My STEP Signature project was an internship as an Ethics Resident at Mount Carmel Health System. Primary duties included research, ethics consultant curriculum revision, and shadowing in a variety of settings. Also learned frameworks related to and methods of ethics consultation.
Through my two assigned research projects, I received a greater understanding of housing insecurity in Columbus and female genital circumcision, though the latter was less transformative. Housing insecurity in Columbus is a huge issue, but being so close to campus and not really exploring the less privileged areas of Columbus, it didn’t seem that bad. While Columbus is better than most large cities at meeting overnight and short-term needs for shelter, the current resources do not enable social mobility. Relatively few make it into permanent housing situations for a variety of reasons. I really knew nothing going into my internship about the plight of homelessness in Columbus, other than the folks near campus who would occasionally share a conversation or ask for help meeting their needs for the day.
While I’m simplifying the transformation here, I’ve learned that there is so much more to the homeless issue. I wasn’t particularly judgmental before, but now, while I don’t have anything to give, I would be more likely to help in the future. My previous assumptions were rudimentary. The people on the street were there because of bad luck or bad choices. While that’s not necessarily false, aspects of social health, such as housing insecurity, feeds back into the more medicalized aspects of wellness and creates a perpetuating downward spiral. They’re often without the first line care and social safety net that I take for granted. This raises costs for hospitals in areas with higher homelessness, including Nationwide, OSU East, and Mount Carmel West as they provide life-saving care in the emergency department that can’t be reimbursed because these patients often lack insurance and an address to bill to. To sum up, I had some ignorance before, and because of the knowledge I was allowed to receive through an experience of my internship, I feel more compassion toward their struggle. It is so easy to pass initial judgement but getting over this quick conclusion is a process that can only be forwarded by experiencing things you don’t understand.
Being tasked with the research on homelessness as a social determinant of health for a grant project to create affordable housing was the primary change in my understanding. Simply being exposed to information on national homeless statistics over time, eviction rates, healthcare outcomes for those without housing security, and housing affordability locally and nationally made me understand how the problem was not as simple as building affordable housing or getting people off the street. Half a million or more are on the street each night and a problem that large, even if separated by city into chunks around ten thousand, is not easily solved. One eviction can make it harder to find permanent housing. Even if the person is able to get their finances in order, most landlords won’t rent to anyone with an eviction, which further complicates their day to day living.
Secondly, I was able to go out on a shadowing experience with a member of the Street medicine outreach team. The clinical team will visit homeless camps and other places like soup kitchens to provide primary care to those who normally can’t access healthcare resources outside of the emergency department. The outreach team identifies individuals living on the street or camps and scouts for illness and injury that the clinical team can treat, either by coming directly to the individual or meeting them at a place with other resources. The camps were like little tent towns with a sense of community, even though fights did occasionally break out from what I was told. I remember meeting one man in a homeless camp who didn’t want to go back to what I would consider normal living. He spent his days fishing and living on substances. In that, he was happy. Someone being satisfied with a low social standing was foreign to me. I’m grateful for what I have, but part of my academic path is a social climb. Everyone in my family finished undergrad, but only one finished graduate school. The man of note’s past is completely foreign to me, but I find comfort in what I have now as well, so perhaps his comfort is not as foreign as it seems. While the differences are profound, perhaps there is more in common between us than the research would imply. This bolstered a tiny thought I had: I don’t know everything and part of practicing ethics is understanding just that. Overcoming my biases is critical if I am going to practice clinical ethics and be tasked with researching or exploring sensitive situations firsthand.
My second research project, on the sociocultural aspects of female genital cutting (FGC) was a chance to really apply this epistemic humility and test my ability to handle topics that might make me or anyone else uncomfortable. Like homelessness, certain parts of FGC are hard to look at. Statistical research and justification often collected through interviews were the easy part, despite the fact that these people often dealt with long term complications due to going through with the procedure. Reading about the actual process and seeing photographs and illustrations of the process was much more difficult. In Somalia, where FGC is almost universal, girls as young as four will have a very sensitive part of their body changed for cosmetic conformity and the intention of maintaining sexual purity. Modern medical practices, like anesthesia and stitches that dissolve, are not to be found. These young girls are tied down, cut up, and sewn back together without any anesthesia. Chances of infection are very high, but without this uniformity, girls lack social power. As well, they come to know their bodies this way for better or worse. One Somali woman who gave birth at Mount Carmel wanted her body restored to the familiar.
Condemning the practice of FGC or begging or drug use in homeless populations is quick and easy but does not do anything to fix the problem on a societal or individual level. Morally neutral language is so important to any productive discussion. Everyone will have their own positions and judgements, but working beyond bias to find a more practical and fitting solution than the solutions offered at the extremes is part of the unwritten duties of a healthcare ethicist. They are often brought into consult in sensitive situation, but the recommendations they make will be affected by their own opinions outside of what ethical directives they follow. To further a healthcare system’s goal of providing the best care, an ethicist must do their part. Developing this understanding of people over problems and considering all perspectives is one that takes a long time to develop. I hope these research and field experiences stay with me in my future academic and professional career.
Although this is just a start, the internship is a springboard to my future professional goals. I hope to complete a JD and a PhD in medical ethics or philosophy. I’d prefer to get them at the same time, but my pacing will be determined in the future. Although I’d consider myself to be mature, healthcare has a side that can be hard to look at and work with. Following the path I intend on pursuing will bring me eye to eye with that side on many occasions. Being able to evaluate information objectively despite a gruesome nature is difficult. While I was a little uncomfortable, I didn’t run from any part of that experience. Additionally, housing insecurity as an influencer of health is now one of my research interests. If I get an opportunity to explore it further, I would take it wholeheartedly. I can’t say I have any interest in being on the clinical side of street medicine, but being in a research role to direct care or argue for additional resources has appeal, particularly under the systematic lens of urban planning.