 All right. Good afternoon, everyone. Welcome to the Harvard Medical School Organizational Ethics Consortium where we explore ethical challenges and opportunities faced by organizations in the health sector. I'm joined by my co-chairs, Jim Satan and Charlotte Harrison in thanking you all for joining us today. And we have a really great session planned for today. We're very privileged to welcome three of the most thoughtful people that I've had the pleasure to learn from as they will take us through a conversation about an issue that's been on the minds and probably agendas of nearly every hospital health care system and employer since COVID-19 vaccines have become available, which is how exactly to navigate this vaccination territory and perhaps even develop a policy of mandatory vaccination for employees. So one of the toughest aspects I think surrounding this issue of vaccination mandates is that they often get framed quite simply, right, whether to mandate or not. And it's really not hard to see how in this forced binary, coalitions can form up on either side of the issue, which makes it a matter of fierce and often polemical debate. Instead of really creating this space for there to be ideas and approaches and a dialogue to figure out how to all chart a course together for us. So for the philosophers in the room of which I'm sure there are several, I won't deny that these kind of fierce ethical debates can be really exciting, but exhilarating as it can be to kind of sharpen the swords of our philosophical argumentation. In the world before us, we often have to find ways to make progress together, not just live in the debate space, but in the kind of progress space. And that usually means rolling up our sleeves and really taking a look not just at what we do as a top line matter, but how do we do what we do and why and how do we answer those questions in conversation with the communities that we serve and who are impacted by the kinds of decisions that are made by organizations. So what are the values and the commitments that a health care system might appeal to in crafting a vaccination policy within its setting? And how might those policies thread the needle between securing health and yet respecting those that they impact? So these are important questions and they exist really saliently in the doing of bioethics and organizational ethics, often more so than just in the thinking or conceiving of what the debates might be. And this is one of the reasons why I'm so grateful that we have Dr. Susan M. Miller here with us today from Houston Methodist, who will share the example of her institution's approach to developing a mandatory COVID-19 vaccination and now booster policy for it's more than 30,000 employees. As many of you likely recall, Houston Methodist was the first health care system in the nation to implement a mandatory vaccination policy way back in June 2021. And the effort that it undertook then and also now with respect to boosters is really nothing short of an extraordinary example of organizational ethics in action. So Susan was one of the chief architects and participants in this vaccination policy and the ethics process that underlies it. She's the chair of the Department of Family Medicine and the John S. Dunn Senior Research Chair in General Internal Medicine at Houston Methodist Hospital, as well as a professor of clinical medicine at Houston Methodist Research Institute and an associate professor at Wild Cornell Medical College. One of the things that I most admire about Susan and one of the reasons that she's here today is that not only has she been deeply involved in kind of crafting this mandatory vaccination policy for Houston Methodist, but then really sharing and disseminating the process and learnings from that mandate with the general community. And that's really a gold standard for supporting the learning that we've all come here to do today. And also the kind of dialogue that we owe one another, right, as professionals and as community members in these difficult times. So we're very excited for Susan to bring us through this presentation, but before we turn to her remarks, let me introduce our other discussants today who are esteemed leaders in organized medicine and in bioethics, Dr. Elliot Krigger and Dr. Rebecca Brindell. So Elliot is currently the director of ethics policy with the American Medical Association. And he's also secretary to the Council on Ethical and Judicial Affairs there. So that means that he maintains and advances the AMA code of medical ethics. And for that, he's calling on a wealth of prior experience with the National Center for Ethics and Health Care with the Veterans Health Administration and with the Hastings Center, and also from his doctoral work in anthropology and linguistics, no less. So we're very excited to have Elliot. And then secondly, we have Dr. Rebecca Brindell or Becca, as many of us know her, who is our own associate director of the Harvard Medical School Center for Bioethics, where she also directs the master's degree in bioethics. Becca is a lawyer. She's a practicing psychiatrist at Mass General where she directs law and ethics at the Center for Law, Brain and Behavior. And this May Becca will be beginning her term as the president of the American Psychiatric Association, which is something that no one who knows Becca is even remotely surprised by. So with these great three colleagues here, we can have quite a good conversation today. And most importantly, if we can advance to the next slide, Ashley, Susan, Becca and Elliot are really looking forward to hearing questions from all of you in the audience. That's really why we're here today. So please do use the Q&A feature. You can start now. You can ask questions throughout the session in the Q&A feature to raise questions for our speaker and discussants. The chat box is a good place to flag if you're having technical difficulties or if you just have some general observations about the conversation. But please do make sure you're putting your questions in the Q&A. Otherwise, we might overlook them as so many different things are happening in the virtual presentation space. All right. I think that that gets us off on the right foot. And with that preamble, Susan, if you'd like to get us started, and then we'll turn to the conversation for the second half of the session. Thank you so much. And I really want to thank all of my colleagues for this honor of working with you today. It's a privilege. And thank you again for inviting me to speak. So let's advance to the first slide. Okay. So I would like to start by telling our origin story. I think that can be helpful for people to understand our processes for how we develop this policy. And just as an aside, I mean, at our hospital, we try and look through the windshield. We don't like to make changes based on looking through every year view mirror. So understanding that can help us know how we got to where we are today. And before we administered our first vaccine, people need to understand that we organize the FEMA process, which is the failure mode and effect analysis, because we asked, what can go wrong? How are we going to do this? How are we going to do consent? How are we going to schedule? How are we going to get the vaccine? How are we going to distribute and administer the vaccine? How are we going to make sure that people appropriately are receiving the vaccine, etc. So we had all of these questions that we had a plan that we thought was going to be how we would initiate this initiative. And so what happened was we received our vaccine on the evening of December the 14th. And because we're a religious institution, the spiritual services was actually there to great the vaccine and the institution had a prayer and a blessing for our first administration of it. And then we had a soft rollout on December the 15th, because at that time, only 30,000 individuals had actually participated in the Pfizer BioNTech study. So we knew that there was evidence that it was a safe and effective, but we really wanted to see what that looked like in real time. So our institution asked for volunteers in that first half day so that we could monitor what happened to those individuals and to see if there were any unanticipated side effects, did we have any problems with the process of administering the vaccine? And that happened on December the 15th. And then what happened in early January of 2021? I received a telephone call in my role as IRB chair from the the liver transplant service. And they said, look, you know, we have evidence that this vaccine works in immune competent people, but there were these vaccines were not administered to people with immunosuppression like oncology and transplant patients. And they said, can we assess whether or not administering the vaccine is actually effective in this group? And so what they did is that they submitted a research protocol. And within a few weeks, we had 950 transplant patients that had enrolled onto this minimal risk study. They performed informed consent and our institution saw what happened when we administer the vaccine. And then we did neutralizing antibody titers to see if they were actually responding to the vaccine. And we did this for some of our oncology patients also. And we knew by February 2021 that we had a problem that our immune suppressed patients were not as robustly responding to the vaccine as our immune competent patients. And so by March of 31, Methodist then mandated a COVID vaccination policy for our system employees and any of the credentialed staff. And prior to this mandate, actually 84% of the employees that actually received the COVID vaccine and we're in the process of getting their second vaccine. And our process of mandatory vaccination absolutely included accommodations for individuals that would have medical contraindications and also religious exemptions. And we allowed this early stage of the pandemic that individuals that were pregnant could have a deferral to receiving the vaccine during their pregnancy, although we thought that it was safe and that the pregnant patients had the higher risk of having complications, but we did allow a deferral process for that. And by June 7, 2021, we reached 100% compliance for individuals at our institution. 