healthcare professionals themselves. Knowing how the treatment of patients and ethics around patient care might be affected, if someone coming in is a Hindu or a Buddhist or a secular Humanist, for that matter, that the way that care is delivered might be very different, depending on how that person again, understands their body understands the nature of life and death, understands the procedures and the ethics of those procedures. The other part of this that I think is really interesting is the confluence of ethics, and morality, legality, and patient autonomy. We as a 21st century American society with a particularly capitalist and materialist worldview are really interested in what is legal to do. And so sometimes there is a conflict between ethics and legality and the individual beliefs practices of both the practitioner and the patient themselves. Dr. Machamer comes in as somebody who is responsible for talking to students headed into health care about some of these issues and to make them aware. And so with that, I welcome Dr. Machamer to the program. Dr. Bob Machamer, thank you for coming on ReligionWise.

Bob Machamer: 5:13

Chip I'm excited to be here with you and to continue the conversations that we started just a few weeks ago.

Chip Gruen: 5:20

All right, so let's jump right into it. So I'd like to start our conversation by having you introduce yourself and the trajectory of your professional life. Your training is really wide. It's both scholastic as well as clinical and practical. Can you tell us a little bit about your biography and background that led you to the place now where you teach ethical issues in healthcare?

Bob Machamer: 5:40

Surely, coming out of Grove City College as a psychology major, I found myself in seminary in Boston, exposed to all kinds of traditions diversity that I never experienced growing up in Lebanon County or in Grove City. That was the challenging part for me, learning not only the academics at Grove City, and Gordon Conwell putting together my organizing principles of theology, but then trying to figure out how to, in a practical way to relate to God's creation. In my first congregation, I realized that my training was pretty inadequate, when it came to the problems that people would come into my office and want to discuss, and the field of ethics opened up right there, because I think the field of ethics is about practical decision making. And I think that the principles and the theories that we talked about when studying ethics are incredibly helpful. The theories of course, the decision making models that we use with them, and then the principles that focus specifically on the individual, are they upheld, arethey violated. My work at the college as an adjunct has exposed me to health care workers, those in training, those that had been there for 20, 30 years, but came back to get their BSN, the bachelor's in nursing, and that was a marvelous experience, because they already knew 20 times more than I knew. And then they would put it into their case studies. And it started my thinking of how can we help? And how can we be a people who regard each other with respect? How can we uphold these things that we talked about in the textbook? How can we do that for and with one another? I think simply at the end of the day, it'll boil down to what kind of person do we want to be?

Chip Gruen: 7:37

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's important to consider, at least in brief, a little background, the method of the field, that this you know, ethics isn't sitting around in a circle and talking about our feelings, it is grounded in a very old discipline. So can you give us the one foot version, the brief version of the intellectual tradition that sits behind the way that you teach this topic?

Bob Machamer: 8:12

Absolutely. Our first class, the first hour and a half of teaching the class that I teach, and it's generally an intensive it's a five week program. We talked about Western world, of course, and it's, it's traced back to the ancient roots with the Greeks, the School of Hippocrates, and all of the work that they put out. I mean, back then you have physicians who are both healers and executioner's they supported euthanasia. So coming out of that tradition and shifting that through the years, and that's BC, that's 300 years before. And and if ethics is the practice of decision making, if it's if it's to be practical, and it's problem solving, those key components that were put forth by people like Aristotle, that pursuit of excellence for Aristotle, being a virtuous person, what does it mean to be a virtuous person, and the word that he used Eudaimonia it's not just happiness, it's not just flourishing, 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 more toward Aquinas, 1500 years later, as a philosopher as a theologian, I think that Aquinas brings both the head and the heart puts together right action and right thinking in terms of good and evil of course, during that time of history, virtues, the preservation of life, the preservation of the species, the pursuit of truth, which kind of sounds like something that in our country was written right about the time of the Declaration of Independence. So we talk about that, yeah, we get we, we spend a little bit of time in Aristotle, we move to Aquinas. And then we get into where we are today, and the challenges of what it means to be one who is in healthcare as a professional, not just physicians, but everyone in healthcare.

