Pain Medication in Maternity Care with Dr. Becket Gremmels

In this episode, Dr. Becket Gremmels discusses a success story involving a pregnant teenager and her parents.

To learn more about Dr. Gremmels, check out his podcast Ethics Lab here: https://www.missiononline.net/ethics/ethics-lab/

Transcript

0:00 

Before we begin, Please note that the names and specific details of the clinical cases we discuss in this episode and in all of our episodes have been altered to protect patient confidentiality.Now on with the episode.Welcome to this episode of Bioethics for the People, the most popular podcast on the planet according to Grandma Nancy. 

0:22 

I'm joined by my Co host Doctor Tyler Gibb, who if he weren't here recording right now, would probably be golfing.And I'm joined by my Co host Doctor Devin Stahl, who dutifully completes the same 5 New York Times puzzles every day.So Tyler, we have a very special guest today, somebody who I probably text at least every other week because I have a question about clinical ethics. 

0:52 

This is my absolute go to person and the first person who trained me in clinical ethics.Did you know that?No, it actually like taught little baby Devin how to do clinical ethics.That's right, I was in the final year of my PhD program.I moved back to be with my husband in Tennessee and this person was working already as a clinical ethicist at the hospital and I begged him to let me shadow him. 

1:19 

Really.I had no idea.All right, so who is it?It's our good friend Beckett.Welcome, Beckett.Beckett, thank you.Glad to be here.Yeah, introduce yourself with all of your positions because you're a very important person.Oh.I don't know about that, but so I'm the assistant vice president for theology and ethics at Common Spirit Health, which is a large Catholic health system. 

1:42 

And I've also been at CHRISTUS Health.I was the system director of ethics there and then also at Saint Thomas in Nashville, which is where I met Devin all those years ago.I think you actually first met me when I was a chaplain, right?Yeah.You were in the CP program. 

1:58 

Yep.And then you came back.Yep.I would definitely remember.That so Common Spirit is a large healthcare system.What makes it unique?Tell us more about Common Spirit.The size I think is part of it.I mean we've got I think 143 hospitals in 24 States and 180,000 employees. 

2:14 

If you include contractors and stuff like it's, it's it.It boggles my mind still.I've been here 4 plus years and it still shocks me how large the organization is.So that that in of itself makes it unique.We're the largest nonprofit health system excluding the VA. 

2:31 

Wow.And I think the third largest even when you include for profit.So it's it's huge.I think another unique factor is, I mean, we are a Catholic health system.So that certainly has its own unique elements to it.Definitely.But even within that we have non Catholic hospitals within our Catholic health system. 

2:48 

So that that's a unique feature too that that follow most of of Catholic teaching, but there's going to be some pieces that they don't follow so.Which could be, I imagine, a whole episode on its own.That that could be as well.It's very different.Yeah.So even within Catholic healthcare, we're pretty unique. 

3:04 

Yeah, but we asked you here today because I imagine you, in all the years of practice, have many, many success stories.I've heard great stories from you, but we asked you today to just pick one.And actually, Tyler and I have no idea what you're going to talk about as is our, you know, way. 

3:23 

So you have a case that you feel particularly like shows a success that you had in your work.So this was a case I had quite a while ago.So not not anytime recently.And it's one of those things where somebody says something and you're like, really like that's happening. 

3:41 

I didn't ever think that could happen sort of a thing.So this was a young woman who came in to deliver a, a baby, I think I believe she was 15 years old and didn't have any clinical complications with the pregnancy itself. 

3:58 

The she had prenatal care, everything went went fine as far as that's concerned.And she had a whole birth plan written up, which is many people do nowadays.It's rather common to have this is kind of what I'd like to have.I definitely want this.I definitely don't want that.And I mean, you can Google and get a whole checklist about that kind of stuff right now. 

4:17 

Part of her birth plan was that she wanted a natural birth, and that means something very different to everybody who says that they want that.And for this particular patient, what she wanted was no pain medication as part of her natural birth.That's what Tylers wife said too, right Tyler? 

