Fourth Year Medical Fourth Year Medical Ethics Ethics

2pm, Oct 312pm, Oct 31stst 2008 2008AMNCHAMNCH

Dr. Martin DyarDr. Martin DyarEthics and the Medical Student: Standards Ethics and the Medical Student: Standards

and Challenges,and Challenges,Including a Narrative Ethics ExerciseIncluding a Narrative Ethics Exercise

(See also accompanying handout)(See also accompanying handout)

‘‘The Scalpel’ The Scalpel’ They’d stunned me groggy with Demerol and bland They’d stunned me groggy with Demerol and bland assurances, but I could see it: a dour adolescent scythe.assurances, but I could see it: a dour adolescent scythe.100 I’d hate to see that 99 tad when it grows 98100 I’d hate to see that 99 tad when it grows 98up. And here’s what else I saw: my glowing corpseup. And here’s what else I saw: my glowing corpse

amidst a huddle of apprentice docs – this is a teaching amidst a huddle of apprentice docs – this is a teaching hospital I’ve died in. Of course I can’t hear a wordhospital I’ve died in. Of course I can’t hear a wordthey’re saying. ‘Let him be a lesson to you?’ ‘What didthey’re saying. ‘Let him be a lesson to you?’ ‘What didhe do to be so black and blue?’ I’m now curriculumhe do to be so black and blue?’ I’m now curriculum

to them, though to the scalpel I’m the sweetest dream to them, though to the scalpel I’m the sweetest dream that labour knows. And to myself? I’m like a dwindling that labour knows. And to myself? I’m like a dwindling star. I watch the energy leap off me in tarry blobsstar. I watch the energy leap off me in tarry blobsand writhing spurts of flame. How can they stand so close?and writhing spurts of flame. How can they stand so close?

So this is what I came to, this last pyrotechnic dither.So this is what I came to, this last pyrotechnic dither.The last imploding gleam of me winks out, reflectedThe last imploding gleam of me winks out, reflectedby the scalpel. That’s a nice touch, I think, that mortalby the scalpel. That’s a nice touch, I think, that mortalflashbulb fading, first on the blade, then on the retina. flashbulb fading, first on the blade, then on the retina.

William MathewsWilliam Mathews

Lecture outlineLecture outline

Standards: principles for med students (an Standards: principles for med students (an exemption?)exemption?)

Challenges: typical concerns, harms, moral distressChallenges: typical concerns, harms, moral distress Hidden curriculum: relationships with clinical Hidden curriculum: relationships with clinical

teachers, role models, challenging authority, ethical teachers, role models, challenging authority, ethical erosion, professional distance and the idea of erosion, professional distance and the idea of dehumanisation.dehumanisation.

Maintaining integrity, wellbeing, addressing Maintaining integrity, wellbeing, addressing challengeschallenges

Medical Humanities: Narrative Ethics, and the idea Medical Humanities: Narrative Ethics, and the idea of a professional engagement with the arts. of a professional engagement with the arts. Enhancing Ethical perceptions?Enhancing Ethical perceptions?

Ethics and the medical studentEthics and the medical student

Halfway between the layperson and the Halfway between the layperson and the medical professional. The need for a medical professional. The need for a specific set of principles? (BMA on specific set of principles? (BMA on detachment)detachment)

Tending to conform? The experience of Tending to conform? The experience of passivity and suspension may distract passivity and suspension may distract from ethical substance of experience, from ethical substance of experience, and may undermine ethical agency. and may undermine ethical agency. Principles: a set of dormant gods? Principles: a set of dormant gods?

Learning before healing and care? Learning before healing and care? (Gawande)(Gawande)

Gawande on the idea of the noviceGawande on the idea of the novice

‘‘A patient’s right to the A patient’s right to the best care possible must best care possible must trump the objective of trump the objective of training novices. We training novices. We want perfection without want perfection without practice. Yet everyone practice. Yet everyone is harmed if no one is is harmed if no one is trained for the future. trained for the future. So learning is hidden, So learning is hidden, behind drapes and behind drapes and anaesthesia and the anaesthesia and the elisions of language’ elisions of language’ ComplicationsComplications, p. 24, p. 24

AMNCH 2008

For medical students, are principles dormant until after graduation, when fuller responsibilities are involved?