Chip Gruen: 10:25

So I think we'll get the opportunity to talk about this more, but I just want to put a marker here and get some preliminary comments on the ways in 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 the Western intellectual tradition, but then the Catholic scholastic tradition as well. And I think it from my perspective, it looks like, particularly the Catholic piece, the Christian intellectual history piece of that can sometimes be occluded when we have these conversations. It's not fronted right, that ethics is imagined as secular. But it seems like looking at this, the contemporary at conversation and ethics 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 but it's not. The traditions of faith, Judeo Christian, are so deeply embedded in ethics, our traditions have something to say, when people come in to ask questions, they're looking for guidance, they're looking for a direction to go. And I believe the combination of the two, provide us with those possibilities in Judaism, of course, tradition has something to say about life life, before it comes out of the womb life after it comes out of the womb, a sense of community, perhaps different than we've experienced in the Catholic Church or the Protestant church, it's vital that we find a way to have those discussions and continue to have those discussions not in a legalistic way. But in the methods of discovery of where humanity share a common good, share a common good end common perhaps, if I can say, a common not so good or evil, to identify that, and then to operate out of that in the way we provide care for one another.

Chip Gruen: 12:28

So your background is one that is I mean, you've mentioned your seminary training, that, you know, the way that you practice is informed clearly, by the religious intellectual tradition as well. But at the same time, and this is one of the things I really want to get across in this conversation, that that tradition, as you understand it, is very progressive and very inclusive. And so I wonder about how, again, that intellectual tradition within Catholicism and then moving moving forward in time, is that a barrier, you know, to that kind of inclusive, multicultural, you know, world and context in which you're living in or do you recognize that and then move on? How How does the coloring of that religious tradition affect the practice and understanding of contemporary ethics for a people who is not necessarily lockstep on the same page for those sorts of spiritual or theological...

Bob Machamer: 13:35

It smacks us in the face, you think about the Hippocratic Oath, hundreds of years before Christ walked the planet. Then you see the influences by the Middle Ages where Islamic communities also accept the Hippocratic Oath. And it goes right down the line. Now we have, we're not we're the traditions, the religion that we have, what we've been taught, didn't know the internet was going to arrive. They didn't know that we would have reproductive technologies for in vitro fertilization. They didn't know that there will be non blood products available for blood transfusions. So for us in my area in this Lehigh County, born and raised in Lebanon County and close to Lancaster County, Amish population and Jehovah's Witness, they now have available to them the blood products that their religion and their hierarchical structures would have said, You are prohibited from receiving that except in the case of a minor that's, that's a whole other legal issue. But I think those are the things that are in current medical practice, now being questioned and being discussed and I'd see lots of discussions going on around the country. Our large major health care systems are now extended programs 3, 4, 5 sessions 3, 4, 5 weeks to time, exposing their healthcare practitioners, their nursing staffs their, their radiologists it's all coming to a beautiful head, I think. And I see it as a positive experience having 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 the beginning of learning about it. I don't, I don't know all of this. I know that I need to know more.

Chip Gruen: 15:32

So one more question on context. And then we'll start jumping more into the practical the case studies the where the rubber hits the road. When you're introducing these topics to students, it's my understanding that you give them a few broad categories, or principles to anchor their thinking in the field. Can you tell us a little bit about that basic schema, even if it's just to give us the vocabulary that we need in order to understand the conversation or the field?

