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Ethics Talk: Public, Civic, and Spiritual Health During COVID

Learning Objective
Identify key ethical values or principles at stake, as described in the program
0.25 Credit CME

In this video edition of Ethics Talk, journal editor in chief, Dr Audiey Kao, talks with Dr Patrick Smith about intersections of public health, civic good and spiritual well-being during this COVID-19 pandemic.

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The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more

Video Transcript

Tim Hoff: Welcome to Ethics Talk, the American Medical Association Journal of Ethics podcast on ethics in health and health care. I'm your host, Tim Hoff. This episode is an audio version of a video interview conducted by the journal's Editor in Chief, Dr Audiey Kao, with Dr Patrick Smith, Associate Research Professor of Theological Ethics and Bioethics at the Duke Divinity School, Senior Fellow at the Kenan Institute for Ethics at Duke University, and Core Faculty with the Trent Center for Bioethics, Humanities, and History of Medicine at Duke University School of Medicine. He joined us to talk about the intersections of public health, civic good, and spiritual well-being during this COVID-19 pandemic. To watch the full video interview, head to our site, JournalOfEthics.org, or check out our YouTube channel.

Dr Audiey Kao: Professor Smith, thanks for being a guest on Ethics Talk today. [music fades out]

Dr Patrick Smith: Dr Kao, thank you so much for having me. It's a pleasure. I'm looking forward to the conversation.

Kao: So, I've heard you describe yourself as a moral philosopher working at the intersection of bioethics and religious social ethics. How has your scholarly work informed your perspectives and deliberations during these pandemic times?

Smith: Yeah, thank you for that question. You know, in some ways—I hope I'm not too much of an anomaly—but my scholarly work was deeply informed by, I think, my kind of personal background, along with my educational and professional background. And so, usually, with questions like this, I like to take one step back before taking a step forward in answering a question. So, my educational background is pretty eclectic. I started off undergraduate work looking at Business Administration. Then I moved to doing work in Theological Studies and then training in the areas of Analytic Philosophy. It is pretty broad in terms of that disciplinary background, but I see how all of that comes together when I start thinking about questions of bioethics.

And the conversation with religious social ethics comes from that, my familial background. I come from a family where things like religion, education, music, the life of the mind were very important in terms of cultivating many of the kids there. Uncle who was a pastor in Birmingham, Alabama, a civil rights leader for a number of years there, worked very prominently in the Civil Rights Movement there. Another aunt who was involved in education and also involved in the Civil Rights Movement in her own way. And one of the things my uncle always would say, as many of us were engaging in academic discipline and professional pursuit, he would listen to us, he would kind of smile and nod, and then he would always say, “Don't forget about the people, right? Just don't forget about the people.” And so, for me, this notion of religious social ethics, questions of justice, questions of solidarity, questions of working for the common good, what role may be something like love, right—not as a sentiment, but as a political virtue—what role might that have in thinking about these issues? And so, for me, all of this, I think, really comes together that has informed not only my work over this last year with regard to COVID-19, but hopefully overall as well.

Kao: Yeah. We can all certainly benefit from a lot more love in this country during this pandemic. And as you just alluded to, the pandemic has prompted us to talk about public health response and readiness, but also to think about the foundations of our civic well-being.

Smith: Yeah.

Kao: Voter suppression is an affront to self-determination and democratic values. Yet such suppression is making a resurgence in Georgia and elsewhere in our country. What do you think we should be paying attention to right now at the nexus of public health, religious social ethics, and deliberative democracy?

Smith: Yeah. Yeah, I mean, I would suggest that there, just for us to be mindful again and again, that there's a deep connection between social and political conditions or circumstances, or some would say even determinants, in relationship to our overall health. Or another way of putting this, that these conditions, along with human agency, obviously, can either promote or stifle different ways of accounting for human flourishing, or some would say human flourishings, right? Because there's not one particular way of what it means for human beings to flourish. But certainly, we know there are situations in which, that can certainly stifle human well-being, human flourishing, and overall health outcomes. So, I think this becomes really important to kind of keep that in mind.

