What kind of ethical questions does a clinical bioethicist encounter? How does one conduct research on faith? How does this role differ from that of a hospital chaplain? Assistant professor of medicine in the Center for Medical Ethics and Health Policy Dr. Trevor Bibler explains.
Trevor M. Bibler, Ph.D. is a clinical bioethicist with a background in religious studies and philosophy. Dr. Bibler performs clinical ethics consultations at Houston Methodist Hospital. He teaches a variety of audiences and conducts research in clinical bioethics, religion and medicine, and philosophical ethics. His current research focuses on the ways religious worldviews—especially worldviews that include ideas related to miracles—influence clinical medicine.
See more of Dr. Bibler’s research:
For Heaven’s Sake: What is a Clinical Bioethicist?
Erin: Welcome to Body of Work an exploration of health topics in the news and important issues facing science with experts from Baylor College of Medicine. I'm Erin Blair, and my guest today is Clinical Bioethicist Dr. Trevor Bibler.
Erin: You are a Clinical Bioethicist. Can you tell us a bit about what that means and what goes into your day to day job?
Dr. Bibler: Yeah yeah gladly. So there are quite a few different types of medical ethicists but
I'm a Clinical Bioethicist which means that I go to Patients’ bedsides, families as well, talk with healthcare professionals and so on and my main task is really to try to identify and analyze and sometimes even hopefully resolve any type of ethical conflicts or even any types of ethical confusions that end up popping up in the course of clinical care. That's really what I do. It primarily involves talking with people. Asking questions, facilitating conversations, sometimes mediating conflict, but in general we're the ones who go by the bedside. Here in the U.S. some hospitals have clinical bioethicists who are their volunteers or are staffed such as myself. Most hospitals some have to have some way of I believe what the regulations call “resolving ethical conflicts” but most of the time that has to do primarily with implementing policy rather than actually going to the bedside. So that's most of most of my job is spending time at the bedside.
Erin: How did you get into this field?
Dr. Bibler: Well I first heard about clinical bioethics when I was a Master's of Theological Studies student at Vanderbilt Divinity School and I took a course called “Theology in Medicine” and as part of that the bioethicist who was also an MD and philosopher, Jeff Bishop, he had us round with the palliative care doctors and then also round with the Clinical Bioethicists and I really got a sense of what they were doing; I thought it was extremely interesting, I thought it was a good way of combining my analytic interests with trying to help people out and a little bit of personal skills. And the first case discussion that I actually ever sat in on was of a little boy who was about four years old and dying of liver failure and his parents were saying, “No he should not have a liver transplant because we're hoping for a miracle.” And so I was extremely interested by this and I asked the bioethicist if he asked them what they mean by miracle and he said “oh no not really I just kind of assumed I knew what they meant.” So I became very interested in that question as well and I stuck around and at Vanderbilt Divinity School and then I went to Vanderbilt’s graduate school to get my PhD in in Clinical Ethics and I spent quite a bit of time shadowing and then leading a few cases on my own at Vanderbilt University but then I came to Baylor College of Medicine and I was their inaugural clinical ethics fellow and I got lots of experience there.
Erin: So tell us a little bit about your own research.
Dr. Bibler: Sure gladly. My own research is primarily it really does center around the ways in which religion and spirituality, and I think faith in general, how that plays a role in medical decision making. As I mentioned that first time I heard about the patient, the little kid who was very sick and his family said “We don't need the liver, we're hoping for a miracle,” I've been very interested in this question of what people mean when they say “miracle.” To my mind it's a very complex idea and it can end up affecting people in many different ways and it can definitely play a role in the way in which they think about medical decisions that they have in front of them, both when you're a patient and when you are a health care professional and when you're a family member; it can end up having an effect on all of that. I also do quite a bit of research into what I is a clinical ethicists I'm actually doing, like what am I committed to when I'm saying “Yes this path seems like the good thing to do this seems like something that's okay to do, this seems like something that you should definitely not do,” what are my commitments as part of that? Because I think there's a lot that is really we assume a lot as Clinical Ethicists and there's been lots of about that but it's still I think quite a open question as to what we actually mean when we say that. And I've also done a little bit of research more recently into the ways in which individual healthcare professionals faith has an effect on the way in which they see medicine or the way in which they talk with patients and families to begin with. Yeah so it's those are my those are a couple areas but I am just really fascinated by this question of how in general I think how faith and medicine function in America and in the West today because it's a complex relationship.
