THE PRACTICE OF MEDICINE 2
MODULE 5
HUMANITIES, ETHICS and PROFESSIONALISM
Course Syllabus
INSTITUTE FOR THE MEDICAL HUMANITIES
2002
The University of Texas Medical Branch
Galveston, Texas
INTRODUCTORY INFORMATION
Course Director:
Michele A. Carter, Ph.D.
Course Instructors:
Eric Avery, M.D.
Jennifer S. Bard, J.D., MPH
Chester R. Burns, M.D., Ph.D.
Ronald A. Carson, Ph.D.
Thomas R. Cole, Ph.D.
Anne Hudson Jones, Ph.D.
Ellen S. More, Ph.D.
Cheryl E. Vaiani, Ph.D.
Harold Y. Vanderpool, Ph.D. Th.M
William J. Winslade, Ph.D., J.D.
Office & Telephone:
Ashbel Smith (Old Red) Building, Second Floor West,
ext. 22376.
Scheduling and Room
Assignments:
See POM master schedule.
Course Syllabus:
This syllabus contains the topics that will be covered each week.
Introductions for each week include discussion questions and in
class activities, followed by required readings.
Course Requirements:
Class preparation, attendance and participation.
One writing assignment.
Overall Course Goal
and Perspective:
Questions of moral value and purpose are implicit in all aspects of
medicine, including medical education and patient care. The goal
of this course is for medical students to become more responsible
and competent physicians-in-training by investigating the personal,
ethical, philosophical, and social dimensions of medicine. By
cultivating greater knowledge and sensitivity about the everpresent moral concerns, humanistic issues, and conflicts in medical
practice, courses in medical ethics have become an essential
component of sound contemporary medical education.
Learning Objectives:
This course is designed to meet each of the specific objectives
listed below. The small group discussion format facilitates
acquiring ethical competence in medicine through the exchange of
information, ideas, opinions and reasoned argument. With
completion of the course students should be able to:
2
1. Understand and critically assess their own personal and cultural
values in relation to the values of peers, patients, and nonphysician caregivers.
2. Increase knowledge of the core professional values and virtues
inherent in medical practice.
3. Increase understanding of the psychological and behavioral
aspects of health, disease, death, disability, suffering, healing
and helping.
4. Demonstrate a basic level of skill in analyzing, interpreting,
communicating, and problem solving with respect to ethical
problems in medical training and professional practice.
5. Identify and discuss ethical, affective, and humanistic
dimensions of the doctor-patient encounter and the professional
responsibilities associated with this relationship.
Course Format:
Small group discussions, lectures and essay writing.
Teaching Methods:
Required reading
Discussions in class
Special lectures and slides
Writing assignment
Standards for
Class Participation:
Each instructor will evaluate students according 1) to their
attendance and 2) the quality and extent of their participation in
class discussions. Excellence in class participation will depend on
the extent of student participation and the degree to which students
reveal that they have:
(1)
(2)
(3)
General Remarks on
Approaches to Class
Discussions and
Writing
Assignments:
Read, understood, and critically analyzed the
readings assigned for that week,
Thought carefully about the discussion questions
suggested for that week, and
Responded constructively to the comments of
fellow students and the instructor.
In the past some students have expressed concern about right
answers for writing assignments. Others have been unsure
about "what the instructors want" for answers.
Our perspective is that knowledge and disciplined thinking can be
adequate and convincing in resolving conceptual, historical, and
ethical issues. Disciplined inquiry in the humanities need not
arrive at some irrefutably "right answer" to be important and valid.
We can achieve a certain grasp of and wisdom about problems and
issues even if our insights and arguments remain incomplete. The
3
phrase "there are no 'right' answers" may be true insofar as a
knowledgeable and disciplined pursuit of answers gives rise to
complex judgments and further questioning. But this phrase is
invalid when it reflects a skeptical attitude that masks intellectual
laziness or assumes that ethics and the humanities are unnecessary
if they cannot produce exact and indisputable answers. Even if
"correct" and "incorrect" are not always applicable, "responsible"
and "irresponsible" answers can be distinguished in the search and
formation of answers about moral matters.