And the connection here I would say with this larger question of representative democracy, right, we have to be clear, I think, that democracy, yes, is more than voting, right? Now it certainly includes voting, but it's more than that. There's a kind of civic engagement that is needed that requires a commitment to the common good. It requires a kind of cultivation of certain dispositions to operate and navigate the fragility of democracies. But just because voting is not the end-all be-all or the sum total of democracy, it doesn't mean that it's not essential. We do know that along with civic engagement, there is this political participation, and part of the political participation is in the voting process. Dr Martin Luther King Jr often talked about, in his kind of Black religious social ethical framework, that questions of voting are tied deeply to dignity, the ability for individuals to have a kind of freedom in engaging in this kind of self-governing process. And so, when groups of people are disenfranchised and marginalized and kept from voting, not only does that undermine their dignity, but it also undermines their ability to create a kind of common life together that can promote their own flourishing and well-being.

Give you two quick examples real quick. Two quick examples, hopefully. First would be this notion of thinking about housing and the zoning laws and issues that come along with that. We elect officials who make certain decisions about how our communities are formed, how our neighborhoods are shaped. Often that is through policy. How do we have a say in that? Where our houses are located, that means access to perhaps health care, in some spaces. It means also what type of resources our public schools have. It also means what types of pollutants may or may not be dumped in the particular areas where we live. And we also know there's a lot of social scientific data that makes the connections between all of these issues and overall health. And so, disenfranchising people from the ability to vote and have voice certainly is connected to these questions of health.

And I also think something like mass incarceration, I think that is a huge public health issue. I'm not sure if we see it in that way, but I actually think there's a pretty decent case that can be made that it should. Again, I mean, there are multiple levels in which this is problematic. First, you think about those who are in, who are of a kind of a lower socioeconomic status and also along racialized lines, the disparities in terms of the way our criminal justice system is playing out in terms of mass incarceration are stark. And those divergences should capture, I think, our moral attention, and we should ask what is happening, especially when you link that with these three levels, right: the individual health concern for having so many people incarcerated, maybe having mental health challenges. You're thinking about infectious diseases. You think about the prevalence of HIV, hepatitis C in those spaces. The kind of solitary confinement or either these what is control unit prisons and the impact and toll that takes on mental health.

Then you think about the family. So, not only are families devoid of loved ones who may be contributing to the overall kind of household or having parents who can help shape and nurture children, if these individuals who were incarcerated, as returning citizens going back into their families, if they have these undiagnosed health problems or these challenges that have not been addressed, that's coming back to the home, right? And oftentimes, women are the ones who bear a disproportionate burden of being caregivers. And then the stress and toll that that takes on their body and well-being contributes, or can contribute, to their diminishing health status. And then largely in the community, if you think about infectious diseases, right, as these continue to spread in these close quarters that are connected with housing.

Now, Dr Kao, I said all of that to say that there's this deep connection between the social situations and conditions in which we find ourselves, recognizing the fact that legislators are the ones who can define crime, as to what counts as crime, and how that all plays out, and then the larger impact of how we do life together.

And I'll close with this in terms of this question, that religious social ethics would often remind us of three things of finitude, right? The mere fact that we are finite, we're limited. We have limited resources. We're embodied individuals trying to live in community. We don't always see things clearly, right? That's connected to this notion of dependence, which means that we are dependent on the environment in which we live that contributes to our flourishing. So, questions of ecological justice and environmental ethics are very much important and central to this. And then also, we are interdependent, meaning that we need one another really to flourish and do life together. And religious social ethics, bringing those values along with what we're thinking about public health, I think, really shows the magnitude of the problem, but also resources about moving forward.

Kao: So, I'm thinking about what you just said about religious social ethics. You mentioned earlier that you had an uncle who was a pastor.

Smith: Yes, mmhmm.

Kao: So, what do you see the role of churches, and more specifically, Black churches in human flourishing and civic health?

Smith: Yeah. So, this is, [chuckles] I really appreciate that question. You know, obviously, when you start talking about things like religion, and particularly the Christian tradition, which is the one that I know the best, the one that I would consider myself or count myself a part of, that there are a lot of theologies that are involved there and a lot of political theologies that are also involved in those endeavors. And there've been some religious traditions or aspects of religious traditions that have promoted, I think, health and human flourishing and many that have stifled it, right? And we all know too well, unfortunately, instances of how these resources have gone wrong, can go wrong, and still are currently going wrong. And so, as I'm thinking from this kind of African-American church kind of context and background—now I'm speaking in broad strokes here and not to the individual churches—but in the broad strokes, there has been this emphasis of a kind of social engagement, if I may in a space like this use the theological language of a kind of prophetic tradition.