MOUNT

AUTONOMY

Some principles of med student Some principles of med student ethicsethics

(1) Respecting the needs, values (1) Respecting the needs, values and culture of patients you and culture of patients you encounter during your trainingencounter during your training

CommunicationCommunication

Cultural awareness/humility, Cultural awareness/humility, discrimination: discrimination: constant expansionconstant expansion

Vulnerability: autonomy, supportVulnerability: autonomy, support

(2) Patients and their families: (2) Patients and their families: exploitation?exploitation?

Patient well being above all elsePatient well being above all else Generosity, financial gainGenerosity, financial gain Sexual relations. Medical Council Guide: Sexual relations. Medical Council Guide:

3.113.11 Representing yourself, or allowing Representing yourself, or allowing

yourself to be represented, as a more yourself to be represented, as a more qualified member of the healthcare team qualified member of the healthcare team (phenomenology? shame, exhilaration? (phenomenology? shame, exhilaration? Gawande: ‘the elisions of language’)Gawande: ‘the elisions of language’)

(3) Confidentiality(3) Confidentiality

Scope of obligationScope of obligation Breaching confidentiality in the Breaching confidentiality in the

patient’s interestpatient’s interest Medical records and disposal of Medical records and disposal of

student notesstudent notes Greater likelihood of patient Greater likelihood of patient

openness to medical students?openness to medical students?

(4) Informed consent and medical (4) Informed consent and medical trainingtraining

Information: purpose and nature of ‘any Information: purpose and nature of ‘any proposed interaction’ (AMSA) ‘Any proposed interaction’ (AMSA) ‘Any touching …’ (BMA)touching …’ (BMA)

Coercion: presumption. Examination for Coercion: presumption. Examination for student benefit?student benefit?

Withdrawal of consent: unique expectation Withdrawal of consent: unique expectation of sustained participation. Reassurance of of sustained participation. Reassurance of no impact on healthcare. Nuisance factor?no impact on healthcare. Nuisance factor?

Approaching the patient in groupsApproaching the patient in groups Language barriers, and the impeding of Language barriers, and the impeding of

communication by illnesscommunication by illness Anesthetised and sedated patientsAnesthetised and sedated patients

(5) An awareness of the limits of (5) An awareness of the limits of the medical student role in the the medical student role in the

clinical settingclinical setting Advice and information beyond one’s Advice and information beyond one’s

knowledge and expertiseknowledge and expertise Giving information about illness or Giving information about illness or

prognosis that has not already been prognosis that has not already been explained by a professional explained by a professional responsible for that patientresponsible for that patient

Except in an emergency medical Except in an emergency medical students should not initiate any form students should not initiate any form of treatmentof treatment

(6) Relationships with clinical (6) Relationships with clinical teachersteachers

Respectful interaction, developing Respectful interaction, developing relationships: acknowledging relationships: acknowledging commitment and inputcommitment and input

Adjusting to a varying quality of Adjusting to a varying quality of experience, contributing to the experience, contributing to the institutional culture, rationalising institutional culture, rationalising disappointment. Ethical impact of disappointment. Ethical impact of these? these?

The broader healthcare team The broader healthcare team Addressing difficulties with staffAddressing difficulties with staff

(7) Personal integrity and well-(7) Personal integrity and well-beingbeing

‘‘Medical students should ensure that their Medical students should ensure that their physical and mental health enables them physical and mental health enables them to relate effectively with patients to relate effectively with patients andand professional staff’ (AMSA)professional staff’ (AMSA)

Moral conscience and participation: a Moral conscience and participation: a right to abstainright to abstain

Contributing to teaching, course Contributing to teaching, course developmentdevelopment

Awareness of and reflection on ethical Awareness of and reflection on ethical development: moral erosion, role-models, development: moral erosion, role-models, hidden curriculumhidden curriculum