Personal
Responsibility
for Writing Assignments:
We encourage students to talk with each other and learn from each
other as you explore the various topics in this course and make
decisions about your paper topics and approaches. Nevertheless,
the research, content, and wording of the written assignments in
this course must represent each student’s own personal thought and
investigation. In keeping with well-established rules of academic
responsibility and plagiarism, students should also, for example,
reference all the sources (written and verbal) utilized in papers.
HEP Writing
Assignment:
All students will be provided a writing assignment during Week 4.
It represents 50% of your grade for the Humanities, Ethics, and
Professionalism component of the course module and involves a
case analysis. The paper must be typed, double-spaced, and 3-5
pages in length. It is due in Week 6.
4
NOTES ON THE INSTITUTE FOR THE MEDICAL HUMANITIES
The Institute for the Medical Humanities (IMH) at UTMB serves several roles. Initially
established in 1973, the Institute now includes faculty members, and visiting scholars and
researchers. The IMH conducts teaching programs in the medical school (on both undergraduate
and graduate levels), the Graduate School for the Biomedical Sciences, (through which M.A. and
Ph.D. degrees are granted), the School of Nursing, and the School of Allied Health Sciences.
Institute faculty will be involved in your medical education at several points, including clinical
clerkship seminars during the Internal Medicine rotation your junior year, lectures and
discussions in a number of standard courses, medical rounds and Grand Rounds in various
clinical departments, an ethics consultation service, and a number of elective tutorials for fourth
year medical students.
IMH Faculty
Eric Avery, M.D.: University of Texas Medical Branch. Assistant Professor. Psychiatry, art
and medicine.
Jennifer S. Bard, J.D., MPH:. Wellesley College, 1983; Yale Law School, 1987. Assistant
Professor. Bioethics, legal issues, women’s health, and medical responses to terrorism.
Chester R. Burns, M.D., Ph.D.: Vanderbilt University School of Medicine, 1963; Johns
Hopkins University School of Medicine, 1969. Professor. History of medicine and medical
ethics.
Ronald A. Carson, Ph.D.: University of Glasgow, Scotland, 1968. Professor. IMH Director.
Humanities, religious studies, ethics.
Michele A. Carter, Ph.D.: University of Tennessee, 1989. Associate Professor. Healthcare
ethics, clinical and research ethics, moral philosophy.
Thomas R. Cole, Ph.D.: University of Rochester, 1981. Professor. Social and cultural history,
aging, geriatrics.
Anne Hudson Jones, Ph.D.: University of North Carolina, 1974. Professor. Literature and
medicine, medical writing, medicine and the physician in American popular culture.
Ellen S. More, Ph.D.: University of Rochester, 1980. Professor. History of medicine and
health care, history of women in medicine.
Cheryl E. Vaiani, Ph.D.: University of Texas Medical Branch, 1998. Assistant Professor.
Clinical ethics, end of life care.
Harold Y. Vanderpool, Ph.D., Th.M.: Harvard University, 1971, 1974. Professor. History of
medicine, medical ethics, religion and medicine.
William J. Winslade, Ph.D., J.D.: Northwestern University, 1967; University of California,
Los Angeles, School of Law, 1972. Professor. Law and medicine, psychoanalysis, medical
ethics, the doctor-patient relationship.
5
ORIENTATION TO HUMANITIES, ETHICS AND PROFESSIONALISM UNIT
WEEK 1 (Humanities small groups do not meet during week 1)
What do the humanities have to do with the knowledge and practice of medicine?
The answer to this question may not be clear now but we hope by the end of these five weeks
some clarity will be shed on the subject. Medicine consists of judgments and interventions that
are dependent upon and shaped by scientific, religious, cultural, social, economic, and moral
values. The knowledge and practice of medicine should include an awareness and exploration of
such values. Ethics is concerned with judgments about, therefore, what is right or wrong in
terms of human action as well as what is praise-worthy or blame-worthy in terms of human
character. Ethical values are intrinsic to patient care and infuse all facets of medical practice.
In order to make the underlying values explicit, we will use disciplines from the humanities—for
example: literature, history, philosophy, ethics, religious studies, the visual arts, and law. Each
of these disciplines contributes to the objectives outlined. Literature enables us to explore,
vicariously experience, and understand the many-sided dimensions of sickness and healing.