4:34 

She never took any pain medication.Yeah, my I, I'll brag about my wife for a second.Three kids, all natural births and like she walked herself from the delivery room to the recovery room, usually with like a nurse standing behind her, but and they were like nurses like slow clapping like as she was walking down the hallway. 

4:54 

She's awesome.I want to brag on myself that I had, I asked for the most unnatural birth plan possible.I was like, give me all the drugs.Give me.I don't want to experience any of this.That's impossible.You experienced quite a lot of it, but I have a very low pain tolerance and took all the drugs I could. 

5:15 

That that's my wife give me the drugs she's we have 4 kids and and for one of them it didn't take so she ended up doing it naturally.Unbeknownst to her, at least one side didn't take so.All right, so 15 year old wants all wants to experience the the pain. 

5:32 

No pain medication whatsoever and comes in kind of spontaneous delivery, no induction, right.And around term, I want to say it was like 30 and a half, 39 weeks and uncomplicated pregnancy.Everything's going fine and labor's going fine. 

5:48 

She's progressing just as you would normally expect.Baby's doing great, everything's going well.And then she stalls and she gets to 9 centimeters and she just kind of stuck.The contractions are still there.They kind of are not as frequent as they would be that increasing in frequency and intensity that you would typically expect. 

6:06 

She stops dilating at she's kind of stuck at 9.And I mean, that happens.That's not that unusual.It occurs.Not what you want to happen necessarily, but it certainly can happen.And content labor continues.And the doctor just kind of says, let's assess it, let's talk about it. 

6:22 

Let's just kind of see where we are.Let's give you some more time.Well, more time turns into more time turns into more time.And now she's been there for almost 24 hours, stuck at 9 centimeters.Oh my gosh.And, and just so we're, we're all on the same page, 9 centimeters is 90% there, right, 10 centimeters, yeah, 10 centimeters is considered fully dilated and. 

6:45 

The baby's not in transition yet.Partially not, not completely, not enough to really obviously push through.Because usually what happens is my non physician understanding is the head pushes on the cervix, which is really what kind of forces the dilation in effacement to really go all the way complete to where she can actually start pushing and and deliver. 

7:06 

Poor thing, this is a lot of pain for a long time.Yeah, well, and I I mean, I don't mean just not an epidural.She didn't have Tylenol, she didn't have non opioid pain meds, no opioid, nothing.Wow, just and 15 years old, mind you.Right.So but what I would do, but more power to you. 

7:23 

Like great, go for it.That's what you want all the way.Let's do it.Do you have any any insight into why she was doing that?Was it like a natural?Was it religious?Was it any idea like what her motivation was for?Not taking the drugs, no, I I think it was just personal. 

7:38 

I I don't know what her exact reasoning is.That's a good question.I would imagine it's not religious to simply based on how the rest of the story unfolds.OK, but that's what I would imagine.And the physician gets to the point to where they say that, look, if, if you don't deliver soon, we're going to have to do AC section because you're, you're not, you're not progressing or it it and, and the baby's kind of getting stuck. 

8:09 

It's not really coming through and you're going to get an infection.If we don't, 24 hours is about the time where they start saying, OK, we need to start having a conversation about how do we precipitate delivery?How do we make delivery happen one way or another?Because you're going to start getting infected. 

8:24 

And that historically is one of the most common causes of maternal and infant mortality around delivery.Is that child bed fever, purple fever, right?Because you labor stalls, they can't make it go faster.And bacteria does what bacteria does right? 

8:41 

And the patient?Sorry, go ahead.No, just so we're at a crucial point right now and you'll probably say this, but at some point they call you because I don't know why they would call you, but I'm eager to find out.Right now there's no reason to, right?Just normal clinical care, everything sounds good. 

8:57 

Well, the patient says so the physician says, I have one idea before C-section, right?Because the C-section, I know you didn't want that.That's definitely not natural, right?That's not the natural birth and and the my idea is an epidural and the physician's idea, reasoning behind that is look, pain causes you to your muscles to contract. 

