Table.

Types of ethical dilemmas faced by students, with examples and quotations from focus groups

Type of ethical dilemma (No of students reporting the problem)	Examples	Illustrative quotations from students
Conflict between medical education and patient care (17)	• Patients asked to return to clinic for follow up visits and not informed that the visits were entirely for teaching purposes	Once, when I was on call, there was a patient who was palliative, in a vegetative state. The resident [house officer] I was working with decided that this would be a good opportunity for me to learn how to do a femoral stab, even though it was not necessarily medically required. The patient was not expected to [recover] from his current condition, and wasn't in a position to argue, and I think there was a very thinly veiled excuse that we could do it. It was more or less for the exercise in education on a non-consenting patient. It struck me as so at the time too, but we don't really get a lot of opportunity to practise those types of procedures.
	• House officer instructed a student to perform a femoral puncture, for purely educational reasons, on a comatose patient who did not need the procedure
	• Students asked to perform pelvic examinations on patients under general anaesthesia without patients' prior consent
	• Patient's name and details of care discussed by staff and students in a public place
Responsibility exceeding student's capabilities (15)	• Student completed antenatal visits with patients who were never seen by a doctor	I had one [an ethical dilemma] on obstetrics, being asked to go get a consent for a dilatation and curettage. I was on call at a peripheral hospital on the weekend. No resident; just the staff [consultant]. The staff wasn't the most cooperative. And so I went and did it. But I checked with the patient: “Did the staff talk with you about the complications and the risks and the expectations? Because, frankly, I would not be capable of doing that.” The patient said “Yes, yes, yes,” and I documented that I didn't do the discussion [and that] the staff did the discussion. And on the consent [form] I put my name and “CC3” [denoting medical student status] in big letters after it, but I still thought it was ridiculous.
	• House officer refused to respond to student's request for help in assessing an unstable patient
	• Student and house officer left by teacher to close a wound, without knowing how to close it properly
	• Student expected to give weekly psychotherapy sessions without supervision
Involvement in care perceived to be substandard (9)	• Student witnessed house officer responding inappropriately to patient's refusal to have joint aspiration; consent form completed, but consent not meaningfully given	On my medical rotation, there was a patient on the floor who had lung cancer but [the physicians] weren't sure [of the type]. Nobody would tell the patient that he had cancer. The pathology report said that it was very suspicious for malignant cells. Anyone with any sort of medical training would know that the chances of it being malignant were very high. [Yet] nobody talked to the pathologist to find out what information they could tell the patient based on that. I asked the pathologist afterwards, and it was very clear that the patient could have been told he had cancer but they just didn't know exactly what type it was and they didn't want to get into specifics until they knew that every test had been done. This patient was probably in the hospital close to a week and a half and, every time I would go in the room, he would keep saying to me, “I don't have cancer do I?” And I was not at liberty to even tell him anything because the staff and the respirologist wouldn't tell him.
	• Student instructed by house officer to repair a child's scalp laceration with inappropriate supplies
	• Patient requested a narcotic-free vaginal delivery but given intravenous narcotics without her knowledge
	• Student uncomfortable about inadequate pain relief in patient care; felt it was ‘constantly put off’ by house officer