The Examined Life. A Tribute to Edmund Pellegrino
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field notes Officers of The Center – 2013 David L. Roscoe Chair Mildred Z. Solomon President and Chief Executive Officer Harriet S. Rabb Secretary Andrew S. Adelson Treasurer Board of Directors – 2013 Andrew S. Adelson Liza Bailey Joshua S. Boger Vertex Pharmaceuticals Daniel Callahan (ex officio) Edgar Cheng The World-Wide Investment Co., Ltd. Rebecca Dresser (ex officio) Washington University School of Law Joseph J. Fins (ex officio) Weill Cornell Medical College Alan R. Fleischman Albert Einstein College of Medicine Willard Gaylin (ex officio) Francis H. Geer St. Philip’s Church in the Highlands Thomas B. Hakes C/S Group Geoffrey R. Hoguet GRH Holdings, LLC Kim Kamdar Domain Associates Patricia Klingenstein Ilene Sackler Lefcourt Sackler Lefcourt Center for Child Development Robert Michels Weill Cornell Medical College Michele Moody-Adams Columbia College Gilbert S. Omenn University of Michigan Michael E. Patterson Richard Payne Duke Divinity School Harriet S. Rabb Rockefeller University Eve Hart Rice David L. Roscoe Michael Roth Wesleyan University Barbra Rothschild Columbia University and the University of North Carolina at Chapel Hill Blair L. Sadler Institute for Healthcare Improvement Mildred Z. Solomon (ex officio) Francis H. Trainer, Jr. John Eu-Li Wong Yong Loo Lin School of Medicine, National University of Singapore The Examined Life. A Tribute to Edmund Pellegrino. Edmund Pellegrino was a huge figure who leaves a huge legacy. Since his death on June 13, 2013, much has been written to honor his prodigious accomplishments in scholarship, public policy, and institution-building and to express gratitude for his kindness, humility, and sense of humor. I want to honor his commitment to living a life in which ideas mattered. For him, ideas were not just the stuff by which to build an academic career or rocks to hurl at opposing scholars and policy-makers. Dr. Pellegrino’s scholarship articulated the centrality of human relation- ships, the virtues that should emerge and be sustained when people are vul- nerable and more powerful people care for them. His writings profoundly influenced the ethics programs my colleagues and I designed to build what we called “relational care.” Dr. Pellegrino did not only brillinatly write about these matters; he took action to realize them in practice. In 1959, years before “bioethics” had emerged as a word, when he chaired the Department of Medicine at the University of Kentucky, he started what he called “Morning Report,” probably making him the first physician in the nation to do rounds with residents that integrated ethical questions about how to honor the patient as person. On a larger scale, he enacted his commitment to social justice by creating a health care network in Washington, D.C., that now serves two thousand people with little or no insurance. His institution-building skills are legion. He served as president of the Catholic University of America, directed Georgetown’s Kennedy School of Ethics, and founded numerous departments and centers, including the Center for Clinical Bioethics that bears his name at Georgetown Medical School. Where lesser thinkers drew lines in the sand, Dr. Pellegrino achieved syn- thesis. A devout Catholic, he contributed to secular bioethics. A physician, he integrated science and the humanities. A philosopher, he made public policy. When George W. Bush suddenly dismissed the President’s Council on Bioethics, which Dr. Pellegrino chaired between 2005 and 2009, the White House press officer said the Council was terminated because it was a “philosophically leaning advisory group.” In an enormously gracious article, Dr. Pellegrino responded to the sharp contrast drawn between philosophical analysis and public policy-making: “Policy without an underlying phi- losophy is an edifice without a foundation; philosophy without policy is a foundation without an edifice.” I met him briefly early in my career, when his support of my desire to do empirical research on how physicians think about end-of-life care affirmed my intuition that empirical and normative analyses could inform one another in powerful ways. He influenced me and so many others not only through his huge opus but also by really engaging with people and provid- ing an example of a life of serious purpose that combined great leadership with humility. It is difficult at any time to lose a person of such authenticity, but now especially—when there are so few examples of respectful dialogue across secular and religious lines, scant opportunities to integrate science, medicine, and the humanities, and a great societal pull toward action with- out reflection—let us pause to celebrate and emulate his life. —Mildred Z. Solomon President
Transcript of The Examined Life. A Tribute to Edmund Pellegrino
Carmen, the young woman in my exam room with a knee injury, told me her story. Several days earlier, she had fallen in the Sonoran Desert while crossing
into the United States from Mexico. She had worked in New York City for twelve years and returned to Mexico to care for a sick parent. As an undocumented immigrant, she knew the risk of returning to Mexico and the increasingly dangerous path of reentering the United States. After she was picked up in the Arizona desert for the long ride back to New York, her fi rst stop was our health center, Gouver-neur, the largest ambulatory care facil-ity in the public New York City Health and Hospitals Corporation network.
