Medical, health-science students bring different perspectives to interdisciplinary ethics course
Heather Kent
CMAJ 1997;156:1317-8
[ en bref ]
Heather Kent is a freelance writer living in West Vancouver, BC.
© 1997 Heather Kent
In brief
The University of British Columbia offers a unique health care ethics course to students in 12 disciplines, including medicine. Organizers say the course addresses the "traditional separatism" in health-sciences teaching that for too long has been characterized by a lack of interdisciplinary collaboration.
En bref
L'Université de la Colombie-Britannique offre un programme unique en son genre, en éthique des soins de santé, aux étudiants de 12 disciplines, dont la médecine. Les concepteurs du programme affirment que le cours cherche à surmonter «le séparatisme traditionnel» dans l'enseignement des sciences de la santé, trop longtemps caractérisé par l'absence de collaboration interdisciplinaire.
The doctor is a highly respected and much-sought-after cardiac surgeon. He is also HIV positive, and wants to continue performing operations. In about 25% of the procedures he performs he will cut a glove, potentially putting the patient at risk of HIV infection during an invasive procedure. Should the surgeon disclose his HIV status, exposing himself to discrimination and a loss of privacy but allowing patients to make an informed choice about their surgeon? Or should he withhold his HIV status and risk having the patient contract the virus, with all of the resulting legal and social ramifications?
Ethical principles clashed with the challenges of clinical practice in this scenario, which was examined by 3 students -- 1 from nursing, 1 from physiotherapy and a graduate student in audiology -- during an interdisciplinary ethics seminar at the University of British Columbia (UBC).
The course, the first of its kind in Canada, was launched in 1993 by Dr. Alister Browne, director of UBC's Division of Health Care Ethics, and colleagues from various health care disciplines. Browne, a philosopher, says the program addresses a "traditional separatism" in health-sciences teaching that is characterized by a lack of interdisciplinary collaboration.
UBC medical students had been taught ethics in isolation from other health care undergraduates until the division opened one of its courses to nursing students. The success of that experiment encouraged Browne to offer an elective course to a broad group of health-sciences students.
Medical students currently take mandatory ethics courses during their first and fourth years at UBC, but some also sign up for the interdisciplinary course. Instructors hope that despite their heavy course load, more medical students will take the interdisciplinary course.
Browne says students in different health care fields are often ignorant of their colleagues' ethical perspectives and the codes that guide their professional behaviour. However, all health care professionals experience ethical dilemmas and every significant health care decision has an ethical component.
Browne and his colleagues felt there was a pressing need for a course that offered a shared approach to decision-making. They hope graduates educated in this context will bring effective ethical decision-making to the workplace. Carson Cooledge, a social worker who was one of the course organizers, says the awareness of other professionals' perspectives offers a multidisciplinary framework for clinical practice. "When you run into difficult decisions, you pool knowledge and skills."
The course, which has expanded since 1993, now is offered to undergraduate and graduate students in medicine, nursing, dentistry, dental hygiene, pharmaceutical sciences, rehabilitation science, audiology and speech science, social work, health care administration, laboratory science, nutrition science and law. Practising health care professionals may also attend. A flexible quota system for each discipline determines class makeup.
The number of students applying each year and graduates' evaluations of the course are signs of the program's success. Glenn Campbell took the course as a second-year medical student because he wanted to learn about the dynamics of interdisciplinary interaction, particularly in issues such as euthanasia and patient rights. He found that the differing viewpoints across disciplines were "not as big as he expected," and realized that physicians "don't have the only say" in ethical decision-making.
Topics covered during the 12-week course include ethical decision-making and alternative approaches, patient autonomy and truth telling, treatment and nontreatment decisions, confidentiality, the obligation to disclose and treat, and resource allocation. Course material describes established ethical principles, and is supplemented with literature illustrating their application in actual cases.
The organizers wrote their own textbook, which has been available to other Canadian medical schools since 1995. The course features lectures and expert panel presentations, plus small-group seminars on clinical ethical scenarios selected from a casebook containing 44 cases. In past years ethical problems relating to medicine were brought to life by actors playing the role of patients, but this has been discontinued for budgetary reasons. Students also study ethical codes from 11 health care professions.
Teaching is done by instructors from different disciplines who have special training in ethics. Seminars are led by 2 tutors -- a health care practitioner with extensive clinical experience and someone with special expertise in ethics.
Frank Archer, a pharmacy consultant and medical ethics instructor who has taught the course since its inception, says students are very interested in truth-telling and patient-autonomy issues. He adds that "hard-science" students such as medical students are more likely to look for definitive answers to ethical dilemmas, while "softer-science" students, such as those in social work, may be more accustomed to dealing with issues that have no clear solution. Archer says hard-science students have to realize that the resolution is "just a judgement that has been reached."
The fact decision-making is shared by people from several backgrounds enhances the process, says Archer. "[It] surprises a lot of people that there is a lot of information within the group."
The popular issues of patient/professional autonomy and informed consent are explored during debate surrounding several questions. When is consent fully informed? Who is responsible for securing consent? Is there a morally relevant difference between withholding information and lying? Professional autonomy also covers the issue of futile treatment. Students are made aware of the differences between value-free judgements in physiologically futile cases and value-laden judgements when treatment may be deemed not worth while for the patient or society.
Archer says his role is to gather all available facts in a case and offer guidance "in a classical ethical sense." He also plays devil's advocate when this is appropriate.
"Teasing out" classical ethical principles and exploring them thoroughly makes the teaching interesting, he says. This may also involve separating prejudice from principle in a clinical situation. In discussing a case where a doctor had asked a nurse to search a patient's hospital room for possible undisclosed drugs -- the question was whether it is ethical to search patients' belongings without their permission -- Archer asked the students whether it made a difference if the drugs concerned were laxatives or illegal narcotics. "Is it the principle or the drug?" he asked. He pointed out that in one downtown Vancouver hospital heroin was often bought into wards when addicts were admitted, since the habit did not end at the hospital door; students recognized that the ethical principle may not be upheld as vigorously if the drug being sought is heroin.
Instructors and students generally agree that the multidisciplinary approach is the best route to ethical problem-solving in clinical cases, and that the health care team will be strengthened as a result.
UBC's course, available to students in 12 disciplines, remains unique in Canada, although the University of Toronto's Joint Centre for Bioethics offers a graduate program that serves students from several fields, including nursing, law, religious studies and community health. Dr. Peter Singer, the centre's director, says that "exciting discoveries occur at the interface of disciplines" and faculty are considering opening an undergraduate medical ethics course to more health care disciplines.
As for the scenario involving the HIV-positive surgeon, the French health ministry reported in January that a surgeon at a hospital near Paris "almost certainly" infected a patient during an operation 5 years ago. The surgeon, who had been infected during an operation, was unaware of his HIV status until 1994. He no longer performs surgery.
 |
Send a letter to the editor responding to this article
Envoyez une lettre à la rédaction au sujet de cet article |
Features