Bob Machamer: 16:02

Sure, the the first day of class, they're handed two pieces of paper on the one, they have the definitions of the four ethical principles that I use in class autonomy, everyone has the right to decide for oneself. The danger, of course in modern medicine is paternalism, doctor knows best. Beneficence is the second ethical principle to do well to do a kindness to do good and, and to not do harm. Nonmaleficence is to do no harm, or the way I teach it is to do no further harm, harm probably has already happened. And then justice, to be fair, to be honest, those four ethical principles are at the root of medicine for centuries. But in recent years, they've become even more important to the conversation of how do we decide you have ethical theories. So you have the theory in and of itself, and then you have meta ethics, which is the questioning about those particular stated theories. So for us, we start with those four words. And I tell them at the end of the first class, please learn these words, learn learn what they are, because you're going to use them and ethical principles are always about the individual. They're never about the healthcare system. They're never about the family in the room. They're always and only about the individual. So autonomy can either be upheld or violated on behalf of the person. Beneficence can neither be upheld or violated justice can either be upheld or violated. And sometimes it's really hard to distinguish which way to go, the ethical theories of consequentialism, where the outcome is more important than the intent, where the the the overall consequence, what do what's more morally right. And, and seek to do the greatest good for all people, it's not just the greatest good for the patient is the greatest good, it has to be a larger number to be understood as consequentialism. Deontology is always duty based. And I laugh, because this is the example that we use is one that is familiar to those who are nurses in the profession of nursing, they will invariably be with a patient and they're, they're cleaning a line or they're working with the patient or they're, they're changing a dressing, and an x ray technician might show up and the x ray technician is there to simply do their duty. And their job is get the job done and get the x ray. So in the middle of things, they're ready to move on to the next patient, they have another patient that they've got to get their equipment to. And the nurse then is in conflict with their own healthcare team. So we have those deontological conflicts. Again, it's theory, virtue ethics, probably where we could spend the most of our time because I am one that believes in virtue ethics. So at the end of the day, what kind of Pastor do I want to be? What kind of therapist do I want to be? What kind of husband do I want to be? What kind of human do I want to be? What kind of advocate do I want to be for marginalized groups? I think modern healthcare is going to be looking at that. I think modern healthcare has to be looking at everyone who is marginalized. If 50% of the research is correct, that 50% of physicians, prescriptions that are handed to a patient are that they go unfilled, primarily because the physician didn't ask or they didn't know they can't afford it. So 50% of prescriptions go unfilled, or they go to the back shelf of the pharmacy at Wegmans and no one picks them up. It's because they can't afford it. So healthcare has to get way past patient as client, they have to be patients as people. Those are the challenges that I talk about with with my class, and then of course, authority based religious ethics, in the Amish population, your Bishop comes into the hospital and helps you and if not helps you makes the decision on your behalf that can happen with Jehovah's Witness at well, my Bishop has never been in my office never been in my hospital room to tell me what my next procedure is going to be. And I'm grateful for that, because I'm not sure my Bishop would know any better than I would. So.

Chip Gruen: 20:28

So I want to push on this a little because you you mentioned, right, you give this framework you give these ways of understanding. I've noticed and I've had the privilege to talk to, you know, first year students who are interested in studying health care that I've had the privilege to have the humans are not cars conversation, like how can we think about religious and cultural backgrounds? As a as one of the, you know, the primary context for delivering care. And one of the things that I've noticed in those conversations is that they're really interested in thinking about what's legal. And then they have a hard time separating the con... the conversation about what's legal, from what ethical. Do you see a similar propensity 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 I rarely have conversation where that does not enter in. And that's why the class that I teach always has a legal component and most healthcare institutions or health care oriented programs, college programs, at the undergraduate level, in their very first class, there is always the legal dimension. Frequently, it's discussed by using case studies, case studies such as Tuskegee Airmen, and and how they were never. Their consent was never, it wasn't even known to them. They didn't have any option to consent to the study on syphilis and all that longitudinal work that was done. Henrietta Lacks, there was no awareness. And in fact, there was a blatant, her husband said, No, you may not. And yet her genetic material has been purchased. And it's probably in most labs around the world to think that we could have had people of faith based backgrounds promote promoting, advocating for necessarily hiding that, that now is in the front of 18, 19, 20 year olds, when they're sitting at an undergraduate class, and they're saying, how could that have happened? That's good question. What we do in that it did happen? I think is the question that we want to be responding to and making sure that in the future, those things don't happen. Informed consent is a big one. Implied Consent is big for folks, seemingly smaller, but not so much. So what does one do when an attorney comes in a prominent attorney, and the staff are preparing the paperwork and the doctor and the attorney are talking and the doctor knows that the paperwork is only good for 30 days, and the surgery is scheduled now for 35 days? And the attorney says yeah, but I'll sign it now. That paper is illegitimate. It's, it's and it would be wrong to proceed. What does the nurse what does the lower level on the hierarchical chain do? How do they confront? How do they uphold the patient's right to making an informed decision, however, holding Upholding justice for the organization and its documents? I have folks writing practice dilemmas. For the five weeks. I have hundreds and hundreds. In fact, I have some with me right now, of healthcare staff that had been put in positions where they're in direct violation of not only the regulations of the hospital, but also of general practice of law.