9:14 

That's just what pain does, no matter where it is.One, sometimes A cause of being unable to dilate is your pain.It's hurts so much that your body just tenses up and your muscles can't relax fully to allow that dilation to occur.That was his his reasoning.So my recommendation he said as a physician is epidural. 

9:32 

That's what I recommend for you to have because that can relieve your pain, which could allow you to fully dilate and deliver the baby.The patient says, well, you know, I really didn't want an epidural, but you know, an epidural is less intervention than C-section.So yeah, cool, let's go for it.How she could form any coherent sentence at that point in her labor is beyond me. 

9:51 

But the patient's parents say no.We refuse to consent to the epidural.Oh, and interesting.Oh oh.Uh oh.Because it depends on where, what state you live in whether they have the authority over their child in that way or not. 

10:07 

Yeah.Exactly.Oh, goodness.OK, so she has kind of changed her mind after experiencing the the labor and her parents, who was, are they at the bedside?Are they calling in like at the bedside, at the bedside? 

10:23 

And are they like cheering her on and saying no no, no you, you can do this with no pain medication.Kind of in a certain sense, but I mean, just to be clear, to your point, Devin, that state laws vary drastically on this.You have some states which have no limitation on minors making decisions. 

10:41 

Like in Louisiana, the statute says a minor can make a decision just as if they were adult and there's no age limitation.Now, in practice, obviously that unhappy you don't have your 3 year old consenting to stuff, but that's what the statute says, right?And then you have places like minor standing in Connecticut.There's no ability for somebody who's 17 years and 352 days to make a decision and then there's everything in between, right? 

11:02 

So the state really makes a difference there.But I think that up until this point, the parents have been completely fine and supporting the patient and, and being very appropriate and caring and compassionate as you would expect parents to do when their 15 year old daughter is delivering a baby. 

11:22 

It was their reasoning for refusing.I think this is what prompted the Ethics Council.And the reasoning for refusing was not to your point.I wasn't religious, right?It wasn't like we have a philosophical, religious, moral objection to this.It wasn't no, you can do it. 

11:37 

You just need a little bit more, you know, backbone and you can push through and you could do it.It was she needs to feel the pain so she doesn't get pregnant again.No, she has felt the pain also.That not a verifiable way to ensure that. 

11:57 

Wow, that is like gut wrenching reason.Interesting, that's A twist I was not expecting.So they want her to feel all of the pain in order for her not to get pregnant?Don't love that, I'm going to be honest.Don't love and it's putting her life in danger.Like I guess if she dies she won't get pregnant again but well. 

12:16 

I mean, it kind of is putting her life in danger if the only option is non intervention.But if the other option is C-section, right, that's that's enough.That's not going to necessarily put your life in danger, right?So there is another option besides an epidural.But are they OK with C-section? 

12:32 

Unclear.OK, never quite got to that point, so.Yeah.And so you and so you get this call at what point during this process?Right about that time when the reasoning was there.So, well, what what happened?If the so the physician says, I'm going to order it anyway, I don't care, we're going to do it. 

12:51 

Patient says go, I'm go.Good, Good for that physician.And the anesthesiologist walks into the room for a consent conversation and discussion, and the parents chase him out and you can hear them screaming up and down the hallway.We're going to sue you.If you come anywhere near her and touch her at all, you're going to be sued. 

13:08 

So anesthesiology to understand Lisa's, I'm not going in there again.Yeah.And that's the point where the ethics consult occurred.OK.So was it by the anesthesiologist or by the physician?I I think it was collective.OK.It was a collective call for help. 

13:25 

Basically.Well, and are you like an emergency?So typically most clinical ethics consultants don't work fast enough to like.Like unless you're a full time clinical ethicist who has a pager 24/7, you're not expected to answer consults like immediately. 

13:42 

But this one has to be answered immediately.Yeah.And that structure at that time, it was 24/7.Wow.So.I think it's really unusual to get truly emergent ethical issues.I've had a handful in my career, but this sounds like sounds like one of them. 