As Carmen’s story unfolded, I felt deeply gratifi ed that on her journey cross-country, she knew we were here to provide care for her injury with-out questioning her immigration sta-tus. My gratifi cation was deepened by my familiarity with those migrant desert trails. I had walked them while vol-unteering on foot patrols to provide food and medical aid with the humanitarian organization No More Deaths. Now, this simple clinical encounter represented the compli-cated interplay of local and federal health care policy with immigration policy and international migration dynamics.
Working in an urban safety net facility, my colleagues and I daily face any number of challenges. In some respects, an undocumented immigration status is just another one of those challenges. However, it is a particularly interesting one given the context created by political, social, and ethical debate about immigration.
Immigration status can be a social determinant of health. But what do the factors composing this determinant look like at the ground level? Fear of “authorities” prevents many from seeking needed care. Although a mayoral executive order limits New York City employees’ ability to ask about immigration status, many immigrants may not know this.
And our patients would still be anxious because of increased federal immigration enforcement and deportations.
New York City has invested in an extensive public safety net health system. Still, health care providers must cobble together care plans for undocumented patients using safety net tertiary care facilities, emergency Medicaid, grant-fund-ed health screenings, and pharmacy assistance programs. The patients’ eligibility for these resources can be uncertain. Depression and isolation are common among this mostly low-income population. Finding referrals for mental health
care can be diffi cult. Patients sometimes hesitate to share contact information or details about prior medical treat-ment, challenging our ability to follow up and plan treatments. Some patients report having paid cash for diagnostic studies or medicines but provide little other information. We sometimes sus-
pect the providers they’ve seen are unlicensed.We hear about only pieces of our undocumented pa-
tients’ everyday realities. Some patients tell me they missed follow-up appointments because they never have a day off and are afraid to ask for one. Their embarrassment and dis-tress leave me no doubt this is true. We know that a family of four from Mexico will share one bedroom in a multi-family apartment and that recent Fujian Province immi-grants often send their U.S. born infants to China to be raised by relatives while they work to repay debts incurred from being smuggled here. What don’t we know about our patients’ lives that may also have implications for their physical and mental health and the overall public health?
Cuts in Disproportionate Share Hospital funding to safety net facilities under the Patient Protection and Afford-able Care Act and the ongoing debates over immigration reform proposals create uncertainty among clinicians about resources and the political will to care for the undocument-ed population. There are concerns about the health of the safety net itself. What is certain, however, is that people’s need for adequate health care, despite immigration status, will continue and that addressing this need is vital for our nation’s health.