Chip Gruen: 24:20

Yeah, the case that sort of sticks out to me and I don't have the details at my fingertips, but it was someone who served as an EMT, and that the EMTs are sort of both on the frontline and with relatively minimal training to do what they're being asked to do. But it was a blood transfusion case. And I think that they had been instructed that well long as the person's unconscious. It doesn't matter. Like legally, you can do whatever you need to do, and you're you're protected. You're covered. And it was it was very, it's very odd conversation because it felt I mean, it felt very pragmatic, it felt very practical. But the values of the of the system were values at life at any cost, as opposed to following the wishes of the of the patient, even if those are known and sort of the legal maneuvering, right, or the legal ways 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 agent majority if they're adults, and they say I do not want a blood product that is honored. In most cases. Sometimes injunctions are brought in court systems people are rbrought in. If they're a minor, all bets are off. And again, I'm not an attorney. But from the studies that we've used in class, the case studies that we've, we've read together as a class, and we've discussed as a class. And they are concerned about that they're always looking for good up to date medical records. Now that's on the patient. So if my chart, and if I were in an accident, when I leave here, the healthcare people that are arriving in that ambulance can pull up my records, because I'm in that big system, so whether I'm transported to Lehigh Valley Health Network or St. Luke's they'll have my chart and they'll know all those things right at the top. He may he does not he wills he does. All of that is right there. So we live in a great age, to be able to create that environment of consent. But what about the rural areas? And what about where that technology doesn't exist to the degree that we have here in the Lehigh Valley, we do talk about that we do talk about the religious orders that we may or may not know, because that may not be on the chart. That's what confronts the students in Lancaster. They're not always sure what to do. When a patient comes in, and a person comes in, and they are Amish, they don't always know what to do. But that I know, the hospital system has worked very, very hard to work with those denominations and those particular religious groups to talk about the law and the medical practice before we arrive at the need for that to take place. Those discussions I know are going on in Lancaster. So I've got to believe they're going on all across the country, or at least I hope so. And if not, we need to advocate for that to happen. Let's have the conversation before we are in that last minute where we need those life saving measures. Now those are my words. Because for the person who is Amish, it might not be life saving at all it because it might be an affront to what they believe to be the will of God. For me, my body. And maybe this helps with the legal question. For me, I have an obligation to take care of 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 have certain obligations to not destroy it, I have certain obligations do not leave the water running and that the flood pours out over the window sills. I have legal obligations also to maintain it so that it doesn't become infested with bugs, health care professionals today are being confronted with all of that, in an environment where patients can be seen as clients, and that people in an environment where physicians aren't just medical practitioners. They're in an industry, they're they're joined to a business contract. And when we sign all those sheets of paper, I do not read all of those sheets of paper word for word. But I was shocked I was at a doctor appointment not too long ago. And on the desk, it said if you have ever or plan to or think you might want to file an action against us, we will not see you as a patient. I have never seen that in a major health care system right here in the southeastern part of Pennsylvania. And I asked the person at the desk. Can you explain this? And they said no, you have to talk to your doctor about that. When I asked my doctor about it. They said we just don't have the time to spend in the courtroom. So we you're vetted. We already knew that you haven't filed any legal action.

Chip Gruen: 29:41

Wow.

