AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.

Kicking off 2022 with the AMA's "Look Forward/Look Back” series, AMA Chief Experience Officer Todd Unger talks with Audiey Kao, MD, PhD, the AMA's vice president of ethics, about the AMA's critical work in medical ethics and what to expect in the months ahead.

Find out more about the AMA Journal of Ethics.

Speaker

  • Audiey Kao, MD, PhD, vice president, ethics, AMA

Moving Medicine video series

AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.

Unger: Hello, this is the American Medical Association's Moving Medicine video and podcast. As we begin the new year, we thought we'd take this opportunity to take a look back at AMA's work over the past year in several key areas and also find out what's in store for 2022. Today in our Look Forward, Look Back series, we're talking with Dr. Audiey Kao, the AMA's vice president of ethics in Chicago about the AMA's critical work in medical ethics.

Dr. Kao, it is great to have you back. Ethics work has always been fundamental to the AMA since our organization's inception. But boy, this past year, it's been incredibly important as physicians faced challenges and ethics questions with the pandemic they've really never encountered before. One of those issues, still in the headlines, pretty much roiling this country. It's around vaccine mandates, the ethical considerations involved and what's AMA's guidance for health care workers in particular?

Dr. Kao: First, it's great to be with you again, Todd. As I've talked about in our past conversations, a foundational ethic in medicine is first, do no harm. This ethical obligation can manifest in many ways. And during this pandemic, getting vaccinated is one of those ways. That is why the AMA came out strongly in support of vaccine mandates for health care workers. And beyond health care workers, the AMA generally supports vaccine mandates as a key way to bring this COVID-19 pandemic to an end.

Unger: Well, that's a good question. Why is it critical that the AMA weigh in on this question, even outside of medical ethics?

Dr. Kao: Yeah. So, as the national organization representing all physicians, it's important for the AMA to speak out about issues that affect the health of the public. In fact, the AMA was founded, in large part, to create the world's first national code of ethics for physicians. Thus, establishing the standards of ethical conduct for the profession remains an essential part of AMA's mission through its stewardship of the Code of Medical Ethics.

Unger: In addition to mandates, another one of these key ethics challenges that physicians faced in 2021, and this is a very painful one, is about allocating scarce resources. Throughout the pandemic, we've seen hospitals goal with shortages of ventilators, ICU beds, even staff to take care of critically ill patients. And sometimes, hospitals are forced to implement "crisis standards of care," in which they prioritize patients largely on their likelihood of survival. How did the AMA guide physicians and hospitals in what is an extremely difficult decision?

Dr. Kao: Yeah, I mean, you raise a great point. I mean, according to the AMA Code of Medical Ethics, allocation policies should be based on criteria relating to medical need. It's not appropriate to base allocation policies on social worth, perceived obstacles to treatment, patient contribution to illness or, frankly, past use of resources.

While the Code provides a general framework for addressing allocation decisions, the COVID pandemic revealed that much of the health care system was not prepared to implement allocation policies. To be blunt, these are not decisions we can make on the fly. So, we need to be better prepared. And for the Code, that means its ethical guidance on this critically important topic should be updated. As a living document, the Code is continually updated and this is a prime example of AMA's stewardship of the code I mentioned earlier.

Unger: That's interesting. It's almost this opportunity to take a look back at the year and look beyond what are, I don't know, more theoretical in terms of the ethics and how they were applied to help people learn that. When you're talking about a living document, is that what you're meaning?

Dr. Kao: Yeah, that's right. I mean, I think we have to have a strong dose of humility in medicine to know what we know and what we don't know. And so, to not learn the lessons of this pandemic to apply to how we should care for patients in the future would not speak well of our commitment to promote the health of the public.

Unger: One of the things I've learned, I know over the past year of talking to so many different physicians is, whatever was wrong with health care going into the pandemic certainly became a lot worse, exposed so many issues. When physicians make decisions on things like a prognosis, we have found that the cards are already stacked against patients who've been medically underserved. What ethical guidance did the AMA provide about responding to health inequities that we've seen during the pandemic?

Dr. Kao: Respecting human dignity is one of the core principles underlying the AMA Code of Medical Ethics. And so, the Code, for example, offers guidance to physicians in how to realize their ethical responsibility to address health disparities and inequities. That said, we have also seen how the COVID-19 pandemic has greatly affected historically marginalized and minoritized populations who have been long oppressed by racist policies and structures.

This past June, the AMA Journal of Ethics published an entire issue on the topic of transgenerational trauma and how clinicians can respond to individuals and communities to address the health inequities created by such trauma.