Erin: How do you conduct research on faith in such a multicultural world
Dr. Bibler: Yeah that's that's a really really important question. One of the ways in which I do my research is to appeal to this idea of an insider versus outsider perspective. I don't really do research from an insider perspective. I'm much more interested in the ways in which people who profess a faith or profess a spirituality how they're wrestling with these types of issues. I'm extremely extremely interested in that. And the point about it being a multicultural world and that there are just so many faiths and that we in medicine try our absolute best to attend and pay attention to people of different faith backgrounds, because it's not always the case that if you are a Sunni Muslim your patients are all Sunni Muslim or if you're if you're a protestant that all your patients will be protestant. So it ends up being a little bit of, to my mind at least the research that I do ends up starting out with a pretty specific question, like I began my research on miracle language with just really concentrating on Christian faith because that's where I thought I could based on my background that's where I thought I could best understand what was going on, but then I’ve gradually expanded to other monotheistic faiths, so Judaism and Islam primarily and working with scholars who have additional experience and knowledge of those faith traditions and then just kind of expanding expanding and expanding based on the different professionals I talked with and based on their own professional responsibilities. That is something that I'm always trying to think through, is that I as an ethicist have a different set of responsibilities than the chaplain, than the doctor, than the bedside nurse, than the social worker, than the food service worker. And so when I hear this language, what am I actually what am I actually committed to? And to my mind at least taking an outsider's approach it's been extremely helpful because I'm able to try to get a sense of where they're coming from without having to identify with a specific faith tradition itself.
Erin: How do you put aside personal faith biases when doing your research, or does your faith background aid in your research and in working with other researchers and patients?
Dr. Bibler: Yeah yeah that's a that's a good question, one that I I think about myself quite often. I was raised Catholic but I don't identify as Catholic anymore. I've gotten a lot of guff from my colleagues when I say not only am I not religious but I'm not spiritual either. They don't quite believe that because of my interest in these types of things, but it is it is a fair question it's a good one because there is always I think some concern that the beliefs of the individual researcher will end up affecting either the research question or their answers to the research question. Luckily that, as an as an outsider to the faiths that I research, I don't really find myself all that concerned with whether or not I think they are right or wrong. I just don't know. My unfortunate sneaking suspicion is that everybody's wrong but me. What not really. But I have no I have no real skin in the game. Let's say so let's say I'm researching the ways in which patients from Islamic faith background use a term “miracle.” I'm not interested in saying that their theology is right or wrong or that the way in which they reason through these issues is right or wrong; what I'm most interested in is the process and how I as a healthcare professional can help them receive the best medical care possible when they use this language that might be a little bit for. Whether or not the healthcare professional is Christian or Islamic or Jewish or or any or any other world Religion, my hope is that the type of research that I do would be applicable to pediatricians independent of what confessional faith they might have, would be of interest to chaplains independent of what type of chaplain they are, because what I really and my group really try to hone in on is what we as healthcare professionals not we as individual believers what's required of us in medicine today rather than what's required of us as Christian bioethicists or Islamic chaplains or any type of permutation of that.
Erin: It's almost more a translation job.
Dr. Bibler: Translation I think is a great word for it. Yeah I'm definitely trying my best to get healthcare professionals to recognize that when religious language is used it's not the case that this is something that we can't question or that we already know the answer to or anything like that. It's trying to dig through in a in a very conscientious way about what people's individual faiths actually commits them to, because sometimes the people of these individual faiths have a very clear idea as to what their faith requires and sometimes they're just making assumptions. I hope that my research helps sort through the issue and a little bit of a way that relies more upon our professional identity than our personal confessional beliefs.
Erin: How is your job different from that of a chaplain?
