Medical education must make room for student-specific ethical dilemmas
Joye St. Onge
CMAJ 1997;156:1175-7
[ en bref ]
Joye St. Onge is a third-year medical student at Queen's University, Kingston, Ont.
© 1997 Canadian Medical Association (text and abstract/résumé)
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In brief
Most contemporary undergraduate courses in medical ethics leave a critical gap unfilled because they fail to address student-specific issues, says third-year student Joye St. Onge. In this article, which won third prize in CMAJ's 1996 Dr. William Logie Medical Ethics Essay Contest, St. Onge outlines the importance of discussing student-specific ethical dilemmas and suggests ways to introduce such teaching in medical schools.
En bref
La plupart des cours modernes en éthique médicale laissent une lacune critique dans la formation en n'abordant pas des enjeux particuliers aux étudiants, affirme Joye St. Onge, étudiante de troisième année. Dans cet article, qui s'est mérité le troisième prix au Concours Dr William Logie de dissertation en éthique médicale de 1996 organisé par le JAMC, Mme St. Onge décrit l'importance de discuter de dilemmes éthiques particuliers aux étudiants et propose des façons de mettre en œuvre de tels cours dans les facultés de médecine.
The role of ethics courses in undergraduate medical education has expanded significantly in recent years. However, a critical gap exists in most contemporary curricula because of a failure to address student-specific issues.
Medical students receive formal instruction in the principles of beneficence, nonmaleficence, justice and respect for autonomy and learn to apply these basic tenets to the ethical dilemmas they will face as physicians. They discuss weighty issues such as withdrawal or withholding of life-sustaining treatment, reproductive technologies, confidentiality, informed consent, the right to refuse treatment and allocation of scarce resources. However, the education system largely ignores the ethical dilemmas medical students repeatedly encounter during training.
These may not be as important to society as the situations they will face in practice and the consequences of choosing an ethically questionable alternative may be less critical. As well, most of these questions will vanish once the student attains the skills and full authority of a licensed physician. Nonetheless, treating these dilemmas simply as necessary rites of passage is neither defensible nor desirable, and is potentially harmful to students' moral development.
Christakis and Feudtner identified several ethical dilemmas that medical students confront[1] and made a quantitative investigation of these experiences in a survey mailed to clinical clerks.[2] Pressure to "fit in with the team," reported by 40% of respondents, was a prominent contributing factor in self-perceived unethical conduct. For example, the "team-player" ethos interfered with a student's willingness to object when asked to update the histories of patients who had not been seen by the overworked resident.
The notorious hierarchical structure of the health care team magnifies many student dilemmas that would not cause so many problems in a different setting (or if the students were in a different position in the pecking order). Witnessing and/or feeling compelled to participate in unethical behaviour was reported by 61% of survey respondents. Many students conclude that, given their inferior status and relative ignorance of the tacit ground rules, "squealing" is not even an option.
Fear of jeopardizing an evaluation was also a serious concern for 40% of respondents. In learning new procedures students often inflict pain or discomfort, which contradicts the foremost aim of caring for patients. At some point, every student must formulate personal guidelines that limit how many attempts and how much patient distress can be justified for the sake of gaining clinical experience. And while medical students are not allowed to give diagnoses to patients, they may see and be questioned by a patient about test results or findings in the period before confirmation and communication of a diagnosis. Fully 53% of respondents felt obliged to mislead patients, either by withholding information or lying.
Ethical dilemmas or valuable experience?
The issues students must deal with are sometimes perceived not as ethical dilemmas but as necessary prerequisites for travelling along the path to licensure. Often such situations are not even acknowledged as problems. However, as Kass explained, "every human encounter is an ethical encounter, an occasion for the practice (and cultivation) of virtue and respect, and, between doctors and patients, for the exercise of responsibility and trust, on both sides."[3] Issues such as assisted suicide and surrogate pregnancy understandably garner the most attention, yet their dominance of the ethical debate obscures the morality of medicine's everyday events.