History identifies crucial documents and developments responsible for shaping contemporary
medicine and its values. Philosophy is used as a tool to evaluate assumptions regarding the
theory and practice of medicine. In medical ethics, we seek to analyze, critique, and defend
actions and relationships within medicine that are judged to be right or wrong. Religious studies
offer an exploration of the assumptions, backgrounds, and meanings of religious traditions
pertaining to medical decisions. Visual studies assist us in developing a reflective imagination
and understanding of the human condition and in becoming more empathic practitioners. Law
protects and reinforces ethical values and provides procedures for resolving value conflicts.
In an important sense, each of these disciplines is a lens for interpreting clinical reality. A multifocal lens enables us to see all that is going on in clinical encounters. These encounters reflect a
long history of patterned and expected responses by patients and doctors. They help us
understand different types and levels of verbal and non-verbal interactions and feelings (the
content of much literature and poetry), and the underlying ethical, philosophical, and religious
assumptions and beliefs.
Humanities disciplines are interpretive devices in that they give us certain angles of vision about
events and why they occur. These disciplines enable us to think about medical cases and
discussions as texts, as documents that are constructed from a particular point of view, for
specified purposes, and according to certain assumptions. The humanities enable us to sort out
what these views, purposes, and assumptions are and to ask whether they are accurate, complete,
and ethically sound.
These disciplines enable us to grasp and probe clinical reality by alerting us to what may be
transpiring beneath the surface of decisions and relationships, to discover what is being tuned
out, and to explore sources of perception and conflict. As “windows” on human experience and
perception, the humanities enable us to size up, evaluate, and critically analyze descriptions of
such experiences and perceptions.
6
WEEK 2
DAX’S CASE
KEY CONCEPTS: autonomy, paternalism, decision-making
In the summer of 1973, a 24-year-old former Air Force pilot, Donald Cowart was severely
burned (over 65% TBSB) in a propane gas explosion that killed his father. For over a year, Dax
(as he renamed himself) underwent painful and invasive treatments and surgical procedures
against his will and in spite of his repeated requests to be allowed to die. In three different
hospitals, including our own, UTMB at Galveston, Dax’s pleas to be allowed to stop treatment
and be discharged were disregarded by his family and treatment team. Dax survives today,
totally blind, permanently disfigured, and severely maimed. He is financially independent and
practices law with a firm in Corpus Christi. Yet he still believes he should have been allowed to
die and escape the suffering he endured.
For almost 30 years, the case of Dax Cowart has provided a forum for the discussion of a range
of life-or-death issues that challenge health care professionals and our society. Two films, Please
Let Me Die and Dax’s Case were made to illustrate the issues of his case for public and
professional audiences. Please Let Me Die was produced in the mid-70’s for in-house
educational use and features an interview of Dax by Dr. Robert B. White, the consulting
psychiatrist while he was at UTMB. It also vividly depicts the painful process of debridement
and the extent of Dax’s injuries. Dax’s Case, released in 1985, was produced for a wider
audience, updates the case through 1984, and provides perspectives from others involved in the
case, Dax’s mother, family lawyer, and members of the treatment team.
As the opening session of this summer course viewing the practice of medicine through the
perspectives of the humanities, we are pleased to not only be able to show you portions of these
two films, but also to have Dax Cowart here to engage you and answer your questions as we
discuss this complex and remarkable case.
Questions for Discussion:
1. What are the limits on life-supporting and death-postponing medical treatment?
2. Who are the parties responsible for making treatment decisions for patients in lifethreatening situations?
3. What happens when the physician’s duty to do no harm and the patient’s right to selfdetermination are not compatible?
4. Can Dax’s case be interpreted as a justification for paternalistic intervention by
physicians?
5. Some have suggested the severely burned patients are “incompetent” to make decisions
about their treatment. Do you agree? How would you support your opinion?
7
Readings:
1. Bernard Lo, Resolving Ethical Dilemmas: A Guide for Physicians, Second Edition.
Lippicott, Williams & Wilkins, 2000, pps. 11-18, 30-41, 89-93.
