Ethical Conversations: Robert Swidler on Health and Law Intersection

In this episode of Taking Healthcare by Storm, Quality Insights Medical Director Dr. Jean Storm speaks with Robert Swidler, M.A., J.D., a veteran health law attorney and bioethicist who served as General Counsel to St. Peter's Health Partners for over a decade, co-teaches Law & Bioethics at Columbia University, and helped shape many of New York's foundational health care laws, including its Health Care Proxy Law and Family Health Care Decisions Act. 

Robert discusses how informed consent and medical decision-making capacity guide treatment decisions, and explains the purpose of healthcare proxies and New York’s Family Health Care Decisions Act when patients can’t decide for themselves. He also describes forming the Empire State Bioethics Consortium during COVID-19, reflects on why end-of-life choices can become contentious, and argues for moving toward universal single-payer health coverage.

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website.

The views and opinions expressed by the host and guests are their own and do not necessarily reflect the views, positions, or policies of Quality Insights. Publication number QI-072426-GK

Transcript

Welcome to "Taking Healthcare by Storm: Industry Insights," the podcast that delves into the captivating intersection of innovation, science, compassion, and care. 

In each episode, Quality Insights’ Medical Director Dr. Jean Storm will have the privilege of engaging with leading experts across diverse fields, including dieticians, pharmacists, and brave patients navigating their own healthcare journeys. 

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Hi, everyone. Welcome to another episode of Taking Healthcare by Storm. I am Dr. Jean Storm, the medical director here at Quality Insights. Today's guest is someone who has spent more than four decades at the intersection of healthcare, law, ethics, and public policy. Robert Swidler is a nationally respected health law attorney, bioethics leader, educator, and former general counsel for St. Peter's Health Partners in New York. Throughout his career, he has helped shape some of the most important healthcare laws and ethical frameworks in New York State, including work involving healthcare proxies, do not resuscitate orders, brain death, organ transplantation, and family healthcare decision-making. He has served in the Governor's Council's office under Mario Cuomo, on the New York State Task Force on Law- Life and the Law, and as an educator in Columbia University's bioethics program. During the COVID-19 pandemic, he also helped found the Empire State Bioethics Consortium to address some of the most complex ethical questions facing healthcare providers and families, and those questions are still facing us today. Today, we're talking about informed consent, medical decision-making capacity, end of life choices, healthcare proxies, and why these deeply human conversations can become so emotionally and, unfortunately, politically charged. Robert brings not only legal expertise, but decades of real-world experience helping patients, families, clinicians, and healthcare systems navigate some of life's hardest decisions. Robert, thank you so very much for joining me today. Oh, thanks for having me. It's nice to be here. As I mentioned in the introduction, you spent decades at the intersection of law, ethics, government, and health systems from the New York State Task Force on Life and the Law to St. Peter's Health Partners. What first drew you into bioethics and health law, and was there a defining moment when you realized that this challenging subject would become your life's work? Well, yes, there was a defining moment that made it my life's work, although I didn't realize it at the time. So after law school, I took a job at a big New York City law firm in Rockefeller Plaza and hated it. I mean, apart from getting to see the, um, Christmas tree lighting from my office window, which was pretty cool. But apart from that, I really disliked it. I didn't feel good about the clients I was working for, didn't feel good about the matters I was working on. And maybe about a year into it another associate came over to my office and told me about this task force that Governor Mario Cuomo was forming to look into medical ethics issues and help develop state policies on them. And said they were looking for a council, and I- did I know anybody who might be good for it. And I said, "Yeah, me," without knowing that much about the topic. I interviewed with the health commissioner, and to my surprise, I got the position. And once I started working there, very quickly I realized I love this stuff, and did feel very fulfilled and fascinated, and was working on these great issues about brain death, you mentioned a few, healthcare proxies, allocation of organs, surrogate parenting, was talking to the leading people in the field, was reading a lot. And felt good about my client, and felt good about the matters, and realized that this was a field that I wanted to be involved in. I mean, since then it's branched out to other areas of health law. but that's always been a key interest of mine in the bioethical issues, and a key area of my work. so yeah, there was that defining moment when I said, "Yeah, me, I'll apply for that job." I love those moments when you're like, "Yeah, that's mine," right? Right. And we hear a lot about informed consent, and I don't think people really understand what it means. How do you define informed consent, and why is it such a foundational ethical