2% of this 100% of individuals were actually exempted for medical or religious reasons. Out of our 33,000 system staff, 158 employees were terminated for failure to comply. And one employed physician actually chose to resign. And then based on more of the story, which I'll tell later, is that we then enacted mandates for COVID-19 boosters of March 1, 2022. So let's get to the next slide. Okay, so before we get into the ethics of how we got there, we also looked at the legal issues associated with it. And so one of the most frequent questions that I receive is, did we anticipate lawsuits? Did we anticipate public protests or were these unexpected? Were these a surprise? And we actually anticipated that there would be a legal pushback. And so before we created the policy is that we did internal and got separate external legal review prior to the mandate to see if this policy was actually consistent with legal requirements. And so looking at federal and state government requirements and actually it's Supreme Court cases that the states have long had the constitutional authority to mandate vaccinations. And this is separate. We're in a pandemic, okay? And so we thought that was another reason to have this mandate. And the Supreme Court upheld this twice, first in 1905 and then again in 2022 and then again in 2022. So on January 13th, the US Supreme Court upheld the CMS requirements requiring hospitals to fully vaccinate employees against COVID-19. And this represented 76,000 federally funded facilities. But when we had our policy, we didn't know that the Supreme Court was really going to support this. We had the assumption that they would and we move forward based on that. Next slide, please. Okay, so was the termination of unvaccinated employees included in this policy? And the answer to that was yes. And we knew that the EEOC ruled that businesses may lawfully require workers to obtain a COVID vaccine as a condition of coming to the workplace. And the private sector has a wide discretion in setting conditions for workers and customers that businesses have a legal and ethical duty to keep the workplace safe. So not only did we look at this as that it was legally permissible to have this mandate, but we also looked at it from a perspective that we have to keep our workplace safe, not only for our patients, but for our employees. And although the Supreme Court struck down the mandate under OSHA for large businesses, they did allow states to allow this to happen within their borders. And many companies proceeded with the vaccine requirement as the most straightforward approach to workplace safety. But this contrasting ruling between yeses for healthcare workers and maybe yes for individuals in other businesses had the potential to impact more than 80 million workers. So the safety issues and the legal issues have a significant impact on society. Next slide, please. Okay. So but what happened? Very early in the process at 117 of our full-time and part-time employees claimed that Methodist could not require mandatory vaccinations as a prerequisite for employment. And when we talk about part-time, anyone that was employed in the year prior to the mandate could part that there were had individuals that participated, even though they were no longer employed by Methodist. But a federal judge in the U.S. District Court of the Southern District of Texas summarily dismissed the lawsuit. They said he said these vaccines are not experimental and that the hospital was making this as a decision to keep their staff, patients, and families safer. One of the arguments that the litigants had is they said that we were committing Nazi war crimes. And the judge also rejected that argument. He said Texas law only protects employees from being illegally terminated if they're committing an illegal act. And so having receipt of a vaccine or mandating a vaccine, he said is not illegal. And he's also stated that hospitals and medical facilities have a greater justification than other businesses for mandating because medical employees are at a higher risk for exposure and they're more likely to interact with vulnerable populations due to the nature of their work. And so he also in his summary judgment said this vaccine was not contrary to public policy. So these are part of the legal arguments to support our mandate. Next slide. Did we expect protests? And we actually had demonstrators outside of the hospital and Methodist believes in free speech. And they said yes, we anticipated this, but they just couldn't do it on hospital grounds. They had to be across the street. So there was a lot of activity around this. This was covered by the news and you can see some of the posters that were used demonstrating against Methodist. Next slide. Okay. So how did we get to the ethics of this? And part of the ethics is that Methodist hospital said we have a pyramid of responsibilities. We are responsible to our patients, to their families, followed by the employees and then the Houston community. So that triangle formed the base of our approach. And what Methodist did is starting in 2020, we would have town halls and weekly meetings looking at the science of what was going on with COVID-19, not only the clinical research that was going, not only the changing epidemiology of this and not only looking at underserved populations and our own internal data in terms of epidemiology, but they said we were very early starting in May trying to determine if there were going to be vaccine candidates that we could use because the hospital felt they had an institutional responsibility to provide a safe place for their patients and for the staff. And they felt that this responsibility was actually justified by the precepts of beneficence and non-maleficence. But in spite of these ethical constructs, we thought that any scientific decisioning had to be the scaffolding for the process that we weren't going to mandate a vaccine that was not effective, was only partially effective. And we were actually pleasantly surprised that the early EUA showed that this vaccine had a 90% efficacy with minimal unexpected adverse events. So the final construct of this is that Methodist says that we have to focus on safety and we had to avoid a preventable harm. So examples of avoiding preventable harm were no-sacomial transmissions to patients because if we had infected healthcare workers and we infected our patients that were in the ICUs and all that, we said that's a preventable harm. We also looked at any of our analysis to determine how we implemented any vaccination period prior to the vaccine, were there mechanisms to do this in a safe way that prevented harm and how did we assess for this. And that, so these basis of looking at safety and preventable harm in science really were foundational in how we approach this administration of the vaccine and then the vaccine mandate. Next slide, please. Okay, but it wasn't enough just to look at the science. Okay, we also had to say, was there enough vaccine available? Period. Okay, we weren't going to mandate the vaccine if we didn't have enough to give to our patients or high-risk populations. And this was based on the construct of distributive justice. So we did not want to create separate vaccine shortages within the community by maintaining the vaccine. And we also very much were aware of our patients' own rights to autonomy, that they have the right to make decisions without interference with others. But this was in conflict with patient safety so that if someone was making an autonomous decision and then we were trying to say what's the way to have the most safe work environment, you could have a conflict. And at that point, we had to prioritize the beneficence and now maleficence to our patients versus an individual's right, a healthy individual's right to autonomy because we did not want their actions to harm others. And we also thought that physicians and healthcare workers that in this profession, we have a duty to take care of our patients and to have a virtuous behaviors in terms of self-sacrifice so that we couldn't just let autonomy be the final trump card that would say, no, we're not going to get the vaccine. Now, this is separate from having exemption criteria for medical reasons for religious reasons, but we did not want to have an irreversible harm by creating an individual death. And death from COVID was considered an irreversible harm. And again, I just want to reiterate that we had tracking processes in place to look for nosocomial infections and these were defined as within 34, I mean, 48 hours of hospital admission or three days after discharge or 30 days after an operation. And even through our ongoing processes, when we had the Omicron surge that it appeared that our healthcare workers were getting Omicron, not from what was happening in the hospital, but from personal behaviors outside of the hospital environment. And when we were looking at patients that were developing COVID infection in the hospital, that the majority of those were occurring because family members were transmitting at the bedside. Next slide. Okay. But again, the point is that we have data to look at this. So we again looked at professional standards. Was there a risk benefit analysis between vaccination versus non-vaccination? And we had subject matter experts who looked at this, we did not want to have tunnel vision and just have one person's philosophy driving this at these multidisciplinary committees, which would include legal medicine, nursing, our IT people, our outcomes individuals, HR and hospital leadership is that we wanted to have the best policy available based on changing knowledge that any policy we