By: Ann Freeman Cool, Ph.D.
Presented by: AMSA Professionalism & Ethics Committee
I still remember the look on the young physician’s face when I invited him to talk about the ethical issues he faced in caring for his patients. He explained: “Nothing in medical school prepared me for some of the decisions I have to make, the conversations I have to have. Not really. There are days when I feel I am floundering.” I have spent many years developing studies and conducting key informant interviews, focus groups, and surveys to empirically explore the role that ethics plays in the provision of medical care. Over the years, physicians have often echoed the comments of that young physician, noting that ethics didn’t seem as critical as other subjects when they were in medical school. Sometimes the teaching of ethics seemed academic and theoretical, more relevant to the classroom or the philosophy seminar than the bedside. Upon entering practice, however, physicians have reported that an array of factors create risks for ethically difficult experiences. As one physician explained: “Values collide. How do you really determine if a patient can offer informed consent? What do you say when you need to talk about issues like quality of life or withholding or withdrawing care?” Another noted: “Inadequate resources. Autonomy. Family conflicts. Differences of opinion. It can be very hard to know what to do. I can’t say that I really know how to talk about this stuff. Not really. This is not something we practiced.”
The stories of physicians have underscored the central role that ethics plays in the art and practice of medicine. And yet most physicians who have participated in my studies reported that they rarely had conversations about ethics with their peers or attendings during their training years. Moreover findings from other studies suggest that traditional ethics coursework may have limited utility. For example, once in practice, many physicians have limited recall of key elements of their ethics-training such as the names of ethical principles, other sources of ethical value, or systematic approaches to decision-making. Many physicians claim they are not sure if the issues they encounter would even be deemed “ethical” by their peers or colleagues. Noted one physician: “I don’t know if it’s an ethical issue. I don’t know. It happened and I just didn’t know what to do. It could be a practice variance, or something else, a sub-optimal outcome or maybe it’s just a difference in our clinical judgment. But the conversation didn’t go well. I didn’t have the right words and it feels like a weight on my shoulder.”
What does appear to be memorable and helpful, according to a number of studies, involves the acquisition of practical skills that help physicians respond and engage in conversations when ethics-related problems emerge. Physicians have underscored the value of learning how to be strategic, proactive, and preventive when responding to ethical issues. They have endorsed the values of mindfulness and attentiveness in learning how to more readily recognize ethical issues; they have also affirmed the need for communication skills that help them initiate and engage in ethics-related conversations with patients, families, and peers. Many have reported that skill and practice can make a big difference when trying to facilitate discussions that involve diverse perspectives. Practice helps when trying to care for one’s patient on one hand and defer to colleagues or accommodate hospital policies on the other. It is useful to have words and concepts and some experience when cost containment issues or difficult family situations influence decisions about medical care. It requires skill and insight to recognize how external forces – pressure from drug companies or requests to do something that feels questionable – could undermine one’s integrity.
The online ethics forum offers a way to explore the inseparable relationship between ethics and medicine – a way to help us see ethical issues with greater clarity, find words to talk about them, and envision approaches that could reduce conflicts. The case studies provide a framework for practicing the skills we need for problems we will surely face. Sometimes the ethical problems that accompany clinical practice are easily recognized. Other times the ethical issues are more subtle or shaded – the micro-ethical dimensions of everyday clinical practice, quiet problems at the bedside. But regardless of the dimensions, ethical issues can challenge our beliefs and values, causing us to question the services we provide. By talking and telling we find new ways of thinking about ethical issues, about the nature of suffering, and the value patients place on empathy. We learn about kindness, about what it means to be a healer, and what good care looks like.
At the end of the day we may not agree about how the ethical problems we face ought to be resolved. Questions will always remain; people are complicated and ethical theories can only point us toward possible paths to wisdom. But the time spent in dialogue – the sharing and questioning – might help us extend those paths so that, with the passing of years, we can honor and uphold the covenant to care with as much grace as possible.
Ann Freeman Cook, Ph.D.
Research Professor, Department of Psychology
Director of the National Rural Bioethics Project
The University of Montana
Missoula, MT 59812
Adjunct Professor, Department of Neuroscience/Internal Medicine
University of South Dakota Medical School
Email: ann.cook@umontana.edu
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