principle in medicine? Yeah, sure. So put simply, informed consent is just the permission that a patient gives to a physician, I mean, it could be more than a physician, but let's say a doctor, to provide treatment or to, a test on the patient given after the doctor explains the risks, benefits, and alternatives to the treatment. So I like to explain the concept of informed consent in its two separate components: informed and consent. I mean, I start with consent because that's the older and more fundamental principle here, which is that you can't treat somebody without their permission. You can't treat somebody without their consent. In law there's a landmark decision in 1914 that bioethics, people in bioethics are mostly familiar with this Schloendorff versus New York Hospital, that established this principle. You can't treat somebody without... You can't do surgery on somebody without their consent in that case. And the principle is intuitive and obvious. You can't touch me unless I allow you to. And in the Nuremberg trials after World War II, they made it very clear that doing medical research on somebody without their consent- Is not only unethical, but is a war crime. So that principle, consent, is really foundational. The informed part of it is more of a recent concept, and it developed out of case law in in the US in the 1950s that said it's not enough to just give consent. It has to be based on information about the risks, benefits, and alternatives to the treatment. The doctor knows those risks, benefits, and alternatives. The patient doesn't, and their consent is not meaningful unless that's explained to them. And case law has developed that concept, but it's also become accepted and part of professional ethics and part of just general bioethics, medical ethics. So it's a key concept in both law and ethics. A physician has an obligation to get informed consent and would have that obligation even if it wasn't required in law. One last point about it, like a lot of things in law and ethics, it has gray areas, and it has exceptions and exceptions to the exceptions. And so that's where it becomes complicated and where it becomes confusing to people. What treatments require informed consent? Is it just things like surgery, or do you need informed consent for an X-ray? And why didn't anybody give me informed consent for that X-ray? What has to be disclosed, and in what detail? What about emergencies? And an issue we're gonna talk about, what about patients who lack capacity and don't have the ability to give consent? So all those issues make it a very rich topic in both law and medicine and ethics. But the core principle is simply you need a patient's permission to treat them, and it's only valid it's, if it's given after an explanation of the risks, benefits, and alternatives. I think that's so interesting you brought up the X-ray. You know- Yeah ... people don't think of it as as really needing consent, but I- people oftentimes when I talk to... I work with a lot of nurse practitioners, and many may be listening right now, and they say, "Well, I'm just gonna order an X-ray." And I, y- I often have to remind them, you need to think about what you are gonna do with the results. And patients need to know that as well, right? Some patients may not want to know if they have a, a mass in their lung. And- Right ... you're forcing them to know by getting that X-ray. Well, that's another issue. Can I waive informed consent and say, "Don't tell me. I would-- I don't wanna know what the risks are. Just go ahead and do it"? And also, at least in New York law, there's an exception for risks that are too well-known or too minimal to have to disclose, and like a dental X-ray is probably one of them too well-known that cumulative X-rays can be dangerous. Yeah. So you mentioned medical decision-making capacity, and I just will say I, I work, do a lot of work, have done a lot of work in nursing homes. This is a constant challenge all the time. Yeah. Day to day. I mean, you might have it differently day to day depending on the patient. So what does medical decision-making capacity actually mean from a legal and ethical standpoint, and how should clinicians and families think about it when they have to make a difficult decision? Well, I look at capacity as linked very closely to the concept of informed consent. So informed consent says, as we've been talking about, that a doctor has to explain the risks, benefits, and alternatives to a proposed treatment and get the patient's permission for it. Otherwise, the permission isn't meaningful. Capacity means the patient has the ability to understand those risks, benefits, and alternatives, and to make a reasoned decision based on that explanation of the risk and understanding of the risks, benefits, and alternatives. Otherwise, the patient is incapable of giving a meaningful consent. So it's complicated though, like informed consent, and also a rich topic like informed consent, because there's a lot of elements to it. And capacity, or I should say lack of capacity, can be obvious the patient's unconscious, or not so obvious, like the patient has moderate dementia or moderate intellectual disability. It could be long-term like intellectual disability, or short-term intoxication, inebriation. It could be intermittent, like your nursing home colleagues deal with residents who may have capacity in the morning and not in the evening. And someone can lack capacity for some decisions, maybe more complex decisions, and not other simpler ones. So it is a complex concept. And I think there's