Download Ethics-of-Medical-Training-and-Scalpel

Fourth Year Medical Ethics
2pm, Oct 31st 2008
AMNCH
Dr. Martin Dyar
Ethics and the Medical Student: Standards and
Challenges,
Including a Narrative Ethics Exercise
(See also accompanying handout)
‘The Scalpel’
They’d stunned me groggy with Demerol and bland
assurances, but I could see it: a dour adolescent scythe.
100 I’d hate to see that 99 tad when it grows 98
up. And here’s what else I saw: my glowing corpse
amidst a huddle of apprentice docs – this is a teaching
hospital I’ve died in. Of course I can’t hear a word
they’re saying. ‘Let him be a lesson to you?’ ‘What did
he do to be so black and blue?’ I’m now curriculum
to them, though to the scalpel I’m the sweetest dream
that labour knows. And to myself ? I’m like a dwindling
star. I watch the energy leap off me in tarry blobs
and writhing spurts of flame. How can they stand so close?
So this is what I came to, this last pyrotechnic dither.
The last imploding gleam of me winks out, reflected
by the scalpel. That’s a nice touch, I think, that mortal
flashbulb fading, first on the blade, then on the retina.
William Mathews
Lecture outline
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Standards: principles for med students (an exemption?)
Challenges: typical concerns, harms, moral distress
Hidden curriculum: relationships with clinical teachers,
role models, challenging authority, ethical erosion,
professional distance and the idea of dehumanisation.
Maintaining integrity, wellbeing, addressing challenges
Medical Humanities: Narrative Ethics, and the idea of a
professional engagement with the arts. Enhancing
Ethical perceptions?
Ethics and the medical student
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Halfway between the layperson and the medical
professional. The need for a specific set of
principles? (BMA on detachment)
Tending to conform? The experience of
passivity and suspension may distract from
ethical substance of experience, and may
undermine ethical agency. Principles: a set of
dormant gods?
Learning before healing and care? (Gawande)
Gawande on the idea of the novice
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‘A patient’s right to the best
care possible must trump the
objective of training novices.
We want perfection without
practice. Yet everyone is
harmed if no one is trained
for the future. So learning is
hidden, behind drapes and
anaesthesia and the elisions
of language’ Complications, p.
24
MOUNT
For medical students, are principles
dormant until after graduation,
when fuller responsibilities are
involved?
AUTONOMY
AMNCH 2008
Some principles of med student ethics
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(1) Respecting the needs, values and culture of
patients you encounter during your training
Communication
Cultural awareness/humility, discrimination:
constant expansion
Vulnerability: autonomy, support
(2) Patients and their families: exploitation?
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Patient well being above all else
Generosity, financial gain
Sexual relations. Medical Council Guide: 3.11
Representing yourself, or allowing yourself to be
represented, as a more qualified member of the
healthcare team (phenomenology? shame,
exhilaration? Gawande: ‘the elisions of
language’)
(3) Confidentiality
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Scope of obligation
Breaching confidentiality in the patient’s interest
Medical records and disposal of student notes
Greater likelihood of patient openness to
medical students?
(4) Informed consent and medical training
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Information: purpose and nature of ‘any proposed
interaction’ (AMSA) ‘Any touching …’ (BMA)
Coercion: presumption. Examination for student
benefit?
Withdrawal of consent: unique expectation of
sustained participation. Reassurance of no impact on
healthcare. Nuisance factor?
Approaching the patient in groups
Language barriers, and the impeding of communication
by illness
Anesthetised and sedated patients
(5) An awareness of the limits of the medical
student role in the clinical setting
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Advice and information beyond one’s
knowledge and expertise
Giving information about illness or prognosis
that has not already been explained by a
professional responsible for that patient
Except in an emergency medical students should
not initiate any form of treatment
(6) Relationships with clinical teachers
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Respectful interaction, developing relationships:
acknowledging commitment and input
Adjusting to a varying quality of experience,
contributing to the institutional culture,
rationalising disappointment. Ethical impact of
these?