2. James F. Childress and Courtney C. Campbell, “Who is a Doctor to Decide Whether
a Person Lives or Dies?” Reflection on Dax’s Case,” in Dax’s Case: Essays in
Medical Ethics and Human Meaning. Lonnie Kliever (Ed.), Dallas: Southern
Methodist University Press, 1989, pp. 23-41.
3. William J. Winslade, “Taken to the Limits: Pain Identity, and Self-Transformation,”
in Dax’s Case: Essays in Medical Ethics and Human Meaning. Lonnie Kliever (Ed.),
Dallas: Southern Methodist University Press, 1989, pp. 115-130.
4. William F. May, “Dealing with Catastrophe,” in Dax’s Case: Essays in Medical
Ethics and Human Meaning. Lonnie Kliever (Ed.), Dallas: Southern Methodist
University Press, 1989, pp. 131-150.
8
WEEK 3
MEDICINE AS HELPING PROFESSION
KEY CONCEPTS: trust, helping, caring, communication, professionalism, power, integrity
Practitioners such as physicians, nurses, and psychiatrists occupy a unique and privileged
position in society. Health care professionals undertake certain voluntary commitments and
obligations to further the legitimate health-related needs of persons who are ill or hurt. The
relationships formed in furthering those interests are called therapeutic relationships, because
they have as their mission the rendering of some kind of aid or treatment. In general the
therapeutic relationship is “a relationship between an individual who is seen as suffering from
some defect, disability, or discomfort and a practitioner who possesses a specific technical skill
or knowledge and occupies a recognized social role.”1 The core ingredient of a therapeutic
relationship is the patient’s preferences or values regarding care. These preferences are the basis
of values such as respect for patient autonomy, self-determination, choice, and the process of
informed consent for medical treatment.
The doctor-patient relationship is the frame of reference for all therapeutic decision-making and
is the structure that gives those decisions their ethical and professional integrity. These decisions
reflect the values of both the doctor and the patient regarding the following: the improvement or
preservation of life; the promotion of optimal health; knowledge about one’s body-mind; and the
desire to be free of disease, dysfunction, pain, suffering and despair. These expectations are
grounded in individual and social attitudes regarding the meaning of health and in the belief that
doctors will use their special knowledge and training to serve the medical needs of the patient in
ethically appropriate ways. This belief is the basis for the claim that the doctor-patient
relationship, as with all other therapeutic relationships, is a relationship built on trust. Ill persons
often must depend on the technical knowledge and professional skills of the health care provider
in order to achieve health, or regain function, hope, and/or a sense of self. This dependence
creates ethical responsibilities to help or at least never to harm the patient. It also obliges
caregivers not to take advantage of the patient’s vulnerability or to exploit the dependence that
accompanies the illness experience.
Much has been written about the therapeutic relationship and its various forms.2 The important
thing to remember is that this relationship is never morally neutral. It is the locus for values and
beliefs regarding fundamental health concerns.
Questions for Discussion:
1. What values are at the core of the doctor-patient relationship?
2. What qualities of character are necessary for a person to be a good doctor?
Agich, George J., “Scope of the Therapeutic Relationship” in The Clinical Encounter: The Moral Fabric of the
Patient-Physician Relationship, Earl. E. Shelp (ed. Vol. 14 Holland” d. Reidel Publishing Co., 1983), p. 236
2
Veatch, Robert M., “Models for Ethical Medicine in a Revolutionary Age,” in Biomedical Ethics (Third Edition)
by Thomas A. Mappes and Jane S. Zembaty (eds.) McGraw-Hill, Inc., 1991), pp. 55-59.
1
9
3. Drawing on the readings, describe and discuss how the doctor-patient relationship creates
ethical obligations for the physician.
4. What are some of the ways the physician’s experience of doctoring can affect the
patient’s experience of illness, and vice versa?
5. What are the characteristics of a “profession?” What does the statement, “Now that
doctor behaved like a true professional” mean? Does it mean the same to each of us?
What does it mean for a medical student to act in a professional manner?