also a really an important distinction often overlooked between the incapable patient who is just passive and not not playing a role in their decision-making, and the incapable patient who is kicking and screaming and either demanding something or refusing something, but doesn't understand the risk, benefits, and alternatives. And those are two very different scenarios, both in medicine and in, in law. That patient who's attempting to play a role in their decision-making is entitled to due process before we displace them. So that, that raises a whole different set of legal and ethical issues. Yeah. But we start with a presumption that adult patients have capacity, and you need some strong basis to overcome that, even for the passive patient because we respect patient autonomy. One other last point is that I'll tell you what what is not proof of incapacity is disagreeing with your doctor. I think a lot of doctors when they make a recommendation and the patient rejects that thinks, "Well, this patient doesn't have the ability to understand what's going on." And you need something more than just your disagreement with a doctor to establish a patient lacks capacity Yeah, and it's, it's so interesting. You, come at it from a standpoint of we assume that the patient has capacity, and then w- we're operating from that point. I think that it's the reverse oftentimes in medicine, especially with a patient who has cognitive impairment like dementia. Well, I think in nursing homes there may be that you start from that baseline that many of the residents don't have capacity. But I think in each individual case you've got to start with that presumption, and that's the le- that's a legal presumption as well as an ethical one. I think the law and ethics are aligned when it comes to how they look at capacity. Yeah. So let's talk something related to that about proxies. And since you shaped- Right ... New York's healthcare proxy law and you later participated in negotiations that led to the Family Health Care Decisions Act, for listeners who may not know, what is a healthcare proxy, and why do these conversations become so emotionally and ethically challenging for families? Well, healthcare proxy is a very simple document. It says, "I appoint my wife or my cousin or my close friend to make healthcare decisions for me if I lose the capacity to make them personally." That's all it is. Under New York law, that healthcare agent, we call them the agent I'll be trying to make this point forever without success, but the proxy is the document and the agent is the person. But the healthcare agent then has to make decisions based on the patient's wishes, if reasonably known, or else the patient's best interests. And that's all it is. I could write one right now on a slip of paper next to me, and in fact, some of the forms come as the size of cards that you could put in your wallet. "I hereby appoint so-and-so to be my healthcare agent." Now, you could add guidance and instructions, and the standard health department model form has a place for you to do that, or you could even staple a living will to it. And I can name an alternate, and I could do other things with the form, but the basic elements are just those simple elements of appointing somebody. If I can't decide personally, talk to this guy. I'm very proud that when I worked at the task force in Life and the Law, we helped develop the first statewide healthcare proxy law. California had something similar before, but none of the other states did. And since then it's become a standard tool for advanced directives in every state. And I think the law has been very successful. Providers like it a lot because it answers this core question, if the patient lacks capacity, who do I get a decision from? And it also gives you a lot of flexibility, even if you are close with your spouse, for instance, but you don't think they would be good at making decisions that you want reflecting your wishes, you can appoint somebody else, or if you don't have somebody who's a close relative, it gives you flexibility to find somebody who might be willing, and it doesn't impose any obligation on the agent to accept that position. So it's a great tool. As to why these are ethically challenging for people, I think this is less fraught than a living will or some of the other advanced directives or actually making decisions because all you're doing is saying Hey, if something happens to me, could you make decisions for me?" Now, you should be coupling that with a discussion about your wishes, your values, so that the agent can make decisions that reflect your wishes and values. But really, it should be a pretty neutral thing to do, and that's why I think it is a basic tool that people should have So you believe so we were talking about proxies. So- Yeah, proxy, the healthcare proxy ... so do you believe every adult should have an advanced directive or healthcare proxy in place? And I guess what I'm getting at, I think there's a lot of misconceptions people have about- Yeah ... advanced care planning. So what happens when families avoid these conversations? And then this is- Okay ... another question we'll talk about, the Family Healthcare Decisions Act. Sure. Well, first of all I look at the healthcare proxy as a type of advanced directive. You're just making decisions about what happens if you lose capacity in the future. And in that case, you're not making the decision, itself in advance, you're making the appointment of somebody in advance, but it's still an advance, a type of advanced directive. And I was saying