had had to be flexible and would need to pivot based on information that became available. And so the first question we said, do these vaccines cause more harm than COVID-19 or do they reduce the risk of harm from COVID-19? Because we didn't want to have a mandate for something that was actually more harmful than an infection. And as part of this process, we continue to monitor safety and efficacy signals because we wanted to look for unvaccinated employees and whether this would cause a danger to not only each other, but to our patients and for individuals that underwent an exemption for a medical and religious exemption, they actually had to undergo weekly surveillance screening for COVID infection and that was provided free to individuals that received that surveillance screening on site. Next slide. Okay, so how do we motivate people? I mean, this is actually an extraordinarily important question. And so that whenever you have a policy, we were open to the process of feedback and pushback to see, are we having a rush to judgment? Are there issues that we've not discussed? And what are the consequences of this policy? We did not want anyone to have a termination of their job based on this, that we have processes in place, that we could have specific education for these individuals, that we could try and figure out what their hesitancy was, and to try and have a way to help address any of their anxiety for this. We wanted to help people understand that this was for not only our patients' interests, but as a way for their healthcare to be protected. But one of the first things that we did is that we led by example. We had images of colleagues who were vaccinated, but we also had a policy that the administrative and senior leadership of the institution had a mandate prior to the employed individuals, the staff and other healthcare professionals. We disseminated our scientific rationale for this and our ethical rationale. We were very transparent about our own internal surveillance information, so that individuals could actually determine whether they had more than a theoretical risk. We had town hall meetings on a weekly basis that were available not only to the staff, but to the community. And one of our town hall meetings actually utilized senior religious leaders within the community that could talk about religious exemption for that. We had education that was in general to frequently ask questions, but then we would have individual specific education based on individual concerns. And we had to have develop education programs to counteract misinformation. Although there were individual bonuses that Methodist did provide, thank you bonuses for people for working in the pandemic and for getting vaccinations. It was not intended to have a quid pro queue that they would get a bonus and that that would then force them to get vaccinated. It was not intended to be coercive, it was meant to be out of gratitude. And of course, as I discussed earlier, there were mechanisms for exemptions. Next slide. Okay. So what was the justification for an employee termination is that it came down to patient safety that that ultimately superseded individual autonomy claims. So how do we determine whether individuals could receive an exemption? And there for 20 years, we've had a vaccine mandates at our institution for TB testing influenza measles hepatitis. And we have a committee that's multidisciplinary that was existing for 20 years that would look at requests for vaccine exemptions. And there was the same committee that then looked at COVID-19 vaccination committee request. And then if there were individuals that were not approved for a vaccine exemption, then a separate committee would review anyone that wanted to appeal that process. And that was another confidential committee so that individuals could come in front of the committee and express their concerns because we needed to protect the confidentiality of individuals that were receiving or not receiving an exemption. And so in that peer review committee, it was protected information that no one could find out whether Dr. Susan Miller, for example, received an exemption. And that individuals who were denied these exemption requests were then referred to other committees, the MedExec committee, before a final termination of privileges did occur. Next slide. Okay. So individuals who refused or did not complete by June 19th were suspended for two weeks without pay. So it didn't result in an automatic termination. They received additional education and actually a subset of individuals within this category either completely their vaccination process or underwent vaccination. And we have used the same process for individuals who refuse to undergo subsequent booster vaccination. And I'll discuss that process soon. Next slide. Okay. So people said, well, how did you determine if someone really could receive a religious exemption? And we looked at whether it was sincerely held religious beliefs that were inconsistent with vaccination. And that typically were individuals that thought that if they received the vaccine, it would affect their afterlife. Again, as I mentioned, they were grant pregnant women were granted deferrals. And out of this, we had to create institutional monitoring systems for individuals that were revaccinated individuals that received the booster vaccination individuals that had exemptions for where they appropriately undergoing their surveillance testing. And for individuals that received an exemption, but did not undergo surveillance testing, then they actually had a termination of their privileges at the institution or termination of employment because by making an accommodation for this group, if they did not follow those oversight that was a component of this exemption, then they were not following hospital policy. And those granted permanent or temporary exemptions had to use additional PPE as part of their process. Next slide. Okay, so this is a image of our CEO, Dr. Mark Boom, and he really was a face, a trusted face of this within the institution. He participated in the weekly ground rounds, he was part of the community, patients and staff could actually contact him and the community directly via email. And he would thoughtfully answer their questions. He really wanted the institution to understand what the what this policy was based on very much. It was important that we maintain transparency. And he really was instrumental in listening to concerns of the employees. This this educational access was across all employees shift it was provided in multiple languages. It could be in the education that could occur face to face on all time shifts. It wasn't just something available nine to five. Next slide. And they and these town halls really updated information because we had to proactively identify and correct misinformation as part of the process. Because this misinformation created separate levels of anxiety. And especially for some of the patients that thought that it would affect their fertility or such as an example of misinformation. Next slide. Okay, so again, as leading by example, that the management were the first ones the executives they had to be fully vaccinated two months prior to the other employees, and that the medical leadership were the early adopters of the vaccine and the vaccine mandates. Next slide. Okay, so what if the non medical managers refused to get vaccinated? It was one question. Did we hide this information? And so this is actually the answer to that is no, but it was de identified that we did not as an institution identify individuals that refuse to get vaccinated, even though we have transparency in the process and we would have data, we didn't say that Susan Miller refused to be vaccinated. So we had to protect the confidentiality of the process. Now, one of the individuals actually went on the news and self identified himself. And so we have an example of that. So that individual saying no, I didn't get the vaccine was different than methods hospital revealing this information, nor did we reveal if anyone had a medical exemption, what the rationale for that was to the public. Next slide. Okay, so then, if you're going to have a policy, you have to say does it work and does it remain safe? Okay, so we measure the vaccine rates over time, we share this information. And because we also thought part of the transparency was for people to understand that we're being equitable in this and it's an institutional priority. And we found that individuals were more likely to voluntarily receive the vaccine if they observed this being completed by other individuals. And we also monitored individuals who reserved deferrals and this process was implemented for new hire so you couldn't be come into the institution without being vaccinated. Next slide. Okay, so what happened next? So a subset of individuals, as I said, underwent vaccination because they did want to have the weekly surveillance testing. And then we then continue to look at this data because we would intentionally pivot any decisioning if there was new information. And we continue to have the committees that reviewing our internal and external data. So then in September 2021, when the Pfizer vaccine was no longer under EUA and it had received full FDA approval, we started asking the question, do we need to have a booster in September 2021? And we looked at the data and said no, we did not have to mandate a booster at that time because the primary vaccination series was actually effective against the Delta variant. However, by November 24th, 2021, we began to start hearing the information about the Omicron variant. And that we then started seeing that the data externalatory institution showed that it was had a formidable capacity to evade immunity. So in November, we were looking at this. And then we were also looking at data that we had internally looking at the decay in immune responses from individuals that received the initial vaccination