TEACHING CLINICAL ETHICS
and PROFESSIONALISM:
WHY and HOW
Prof. Alan Rubinow M.D.
Hadassah-Hebrew University Medical School
29th February, 2012
“Doctors are men who prescribe
medicines of which they know
little,
for diseases about which they
understand even less, for people
about whom they know nothing”
Voltaire
Medicine in the 21st Century:
Patient, Physician and Society
Advances in technology
Health care economics
Public awareness of health care issues
Patients’ advocate groups/media
Negative elements: greed, arrogance,
deception, coercion
Transfer of decision-making to patient
Professionalism
Student/Profession
Student/Physician
Student/Patient(strangers)
Student/Patient/Family
Student/Health and Disease
Student/Health and Disability
Student/Personal and Professional life
The Moral Context of the
Doctor-Patient Relationship
Honesty and integrity
Mutual respect
Trust
Empathy
Mutual goals
Professionalism
Introduction of student
Medical student?
Young doctor?
Soon to be doctor?
Student doctor?
What difference does it make?
Professionalism
Altruism- best interests of patient: not self-interests
Accountability- patient, society, profession
Excellence- exceed ordinary expectations
Duty- acceptance of a commitment to service
Honor and integrity- highest standards of behavior,
be fair, truthful, keep promises, meet commitments
Respect for persons- humanism, collegiality, dignity
Confidentiality-communications are private
Teaching
Ethics and Professionalism
Can the concepts of ethics, values
and professionalism be taught?
Autonomy
Beneficence
PHYSICIAN
Do no harm
Justice
Teaching Clinical Ethics
Why?
Why Teach Ethics?
Much debated:
“ if you can’t evaluate it, don’t
teach it”
Teaching Clinical Ethics
Justification
Practice of medicine moral issue
Clinical medicine more than technical
skills
Ethics has its own content and method
Ethics is as teachable as any discipline
Make ethically defensible decisions
Goals of Teaching Ethics
Philosophy of medicine/principles
Sensitize students to value issues
Teach moral reasoning
Highlight the uniqueness of patientdoctor relationship
Place medicine in broader, social,
professional perspective
Not to teach students to be ethical
Teaching Clinical Ethics
What?
Teaching
Ethics and Professionalism
What concepts should be
highlighted in a course designed to
foster empathy, respect,
responsibility and commitment?
“… initiatives for teaching medical
humanities and bioethics have the
goal of turning high-tech medical
performance into a high-touch one in
which the human essence is
revalued”
Prof Donatella Lippi Bull.Med.Ethics (2005)
Topics in Clinical Ethics
Philosophy and medicine
Informed Consent
Truth-telling
Confidentiality
Justice, resource
allocation: macro/micro
Transplantation Ethics
Ethical issues in HIV/AIDS
Maternal-fetal conflicts
Family-dispute resolution
Ethical issues in surgery
Theories and principles
Brain death, dying, DNR
Advance directives
Disclosing mistakes
Ethical issues in pediatrics
Ethical issues in psychiatry
Ethical issues in intensive care
Patients who refuse food/water
Research on human subjects
Ethics in geriatric care
Ethics in stem-cell research
Teaching Clinical Ethics
When?
Clinical Ethics
Throughout the Medical Curriculum
and Clinical Practice
Pre-clinical - intellectual tools
- interpersonal skills
Clinical
- teaching essential in clinical years
- ethics only relevant in resolving
practical questions
- integrated into medical curriculum
Teaching Clinical Ethics
Who?
Clinical Ethics
Physicians vs non-physicians
Consensus : physicians with adequate ethics
training
Benefits of clinician teaching ethics
- credibility with students
- serve as role models
- bring relevant experience/ cases
Teaching Clinical Ethics
How?
How to Teach Ethics?
