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Unpacking Neuro-Ethical Challenges

Karen Hirsch Presenting in front of whiteboard

Imagine a scenario where a person has a horrific accident resulting in severe brain injury and is now declared brain dead. Now consider this: the accident occurred in the US and care is taking place in the US, but the patient is originally from a country where brain death is not widely accepted, and organ donation is rare and often met with mistrust. As the patient’s care team, how do you manage the differences in the cultural, legal, and ethical perceptions and implications of brain death between the United States and the home country? How do you talk to the family about removing life support? And what about the question of organ donation? This scenario was not hypothetical for Dr. Holly Tabor, Professor of Medicine and Co-Chair of Stanford Hospital’s Ethics Committee, and Dr. Karen Hirsch, Associate Professor and Division Chief of Neurocritical Care. It was a scenario similar to this and the profound conversations that unfolded that would eventually give rise to a course that delves into the intricate ethical considerations around brain death, and organ transplantation. 

When they confronted this case, Tabor and Hirsch were no strangers to working with patients with neurological injuries and they regularly collaborated on prognosis and decision-making for patients and the coordination of the donor network. However, this case opened their eyes to the stark cultural differences between other countries and the U.S. on neuro-ethical issues. With a passion for working with students and a desire to learn more about cross-cultural differences in managing the ethical terrain of neurological injuries, Tabor and Hirsch created a course that would serve as a learning opportunity for themselves and their students. HumBio 171E, Modern Ethical Challenges in Neuroscience and Organ Transplantation, was initially conceived in the Spring of 2020 as a seminar for a Bing Study Abroad Summer Program on neuro-ethical issues in Japan. When the COVID-19 pandemic forced classes to go remote and suspended all study abroad programs, the course was opened up to graduate and undergraduate students from diverse backgrounds. Despite the changed context and the challenge of shifting to remote teaching, the course flourished and has since become a regular offering, not only as part of the Bing Overseas Program but also as a course for both undergraduate and medical students. 

After developing a foundation in bioethics and exploring and applying fundamental ethical principles to real-world medical and legal challenges, students dive into topics such as brain death, disorders of consciousness, organ donation, scarce resource allocation, and brain-computer interfaces for patients with brain injuries from stroke or trauma. Weaving together clinical cases, legal frameworks, scientific literature, film, and popular cultural comparisons between the US and Japan, the course challenges students to think critically about the intricate ethical constructs surrounding these topics. With the pandemic bringing to light issues around resources such as ventilators, ICU care, and vaccines, Hirsch and Tabor have increased the class time focused on resource allocation. The course consists of lectures, small group discussions, and conversations with professionals from various disciplines and backgrounds such as physicians, authors, filmmakers, and team members from the United Network for Organ Sharing (UNOS) and the Stanford Transplant team. Through these interactions, students gain insights into the multifaceted nature of healthcare ethics, broadening their perspectives and enriching their understanding of ethical dilemmas. The guest speakers also showcase the different dimensions of work that people can do in these areas. Beyond theoretical discussions, students also have the opportunity to attend Stanford Medicine’s ethics committee meetings and transplant listing sessions, deepening their understanding of the real-world ethical challenges people face and the complexities of medical decision-making. 

Holly Tabor Teaching in Front of an Auditorium of Students
Dr. Holly Tabor discusses the Ring Theory for grief

Students often begin the class with a common misconception: “[they] often come in thinking that things are black and white, that there’s no unknown, and that the medical system has it all figured out,” Hirsch explained. “We try to tell them that it is not and that there are many controversies.” Students are encouraged to confront their own black and white thinking in their first reflection assignment, where they consider ethical challenges in their own lives and often come to realize that there are many shades of grey between those “right” and “wrong” answers. Tabor shares that this lack of certainty can feel frustrating for students who are looking for concrete answers; “I think many people wish there was a formula you could plug into and get answers to things. And part of this class is learning that it’s more about a process of thinking, reflecting, and engaging than it is plugging things in and getting a right or wrong answer.” 

Throughout the course, students cultivate a wide range of skills while navigating the complexities of medical ethics and neurological issues. With an emphasis on scientific literacy and communication, they learn to interpret information with a critical eye rather than accepting it at face value. Hirsch’s mantra of “trust no one, question everything” underscores the importance of continual inquiry, especially in fields like medicine where scientific advances often change the way we understand our observations. Students learn to discern misleading popular narratives and apply scientific reasoning to real-world situations. For example, when doctors declared 13-year-old Jahi McMath brain dead after surgery, her parents did not accept the finding. Guest speaker Dr. Paul Fisher ‘85, who was an expert witness in the case, talked about how the media representations often distorted or omitted important details that informed clinical decision making.

Tabor and Hirsch find that they too are always learning from their students. With a group of students who have a broad spectrum of life experiences and knowledge, the team constantly asks themselves how they can create a rewarding learning experience and build on the students’ reflections, experiences, and engagement. “I’m often struck by how thoughtful and courageous some of our students are,” Tabor said. “We often have students in the class who have direct or indirect experiences with brain death, strokes, significant injuries, or organ transplantation,” Hirsch added. “The insights they bring to the classroom only enrich the conversations we have and it helps me think about how I deliver information to them, how I approach teaching, and even how I practice medicine.”

As with many Human Biology courses, the content of HumBio 171E can bring up many emotions and perspectives. Hirsch noted that many students who come into the course are not comfortable talking about neurologic injury or prognosis, disability, or death and dying due to a lack of prior conversations, limited knowledge, or cultural or religious taboos. The teaching team acknowledges this at the beginning of the course and teaches students how to navigate and talk about these difficult topics more comfortably. 

Karen Hirsch asks students a question
Dr. Hirsch introduces students to the principles of bioethics

HumBio 171E is a class that meets undergraduates where they are in their education and lives. The team emphasizes respect for differing experiences, encouraging empathy and tolerance for alternate viewpoints. They model constructive and respectful discourse through their conversations and disagreements during class. Ultimately, the point isn't to teach students that the answers are right or wrong, but rather how to have difficult conversations when there is no easy solution. “Part of what we try to teach,” Tabor explained, “is that if you can get yourself to believe that the right answer isn’t a straightforward singular answer, then you can hold space for a great deal of empathy and tolerance for others who may have different perspectives or experiences than your own.”