The broader healthcare team
Addressing difficulties with staff
(7) Personal integrity and well-being
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‘Medical students should ensure that their physical and
mental health enables them to relate effectively with
patients and professional staff ’ (AMSA)
Moral conscience and participation: a right to abstain
Contributing to teaching, course development
Awareness of and reflection on ethical development:
moral erosion, role-models, hidden curriculum
Maintaining integrity: some important
concepts
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Hidden curriculum/role
modelling
Ethical erosion
Dehumanisation
‘Primum non tacere’
A discourse of student
ethics
The professional disregard of ethical
principles
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In a survey of a group of Canadian medical
students, half reported pressure to act
unethically and 60% had observed unethical
conduct in a clinical teacher. A majority of these
felt ‘impotent in the face of these circumstances
because of the teacher’s intimidatory attitude’
(Hicks et al 2001)
Common types of ethical difficulty for
medical students
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Conflict between the priorities of medical education and those of patient
care
Examples: Patients asked to return to clinic for follow up visits, not informed
that the visits were entirely for teaching purposes. Student instructed to
perform femoral puncture on a comatose patient for purely educational
reasons. Patient’s name and details of care discussed by staff and students in a
public place. Students distressed by patient presence in seminar, where
accounts of illness and mortality appear overly candid.
Responsibility beyond a student’s capacities
Examples: Seniors refuse to assist student in assessing an unstable patient.
Student left by teacher to close wound, without knowing how to close it
properly. Student completed antenatal visits with patients who were never seen
by a doctor.
Involvement in patient care perceived to be substandard
Examples: Student witnessed house officer responding inappropriately to
patient’s refusal to have joint aspiration; consent form completed but consent
not meaningfully given. Patient requested a narcotic-free vaginal delivery but
given intravenous narcotics without her knowledge. (Hicks et al 2001)
There are many ethical concerns in medical
training. Why is it difficult to speak up?
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Fear associated with exams and
references
Taboo in professional culture
surrounding the questioning of a
senior
A culture of protecting one
another. Related to a siege
mentality regarding the legal
profession
Confidence: perhaps I am not able
to tease out all the aspects?
BMA on med ed: ‘A positive
emotional and social learning
environment should be created to
encourage cooperation and
collaboration’ (p.650)
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Rationalisations related to nonconfrontational attitude: 1) Am I
justified? I too may one day act
unethically. 2) the common plight.
‘Is it not understandable that a
doctor sometimes, in a state of
frustration or fatigue, may fail to
maintain optimal ethical
standards?’ (Botch 2003)
‘The failure to speak up in certain
situations is a failure of learning
and caring’ ‘Primum non tacere:
First, do not be silent’ (Dwyer
1994)
Witnessing unethical practice
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Is it possible to raise questions about the episode in an
enquiring and non-confrontational manner?
If not, or if this proves unsatisfactory: are there local
protocols for managing problems of this nature?
Are there personal tutors or mentors who may be able
to advise?
Are there other senior colleagues who may be able to
give advice?
Would it be useful to discuss the concerns with fellow
students to see if they agree?
It has been argued that ethical concerns in training should
mirror the ‘medical error movement’: a blame free
environment
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Medical schools need to: Highlight the responsibility of clinical
staff to serve as appropriate role models to medical students and
to provide them with an opportunity to discuss ethical challenges
Require university and teaching hospitals to develop processes
for reporting ethical concerns
Ensure that medical students and their tutors have access to
individuals they can approach with ethical problems
Ensure that when medical students express concern about
ethical issues or decline to take part in certain activities for
ethical reasons, this will not have any repercussions for them.
The hidden curriculum 1 (assimilation)
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Studies indicate that moral erosion is inevitable … By
learning to recognise and explore the types of ethical
dilemma characteristic of early clinical training, we can
attempt to ‘expose and dismantle deleterious aspects of
the hidden curriculum’ (Hicks et al 2001)
Distinction: formal and informal learning, edicts v.
example of teachers
Role model: can reinforce and extend lessons and
principles
In corridors, cafeteria, in methods and manners, a
contrary medical morality can be absorbed
The hidden curriculum 2
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‘Senior colleagues may unwittingly give the impression
that medical ethics gets in the way of good practice’
(BMA 2004) How might this effect an aspiration
toward professionalism and confidence?