Maintaining integrity: some Maintaining integrity: some important conceptsimportant concepts

Hidden Hidden curriculum/role curriculum/role modellingmodelling

Ethical erosionEthical erosion DehumanisationDehumanisation ‘‘Primum non Primum non

tacere’tacere’ A discourse of A discourse of

student ethicsstudent ethics

The professional disregard of The professional disregard of ethical principlesethical principles

In a survey of a group of Canadian In a survey of a group of Canadian medical students, half reported medical students, half reported pressure to act unethically and 60% pressure to act unethically and 60% had observed unethical conduct in a had observed unethical conduct in a clinical teacher. A majority of these clinical teacher. A majority of these felt ‘impotent in the face of these felt ‘impotent in the face of these circumstances because of the circumstances because of the teacher’s intimidatory attitude’ teacher’s intimidatory attitude’ (Hicks et al 2001)(Hicks et al 2001)

Common types of ethical difficulty Common types of ethical difficulty for medical studentsfor medical students

1.1. Conflict between the priorities of medical education and those of Conflict between the priorities of medical education and those of patient carepatient care

Examples: Patients asked to return to clinic for follow up visits, not Examples: Patients asked to return to clinic for follow up visits, not informed that the visits were entirely for teaching purposes. Student informed that the visits were entirely for teaching purposes. Student instructed to perform femoral puncture on a comatose patient for instructed to perform femoral puncture on a comatose patient for purely educational reasons. Patient’s name and details of care purely educational reasons. Patient’s name and details of care discussed by staff and students in a public place. Students distressed discussed by staff and students in a public place. Students distressed by patient presence in seminar, where accounts of illness and mortality by patient presence in seminar, where accounts of illness and mortality appear overly candid.appear overly candid.

2.2. Responsibility beyond a student’s capacitiesResponsibility beyond a student’s capacitiesExamples: Seniors refuse to assist student in assessing an unstable Examples: Seniors refuse to assist student in assessing an unstable patient. Student left by teacher to close wound, without knowing how patient. Student left by teacher to close wound, without knowing how to close it properly. Student completed antenatal visits with patients to close it properly. Student completed antenatal visits with patients who were never seen by a doctor.who were never seen by a doctor.

3.3. Involvement in patient care perceived to be substandardInvolvement in patient care perceived to be substandardExamples: Student witnessed house officer responding inappropriately Examples: Student witnessed house officer responding inappropriately to patient’s refusal to have joint aspiration; consent form completed but to patient’s refusal to have joint aspiration; consent form completed but consent not meaningfully given. Patient requested a narcotic-free consent not meaningfully given. Patient requested a narcotic-free vaginal delivery but given intravenous narcotics without her vaginal delivery but given intravenous narcotics without her knowledge. (Hicks et al 2001)knowledge. (Hicks et al 2001)

There are many ethical concerns There are many ethical concerns in medical training. Why is it in medical training. Why is it

difficult to speak up?difficult to speak up? Fear associated with exams Fear associated with exams

and referencesand references Taboo in professional Taboo in professional

culture surrounding the culture surrounding the questioning of a seniorquestioning of a senior

A culture of protecting one A culture of protecting one another. Related to a siege another. Related to a siege mentality regarding the mentality regarding the legal professionlegal profession

Confidence: perhaps I am Confidence: perhaps I am not able to tease out all the not able to tease out all the aspects?aspects?

BMA on med ed: ‘A positive BMA on med ed: ‘A positive emotional and social emotional and social learning environment learning environment should be created to should be created to encourage cooperation and encourage cooperation and collaboration’ (p.650)collaboration’ (p.650)

Rationalisations related to Rationalisations related to non-confrontational non-confrontational attitude: 1) Am I justified? attitude: 1) Am I justified? I too may one day act I too may one day act unethically. 2) the unethically. 2) the common plight. ‘Is it not common plight. ‘Is it not understandable that a understandable that a doctor sometimes, in a doctor sometimes, in a state of frustration or state of frustration or fatigue, may fail to fatigue, may fail to maintain optimal ethical maintain optimal ethical standards?’ (Botch 2003) standards?’ (Botch 2003)

‘‘The failure to speak up in The failure to speak up in certain situations is a certain situations is a failure of learning failure of learning andand caring’ ‘Primum non caring’ ‘Primum non tacere: First, do not be tacere: First, do not be silent’ (Dwyer 1994)silent’ (Dwyer 1994)

Witnessing unethical Witnessing unethical practicepractice

Is it possible to raise questions about the Is it possible to raise questions about the episode in an enquiring and non-episode in an enquiring and non-confrontational manner?confrontational manner?

