Researcher Spotlight: Elizabeth Dzeng, MD, MPH, PhD

Liz Dzeng, MD, MPH, PhD
Elizabeth Dzeng, MD, MPH, PhD

What are you thinking about?

My research focuses on understanding the systems-level factors that contribute to potentially non-beneficial high-intensity life-sustaining treatments near the end of life from a sociological and ethical perspective. I am most concerned about how sociopolitical forces beyond the hospital affect the way that patients, families, clinicians, staff, and hospital administrators think and behave. I have been particularly interested in neoliberalism and how that influences the ethics and culture of healthcare. Neoliberalism is an ideology that believes in the primacy of free market capitalism in all aspects of life, including areas which were not traditionally seen as areas where market capitalism could dominate such as in healthcare and education. In the United States, neoliberalism is so pervasive that it’s just seen as the way things are. Even though neoliberalism is so dominant, it is completely absent from the political or social discourse in the US. 

Why is this interesting to you?

Ethics is a central intellectual and personal driving force for my work. I did my graduate studies in Sociology and Development Studies at Cambridge in the United Kingdom. I spent time interviewing and talking to doctors who work for the National Health Service (NHS) as a part of my research, where doctors pride themselves on the fact that all healthcare is free at the point of service. When I returned to the US after five years living in the UK, I experienced re-entry culture shock around the healthcare I was being asked to practice. The degree to which financial decisions colored every aspect of the way healthcare was delivered and the way that ethos trickled down to influence daily clinical decisions was troublesome and unethical to me. The fact that our healthcare system is built to profit off of other people’s illnesses felt fundamentally wrong. I felt a need to raise awareness of the concepts of neoliberalism to the medical field and attempt to elucidate how neoliberalism creates a specific culture and ethics of medicine that may be deleterious to patient welfare. 

What are the practical implications for healthcare and health policy?

Neoliberalism is deeply entrenched into the political, economic, and social fabric of America. Until seismic shifts in the political system occur, there will be few opportunities to mitigate the deleterious effects of neoliberalism in health and other areas. Advocacy for policies such as Medicare for All are a start. However, my research has found that there are things that individual institutions can do to mitigate and shelter their clinicians and staff from the worst effects of neoliberalism such as incentivizing and rewarding metrics focused on clinical best practices rather than patient satisfaction. 

A customer service orientation towards health care changes the focus towards providing a service where clinicians are evaluated by how well their patients are satisfied with their service rather than clinically focused metrics. This is not to say that patient satisfaction is not something to aspire to. This ethos becomes problematic when nurses are preoccupied with providing service amenities at the expense of focusing on medical care or when physicians worry about not prescribing opioids or giving bad news so as not to affect their patient’s satisfaction.

How do the things you are thinking about pertain to the challenges facing the world today?

We are clearly in a deeply divided and concerning moment in American history. For too long, our politics and economy has been driven by those with power and money. America today benefits corporations and the rich, rather than the everyday American. The ideology of neoliberalism has pervaded every aspect of the American psyche such that we all accept that our healthcare system is built to benefit insurance companies and pharmaceutical companies at the expense of American lives. Hospitals and thus physicians are incentivized to avoid patients who are from disadvantaged groups. Those who are least able to benefit from these neoliberal systems are frequently people of color who further experience structural racism stemming from histories of racial discrimination as well as capitalist systems that were intentionally created to benefit the dominant majority. 

The COVID-19 pandemic has shone a stark light on how neoliberal policies are directly responsible for the deaths of thousands of Americans. When an economic system is driven towards ever greater efficiency at the expense of public health and the greater good, that system has no resilience in times of crisis. Over a decade ago, the US Public Health system contracted a small company, Covidien, to build a national stockpile of inexpensive, portable ventilators to deploy in a future respiratory pandemic. This company was bought by a larger company who decided to abandon that government contract because it was unprofitable. We are paying the price today. Neoliberal policies are incompatible with the priorities of public health and the right to healthcare. Until we confront the underlying cause of our society’s ills, we will only be skirting around the edges with incremental and inadequate solutions. 

How do you see this work building from your previous work, or from previous collaborative endeavors?

My doctoral research focused on how institutional ethical frameworks, in particular around best interest (beneficence) and patient autonomy, influenced physician communication practices around end-of-life decision-making. My current work is a natural extension of that work, as the primacy of patient choice and individualism is an inherently American and neoliberal mindset. In my doctoral research, I found that physician trainees at institutions (hospitals) where patient autonomy was the dominant ethical framework had a reductionist notion of autonomy to mean patient choice and felt more uncomfortable making clinical recommendations against potentially non-beneficial life-sustaining treatments near the end of life such as resuscitation (CPR). In contrast trainees at institutions that were more best interest focused felt more comfortable recommending against treatments that would not benefit the patient near the end of life. This prior research demonstrates the importance of institutional cultures and policies on individual physician practices and ethical attitudes.