14:03 

Yeah, I've had some too, but they're they're pretty rare.But yeah, this was one where a quick answer is is probably needed.How do you approach this so before you we get to like your answers and your analysis, like what are you thinking as an ethicist going into being called into this case? 

14:20 

Yeah.I think there's lots of literature about the discrepancy I think between how we think about decision capacity and minors ability to make decisions and statutes.And obviously there's no perfect answer for this, right?And it varies so widely. 

14:35 

I mean, Nebraska and Alabama are 19 years old, not 18 years old.What because why?I don't know, because Puerto Rico also, but most states it's 18 is the age of majority.But those three, it's 19.I don't know why, it's just this.I'm sure there's some historical reason that somebody can tell us, but I don't know. 

14:53 

I thought looked it up.That just shows you, I think, how arbitrary it is to say that I think we can all agree a 2 year old shouldn't be making decisions and somebody who's, you know, 1817 years and 350 days, what does 6 days matter, right?At that point?It's always going to be arbitrary to some extent, but we got to pick some time. 

15:11 

But but that that was going through my head is does this person really have the ability to make the understanding that does she understand what she's consenting to and agreeing to?Can she make that decision?And you know, when you get to 1415 or so, you start asking those questions to where sometimes they, they probably could understand, right? 

15:27 

I've seen some 14 year olds who are way more mature and able to understand than some 25 year olds and and vice versa.And there's a whole bunch of different factors that go into that.But that that was kind of what's going through my head is, is that typical?Does this patient have capacity? 

15:43 

Have they been given appropriate information?Can they actually give informed consent or not?And then other questions about what, what is policy say, what does state law say, all that kind of stuff?And how does how does that conflux work in this particular case?I I think what an interesting wrinkle to this case is not just the consent or refusal of treatment, it's specifically pain medication. 

16:08 

And I think pain medication often is in a category by itself for different, you know, for for reasons that surrogates.I don't know, I'm really uncomfortable when people start saying that person should feel more pain, right? 

16:23 

Avoidable pain, particularly in a situation like this.So tell us more.Yeah.So my initial response was because I was somewhat familiar with the state, I was relatively new to working in that state or with that state. 

16:39 

And because I work with states that I very often don't live in, I've actually worked with states that I've never visited.So that's an interesting factor of being at a system level of a role, but I didn't know the local policy because I was new to working with this, with this place. 

16:56 

So I knew state law had a number of different exceptions, as many states do to when minors can make decisions without or against their parents consent her wishes.And they're very often emergency situations and and often many states make exceptions for pregnancy related treatment. 

17:15 

And this particular state had that exception.Any treatment related to pregnancy the minor can consent to on her own.I mentioned that had a conversation with the physician and the physician says, well, that's not what policy says.Policy says minors never make decisions in any circumstances whatsoever. 

17:32 

So we have a kind of a conflict between what potentially you you think could be the general approach of this patient seems to have capacity seems to be getting consent and has has agreed to and hospital policy and state law.There's the all three of them don't really necessarily with each other, which is always an interesting position to be in as an ethicist, especially when and when you're recommending something or when the right thing to do seems to be not permitted by the law, that that's one dilemma. 

18:00 

And another one is when the policy says something different than the law says, which is also different from what you're recommending.So you kind of have kind of a trifecta almost of a conflict between what seems to be appropriate and what what constraints there are on behavior. 

18:17 

I feel like if, if between the two, like if I would feel more comfortable saying the state law says this, but our hospital policy says this, overriding the hospital policy in favor of the law.Because clearly somebody wrote a bad policy and we've all helped to craft policy and we could do so after the fact identifying that the policy didn't seem to match the law. 

18:38 

The policy needs to change probably because as, as especially Beckett knows who goes before the legislature all the time to advocate for stuff.It's really hard to change laws, but it's pretty easy to change hospital policy.Yeah, well, sometimes it depends on the hospital.Fair enough.But yes, it does. 