If not, or if this proves unsatisfactory: are If not, or if this proves unsatisfactory: are there local protocols for managing problems there local protocols for managing problems of this nature?of this nature?

Are there personal tutors or mentors who may Are there personal tutors or mentors who may be able to advise?be able to advise?

Are there other senior colleagues who may be Are there other senior colleagues who may be able to give advice?able to give advice?

Would it be useful to discuss the concerns Would it be useful to discuss the concerns with fellow students to see if they agree? with fellow students to see if they agree?

It has been argued that ethical concerns in It has been argued that ethical concerns in training should mirror the ‘medical error training should mirror the ‘medical error

movement’: a blame free environmentmovement’: a blame free environment

Medical schools need to: Highlight the responsibility Medical schools need to: Highlight the responsibility of clinical staff to serve as appropriate role models of clinical staff to serve as appropriate role models to medical students and to provide them with an to medical students and to provide them with an opportunity to discuss ethical challengesopportunity to discuss ethical challenges

Require university and teaching hospitals to develop Require university and teaching hospitals to develop processes for reporting ethical concernsprocesses for reporting ethical concerns

Ensure that medical students and their tutors have Ensure that medical students and their tutors have access to individuals they can approach with ethical access to individuals they can approach with ethical problemsproblems

Ensure that when medical students express concern Ensure that when medical students express concern about ethical issues or decline to take part in certain about ethical issues or decline to take part in certain activities for ethical reasons, this will not have any activities for ethical reasons, this will not have any repercussions for them.repercussions for them.

The hidden curriculum 1 The hidden curriculum 1 (assimilation)(assimilation)

Studies indicate that moral erosion is Studies indicate that moral erosion is inevitable … By learning to recognise and inevitable … By learning to recognise and explore the types of ethical dilemma explore the types of ethical dilemma characteristic of early clinical training, we can characteristic of early clinical training, we can attempt to ‘expose and dismantle deleterious attempt to ‘expose and dismantle deleterious aspects of the hidden curriculum’ (Hicks et al aspects of the hidden curriculum’ (Hicks et al 2001)2001)

Distinction: formal and informal learning, Distinction: formal and informal learning, edicts v. example of teachers edicts v. example of teachers

Role model: can reinforce and extend lessons Role model: can reinforce and extend lessons and principlesand principles

In corridors, cafeteria, in methods and In corridors, cafeteria, in methods and manners, a contrary medical morality can be manners, a contrary medical morality can be absorbedabsorbed

The hidden curriculum 2The hidden curriculum 2

‘‘Senior colleagues may unwittingly give Senior colleagues may unwittingly give the impression that medical ethics gets in the impression that medical ethics gets in the way of good practice’ (BMA 2004) the way of good practice’ (BMA 2004) How might this effect an aspiration How might this effect an aspiration toward professionalism and confidence?toward professionalism and confidence?

‘‘When there is a discrepancy between When there is a discrepancy between what students are taught about good what students are taught about good ethico-legal practice and what they ethico-legal practice and what they experience on placement, anger, experience on placement, anger, disillusionment and cynicism may follow’ disillusionment and cynicism may follow’ (Roach 2001) (Roach 2001)

