By Richard P. Morin
Ten medical students sit around a small conference table in Rhode Island Hospital. The conversation starts and stops, with Dan Brock, professor of philosophy, pushing the aspiring doctors to dig deeper: What should you have done? Was that appropriate? Where do you draw the line?
This gathering is a unique teaching situation called Ethics Round. Twice each month, during each of the 12 required clerkships, students gather for an actual case presentation and ethics discussion led by a member of Brown's Center for the Bio-Medical Ethics.
This morning's case is of a woman requesting a medication doctors know won't cure her minor ailment. But if something isn't done to alleviate the problem, the patient will persist with behavior that has exasperated doctors and nurses alike. Led by Brock, the students and residents discuss whether the requested medication should be administered, whether a placebo should be given or whether the patient should be told the medication she requested won't cure her ills.
"I don't know what the right thing is to do," says one of the aspiring doctors.
The participants wrestle with the issue for some 45 minutes. Beepers go off, the students and residents make phone calls, and charts as well as advice are exchanged while the conversation winds its way around the table. "Are there any other management strategies?" Brock asks, prodding them along.
The conversation eventually concludes. Some participants head for the door while others linger. Dr. Kristine Tenebruso, a third-year medical resident in primary care, thanks Brock for the ethical discussion.
Does she believe ethics classes for doctors to be good medicine? Dr. Tenebruso is quick to respond. "You're preaching to the converted," she says. "If you don't have these types of situations in your training, it becomes much harder to figure out."
Some students, according to Brock, are more skeptical, believing medicine to be purely a science. "There are tremendous gaps in which the science of medicine does not provide an answer," counters Edward Beiser, associate dean of medicine and another leader of Ethics Rounds.
Before the formal inclusion of ethics as part of medical school training, doctors learned medical ethics "implicitly" from their medical mentors. "It was thought, in those quarters, that it didn't need to be explicitly discussed," says Brock. "In part, I think we have simply recognized that ... it did need to be explicitly taught." Brown initiated the nation's first undergraduate bio-medical ethics program in the early 1970s and began ethics training in the medical school in the 1980s.
Today, most medical schools nationwide teach ethics in some form of a classroom course for first- and second-year students. But these students are merely "undergraduates with a deep knowledge of biology," says Brock. "If you teach them the ethical issues at that point, they don't have the clinical context in which the issues arise."
He adds: "If we teach it in their first or second year, we are only providing a promissory note that you will later see why this is important when you have experience with patients." This is why Brown chooses to focus its ethics education in the third-year clerkship. "What we can then do is to teach off actual cases that the students are encountering in their clinical clerkships," Brock says.
The School of Medicine recognizes the importance of teaching ethics to future doctors. As part of the M.D. 2000 Plan, the School of Medicine has included moral reasoning and ethical judgment as one of its nine competencies students must demonstrate to graduate.
Dr. Stephen Smith, associate dean of medicine, says implementing moral reasoning and ethical judgment as part of the medical school's curriculum was at the behest of faculty and students. "Physicians of the future need to recognize ethical situations in the profession of medicine," he says. "They need to recognize such things as when there is an ethical conflict related to their employment. They need to be sensitive to that and act accordingly. Our graduates also have a social responsibility in terms of being a good citizen. By that I mean knowing how to analyze health care policy from an ethical perspective."
Ethics Rounds are not meant to provide students with ready-made answers. "There are always going to be ethical issues," says Beiser. "My job is to help them identify the values that [medical students] are working from and with."
"We are not trying to teach right or wrong answers to these rather complex and difficult cases," Brock adds. Rather, they are trying to teach young doctors "to recognize the complexity of the cases, how to think systematically through to a conclusion that they cannot only be comfortable with, but has seen the light of criticism. We are not creating good persons out of bad persons," he continues. "The idea isn't to instill a motive to be moral that isn't there."
Ethics Rounds are taught jointly by physicians and non-physicians. Medical students, house officers and physicians all participate, ensuring a range of knowledge and experience is represented. There also are separate conferences for medical students to alleviate any reticence about speaking before the doctors and residents who oversee their work in the hospitals.
Beiser also tags along on medical rounds to observe students in action. "I know I have been successful when a student is struggling with an issue," he says.
The emergence of physician-assisted suicide as front page news has sparked public debate about medical ethics. But what really propels the buzz is medicine itself.
"Many forms of life support, about which there often difficult questions now, didn't exist four decades ago or even three decades ago," says Brock. "Many ethical issues have arisen from the advances and success of medicine. Now that it can do so much more for people, issues about justice and distribution become more important."
Beiser also believes that medical ethics is a hot topic because of the changes in popular culture. "There have been medical ethics since antiquity," Beiser says. "The current explosion is happening in part because we can discuss things in public that we couldn't 30 years ago."
But Brock believes there are even more pressing ethical issues than physician-assisted suicide. "The issues of access to medical care, health care reform and the growth of managed care are far more important," he says. "Physician-assisted suicide is only going to be a real issue for a small number of patients."
The two liberal arts educators enjoy their time in the hospitals. They say they believe their presence adds to the life blood of the hospital. "We are having an educational impact on attending physicians," says Beiser. "That is a good thing."