Med students learn when to label it an ethical dilemma

Recognizing true ethical questions an important skill

How and when, during the course of a medical student’s education, should the subject of ethics be taught is a matter of much discussion. One program at the University of Iowa’s (UI) Carver College of Medicine adds an additional basic element — teaching med students how to tell if an ethical problem is really an ethical problem.

"Sometimes, a problem arises and it too quickly is labeled an ethical problem," says Lauris Kaldjian, MD, PhD, an assistant professor of internal medicine who teaches second-year medical ethics at the UI medical school. Kaldjian and some ethicist colleagues — Robert Weir, PhD, the Richard M. Caplan Endowed Chair in Biomedical Ethics and Medical Humanities at UI; and Thomas P. Duffy, MD, professor of internal medicine at the Yale University School of Medicine — looked at this paradox and developed what they call a clinical approach to ethical reasoning.

"We were interested in integrating medical understanding and ethical understanding," says Kaldjian. They used the orderly way medical professionals think and applied that to situations that might appear at first glance to be ethical questions, when they’re really something else.

"There are situations that arise that people might think the only way to solve is through ethical thinking or an ethics consultation, when they might simply require talking to the patient a little more," he adds. 

Going beyond theory

Ethical reasoning and decision making often are considered cultivated professional skills, but a group of researchers at Stanford University found that undergraduate medical programs in ethics tend to focus on teaching bioethical theories, concepts, and major ethical issues such as in vitro fertilization and euthanasia, rather than how to put those principals and theories into clinical practice.(See resource at end of article.)

"Not surprisingly, many students and clinicians experience considerable difficulty in using what they know about ethics to help them make competent ethical decisions in their day-to-day clinical practice," the Stanford group found.

Using what they already know, Kaldjian says, is an important factor in learning to practice good clinical ethics.

"In medicine, we have an orderly way of thinking," he explains. "There’s much about the practice of medicine that is truly unregulated, but there are also guidelines that encourage us to practice within standards of care.

"Those standards are individualized by patients and providers, so it is hard to regulate. Our approach honors the fact that every physician brings to ethical reasoning their own set of priorities and set of values."

Kaldjian says removing the mystery behind ethics helps make ethical decision making make more meaningful to the medical student. Because medical students are accustomed to — and encouraged to seek the single correct answer to any question, making ethics-based decisions can be unsettling to them, he observes.

The approach he and his colleagues have developed capitalizes on both a systematic way of organizing information and incorporating the clinician’s knowledge, skills, and attitudes.

"By capitalizing on the way clinicians think, we believe this approach provides a practical means to articulate ethical justifications for challenging clinical decisions," he says. "Such articulation allows the ethical basis of a difficult decision to become transparent.

"Transparency, in turn, allows clinicians to communicate and document an explanation for a course of action, and it is likely to facilitate consensus based on a shared understanding of values and goals or, at least, clarify causes of lingering disagreements."

Breaking down the process

Determining whether the clinician is, in fact, facing an ethical decision is the first skill he or she must become comfortable with, Kaldjian says. What appears to be an ethical problem may be a lack of communication or trust, or insufficient medical information, and determining the difference will let the clinician know better what comes next.

"The situation may need something as common as communication or a family meeting. Maybe the doctors haven’t done their work as well as possible," he suggests. "Maybe the patient just wants care on his or her own terms, so it requires the physician to do more homework, another literature review, and then suggest a wider range of options." (For a simple, step-by-step approach to determining if an ethical problem exists, see below.)

"We needed a scheme that made sense to clinicians, so it was useful to borrow the trajectory of reasoning we use as clinicians and apply that to clinical ethical reasoning," Kaldjian explains.

Ethical reasoning, he says, merges the core set of values demanded by the medical profession and the personal values (as our "moral selves," Kaldjian describes it) of individual clinicians.

"Everyone is familiar with the term differential diagnosis,’" he points out. "A differential diagnostic evaluation [of a possible ethical issue] includes the possibilities of poor communication, strained interpersonal relationships, or incomplete exploration of medical alternatives."

Though the clinical ethical reasoning approach has not been subjected to feedback evaluation from students, Kaldjian says he is encouraged by what he has been observing.

"Our overall impression [from students’ responses] is that people agree this style of reasoning is accessible and reasonable," he says. "It basically gives them a structure. If clinicians have hard time with anything, it’s when they’re presented information in a disorganized manner. If it’s chaotic, it’s difficult to make sense of it, so this gives them a scheme that echoes or parallels what we’re already used to."

Roles of patient and family

Because what often is mistaken for an ethics-caused impasse is actually a shortfall in communication, clinicians should learn how to draw patients and families into discussions when questions about care arise. Patients and families should be made aware that physicians’ training and values may cause them to respond to a clinical presentation in one way, while the family’s or patient’s values and understanding may cause them to see things differently, and what may initially seem to be an ethical problem can be remedied with discussion and more information.

Family members should listen carefully when a doctor makes a recommendation and ask the doctor to explain the rationale for the approach if one is not forthcoming, suggests Kaldjian — an approach that will keep communication open rather than leading to an assumption that the physician and patient are in complete disagreement.

"Medical ethics is not only about asking and exploring questions but also about decision making," he says. "In clinical care, you can’t just sit back and have a discussion with no follow-up action."

Kaldjian says it is important that students be taught that there is more than one way to determine a right or wrong answer, and it’s important that they are able to explain their reasons for making the decisions they do.

"Maybe a patient refuses what the physician believes to be the best recommendation," he says. "But if the recommendation was made too quickly, without enough discussion, and rejected, the physician may think there’s an ethical conflict when really there just needs to be additional dialogue."

Sometimes, involving a third party — a staff ethicist, chaplain, social worker, or another physician — can help move discussion along, particularly if there appears to be a lack of trust between the clinician and patient.

Kaldjian and his co-authors stress the clinician’s own ethical integrity and the need for preserving it when ethical conflicts do arise. Physicians must engage in "conscientious practice," they wrote, allowing them to deliver care without compromising their own personal and professional conscience.

Resource

  • Myser C, et al. Teaching clinical ethics as a professional skill: Bridging the gap between knowledge about ethics and its use in clinical practice. J Med Ethics 1995; 21:97-103.

Sources

  • Thomas P. Duffy, MD, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT. Phone: (203) 785-4744. E-mail: thomas. duffy@yale.edu.
  • Lauris C. Kaldjian, MD, PhD, Division of General Internal Medicine, Department of Internal Medicine, Program in Biomedical Ethics and Medical Humanities, University of Iowa Carver College of Medicine, Iowa City. Phone: (319) 384-6180. E-mail: lauris-kaldjian@uiowa.edu.
  • Robert F. Weir, PhD, Program in Biomedical Ethics and Medical Humanities, and Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City. Phone: (319) 335-6706. E-mail: robert-weir@uiowa.edu.