The hidden curriculum 3The hidden curriculum 3

‘‘It is essential that all doctors are It is essential that all doctors are conscious of the impact of their words and conscious of the impact of their words and behaviour on those who are learning behaviour on those who are learning [mirroring patient vulnerability/verbal [mirroring patient vulnerability/verbal sense ethos]. In terms of their own sense ethos]. In terms of their own practice, as well as their informal role as practice, as well as their informal role as teachers, doctors should ensure that they teachers, doctors should ensure that they always act in accordance with good ethical always act in accordance with good ethical practice and that they are willing to practice and that they are willing to respond to questions and challenges about respond to questions and challenges about their methods and decisions’ (BMA 2004)their methods and decisions’ (BMA 2004)

Illuminating the hidden Illuminating the hidden curriculumcurriculum

Studies indicate that moral erosion Studies indicate that moral erosion is inevitableis inevitable

By learning to recognise and explore By learning to recognise and explore the types of ethical dilemma the types of ethical dilemma characteristic of early clinical characteristic of early clinical training, we can attempt to ‘expose training, we can attempt to ‘expose and dismantle deleterious aspects of and dismantle deleterious aspects of the hidden curriculum’ (Hicks et al the hidden curriculum’ (Hicks et al 2001)2001)

Transcending erosionTranscending erosion

Chose your role models consciously: Identify qualities Chose your role models consciously: Identify qualities and style that impress, and reflect consciously on and style that impress, and reflect consciously on emulation: patience, compassion, teaching style, a emulation: patience, compassion, teaching style, a wayway with patients. The meaning of a popular consultant.with patients. The meaning of a popular consultant.

Similarly, expect to experience ethical challenges and Similarly, expect to experience ethical challenges and professional disappointment: be prepared to filter out professional disappointment: be prepared to filter out the negative influence. the negative influence.

Reflect on the potential for ethical erosion and ethical Reflect on the potential for ethical erosion and ethical enhancementenhancement

Patience, compassion, teaching style, a Patience, compassion, teaching style, a wayway with with patients. The meaning of a popular consultant.patients. The meaning of a popular consultant.

Articulate your own standards regularlyArticulate your own standards regularly Develop simple objectives for ethical development, Develop simple objectives for ethical development,

reading and discussionreading and discussion Be prepared to express your ethical concernsBe prepared to express your ethical concerns

Medical HumanitiesMedical Humanities Science can tell us nothing about an Science can tell us nothing about an

individual. Science speaks in terms of individual. Science speaks in terms of probabilities, of means and standard probabilities, of means and standard deviations, the behaviour of groups of deviations, the behaviour of groups of electrons or proteins or people, not of electrons or proteins or people, not of individual entities. Everything that makes individual entities. Everything that makes an individual an individual, eveything that an individual an individual, eveything that importantly defines an individuals life is importantly defines an individuals life is outside the realm of science. The practice outside the realm of science. The practice of medicine involves only individuals. of medicine involves only individuals. (Goodwin, cited in BMA, 660) (See also (Goodwin, cited in BMA, 660) (See also handout)handout)

Issues in Williams Mathews’ poem, Issues in Williams Mathews’ poem, ‘The Scalpel’‘The Scalpel’

The critique of the medical settingThe critique of the medical setting Medical students perceptions and sensitivities thwarted by Medical students perceptions and sensitivities thwarted by

the ‘curriculum’the ‘curriculum’ The patient’s voice and personalityThe patient’s voice and personality Contrast between patient experience and doctor experienceContrast between patient experience and doctor experience Contrast between perceptions of life and death. The patient Contrast between perceptions of life and death. The patient

luxuriates in mystery, sensation, humour, a balance of luxuriates in mystery, sensation, humour, a balance of wholeness and disintegration.wholeness and disintegration.

Medical focus on symptom, history, learning, parts, Medical focus on symptom, history, learning, parts, typologies.typologies.

Personhood is the exalted category: an enflamed presence Personhood is the exalted category: an enflamed presence and subjectivity. A subjectivity in flames. Representing the and subjectivity. A subjectivity in flames. Representing the marrow of the person, the marrow of death, the marrow of the person, the marrow of death, the phenomenology that eludes, or that is bypassed by the phenomenology that eludes, or that is bypassed by the medical gaze.medical gaze.