series. By December the 18th, we knew internally that 90% of our admissions and our COVID testing were by then Omicron. And it was just an extraordinary amount of individuals that in our surveillance testing were now all of a sudden testing positive. And these were employees that had undergone the primary series and it was related to also to the infections that we were seeing. And so what they then looking at the science is that we recognize that there was synergistic hybrid immunity and individuals who had an infection and then had a vaccination after that that provided additional immunity. And then by looking at our own surveillance data, our genotypic data and our interim vaccine hesitancy and rumor surveillance, all of this was evaluated. And then we looked at the safety profile of the mRNA COVID vaccines. This was re-reviewed. So at this point, Methodist then initiated a process where we redefined what we considered fully immunized. And at the same time, we had a mechanism for pre-exposure monoclonal antibody prophylaxis for high risk populations, which are the transport patients that they could get these monoclonal antibodies that would provide up to six months of protection. That was available. Supply was still an issue, but it became available in January 2022. Next slide. Okay. So although the Pfizer vaccine was approved, we began recommending booster shots based on this data in November. And we saw that there was further evaluation of booster effectiveness and individuals that had the booster that seem to protect those voluntary recipients against the Omicron variant by December of 2021. But with the explosion that we were seeing in the community of numbers that were greater than what we saw in any of the previous variants, we then mandated a booster vaccination. We utilized the same process for medical and religious exemptions. And we had a new subset of individuals for individuals that actually had SAEs to the COVID vaccines. We allowed a deferment for individuals that had monoclonal antibody infusions for 90 days, but we didn't allow an extended deferment for individuals that were infected. Nor did we allow a substitution of surveillance as a mechanism for monitoring if the individual didn't qualify for medical and religious exemptions. All of this was based on the fact that we had a sufficient vaccine supply, that we had a sufficient infrastructure for vaccine administration and appointment availability. And as of the 13th of this month, Methodist Hospital itself has provided nearly 1.2 million vaccinations to the staff and to the Houston community. Next slide. Okay, so what are the challenges? We had COVID fatigue. I mean, people were having a hard time with this and that we still had to address the issues of intentional misinformation or that individuals would say, you know, is this really a strategic step that we need to take? And that that was part of the science. At this time that we actually saw more volatility in terms of responsiveness, but with the town halls and the education, that seemed to be tampered. And individuals had a perception that, well, you know, I didn't get infected the first time, maybe I'm safer, I have something with my own immune system, but this was contradicted by what was happening in the community and our healthcare staff that had not been infected before became infected, about 10% of individuals with the Omicron variant. And I think, is there a next slide after this? Okay, these are just our references. So I mean, my final points are it's got to be data driven, it's got to be a transparent process. You need to have a mechanism to have pushback and to look at that to make sure that there's not a rush to judgment in the policies that are implemented. And the other thing that I think is very important is the tone with which these institution deals with this, that individuals have hesitancy or that they have anxiety about this, that we do not define them as a moral persons. Okay, we really do have to listen with a separate consciousness to help understand what an individual's concerns are that we can address in a specific manner. So I'm going to leave it at that for right now because I know that we need to have some time for discussion and thank you. Thank you so much, Susan. That's something of a whirlwind tour through what is truly a complex space. And I guess, you know, just to, as we get ready for, maybe we'll call up Elliot as our first discussant, just wanted to reflect on the clarity with which you were able to define the institutional values that you were resting on in developing the vaccine, you know, the vaccination policy and the commitment institutionally to generating a safe space in which patient care can occur. So something that we can return to and thinking about the import of being able to state values and really discern what they mean for policy. But I will step back and invite Elliot, if you'd like to take us through some of your reflections. How to do things right. That was the story we just heard, I guess, top line. But I think Susan has done a marvelous job of showing us what it looks like on the ground when things work well, when things are thought through in an appropriate way. So I want to sort of pull back to the 30,000 foot level, if you will, and look at it, not through a theoretical lens, but through a more abstract lens, if you will. And I think that two of the points that so impressed me about Easton Methodist's approach were not only that they had already had in place reasonable processes that they could adapt to this new situation, but that they really, really paid attention to the implementation of decisions made, not just to how well the decisions were made in the making part of it, but how they operated on the ground, how they were put into practice in ways that were sensitive to the fact, to the varieties, sorry, sometimes I speak English, to the various sensibilities that they could find throughout the institution. Because not all healthcare staff are the same person, not all have the same understanding of their job, not all have the same understanding of the science. And they range in power and influence within the institution tremendously. So it's how you get this very complex community to accept a necessary step that we can explain for good reasons why we're doing this, but also respect them as having unique roles in the institution, as having unique challenges within the institution. And I think one of the things that really is impressive here is not only that the process was transparent and data driven, but that the monitoring was an essential piece of it. Because I think that's something that we in ethics tend to think less about, right? We're here to get to the decision, we want the decision to be well made. And then there you go, we have a decision. That's not always the case. And I think particularly what COVID has shown us with the disparities in impact across differently situated communities, thinking about and strategizing about and thinking about the ethics of implementation is crucially important. So that how you get to yes matters. And what you're really trying to do with something like a vaccine mandate is get to yes, isn't it? So in my copious spare time, I do try to actually read and there's a notion that I've discovered in political philosophy that I think is very appealing, although I will be the first person to say I'm probably not using it accurately. If a political philosopher were listening to it to me, but I think it's really important here is this notion of thinking about the most deeply affected person, who's going to be made least well off if we fail in implementing this in an ethically sound way. And I think that that's really something we don't pay enough attention to. And if nothing else COVID has shown us that he absolutely have to. We can't call ourselves well reasoned ethically sound decision makers if we haven't taken that into account. Who's this going to hurt in what ways? And I think Houston Methodist again seems to have done a really extraordinary job of reaching that goal, even if they weren't thinking of it in those terms. So I think I'll stop there and invite comment back from Rebecca or Susan. Thank you, Elliot. Concern for the worst off and the harms, the greatest harms that can befall a particular community as a standard and a baseline for thinking about how we approach generating policy and working with people, I think is something that we can all appreciate as important. Becca, I see you've come off video and I will invite you to share your thoughts. Thank you. And I'm having to dig a little bit deep for additional comments because my dear colleagues have done such a beautiful job. Susan, both in describing a really elegant and nearly perfect, although I can't figure out where nearly comes in process for how we all wish we would have approached a similar policy. And then Elliot's very cogent comments and anyone who knows, Elliot knows you never want to have to speak after Elliot because Elliot usually has the last word. So let me pick up just on a couple of things that both of them have said. To Elliot's point that how you get to yes matters, I thought maybe I'd add a little bit of perspective about exactly why the way in which Houston Methodists engaged the data and the data monitoring is so important. So I see in the attendees a number of our foundation students and where we'll get to when we come back from spring break on Tuesday is really thinking about the ways that we make decisions in public spaces and how prone we all are to make our judgments initially and then justify them with reasoned explanations after the fact. So for those of you who aren't familiar with this work and would like an introduction to it, this is largely based on the social intuitionist model on the empirical sociology research by Jonathan Haidt. It's H-A-I-D-T is the spelling. And one of the things I think that really has struck me and I'll confess this is the third, maybe the fourth