Dan: 0:00

Hey folks, I just wanna say at the top here that this episode deals with some heavy themes, like death and suicide, so keep that in mind if you're listening with kids. An ethicist is someone who studies morality. You know, what's right, what's wrong, how we ought to act. A clinical ethicist does that work in the middle of a hospital where the questions they have to address are heartbreakingly real and high stakes. Questions like, "Who should make decisions for a patient in a coma?""When should a doctor honor a patient's wish to stop treatment?" These can be excruciating dilemmas, which got me wondering, there was surely a career that you could have done that would have featured more giggles, more lightness. Like, what do you think it was about you that propelled you into this fraught moral domain?

Esther: 0:57

I love grappling with tough questions. I think that for me, the joy in life isn't necessarily the giggles part. It's the making sense of life part.

Dan: 1:13

Hmm.

Esther: 1:13

The integration of all the bits of life that make it meaningful.

Dan: 1:18

Esther Berkowitz is a clinical ethicist at a large hospital system in the US. She says for her, the search for meaning began as a kid with conversations around the dinner table.

Esther: 1:30

It's perhaps typified by the fact that when our oldest son went to college and had to write his college application essay and you could choose to write about anything you want, his essay was titled "Dinner Table University". And he described our family dinner table much like I would describe the one I grew up with, which is that your dinner table becomes how you learn about how to think about life.

Dan: 1:57

Hmm.

Esther: 1:57

They're just things that shape the kind of inputs that you bring to decision making. It's how you want to live your life. Why does this matter to you? Are you gonna act on it?

Dan: 2:08

Well, that is a great insight. It's like reconciling beliefs and actions is a critical part of the work you do.

Esther: 2:16

Yes. It is. And it's also not only us doing that as ethicists, but really what we're trying to do is help patients, families, and care teams do that, to help them identify their values and then decide how their actions should follow based on those values.

Dan: 2:46

I'm Dan Heath, and this is What It's Like To Be. In every episode, we walk in the shoes of someone from a different profession. A software engineer, a hospice nurse, a conductor. We wanna know what they do all day at work. Today, we'll ask Esther Berkowitz what it's like to be a clinical ethicist. We'll talk about a case that haunts her to this day, what the dignity of risk means, and why sometimes a case hinges on which version of a person you should trust. Stay with us. Esther works most directly with care teams, the doctors and nurses who see patients directly. They come to her when it's not clear how they should proceed with a patient. Often, it's when a patient can't speak for themselves. And a key part of Esther's job is figuring out what the patient would have wanted. Here's an example. An 81 year old woman had been diagnosed with a terminal lung condition. She'd been in hospice care for three months before Esther was called in.

Esther: 3:57

And we were called because this patient had been brought to the emergency department when her hospice nurse had made a routine visit, gone into her apartment, and found her unresponsive on the floor surrounded by empty bottles of morphine and patches of this very, very high dose opioid medication applied to her body. And there was a suicide note next to her body and it said, I no longer wish to live with weakness and pain. I can't breathe properly. I can't care for myself. I want to end my life. And we were called because the emergency physician was asking, "Do I have to give the drug that we know can reverse the effects of this and give her a chance to live?""And if I don't, am I complicit in her suicide?"

Dan: 4:43

Oh, my gosh. And so how did you approach that? Like, once you knew the facts of the case, was it pretty clear in your mind what the right advice would be, or did you have to go do some legwork to think through it?

Esther: 4:56

We always do legwork because very few things are what they seem on the surface. Because we see such a tiny piece of any one person's life in the moment that we are called in.

Dan: 5:05

Yeah.

Esther: 5:06

So we see like a cross section of their life, one moment in time, and there's an entire life that's been lived before they get to us. And we know nothing about that. We know nothing about their relationships and their value system and their religious beliefs and all those things, and all of those are relevant when we consult. So in this case, and this is something that is really important to us, a lot of people have heard of, but very few people have, what we call advanced care planning documents. So that might be a living will, an advanced directive, some document that tells the clinical team and family members, under certain circumstances, I do or don't want this kind of intervention. I do or don't want to be resuscitated. I do or don't want to be on a ventilator.

