Scholarly values and healthcare

On this final edition of the Year of Scholarly Values podcast series, host Duncan Pritchard, Distinguished Professor of philosophy and chair of the Year of Scholarly Values Committee, will discuss how the scholarly values drive health education and patient care with Mark Lazenby, the dean of the Sue & Bill Gross School of Nursing.

Lazenby integrates the humanities into his school’s teaching and research efforts. His approach may seem revolutionary, but from the pioneering work of Mary Seacole and Florence Nightingale, through the academic advancements led by Annie Goodrich, to Lazenby’s modern reflections, the humanities have remained a constant, transformative force in nursing. Integrating literature, philosophy, history, ethics and the arts remains vital for preparing nurses to address the challenges of human suffering and to advocate for a more just and compassionate healthcare system.

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TRANSCRIPT

Duncan Pritchard:

I want to begin with the scholarly values such as respect, humility, concern for humanity and open inquiry that are foundational to academia. I’m particularly interested in how these sorts of values take on a distinctive significance in a practice-based discipline such as yours, where patient care has a real real-world impact.

Mark Lazenby:

It’s an important question. We think of the scholarly values as something that just happens or that has meaning just within an academic institution, but they have meaning in our lived lives. And I think the one thing that distinguishes nursing and medicine is that we live our scholarly values. They take on significance in how we interact with other people. The importance of learning the scholarly values while in university is that it gives you a foundation, and then it becomes part of a way of life, a professional way of life. That’s what’s really important – the ideal of respect and the ideal of intellectual humility. You have to live them.

So, what does it mean to respect another human being? The philosopher Michael Rosen says that it means to look back and see your fellow human. So, say, in an ethics class in nursing, we talk about what respect means. It’s not just respect for the truth or not just respect for honest and open inquiry – though it is those – but it becomes this looking at your fellow human being and seeing their humanity. So that very ideal of respect takes on a lived quality. The same thing about intellectual humility – being able to say I don’t know – is very important when answering patients. The scientific humility that we all value within the academy takes on a real lived quality when you’re interacting with patients. The same would be true in any practice discipline.

Duncan Pritchard:

This connects to something you and I have discussed an awful lot, which is how nursing education done well needs to go beyond merely developing clinical skills. And that’s where one area where the humanities come in. Can you tell us a little bit more about this? For example, how does a humanities-based approach cultivate deeper ethical reasoning, cultural competence and resilience in future nurses, and so forth?

Mark Lazenby:

Well, don’t get me wrong. There is a skills-based approach in any practice-based discipline with the practice of medicine, the practice of nursing, the practice of pharmacy and the practice of public health – the health sciences that we teach at UC Irvine. When you’re putting something into a human being’s body or you have their life in your hands, you have to have skills. And those skills have to be tried and tested under extreme circumstances. They’re still people with hopes and dreams and goals who may be at death’s door or who may have just recently been diagnosed with a chronic disease. So, how do you go from the skill of teaching, the skill of treating that chronic disease, to helping them live a good life?

This is where I think it’s important that the humanities come in. For example, I use in my ethics class a theory of justice from a philosopher and economist currently working at Harvard. He defines justice as this: That people who have conditions have access to the necessary conditions to lead their lives. A nurse who’s working with somebody who’s been diagnosed with a chronic disease has to understand what life that person values, then has to understand the conditions necessary for the person to lead that life, and then has to work with them over time to make sure that those conditions are in place. And if not, the nurse has to advocate for them so that they can go on and live their life as independently of the nurses as possible, or as independently of healthcare as possible. So that’s where ethics and the scholarly values of science and teaching skills come hand in hand.

Duncan Pritchard:

That’s really interesting. It partially answers my next question, but I think there’s still something here that I’d like to press on, which is that the tangible consequences for the health outcomes from clinical skills are pretty straightforward. What are the tangible health outcomes of having scholarly values embedded in nursing education? How does it lead to discrete tangible improvements in patient care, healthcare policy and systemic change? Maybe you can give us a few examples from your experience.

Mark Lazenby:

Let’s talk about policy on a national level. There’s one great example I know of, and that’s of Lois Capps, who was a nurse and then became a philosopher of religion. She represented Santa Barbara in the House of Representatives for many years. She retired in 2017, and she’s had several bills passed in Congress that support not just nursing education but people having access to the conditions necessary to lead their lives. Bills that involved food insecurity and providing access to food, to healthful foods. That’s one classic example, a policy-level and a granular teaching-level approach we have here at the school. We use a program developed at Yale called “Looking is not seeing,” where you take students into the art museum and train them to observe what’s on the canvas. Usually, we do it with portraiture and have them start looking behind just the appearances and see the setting, the demeanor, the tone of the painting and the tone of the person, so that when a student engages people, they’re no longer just asking them what’s wrong. They’re actually looking at them, they’re observing their emotional state, and then maybe inquiring about that. It’s using the arts as a teaching tool for engaging humanity. And that’s at a very granular level.