that's less fraught than, say, a living will. In a living will, you are trying to be a bit clairvoyant and predicting, if not predicting, at least planning for different treatment decisions that may or may not arise, and saying what your wishes would be if I ever am permanently unconscious, if I ever lack capacity and am terminally ill. And so those conditions may or may not arise. That gets far more sensitive, and your values may be very different from a close family member's values, and if you have that conversation with them it's very important for you to let them know what your wishes are so that they're more likely to honor them. But I look, personally, I look at the healthcare proxy coupled with some instructions, and if there are treatment issues that you feel very strongly about, coupled with directions on those treatment issues, I look at that as the preferable type of advanced directive. Okay. Now tell, can you tell us about the Family Healthcare Decisions Act, and do you think it's working well? Yeah, thanks for asking about that. The Family Healthcare Decisions Act is New York's surrogate decision-making statute. It says if you lack capacity, and you didn't previously appoint a healthcare agent or make decisions in advance about a proposed treatment then here's a priority list of who will make those decisions for you. It's like in the area of trust and estates, it's like an, an intestacy law. If you don't make a will, then the law prescribes who gets your money based on who most people would expect would get their money. So a surrogate decision-making statute says if you didn't appoint somebody to make these healthcare decisions for you if you lose capacity, then the law will prescribe who can make these decisions for you based on who most people would expect to make these decisions for you. Spouse, adult child, sibling, and it goes down a list. So most states have a surrogate decision-making statute. New York was a late comer. It only passed its decision-making statute, surrogate decision-making statute in 2010 after many years of advocacy. But it's different from a healthcare agent because the Family Healthcare Decisions Act gives this unappointed person, this default person, less authority than the healthcare agent could have. And in particular, when it comes to end-of-life decisions, the surrogate decision maker is restricted to the patient has to meet a pretty strict clinical criteria before the surrogate has the authority to authorize the withdrawal or withholding of life-sustaining treatment, and then it still has to be based on the patient's wishes if no- if reasonably known, or else best interests. And yeah, you asked if it's working well. I think it's working very well. Before it was enacted in 2010, there was both confusion about who the decision maker was, and sometimes disputes about that. And there was also confusion about what authority, or actually not so much confusion as family members didn't have authority to make a lot of decisions. And in many cases, that was very harsh. They couldn't authorize the withdrawal or withholding of life-sustaining treatment for dying or unconscious patients, even in situations where it was pretty clear that the patient would have wanted it. And it's generally regarded as ethically sound. It's worked well. It's not perfect. There are areas that I've recommended amendments to it but overall, in most cases, it works quite well particularly compared to the pre-Family Healthcare Decisions Act days. You still need a healthcare proxy, though, to stay out of the world of Family Healthcare Decisions Act. Yeah. I think it's interesting that y- you said it works well in most cases. There's always something, right? There's always some gray areas. Yes, there are. There are. Yeah. One thing is it doesn't apply to people with intellectual or developmental disabilities because there's a special law in New York that applies to them, a separate surrogate decision-making law, and that creates a lot of confusion and delay and impairs, in my view, quality of care for that population. So I've been advocating extending the Family Healthcare Decisions Act to cover decisions for that population. So that's, one example of something that would improve it. It's not so much a flaw in the Family Healthcare Decisions Act as it needs to be extended further. Yeah. I mentioned during the COVID pandemic you helped form the Empire State Bioethics Consortium. What gap or need were you trying to address at that moment, and what are some of the most important contributions the consortium has made since its founding? Well, at the start of the pandemic, things were horrible beyond words. I'm not telling you something you don't al- already know. Yes. I'm sure you remember this. Healthcare professionals didn't know what this disease was. They didn't know how to test for it. They didn't know how to treat it. The, they didn't know how to advise the public on how to avoid getting it. They didn't know how to protect staff. They didn't know practically everything. And what I remember is we didn't know whether it was gonna burn out quickly or be another Black Death or like the 1918 flu. All we knew is patients were dying everywhere you turned, particularly New York City, and soon in, in New York State and then elsewhere. So it was a public health catastrophe. But it also elevated these medical ethics issues that were discussed a lot in theory before then, but now became terribly real. Who gets a ventilator or an ICU bed when there's not enough for everybody? And can we write a DNR order for a clearly