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Students look at the human side of medical decisions.

Bob Suhanek was a senior at Thurston High School in Springfield when a multiple murder rocked the school, the community, and—ultimately—the entire state of Oregon. One spring day in 1998, a Thurston High freshman, Kip Kinkel, killed his mother and father. The next day he took a rifle and two pistols to school, killing two students and wounding 24 when he opened fire in the school cafeteria.

There was a feeling in the shocked community, Suhanek says, that Kinkel should be "locked away and given the death sentence."

But a presentation by Kip Kinkel's current treating psychiatrist, William Sack, to a Portland State Biomedical Ethics class made Suhanek realize that he had not understood enough about this tragedy. After the presentation and class discussion, he approached the course professor, Patricia Backlar, with tears in his eyes. "I had never taken into consideration before that Kinkel could be suffering from a mental illness."

How responsible was Kip Kinkel for his crimes? What, if anything, could have been done to help him before he became delusional and psychotic? These are the kind of questions students examine in the three-term class. The students—future physicians, dentists, nurses, psychologists, social workers, and administrators—grapple with the complex and often emotionally wrenching issues that crop up daily for those who are involved in the health professions.

Sack told the class that if Kinkel had been under treatment with appropriate medication for paranoid schizophrenia, he would not have committed the murderous acts. The voices that for years told him to kill could have been quieted.

The class not only introduces students to the issues and decision-making processes of biomedical ethics, but also offers a Certificate of Completion granted jointly by the PSU Department of Philosophy; the Program for Ethics, Science and the Environment at Oregon State University; and Kaiser Permanente, Center for Health Research, Northwest/Hawaii. The Center for Ethics in Health Care at Oregon Health & Science University provides a practicum on the hill for designated professionals who have completed the course; and Oregon Health Forum, a health policy publication, offers internships to students enrolled in the course.

Backlar developed the program and has taught the class since its inception in 1997. The course reflects her interest in identifying and examining the significant, and often controversial, ethical and public policy issues relevant to biomedical and behavioral research, health care, and public health. Students in Backlar's classes learn the methodologies (and the art) involved in addressing and resolving biomedical dilemmas, whose outcomes have the potential for profound impact on many lives.

Because practical experience is essential for doing the actual work of bioethics, Backlar combines her lectures with case-based class discussions. She asks students to work together in small groups to present case analyses as if they were members of a hospital ethics consulting service or an institutional review board that must evaluate the risks and benefits of human participant research. Backlar urges her students to use the classroom as a safe harbor in which they may examine their own opinions and unpack the thorny issues and dilemmas that they may someday have to face.

In Backlar's spring term seminar, student Weiyi Zhao, a physics researcher whose goal is to become a public health administrator, led the presentation of a clinical case, Ferguson vs. City of Charleston (N.C.), which had reached the courts.

Zhao described the case to her fellow students: "In 1989, the medical personnel and hospital administrators at the Medical University of South Carolina (MUSC), working in collaboration with the police and prosecutor's office, instituted a policy of searching certain pregnant women and new mothers for evidence of cocaine. Urine tests, normally used by health care professionals to aid medical decision-making, were turned over to the police and used as criminal evidence when the tests suggested cocaine use. Patients who tested positive for cocaine were then arrested."

Zhao explained that most of the women who used the free clinic were typically impoverished African Americans. The clinicians felt justified in their approach—identification of drug-addicted mothers would ultimately benefit the children involved.

The students' responses showed how deeply troubled they were by this case: "The action was taken without the patients' consent or knowledge; there was a breach of confidentiality in giving results to law enforcement," students said.

"This is a good beginning," Backlar replied. "But are there other factors that should be considered? Is there anything that might justify such an intervention?" she asked.

Students then asked: "Was treatment offered to the women? Were they given access to drug treatment? Was treatment offered for the newborns?"

With each question, the answer was no. From the perspective of many of the students, MUSC clinicians failed in their fiduciary duties toward the patients. Other students saw that the implementation of public health policies intended to benefit populations can come into direct conflict with individual human rights.

The knowledge Backlar gains from her own research is an essential component in her approach to the policy and practice of bioethics. She piloted the study of a novel method of intervention in mental health treatment, known as psychiatric advance directives, which received funding from the National Institute of Mental Health. In 1994 Backlar received the Oregon Mental Health and Developmental Disability Division's Mental Health Award of Excellence. Active as both a writer and editor, Backlar publishes widely on issues relevant to biomedical ethics. In 1996 President Bill Clinton appointed her to the National Bioethics Advisory Commission, where she worked on such ethical issues as genetic research, human cloning, human embryonic stem cell research, and public policy on international research in developing countries.

During the fall term course, a team of students presented a sketch set in an emergency room. A dying, overdosed patient is admitted with a note pinned to his chest: "I have Huntington's disease. Do not resuscitate." His wife tells the emergency department doctor to save him; she can't live without him. What is to be done?

The students who presented the sketch had weeks to ponder a decision and ask themselves questions. Was the patient informed? Was he competent to make a decision to end his life? When he came to the emergency department, he was unconscious and could not answer these questions, but his surrogate—his wife—requested treatment. What should the clinician do?

The students know that in reality decisions must be made quickly and decisively. Since the patient's preferences are unclear, the acute condition is easily treatable, and the harm of not treating is very great, the students' consensus is to provide treatment for the immediate, life-threatening condition and create the opportunity to talk with the patient about his preferences regarding his chronic condition at a later time.

Although the concept of biomedical ethics is not new, the comprehensive teaching of the processes involved in "doing bioethics" is a relatively new field of academic study. William Sack, Kip Kinkel's psychiatrist and professor emeritus of child and adolescent psychiatry at Oregon Health & Science University, says he never had an ethics class when he was in medical school or during residency and that "the ethical issues were kept in the background . . . it is something quite new, to present biomedical ethics issues in a didactic and formal way."

This change, he says, is due both to medicine becoming more complicated, and to society becoming more diverse. "You don't just rely on a minister or a priest in these situations as you used to."

The broad approach of Backlar's classes, says former student Ben Reich, who is awaiting news about his application to medical school, offers tools students will use not only in medical school and eventual practice, but also for life itself. "The course pushes us to become whole human beings, to look beyond our own belief systems," he says. And, yes, Reich says, maybe what is learned here could be characterized as the process of gaining wisdom.

Eva Hunter is a freelance writer based in Portland.