Readings:
1. Bernard Lo, Resolving Ethical Dilemmas: A Guide for Physicians, Second Edition.
Lippicott, Williams & Wilkins, 2000, pps. 195-196, 277-282.
2. Jay Greene, “Can Professional Behavior Be Taught?” American Medical News, Vol 42,
No 12, 1999: pp. 1-5.
3. Francis Weld Peabody, “Lecture to Medical Students about Patient Care,” 1926, Journal
of the American Medical Association, 88:877-882, 1927.
4. Samuel Gorovitz “Good Doctors,” in Doctor’s Dilemmas: Moral Conflict and Medical
Care, New York: Oxford University Press, 1983, pp. 191-224.
5. Arthur Kleinman, “The Healers: Varieties of Experience in Doctoring,” from The Illness
Narratives (Basic Books, 1988) pp. 209-226.
In Class Activity:
Case Discussion
Dr. Y is a GP who has a thriving suburban practice. As one might expect, he has a crowded
waiting room. On Tuesdays he usually lunches with a colleague at the hospital and then returns
to his office to see patients. These lunches cause him to run late getting back to his office about
1/2 the time. When that happens, his patients must wait a bit longer than normal. But, in any
event, he rarely manages to see his patients on time. Doing so would be too inefficient.
On a Tuesday in February, he was running unusually late. Lunch had taken a long time and he
was tired. By 4:30 he was seeing patients scheduled for 3:30. One of these patients was Donald
T, an economics professor at the local university. This was T's first visit. He was new to the
area, wanted to find a GP and to have a recently sustained running injury checked. When Dr. Y
entered the cubicle in which T was waiting, he noticed T glance at his watch. Dr. Y promptly
introduced himself. "Hello, Don, I'm Dr. Y. I'm glad to meet you. What seems to be the
problem?" During the course of the exam, T said little, even though Y sought to engage him in
conversation. Fortunately, T's injury was minor. Dr. Y told him what to do, asked if he had any
questions, and then departed. Dr. Y thought nothing more of the matter.
Two days later, Dr. Y's wife asked if he had treated a colleague of hers, Donald T. "You know,
Ted, he didn't care much for you. Said you were rude, saw him an hour late, and didn't offer a
word of explanation or apology. Don also didn't like your introducing yourself as 'Doctor' while
you called him 'Don'. You might have treated him better. He's a friend, you know." Dr. Y felt
himself getting angry. "Are you joking? I gave him good care, tried to be pleasant, and the
10
sullen SOB sat there without saying a word, and then ran off to bad mouth me to you. I got into
medicine to help people. I've serious things to think about. I'm surrounded by sickness and
death, and then I have to come home to listen to chicken shit. In the future, spare me your
referrals." His wife flushed. "Ted, stop being so pompous. Just because you're a doctor doesn't
mean you're exempted from good manners. Have you ever thought about how you treat people?
Why I'm surprised you don't make me call you 'Dr. Y'. How do you think your nurses feel when
you call them 'sweetie' or by their first names while you're expecting them to always call you
‘doctor’? Yours is an overly righteous profession." Although angry, Dr. Y saw that the
conversation was not going to improve. He promised to give the matter some thought.
1. What ethical concerns are raised by this case?
2. How did the doctor’s style of communication affect the doctor-patient relationship?
3. What conflicts occur because of the power relationships operating in this case?
[Joan C. Callahan, Ethical Issues in Professional Life, (New York: Oxford University Press,
1988).]
11
WEEK 4
THE MEANING OF ILLNESS
KEY CONCEPTS: death & dying, vulnerability, role change
Generally speaking, in our society people think of sickness in terms of disease but they
experience sickness as an illness. A disease is a (mal)function of an organ or organ system. An
illness befalls a person. For many the experience of illness is the experience of lack of
connection, control, and understanding. Our sense of being in control of ourselves is threatened
and reason fails us.
The ethical care of patients depends, however, on the ability of physician and patient fully to
communicate with each other. In the language of literature, physician and patient must tell each
other their “story.” The physician, ideally, will tell a narrative of professional concern and
competence; the patient, a personal narrative or “story” of sickness.