Dan: 5:53

So in in this situation, like, where you're trying to figure out if she had an advanced directive

Esther: 5:58

Mhmm.

Dan: 5:59

I mean, isn't the clock kind of ticking? Like, don't you need to administer the the antidote to the tumor?

Esther: 6:05

Well, it depends on the in in this particular situation, it was a bit unclear, to be honest, because they'd found all these empty pill bottles, and they really didn't know how much she'd taken.

Dan: 6:14

Mm.

Esther: 6:14

So, yes, there was a sense of urgency because we felt, rightly or wrongly, because we didn't know that we were up against the clock.

Dan: 6:21

Yeah.

Esther: 6:21

So we managed to find the POLST form.

Dan: 6:24

Okay. Breaking in here. The POLST form stands for "Practitioner Orders for Life Sustaining Treatment". It basically tells doctors what life sustaining treatments a patient wants or doesn't want.

Esther: 6:36

And it had asked specifically for no resuscitation, do not put me on a ventilator, I only want comfort care. And then we have to identify if there's also another decision maker who might want to know what's going on. In this case, there was a daughter who was the agent with power of attorney for health care. So we're trying to get hold of her. And in this case, what we're trying to do is really to kind of balance the decisions under the pressure of time. So the way that our minds work in these situations is we're looking at what the proposed actions could be. So in this case, we could give the antidote if the patient starts to decline to the point that she needs it, which she didn't immediately. That was just predicted. If her breathing gets so shallow and so ineffective that she would die without support, you know, do we give this antidote, which would reverse the effects of the morphine? And we look at the balance of risks and the balance of benefits or what we call burdens benefits analysis. And so we're looking at, okay, what is it like to experience receiving this drug? Is it painful? I think it can be for some people. It's also clearly not aligned with this patient's goals because she made it very clear she did not want to be resuscitated and she wanted to die. So those are the risks of going in there all guns blazing and and reversing the the treatment. On the other side, you know, if we allow this to progress, she might die. We know that she already has a life limiting condition. That's why she was on hospice. She wants a peaceful end to her life. She made that quite clear. If we don't administer the antidote, we're honoring her wishes. But are we potentially participating in suicide? So in this case, we were able to tell the physician that it was acceptable not to give the antidote because in this case, first of all, the patient had a life limiting condition. Secondly, it was very clear that she wanted to die and she was doing so on her own terms. And that actually by trying to reverse that, we would likely be doing more harm because it's apparently quite an uncomfortable treatment to receive and it goes against her wishes. We're doing more harm than good. We know her wishes and we can In this situation, we can step back and let let nature sort of continue to do what it was doing anyway because she was in the process of a life limiting illness.

Dan: 9:01

Now, imagine this exact same situation, but there was no advance directive, and the woman's daughter said, no. Save her. What happens then?

Esther: 9:12

If we haven't got an advance directive, which is the patient's own expressed wishes, we're then turning to somebody who we hope the patient already trusts if they've nominated to be their agent for healthcare decision making. So we assume that the person we're talking to, in this case it was the daughter, would likely know the the patient's wishes and values. And so we would first turn to them because they are legally authorized to make decisions for the patient. And what we are asking them to do, and this is interesting piece of what we do, is we're asking them to make the decisions based on a standard that we call substituted judgment. And what that means is we're asking them not to think what they want for themselves

Dan: 9:58

Mhmm.

Esther: 9:59

In terms of this is my mother. I really want to keep her alive. We're asking them to say, if your mother could sit up in bed right now and tell us what she wants, what would she tell us?

Dan: 10:09

Mmm.

Esther: 10:09

So we're asking them to speak on behalf and sort of give voice to the wishes of the patient who can't speak for themselves.

Dan: 10:16

That's so interesting. Yeah. And if you have disagreements, like if the spouse, their substituted judgment is one thing and the kids is another thing, how do you handle that?

Esther: 10:29

And that happens all the time. That's a very, very common part of our work.

Dan: 10:34

That's gotta be excruciating.