time I've heard a version of Susan's talk on this is the way in which the data drove the decision making and with a clear identification of values as a community and public engagement around shared values. What do I mean by that? Well, from the very, very beginning, the values were values at the institution and those who worked in it shared about avoiding preventable harm and with the pyramid of responsibility to patients and to the people that the hospital was serving. And so the ways that the policy was framed was really about what do we know about the risks, how are we going to monitor them and knowing that moral judgment frequently, if not most or all the time, turn on non-moral facts really following the facts. So deriving the policy from the data about the risks of transmission, the risks of no sacromial infection and the very real responsibility that everyone shared about commitments to patients rather than framing in a forced binary around the autonomy of some versus the autonomy of others. So I think some of the examples of that are what you already heard, Elliott Highlight, we already heard Kelsey Highlight, but this not only taking the data where it was when the vaccine first arrived with the first or second wave of COVID, but looking at the monitoring and looking at the effect. So one of the particularly elegant places, the importance of the data first approach came through was in not mandating booster based in fact on the data and the monitoring in September of 2021, but then reversing course and mandating the booster in December of 2021 in response to Omicron, but having not done so in response to the Delta variant. So I think that's one place really that we could all learn from, working from the level of the facts to the policy and as opposed to only from the top down or really from the top down and from the bottom up in an ongoing way. Along with that really the willingness, part of transparency was really the willingness to modify the policy, modify the implementation and be receptive to what was being heard on behalf of those who were implementing and enforcing the policy. A couple more quick points because we have so much to talk about in conversation with each other is the idea of avoiding harm as the rationale for the policy even more than justification in beneficence. I just want to point out that when we think about the four principles, it's usually we think about autonomy, beneficence, that other thing that starts with an N and then maybe justice if you wouldn't get there, but we do know how common it is certainly in our political spaces to just stop with autonomy and how much of a feature of American society in particular, the right to be free from intrusion of others plays this prominent role both in our legal system, but also with very prominent translation into our medical system, so favoring the decisions of patients and individuals over other values and we have to be reminded not to do that. But just to remind everybody that the obligation not to harm non-maleficence is really a much more stringent responsibility than beneficence is, so our obligations to help or to do good are really particular and subjective depending on our relationship to others whereas obligations of non-maleficence are really universal and so I point that out to say this is really also in what's so elegant about this policy is really grounding it in the most stringent obligation from a values perspective as well and so in the coming together of the facts and values in this iterative process of the policy and its implementation really the success if there was a chance of success and clearly I think we would all agree that this was incredibly successful that the work was done on every level across the system really well. Last point is just to emphasize the importance of leadership. So those who study leadership know that leaderless systems and situations can lead to chaos and that strong the question is what kinds of strong leadership can lead to order and to success and really here are two critical elements one was the showing there was some telling but there was a lot of showing right so leadership being asked to be vaccinated early leadership buying in and demonstrating by example the way that this could work as well as the tone that was set right so it wasn't it wasn't only top down that there really was this dialogue that was happening on a regular and weekly basis and an inviting of perspectives as well as multiple points along the pathway of review of those procedures and processes that Elliott mentioned that were already in place and then could be used and then building in added systems of review to really have all voices be heard in that process so I think that that was another really important from an implementation perspective a reason for the success and demonstration and illustration of exactly the ways in which this was done so well so I'm going to stop there and I'll look forward to hearing my colleagues respond and to hearing questions from those who are participating. Thank you so much Becca so we have a huge treasure chest of reflections to mine into in conversation and maybe I'll invite Susan and Elliot if you'd like to restart your videos that's great so I imagine that you like I had a lot of thoughts as Becca and Elliot were talking Susan or perhaps Elliot you had thoughts as Becca was talking in vice versa so let me just pause for a moment and ask the three of you if you one of you wants to share some reflections or questions based on the commentary already raised. I'll start first of all I want to say that one of the things that I didn't mention up front is that the people that were first in line to get the vaccine to do the soft rollout because we they were they were willing to take that risk based on uncertainty because one of the comments was how can I ask my patients to have a vaccine if I'm not willing to do it myself so that they wanted to see if there was some sort of unanticipated harm that occurred to them before they asked their patients or their colleagues to do that so I think that's an important virtue that that needs to be addressed and we considered that the system had angst that if individuals had a true medical exemption and then they became infected and they ended up in the hospital we had a sense that we our system had failed them we weren't able to protect that individual even though there was a process in place that allowed them to have what we thought was safer at the time but then they still and either got infected or ended up in the hospital but the other types of data that we monitored is that we'd looked at our data for hospital employees that were admitted to the hospital before the vaccine existed okay which percentage of our staff got admitted which percentage of our staff actually died from COVID and compared that to post vaccination status and again that was another part of the safety information that was disseminated of saying look this really works we are we internally were thankful that we had an ability to provide additional safety to our staff separate from our patients so and I'm struck just by the incredible trust you know that not only in doing the work of monitoring right developing the data surveilling the risks looking at the outcomes monitoring the rate of vaccination that occurred following the policy but then transparently sharing this information with all of the employees reflects a particular level of trust right that the employees themselves can take this information and make of it interpretations that are conducive to their participating in the project that you were developing as an institution and so you know it's a it's an interesting dynamic right to say we don't have to hide what we're doing or what's happening in order to bring people along with us in this project so Elliott I saw you coming off of why don't you jump in with your thoughts thank you for a perfect segue because I wanted to mention that what Susan was saying about especially the early adopters in their institution was how can I ask my patient to do this if I'm not willing to I think unlike much of bioethics or in complement to much of bioethics the AMA code is really not so much rooted in the principles in the Georgetown mantra they're important no question but it takes its foundation in a much more um role-derived sense of ethics in that what Ed Pellegrino referred to is the covenant of trust between patient and physician that here is someone who needs me and I have said I will help and in some ways what you can say that Houston Methodist did or how you can describe it is to say they extended that covenant of trust to staff to the community it's not just in the patient-physician interaction but across the institution to say we are committed to providing a certain kind of service that in itself has moral character and to do that we need to be able to trust one another we build that trust in one another and I think that's incredibly important that's hearing why people are hesitant bringing in trusted sources of information that they can work with um acknowledging that people where people are actually living around their concerns with COVID or with anything else for that matter but this this sense of building trust is absolutely fundamental to success of these programs and then giving us some marvelous examples of how to go about doing that and I would say uh Elliott and Becca if if we found that the vaccine was causing more harm we would have stopped right then and there because we we and it's not the data was collected in real time I mean we would have weekly updates of the data and and pharmacy was instrumental and looking for internal adverse events and of course we would certainly allow everyone to report their own adverse events to the the CDC program but we were looking at data for adverse events were we seeing any unusual signaling and if we could hear echoes of something that we didn't anticipate we were looking to see if that was experience