Bob Machamer: 29:42

Patient care, patient autonomy, justice, all that's on the table right now and 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 and where you have been a therapist the examples that you bring up are good ones as a Jehovah's Witness and Amish. But I'll just sort of say, you know, one of the goals of the Institute is to get people broadly literate across all kinds of religious difference in that one of the examples that I bring up and it might sound very small to to people, but the prohibition against cutting hair in Sikh or Sikh communities. And so you think somebody comes in for an emergency surgery, and you have no idea why that person wears that turban, right, much less anything else, or that there are particular undergarments that married individuals don't take off in that community, right, and you cut those things off, or you cut the you shave an area for surgery, or whatever, and you have just committed a major violation of that person. And so and that's one of the examples that I know about. But as our as our world, I won't say becomes more multicultural pluralistic, but as we're recognizing that pluralism and multiculturalism and religious difference more and more and more, I've got to think the numbers of those kinds of literacy issues, right, that people need to be aware of is just going to grow and grow and grow and grow. And I hope our healthcare 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's frightening for others. And I believe that many people would say, Gosh, how much time is it going to take to train that number of people. And the reality is, we're going to have to take the time. So programs may need to be lengthened, rather than abbreviated. What once took four years to receive your degree. Now, one can do in 18 months or 24 months, to save money and to create money for institutions, we may have to backpedal and prioritize people over dollars, medical treatment is big business. That is not something said lightly. Because it should be about people. And I believe in general, I meet very few, I can't say that any of my family's physicians treat us like we are widgets. I really can't. Now we we're careful about where we go. And we have met physicians, and we've said, No, thank you, and we move on, and we find the next person, because we look for people who treat us as people. Now, when it comes to the variety, the pluralistic society that we have been for decades, we can't ignore that any longer. I think that will happen through conversations like this one. And you'll have people on that are far more knowledgeable than I am. And that's the benefit. Because I'll listen to the next conversation, not one that I'm on with you. But I'll listen to the next person. This is a great opportunity, I think, to open people's eyes to diversity, to equity, to inclusivity. To, to religions that they've never heard of. And to do it in a way that perhaps doesn't engender fear or threat, like around 9/11. Oh, my goodness sakes. And for Asian Americans, oh, my goodness sakes. Health care has to be aware of that when a prisoner is brought in when somebody in an orange jumpsuit is brought into the hospital, and they are in line to receive treatment. And people are screaming in the waiting room? Why does that person get to receive treatment over my child who is crying and in pain? There's a reason because they're treated as humans, regardless of what their resume says something has happened in their life that's put them in that orange jumpsuit, law and health care. It's wide open now. And we want to participate in it. Thanks for asking that question. In particular, because of all the things that we've talked about so far, I think I could probably talk about the principles and I could talk about the theories and I can speak about it with some fact based confidence. But you're asking questions, that it seems to me, we don't have good answers. But I appreciate the good questions. And I hope that the listeners are hearing that good questions might just be more important right now than the good answers.

Chip Gruen: 34:26

When we think about something like religious literacy, for example, cultural literacy, and we think about how is it that we deal with that in the medical training of individuals? Well, those people who are trained to be doctors or nurses or whatever in the medical field, have been to an undergraduate institution. And here's my soapbox moment, is that the humanities right and teaching about, about difference and about ways of being in the world and about meaning and Those sorts of things that I think informed this conversation don't have to wait until you get to medical school, right that if you were having a, a an education that prioritizes thinking about, about difference in people and, and maybe not even all the details of that. But that there are different ways of being in the world and the way that you are in the world, then you're already sort of a step ahead for that conversation 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 College of Health Sciences, they receive an undergraduate degree. And as such, there's a general education component the nurses that I've had the privilege of working with throughout my 12, 13, 14 years of being an adjunct, those who have 20, 30 years of experience as RNs in the hospital. They are they bring massive experience, massive knowledge, massive heart. They just didn't bring the piece of paper. And they would say, Yeah, but why do we need the piece of paper because that general education component is critical. Yes, you do write in a chart, and it's abbreviated. It's important to know 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 the general education experience, you're going to learn more about the influence of religion, you're going to learn more about and have much more taught around that the theories and the principles of ethics in modern medicine, we can't short sheet those discussions any longer.

Chip Gruen: 36:42

All right. So let's talk about the practical implications. We've, we've sort of hit around the edges of this a little bit. But I know that one of your key pedagogical tools for discussing these topics is the introduction of case studies that explore particular fault lines and dilemmas that might be encountered in the healthcare field for the next part of the conversation. It would be great if we could just if you could give us a few of the examples that you'd like to introduce to students to get the conversation going. Do you have any good case studies sort of ready for us?

