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Christine Mitchell, lecturer on global health and social medicine at Harvard Medical School, retired in September after eight years as founding executive director of the HMS Center for Bioethics. Mitchell also founded the clinical ethics program at Boston Children’s Hospital and led its Ethics Advisory Committee for more than 30 years. She has shaped the field of bioethics at Harvard and beyond.
Mitchell talks here about her time at the center, how the field has changed during her career, and where she sees it going in the future.
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HMS: When you think back on your time at the center, what are you most proud of?
Mitchell: I’m really pleased about not only getting the Master of Science in Bioethics program up and running so quickly and successfully, but also of our deep commitment to the hospitals affiliated with Harvard Medical School and their ethics programs. That work can fly under the radar, but it’s a piece of what we do that I’m very proud of. The center is broader than its graduate and midcareer educational programs. It also includes ongoing professional education in ethics for practitioners. These are the people doing the work of bioethics in the field.
HMS: How has the field changed during your career?
Mitchell: The ethics training that we offer through the center didn’t exist when I was starting my career. In the time I’ve been here, bioethics has become professionalized much more broadly. When those of us who teach in, and lead the development of, this program were trying to learn ethics, we had to study it in other places and then bring it into our work.
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HMS: What made you want to study bioethics?
Mitchell: In my training as a nurse, I had a teenage patient that I got to know very well because he participated in my senior year project. He had a kind of cancer that we knew was not curable, and his parents were absolutely dead set against him knowing. I knew he didn’t know his diagnosis, but no red flags, no little bells, no light went off when I read it, because I was concentrating on all the drugs he was taking, which I knew I was going to get quizzed about.
So, I looked up all the drugs and I never thought about the ethical problem that was sitting there in front of me. I was totally unprepared to be asked for the truth from my patient. And of course, if you get to know somebody and they begin to trust you, they save their hard questions for you.
I’m sitting at his bedside, doing my teaching project, and he said to me, “Wouldn’t it be awful if I had something like leukemia?” Which he did. I was like a deer in headlights. I had no idea what to say. None. I said what many nurses usually say, “Well, you should probably talk to your doctor about that.” He had invested the risk of asking about something that probably terrified him, asking someone he thought he had a relationship with. And I couldn’t deal with it.
So, I did an analysis, which was partly about my place as a nurse in the hierarchy, and what I could and couldn’t say to patients, but also examined the conflict of values between honesty and protecting a patient from the harms that his parents foresaw. It made me think, “Oh, I need to understand this better.” And so, when I went to the University of Virginia and was team teaching in one of the professional courses, I insisted that we needed to have an ethics component in that year-long course. I found someone to teach it with me. It was a great way to learn.
HMS: What would you tell a student starting to study bioethics now?
Mitchell: We used to ask students to write in journals — paper journals — about their capstone experience. My advice is to let the experiences you’re having sink in. One way of letting things sink in is to process them, every day if you can. I used to talk about the importance of sitting on your own shoulder, and watching yourself, as a mode of internalizing self-reflection. I used to advise our students to keep journals, because I wanted to inculcate a habit of self-reflection. I think it’s a good human habit: thinking about your day and why something felt good, or didn’t feel right, or made you worry. Everybody has that little list in their mind of things that made them wince. That’s a part of the process of self-reflection, and I think that is a habit of mind that people in ethics should cultivate.
HMS: Where do you see the field going in the future?
Mitchell: I served on the Presidential Task Force on Racial Equity, Diversity, and Inclusion in Bioethics for the Association of Bioethics Program Directors, trying to figure out how to make changes more quickly in the field of bioethics as a whole. If we’re successful in diversifying the voices and perspectives within the field, we’re really going to have to rethink our methodology. In practice, a very common method of doing ethics is rational argument, persuasion — and consensus. Consensus works effectively when people are already alike in their deep values, the ones they don’t even know they have.
As soon as you have genuine diversity and people who bring deeply different life experiences and world views, we really are going to have to think about what our methodology should be. It’s clearly stated in clinical ethics that a core competency of the profession is “qualified facilitation.” That’s a term for discussion on the cognitive level that gets everybody to a point where they see things similarly enough to work out a compromise on the right thing to do, or best thing to do, in a difficult circumstance. That’s not going to work so well when we have much deeper and more numerous differences in ways of seeing the world, and in values, among bioethicists.
HMS: And maybe that disagreement will be proof that we’ve finally gotten to where we needed to go.
Mitchell: Yes, but people won’t see it that way. They want an answer, and no matter how much you say that you’re not in the business of giving answers, we do give answers sometimes about what’s wrong, and about what the justifiable alternatives are. But it’s going to be a lot harder to get to that.
HMS: Do you think that consensus will remain a goal?
Mitchell: I think we’ll still have, as our broad fundamental responsibility, the making of space institutionally for ethical deliberation. And that is,essentially, a cognitive activity. But you know, which voices you bring in, and what weight you give to them, is really going to have to change. And that’s a positive thing for this work. What good is it if it doesn’t make change?
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