Once a month during my second year of graduate school, I attended the Ethics Committee Meetings of the University of Michigan Health System and listened to fascinating discussions about the ethical dilemmas and consults requested by various members of the healthcare staff. A member of the committee presented a case, and a discussion followed to reach a potential solution for the case at hand or for future similar cases. One such case comes to mind: a committee member reported that she had a patient in the ICU who had passed away and, according to his religious beliefs, his body was not to be touched for eight hours postmortem. In an effort to respect the religious beliefs of the patient, the medical team left the body in its place for the eight hours before moving it to the morgue. After hearing this story, another committee member stated that he was on the Survival Flight helicopter which was transporting a critical patient who needed an ICU bed on that same day, but unfortunately, none were available for four hours. We realized that the otherwise available ICU bed had been occupied by a corpse for eight hours, during which time the other critical patient was unable to receive care. This case posed a series of challenging issues regarding ethical healthcare practice. Should one patient’s autonomy take precedent over the efficacious care of another patient?
Physicians need to prepare to grapple with these and other ethical dilemmas in healthcare delivery on a daily basis. The question to be addressed in this essay is whether medical ethics preparation should occur as part of pre-medical coursework. One might argue that the solution to these ethical dilemmas is subjective and exists on a case-by-case basis and, therefore, is not necessary to be addressed during the pre-medical years. As it is, pre-medical students have a full course load of science requirements to prepare them for medical school, and adding a medical ethics course is an unnecessary burden. Others say that pre-medical students benefit from beginning to understand the thought processes involved in answering some of these difficult questions by taking such a course.
My decision to co-create a medical ethics course has been an invaluable asset to becoming prepared for my future career as a physician. The typical pre-medical curriculum consists of an array of basic science courses to prepare us for the technical skills we will learn in medical school. It is important that students also be encouraged to study medical ethics to learn about such topics as the doctor-patient relationship, beneficence and non-maleficence, autonomy and informed consent, confidentiality, respect for public welfare, cultural factors in healthcare, and issues at end-of-life care. Students should learn about the dilemmas inherent in withholding treatment, euthanasia, assisted suicide, and the specific conflicts that arise in a fee-for-service healthcare system. In a society with limited medical resources, such as organs for transplantation or beds in an ICU, allocation decisions need to be made. This often creates important ethical dilemmas and challenges, such as the one presented earlier. Most situations that arise are not clear as to the ethical course of action—there is usually not a “black and white” scenario, but rather shades of gray. Ethical practice in healthcare delivery requires the physician to recognize that our training does not consist of learning the answers to all the questions and problems, but rather learning how to ask the right questions and to learn the methodology for addressing future ethical concerns.
My experience as part of this course consisted of reading a variety of texts, discussing the different themes of bioethics and various real-life examples with a physician and scholar in the field, and regular attendance at the Medical Ethics Grand Rounds and the Medical Ethics Committee meetings. The books addressed various topics. Clinical Ethics (Jonsen et al. 2006) is a review of case studies in which medical ethics issues were raised, how the physicians proceeded, and how the ethics committee assessed the course of action. Ethics on Call (Dubler and Nimmons 1992) is a medical ethicist’s perspective on the critical-care dilemmas and how they are addressed in the hospital. Another book, A Palliative Ethic of Care: Clinical Wisdom at Life’s End (Fins 2006), focuses on palliative care, end-of-life decision-making, and goal setting as a strategy for effective care. Bioethics: A Clinical Guide for Medical Students (English 1994) is a clinical guide for medical students on how to address medical issues in the future, including case examples and practical suggestions. These texts provided me with a strong introduction to ethical issues involved in medical practice.
At the committee meetings, I learned first-hand how ethical decisions are made and the process by which the physicians and allied healthcare professionals collaborate to reach a decision that is ethically sound. The goals of the committee are to educate hospital staff, to consult in difficult cases, and to help develop policies to guide caregivers in similar difficult cases.