Bob Machamer: 37:13

I think so. I think one is what I kind of touched on earlier, a doctor presented they were doing the prep work for a surgery that was going to take place outside the 30 day informed consent form signature requirement, and the surgery was going to be 35 days. And the person who is taking the notes was hesitant, they didn't want to approach the physician and 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 that is still embedded in our healthcare system. But in fact, by pushing that paperwork through, while the patient does have a right to self determination, they don't have a right to falsify documents, nor does the physician. And just because they are the physician, they have to maintain, they have to uphold the ethical principle of autonomy by making sure that the documents are in compliance. Justice was clearly violated. It was not upheld for the patient. Even though the patient colluded in the violation of falsifying that document. That happens more frequently than not, we're doing a lot in recent years to clean it up. And there are flags, even in the programs, the software packages that will flag it if it's outside the rubric of the timeline. So with technology, we have the benefit of of reinforcing, informed consent, we have the benefit of now software packages that won't let us step out of the law. When I think about Henrietta Lacks. That really touches me, I remember that picture. And maybe you do too, back in science classes. And I remember that picture and thinking, what's that story all about? And now that I'm much older than when I was reading that little science book, way back when in high school, it's somewhat infuriating to believe and to know, that her person was violated, she her body had died, but she hadn't died in the heart and mind of her husband, who clearly declined, that her body be touched. I think about the troubles in when an EMT or an ambulance shows up in a home. Do they know if the patient has an advanced directive that says Do Not Resuscitate once they start they can't stop and they're trained both in curative and to provide any success of maintaining that life. But everyone that I know that runs on an ambulance they also know there's a difference between curing a patient and healing a patient, even if that healing comes in death. For me, as as a Christian, I believe that life doesn't end when my heart stops beating. I believe that my life continues on in whatever way God chooses. Those are case studies that are before courts constantly. And we have, we have individuals, because Muslim population, it doesn't take but a 10 second Google search to see dozens of cases where their religious beliefs and rights were violated over and over and over again, we see major chains CVS, we see major healthcare systems saying, you may not do this, the doctor, you may not provide alternative reproductive treatments for a certain population for certain I know of a hospital where a doctor decades ago, would give the young woman money to go to another hospital where they had the option to terminate the pregnancy. But the hospital system that she came to originally would have never done that. There would have been shame there would have been blame, there would have been one alternative. I believe that we do much better today. But I know that there are still cases like this in the faces of the attorneys. I spoke last week with an attorney with a local health care network. And I asked specifically, what are the major issues between ethics, healthcare and religion. And they said, it's almost always in consent. When a person does not consent to treatment because of their, their, their beliefs. The young boy that was in the car accident, and said to the ambulance, I am Jehovah's Witness, I am not to have a blood product was taken to the hospital. His decision was honored. The first day the bloodwork came back, and we saw as the levels were going down, and then the next day even further. And finally, the hospital said this can be treated and it's not a difficult treatment. And they requested and received an injunction. They gave this young man a blood infusion. And he survived. And after he survived, they sued the hospital. And it was upheld in the court that the injunction was upheld. And, and they didn't lose the case for trying to to cure this young man. But even so was this young man's autonomy violated, even though he is alive, well part of this young man will now for the rest of this years struggle with maybe it was God's will for me to die, and that my life isn't to be here but to be with God. Those are the kinds of things that are presenting in 2023. These issues aren't solved yet. But these discussions I think are helpful. If we could have the conversations before we get to the hospital. Is it unethical for a human being to not have an Advanced Directive? I think it's cruel and unusual punishment for someone to not have an Advanced Directive, and for their family to not specifically know in writing what their wishes are. I think it's as equally cruel to have an Advanced Directive but to not have shared that. I think it's equally cruel. When a patient says Please don't tell my husband that I'm going to die in three days. I'd rather have them stay with me until I die. And the doctor is required to honor the patient's request. Please don't tell my husband, that I am pregnant with another person's child. Don't allow that to be revealed. Please don't put in my chart. These fears. I've come to you for answers to questions. I need peace. I need comfort. That's where the healing for these people is experienced. Please don't tell anyone else. So now we bring in the therapists hopefully, the emotional therapist, because if we're talking about healthcare, we can't just talk about the physical body. We have to talk about the spiritual and the emotional bodies as well. I think hospitals are doing a much better job at that. Note that the first person that's called in an ethics question in a hospital is the chaplain now I find that unbelievably intriguing. Not the attorney, legal counsel for a local hospital network but the chaplain is called. So think about how that chaplain has to know about Roman Catholicism has to know about Judaism has to know about Protestantism has to know about Muslim, Hindu, everything that's available in their potential service area. They've got to know that. Well, thank God we have that person on staff. I feel really good about all that. Reproductive technology, what does one do if the doctor doesn't believe in a male that shows up to the urologist and says, I'd like to have a vasectomy. But I don't want my wife to know, how are you going to do that? Well, she's going to be way on vacation. Okay, well, why do you want this? Well, because there's someone else that I want to be physically intimate with. I was privileged to have that, as a circumstance show up in one of my practice dilemmas with a student. And that student handled it remarkably, because they didn't impose they're very conservative, very conservative, evangelical, I can use those terms very broadly, conservative evangelical beliefs with their patient.