Dr. Bibler: Yeah that's a you keep asking me questions that I've thought a lot about but still don't have good answers to. One of the one of the ways that I try to disentangle myself from a chaplain is that I at least if I go to the bedside and I talk with a patient or family and they bring up these religious terms these spiritual terms my job isn't to provide them with spiritual care; my job is to actually try to think through what these terms mean and how they're affecting their own medical decisions. In the same way that if I go by and talk with a patient or family and they don't use religious terms in the least it's still my job to kind of sort through what they mean. So even if they don't say miracle, what if they are hoping for something that's one in a hundred or one in a thousand, right? So even if there's not this religious language, my job is to try to get at the moral fabric and the ethical framework that underlies it. To my mind it's just often the case that, where I trained in Nashville and here in Texas, that often includes an appeal to spiritual or religious issues. So I think that my main job is to really try to unpack the way in which people decide what is good, what's valuable, and how that relates to medical care, whereas the job of the chaplain is to provide spiritual care and be the open voice and sometimes be a patient advocate for those who are undergoing spiritual crises. And I just don't have the tools or the inclination really because it's not part of who I am to try to address that, but it does end up being a challenge. And I should also mention that different ethicists and different healthcare professionals disagree with my approach. Some healthcare ethicists who I really respect say, “This is the job of the chaplain. We have absolutely no reason to even ask, ‘What do you mean by miracle?’ This is what the chaplain should be doing.” Others go to the other side of the continuum and say no not only do we need to jump in on this we actually need to negotiate these theological tenants with them and argue with them about, “Well if you're saying God has the power to perform miracles, then surely if we stop the ventilator God could still provide the miracle, so why don't we stop the ventilator?” So it's a whole big spectrum of responses and what I've tried to do is really stake out a middle position that says, “I'm not there to negotiate theology, I'm not there to offer spiritual care; I'm there to try to understand how these spiritual and religious ideas play a role in your decision-making and see if we can't map up the values that you have with a course of care that the health care professionals also think is a good idea.” That's really my job.
Erin: Wow, that's really remarkable
Dr. Bibler: Yes it's rewarding. It's tough but it's rewarding.
Erin: I can imagine. I can just imagine. I would imagine that working with surrogate decision makers of family members who have the responsibility to make health care decisions for a patient who can't speak for herself, I would imagine that that would be a particularly sensitive part of your job. Do you have a set method for unpacking that sort of a conversation?
Dr. Bibler: Mm-hmm yeah, I do have a couple practices that end up being quite helpful because there's a couple concrete steps that are involved in these types of conversations. One is I always ask if the patient ever filled out any type of advance care planning documentation, and that can end up being quite helpful. Sometimes not all that helpful but oftentimes quite helpful. And if they haven't then I've tried my best to try to get a sense of what's important to the patient, get a sense of their values, and just asking a family member what was the patient's values isn't going to get you very far. So a question that I returned to all the time and it's a question I really drill into my fellows is this question of, “What did a good day look like before our loved one got this sick?” And when you ask that question people just open up often. They'll say, “Oh yeah no they he loved to go and spend time with family, she loved to cook, we'd always get together on Wednesday nights for card games,” and you just start building a little bit of a portrait of who this person was and then I asked about well what their job was, and then I get some sense of that there's this combination of questions with that often being one I appeal to of trying to get at what was important for this person. And the reason I'm doing that isn't just my own fascination. It's, which does play a role to some degree I am very interested in what people have to say about this, but I'm able to try to help think through with the. It's more of a thinking through with than anything else. If this if this was a person who if his ideal day was having an apple for breakfast and then going for a jog and then going to work and then spend in the evening with the kids and watching TV, what happens if he can never eat an apple again? What happens if he can never go to work again or take a walk or be able to hold his kids, be able to say hello to his grandkids again, right? What happens if that's the case? And then once you get the sense and again people have different answers to this question. If we hear from family members that, “Oh yeah well no, I know he'd like to run, but really if but really if he was never able to speak with his grandkids again, I don't think he would want to live.” Or if we hear, I had a patient a couple years ago who spent his entire life on the water he was a sailor and he had just retired and he raced in boat races and so on, and he was a candidate for a left ventricular assist device which you can't get wet, and the possibility of him not spending his entire life on the water was just unfathomable, but that's different than other people. So it's these types of questions where you're able to get a get a sense of who the patient is and then think through, “Okay well if this is who they are what interventions are then available for them?” and at that point I try to I rely very heavily on the clinical care team to try to help me sort out what the most likely scenario is, what a best-case scenario is, and then speaking honestly about what a worst-case scenario would be, and then we're able to do a little bit of a mapping I suppose of these values. If they can meet what the clinical care team views to be as appropriate how can we have we actually put those together? And a lot of my job ends up trying to be again you used it earlier translate trying to translate these values and preferences into a plan of care that makes most sense for the individual patient. That's really that's really where I spend a lot of my time is it's I really do think ethics at the bedside at least it's primarily inquiry driven, where I'm there to ask questions and listen to the answers and try to add a little bit of the person into people's descriptions of the patient, and then see if the health care professionals feel comfortable offering interventions that the patient, or in this case I guess the family, views that the patient would have wanted, and when we can make that plan overlap then I think I've really done my job to help a patient get care that he or she would have wanted in this context.