But communication and empathy may not come so easily to the young physician or medical
student who is a stranger to illness or disability. Fortunately, written accounts—whether
memoirs, poetry or fiction—of others’ experiences of illness can help to bridge the experiential
divide between professional and patient. In our first reading, “Literature and Medicine: Illness
from the Patient’s Point of View,” Dr. Anne Hudson Jones discusses the use of literature in
medical practice and medical ethics.
The author of our second reading, Vital Signs: A Young Doctor’s Struggle with Cancer,
Fitzhugh Mullan, M.D., had the unusual opportunity to speak from the perspectives of both
patient and physician. When Mullan, at the time a thirty-two year old pediatrician in the U.S.
Public Health Service working in a community clinic in the barrio of Santa Fe, discovered a
large malignant mass—a seminoma—in his chest. His world as a young physician, husband, and
father, began to unravel. As Mullan later wrote, “I had trouble understanding. I couldn’t grasp
what it meant for me or foretold for my family. I am a physician and have seen illness of all sorts
in people of all ages, but it was difficult to translate that into personal terms.”3 He decided to tell
his “story” so that others, particularly physicians, might more readily understand the stories of
their own and their patient’s illnesses.
Mullan’s account describes not only the technical dimension of his treatment, but the social and
psychological effects of hospitalization, surgery, radiation therapy, chemotherapy, and a
grueling, post-operative recovery. An accident during his initial surgery produced heavy internal
bleeding and a much more massive invasion of his chest cavity than had been predicted.
Radiation therapy resulted in burns to his esophagus and massive trauma and infection of the
sternum. The passages reproduced below trace Mullan’s progress from surgical biopsy, to postradiation plastic surgery, to the problem of his iatrogenically induced infection of the breastbone.
Mullan’s narrative moves between the perspectives of physician and patient as he recounts his
bewilderment, anger, despair, and ultimate triumph of the spirit.
3
Mullan, p. ix.
12
Questions for Class Discussion:
1. How do the stories contained in the readings highlight the differing perspectives of the
patient and the physician on the experience of illness?
2. From the perspective of ethics, why is it necessary for the physician to try to understand
the illness experience from the patient’s point of view?
3. Compare the advantages and disadvantages of fiction (or poetry) and autobiography to
empathically convey the subjective experience of illness.
Readings:
1. Anne Hudson Jones, “Literature and Medicine: Illness from the Patient’s Point of View,”
in William J. Winslade, Personal Choices and Public Commitments: Perspectives on the
Medical Humanities (Galveston, Texas: Institute for the Medical Humanities, 1988), pp.
1-15.
2. Fitzhugh Mullan, M.D., Vital Signs: A Young Doctor’s Struggle with Cancer (New
York: Farrar, Straus, Giroux, 1975), esp. pp. 8-24, 118-32, 154-56.
3. Alexandr I. Solzhenitsyn, "Story Of A Diagnosis," The Cancer Ward, Dell Publishing,
New York, 1968, pp. 75-92.
4. Richard Selzer, “Mercy,” in Letters to a Young Doctor (New York, 1982), pp. 70-74.
In Class Activity:
PBS segment from Moyer’s End of Life Series.
13
WEEK 5
EMPATHY IN CLINICAL PRACTICE
KEY CONCEPTS: diversity, sex, race, class, gender, stereotypes, “the other”
In Week 4 we explored the meaning of illness to the patient and how listening to the patient’s
“story” allows us to provide better care for that patient. Today we are going to explore how
“seeing” the patient can aid or detract from the quality of care we provide.
In many ways medicine is a visual science: doctors speak of "seeing patients" without realizing
the deeper significance of the phrase. The art of really seeing patients as whole human beings is
arduously acquired through years of intellectual discipline, empathy, and practice. The
physician’s eyes must observe methodically and discern compassionately, valuing both objective
information and personal experience. They must see beyond stereotypes that categorize patients
and make them less visible. Stereotypes, especially based on race, gender, social class, or age,
block our efforts to provide humane and respectful care. Stereotyping – or pre-judging –
diminishes the ideals of justice, personalized care, respect, and human dignity. “Labeling”
patients makes them less visible as individuals. It keeps us from seeing – really seeing – our
patients and ourselves. Resorting to quick conventional labels is a constant temptation in the
often impersonal setting of a university teaching hospital as evidence in the standardized clinical
case presentation (“The patient is a 42-year-old black male….”). It is tempting to think that
stereotyping can streamline the process of caregiving. In fact, it slows down the process by
obscuring the actual concerns of the patient. It offers the illusion of understanding while, in fact,
promoting misunderstanding and a sense of the patient’s “other-ness.” It directly impairs the
process of visualizing the patient as a unique person, a self striving to be whole in the face of
illness.