Esther: 10:36

It can be. The law sometimes helps us, and the law sometimes gets in our way. It depends which state you work in. So in some states, they have laws that dictate the hierarchy of decision makers. If the patient hasn't nominated somebody themselves to be their power of attorney for health care, the law will sometimes step in and say, if there's nothing written by the patient, this is the order in which you turn to people, and there's this ladder. You know, we go down. Okay. The spouse is the first person typically. If they don't have a spouse, who's next? And you go down the the hierarchy. So that's an option in some states. And in fact, legally, we have to do that in the states where those kind of laws exist. In other states, there aren't laws that exist. And obviously, that frees you up in some ways, and it constrains you in others. Because if, for example, somebody is in the process of a very acrimonious divorce but is not yet divorced, they may not want their spouse to be their primary decision maker.

Dan: 11:36

Right.

Esther: 11:36

But legally, they may be. So in states where there isn't that, we will help the care team try and make sense of who is the most appropriate decision maker based on their relationship with the patient, how long they've known them, do they live together, have they had conversations about the patient's wishes over years? And usually, we're able to come to some sort of understanding. Occasionally, there are really deep conflicts within families, and that can be really excruciating for everybody.

Dan: 12:08

And if the law does not give clear guidance in terms of what the right answer is, and you have these acrimonious situations where people believe different things, whose call is it ultimately in which decision to make?

Esther: 12:23

Ultimately, ethics is an advisory service. So we will make recommendations, but they're not medical orders in the way that a physician would write orders that need to be carried out.

Dan: 12:35

Mhmm.

Esther: 12:35

So we will advise, we will write in the medical chart what our recommendations are.

Dan: 12:40

Mmm.

Esther: 12:40

And then ultimately, it's up to the the primary physician in charge of the case to decide what to do. And they will usually follow our recommendations, but they don't always. They will probably have a very, lengthy discussion with the primary bedside nurse because the nurses spend much more time closely conversing with patients and families than the physicians do. So the bedside nurses often have a really good insight into family dynamics, and that can be helpful. And the other service that is incredibly helpful is chaplaincy because our hospital chaplains are masters of unearthing people's beliefs and value systems and hopes and fears, and they can often and often have by the time we're brought in, have conversations with the patients or the family to make sense of the arc of the patient's life up to the point that we're brought in so that they can contextualize and sort of use past experience as a guide to what to do in the current moment.

Dan: 13:41

What's the end of an assignment for you?

Esther: 13:45

It's hard to answer that in one sentence. Some consults are quick and easy and, you know, who's the decision maker? Well, we live in a state where there's a law that tells us who the decision maker is. That's probably the end of the consult. There are some consults that will go on for days, weeks where the evolution of the patient's clinical condition causes an evolution in the ethical issues at play. And in those situations, it may take quite a long time for the situation to play out. And the resolution may be anything from it never truly got resolved and the patient died before there was any clear resolution.

Dan: 14:24

Right.

Esther: 14:24

Or sometimes the evolution of a patient's disease and or the shifts in family dynamics that happen when a patient is extremely unwell. Sometimes those shifts move things in a different direction and people come to some sort of agreement. There's some sort of reconciliation between family members. There's some acute clinical event that sort of makes the decision for us. Or the patient suddenly takes a turn for the better and some of these decisions become moot and unnecessary. So it's hard to answer that question simply.

Dan: 14:58

Yeah. Are there situations where the patient is able to speak for him or herself, and they want something different than the medical team wants?

Esther: 15:11

Oh, yes. Yes. And sometimes that's very, very difficult for all involved because ethically and legally, if we have a patient who has the capacity to make decisions for themselves, that is their right. Right? This is our principle of respect for autonomy, for the right to make decisions about what happens to your body. So if a patient who is perfectly capable of making the decisions makes a decision, we have to honor it even if we think it's very unwise. And there's this concept that I really love called the "dignity of risk", which is the idea that we support people's dignity in allowing them to make decisions that sometimes are high risk or very inadvisable. But that's a part of human dignity to be allowed to take risks and potentially not have good outcomes.