dying patient, even over the family's objection, and even when futile resuscitation would expose the staff to a potentially fatal disease and infection? When the hospital's overcrowded, can you transfer patients over objection? And what's the obligation of a healthcare worker to place their own life at risk? So we're seeing these... It just occurred to me we're seeing these issues in the Congo now with the latest outbreak of Ebola, and it's bringing back nightmares. Yes. At any rate, a lot of New York City health systems had, at the time, professionals who were trained in medical ethics, and many of them even had certifications what we call the HEC, the health ethics certification. And a lot of hospitals also had, even if they didn't have a HEC on staff, they had doctors or nurses or social workers or chaplains- Were lawyers who were conversant in the, in medical ethics and medical ethics policy. But what was missing was that prior to Empire State Bioethics Consortium, these people didn't know each other. They didn't talk to each other. I mean, there were individual friendships and professional relationships and there were journal articles, but they didn't have real broad spread broadly based communication or real-time communication across the field. And people in ethics at Mount Sinai needed to know, "Hey, what are you guys doing at Northwell?" And Northwell needed to know, "What are you guys doing at University of Rochester or Roswell?" And that wasn't happening before this organization. So the organization started really as a few people having a conference call, which led to a larger group of people having a Zoom call, and Zoom was pretty new at the time too, and made this possible, and that led to the formation of an organization. The other thing that these people in New York had in common was New York wasn't only the epicenter of the pandemic at the beginning but it's also the epicenter of health regulations, maybe over-regulation. So it was necessary for people to talk to other people That were operating under the same regulatory framework. So ESBC, Empire State Bioethics Consortium, provided an information network among ethicists across New York State, and a support network, a sense of where the norm was, and it also engaged in a bit of advocacy. But I think most importantly, it, at that time, it provided m- peer moral support. We know what you're going through. We're going through it too. Maybe we can... How are you dealing with this? That's helpful to know. Are we within the the norm or are we an outlier? Since then, I mean, the crisis has passed, but it's still become now an invaluable area for people to excha- people involved in medical ethics to, in New York, to exchange information and ideas, and do professional education, and there are some great presentations and discussions every month. Feel like I'm doing an advertisement for it, esbc.org. But what we're trying to do now is branch out and not just help each other, but do more to reach out and help patients and other professionals outside of the bioethics arena. And so we've got some growing and expanding and increasing our, goals to do. Very nice. Yeah, and I, I will say if I had access to something like that during the pandemic, I think it would've been, made things a lot easier for me- Yeah ... most definitely. End of life decisions often become politically charged. They're very difficult, whether the issue is withdrawing treatment, medical aid in dying, ICU care, patient autonomy. Why do you think that these deeply personal healthcare choices, because that's how, what I feel, they're deeply personal, why do they become such contentious public and political debates? Well, let me start with withdrawal or withholding of life-sustaining treatment, which is the area where I've done most of my work, and I'll throw you a curveball. What's been remarkable to me is how broad the consensus is, even nationally, on policies about withdrawal or withholding of life-sustaining treatment. Not talking about medical aid in dying, but discontinuing ventilators, DNR orders dialysis, that sort of thing. There's a cultural war out there, but somehow this issue has not been immune to it, but has largely been floating above it, at least since the Schiavo case in the 1990s, which was terribly controversial on a withdrawal of treatment case. But I think if you look around, red states as well as blue states have laws that allow or even promote living wills, healthcare proxies, surrogate decision-making. They differ on some of the hot button issues like what do we do about the pregnant patient? But for the most part throughout red states and blue states, they respect patient autonomy. They respect the right of an adult to forego life-sustaining treatment. These are all things that were terribly controversial in the 1970s, maybe even considered idiosyncratic, but are accepted across the country now. And in fact, the Supreme Court in its Cruzan decision in 1990 recognized that an adult has a constitutional right to opt to not have life-sustaining treatment, and that was a unanimous decision written by a very conservative judge, the Chief Justice William Rehnquist. So it is interesting that there seems to be a consensus on this. I mean, as an aside, if that case went to the Supreme Court right now, I'm certain Just- at least Justice Alito and Justice Thomas would say there isn't any such constitutional right. But that has more to do with their view of constitutional law than it does of any objection to patients refusing treatment. They probably support state... Well, I don't