We usually take the sense of sight for granted. We use it unthinkingly to orient ourselves in our
world, to understand our environment, to recognize each other. With our eyes we record
experience and gain knowledge. We gather facts. The things we see may disgust or delight us or they may pass before our eyes unobserved, not really seen. We may fail to notice what falls
within our vision because we hold to assumptions that close off or disconnect thought from sight.
Part of this week's class period will be devoted to the discussion of images. Artists and essayists
construct painted or verbal pictures of what they observe in order to transform their observations
and experiences by means of fellow-feeling and sensitive imagination. They stand as observers
and, by a stretch of the imagination, in the place of suffering. We are asking you to do
something similar in this week's class period. Interpretation occurs when mind and eyes meet.
Compassion for suffering occurs when one tries to interpret the situation of the sufferer correctly,
in all its complexity.
Questions for Class Discussion:
1. What do you see?
14
2. How does close observation alter your perception of what you see?
3. What does “respecting persons” mean? What does it mean to respect others as equal to
ourselves? What are the philosophical grounds for respect?
4. How do stereotypes based on race, social class, gender, or age make it difficult to act on
the principle of respect of persons?
Readings:
1. Bernard Lo, Resolving Ethical Dilemmas: A Guide for Physicians, Second Edition.
Lippicott, Williams & Wilkins, 2000, pp. 197-205.
2. Richard Stern, “Dr. Cahn’s Visit,” Packages, (Coward, McCann and Geogehegen, 1980),
pp. 347-351.
3. William Carlos Williams, “Face of Stone,” The Doctor Stories, (New York: New
Directions Books, 1932), pp. 78-87.
4. Maureen A. Milligan and Ellen More, “The Empathic Practitioner: Empathy, Gender, and
Medicine,” from the Introduction of Empathic Practitioner: Empathy, Gender, and
Medicine, Ellen Singer More and Maureen A. Milligan, Ed. (Rutgers University Press,
1994) pp. 1-5.
In Class Activity:
View Slides
Case
Bill is a profoundly retarded man who has lived in a state hospital for many years. He has no
contact with family members, and he has become a ward of the state. At the age of 58, Bill
developed acute myelogenous leukemia (AML). Chemotherapy has been recommended, but its
appropriateness was questioned on the basis that Bill would not understand the uncomfortable
and prolonged treatment, and the long-term prognosis for him would be poor, regardless of the
intervention. His physicians wonder whether they could forgo attempts at treatment and instead
adopt a palliative care plan.
1. What factors should enter into the decision regarding chemotherapy?
2. Considering the fact that bone marrow transplant offers the best hope of cure for this
disease, should it be considered for this patient?
3. Can a patient who is mentally retarded have the ability to participate in medical decisionmaking?
4. Who may make treatment decisions for a patient who never possessed decisional
capacity?
5. What interests of the state might be invoked that could influence or restrict decisions to
withdraw or withhold care?
6. What is the significance of the low probability of the proposed treatment’s success?
[Judith C. Ahronheim, Jonathan Moreno, and Connie Zuckerman, Ethics in Clinical Practice,
(Boston/New York/Toronto/London: Little Brown and Company), 1994, pp. 130-138.]
15
WEEK 6
PATIENT AUTONOMY AND THE GOALS OF MEDICINE
KEY CONCEPTS: autonomy, self-determination, liberty, risk, harm, physician obligation
This week focuses on the ethical values of self-determination and autonomy, regarded by many
to be at the core of contemporary medical practice as well as American law.
Self-determination is a moral mainstay of our sense of who we are as individuals. We think of
ourselves as largely free to choose how to live our lives. How accurate this mental picture is as a
description of how we actually live is debatable. But when we fall ill it is often the case that our
sense of autonomy and independence is compromised.
