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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 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 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 ‘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 (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? 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 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 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 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 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 ‘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 Hidden curriculum/role modelling Ethical erosion Dehumanisation ‘Primum non tacere’ A discourse of student ethics The professional disregard of ethical principles 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 1. 2. 3. 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? 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) 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 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 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) 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 ‘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 ‘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 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 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 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’ 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? 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) ‘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 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 ‘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 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 ‘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 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