Dan: 16:02

After a quick break, we hear about another case.

Esther: 16:06

We have this expression in ethics, the cases that haunt us. This was one for me. This was a very, very challenging case.

Dan: 16:15

Stay with us. I'm super excited about what's coming up next on the show. On June 16, we're gonna start a series about air travel. We thought it would be cool to sample five different jobs in the same domain. So we're gonna hear from an airline pilot and a flight attendant and an air traffic controller and two others I'll keep you in suspense about. There are gonna be five episodes in the series coming out one per week over five weeks. So think of this as a little thematic binge. I'll be so curious what you make of this. We haven't tried anything like this before. So keep an eye out next time for "Airline Pilot". I loved this interview and I think you will too.

Wendy Zukerman: 17:07

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Dan: 17:39

So here's what happened. A 19 year old was riding in a car with some friends. They were celebrating something and sober for what it's worth. And this kid stuck his head out of the sunroof of the car just goofing off and by an absolute fluke of chance, he was hit by a stray bullet fired by a stranger. He was paralyzed from the neck down. He'd never be able to breathe on his own again. He'd need a ventilator, but his brain was completely unaffected. He was fully aware of everything that had happened to him, and he was able to communicate.

Esther: 18:14

So we were consulted because he was asking to be taken off the ventilator and allowed to die. And the question for us, so we try and frame each question as what I call the central ethics question. The question for us was, is it ethically justifiable for us to follow his request and remove him from the ventilator knowing that he's going to die? And as you would imagine, his family were very closely involved. He had a stream of friends every day, like teens to twenties to thirties in the numbers of friends visiting every day. So this was a young man with a close family and an enormous social support network. And so the care team would see all these people coming in and out every day. The hospital chaplains were very involved. They were providing spiritual care support to the patient and to the family. And through all of that, the patient was adamant that he did not want to live.

Dan: 19:13

Mmm.

Esther: 19:14

We brought in consultants from a lot of different medical specialties to make sure that we were fully evaluating his chances of recovery because there are patients who have very severe spinal injuries that are still able to recover some and occasionally all their functioning depending on the level of the spine that's damaged. So we wanted to make sure that we were able to give him and his family a very clear idea of what to expect in the future. And one of the things that I feel most passionate about as an ethicist is making sure that people know their options and have the resources that they need to make some really, really ethically challenging decisions. So In this case, it was particularly important. Right? Because it's a devastating, sudden traumatic injury with lifelong implications for him and his whole family. So we were able to identify a program outside our own hospital system that connected newly paralyzed patients with people who'd experienced a similar injury and had chosen to live.

Dan: 20:24

Oh, that's really smart because, you know, there's no way in your first hour after a trauma like that that you can imagine a new life, what would effectively be a completely new chapter. So that that seems wise that you have people that have been through the same thing, who could connect with them and kind of let them know it gets better.

Esther: 20:44

Yes. Or it gets different and I'm glad I made this decision. Or this is how I learned to make peace with something that most people can't imagine and would hope to never have to imagine. And you make a really important point, Dan, which is that one of our jobs in ethics is sometimes to hit pause on decision making and to say to people, this is not a decision that needs to be made urgently. Nothing is going to change if this decision is made now or tomorrow. Something might change if we wait a week. Something might change if we wait a month. And in these situations where there's nervous system injury, it sometimes takes months for the nervous system to sort of fully reveal what its capabilities are for recovery. And that's one of the benefits of these peer support programs. It's also one of the benefits of making sure people don't make decisions in the immediate aftermath of a trauma.

Dan: 21:46

What happened in this situation ultimately?

Esther: 21:50

Well, in this case, we provided as many resources as we could to him and his family to help him understand what life could look like, and he was adamant that he wanted to be taken off the ventilator and allowed to die. And because he had the capacity to make his own decisions, that's his right under the law, that is what happened. He was moved to hospice where they were able to peacefully, I think, create the situation where he was taken off the ventilator, and I believe his family were around him, and he was allowed to die. And this is why we talk about cases that haunt us because I think of so many aspects of this case that could have gone in a different direction. And I think about his family and his friends and and I wonder what life is like for them in the shadow of his death.

