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P&S Journal

P&S Journal: Fall 1997, Vol.17, No.3
Ethics in Medicine: Teaching Ethics

Teaching What Is Neither Black Nor White

By Devera Pine
STUDENTS Third-year students participate in the clinical ethics rounds as part of their rotation in medicine.
An elderly woman is admitted to the hospital after suffering a stroke. She is not conscious and must be fed through a nasogastric tube. Although the woman signed a DNR (do not resuscitate) order on a previous hospital visit, she does not have a living will or a health care proxy. However, her son insists to hospital officials that she would not want to go on living given her current condition. He wants the feeding tube removed so his mother can die of starvation.

This could be a hypothetical case history presented in any textbook on the ethics of practicing medicine, but it isn't. It's a situation encountered by a medical student at P&S during a rotation in medicine and then presented at the ongoing clinical ethics rounds.

Dr. Barron Lerner During these rounds, the students discuss the real-life problems from their rotations with Dr. Barron Lerner, the Arnold P. Gold Foundation Assistant Professor of Medicine, and try to formulate acceptable solutions. As in the case of the elderly woman, solutions are not always obvious. "How is [withdrawing the feeding tube] different from someone dying because their respirator gets turned off?" asked one student during the discussion about the case. Another responded, "Starving is not an acceptable way for someone to die in the hospital."

The students in the clinical ethics rounds are in their third year of medical study, but P&S students actually begin their experiences with real cases and ethical questions in their first year. First-year students are required to take Clinical Practice I, a course designed to help them, from the start of their medical training, begin to build the skills they will need as effective physicians. Clinical Practice I includes lectures, small group discussions, and, as of Fall 1996, clinical "selectives" in which students spend one afternoon a week working with patients in a clinical setting. The students practice their interviewing skills, counsel patients about behavioral risk factors, and observe clinicians at work. These experiences provide the real-life clinical material for discussion in small group sessions and reinforce the relevance of the lecture topics. Often the small group discussions focus on the everyday ethics of being a doctor and offer the students a chance to understand their own value systems and those of the patients and doctors they observe.

Students & Ethics Above, first-year P&S students discuss ethics.
The first-year Clinical Practice course covers both basic skills necessary to become a physician and content areas that emphasize health promotion and disease prevention, says Dr. Katherine G. Nickerson, course director and assistant clinical professor of medicine. The course also covers units on medical interviewing, epidemiology, clinical epidemiology, medical ecology, health systems, the life cycle, health-related behavior, substance abuse, and nutrition. The teaching of ethics is an integral part of each unit. For instance, the health systems unit includes a discussion of how managed care is changing the doctor-patient relationship, and the life cycle unit includes a discussion on end-of-life issues. "We teach ethics explicitly, but we think it's important not to have it hanging out on its own," says Dr. Nickerson. "It should be part of the process that helps students form a professional identity."

Integrating actual experiences in the selectives with ethics lessons in the lectures is critical, agrees Dr. Eric Marcus, clinical professor of psychiatry and social medicine, director of the behavioral science curriculum, and director of medical student education in psychiatry. "Without actual cases, ethics are an empty abstraction for most students."

Ethics The ethics lessons are not limited to the obvious major issues, says Dr. Nickerson. "For medical students, a much more profound goal is the day-to-day issues. Students need to know when to talk about a situation, to develop a radar so they know when and why something is making them uncomfortable. They need the tools to recognize the ethical issues that arise every day and the skills to resolve them. This is more important for students to learn than highlighting the big, juicy issues that everyone reads about in the New York Times."

One part of those day-to-day issues: getting used to dealing with different values patients have. "We try to help them see that clinical decisions about real people often involve value systems that may be different from their own," says Dr. Marcus. For instance, experiences students have while working in an infectious disease clinic with patients who have sexually transmitted diseases (STDs) may raise issues about the values and attitudes students have about people with STDs. A student may wonder, for example, why it's not a crime for a person who is HIV-positive to have unprotected sex.