Personal beliefs about health matters influence the decisions that doctors, patients, and families
make regarding medical care. These beliefs embody values and attitudes regarding what people
consider to be important to themselves or to the quality and direction of their lives. Often illness
or injury intrudes upon or alters these value assessments, creating conflict and disagreement
about a person's "best interest" or "quality of life." In medicine, these disputes can be the source
of ethical controversy and debate.
In this unit we will focus on some of the ways in which personal beliefs about the value of
autonomy and self-determination intersect with issues of risk, harm, and individual liberty. An
important ethical concept in this area is the issue of the physician's obligation to provide care to a
patient even when the patient is involved in behaviors which put the health of either the patient
or physician at risk.
Questions for Class Discussion
1. Define the principle of self- determination and demonstrate its application to clinical
medicine.
2. Is personal autonomy an absolute value in health care decision making?
3. Distinguish between "quality of life" and the "value of life." Demonstrate the relevance
of each to ethical problems in clinical practice. Think of at least one situation in which
they might conflict.
4. Are there ever circumstances in which social welfare outweighs the duty physicians have
to their individual patients?
5. How ought we to view people whose behaviors are destructive to their own health? Does
this alter the physician’s obligation to provide care?
Readings:
1. Bernard Lo, Resolving Ethical Dilemmas: A Guide for Physicians, Second
Edition. Lippicott, Williams & Wilkins, 2000, pps. 3-10, 302-309.
16
2. Dan C. English, "Obligations to Treat," in Bioethics: A Clinical Guide for
Medical Students, W. W. North, & Co., New York, 1994, pp. 188-209.
3. Robert M. Veatch, “Voluntary Risks to Health: The Ethical Issues,” in Thomas E.
Mappes, and Jane S. Zembaty, eds., Biomedical Ethics, (Second edition), New
York: McGraw-Hill, 1986, pp. 593-601.
4. Arthur Caplan, “Ethics of Casting the First Stone: Personal Responsibility,
Rationing and Transplants,” Alcohol Clinic. Exp. Res., Vol 18, No 2, 1994: pp.
219-221.
5. George J. Annas, “Legal Issues in Medicine: Testing Poor Pregnant Women For
Cocaine—Physicians as Police Investigators,” N. Engl. J. Med., Vol 344, No 22,
2001: pp. 1729-1732.
In Class Activity:
Case Discussion
Case
Sandra, a young mother, habitually uses cocaine and has abused other illicit drugs in the past.
She has now become pregnant and visits a local clinic where she receives prenatal care. She
states that she is no longer using cocaine, but analysis of her urine reveals cocaine exposure. Her
obstetrician advises her to stop using cocaine because it will harm her fetus. Sandra mentions
that her other baby is “normal.”
A few weeks later Sandra takes her 2-year-old son to the pediatric clinic at the same hospital to
be treated for an ear infection. When the pediatrician becomes aware of Sandra’s pregnancy, he
calls the prenatal clinic. He urges the obstetrician in charge of Sandra’s care to take action. A
pregnant woman who is knowingly going to harm a developing fetus with cocaine use should be
incarcerated, he says, and if this patient refuses to give up her habit, she should be reported to the
district attorney’s office. The obstetrician replies that he shares the pediatrician’s concern but
that they have no authority to do this, it would be a violation of patient confidentiality, and if
“doctors went around reporting pregnant women, no one would seek out prenatal care.”
1. What is the effect of a mother’s cocaine use on the fetus?
2. How will the patient’s prenatal care be affected if her drug use is reported to the
authorities?
3. How would the situation differ if the mother were abusing heroin? Alcohol?
Nicotine?
4. To what extent can Sandra’s physicians or others intervene in order to protect her
developing fetus?
5. What are the physician’s legal obligations in this case?
6. Under what authority was Sandra tested for cocaine?
[Judith C. Ahronheim, Jonathan Moreno, and Connie Zuckerman, Ethics in Clinical Practice,
(Boston/New York/Toronto/London: Little Brown and Company), 1994, pp. 301-310.]
17