Unger: Dr. Kao, you have talked to a lot of physicians and other experts throughout the pandemic on ethics-based issues. I'd love to hear about any standout conversations, any meaningful stories that come to mind when you think about those conversations?

Dr. Kao: Yeah. As you know Todd, when the pandemic started, the journal got creative and developed a series COVID-related in interviews, and I had the privilege of interviewing many thoughtful and engaging individuals. Some that come to mind include Doctors Ceasar and Charles, who helped to start White Coats for Black Lives.

The interview I conducted with Professor Ibram Kendi about what it means to be an anti-racist also stands out in my mind. I also had the opportunity to interview physician poet, Rafael Campo and political cartoonist Matt Wuerker, about the pandemic through the lens of their respective art forms.

I'm particularly of our focus on the pandemic's impact on some of the most vulnerable among us, including individuals experiencing homelessness, those who are living in jails and prisons and those working in low wage jobs, who frankly didn't have the luxury working from home.

Unger: When you think about the stories, is there any particular story or memory that sticks with you from this pandemic era?

Dr. Kao: Yeah. We often talk about treating patients as a member of the health care team. And so, I can recall conversations that I had talking about members of the team, who, for example, were home health aids who went to people's home, even during this pandemic. Who get paid basically slightly above minimum wage, who work long hours but frankly don't get employment-based health insurance, which is just morally shocking and indefensible.

So, I think shining a light and illuminating their stories is what we try to do in the AMA Journal of Ethics, is to shine more light and less heat on topics of ethical imports. So, that's an example of something that comes to mind during my conversations with people during the pandemic.

Unger: And that's a great segue into the next question that begins to answer itself a little bit. I mean, so much of the focus in the pandemic has been on the science and the continuous learning process we've made our way through this pandemic. But you continue to publish, you and your team, the AMA Journal of Ethics. Talk about why this resource has been so important over the last year.

Dr. Kao: Yeah. The journal is like my baby, so to speak. I gave birth to it, so I have a real fondness for its growth over the years. But from its very beginning, Todd, the journal has seen ethics inquiry as a public good. And that is why the AMA Journal of Ethics is free to read and access for everyone.

And early in 2021, the journal published a two-part issue on racial and ethnic health equity in the U.S. The journal has a long history of publishing justice-relevant articles. And in February of 2020, before the pandemic lockdown in this country, I published an editor's letter recommitting our journal to advance discourse and scholarship in motivating health equity.

We also published two issues on topics with titles that seem oxymoronic, the April issue on compassionate force and the October issue on palliative surgery. These two issues are just the latest examples of the journal exploring important topics that have not been but deserve greater examination in the bioethics literature.

And finally, the journal ended the year with an issue on health, justice and diversity in medical school admissions.

Unger: Dr. Kao, you looked to 2022. Assuming we are able to move through a pandemic, maybe to the other side of this, can you talk a little bit about what are your goals? Big things you expect to play out in the coming year.

Dr. Kao: Yeah. So, a couple of thoughts. The AMA Council on Ethical and Judicial Affairs, which is the council whose responsibility is to update and maintain the Code of Medical Ethics, is currently working on a report on physician's ethical obligations to address social determinants of health. This will be another important update of the AMA code once it's adopted by the House of Delegates. You know, but some of them, our audience may not, 2022 also marks AMA's 175th anniversary, so we will be publishing a special edition of the AMA Code of Medical Ethics.

Now, on the journal side, our editorial lineup is structured years advanced, so just to give our audience a sneak preview of next year, the AMA Journal of Ethics will be exploring a wide range of topics from Latinx health equity, to unregulated supplements, to pricing transparency in health care.

And of particularly pressing relevance, the October 2022 issue of the journal will focus on health care waste and the obligations of health care organizations to manage waste in ways that minimize environmental impact on our planets.

And lastly, I also think we need and will be focusing much more energy and attention on global health equity, including getting COVID-19 vaccines into the arms of people around the world because it's not only the smart thing to do but the right thing to do during a global pandemic.

Unger: Dr. Kao, I've really enjoyed our conversations over the last year, and it's so impressive to see a body of work that's really stood the test of time and yet is so dynamic in a circumstance like the pandemic over the past year and going forward. Thanks so much for joining us for this Look Forward, Look Back episode. We'll be back with another Moving Medicine video and podcast shortly. Be sure to click on subscribe on our YouTube channel or Apple, Spotify or wherever you listen to your podcasts. Find all our videos and podcasts at ama-assn.org/podcasts. Thanks for listening. Please take care.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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