Dan: 22:44

Mmm. I mean, it's a horrific ending and I I wonder too if it's the least horrific ending. You know, it it seems like there was no good answer here, that Mhmm. Disregarding what he wanted might have been worse.

Esther: 23:01

That's exactly right. It's a tragic ending. It's a tragic accident. And the alternative may have been worse for him. And that's why sometimes our best option is not a good option, it's the least bad option. And that may have been the case in this situation.

Dan: 23:23

Is there an opposite situation, you know, where there's a treatment that the patient or the patient's family really wants that the doctors don't agree would be medically helpful for them? And if so, how do you handle those?

Esther: 23:41

A very common example is actually if there's a patient who is actively dying, so they're predicted to have perhaps hours or days to live, and the care team has asked the family to change the patient's code status. And what that means is in their chart, it says that they should have full resuscitation if their heart stops.

Dan: 24:01

Mmm.

Esther: 24:01

So this is what we see on all the TV shows. If you've watched, The Pitt or any of these other medical dramas, we've seen this happen numerous times. Right? The electric shocks or people, you know, pounding on the chest. We usually break ribs. It's a very traumatic event. In some cases of patients who are really near the end of life, there is no way that that could possibly restore their heart to functioning in a way that could give them life. And so the care team will say, please, could you, allow us to change this patient from being full code where we would go in all guns blazing and try everything we can to keep them alive? Would you please allow us to change that to do not resuscitate, DNR, where if that happens, we allow nature to take its course because the patient's dying anyway. And the balance of burdens versus benefits really makes this medically inappropriate. And sometimes the family just can't get to that point where they can accept that. And they say, no. We want you to do everything. We know this patient's only got x number of weeks to live or days. I can't have it on my conscience to have said don't do it. That's a very, very common struggle that family members have, particularly in situations where somebody's had an estrangement in the family or there's some family dynamics that are complex. Asking a family member to be the person who says you can stop or don't do that is very, very hard for them to bear. And that's sometimes the reason behind some of these disagreements.

Dan: 25:37

One of the things that just seems so complex about what you do is knowing which version of the patient to trust. You know, you talked about different family members having heard different things, or I'm thinking about what if a patient is depressed and and wants to, you know, to refuse treatment, and and people are arguing, well, it's just because they're depressed right now, and the normal version of mom or dad would not have said that. Like, how do you know which iteration of a human to believe in these situations?

Esther: 26:10

I wish I had an answer for you. I'm not sure anybody does. Right? You know, people go into ethics from a lot of different fields, and philosophy is one, and this is why. Right? There's an enormous amount of philosophy in this work. I actually wrote a paper about this exact issue because there are certain states, including depression and including certain severe eating disorders, where the patient's cognition, the way their brains are working, is altered by the very disease that they're being treated for, and their decision making is affected by that thing. And so what comes into play is exactly what you're asking is what is the authentic version of this person? Is it the depressed person? Is it the person of extremely low body weight who's saying don't feed me? Or is the refusal of that treatment based on changes that actually result from the disorder itself and that the healthy version of that patient would not make those same decisions? And as you're sort of intimating, Dan, in those situations, what we're tasked with is trying to understand what what is the authentic version of this person? What would that person want in this situation? And so we're what we're trying to do in those situations is see a pattern of decisions that suggest a normal for that person. So over time, this is why what we're trying to do is see what is this person's values as demonstrated in the way they've chosen to live their life up to this point. Is there a pattern in how they make decisions? Are they generally risk averse? Are they generally thrill seeking? Are they generally somebody who's very content with small joys, like, you know, seeing the flowers bloom in their garden. Do they make decisions alone? Do they make decisions by leaning on their spouse? Are they deeply religious? Do they usually bring their clergy member in to help them make decisions about tough life choices? And so we try and piece together all those different factors to try and understand what is the authentic version of this person. And is there a thread through their life that suggests their value system, their decision making strategies that we can lean on when we don't have a clear idea of what that person would do in this moment.