Teaching Research Ethics
Ethics in the practice of research is an equally important aspect of the teaching of ethics at P&S. The Responsible Conduct of Research and Related Policy Issues is a graduate-level course that draws students from both the Health Sciences and Morningside campuses, including students from the biomedical sciences (both Ph.D. and M.D.-Ph.D. students), the doctoral nursing program, the schools of public health and social work, and even postgraduate students in the School of Dental and Oral Surgery. Postdoctoral fellows also participate.

"It's probably the only course on campus that draws students from all four of the Health Sciences schools," says Dr. Jaime S. Rubin, assistant professor in the Center for Radiological Research, assistant dean of research administration, and course director. Dr. Rubin has taught the course for four years.

The course's origin lies in the NIH requirement that pre- and postdoctoral trainees supported by NIH training grants receive formal instruction in the responsible conduct of research. The NIH guidelines call for the course to cover at least six topics: authorship, data sharing, conflict of interest, misconduct in science, human subjects in research, and animal subjects in research. But at P&S, the scope of the course extends beyond those initial guidelines.

"I wanted to broaden the course to discuss many more issues that these scientists in training will eventually face," says Dr. Rubin. A major part of the course involves the discussion of case studies that integrate the ethical issues discussed. "I try to pick studies that are full of different degrees of gray areas," says Dr. Rubin. "The black and white cases are easy."

Because the students range from first-year trainees to the postgraduate level and because they come from different schools, they have different--often strong--opinions about ethical issues. "It makes the discussions quite interesting."

Dr. Eileen Hilal, who received her Ph.D. degree in 1997, took the course a few years ago and remembers one particularly heated discussion sparked by a speaker who contended that academic research scientists are public servants who are funded by the federal government and thus have an obligation to fulfill public policy goals, as determined by the government and the public. That led to a debate over whether the government has the right to use scientific findings as it pleases--for instance, to develop nuclear weapons.

Dr. Hilal, now a postdoc in anatomy and cell biology in Dr. Ann-Judith Silverman's lab, finds that she must deal with many of the ethical issues discussed in the course. "For instance, I've encountered authorship dilemmas as a technician, where I wasn't given authorship on a paper because I only contributed technically, not intellectually." Dr. Hilal happens to agree with that decision, which relies on the strict definition of authorship, but others might not.

The course helped her anticipate the issues she would face as a scientist. "As scientists we all need to stay in touch with ethical issues, especially now that technology is permitting us to do things like cloning or gene therapy," she says. "This course was absolutely essential. There was no other course like it in my graduate curriculum."

"The course does not teach right or wrong," says Dr. Marcus. "Instead, we play out the scenario in a discussion. Should everyone who is HIV-positive be incarcerated? What about Arthur Ashe, who was infected with the AIDS virus from a blood transfusion: Should he have been arrested for having unprotected sex with his wife? If that's ridiculous, where do you draw the line? In between Arthur Ashe and a drug-addicted rapist intentionally infecting his victims is a huge series of behaviors. We try to help students see the complexity involved in taking care of human beings."

The Clinical Practice course continues in the second year, with clinical case conferences each week, additional sessions on medical interviewing, and seminars in the medical humanities. Designed and organized by Dr. Rita Charon, associate professor of clinical medicine, the selection of seminars varies each year based on faculty and student interest. The seminars frequently feature ethics-related themes such as multicultural sensitivity in medicine, money and medicine, and religion in the practice of medicine.

Ethics is taught in context in the clinical case conferences, says Dr. David J. Rothman, the Bernard Schoenberg Professor of Social Medicine and director of the Center for the Study of Society and Medicine. "When students learn about brain death in a neurology lecture, we then talk about the social, ethical, and legal complications of brain death."

