 We're now opening the second panel, the panel on Contributions of Clinical Ethics to Patient Care. Our first speaker on that panel will be Lynn Janssen. Lynn is the inaugural holder of the Madeleine Bill Nelson Chair in Ethics Education at the Oregon Health Sciences University. Lynn began her career as a registered nurse, earned a PhD in political theory from Columbia, and has worked combining the fields of clinical care and ethics over the last two decades in various contexts, including oncology, pain management, critical care. Lynn today is going to talk to us on the topic of the complexity of clinical intentions. Lynn Janssen. Well thank you, thank you Mark. I have thank you for inviting me to speak at the conference today, and I'm really overjoyed to be celebrating your 25th anniversary with you and with everyone in the room. So today I'm going to share with you some of my more recent research on what I'm going to be calling the complexity of clinical intentions. But I want to start by giving you a little bit of background that explains my interest in this topic. Several years ago, actually when I finished my fellowship here at the University of Chicago, and I started working with Ansel Macy, we started to think about the ethics of what was then very controversial, the practice of terminal sedation, which has now come to be known as palliative sedation. And at that time I was struck by what physicians and ethicists would say about their intentions, and the intentions of others who actually are engaged in this practice. They would claim that clinical intentions with respect to this practice and indeed with respect to a range of other clinical practices that clinicians are engaged in are inherently uncertain or ambiguous. Timothy Quill captured this mode of thinking in a very influential paper published around that same time in the New England Journal of Medicine. His paper was aptly titled The Ambiguity of Clinical Intentions, but his his thinking was picked up by many others and similar claims were made by people who are also listed on this slide. So I have to confess that I was actually really puzzled by this claim that the clinical intentions of practicing physicians in particular were inherently ambiguous. If this claim is true, then I thought it really surely requires some sort of explanation. We can't just sort of let it stand. After all, how could morally reflective clinicians be so uncertain about what they're intending to do with their patients, especially when they're engaging in life and death decisions? So today I want to present an explanation of what might actually be going on, one explanation of what might be going on when clinicians talk about the ambiguity of their own clinical intentions. And the explanation that I'm going to present will build on some work in a relatively new field of study and philosophy titled Experimental Philosophy. So I'm going to first explain Experimental Philosophy to you, and then I'm going to come back and try to apply some of those insights to this problem that's been bothering me for the last 13 years about the ambiguity of clinical intentions. So to start with, it's important to note that experimental philosophers are interested in studying how ordinary people, like all of us and people out in the world, think and apply concepts. So for example, they might design a study to test how people apply the concept of knowledge or the concept of causation. But actually some of the most recent and interesting work in experimental philosophy has centered on how people understand and apply the notion of intentions. And so it's this work on intentionality that I am going to talk about today. So let me start by just describing to you very briefly, very now very famous study from the experimental philosopher Joshua Knob, who is a philosopher at Yale University. Now Knob hypothesized that intention ascription is influenced by our prior moral judgments. So to test this hypothesis, he went into New York City's parks and he basically just got random people and he asked them and invited them to reflect on two cases. The first case involved a harm scenario and the second case involved a help scenario. So I'm going to read these both of these cases to you right now. In the first case, which involved a harm scenario, respondents were asked to reflect on the following scenario. The vice president of a company went to the chairman of the board and said, we're thinking of starting a new program. It'll help us to increase profits, but it'll also harm the environment. The chairman of the board answered, I don't care at all about harming the environment. I just want to make as much profit as I can. Let's start the new program. They started the new program and sure enough, the environment was harmed. Other respondents were asked to reflect on what Knob called a help case. And this isn't exactly the same case except for the scenario ends with a helping action. So the vice president of the company went to the chairman of the board and said, we are thinking of starting a new program. It will help us increase profits and it will also help the environment. The chairman of the board answered, I don't care at all about helping the environment. I just want to make as much profit as I can. Let's start the new program. So they started the new program and sure enough, the environment was helped. Now, what's interesting about these two cases is that they're exactly symmetrical. The only difference between them is that in case one, the chairman's decisions resulted in something bad happening, that is the environment was harmed, whereas in case two, the decision results in something good happening, that is the environment is helped. And surprisingly, what Knob found was that an overwhelming majority of the people he surveyed in the New York City parks, that is 82% of those folks judged that the chairman had intentionally harmed the environment in case one. While a similar overwhelming majority of people 77% judged that the chairman did not intentionally help the environment in case two. So this is actually a really strange result because the structure of the chairman's actions in both cases is exactly the same. So if the chairman intentionally affected the environment in case two, then surely he did so in case one as well, or so one would think. But Knob's study suggests otherwise. So now we come to a slightly different reformulation of the Knob's hypothesis. And this has come to be called the Knob effect. And the Knob effect simply states that people tend to judge that a bad side effect is brought about intentionally, whereas a good side effect is judged not to be brought about intentionally. The Knob effect has actually been shown to be quite robust, researchers have replicated it in a range of related experiments. But what I'm interested in today is to try to understand how we should actually interpret the Knob effect. Now Knob suggested that the concept of intentional action is moralized. So on his view, the people that he surveyed, they're not actually making any mistake at all when they describe intentions in that way, they're actually applying the concept of intention correctly. But others, and here I include myself, tend to think