Dan: 28:32

All of what you just said makes perfect sense to me, and it clearly seems like the enlightened way to look at these situations. And I keep thinking about what it's like to be in that situation where you find yourself basically making the case to a patient that what you're saying you want doesn't reflect the real you. Like, what what a

Esther: 28:54

Yes.

Dan: 28:54

What a horrible position to be put in.

Esther: 28:57

Yes. And that is not always on us. I'll say that's usually on the bedside providers to try and have those kind of conversations with patients because, you know, we may be acting remotely, but also they know them better than we do.

Dan: 29:10

Mhmm.

Esther: 29:11

But those are extremely difficult conversations and they do raise the question of what is the authentic self? And I think many of us would struggle to identify our own versions of our authentic selves, let alone in a diseased state.

Dan: 29:25

Right. Right. Right. How has this work changed you as a person, would you say?

Esther: 29:32

I think it's made me a lot more not only able, but willing and wanting to live in the gray areas of life. Before this work, I think I found it easier to see things in more binary black and white terms. And when you come to this work, you realize that very, very little is binary. Everything exists on a spectrum. Everything exists in shades of gray. I think I've got a lot more comfortable tolerating uncertainty, lack of clarity, non ideal outcomes, it really forces you to live in the uncertainties. And that's not a place I would say I was especially comfortable in. And now I realize the value of living in that space.

Dan: 30:21

That's so interesting. It's made you more, like, tolerant of the gray. What what's an example outside of clinical ethics where you've experienced that?

Esther: 30:30

I'm less likely to jump to a conclusion about something

Dan: 30:34

Mhmm.

Esther: 30:35

Without the full picture. I'm more likely to try and bring a lot of different perspectives to understand something than sort of have a knee jerk reaction to it, whatever it is. So if somebody has a viewpoint that I don't necessarily agree with, I think I'm much more able now to say, oh, I wonder how they arrived at that. I wonder what influences shaped them to get them to have that viewpoint.

Dan: 31:01

Mhmm.

Esther: 31:01

I think I bring it into everyday life, and I think my kids would say, she's the mother who forced us to have advanced directives before we went off to college. So it's an occupational hazard, being aware of what happens if you don't have your wishes written down.

Dan: 31:22

I feel like what motivates a lot of these discussions is usually some experience in your family somewhere, you know. Maybe it was a a grandparent or another relative who just went through kind of the worst ordeal that health care has to offer, and you think to yourself, like, I don't wanna die like that. Do you find that that people kind of react against something that's happened?

Esther: 31:49

Yes. Absolutely. And that's so understandable because those traumatic events. Watching somebody you love go through an extremely difficult illness or death is something that really stays with people. And I'm very aware in this job of what I think of as a a generational trauma that can develop around difficult deaths. And I do see I see part of my role as being to help people have as good a death as possible as a family when somebody's dying. That people in the family who are left are not traumatized by it and don't pass that down to generations after them. To be able to help people die well and peacefully surrounded by people who love them and having made decisions that align with the values that they've held their whole life is an incredibly powerful thing. And I think that when children are brought into the mix, it's obviously a whole another level of concern that parents have around what will my children take away from this. And if we can help generations to have a positive experience of end of life in their relatives, I think we've done them an enormous service.

Dan: 33:09

So, Esther, we always end our episodes with a quick lightning round of questions. Here we go. What is the most insulting thing you could say about a clinical ethicist's work?

Esther: 33:22

There's no point in calling ethics that don't do anything. That's... when people say that, it makes my heart sink.

Dan: 33:33

Do people actually say that?

Esther: 33:35

Yes. And sometimes, it's because there have been difficult interactions with a specific individual. Sometimes it's because they don't understand how ethics works, and so they believe that we have to execute the recommendations that we make, but we can't because we're not the ones who actually write the medical orders. So they might think the ethicist recommended x, and then nothing happened. And the reason nothing happened was because the doctor had to do it, but the doctor didn't realize. So there's some sort of communication breakdown there.

Dan: 34:06

Mhmm.

Esther: 34:07

The other thing people sometimes say is, oh, ethics, the morality police.