Ethics Debate At an ethics debate for first-year medical students, a slide projected at the front of the lecture hall illustrates one ethics topic--whether 60-year-old women should benefit from assisted reproduction.
P&S is one of a few medical schools that incorporate ethics as an integral part of the medical curriculum and not as a separate course, says Dr. Rothman, who, together with Dr. Lerner, co-directs the ethics component of the first- and second-year Clinical Practice courses. "Ultimately, the result is that students have an understanding that medical ethics is part and parcel of medicine and that it should be a part of their own practice, and not something that they call in a consult for."

Third-year medical students build on this foundation with clinical ethics rounds that meet twice a month. The sessions emphasize ethical issues that medical students typically confront and revisit issues discussed in the first- and second-year ethics discussions, says Dr. Lerner. One typical discussion scenario: A resident asks a student to put in an IV, but the student doesn't know how many times to keep trying or when to stop if the patient gets uncomfortable. Other discussions may center on a student witnessing a resident lying to a patient or an attending physician being disrespectful to a patient or a student doing a procedure for the first time without assistance. "We define ethics broadly to include issues of professionalism," says Dr. Lerner. "The purpose of the sessions is to get the students to feel they can discuss issues in a comfortable and confidential setting."

In many cases, the conclusions to the ethical issues the students raise are not neat and tidy. In the case of the elderly woman admitted following a stroke, for instance, after discussing the woman's prognosis with her doctors, her family decided to have the woman discharged from the hospital so she could die at home without a feeding tube. At the last minute, one family member objected to the plan and the family had to begin the discussion process all over again. However, the woman died before the discussions were set to resume.

In general, student response to P&S ethics courses has been positive. "Traditionally, students have been bored by ethics classes," says Dr. Marcus. But attendance is now high in the first- and second-year courses.

Third- and fourth-year students on clinical ethics rounds also say they benefit from the integrated approach. "It's much more helpful to discuss ethics issues once you've been in a clinical setting for a while," said one student at ethics rounds. "I'm pretty opinionated and I would have thought that I would know what my feelings and approach would have been. But at three in the morning..."

Said another student: "Sessions like this help us. We spend the day with residents, but they're not the people I would look to for ethical questions. I would rather talk to the attendings, but I don't really get the chance to do so. Plus, if the attending is on the case, you're not going to ask him if he's doing the ethical thing."

Another student summed up the general feeling in the room: "You need to talk about ethics early on. For instance, we did debates about videotaped scenarios in the first year. But ethics is not a two-week session, it's an ongoing thing."


From a Student's Journal
First-year students keep a journal to describe their first experiences with patients.
The following is a selection from the Clinical Practice Newsletter.

The Incarnation Children's Center
          By Angela Torres'00

Today we went to prison. Our selective group took the train up to Bedford Hills to visit the women's prison there. Many of the children who live or are treated at the Incarnation Center have mothers who are substance abusers. That is, the mothers are drug addicts whose addiction has given them and their children AIDS. Their substance abuse has landed them in jail and sent their children on to a life of endless doctors visits, multiple medications, and an uncertain future.

We have seen the result of their addiction, their crime. The babies with nasogastric feeding tubes, the developmentally delayed, the child waiting to die. Although the children at Incarnation Center are happy, often fat, and have a child's joy of the world, they are living under a cloud. And we, the people who will someday be caring for these children, wonder how a mother could do such a thing to her child.

I don't know what the others expected at the prison. I'm not sure exactly what I expected to see. Certainly a mother who could pass on AIDS to her child was uneducated, irresponsible, and uncaring. As is often the case, reality intrudes upon our preconceived notions.

We walked into a room full of women dressed in varying colors and differing styles. There were some who fit the picture of what I expected to see in prison: tough, hardened, and almost frightening to me, a product of a middle-class upbringing. Others looked like neighbors, co-workers, or any ordinary person you might see during the day. We sat down together, the medical students crushed together as if for protection in this strange environment. Dr. Nicholas launched into his speech about pediatric AIDS and the miracles the Incarnation Center has brought with children who were expected to die.

We had heard the speech before, so I looked around the room. The women were listening attentively, nodding in agreement when he spoke of the social problems that led to children having AIDS or exclaiming with delight when he talked of children they had saved at the Incarnation Center. These were not unaware or uncaring people. One woman was even taking notes.

