Nancy Neveloff Dubler, a medical ethicist who pioneered using hospital-bedside mediation to navigate the complex dynamics between stubborn doctors, distraught family members and patients in their final days, died April 14 at her Upper West Side home. Manhattan. He was 82 years old.
The cause was heart and lung disease, her family said.
A Harvard-educated lawyer who won her student body presidency by campaigning to dismantle the student government, Ms. Dumbler was a revolutionary health figure who sought, in her words, to “level the playing field” and to “amplify the non-medical voices” of pathological medical conditions, especially when deciding next steps for the sickest patients.
In 1978, Ms. Dubler founded the Bioethics Advisory Service at Montefiore Medical Center in the Bronx. Among the first such groups in the country, the agency employed lawyers, bioethicists and even philosophers who, like doctors on call, carried pagers alerting them to urgent ethical issues.
Bioethics consultants emerged as a medical subspecialty following groundbreaking advances in technology, pharmaceuticals, and surgical techniques.
“Our technology now allows us to provide several decades of healthy and productive life through procedures such as cardiac catheterization or triple bypass surgery,” Ms. Dubler wrote in her book. But it also allows us to take a body with a massive brain bleed, hook it up to a machine and keep it nominally ‘alive’, functioning organs in a bed, with no hope of recovery.”
Such developments can lead to friction among doctors, who have been trained for generations to keep patients alive with whatever tools are available. family members, who may fight over their often incapacitated loved ones. and hospital administrators, who may fear lawsuits.
The questions Ms. Dumbler and her team faced were complex and heartbreaking.
Should a premature baby who is unlikely to survive be intubated? Should an unconscious patient whose religious beliefs prohibit blood transfusions receive one because a family member demands it? Should a teenager be allowed to leave excruciating treatment for terminal cancer?
“Nancy brought a human face to bioethics that focused on empathy and inclusion and really bringing a voice to those who didn’t have one,” Tia Powell, who succeeded Ms. Dumbler at Montefiore, said in an interview.
Mrs. Dumbler’s first tactic for entering these discussions was to sit down with the families.
“They were in the hospital for who knows how long,” he said during one presentation at Columbia University in 2018, “and no one ever sat down to talk to them” — especially doctors. “They run in and finish and look almost the same in their white coats.”
Often, Ms. Dubler encountered family members who did not want their loved ones to know that they, the patients, were terminally ill.
In one essay for Hastings Centrea bioethics research institute in Garrison, New York, Ms. Dubler recalled a case involving an elderly man who was critically ill but was breathing independently after being removed from a ventilator.
The man was clearly dying, but his sons did not want to include him in discussions with hospital staff about further life-prolonging measures.
“I met with the sons and explained that the team felt compelled to have a discussion with their patient about the type of care he would like in the future,” Ms Dubler wrote. “The sons exploded, saying this was unacceptable.”
Mrs. Dumbler—impassioned, but steely—continued the conversation.
“After much discussion about the patient and what a wonderful man and dad he was,” she wrote, “I asked how it would be if I opened a conversation with him with three questions: ‘Do you want to discuss your future care with me?’ Would you like me to talk to your sons about future care? And you want to have this conversation without your sons present?”
The sons worried that such a conversation would give their father away to the fact that he was dying. What was needed, they thought, was hope.
“I described studies showing that when family members try to shield the patient from bad news, the patient usually knows the worst, and silence often translates into feelings of abandonment,” Ms. Dubler wrote.
This disturbed the sons. He approached the man’s bed.
“The patient was clearly very weak and tired,” Ms Dubler wrote. “I asked the patient if, since he had recently been intubated, he would agree to be intubated again if the doctors thought it was necessary. He said, “I would think about it.” The sons said they would think about it too.”
The process worked.
“The complete conflict over whether to ‘tell dad’ subsided,” she wrote. “Mediation in this case worked with the sons to create an approach to their father that they could tolerate, if not embrace.”
Nancy Ann Neveloff was born on November 28, 1941, in Bayport, New York, on the south shore of Long Island. Her parents, Aaron and Bess (Molinoff) Neveloff, had a drug store below their home.
As a student at Barnard College, she studied religion with a focus on Sanskrit. While there, she ran for campus president as a one-issue candidate.
“She won in a landslide and she really took down the student government,” her classmate, Nancy Piore, said in an interview. (Eventually restored.)
Mrs. Piore recalled that she had once seen Mrs. Dumbler reading a James Bond novel in her academic clothes. “She was a character,” he said, “and she was a real force.”
After graduating in 1964, she studied law at Harvard, where she met Walter Dubler, a recent Ph.D. degree in English, at a New Year’s party. These married in 1967, the year he graduated, and moved to New York, where he worked as a lawyer for prisoners, juvenile delinquents and alcoholics.
“If Nancy and I were going to do something after work, I would meet her at the men’s shelter,” Mr. Dumbler said in an interview. “But after one meeting there, I told her I was too stingy and would meet her somewhere else. But she really liked that thing.”
He joined Montefiore in 1975 to work on legal and ethical issues and formed the Bioethics Advisory Service three years later.
In addition to her work at the hospital, Ms. Dubler advocated for equal access to medical care for prisoners. He also served on committees that devised ethical procedures for stem cell research and the allocation of ventilators in case of shortages.
Besides her husband, she is survived by a daughter, Ariela Dubler. a son, Josh Dubler; and five grandchildren.
Ms. Dubler’s colleagues suggested that her greatest legacy was the creation of a certificate program at Montefiore to train doctors, nurses and hospital staff in bioethics.
One of the program’s graduates, a doctor, was at Ms. Dumbler’s bedside in hospital when, in her final months, she gathered her medical team and family around her to declare that she was going home and not coming back.
“He was clearly in awe of her,” Mrs. Dubler’s son-in-law, Jesse Furman, a federal judge in the Southern District of New York, said of the doctor. “She saw how, even in her weakened state, she was able to be in control of her treatment and death.”
The doctor told her he was honored to be there for her.