Negative portrayal. Contrast with Leonard Cohen’s Sisters of Negative portrayal. Contrast with Leonard Cohen’s Sisters of Mercy: praise and gratitude.Mercy: praise and gratitude.

Resisting unethical practice?Resisting unethical practice?

Ethical principles need to be fully integrated Ethical principles need to be fully integrated into doctor’s professional identities before they into doctor’s professional identities before they can begin to resist unethical practice (BMA can begin to resist unethical practice (BMA 666)666)

Medical ethics, perhaps, cannot be taught as a Medical ethics, perhaps, cannot be taught as a skill but requires an understanding of the skill but requires an understanding of the virtues that make a good doctorvirtues that make a good doctor

The centrality of virtues such as caring, The centrality of virtues such as caring, concern for others, appreciation of their concern for others, appreciation of their predicament, a proper sense of humility, and predicament, a proper sense of humility, and the ability to communicate clearly and the ability to communicate clearly and compassionately with a person while they are compassionately with a person while they are under stress under stress

A necessary distance? A necessary distance? Professionalism or Professionalism or

dehumanisation (Detachment)dehumanisation (Detachment) ‘‘An important part of medical An important part of medical

training is to help medical students training is to help medical students to develop the skills required to to develop the skills required to assist people during some of the assist people during some of the most difficult times of their lives, most difficult times of their lives, without themselves ceasing to without themselves ceasing to function either as professionals or as function either as professionals or as human beings’ (BMA 667)human beings’ (BMA 667)

A necessary distance? A necessary distance? Professionalism or Professionalism or dehumanisation 2dehumanisation 2

A period when medical students begin the A period when medical students begin the process of detachment, when some of the process of detachment, when some of the most important ethical lessons are learnt, most important ethical lessons are learnt, and habits of feeling towards patients are and habits of feeling towards patients are developed that can persist for a professional developed that can persist for a professional lifetimelifetime

Those who teach medical students have a Those who teach medical students have a responsibility to show by their words and responsibility to show by their words and example that this process of detachment can example that this process of detachment can be achieved without diminishing the respect be achieved without diminishing the respect and dignity of those who are suffering or and dignity of those who are suffering or who have died (667). Reading detachment?who have died (667). Reading detachment?

A necessary distance? A necessary distance? Professionalism or dehumanisation Professionalism or dehumanisation

33 ‘‘The healing ethos combines this The healing ethos combines this

necessary detachment with a genuine necessary detachment with a genuine concern for the individual patient, an concern for the individual patient, an attitude requiring a degree of empathy attitude requiring a degree of empathy and emotional closeness. Only when the and emotional closeness. Only when the medical ethos includes a profound medical ethos includes a profound respect for the respect for the individualityindividuality of each of each patient will it serve the true purpose of patient will it serve the true purpose of medicine – the health of the patient’ medicine – the health of the patient’ (Campbell 2001)(Campbell 2001)

Key questionsKey questions

Should a medical student always Should a medical student always question a senior? (Context)question a senior? (Context)

Should medical students always Should medical students always question each other?question each other?

Would you welcome a challenge to Would you welcome a challenge to your style of engagement with your style of engagement with patients, or an accusation of ethical patients, or an accusation of ethical laxness?laxness?

Relating to teachersRelating to teachers

‘‘An inability to take instruction or An inability to take instruction or recognise legitimate authority can recognise legitimate authority can be just as much of an impediment to be just as much of an impediment to becoming a good doctor as becoming a good doctor as obsequiousness and a suppression of obsequiousness and a suppression of critical faculties.’ (BMA Handbook, critical faculties.’ (BMA Handbook, 670)670)

The personal root of ethical The personal root of ethical perception: departing from a perception: departing from a

central conceptcentral concept I am here to learnI am here to learn I am here to provide careI am here to provide care I am here to listenI am here to listen I am here to investigateI am here to investigate I am not sure why I am hereI am not sure why I am here I am here for the rest of my lifeI am here for the rest of my life I am here for the next two weeks, I am here for the next two weeks,

then I’m out in James’s for a monththen I’m out in James’s for a month