field notesOfficers of The Center – 2013
David L. RoscoeChair
Mildred Z. SolomonPresident and Chief Executive Offi cer
Harriet S. RabbSecretary
Andrew S. AdelsonTreasurer
Board of Directors – 2013
Andrew S. AdelsonLiza BaileyJoshua S. BogerVertex PharmaceuticalsDaniel Callahan (ex offi cio) Edgar ChengThe World-Wide Investment Co., Ltd.Rebecca Dresser (ex offi cio)Washington University School of LawJoseph J. Fins (ex offi cio)Weill Cornell Medical CollegeAlan R. FleischmanAlbert Einstein College of MedicineWillard Gaylin (ex offi cio) Francis H. GeerSt. Philip’s Church in the HighlandsThomas B. HakesC/S GroupGeoffrey R. HoguetGRH Holdings, LLCKim KamdarDomain AssociatesPatricia KlingensteinIlene Sackler LefcourtSackler Lefcourt Center for Child DevelopmentRobert MichelsWeill Cornell Medical College Michele Moody-AdamsColumbia CollegeGilbert S. OmennUniversity of MichiganMichael E. PattersonRichard PayneDuke Divinity SchoolHarriet S. RabbRockefeller University Eve Hart RiceDavid L. RoscoeMichael RothWesleyan UniversityBarbra RothschildColumbia University and the University of North Carolina at Chapel HillBlair L. SadlerInstitute for Healthcare ImprovementMildred Z. Solomon (ex offi cio)Francis H. Trainer, Jr.John Eu-Li WongYong Loo Lin School of Medicine, National University of Singapore
perspective
Undocumented Patients and the Not-So-Safe Safety Net
BY CAROLINE RATH
n
Borders to our nation’s health
n
Caroline Rath is a physician assistant at Gouverneur Healthcare Ser-vices and a master of public health candidate at Hunter College, City University of New York. DOI: 10.1002.hast.
The Examined Life. A Tribute to Edmund Pellegrino.Edmund Pellegrino was a huge fi gure who leaves a huge legacy. Since his death on June 13, 2013, much has been written to honor his prodigious accomplishments in scholarship, public policy, and institution-building and to express gratitude for his kindness, humility, and sense of humor. I want to honor his commitment to living a life in which ideas mattered. For him, ideas were not just the stuff by which to build an academic career or rocks to hurl at opposing scholars and policy-makers.
Dr. Pellegrino’s scholarship articulated the centrality of human relation-ships, the virtues that should emerge and be sustained when people are vul-nerable and more powerful people care for them. His writings profoundly infl uenced the ethics programs my colleagues and I designed to build what we called “relational care.”
Dr. Pellegrino did not only brillinatly write about these matters; he took action to realize them in practice. In 1959, years before “bioethics” had emerged as a word, when he chaired the Department of Medicine at the University of Kentucky, he started what he called “Morning Report,” probably making him the fi rst physician in the nation to do rounds with residents that integrated ethical questions about how to honor the patient as person. On a larger scale, he enacted his commitment to social justice by creating a health care network in Washington, D.C., that now serves two thousand people with little or no insurance. His institution-building skills are legion. He served as president of the Catholic University of America, directed Georgetown’s Kennedy School of Ethics, and founded numerous departments and centers, including the Center for Clinical Bioethics that bears his name at Georgetown Medical School.
Where lesser thinkers drew lines in the sand, Dr. Pellegrino achieved syn-thesis. A devout Catholic, he contributed to secular bioethics. A physician, he integrated science and the humanities. A philosopher, he made public policy. When George W. Bush suddenly dismissed the President’s Council on Bioethics, which Dr. Pellegrino chaired between 2005 and 2009, the White House press offi cer said the Council was terminated because it was a “philosophically leaning advisory group.” In an enormously gracious article, Dr. Pellegrino responded to the sharp contrast drawn between philosophical analysis and public policy-making: “Policy without an underlying phi-losophy is an edifi ce without a foundation; philosophy without policy is a foundation without an edifi ce.”
I met him briefl y early in my career, when his support of my desire to do empirical research on how physicians think about end-of-life care affi rmed my intuition that empirical and normative analyses could inform one another in powerful ways. He infl uenced me and so many others not only through his huge opus but also by really engaging with people and provid-ing an example of a life of serious purpose that combined great leadership with humility. It is diffi cult at any time to lose a person of such authenticity, but now especially—when there are so few examples of respectful dialogue across secular and religious lines, scant opportunities to integrate science, medicine, and the humanities, and a great societal pull toward action with-out refl ection—let us pause to celebrate and emulate his life.
—Mildred Z. SolomonPresident