Chip Gruen: 46:06

So you're in thinking about some of these case studies and thinking about everything that we've been talking about one of the things that occurs to me, and I will sort of admit to personal experiences where the complicatedness of our medical system is very frustrating. Right, that one hand doesn't know what the other is doing, 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 talked about doctors, we've talked about hospital systems, even within those hospital systems, we can think about the chaplain, right, we can think about insurance companies, we can call think about legal representation. Thinking about even if our best minds, right, our best ethical minds can get in a room and imagine the world that we would want that values autonomy, and beneficence and justice. How does that become affected by the complicated structures that I think are these organic, nobody would design the system the way that it is now, right? That it sort of organically grown up to have these a million appendages that don't always know what they're doing? How does even if we can make really good decisions? How does that? How's that affected by this complicated system, then that we're confronted with?

Bob Machamer: 47:32

I understand what you're asking I think about my field exegesis, taking a passage and tearing it apart to try and understand it, not just the words, but the historical context at cetera. I think healthcare is more like eisegesis, we take our traditions and our past, and we try and find ways to insert it into current dynamic, and that's where we end up in trouble. When we take that which is old, and it doesn't fit. So we jam it in there, we force it, rather than allowing the flexibility of these conversations. I love my favorite symposiums that I go to are when they're opposing views. And then someone steps in and says, But you know, they actually are less in opposition. When we add these principles, they are no longer, completely oppositional. Think about, think about double effect. I think that's Thomas Aquinas. If a person receives morphine for pain, and the intention wasn't that they die, but they die, that's okay. That's acceptable. I shouldn't say okay, that's acceptable. But if we just simply euthanize them, that is not okay. except in a few states, where physician assisted suicide is permitted under very, very, very strict standards. So people think, well, you can go there and Oh, my goodness sakes no, there's a ton of paperwork 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, really value this physical life, this physical body, this physical being. I think if that's something that we can move forward then but can you imagine who will make the final decision with that? Legislators. How do you get in their ears? And how do you teach them? Do we send them back to school? Aren't we going to have to? We've got to have people this is a time for really serious people, serious learners, serious thinkers, and not just the academics of course, but the people that are with it, you have to be willing to my opinion, you have to listen to the people that are in the stories. For me, the LGBTQI+ has been perhaps one of the best things that ever happened to me in the last decade of my life. In health care. I've experienced repeatedly, folks will go to their doctors, and they would want to talk about what they were feeling, what they were experiencing what they knew to be their truth. And the doctor just did not know what to do with transgender people. And I've experienced close friends, that it was almost an abusive pain to go to someone that they, they had to have trust, because they needed to know. But they would be brushed off mostly because the person didn't have any idea. I don't know if I answered your question. a little bit. You say this is a time for serious people, right for people to engage with these issues. And I think that we can look around here in 2023 and we can see that in some ways we've taken we've made forward progress, right in valuing identity in valuing individual in letting people tell their own stories to express their own worldview. Yet, in many ways, we are seeing some of that progress taken away, as well, because of the nature of the conversation in public life.

Bob Machamer: 51:13

With regard to women's health, and and choice. I don't even know if I can say on the recording, I it's painful to think about the women that I know. 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 in this conversation right now, and maybe I'm just a little more of a pessimistic person than you are, but I talk to you and you have hope, right? That systems can do better, that that learning is possible, that we can in the light of ethical reasoning get to places where the individual is valued. And I look around not as an ethics specialist, but but just somebody who looks around and is curious about the world. And I see the complicatedness of political conversations of legislators who will end up being responsible for this, of the stock options and shareholders that are involved in these health care systems, with people who might mean well, but nurses and doctors and other health care providers who think very differently about all a host of issues. And I just think, Oh, my goodness, this is a mess. I know we can do better, I have hoped that we can do better, but I'm not sure that I see the way forward.