Dan: 34:11

The morality police.

Esther: 34:12

That's also something we don't like to hear because that's not at all how we see ourselves.

Dan: 34:18

Is there ever, like, an economic layer that intrudes on what you do? Like, I mean, you work for a health system which has, you know, responsibility to its shareholders, blah blah blah, and I'm sure some of these decisions really do have a a significant economic consequence of how you treat something. Do you ever feel a a conflict of interest between what ethics prescribes and and what the business would need?

Esther: 34:44

I think the the financial conflict that I would describe is less around that. Although, you know, it is an ethical principle that we should steward our resources wisely.

Dan: 34:54

Mhmm.

Esther: 34:55

So that does come into play. It's not how decisions are made, but it is a factor in how we think about things. But the way that finance is butt up against what we do in a more distressing way, I think, is when people are uninsured and that limits the care that they can get. And that is just morally abhorrent to most of us in the profession and actually to most people.

Dan: 35:21

Yeah.

Esther: 35:21

So when you live in a a country that relies on either private health insurance or limited government funded health insurance, you find that there are many, many people who fall through the cracks. And that's where the finances and the ethics, you know, there's a jarring disconnect sometimes between what's right for the patient and what can be achieved given the financial limitations.

Dan: 35:42

What phrase or sentence strikes fear in the heart of a clinical ethicist?

Esther: 35:48

This one for me is not difficult. This is when people say, "Oh, I didn't know they had an advanced directive.""It's not scanned into the chart." And they say that after something has been done, that is very invasive. Like, the patient has been put on a ventilator, and then somebody unearths the advance directive, and it indicates they never ever wanted to be on a ventilator.

Dan: 36:10

Yeah.

Esther: 36:12

So when people say, "Oh, I didn't know there was a POLST form.""I didn't know there was a power of attorney document." That just makes my heart sink.

Dan: 36:20

What is an aspect of your work that you consistently savor?

Esther: 36:25

I think the feeling that I get when I helped somebody who was in distress to think more clearly about a choice or a treatment decision so that they can make peace with it or at least that they feel that they perceived the most appropriate way forward. I think you can feel a sense of calm descend in a room when something has landed. Like when a discussion's been had and all these different aspects of it have been teased out and there's some sort of resolution or agreement and you can feel a sense of peace and calm descend on the space. And that is when you know that you got to the right place.

Dan: 37:18

Esther Berkowitz is a clinical ethicist at a large hospital system in the US. Esther said, sometimes our best option is not a good option, it's the least bad option. Which reminded me of the turnaround consultant. Remember him? He's the guy who comes in to fix companies who are on the brink of failing And he said his job was often to pick the LCO, the least crappy option. Meanwhile, other careers might have the opposite orientation. Not the least bad option, but the best possible option. Think of the baker and the floral decorator and the professional Santa Claus. They're dealing with fundamentally good things and trying to make them as good as they can be. Probably many careers feature some of both. Like a software engineer is mostly concerned with the best possible option in terms of features and whatnot, but I suspect they're also frequently having to make the least crappy trade off available in a certain situation. What do you think of your own career? Are you in more of a best possible option career or a least bad option career? You might think least bad option type careers might be depressing, but that's not how the practitioners seem to experience them. The divorce lawyer, who you'd think would have every reason to be a cynic, said getting divorced is an act of hope. And Esther said that when she did her job well, she could prevent the generational trauma that comes from watching your loved ones die in a protracted and grueling way. And that's where the categories start to break down. The least bad option done well could have a profoundly positive effect on the future. And that hope is what keeps Esther committed to the role. Weighing burdens against benefits, searching records for advance directives, tracing a patient's values through a lifetime of choices, and making peace possible in a room where no miracle is coming. Folks, that's what it's like to be a clinical ethicist. A shout out to recent Apple podcast reviewers, Btown Mike, KayElCerrito, nonickname1966, Piper Ski, and Jack, an 11 year old. Thanks for listening, Jack. This episode was produced by Matt Purdy. I'm Dan Heath. See you next time for the start of the air travel series.