18:54 

And I think we can all say, I think everybody could probably point to at least one law.We think that that was a badly written law.Sure, especially the more you start to read them.I think that I would agree that it's a lot easier to kind of change hospital policy and override that that that is the opposite.So yeah, but that's what this case led to. 

19:11 

We had conversations brought in risk and legal and and looked at the policy, looked at this that the law and said clearly this doesn't line up.Here's good reasons to permit what the law permits, especially in a case like this.And so we ended up changing the policy based on that one case, conform more to the exceptions and stay law. 

19:34 

But how fast did you?I mean, you didn't do all, you didn't have to rewrite hospital policy before you let this poor girl get her epidural, right?No, the, the wheels of hospital administration don't usually turn that quickly.So no, they, they don't.But we with, with risk and legal, we did allow this particular case to go through knowing that we were going to then change policy as soon as possible. 

19:55 

It it did only take I think about four or five weeks.So it was relatively quick as far as a policy changes.I'm currently involved in a policy.That's been going on for like November will be two years.So just to give you some perspective.Yeah.And yeah. 

20:10 

So in this particular case, once that was made clear to the end, I mean, I when I went to the unit, when I heard this and I printed out the statute and I printed out the policy and had conversations with anesthesia and the physicians and the nurses and everyone.I mean, I don't think anybody felt that they shouldn't place the epidural once the patient agreed to it. 

20:30 

I think there were just kind of concerns about the implications of it.But once those conversations occurred and we had the blessing of legal and risk, then then the clinical care for that patient was able to proceed and she received an epidural and was able to avoid AC section.So how did the the parents react to being informed about did? 

20:48 

Did you?Were you the one that informed them that?I think that's an interesting question about how much an ethicist gets involved in face to face conversations with patients and family members.And normally I err on the side of getting involved.I, I'm meeting them, I, that's usually my default position. 

21:03 

I always though ask the care team, is that a good idea or is given the dynamics, is that going to make it more difficult?And in this particular case to a person, they said it'd make it more difficult.And so I did not actually meet the patient and, and the family in this particular case. 

21:23 

But if they had had a very negative reaction to the news, then I, I may have very well done that.But when they heard the news, they weren't exactly happy about it, I would say, because they had their vision of what should happen and that was not it.And but that they kind of continued on and didn't really object that much and she received the epidural. 

21:45 

And did they sue?You they did not sue as far as.They, I think people shout that in the heat of the moment and it's not actually all that common to follow through.Well, especially a case like that and I've had a number of conversations with plaintiffs attorneys and that's not the kind of case that they want to take, right. 

22:03 

I mean, on the on the cynical side of things, you could say they only get paid if they win and they know they're not going to win a case like that really, because what jury is probably going to side with the parents in that case?They're going to be hard pressed to find a duty to death.But on the other side of things, what I've heard them say, the non cynical side.And, and I, I mean, I know many plaintiffs attorneys. 

22:20 

So I, I have a soft spot in my heart for those individuals and my family who are, but they, they say, look, that I got into, into medical plaintiffs law, medical law to find the bad actors and hold them accountable.I'm not going to take a case where I think this is a bad actor, but I've had a few of them even say I spend more time talking patients and family members out of suing when I felt the physician acted appropriately in the hospital, elected properly. 

22:43 

Then I do actually those the, the big names that people are worried that that's kind of what they that's what they've said.And most importantly, they were wrong.Like they were ethically wrong to want their daughter to suffer in this way for those reasons, right? 

23:00 

At least, you know, my ethical judgement would be like, this was a bad thing for them to do.They might have had reasons for that that they thought were justified.But I don't want to make patients suffer for to like a swage this kind of perception by surrogates that this might teach her some sort of a lesson. 

23:18 

I think that the reasoning had been different.It, it, it may have resulted in the same outcome, but a different conversation that they had said, look, as as part of our, to your point earlier, to religious tradition or our values, our beliefs is that this is that we're, we're a naturopathic approach, that kind of thing, which is definitely out there that a lot of, a lot of I've even had delivery cases where that's a, that's an element of it that, that would have been maybe a disagreement about values, perhaps that, you know, we might, I might disagree, but that's a reasonable cogent approach to take. 

