In a pediatric clinic, a medical student is treating a 9-year-old child who is HIV-positive. The child's mother has not told the child about his condition and does not wish to do so. The student believes the patient should be informed, but wonders which takes precedence, the mother's legal authority, or the rights of the child?
A new course in the School of Medicine is helping medical students learn to grapple with these kinds of difficult ethical dilemmas, faced each day by practicing physicians. The third-year course, called "Clinical Ethics," is a collaborative project of the medical school and the Ethics Center. Alan Stoudemire, professor of psychiatry and behavioral sciences; Kathy Kinlaw, associate director of the Ethics Center; and Mary Lynn Dell, assistant professor of psychiatry, are co-directors of the course. The course also is supported by the medical school's Quality of Life Program, funded several years ago by an anonymous donor interested in ethical and quality-of-care issues in terminally ill patients.
During each of their five clinical rotations, third-year medical students participate in six to eight hours of problem-solving seminars. Under the guidance of faculty facilitators, they study two or three cases in medical ethics, both actual and fictionalized, which relate to that specialty. They research similar cases and discuss moral reasoning within the context of clinical problem solving.
Many of the cases deal with compassionate care of terminally ill patients. In pediatrics, for example, a case might deal with the dilemma of continuing life support in a premature infant with brain damage. In internal medicine, it might deal with whether or not to continue hydration and nutrition in a patient with Alzheimer's disease who is in a vegetative state. In surgery and anesthesia, the debate might involve whether or not to continue respirator support in a patient with severe head trauma who will not recover cognitively. In obstetrics and gynecology, students might discuss issues of surrogate parenting, ethical issues of selective termination of pregnancy in multiple births, or prescribing contraceptives for underage teenagers.
Faculty facilitators are recruited on a rotating basis from the clinical departments and prepared through a mini-course presented by the Ethics Center.
"Not only will we be graduating medical students who are well-informed about medical ethics, but we also will be increasing faculty members' levels of knowledge and sensitivity in ethical matters," he pointed out.
Medical ethics has been a part of Emory's medical school curriculum for many years through a second-year lecture course called "Human Values in Medicine," taught by John Stone. But teaching students and faculty the structured skills needed to reason out a dilemma and arrive at a decision has been rare in medical schools until recently.
Emory medical students had expressed an interest in having a method for analyzing difficult ethical dilemmas, said Kinlaw. The language of ethics gives them a way to articulate their reasoning, since the basic methodologies in moral reasoning are very practical and somewhat structured. "This is not an equation, but simply a framework around which to organize their thinking," she explained.
The clinical ethics course also introduces students to resources that the average doctor might not be familiar with, such as ways to access the legal system for assistance in ethical dilemmas.
Legal guidance might be helpful if there is division within a family about whether or not to continue life support, as demonstrated by a recent case encountered by an Emory physician. A patient dying of painful metastatic breast cancer, although she was delirious and confused, asked to have all drugs, chemotherapy and life support withheld. Her family, on the other hand, wanted all possible measures taken to prolong her life.
"We hope to give students the knowledge base in medical ethics as well as basic methodologies that they can use along with more scientifically based skills for reasoning through these kinds of ethical dilemmas," said Stoudemire.
New ethical challenges presented by managed care and advances in technology have fueled a resurgence of interest in medical ethics across the country. Before managed care, physicians usually were motivated to provide more rather than less medical care, which theoretically was of greater benefit to their patients. In some managed care systems, however, physicians are forced to make medical decisions based on allocation of limited resources.
"For example," explained Stoudemire, "within some managed care systems, if a patient came to me for depression, the cheapest way for me to treat that patient would be to prescribe an antidepressant and suggest a brief office visit in a month. Although the patient would most likely benefit from weekly psychotherapy, that would be money out of my pocket or my system's pocket. Do I choose the cheapest method, or risk losing money by providing the better quality of care?"
The ethical dilemmas presented by advances in technology and medical genetics are staggering. The human genome project will soon make it possible for physicians to predict rather accurately the diseases people might die from. Already, health care professionals and society in general are confronting issues presented by new reprodutive technologies, such as the capability of selecting particular genetic characteristics. When embryos are harvested and only one is implanted, what do you do with the extras? And after a divorce, who has custody over frozen embryos?
Legal and moral issues often are intertwined in ethical decision making. Robert Gordon, an Emory liver transplantation surgeon, recently presented a case to his class of medical students in which a federal prisoner with a long history of alcohol and narcotic abuse became a candidate for a liver transplant. The students reasoned through the moral and legal issues used to determine whether prisoners have the same rights to medical care as other citizens.
"If we can imprint the skills for ethical decision making on students at a formative stage of their professional development," said Stoudemire, "we believe it will have a lifelong impact. This may be one of the most helpful things we can impart to medical students."
-- Holly Korschun