‘When there is a discrepancy between what students are
taught about good ethico-legal practice and what they
experience on placement, anger, disillusionment and
cynicism may follow’ (Roach 2001)
The hidden curriculum 3
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‘It is essential that all doctors are conscious of the
impact of their words and behaviour on those who are
learning [mirroring patient vulnerability/verbal sense
ethos]. In terms of their own practice, as well as their
informal role as teachers, doctors should ensure that
they always act in accordance with good ethical practice
and that they are willing to respond to questions and
challenges about their methods and decisions’ (BMA
2004)
Illuminating the hidden curriculum
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Studies indicate that moral erosion is inevitable
By learning to recognise and explore the types
of ethical dilemma characteristic of early clinical
training, we can attempt to ‘expose and
dismantle deleterious aspects of the hidden
curriculum’ (Hicks et al 2001)
Transcending erosion
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Chose your role models consciously: Identify qualities and style
that impress, and reflect consciously on emulation: patience,
compassion, teaching style, a way with patients. The meaning of a
popular consultant.
Similarly, expect to experience ethical challenges and professional
disappointment: be prepared to filter out the negative influence.
Reflect on the potential for ethical erosion and ethical
enhancement
Patience, compassion, teaching style, a way with patients. The
meaning of a popular consultant.
Articulate your own standards regularly
Develop simple objectives for ethical development, reading and
discussion
Be prepared to express your ethical concerns
Medical Humanities
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Science can tell us nothing about an individual.
Science speaks in terms of probabilities, of
means and standard deviations, the behaviour of
groups of electrons or proteins or people, not
of individual entities. Everything that makes an
individual an individual, eveything that
importantly defines an individuals life is outside
the realm of science. The practice of medicine
involves only individuals. (Goodwin, cited in
BMA, 660) (See also handout)
Issues in Williams Mathews’ poem, ‘The
Scalpel’
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The critique of the medical setting
Medical students perceptions and sensitivities thwarted by the ‘curriculum’
The patient’s voice and personality
Contrast between patient experience and doctor experience
Contrast between perceptions of life and death. The patient luxuriates in
mystery, sensation, humour, a balance of wholeness and disintegration.
Medical focus on symptom, history, learning, parts, typologies.
Personhood is the exalted category: an enflamed presence and subjectivity. A
subjectivity in flames. Representing the marrow of the person, the marrow of
death, the phenomenology that eludes, or that is bypassed by the medical
gaze.
Negative portrayal. Contrast with Leonard Cohen’s Sisters of Mercy: praise
and gratitude.
Resisting unethical practice?
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Ethical principles need to be fully integrated into
doctor’s professional identities before they can begin to
resist unethical practice (BMA 666)
Medical ethics, perhaps, cannot be taught as a skill but
requires an understanding of the virtues that make a
good doctor
The centrality of virtues such as caring, concern for
others, appreciation of their predicament, a proper
sense of humility, and the ability to communicate
clearly and compassionately with a person while they
are under stress
A necessary distance? Professionalism or
dehumanisation (Detachment)
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‘An important part of medical training is to help
medical students to develop the skills required to
assist people during some of the most difficult
times of their lives, without themselves ceasing
to function either as professionals or as human
beings’ (BMA 667)
A necessary distance? Professionalism or
dehumanisation 2
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A period when medical students begin the process of
detachment, when some of the most important ethical
lessons are learnt, and habits of feeling towards patients
are developed that can persist for a professional lifetime
Those who teach medical students have a responsibility
to show by their words and example that this process
of detachment can be achieved without diminishing the
respect and dignity of those who are suffering or who
have died (667). Reading detachment?
A necessary distance? Professionalism or
dehumanisation 3
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‘The healing ethos combines this necessary
detachment with a genuine concern for the
individual patient, an attitude requiring a degree
of empathy and emotional closeness. Only when
the medical ethos includes a profound respect
for the individuality of each patient will it serve
the true purpose of medicine – the health of the
patient’ (Campbell 2001)
Key questions
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Should a medical student always question a
senior? (Context)
Should medical students always question each
other?
Would you welcome a challenge to your style of
engagement with patients, or an accusation of
ethical laxness?
Relating to teachers
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‘An inability to take instruction or recognise
legitimate authority can be just as much of an
impediment to becoming a good doctor as
obsequiousness and a suppression of critical
faculties.’ (BMA Handbook, 670)
The personal root of ethical perception:
departing from a central concept
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I am here to learn
I am here to provide care
I am here to listen
I am here to investigate
I am not sure why I am here
I am here for the rest of my life
I am here for the next two weeks, then I’m out
in James’s for a month