so just because you initiate something you may have to do a stop and pause to see if you need to go forward and I think that's important for for people to understand so you know when you said that Susan you know the immediate reaction I had was well of course you would have stopped right but that but already right that's to Elliott's point about the about the trust and the trustworthiness that Houston Methodist really demonstrated and earned in the process which you know other institutions may have said well of course we would have done that but it would not have been so transparent right the way in which the communication occurred and the listening happened not just the telling but the demonstrating the setting the example and the listening really made that come through loud and clear and you know in mandatory policies in particular right we're always thinking about well I have the right to tell you to do X Y or Z not we're in this together and even though the leadership has actually made the decision this is the decision based on the facts that though that covenant of trust or our our pyramid of responsibility would lead us to and these are also the commitments that we have that we're responsible for following up on it as we monitor and I think institutions have to have an ability to recognize that they need their own resilience in periods of uncertainty because if you have changing information how do you make the best decision on data from last week versus this week versus next week because none of us have the crystal ball to protect it but to acknowledge up front what do we know and not know and that's why it takes multidisciplinary teams that the individuals can you know we have a stop stop the line before you're starting a case or if you have something that you think that there's an unsafe process that can occur and and we just use that sort of safety process that we've already got for all the other hospital processes that we just brought to to the COVID vaccination process but it and I think that it's important for institutions to know we don't have to have every bit of information to make a decision process that's why I'm saying looking through the windshield not the rear view mirror it's a question you know as you mentioned the way in which information was shared with the employees and clearly there's been an evolution and an ebb and flow of the relative risk never I think has it been truly theoretical right but there's been periods of higher risk and lower risk and so you know one question is how has that influenced the kind of employee population and Susan you mentioned that it's not just sharing information that you were doing but also having town halls and having dialogue which is something that's very different than just putting you know a page of facts on the on you know on the table in front of someone and saying you know do with this what you will so I'm just curious how you know the the discourse between the information you were producing and then the work that you were doing in dialogue how did that shape the the kind of employees participation in the polls incredibly important question incredibly important okay so town halls were not the only way that information was disseminated all the employees would get weekly emails and newsletters so that would just talk about the data and it would also go to their phone they could get text emails on a weekly basis that they could link in to have access to the information um and that um when individuals would raise questions including members of the committee that were making decisioning these were discussed separately in a weekly meeting to make sure that the newsletter addressed these questions uh because the frequently asked questions would be things that would come up would pop up and we want to make sure that everyone would have access to that so HR was also another important component of this decisioning and the other way that we had of addressing harm is if someone has some disability that there were mechanisms that we had in place for health insurance and for um uh and re employment benefits if they had a harm associated with the vaccine so that we it was not just safety from the vaccine but financial safety issues were addressed um also but we lots of different ways that the information was disseminated and bidirectional it was bidirectional here's a question in the chat box today I want to erase all of you and especially pulling from Elliot's comments about how you know the practice of medicine and the role of the physician is really based on this covenant of trust and in some respects that then permeates right the institution in which healthcare is is going on um but you know we can also think about there being other organizations and systems that are making decisions about whether or not to implement vaccine mandates that are not built on this really strong kind of professional ethic and foundation that is oriented in medicine um so I'm just curious one of the attendees is kind of asking you know school systems are making decisions for example um other organizations in the healthcare sector uh insurers right who make their mission something to do with health although not in particular the delivery of it in a care setting um you know I'm just curious for any of the panelists as you think about um the learning right that might be taken from this example um for other systems or organizations that are also considering these challenging questions for their own setting well I was going to bring up that question myself because I thought it was a good one right because it was sort of um uh like the tv show what not to wear right so the idea being like all the things that one shouldn't do and what we've done in our public spaces for a large part is um is politicized the debate to such a degree and departed so far from the data right that the data itself and the facts themselves have become subject to skepticism in response right to um in response to what the perceived values or values infringement have been right all of which is to say that we're not going to have masks in school because we're good americans and we believe in freedom not the many other versions of that narrative you know as opposed to a narrative of well we care about our community and so we're going to take this small intrusion on our liberty to take care of each other right when actually it was it we never even needed to get there right so that um things started becoming done by ballot initiative and by political process rather than one that could have been more fully informed and then worthy of trust right to bring people together so I think it's in many many places um even when there was good data driving the decisions it wasn't communicated very well right so uh it would say something like well based on the available data we're lifted we're making masks um optional uh this coming monday for everybody in our school system right and then three days later with lots of complaints um there was uh there were responses about what the vaccination rate what the transmission rate was how many cases there were um and and what was actually happening within the school buildings so I think if we took a page from the Houston Methodist playbook right we would have led led with the fact that you know because of all because um that uh this is safe to do because of the data and we're going to monitor it and we're going to be flexible um so that we really as you said in your introduction get ourselves to a place of avoiding false binaries and can I add on to that Becca so thank you both um one of the things that we think in terms of a social justice argument is that we were early very early on we didn't want people jumping the line okay when there was a limited supply a vaccine so that people couldn't buy their way onto the line if you had were a certain VIP status that you couldn't jump the line that that we were transparent about that too and we had to develop it processes for how the vaccinations were scheduled to see whether they they truly qualified for that um and so I think it's I think that's kind of an important nuance it's not just that we have it but that we have mechanisms that it is really equitably uh applied and separate from this is that in the community vaccinations that we were very instrumental in developing outreach program to high-risk at-risk populations that might have had some vaccine hesitancies and that we would have political leaders that would participate in the process uh mark had to develop uh political uh uh relationships to help make sure that we one had access to vaccines or that they were appropriate policies um and he was very much on the phone with other businesses about how to implement a policy that we felt that this should be transparent so the justice is not just whether or not how you're doing the vaccine but that you're making sure that it's going to uh uh populations that might have barriers to access so that that was also part of our justice issue that we had to make sure there was sufficient vaccine available before we came to uh mandate. I think that's a good point too but you you both raised points that I think are applicable as much in a in an educational situation a schooling situation is that we have tended to have a model of inflicting the facts right and we've even seen that in bedside decision-making if I just tell this surrogate exactly what's going on with the patient the facts will speak for themselves that's not the case that's not how human beings make decisions and I think one of the things that's most important is you have to hear what that person is saying or how that person perceives it because as far as a decision is concerned or reaction to a mandate is concerned perception is the reality and and you have to deal with that and it doesn't matter if it's not your perception you have to understand what that perception is and I think Houston Methodists did that but I think also that one of the things that