Learning about medical ethics before beginning medical school prepares students to appreciate the art of medical practice. In medical school, students begin an intense course of science and medical board preparation. The curriculum generally has some mention of medical ethics, but many students and physicians alike complain that most medical school curricula do not include enough emphasis on the importance of ethics. The study of medicine spans far beyond the science of diagnosis and providing appropriate treatment—it also incorporates these moral human factors.
The practice of medicine entails a combination of science, technology, and interpersonal relationships, all of which are melded together by a series of ethical questions. Emphasis should be placed on the ethical aspects of daily medical practice and not just on the dramatic dilemmas raised by modern technology (Glick 1994). For example, patients may need help framing questions, absorbing information, and considering the consequences. Assisting patients in these areas is as much a part of being a modern physician as is diagnosing an ailment and treating a disease condition. Informed consent requires that the doctor explain to the patient all the facts that are necessary and relevant to make a decision without overwhelming the patient, causing suffering, prejudicing the decision, or just plain being insensitive (Dubler and Nimmons 1992).
One important aspect of bioethics that became more apparent through my coursework is the process of determining who makes the medical-care decisions. Dubler and Nimmons (1992) suggests four circles in the decision-making process. The first circle being the patient, reflecting the law in the United States recognizing that if a person is capable of making decisions, and if he or she has been provided with the information necessary to do so, then medically, legally, and ethically, the decision belongs to the patient. The question often arises whether a person has decisional capacity. Decisional capacity involves an understanding of the alternatives and options, risks and benefits of the decision, an ability to process the information with respect to a personal framework of values and preferences, such as quality-of-life wishes, and an ability to communicate one’s decision (Dubler and Nimmons 1992).
The second circle is the advanced directive, which is still the patient’s choice, but instead of deciding in the moment, the patient decides in advance. The third circle involves others deciding for the patient. This tier can leave many questions to be asked, such as the actual desires of the patient, or what is truly in the patient’s best interest. The fourth and final circle is the last resort when all other modes of decision-making are unavailable: the courts and bureaucrats, which can often involve people who have never known the patient to make decisions about his/her care, life, and death (Dubler and Nimmons 1992).
Another dimension that impacts directly on ethical medical practice is what ethicists term the “technological imperative”, which demands that because a technology exists, it should be used, regardless of whether or not it will really benefit the patient. This controversial school of thought may have stemmed from the fears that families might sue doctors for not “doing everything” for patients. Nonetheless, many families can be traumatized by watching their loved ones spend the last stage of their lives connected to life preserving machines in dehumanizing settings among strangers. To balance this end, palliative medicine and end-of-life care has been a strong emphasis in medical ethics. Part of our challenge as future physicians is to communicate effectively with patients and their families to formulate a care plan that respects patient autonomy, personhood, and dignity (Finn 2006, Dubler and Nimmons 1992).
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At the discussion that followed the case presentation at the Ethics Committee meeting mentioned earlier, the committee members raised several issues surrounding this situation. The main topic for consideration was the extent to which a patient’s individual autonomy trumps the greater social issue of allocation of resources. The committee addressed this and other issues, mentioning that the role of the physician is to be an advocate for the patient, and that rationing at the bedside is unethical. While physicians need to be aware of issues surrounding limited resources, it is the duty of administrators to handle concerns with the allocation of those resources, and the physician’s role is to advocate for his/her patient. In this case, however, more questions were raised as to whether patient advocacy should continue to be a primary concern even after the patient dies.
Medicine is more than the science of disease and the scientific basis for treating disease: it is both an art and science. The art of medical practice is influenced by ethical and moral considerations and is an extremely important component of healthcare delivery. Therefore, it is essential to integrate medical ethics into the curriculum of students as early in their training as possible, so they can become familiar with the ethical challenges they will face in the future and be exposed to the thought processes needed in resolving these dilemmas. Incorporating the study of medical ethics is another step toward ensuring that the human factor remains paramount in providing the best quality care possible to those we serve.