Duncan Pritchard:

I also wanted to ask about the distinctive challenges that healthcare environments pose. As academics, there’s not that much that hangs upon whether we make a mistake, but in healthcare environments, a lot can hang upon a wrong judgment. Often, healthcare professionals are in environments with tricky competing demands of efficiency, containment and patient-centered care. All of these things can be at odds with each other. What do you think are the biggest challenges that healthcare professionals face in upholding scholarly values in those kinds of settings? And how would academic institutions such as our own instill and sustain these values in future healthcare professionals?

Mark Lazenby:

Some philosophers call these conditions the moral conditions of work, and they are real, and they often do get in the way of offering the care we know we need to offer. In my own example, when I was a new nurse, I had a patient in room one who was actively dying, and I had a patient in room two who needed chemotherapy hung, and I was the only certified oncology on the floor who could hang it. Then in room three, I needed to discharge a patient by a certain time or else that patient would be charged for another night’s stay, and the hospital needed the bed to admit another patient. And I totally forgot who was in room four. So, you get the moral dilemma, right?

We are very much at odds with the moral conditions of work that I faced and that many nurses and physicians face on a daily basis. And two scholarly values come to mind for me that we have to go with – one, of course, is truth. In the university, we have the responsibility of speaking the truth, the truth as we see it. And so calling out the moral conditions of work, or in this case, the immoral conditions of work, was something I had to do. It was to get to where I needed to be to have access to the conditions of the work life I had reason to value. So I had to speak the truth.

And second is a belief in the beauty of human life. Elaine Scarry is an English professor and essayist at Harvard who has a wonderful book published in 1999. It’s getting old now, but it’s still very relevant. It’s called “On Beauty and Being Just,” and she makes an argument in this little book about the importance of beauty in justice. The way to encapsulate it is that the opposite of beauty is not ugly. The opposite of beauty is injury – the “juror” being connected to justice, right? It’s doing harm, an injustice. And I had to say that my patients’ lives were beautiful enough that my care could not be injurious to them. I teach that to my students, and when I do, a light bulb goes on, because then it’s not just about what you are experiencing as a healthcare provider, it’s also who the recipient of that healthcare is. Connecting the beauty of human life, the beauty that you see in the art that’s brought you to, leads you to the desire not to injure that beauty, not to do an injustice to it. And I think that leads ultimately to advocacy, to changing the moral conditions of work.

Duncan Pritchard:

What’s fascinating about that story you tell here, and it’s something we’ve talked about a lot, is that people often downgrade the contributions that nurses make, compared, let’s say, with physicians. And yet think about the responsibility you’re carrying in that scenario. My sister, for many years, was a nurse, and she would tell similar stories, and she also wasn’t given due respect for the heavy load that she used to carry. I think nursing is a particularly interesting field, because it was pointed out in the introduction – and it’s clear from your comments today – it’s very much at the intersection of science and the humanities. It is in a way that very few fields could play into. How would you think a scholarly values-driven approach could bridge the gap between evidence-based practice on the one hand and the human-centered aspects of care? Because I could see those two things drifting apart very easily, with people not seeing how they connect and how they intersect with one another.

Mark Lazenby:

Evidence-based practice is very important, so once again, that we don’t do something injurious, that it actually improves a person’s health. Also, the whole evidence-based practice movement arose out of a need to be cost-effective. Don’t do or prescribe something that’s going to cost the system, or the patient and family, that will not have any benefit. And all of that is true. But it can become sterile, because evidence-based practice leads to protocols, and protocols are algorithms, and these algorithms can be implemented very rotely, almost robotically. But the humanistic values of this are a human life, a person with values, a person with goals, a person with desires – that’s where that protocol or the algorithm sometimes breaks down. So how do you engage with what the person wants versus what the algorithm says is necessary?