And what that prophetic tradition is, Dr Kao, is this notion of really attending to the larger social and systemic issues that are impacting the shape of the community and the experiences of those in the community. So, it's not only looking at, okay, just a particular personal way of acting or the expression of a particular agency, but it's like what is the larger, what are the larger conditions that are shaping life? And so, I think this Black church tradition historically has really identified those issues, see the disenfranchising nature of certain policies, but beyond that, the dehumanizing and degrading impact of some of those policies and issues. And so, the Black church tradition has historically had what some will call a priestly wing, meaning those ideas that can help substantiate you from within to give you a sense of self-worth.

And so, Martin Luther King Jr talked about a sense of somebodyness, right? So, the first phase of the Civil Rights Movement was establishing the dignity of Black people. And then the prophetic dimension that is kind of what some would suggest bearing witness into the world, embodying what you say you believe about the world for all people. And I think if nothing else, the Black churches can demonstrate what it means to be perhaps politically disenfranchised, and perhaps in some ways disempowered, but yet are able to mobilize in a community, organize in a particular way, draw from the deep reservoir of existential resources that can help you stand up straight. I think I heard Cornel West quote aspects of Martin Luther King Jr when he says that when you stand with your back up straight, it makes it hard for other people to ride your back, right? And I think that's a significant contribution that the Black church, broadly speaking, has played and continues to play in the time in which we are living in some ways.

Kao: So, as we near the end of our conversation, I'd like to switch gears a little and talk to you about your work in hospice and end-of-life care. What do you think are some of the ethical and spiritual issues that the pandemic has raised regarding death and dying?

Smith: Yeah. So, in terms of the kind of ethical issues, I started out years ago doing some work at a hospice care center, being Director of the Ethics Department there. And I, in that space, was wrestling with questions of what does it mean to value life at the end of life? And figuring out how these resources come to bear and what are the challenges that are faced with that. As I started working with particular communities in end-of-life care, I recognized that before I can really think through carefully the question of what does it mean to value life at the end of life, I had to ask, what does it mean to value life before the end of life? Meaning, when I was picking up on the fact of how poorly poor people die and how people who are maybe on the margins socially along racialized lines, there are these disparate treatments and certainly outcomes. And so, again, this was a kind of catalyst for me to bring together questions of social ethics with end-of-life care ethics the way that I had been wrestling with and thinking about.

And what this showed me is that what COVID-19, this pandemic, has done for us is just an X-ray of an already underlying pathology that was a cultural pathology, if you will, that was part of our larger social life together. And so, I do think when we start wrestling with questions of the economic disparities, questions of access to education, access to health care, and these questions of health outcomes, in many ways, the pandemic just exposes, I hope, for a lot of folks, the stark realities that we've always lived with that perhaps have been invisible to us. But now they're visible in a way that I think it's much more difficult to deny.

In terms of spiritual issues, I would say that, you know, there is something—apart from whether or not people are religious or not or spiritual, which spiritual may not be the same thing as religious—but they're these existential longings, a lot of times, for closure and for a sense of completion of lives of people that we have journeyed with or people who we love. And I think one of the spiritual issues is the fact that a lot of people have not been able to gather together to kind of collectively mourn the loss of life. And there's a sense in which you're not present with a person in the way that maybe we have been accustomed to being present with people. And then it makes it more difficult to come together and celebrate that life, hopefully a life well lived. But we know that those are judgments that, you know, all kinds of people make in different ways. But regardless of whatever those judgments are, the fact that these are people we love, we care about, people we know, and not really being able to come together to honor them, to honor their life and their impact on us. And I think that that is just something that has created some existential angst amongst a lot of people in having that kind of closure. So, there's more that could be said, but I certainly will, I think, maybe leave it there, Dr Kao.

Kao: Yeah. Well, I appreciate this time with you today, Professor Smith, and for you sharing your insights and expertise with our audience. Professor Smith, thanks again for being a guest on Ethics Talk.

Smith: It's been my pleasure. Thank you so much.

Kao: For more COVID ethics resources, please visit the AMA Journal of Ethics at JournalOfEthics.org. Thank you for being with us today. We'll see you next time on Ethics Talk. [bright theme music plays]

Video Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.25 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

AMA CME Accreditation Information

Credit Designation Statement:  The American Medical Association designates this Enduring Material activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to: 

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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