know what they would view, but they don't have any noticeable objection to state laws that allow living wills and withdrawal of life-sustaining treatment. Just not a constitutional right. But yes, you get outside of that area of withdrawal or withholding of life-sustaining treatment and respect for patient autonomy in that, and we talk about things like medical aid in dying, that is as contentious as it can get. And so you're asking me why. I mean, the stakes are high there. Clearly they're high in, in other areas as well, but both sides in that debate Have very, very powerful and emotional and legitimate arguments. I mean, the people who support medical aid in dying stress that this decision belongs to the patient. And unlike abortion, it doesn't even arguably involve another person, another human being. It just involves the patient, and these are people who are suffering horribly, so where does society get off telling them they have to continue to suffer horribly? That's that argument. On the other side, the argument is from people who oppose medical aid in dying, is that vulnerable patients are gonna be pressured into agreeing to have medical aid in dying or that the current laws are gonna be expanded to go beyond patients who are terminally ill and maybe even go beyond patients who lack... Who have capacity. 'Cause we've seen end of life decision-making evolve from a right of the capable patient to a right to do an advanced directive to surrogate decision-making. There's a concern that decisions about MAID will, medical aid in dying, will evolve the same way, and that's a real concern. So I've been... I see valid points and passionate points on both sides, and I, to some extent, I've been ambivalent about it personally. So I, kinda get why this is so controversial. Yeah. Interestingly I also haven't been personally ambivalent I think, 'cause I've talked to so many individuals about their personal choice. So you mentioned withdrawal of treatment and medical aid in dying. What did you find were the most difficult types of end of life cases from both a legal and ethical standpoint, and how should they be resolved? Well, I think there are two categories that I would say are, I found have been the most difficult decisions. One is when, and these will probably both be familiar to you. One is when there's a conflict between a patient's prior instructions, and then the patient loses capacity, and the family's current directions to staff. I haven't seen as much problem with disagreements among family or disagreements among, between family and physicians. What I've seen is the patient says, "Hey, if I lose capacity, I know I'm dying. I don't wanna be resuscitated. I don't want it. I don't want it. Please write that down." And they write it down. And then later on, a family member comes in and says, "I don't care what mom told you. I'm telling you, we want everything done." And the staff is caught between the patient's prior instructions and the family's current wishes. And the, from a legal and ethical standpoint, the answer is pretty clear. We had a prior decision by a patient who had been capable. That's our legal and ethical obligation. But from a practical and even risk management standpoint, you could see the problem. You've got a passive or unconscious patient and a kicking, screaming, angry family member that has a friend at the newspaper or in the legislature or And it's, very difficult to face that. And I've counseled on a number of those cases, and I've tried very hard to bring the family around to recognize the obligation to honor the patient's wishes the second category that is also extremely difficult is what I call the socially isolated patient, the patient who doesn't have any family, doesn't have any friend, didn't appoint a healthcare agent, didn't make an advanced decision. Maybe somebody who's been homeless or maybe somebody in a nursing home who's just no longer has involved family, and staff is left trying to figure out what to do for this person, who, who can consent to treatment, who can make a decision about how aggressive to be on life-sustaining treatment. I've called them the socially isolated patient. I think the literature more commonly refers to them either as the unrepresented or the unbefriended, but we're talking about the same population. And I think here, the Family Healthcare Decisions Act is too strict and not clear enough, and I think we need some, some changes in that. But every state is struggling with that problem. It's an ethical problem that law can't satisfactorily resolve. It's one of those what's the least worst policy you could have. And I've called for physician decision-making subject to ethics committee review and confirmation provided the ethics committee meets certain qualification standards, something like that. But it's an extremely difficult question, and it's one that sadly comes up a lot. Do those sound familiar to you? Yes. Yeah. And I think it's very challenging, the, the least worst option, right? Or the least worst- Yeah ... option. It often comes down to that, and that's the best we can do, unfortunately. The last question I wanted to ask you, and I think this is gonna be pretty pivotal. I, I ask a iteration of this question to every s- guest who comes on the podcast. Okay. After decades working inside healthcare systems, government, academia, and ethics, leadership, I mean, you've seen healthcare from almost every angle. If you were suddenly put in charge of healthcare policy in the United States, what is the very first change you would make, and why? Oh, man. Okay. So