Frontal lectures
Seminars (small groups)
Programmed, simulated patients
Role - playing
Video interviews
Case studies
Teaching Ethics and
Professionalism
Ethics Course
Prior to first clinical clerkship in medicine
Frontal lecture course 30-35 hours
Handbook- papers, stories, case studies
Booklet - Patient’s Rights Law
Entire class +/- 100 students/year
Lecturers- senior faculty only
Focus- ethics, law, economics, doctor/patient
relationship, professionalism
Teaching Medical Ethics
“ ability to present a conceptual
framework that students (and
young physicians) can grasp and
build on and to create a teaching
milieu which fosters selfcriticism and personal
development ”
S. Benatar. 1991
Teaching Ethics and
Professionalism
Clerkship Internal Medicine
Seminar
Small groups 6-7 students
Ethical principles – case studies
Ethical issues that impact on medical
students
Project assignment
Ethics and Professionalism
Project in Clinical Ethics
Personal encounter with one patient
clerked by student
Describe pertinent medical facts
Define principal ethical issue
Discuss/balance conflicting ethical
principles
Suggest how dilemma may be resolved
Prepared 8 weeks into the rotation
Ethics and Professionalism
Project in Clinical Ethics
Assignment submitted in two copies
Include up to 5 relevant references
Each student receives individual
written feedback on his/her work
Presents his/her patient to group of
peers (6-20 students)
Since 2008 compulsory: 10% of grade
Ethics and Professionalism
Project in Clinical Ethics
Observations
640 students in clinical rotation (2001-2011)
Majority found exercise rewarding
Few (2-3%) unable to find case without help
24 (3.5%) were unable to suggest a way of
resolving the conflict
Ethics and Professionalism
Project in Clinical Ethics
256 students (40%) presented an ETHICAL
dilemma
Autonomy
Informed consent
Withholding/withdrawing life support
End of life: death, dying, sanctity of life,
Restraining patients
Resource allocation
Ageism
Decision-making capacity
Futility
Ethics and Professionalism
Project in Clinical Ethics
224 students(35%) submitted a PROFESSNAL issue
Truth-telling
Confidentiality
Keeping promises
Disrespect for patients
Whistle-blowing
Surrogate/caregiver/family interactions
Maintaining contact after discharge (intimacy)
Disclosing mistakes
Ethics and Professionalism
Project in Clinical Ethics
160 students (25%) emphasized a dilemma
specific to STUDENT STATUS
Terms of introduction to patients
Power of the “white coat”
Disclosure of information
Practicing skills (blood drawing)
Presumed consent
Intimate physical examination
Duty to learn/teach conflicting with patient
autonomy
Examples
A 92 year old man, with metastatic cancer of the
lungs, signs a living will in the presence of his sons:
when and if a situation occurs that he cannot make
decisions for himself, he will not be artificially
ventilated or kept alive by heroic means. He does
want to have his pain well controlled.
Several months later his sons bring him to
emergency room in severe pain and respiratory
distress. Team is aware of his request and try
control his pain and breathing with small doses of
morphine. His situation gets worse and he implores
the doctors to ”DO SOMETHING!”
Ethics and Professionalism
Project in Clinical Ethics
79 year old woman with Alzheimer disease.
Egg size tumor 1 cm from anus.
Teacher: wants each (7) students to examine
patient. “if you know how to palpate a tumor like
this you will definitely save lives”
Patient: unable to give consent
Student: “learning to palpate a tumor in order to
help some yet undefined individuals in the future
does not override autonomy and consent of
patient”
Ethics and Professionalism
Project in Clinical Ethics
72 y/o man signing consent form. “I cannot read
without reading glasses” (oral consent and forms)
44 y/o woman “not opposed to heart surgery but will
do only what what my Rabbi advises” (substituted
autonomy)
38 year-old male who has had two heart transplants
for dilated cardiomyopathy. Wants/demands third
heart! (resource allocation-scarce vs. expensive)
Professionalism, Ethics,
Intimacy and Boundaries
Can your friend be your
patient?
Can your patient be your
friend?
Ethics and Professionalism
Project in Clinical Ethics
78 year-old man lives alone with foreign
caregiver. On discharge he invites
student (female) to his home
Ethics and Professionalism
25 year-old male with genetic
muscle disease requests student’s
cellular phone number
Professionalism
Confidentiality
“ Whatsoever things I see or
hear, concerning the life of men,
in my attendance on the sick ... I
will keep silence thereon,
counting such things to be as
sacred secrets.“
Hypocratic Oath
Ethics and Professionalism
Confidentiality
Can students be prepared for the
responsibility implicit in obtaining
sensitive, private information from
strangers?