I’ll give you two examples. Both are from cancer, since I’m a cancer nurse. One is with a woman who had been diagnosed with melanoma under her big toenail. She happened to be Black, so it was diagnosed too late – people just didn’t know what a melanoma looked like on a darker-skinned person, and it was life-limiting by the time it was diagnosed. She refused treatment. Many thought that, on the one hand, she might have needed a site consult for refusing treatment, and, on the other, they thought she needed an ethics consult. That’s when they called me in. And lo and behold, I didn’t think she was either crazy or needed an ethics consult. She had lived a life she had reason to value. She had lived a good life, and she didn’t want to go through the pain and suffering of chemotherapy. She just wanted to let nature take its course, as many do, on her terms. She was a very religious woman. She just wanted God to take her home. We had to interrupt the algorithm that said, This is the treatment she had to have. But that treatment would’ve done harm.

On the other hand, I had a patient who was very clearly dying of ovarian cancer. The algorithm said that we should end treatment, but she wanted to dance at her granddaughter’s wedding in nine months. And while I thought that there was no way she could make it nine months, I said OK. I used the phrase we often use, we’ll hope for the best, but we have to plan for the worst. Right? I’m an oncology nurse practitioner, so we prescribed some very low-dose chemotherapy and managed her pain. She died one week after her granddaughter’s wedding. So the algorithm didn’t apply there either. You need to know where evidence leads you but also know what a human values and somehow meet between the two.

Duncan Pritchard:

I get that point about the algorithm. As some people try and operationalize ethics, it always has disastrous consequences, because, ultimately, ethics is in the details. It’s not in the algorithm. You miss too much by going that way. The talk of algorithms brings us to the topic du jour, which is artificial intelligence, which, of course, is everywhere, including in healthcare. How can nursing education maintain a strong foundation in scholarly values while integrating these AI advancements?

Mark Lazenby:

As a school, we’re very interested in AI, and we are doing research in this. It’s very promising. One of our faculty members is taking all the data we generate from the devices we have on our bodies – our phones, our watches, and even data collected in our smart cars that track where we go. We have all of this data, but then we also have healthcare data. And so he’s looking at triangulating all of this data to come up with a prediction over what we need to do to stay healthy. As academics, I’m sure we lead pretty sedentary lives, right?

Do we know how we can engage in more exercise? This is part of what’s very important with using machine learning and predictive analytics or AI in trying to keep us healthy. This technology is by no means equally distributed in society. The benefits aren’t equally accessible. And the data sets that we often use to create predictive analytics and machine learning have been collected on the people who engage in the healthcare system. These are people who have health insurance or have the money to go to the healthcare provider over time. And so whole swaths of society are left out of the data sets. How do we bring those swaths of society into the data sets?

This is another concern we in nursing have and are working on. And all healthcare providers and those in the health sciences have this concern because, ultimately, we’re concerned about all of society. You can’t have just a segment of society that’s healthy –  all of society has to be healthy. We talk about communicable diseases. One of the advancements in health has been that we have been able to curb a lot of the communicable diseases through vaccinations and other public health protocols. But non-communicable diseases are, in a way, the new communicable disease. Sedentary lifestyle, an urban lifestyle, the foods we eat, how we engage in our daily lives with the drive-through, how much alcohol we drink. These sorts of behaviors are really communicable. So using AI to understand this and to come up with a way to address the big communicable disease of non-communicable diseases – heart disease and cancer and diabetes – for all people is something we should be paying attention.

Duncan Pritchard:

Yeah, I was reading somewhere that gout is making a comeback because of lifestyle changes. A final question. I wonder if you could say a little bit about the initiatives underway at UC Irvine, which help to put scholarly values at the heart of healthcare education.

Mark Lazenby:

I’ve already talked about some of them. One is using art to teach the powers of observation. Another is using narrative; I’ve told you several stories here. We encounter human lives at the most joyous moments of life and at the most difficult and saddest times of life. So we use narrative writing exercises to explore them with our students. Also, ethics is front and center in our curriculum. And one of the joys of teaching, as both a philosopher and a nurse, is to teach an ethics class and to get students to really think about who they are as people and who they are as healthcare professionals. But there’s something fundamental about nursing – it has a moral character. Exploring that moral character happens all the time when we’re teaching clinical skills. How would the patient be treated when you’re doing the concepts of privacy and truth telling – this is what I’m doing, and this is why I’m doing it. And of humility, when they ask you, What’s my prognosis? Sometimes you don’t know. We talk about these kinds of scholarly values all the time, and we are also integrating the Anteater Virtues into some of our classes, so that students have a common language across healthcare disciplines. I hope that answers the question.

Duncan Pritchard:

Yes, it does, and naturally, I’m delighted to know that the Anteater Virtues are getting embedded into the curriculum. Thank you very much for joining the Anteater Insider podcast, Mark, that was a fascinating conversation.

Mark Lazenby:

You’re welcome. Thank you.