the first thing I would do would be to decline that job. It's just- ... too complicated, too scary, too contentious for me. I'm trying to reduce my stress at this time of life. That would not do it. But if I could picture myself safely on the sidelines like I am, So the direction I would tell people smarter than me who hopefully took that position or in charge of healthcare, I personally support moving toward universal coverage delinked from employment, supported by taxes, and a single payer like Medicare. Set aside the issue of a national health service for a minute. Maybe we'll talk about that in a minute. But um, something like Medicare for all, and I think that's not gonna solve all the problems of healthcare. Certainly not gonna solve the bioethical issues of how do we resolve this end of life decision. That's a separate category entirely. But if we look at the major problems of the healthcare system and healthcare policy you want coverage, you want quality, and you want cost effectiveness, and I think that is a better approach than the current chaotic employment-based coverage system that we have now with lots and lots of insurers all negotiating separate deals with lots and lots of payers. So I look to some degree, with some degree of envy toward other countries like the UK or like Canada or Nordic countries even Greenland that I, I keep reading that the Greenlanders like their healthcare where every citizen's covered. Coverage has no connection with employment. If you're born, you're covered. Healthcare is paid for by taxes, not by employers and employees separately. Everyone gets emergency care. People are still free to buy private insurance if they want and go to a private doctor if they want, but there's a public coverage. So it's a lot like public schools i- when you think about it. All kids are eligible for public school, and it's, not free. You pay for it with your taxes, but there's no additional charge for it. but if you wanna send your kids to private school you can do so. So again, this has more to do with public health policy, with health policy than with bioethics, 'cause those bioethics questions are largely gonna be the same. Th- except that a key bioethics concern is distributive justice of the fair allocation of scarce resources and the fair stewardship of scarce resources. And this speaks to that issue, that concern of bioethics. Another bioethics concern is protecting vulnerable populations, and our system doesn't do a great job of that. So I think if it became politically feasible, which it isn't at this time, but things change, I'd be pushing for single-payer universal coverage. I'm still working out in my own mind whether there's an advantage to also having a national health service. I look at the amount of money we spend on, on doctors and the salaries that they make, and look in other countries where it's a very highly regarded and esteemed profession, but not making a million dollars a year to be a radiologist. I would like to see us bring that within reason. Maybe I'm picking on them. They're not the principal they're not my highest priority in reforming the system. But a national health service like in UK Would bring, bring that within some more reasonable balance. But I'd start with Medicare for All single-payer universal coverage. And I hope if people disagree with me, 'cause this is almost more passionate than arguing about life-sustaining treatment and more controversial, but I hope if people disagree with me- They won't disregard my other comments on medical ethics and still find that useful. Yeah, I mean, I'll just tell you, I think, I wonder if there was a single payer and we had everyone had more access to healthcare that was obviously affordable, how that would change this withdrawal of care and all of those questions. Because I, I think often when things happen, we can't predict what the outcome is, so I am very curious about what that would mean. Well for one thing, there may be some decisions to forego life-sustaining treatment that are influenced by cost and concerns about cost. Yeah. So I think a universal coverage single payer would help alleviate that. I didn't even get to the bureaucratic red tape in the current system that is not nearly as bad in the Medicare side as it is on the commercial payer side, in my experience. So that's another advantage of it. But back to the bioethics issues. So worrying about cost drives a lot of, drives a lot of problems that have a bioethics dimension. Yeah, absolutely. Last question, if people wanna find out more about your work, how can they do that? I know you mentioned the website for the- Right ... Empire State Bioethics Consortium. Is there anywhere else you would point them for g- guidance, information on these issues? Well, sure. I'd, uh, recommend going first to the esbc.org website for information about the Bioethics Consortium. But if they're interested in the work that I've done, then the two places... Well, the one place I would go is I'm teaching in the bioethics program at Columbia University, and so if you just Googled my name and Columbia University bioethics faculty, it'll give you background information about me, and also more importantly links to about little bit more than 40 articles that I've written on these topics. So uh, if you're really interested in some of those topics, that's the place to look. Wonderful. Robert Swidler, I really enjoyed this conversation. Thank you so much for joining me today. Oh, I enjoyed it as well. Thanks for having me.

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