Bob Machamer: 52:45

I think the way forward is to continue the conversation, I think the way forward is to invite people to sit around a table with a cup of coffee, a cup of tea, a beer, and to find a direction, a common direction. And to mull it over together, and then to get out and add to the numbers of those for whom it could be helpful. We teach this at the college because the college believes not just to check up a box for their licensure. But we actually believe that the person who enters into that room while there's virtue ethics, I mean, it just it's going to stick up all the time. We want I want my students to walk into a room and have a patient say, you're really good at this. What are you good at? I I want them to listen to the person in that bed and to not see patient only but a person who has a story whose spouse might be at home, and they want so desperately to be at home with them because they are that spouse's primary caregiver. And, and to recognize that you have a whole person there, what brought you here, what keeps you here? What are you going to do when you get out of here? I want to happen at every level. And I know I've seen the software packages that say you've got 17 minutes to see this patient. And then you've got to move on because we have to keep a certain dollar amount in the practice. I think it's going to take people saying No, I won't do that, and to probably reform and maybe even recreate and start fresh in a new way of doing and being Catholic institutions are all around the world. Right? They I saw them in Africa, 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 been serving here, they brought their whole self to that position, that I guess my hope is because I wouldn't know what to do if I didn't have hope. And I do believe in God. And I believe that God does have a plan. And I believe that God wants us to do exactly what Aristotle said, Seek the highest fulfillment, through virtuous living, I think, I think that's critical. I think sometimes we just have to keep reminding people, that they matter what they do, what they would what they do matters. That's the heartbreaking thing. In health care. I see health care workers, I see public educators, I don't know how they do it. Remember what it was 35 years, and hey, you have your summers off, and you're retiring at 55. I don't know how many people stay till their 35 any longer. I don't have a lot of answers Chip. But I do want to stay in the game. And I do want to 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'm gonna give you one version of those. And it it really models something that I think is very important that that we all realize our own myopia on these, in these conversations, this isn't something that I spend 40 hours a week thinking about this isn't something that I've read as deeply as many people and certainly anybody in the field has. So what am I missing? You know, I've come up with we've had this conversation, I've come up with a list of questions, I've sort of probed the things that are on the top of my mind. But what is it that I'm missing, that you see from your perspective, or that we might see if we were on site and a healthcare facility that is really, really important about this conversation that we can take away?

Bob Machamer: 56:48

The vast majority of folks that I meet in a healthcare system want to do what matters. And I think the thing that we can miss is an opportunity to thank them, I think that we can miss engaging them at a personal level in the midst of doing their job and reminding them that we appreciate that they are doing their absolute best on our behalf. But they're doing it because internally, they really want to. And if we in the public can help them remove the barriers to providing that kind of loving care. I think that we can go a long way. I think that for me as a Christian man I believe that we're to love God and to love all people. And I really mean all people, which means respecting some of the labels that are out there that they exist, but not allowing them to shape and determine the way we relate to one another. So for me, I think that when we have an opportunity to see somebody in healthcare, when we have an opportunity to see someone that's an ethicist, whether they're an academic or they're practical, like I would consider myself to be just, I get to teach. But I'm not a full time ethicist. I wouldn't call myself an expert in ethics, I would call myself parish pastor, who happens to be a therapist, who happens to really, really believe that health care can be more than just a machine, but it can be people, loving people with certain skill sets, certain gifts, certain talents. That would be the only thing because I think you're asking the right questions. I think that you like all of us don't have a lot of answers. But if you're not at least asking the questions. Well, then I don't think there is hope.

Chip Gruen: 58:42

All right, well, I think that is where we're going to leave it for now. And thank you very much, Dr. Bob Machaer, for being with us on ReligionWise.

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 Religious and Cultural Understanding of Muhlenberg College ReligionWise is produced and directed by Christine Flicker. For more information about additional programming, or to make an inquiry about a speaking engagement. Please visit our website at religionandculture.com. There you'll find our contact information, links to other programming and have the opportunity to support the work of the Institute. Please subscribe to ReligionWise wherever you get your podcasts. We look forward to seeing you next time.