23:45 

There's some logic there behind it.This was quite different in the reasoning I think, and that made a big difference in the recommendation in the process to to help resolve it.Do you think, Beckett, if you had been in a state in which minors have no say over care, even in pregnancy, that you would have advised something different? 

24:06 

I don't know about advise different.I think it would have the conversation would have been different about just so you know, doctor, this is a potential risk that you're taking if that's the route you want to go as a.So that may be more of a here's the options.Here's the pros and cons of each options sort of an advice as opposed to here are the options and here's the one that I think is best and and recommend. 

24:27 

I mean, I would certainly say as a Catholic health system, one of the benefits is having our mission and our values to be able to come into the conversation when it's appropriate.And certainly getting patients pain treatment.It's a part of our our commitment to respecting the dignity of the human person. 

24:43 

And so even in a case where perhaps that was, it was not the statute did not permit for minors to make decisions, that would have certainly been the position I would have advocated for.To an extent, yes.It may change how I approach it, but maybe probably not the ultimate recommendation I would say. 

25:01 

Yeah, I think a really good clinical ethicist has to be very aware of the laws relative to what they're doing.And if there is ethical advice that conflicts or at least isn't exactly in line with state statute or even federal law, they have to be able to articulate that and and be able to give good advice that this is what the law says and this is a reasonable interpretation of the law. 

25:23 

However, ethically, this is a different approach.And then leave it up to the physician to to actually make the decision about what they want to do.Yeah.And you always catch that with talk to legal, talk to risk.You got to have those because they're the ones who are going to help you actually interpret that.But in this particular case, I'd talked to those folks enough about this situation about minors that that I knew what they were going to say, which is exactly what I was going to say. 

25:49 

It's nice when that it's a little bit easier when the law agrees with you.But I mean, I don't think even if the law hadn't been quite so clear, it seems to me you don't.The law doesn't say you have to do whatever parents say in terms of medical care for their children, right?There's all sorts of other ways you might talk about the restrictions on parents. 

26:08 

We're not forced to do what they say.And if they make a really bad judgement that endangers the life of their child for no good reason, then we can override them.So there might have been other ways to argue about this had the law not been so clear.Yeah, usually you would look at something and even those those states where you don't, minors don't have the ability to make decisions. 

26:29 

There's court cases where doctors or hospitals have, have supported the minor against parents when they're making decision like that.I mean, the classic case is obviously Jehovah's Witnesses and and blood transfusions.Like there's strong court precedent for that.But that takes time, right?Usually in that situation, you've got 48 hours or so to get a court order in in in court hospital time is very different from judicial system time, right? 

26:53 

And judicial system is like what, a month, six weeks, That's quick.Hospitals you, you know, six hours and your decision type window is gone.Blood transfusions usually got more ability to play with that.And this one, we didn't even have six hours to get a court order really, right.Yeah, We had a case recently where it was a woman who had a mental health issue, but she had articulated that she only wanted natural birth, but it was very heavily influenced by her mental illness. 

27:20 

And the ethicist and the the legal team actually proactively went to court and got permission to do AC section of over her objection because of her mental illness.This is the first time I've ever seen that.Wow.Do you think that there's anything the parents could have said that would have persuaded you? 

27:36 

Like is there any rash reasonable justification for the intentional infliction of avoidable pain on a minor?There's so many values wrapped up even in the way you just framed that, that it's intentional infliction of avoidable pain, right.I mean, to me, I, I think, I think that reasoning about, look, we're part of a community that that values natural healing processes and we, we frown upon technical medical intervention, right? 

28:05 

Which again, there's many people out there who espouse those values.And if the patient says, yes, I'm a part of that community, yes, I espouse those values.To me that would prompt a conversation if OK, patient, give me a reasoning.What is it?Is it that you're just having a a moment of weakness and and yeah, you really do believe in those values that really, really is what you want. 

