Ethical education

Ward ethics: dilemmas for medical students and doctors in training Thomasine K. Kushner and David C. Thomasma, editors Cambridge (UK): Cambridge University Press; 2001 265 pp US$85 (cloth) 0-521-80291-1 US$29.95 (paper) ISBN 0-521-66452-7

As its title suggests, this timely publication addresses ethical and practical dilemmas encountered by medical students during their training. Edited by the American philosophers Kushner and Thomasma, the book consists of a series of cases that are each commented on by several authors, usually from different disciplines. Most contributors are American, but there is a scattering of Europeans, Asians and Canadians among the 48 (!) authors.

Although it is directed at medical trainees and the physicians responsible for their training, this book would be a useful read for almost anyone concerned about the state of modern medical education. Comprehensive in scope, it covers such topics as trainee inexperience, patient blaming, boundary violations, deliberate deception, cynicism, the fallibility of authority and patient mistreatment. The cases are well-organized, and each chapter is followed by discussion questions. The index is useful, but the appended glossary seems unnecessary.

Physicians and medical trainees will identify with the scenarios discussed in this book. One common thread throughout these disparate and sad tales is the failure to meet rather obvious ethical and legal standards of high-quality care. Another is the failure, as several of the contributors argue, simply to respect patients as people and to exhibit common sense and decency. How could one not respond to the evident need of a patient in tears? The suppressive effect of medical training on the natural empathic response is sometimes astounding.

Although some of the cases seem incredible (for example, a new house officer in the operating room for the first time feels compelled to do a series of fairly minor operations while awaiting the surgeon; in one instance, he even dashes off to the washroom to consult a textbook on how to do the next procedure) others are all too common and compelling. The familiar stories — covering up harmful errors, being uncertain whether to support a patient in time of need, failing to delay a procedure despite lack of experience and supervision — still occur and were recently the subject of an article and editorial in BMJ.^1,2 The furore that the latter generated³ reveals the depth of public concern about such practices.

Although such scenarios are often considered unexceptional by medical professionals, they are anything but for the public,⁴ who are concerned that modern medicine's core values of trustworthiness and accountability are being undermined by unethical practices and attitudes. Are these practices really rife in medicine? Are they accepted as the inevitable by-products of a demanding education? Or are they a result of ingrained behaviours that can be changed by concerted efforts at curriculum renewal?

The discussions in this book should help dispel any idea that medicine doesn't have the capacity to take these sorts of incidents seriously and offer positive change. Moreover, the book's international tinge reveals that they are a concern to educators everywhere. The challenge for educators is to meet the needs of students through humanized training programs. Unless these challenges are met, the “informal” (and often unethical) curriculum will continue to outweigh the formal ethics teaching that trainees receive.⁵ New “charters for physicians in the new millennium” are fine things⁶ but will fail to gain any ground if physicians continue to be educated in the same old ways.

Many medical schools are learning from this debate and are increasingly stressing the ethical dilemmas trainees face, rather than focusing on the big and weighty ethical issues of the day.⁷ The poor funding that most Canadian ethics and humanities programs receive creates a gap between what medical schools must do to change and what they are able to do, however. Until this gap is bridged by better funding, patients will continue to receive less than the best care — and future trainees, too, will suffer the same indignities as in the past.

For the sake of a thorough review, it must be said that this book is weak in some areas. A stronger edit could have reduced the book's length. Not surprisingly, given the number of authors, the cogency of the case discussions varies greatly. Some authors are less directive than others; some are unduly philosophical; and some are simply unclear. Students and their mentors need definitive suggestions to determine a better approach to resolving ethical dilemmas and to recognize the roads not to be travelled.

Also disappointing is the glaring lack of medical trainees' participation in the book's deliberations. Are students always as hapless and spineless as this book suggests? Educators should strive to involve them in finding the solutions to the dilemmas they face.⁸ Listening to and learning from students are essential to the humble attitude that physicians, as educators and mentors, must (and are beginning to) adopt. Or, as a young Karl Marx once wrote, “the educator must himself be educated.”

Philip C. Hébert Bioethics Coordinator University of Toronto Medical School Toronto, Ont.

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Photo by: Barbara Sibbald

Figure.

Photo by: Fred Sebastian