When he asked if anyone knew why they used multiple medications, a woman responded, "because of the rate of mutations in the virus." Then the questions began to come. "How do babies born addicted to cocaine and infected with HIV respond to treatment? How will the new protease inhibitors change the treatment and the future for these children?" I don't remember all their questions, but I do remember my astonishment and wonder at the level of knowledge and sophistication these women possessed. They were definitely not uneducated about AIDS.

The AIDS awareness and education program at the prison was started by inmates who had begun to notice that many of them were dying of the same thing. They educated themselves about AIDS and created a program where they could educate others about it. Many of the women at the meeting were HIV positive and some were pregnant and waiting to hear if they too had AIDS. One of the women involved in the program had even been a pre-med student before she had gone to prison. When faced with an illness that has the social stigmatism of AIDS, we can easily separate those who have it from ourselves. They are uneducated or uncaring. They are not like us. We were all surprised at the level of knowledge these women possessed. They had still done things for which they had been sent to a maximum security prison for the rest of their lives. They had probably abused drugs and contracted HIV in one way or another because of this. Some had even passed on AIDS to their children. But they had changed in my eyes.

It is too easy for us, the would-be physicians, to judge and condemn. We see the effects of these peoples' lives and are all too ready to believe what we want to believe or to lay blame where we can. These women are not blameless, but they are not what I expected them to be. This is something I will need to remember when dealing with the people who come to me for help. This is something we all need to remember.

As we were leaving, a woman came up to us and asked, "Can a woman with AIDS donate an egg and have someone else carry it for her?" We were surprised but answered as best we could. When I thought about it later, I saw it for what it was. Not an interesting or thought-provoking question, but a symbol of hope, hope for the future. No matter how dire the situation, even those that are hopeless, people retain hope. We need to be careful with that hope and not destroy it thoughtlessly with our prejudices or biases.


Options in Ethics Education
In addition to courses, the following options in ethics education are available:

Jay I. Meltzer Fellowship in Medical Ethics
The Meltzer Fellowship gives internal medicine residents the unique opportunity to research medical ethics issues and present their findings to their peers. The fellowship program was conceived by Dr. Jay Meltzer, clinical professor of medicine, and designed by Dr. Lerner in collaboration with Dr. Rothman. It is funded by the Vidda Foundation. Each Meltzer Fellow spends one month conducting an extensive review of recent cases from the medical service. He or she then selects one case for an in-depth analysis of its ethical issues and analyzes the relevant literature. The work culminates in a case presentation to the medical center community. The lunchtime sessions typically attract up to 100 people.

The Simon Rifkind Summer Research Fellowship on Social and Ethical Aspects of Medicine
This elective invites first-year students to participate in one of the ongoing projects at the Center for the Study of Society and Medicine. This past summer, students explored such questions as the role of spirituality in death and dying; the technologies of genetic enhancement; and the factors that do or do not prompt an ethics consultation.

Externship Program in Human Rights and Medicine
In this unique program, fourth-year medical students from a consortium of schools, including P&S, are selected to work in medical humanitarian organizations around the world that provide health care to people whose ethnic, religious, or political status excludes them from existing services. Dr. Sheila M. Rothman, senior research scholar at the Center for the Study of Society and Medicine, directs the program.

Program in Urban Medicine: Immigrant Health Care and Care Near the End of Life
This month-long program provides fourth-year students from P&S and other medical schools the opportunity to live and work on the Lower East Side of Manhattan. Students join a clinical clerkship at a community-based health care facility; provide health education classes in a school, settlement house, or community center; and work with a hospice team providing care for persons near the end of life. Dr. Sheila Rothman directs the program.

Also, P&S students have started an ethics club within the P&S Club and the Center for the Study of Society and Medicine. The club holds frequent discussions of ethical issues and sponsors an annual "ethics night" for the medical center community.

copyright ©, Columbia-Presbyterian Medical Center

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