A new case-based session covers common ethical conflicts medical students encounter during their clinical rotation.
David Oxman, MD, FACP, HEC-C, is an associate professor of medicine in Jefferson’s division of pulmonary, allergy and critical care medicine. He’s also the ethics and professionalism thread director at Sidney Kimmel Medical College and runs the ethics consultation service at Thomas Jefferson University Hospital.
A woman who recently suffered a stroke needs a temporary feeding tube for nutrition. She cannot speak but vigorously resists a doctor’s attempt to place the tube. Should the physician continue with the procedure or stop?
A man with advanced HIV is admitted to the hospital with pneumonia. He has never told his wife about his HIV diagnosis. Do the doctors have an obligation to tell her?
A young man who uses IV drugs develops severe endocarditis and recalcitrant heart failure. He needs complicated and expensive emergency heart surgery, but the surgeons worry that his drug use will just lead to reinfection. Should they offer him the operation?
These questions—all based on actual cases—are examples of real-life ethical dilemmas physicians might face in their practices. Acquiring the background, maturity and intellectual framework to wrestle with these situations is a critical part of becoming a physician.
Yet, ethics education for medical students varies significantly between institutions. Some schools have dedicated courses in medical ethics; others try to embed ethics teaching into other parts of the pre-clinical curriculum. Unfortunately, for many medical students, a glancing exposure to abstract ethical principles in the pre-clinical classroom is where their ethics education begins and ends.
In too many medical schools, ethics education during the clinical years is missing in action. This is, of course, ironic. It’s during the clinical years that students see patients in the hospital or clinic for the first time. And it’s this time when the moral conflicts that sometimes arise in medicine finally come to life.
It’s true that by the end of their pre-clinical years, most students can at least rattle off the major theoretical principles of modern medical ethics. They know about their duty to pursue the best interests of patients (beneficence); to pay special attention to avoiding harm (nonmaleficence); to appreciate and promote patients’ rights to self-determination (autonomy); and to steward limited resources and promote equity (justice).
In the real world, physicians’ ethical duties collide and compete against each other. For doctors to manage their duty to protect a patient from harm while also facilitating her autonomy requires nuance, judgment and comfort with ambiguity.
Knowing about principles is one thing; knowing how to apply them in the messy real world is another.
In the real world, physicians’ ethical duties collide and compete against each other. For doctors to manage their duty to protect a patient from harm while also facilitating her autonomy requires nuance, judgment and comfort with ambiguity. In the real world, ethical dilemmas often have more than one acceptable resolution. Frequently, it’s not about pursuing a singularly correct ethical choice. Instead, it’s finding the “most right” or the “least wrong” way to proceed.
Through the JeffMD Curriculum, the University offers the Humanities Selective “Frontiers of Medical Ethics.” The case-based course helps Sidney Kimmel Medical College students gain a deeper understanding of medical ethics and provides a philosophical framework for discussing complex ethical issues.
In addition, with the help of Dr. Jillian Zavodnick, director of the third-year internal medicine clerkship, I’ve run a small group session, “The Clinical Ethics Lunch,” for the last year for students going through their internal medicine rotation.
The case-based session covers some of the common ethical conflicts students encounter during their clinical rotation and gives them an opportunity to explore their reactions to difficult cases and struggles with developing resolutions.
The aim is to go beyond a dry recitation of ethical principles. Rather, we want to show students that just as they need encounters with real patients to develop their clinical reasoning, they need similar experiences with patients to develop their ethical reasoning skills.
Medical students also need to learn that medicine is an innately moral endeavor. Not that doctors should go around “moralizing” or be in the business of imposing their personal morality on their patients—far from it. A sensitive physician recognizes the complexity and variability of people’s ethical and moral positions.
Rather, it means that if you choose to be in the business of caring for the sick and vulnerable, sometimes you will be called to make difficult choices that test not just your intellect but also your conscience. Furthermore, if you accept the enormous responsibilities and privileges that come with being a doctor, you must understand that patients and society will look to you for more than competence and empathy. They want to know that you will always try your best to do the right thing.
We want to show students that just as they need encounters with real patients to develop their clinical reasoning, they need similar experiences with patients to develop their ethical reasoning skills.
Legendary clinician and educator Dr. William Osler said of clinical medicine, it’s “learned at the bedside, not in the classroom.” I believe the same is true of medical ethics.
Learning to manage ethical dilemmas that arise from patient care requires more than a knowledge of abstract ethical principles gleaned from philosophy textbooks. It requires a bit of what Aristotle referred to as “phronesis.”
Best translated as “practical wisdom,” phronesis is nothing less than the ability to perceive what’s required, in feeling and action, in each situation. Alas, there’s no listing in the course bulletin for phronesis, and it’s not tested by any board exam. Yet, it’s the essential ingredient, or special sauce, of managing difficult ethical conflicts.
Physicians with phronesis know that each ethical quandary they confront is more than a clash of theoretical principles. It involves real people in utterly unique situations. The wisdom needed to navigate these dilemmas well only can be acquired from direct experience and real-time mentoring.
Only when ethics education is brought out of the classroom and to the bedside can we expect the next generation of physicians to develop the skills to cope with the complex ethical problems they will face today and the novel problems of the future.