Ethics and Professionalism
Confidentiality ( 29 students- 14%)
Truth-telling
Keeping promises
Disrespect for patients
Whistle-blowing
Surrogate/caregiver/family/ interactions
Maintaining contact after discharge (intimacy)
Disclosing mistakes
Ethics and Professionalism
30 y/o woman with recurrent asthma
tells student her husband beats her.
Fakes asthma attacks to escape him.
“Don’t tell!”
Ethics and Professionalism
Confidentiality
38 y/o man with acute hepatitis
B tells only student that he
suspects source is extramarital
sexual contact Doesn’t want
information in hospital record
Ethics and
Professionalism
17 year-old boy, ultra-orthodox,
studies in all boys school, is
referred by army physician. He has
a micro-penis, un-descended
testes and evaluation reveals an
XX karyotype
Ethics and Professionalism
44 year-old man with Wilson’s disease is admitted to
evaluate his suitability for a liver transplant. Record states
previous alcohol abuse, strongly denied by patient. Student
develops good rapport with patient. Fourth hospital day
sees patient angry and agitated.
Student:” What happened? Why are you so upset?”
Patient: “Someone stole my cell-phone. What I did was go
down to the second floor and take a cell-phone from a
patient on the orthopedic floor!”
Student: Is this information confidential?
Ethics and Professionalism
Student argued:
On one hand, patient committed a felony
(stealing) and it is my civil duty to report
him.
On the other hand, by such an action I may
indirectly kill him. The committee responsible
for allocating organs (scarce resource) may
deny him a liver on the basis of him being
unreliable, inferior social worth etc.
Professionalism: Truth-telling
Lying:Making false statement, intentionally misleading
listener
Deception: Facts may be true or partially true- intention
to mislead, jargon
Non-Disclosure: Deliberately not providing information
Truth dumping: Overwhelming patient with detailed
medical data: patient provided with data he cannot use
Misrepresentation: Intentional/unintentional quotation of
own experience or medical literature
Coercion: Badgering patient to accept treatment option
Professionalism
The medical student accompanies a
patient who is going to have an
endoscopy for evaluation of abdominal
pain. During the procedure the
gastroenterologist shows you, the
student, a large tumor that is highly
suspicious of being malignant, in the
stomach. On your back to the ward the
patient asks you, “What did you see?
Ethics and Professionalism
Deception intended to mislead patient
74 y/o man with cancer of prostate on
chemotherapy. Oblivious of diagnosis. “he
doesn’t ask, we don’t tell”
42 y/o man with HBV cirrhosis. Has prolonged
fever. Tested for HIV/AIDS among other tests.
No permission requested.
Ethics and Professionalism
Lying to patients
44 y/o woman has had 3 kidney transplants.
Recently HCV terminal liver failure. Not
candidate for fourth transplant. Told with
student present that she is on the list - alleviate
anxiety
73 y/o woman has a malignant pleural effusion.
Patient wants to know. Family not allow data to
get to patient. Student knows. Patient asks.
Told infection
The great enemy of the truth is very
often not the lie -- deliberate,
contrived and dishonest -- but the
myth -- persistent, persuasive and
unrealistic
John F. Kennedy
Interaction with Patients
Professionalism and Conduct
Always wear your identification badge
Always introduce yourself
Never call a patient by first name (without
permission)
Never sit on a patient’s bed
Never discuss patients in the elevator or
coffee shop (even if they cannot be identified)
Clinical Ethics: Conclusions
The 5 C’s of Teaching Clinical Ethics
Teaching should be Clinically based
Real patient Cases should serve as teaching
focus
Teaching Continuous throughout the
curriculum
Teaching Coordinated with other objectives
Clinicians should be active instructors and role
models
Ethics and Professionalism
Project in Clinical Ethics
Summary
Case finding useful and challenging
Allow demonstration/development of
insight, observational and reflective skills
Learn language of ethical argument
Apply bioethical concepts at the bedside
Identify and analyze problematic issues
Fosters empathy, maturity
“Every case has its lesson
which is often,
but not always,
learnt”
Sir William Osler (1902)