In addition to the transient nature of many of these student-specific issues, other arguments may be used to dismiss them. Most practising physicians, who received much less formal schooling in moral reasoning than today's students, exemplify admirable ethical values. The physical and mental strain of clerks and residents is well recognized[4] and certain unethical behaviours might be essential coping mechanisms practised only for that transient period.[5]
We do not live in an ideal society, and it is misleading to promote the belief that those who always do what they morally ought to do will not be placed at a disadvantage by those who put self-interest first. But such arguments miss the point and in no way excuse the disregard shown for student-specific ethical issues. Some, ironically, even illustrate where ethics education is deficient. I do not seek to transform the medical establishment into an utopian system but rather to limit the number of unethical behaviours acquired through convention and habit and to improve the present situation for everyone.
Kass argued that contemporary bioethics focuses too much on rational theory with the intent of applying the derived principles to practice and not enough on what genuinely motivates people to act.[3] However, Beauchamp and Childress maintained that conflicts between moral requirements and self-interest are not moral but rather practical dilemmas because what ought to be done is usually obvious.[6] While I agree with that conclusion, why don't practical dilemmas deserve as much attention as moral dilemmas, especially since they are so ubiquitous throughout medical training?
And even though many students may be able to resolve ethical problems without a detrimental effect, a large proportion may not: 62% of respondents in the survey by Feudtner and colleagues believed that at least some of their ethical principles had been eroded or lost.[2]
Some argue that students' basic moral character has already been determined when they enter medical school and that those who devalue ethical reasons in practical dilemmas during clinical-training years do so because of the type of person they were upon admission. Screening at the point of application could be considered an appropriate and adequate solution. The shift in emphasis from academic criteria to personal expression in interviews, essays, references and extracurricular activities supposedly weeds out candidates with unacceptable character traits, but it is gratuitous to presume that selected applicants who possess healthy moral attitudes will retain them throughout medical school.
Among medical students at the University of Toronto, sensitivity to ethical issues was shown to rise in first and second year, then drop in third and fourth year.[7] The assumption that a student's ethical values may waver but will resist permanent change does not account for the diversity of individual hopes, fears, weaknesses, strengths and life experiences that largely determine one's susceptibility to unethical conduct. Furthermore, learning experiences can vary greatly among students in the same class because of differences in clinical settings, instructors and subjective interpretation of events.
The internal moral struggles of students may be de-emphasized because the negative attitudes that develop during undergraduate years tend to fade with sustained clinical exposure.[8] But why should such attitudes, even if they are temporary, be blindly accepted? Several years spent favouring self-interest over ethical reasoning will have a lasting impact, even if the choice rarely affects anyone besides the student. Oakeshott said ethical knowledge is acquired in 2 ways: by philosophic reflection and thoughtful application of moral ideals, and through habit of behaviour and unconscious adherence to the tradition of conduct to which one is exposed.[9]
If derisive comments about patients are commonplace, the student may assume that such behaviour is acceptable. The high correlation between cheating during undergraduate education, cheating in medical school and falsification of patient information during clerkship also can be interpreted in 2 ways: either the undergraduate student who cheats is basically unethical, and therefore would have no qualms about falsifying records, or the prevalence and acceptance of cheating in university propagates the habit and allows its transference to medical school and patient care.[10]
I believe that the latter situation prevails, because the first implies that nearly 90% of all undergraduate students -- the proportion that admits to cheating[11] -- are fundamentally unethical. Under either interpretation, the practice of falsifying records could be prevented. The person whose values might endanger future patients could be confronted, and offered counselling; and the perpetuation of academic dishonesty from one scenario to the next through unconscious habit could be interrupted with appropriate attention.
Academic dishonesty -- including bluffing about details concerning patient histories, physical examinations or laboratory data in reports to more senior staff -- becomes more tempting as the pressure to obtain an outstanding evaluation intensifies. Today's heightened competition for entry into medical school and eventually popular residency positions are important considerations, since they counteract positive influences such as character-based admission criteria and ethics education.