28:24 

Or is it that you've change those values are found an exception based on this particular circumstance or what is it?But I think that would prompt a conversation with the patient more so than just flat out overriding with the patient says to me, it's hard to find if the patient clearly didn't have capacity to make decisions, right. 

28:42 

I've had many women who've given birth say, boy, when you're at 910 centimeters, it's hard to find any capacity to make rational decisions at that point.Never having been in that position myself, I can't say one or the other, but this seemed to be a cogent person who was talking and and making sense.So the reasoning made sense and it was in line with the clinical recommendation. 

29:01 

So that that's whether you're a minor or not.That's a hard 1 to override I feel like in any situation.Yeah, I think I agree.Refusal of pain medication is something that is particularly maybe not troublesome, but it's interesting in in different ways than other types of treatment refusals I think. 

29:20 

Yeah, I I think about other scenarios where you're talking about someone else refusing pain meds for the patient and that's usually end of life.The patient can't make their own decisions and the family refuses.And there's a whole bunch of reasons to go into that from I don't want them to get addicted to, you know, some sort of redemptive suffering understanding. 

29:37 

And, and those situations, I've seen a handful of cases where the patient made it very clear maybe that they didn't want pain medicine or that they do value redemptive suffering, especially at the end of life.And that was a big importance to the patient.And those are situations where we've thought through and said, OK, maybe that would be appropriate, maybe that would be what, but that's because it's what the patient wants. 

29:58 

The patients clearly stated before they lost capacity that was in line with their values, not something that the surrogate that the surrogates values that they're making using to make decisions with.So, but the most cases that were of pain medicine refusal, I, I, my recommendation has usually been no, because you can't show me that's what the patient would want. 

30:20 

Yeah, these seem like the exceptions to the rule that the rule is you, you provide pain medication when necessary and there might be some instances in which you wouldn't, but those, those require quite a bit of rationale.Yeah, it's definitely a premier fasciet rule, but it's a it's a hard, hard face to overturn there. 

30:38 

Well, Beckett, what I really like about this story is that in the face of parents screaming I'm going to sue you if you do this, it's hard to know exactly what that physician and anesthesiologist would have done, right?So because you were there, it made a positive difference for that patient. 

30:56 

And because you were there, you got to recognize that the hospital policy on this said something that contradicted the law and needed to be changed.Who knows what would have happened had you not been there?I don't know, you know, it's one of the the rare instances where I do feel like I can say I, I did clearly make a difference in that my presence was beneficial not just to the patient, but then future patients as well. 

31:19 

Can't always say that, especially in hospitals, because many hospitals don't have an ethicist for that kind of on the ground support.And I mean, they don't burn down, right?There's still functioning.So it's hard to point out that that clear benefit, but I think in this case you can, you can really look to it and say I made a difference hopefully. 

31:38 

Yeah, you're a hero.Yeah.Do what I can.This is a yeah, this is a great case.Thanks for sharing, Sharing it, Beckett.And I agree.I think that one of the unique things that we get to do in our job as a clinical ethicist is to be at the bedside and see where policy and state law are actually impacting people's lives in a real way. 

32:03 

And gives us an insider, gives us an opportunity to change that either policy or work on state level legislative changes.But that that's an aspect of being a clinical ethicist that I didn't anticipate even when I was going through my training until I actually got on the ground and was doing clinical ethics as professionally. 

32:23 

So yeah, it's super interesting.Yeah, there's a an odd dovetail I think between those those pieces of state law and and even federal law to some extent and policy that it's an odd conflict that I certainly never expected for sure. 

32:39 

Well, thanks, Becca.We really appreciate you sharing this story.I'm sure we'll get you to share more stories in the future.All right.Thank you.Have a good one.Thanks for tuning into this episode of Bioethics for the People.We can't do it alone, so a huge shout out to Christopher Wright for creating our theme music and to Darian Golden Stall for designing our logo and all of the artwork. 

33:01 

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