that the Knob effect points to a bias or a sort of error that we all are subject to making when we think about intended side effects, the intended side effects of ourselves and the intended side effects of others. And actually, if there is an error in this intention description, the good news is it can be corrected. In principle, what we actually might be learning from the Knob effect is that we need to be more careful and perhaps more disciplined in our description of intentions. So I'm going to come back to that point a little later at the end of the talk. But for now, I want to bring the Knob effect into contact with this problem of clinical intentions that I started with. And this brings me to two studies that I and my co-researchers listed on this slide conducted in New York City. So in these two studies, one involving medical students and the other involving practicing physicians, we set out to test whether the Knob effect was actually present with respect to certain defined clinical scenarios. And here I'm only going to talk about the study that involved the physicians, but just note that the one that involved the medical students yielded exactly the same results or very similar results. So we interviewed 143 practicing physicians, and here are their ages and backgrounds. And we've put the subjects into two categories, group A and group B. They were randomly assigned to these categories. Subjects in group A received two separate clinical scenarios, both depicting a harmful or adverse patient outcome following a physician intervention. And subjects in group B received the same two clinical scenarios. However, in these scenarios, the physician intervention resulted in a helpful or beneficial rather than a harmful outcome. So for example, let's go to the group that received the harmful outcomes. The first survey, first scenario that we asked our respondents to consider was this. A patient was admitted to the city hospital with burns over 90% of his body following a house fire. On admission to the hospital, the patient was writhing in pain and was given the standard dose of pain medication. Later that day, his treating doctor, Dr. Smith, told his colleague Dr. Jones, the standard dose is not controlling the patient's pain. We need to increase the pain medication substantially, at least twice the dose that the patient is already receiving. Dr. Jones responded, but increasing the dose of pain medication to that level could cause the patient to die. Dr. Smith replied, I don't care whether the patient lives or dies at this point. I just need to relieve his suffering. I'm going to administer the pain medication. So sure enough, he administers the pain medication. And just as Dr. Jones had worried, the patient dies as a result of receiving it. Now in our study, the question that we're asking, this is a very simple question that we ask the respondents, yes or no? Did Dr. Smith intentionally kill his patient? And in our study, approximately 86% of the respondents said no. He didn't intentionally kill the patients. And actually, the response seems quite sensible. After all, Dr. Smith had made it clear that killing the patient was not part of his plan. It was actually an unintended side effect of his efforts to relieve the patient's suffering. All right, so far so good. So now consider a different scenario. We made things turn out a little differently. It's still a harm scenario, but this one involves a much less favorable character. And this again, this scenario is given to the same group, the same respondents in group A. And this scenario involves Dr. Green. And Dr. Green is a cancer doctor. And he's operating in a practice that's actually not doing well. I'm not going to read the whole scenario because it'll take too long. And he wants to at this point have his finances increased and increase his profits. So a pharmaceutical representative comes to Dr. Green's office and asks, I'll give you a lot of money if you help me enroll some patients. And Dr. Green says, sure, but the pharmaceutical representative says, but it actually, if you help me enroll the patients, it'll improve your finances, but it could also harm the patients too as a result. Dr. Green says, I don't care whether the patients are harmed by participating in the research. I just want to keep my business from going into bankruptcy. He signs up to do the research. And sure enough, several of his patients are harmed as a result of participating. So at some level, I think we might agree that Dr. Green seems to be a morally worse person than Dr. Yeah, I see it. Dr. Smith. But actually, we're not interested in moral assessments right now. We just want to see if he intentionally harmed the patients. And in this scenario, actually 69 of our respondents said that to the question, did he intentionally harm his patients? They said yes. Even though Dr. Green had made it plain that harming his patient was not part of his plan, he just wanted to save his business. So here, what we've demonstrated is that there is a nob effect that's going on with respect to intention descriptions in the clinical situation. It seems like what's going on is that respondents are letting their prior moral judgments affect how they ascribe intentions to the clinical actors. And if you look at some of the narrative responses that we have, we received from the physicians, you can see that this is also the case. They thought that Dr. Green had violated his duty to his patients. He had sold himself out as a medical doctor. He knew he would benefit his patients. And this tells me that his action is more intentional. I'm going to jump to the chase now because I have two minutes left. We replicated this study because we wanted to score, we wanted to really underscore the hypothesis that the nob effect was there. So we gave Group B the same Dr. Green scenario. But this one actually resulted in the helpful outcome. Dr. Green still stated his intention was not to help the patients but to pursue a financial incentive or benefit. And he goes and does this study and he does in fact help the patients as a result. But interestingly the subjects in Group B said that he didn't intentionally help the patients. So again, we have a clear example of the nob effect in clinical intentions taking place in the clinical setting. So it's time to just draw some conclusions here. Our study suggests that the nob effect is present among physicians, at least when they consider certain clinical cases. As I said before, I think that the nob effect is related to an error. If the fact that an intended outcome is morally relevant about an act and morally relevant fact about an action, then we shouldn't ascribe intentions on the basis that the that the action was bad on the on the forefront. So this is simply to argue in a circle. With respect to certain clinical practices like terminal sedation or palliative sedation, there are going to be the potential for good outcomes and bad outcomes. When clinicians voice ambiguity over their in clinical intentions in these contexts, my thought is, is what they're doing is they're simply just voicing their own uncertainty about the moral value of the intervention. So that is where I'm going to stop it. 47 seconds. Thank you.