Erin: Your job sounds really hard, really emotionally intense, stressful, kind of sad in fact. You know these are dire life-or-death sorts of decisions that you're helping a patient’s family make. How do you how do you decompress from a day or a week like that?
Dr. Bibler: Yeah yeah that’s a fair question. It's not it's not easy but because sometimes it just ends up being the case that you end up thinking about a patient or a family for a long time. Just as last time I was on call I talked with a patient who said that he wanted to die; that he did not want CPR, he wanted to go home and play with his dogs one more time and be allowed to die there. And I got a family meeting together with members of the family and members of the hospital team and it sounded like that was the plan. And then we left the room and then the patient's family talked with him he said, “No that's not the plan, I completely changed my mind.” It was a complete 180. And that case I still think about a lot and it's it ends up being quite hard, but one of the one of the nice things as well about clinical ethics is that I don't think there's been a week yet where I haven't made a family laugh, because when you ask this questions like “What a good day look like?” that puts people in a different headspace than “Give me an update on the clinical picture,” because then people concentrate on, “Well for the last month she was in the hospital after she had this stroke and then hasn't moved since,” but when you put people back in that other frame of mind of reflecting on who the patient was when they were really at their best then people lightened up quite a bit. And I really do think it's rare when I don't laugh with a family or a patient or make a joke or engage in some type of self-deprecating dialogue about me missing a point that they said or something. So even though it does end up being quite heavy I do think that we as Ephesus do a pretty good job of keeping some aspects of it light when we can. There's a growing dialogue about moral distress and there's been a lot of conversation about what it means for a nurse or a doctor to feel as though they can't do the right thing but there are these impediments. So there's this distress that they feel that isn't just about being overworked but it's about I can do the right thing. And there's a growing conversation about ethicists who themselves undergo moral distress because we have very often very strong opinions about what the right thing to do is, but sometimes it's just the case that we can't effectuate that either because we're uncertain or because there are institutional barriers. So I it is a very good question and one that the field itself is trying to reconcile with. Where I'm at right now I'm quite lucky because I have an appointment at Baylor College of Medicine and I do clinical ethics consultations at Houston Methodist Hospital and luckily I'm on for two weeks and then doing research and teaching for the next two weeks. So it's only 50 percent of the job and that actually ends up being quite a bit of a relief because you can go from having this type of in-depth conversation and facilitating conversations where there's disagreement and trying to minimize conflict and mediate and all that to then okay well now I'm gonna write a paper or okay now I've got to go and teach a class. So there are there are natural breaks if I was 100 percent clinical ethics I think I'd have a much tougher time with the aspect of it's just incessantly heavy.
Erin: Is there anything else that you'd like to add to you know our audience understanding the clinical bioethics?
Dr. Bibler: Well I think it's just primarily that we're there to help and that many hospitals do have clinical ethics consultant, even if you've never heard of us. I think patients and families if they're at a relatively large hospital they should ask if there's an ethics consultation service. Health care professionals should also know that at these larger institutions there are ethics consultants who can help out with these big issues at the end of life, at the beginning of life, about surrogate decision making and privacy and confidentiality and we're here to help. Sometimes we address moral distress just by being a sounding board and listening to what people have to say that can end up being quite helpful to alleviate moral distress. So whether they're patients or families or healthcare professionals when they feel as though they're really struggling with what the right thing to do is, it might be a good idea to just ask at your institution if they have clinical bioethicists and they very well might. It's a growing field and even when there aren't people who are there to staff it 24 hours a day they're often our volunteers, so we might be able to be of help. I always say err on the side of asking if there's an ethicist around rather than trying to struggle through medical decisions on your own.
Erin: Thank you for tuning in to Body of Work by Baylor College of Medicine. If you enjoyed this episode be sure to subscribe and be on the lookout for part two of our interview with Dr. Bibler. It focuses on his research into miracles. If you like the show please give us a five star review and tell your friends to listen. We're available on Spotify, Apple Podcast and Stitcher, as well as at BCM.edu/podcast. There you can also find the episode notes including information about the experts featured on the show. A quick note about the medical advice and opinions stated in this podcast; each individual's health profile is unique so please see a health care professional about any questions you may have. Until next time, take care.