intrigues me about schools is that we have tended as we do with so many things to think of them as transactional environments right we exchange and many hours of our day for whatever learning is imparted to us in point of fact it's a relationship of trust too right parents and trust their children to this entity to a keep them safe be help them learn see give them a foundation for their ongoing life so it's why wouldn't a school insist on masks why wouldn't a school do what it could to keep my child safe and it's how do we bring that message in a way that can be heard in an environment that is increasingly transactional I think that's a huge challenge not just for COVID but it's going to be for everything go full the more we see this as I just exchange it's it's not a quote per quote but we do tend to think of it that way and that may be a much bigger challenge for ethics than anything we face. Well the other issue that came up had to do with what did we do starting in December when 90% of our inpatient volume was due to the Omicron variant of non-vaccinated patients okay so that created a sense of existential angst for the staff that had been vaccinated that had been on the front lines and now they're saying well what do I do because they would have a distress in terms of this would be a preventable harm if these individuals had only been vaccinated and and and it created crises for how we did that and so we had to come up with separate support systems for that so because the accommodation metric was not that you could refuse to take care of those patients or that you could have the temptation to be morally condemning those patients we had to have a separate support system for that so you still have a duty of care even if you don't like you have to take care of yeah yeah so yeah you know in some ways it's pretty remarkable how far Houston Methodist really went in bringing you know its employees along with it you know all of the things that you discussed Susan and how do we motivate people right not just mandate but motivate the people in our community to participate in this shared project you know that is not necessarily happening right more broadly speaking so the the huge step that Houston Methodist was taking to kind of bring people along we can understand why perhaps other community members who are not invited in right to these kind of processes when they're asked to promote you know the public health might not be quite as likely to participate in the ask right to increase vaccination mandates and so in some ways I mean Becca in one of your early comments mentioned the import of leadership and and the individual leaders in Houston Methodist as being the first line right of demonstrating that we can do this and we will do this but Houston Methodist itself emerged in many ways as an organizational leader right as a way of leading in the community and saying you can bring people along with us and so you know I'm kind of curious as you know as you continue to think about the relationship between Houston Methodist as an institution but in its community how this policy and approach has really impacted you know the community the community relations you know what has that dynamic been like as you've kind of struck out into this policy area well I think part of that's the simple answer has to be that it's a it's a self reflection of our hospital in the role of public health for the community okay so it's a faith-based institution so they have mechanisms in place to take care of individuals there's a whole details for how we do different face within our system but that we have mechanisms that are respective of that but that it's that they feel like in their hundred year history that they are part of the community and how do we take care of the health of the community and the vaccine was a way of doing that and so that when we had in January of 2020 with these big vaccine hub events where we were vaccinating three to four thousand individuals a day because the doctors and the staff were volunteering to work at this but they would Methodist paid the nursing staff and the pharmacy staff for wearing but there were many volunteers of people that said look we've got to get this out there we've got to take care of people because if this is the preventive ethics component that part of public health is taking care of the community but there's a preventive ethics component of it and I think maybe that should be something maybe that Elliott and Becca would want to comment on about the importance of that so you know I would say so that's a good segue and I think it brings up the the question that I was going to ask you is you know thinking about preventive ethics at stage one when the vaccine first comes out and then maybe stage one B when we have the availability of booster Elliott's smiling so he knows where I'm going with this but the you know now right as we think about unmasking and taking steps back from our COVID precautions COVID fatigue getting out of the pandemic how do we continue to get buy in and trust around this ongoing preventive model right so how do we keep getting our how do we keep getting the data right I know this was coming up for our students who are still who are still doing surveillance testing multiple times a week with nasal swabs right and our faculty who's still doing it once a week and you know when when do we stop surveilling right and when and how do we inform those decisions and convince people that it's still important right so there's there's two strands of that one is if you haven't there's a tendency to say if you haven't figured it out by now and just gotten the vaccine it's clear enough that those who are vaccinated aren't dropping dead right and these horrible things aren't happening get vaccinated or you're going to get it end up in the hospital right then there's but there's also this very real other side of preventive ethics which is that the failure now or the those who haven't gotten vaccinated and with each variant are filling 90% of the hospital beds what about the general health right and the delays in general care of the rest of the rest of society for getting their physicals and their health maintenance and you know really level one recommendations from public health about things that all of us should be doing but haven't been able to be done because of the capacity that's being used up around preventable harm from COVID or at least largely preventable harm so how do you know how do we think about or how are you thinking about this preventive ethic now going into the future in in shaping the next phase of the policy I think that that's a really interesting question that that came up while you were speaking and in response to Kelsey's question okay so actually it's really important the fact is to ask the questions that we may not have an answer today but we've got a list of questions that we don't have enough data to say no we get to stop the surveillance testing we don't have enough data for that oh we're paying attention what's happening to Europe they're having a new variant oh when do we permit a second booster do we want to consider that okay and so so there are individuals that have undergone a second booster because it has full FDA authorization you can do it under a doctor's order so we're kind of monitoring that so I think that to to do the infrastructure the architecture for that is you still need to be able to be creative enough to what questions do we need to start asking okay and so even if we don't have that these are the discussions that we're doing is there enough data that allows us to change it so do we let individuals stop masking at the hospital no because we have too many people that are immune suppressant at risk okay so that we're still doing we can't police what people are doing out at their homes and we still have mechanisms for surveillance okay because that's our canary in the cave if we're starting to see our positivity rate from our surveillance testing going up we're going to say okay we need to put all hands on deck to see what's really going on there and because we're doing genetic sequencing of our positive covids and we can determine what kind of variant that we're seeing so I think we're not out of the pandemic we want to be out of the pandemic Becca but we have it so it's it may be tapering down we may be slowing down on it but we have not stopped analyzing and looking for any early signaling that says that we need to ramp back up so that doesn't answer the question except by saying you still have to ask the questions and then gather the data for that but I think that also speaks to a different role for institutions it's not just in patient care but it's keeping the community aware of what's actually going on out there using your most persuasive means possible and a very different role in some ways for healthcare institutions is to be part of the voice of advocacy for public health infrastructure it's completely different from patient care and it's completely different from taking care of your employees or even providing services in the community saying what beyond us does this community mean and how can we help get it there which is a huge lift absolutely no question about that but healthcare institutions are in some ways well positioned for exactly that because we have so many members of the community coming to us for help how can we help them not need us oh that's a good question that's a good point make ourselves obsolete exactly okay how can my goal for ethics is that they won't need us right because everyone will be thinking that way to begin with yeah but it is it is part of it feeds into the notion of an anchor institution in the community you're not just there providing care you're actually a major employer you're you know a tax base well some institutions anyway and and so an institution's role isn't just internal to its walls or in its little catchment area it may in its own best interests have a broader role