Alternative ways to teach ethics
Student-specific dilemmas may be of secondary importance in ethics education because the primary goal of medical school is to prepare students by teaching the skills and knowledge they will need as doctors. However, ethics is not physiology, and it is not necessary to teach ethics and disease in the same manner. The organization of bioethics into theories, principles and representative cases ensures that essential points are covered and clarifies the philosophical fuzziness of the discipline. However, there are alternative ways to teach ethics that could incorporate student-specific issues, supplement traditional instruction and probably enhance interest as well.
More emphasis should be placed on practical dilemmas, for these pervade ordinary practice as well as the clinical training period. This would involve an examinination of fundamental human nature and identification of what causes us to act improperly. The complex interaction between ethical values and human nature is as important and relevant to medical practice as knowledge of the principles of bioethics. Discussions should be based on situations that medical students encounter, since this would make the ethical reasoning outlined in the session more relevant.
Educators have noted that when students direct discussion in small-group sessions, the focus shifts from traditional topics to student-specific dilemmas and the discussion takes on a new vitality.[1,12] Currently students are taught how to apply basic principles to extreme cases, and it is assumed that they will be able to use this skill when dealing with more common dilemmas. Would not the reasoning skills acquired through evaluation of student dilemmas be similarly useful?
The ethical learning acquired by habit and by conforming to the surrounding culture might be optimized and improved by addressing weaknesses within the hospital environment. Unethical practices such as the use of derogatory language when referring to patients could be firmly discouraged, and acts of moral integrity and honesty could be rewarded consistently. Simply recognizing student-specific dilemmas as ethical problems would be a welcome change from "grin-and-bear-it" attitudes. Neglect of student dilemmas implies that they are insignificant and that the anxiety they provoke is unjustified or an over-reaction.
Acknowledging that mental distress is normal and expected in these situations may not solve the dilemmas, but it is reassuring to be told and understand that one's ethical sensitivity is appropriate.
Finally, there are practical, teachable "people" skills that can be useful. For example, a student who knows how to interact rationally with a "difficult" patient is less likely to use deceit in order to gain compliance. Knowing how to speak out tactfully in an ethically compromising situation is also a valuable interpersonal skill that can be learned.
While no tragedy will result if these ideas are ignored, there is much room for improvement in medical-ethics education. Those who design curricula should appreciate the importance of practical ethics and mundane student-specific dilemmas as much as theoretical ethics and challenging physician-specific dilemmas.
A dual approach would not only enhance the learning experience for the student but would also help prevent the loss of ethical integrity and the acquisition of undesirable moral habits in medical school.
References
- Christakis DA, Feudtner C. Ethics in a short white coat: the ethical dilemmas that medical students confront. Acad Med 1993;68:249-54.
- Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students' perceptions of their ethical environment and personal development. Acad Med 1994;69:670-9.
- Kass LR. Practising ethics: Where's the action? Hastings Cent Rep 1990;20(1):5-12.
- Silver HK, Glicken AD. Medical student abuse: incidence, severity, and significance. JAMA 1990;263:527-32.
- Lief HI, Fox RC. The medical student's training for 'detached concern'. In Lief HI, Lief VF, Lief NR (eds): The psychological basis of medical practice, Harper and Row, New York, 1963, 12-35.
- Beauchamp TL, Childress JF. Principles of biomedical ethics, 4th ed, Oxford Unniversity Press, New York, 1994.
- Hebert PC, Meslin EM, Dunn EV. Measuring the ethical sensitivity of medical students: a study at the University of Toronto. J Med Ethics 1992;18:142-7.
- Reinhardt AM, Gray RM. A social psychological study of attitude change in physicians. J Med Educ 1972;47:112-7.
- Oakeshott M. The Tower of Babel. In Oakeshott M (ed): Rationalism in politics and other essays, Basic Books, New York, 1962, 59-79.
- Sierles F, Hendrickx I, Circle S. Cheating in medical school. J Med Educ 1980;55:124-5.
- Smith C, Ryan E, Diggins D. Moral decision making: cheating on examinations. J Pers 1972;40:640-60.
- Osborne LW, Martin CM. The importance of listening to medical students' experiences when teaching them medical ethics. J Med Ethics 1989;15(4):35-8.
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