to play and figuring out how institutions can do that while still cleaving to their mission and not destroying their own resource base is a huge problem but i think it opens up an avenue for thinking in a different way about how institutions can serve their communities and actually help the populations they serve and you talked about the collaboration that is essential so working with community leaders working with other faith-based organizations working with the schools working with political entities it can't be done in in a silo yeah and i think that one of the most important things in doing those and trying to build those collaborations is actually asking the question what do you need how do you see your needs i know what i can i've got a hammer i see your nails we're going to fix those but that may not be the only thing you need and what can we do to help you articulate those other needs and then begin to be advocates for the resources you need not that i'm an idealist or anything like that yeah and i would just say along those lines right that um we that um respect for different values and value plurality can't be replaced by value neutrality right so i think that they're right because eight because um and so that um really back to your point eliot of sort of beating you down with facts right that we have a tendency to do that and just say look it's it's plain and obvious right and that what the risks become when we step away from answering those really important questions about what our commitments are and what they ought to be both from the perspective of those who we wish to serve both individually um and communities within within which we find ourselves and have obligations to so really a really important point about where the where this all leads uh as we continue on into the next chapter and year three uh of this pandemic i have wanted to make sure you know it's among the things that have come up in the q and a is just reflecting on the way in which cove it has revealed that it's very rude right the troubles that our society um continues to suffer and has suffered for a long time perhaps without quite as much explicit attention to them in terms of things like health and health care disparities differential mortality rates and you know it does as you know some of the data around vaccination um showed at the very beginning there are communities for whom they weren't necessarily readily interested in participating in the vaccination um efforts that were going on and so with the dialogue between the institution and the community as more than just a direct care provider but also an employer you know so how how were the think how was the thinking going on around both protecting employment opportunities right for the community including racialized groups individuals and low income groups who might not be ready to participate in the vaccination campaign um and at the same time really taking on that responsibility as an institution to promote health and public health um both inside the walls and outside any thoughts on that okay so just a very quickly one of the things is that we did work with community religious leaders okay and they would help identify needs within their religious community so that they were part of the solution so it was not just Methodist imposing a solution but it was really a cooperative and collaborative effort for that and and and again even within the faith communities they themselves had to be the leaders okay so when the when their communities would see oh my pastor's getting the vaccine maybe it's okay sort of issues so that these communities would lead by example or that they would have an appreciation for having access to the vaccine and a facilitated access and a facilitated access to hospitalization again so it's our data early on we were seeing the demographics of who were getting the vaccines we knew we had a problem and so we had to figure out what the issues were associated with that and that's where the the community and the health department and PSAs and all that would be a component of that so I I don't that may be an entirely different lecture that we could have next year but just a quick answer as we're kind of rounding out you know I wanted to ask if any of the three of you would like to share some concluding thoughts based on this conversation or even just thinking about you know what the future holds um for uh you know the pandemic although it is not over will hopefully become less of a concern in society over time and so thinking about what healthcare systems can do and what organizations can do in stepping into the values and responsibilities that they so at least in houston methodist um case uh clearly demonstrated through this pandemic and through thinking about the vaccination policies that you adopted so two points that I just want to say very quickly is I think that we need to analyze what the long-term COVID are to see what happens with that to see if we're going to start having a population with earlier dementia because of the the COVID impacts on the brain and the other thing is in terms of the stress and distress that our healthcare professionals have had I think Becca uh it would be essential to help evaluate the burnout and the frustrations that people had the trauma that people experience and how that's changing how we educate our doctors and how we maintain a healthcare delivery systems I think these are two priority programs that need to be addressed as part of our society well I can just jump on um on what Susan said about our mental health right so I think you know as as a psychiatrist and mental health professional you know hearing the president of the United States make mental health a priority in a state of the union address is both something we've wished for as a profession and and feared right as a result of the tremendous strain and toll that this pandemic has had on mental health in the country and in particular for healthcare providers so you know we've gotten some federal funding to be able to educate and support healthcare healthcare workers through recent legislation but we don't even know where all of this is going to go and so one of the reasons why it's so important to have developed the kinds of policies and trustworthiness of institutions to be able to continue to do the work that as Susan has pointed out we're going to be needing to do for a long time into the future and you know perhaps when the next pandemic comes a hundred years from now as as predictably it will we would have learned something both from our successes and from the places that we that we fell short and if I can just expand on that a little bit I think it's obviously crucially important to look at the ongoing trajectory of the COVID pandemic or epidemic when we finally decided to merely epidemic merely epidemic but that that would also be a very short-sighted way of seeing institutional responsibilities right because it's the lessons learned through this how do we take them out and make that the way we act in the world all of the time because if it's not COVID it's going to be something else it's going to be those communities that still have higher rates of chronic comorbidities who there's plenty of work to apply the model to and it's learning to do that and learning to live in that model and I think a way that COVID particularly challenged institutions and individuals to do and making it possible for making it easy for people to understand that model and understand and feel comfortable living in it I think it's going to be a real challenge going forward and it's not going to end with COVID it's not going to end period right well I just I'm so grateful to the three of you and it's been truly a pleasure not to only see this conversation today but to have heard from you in the past what I can say I think from the perspective of the organizational ethics consortium is that this is just one of the finest examples in many ways of organizational ethics in action the way in which there is a careful attention to values to data to not just making the decision well but then implementing and constantly tracking and following up and evolving with the context and with the community needs these are some of the things that can be considered as gold standard approaches right in moving forward policies even in controversial and changing times so I want to reinforce a few things which is exactly as Elliot reminded us how we get to yes matters right how an organization implements a policy is just as important as what that policy is and then Susan really showing us through all of the examples of what Houston Methodist has done of how an organization can deeply respect people even in the context of limiting the choice that might be available to them while remaining as employees of the organization and then Becca really drawing our attention to the ways in which we can occupy right spaces of deep fundamental disagreement without that precluding our ability to make progress together and to really be thoughtful about what are the relevant facts that we need to be responsive to and what are the different values that might come to play in coming through these really difficult decisions so it's a great pleasure to think about how organizations can become accountable right for creating an environment both within their walls and outside of their walls in which people can be healthy and safe and supported and flourish and I want to thank you three for bringing that conversation to us we will wrap up this session we have one more organizational ethics consortium in April April 22nd that we invite all of you to attend which will riff a little bit on some ethical issues as pharmaceutical companies attempt to participate in equity and supporting the populations that use their products so very different topic and yet we're very much looking forward to it thank you all so much have a wonderful afternoon and a good weekend thank you everybody appreciate it be safe be safe