Center for Biomedical Ethics

BIOMEDICAL ETHICS IN THE BROWN MEDICINE CLERKSHIPS AND TRAINING PROGRAMS

Department of Medicine Newsletter
October 2005 • Volume 6 • Issue 4 • Published Quarterly


Thomas Bledsoe, MD
Interim Director, Center for Biomedical Ethics, Brown Medical School

*  It is 4 a.m. and you are the senior resident on the overnight shift in the Respiratory Intensive Care Unit. One of your patients was taken off the respirator that afternoon after a long conversation with her family about her prospects and her previously expressed wishes about her care. She has been breathing agonally for close to eight hours. Her family at the bedside asks you to join them in the hall and son wonders whether we couldn’t just give a little more morphine to “relieve her suffering.”

*  You are starting a new month on the medical service and inherit an elderly patient with advanced dementia who has been rehospitalized with another aspiration pneumonia. The intern informs you her unemployed son (who lives in the home she owns) is the family spokesperson and has told the team to continue all aggressive life-support measures.

*  You are a medical student starting the third month of your medicine clerkship and are secure in the knowledge that your new patient, while quite ill, has had a chance to make known to you his wishes regarding end-of-life care and a preferred surrogate decision maker, should one become necessary, and that you’ve documented these in the medical record. You’ve even helped guide him through the Rhode Island statutory advance directive form.


Tom Bledsoe lectures medical students
and residents at Rhode Island Hospital


Historically taught in the form of Socratic dialogue and questioning, medical ethics education has become a rigorous discipline with both philosophical grounding and practical application to real world medical situations. The Center for Biomedical Ethics oversees education in medical ethics in the clerkships for the medical students and for those in the Brown-affiliated Internal Medicine training programs. The Center was founded by noted medical ethicist and former Brown Philosophy professor Dan Brock and nurtured by former BMS Associate Dean of Medicine (Humanities and Social Sciences) Ed Beiser. Tom Bledsoe MD is currently Interim Director and is assisted by Michael Felder DO, Jay Baruch MD, Deirdre Fearon MD, Barry Wall MD, Ed Forman MD and Rosalind Ladd PhD. Drs. Bledsoe, Felder and Baruch are responsible for teaching in the medicine programs at Rhode Island Hospital, the Miriam Hospital, the VA Medical Center and at Memorial Hospital.

We have four basic goals in teaching medical ethics:

First, the students and residents should know the basic facts underlying common ethical dilemmas. Many of the most problematic areas of medical ethics since its inception as a field in the 1960’s, such as deciding for others and withholding and withdrawing care at the end of life, now have fairly well established lines of thought as well as procedures and even legal standards. An example is the development of the Rhode Island advance directive form (available on-line at http:// www.lifespan.org/Services/Ethics/ DPAHC/. There are points of knowledge about who can make decisions for others and how those decisions should be made. There are points of knowledge about the elements of informed decision-making that can be a useful guide to medical professionals in discussing testing and treatment options with their patients.

The second goal is that the students and residents be able to recognize the ethical dimension present in all medical interactions and specifically to recognize ethical conflict. Decisions about care for a patient with Alzheimer’s disease and dementia cannot be made on a purely “medi­cal” level. Is it “best” to treat the pneumonia, or to treat only for comfort? Even a new prescription for hypertension involves ethical aspects. Is the patient aware of the cost of this medication? How much does he or she need to know about possible side effects?

The third goal is that the students and residents develop a practice style that incorporates “preventive ethics.” How can this ethical dilemma be avoided next time a similar clinical situation arises? An important aspect of this goal is nurturing and developing ethical sensitivity. As the students and residents enter the medical field and encounter new situations, they are frequently made uncomfortable or uneasy by situations. All too often, the demands of a hectic training program allow them to simply move on; the rotation is over and the situation passes (or is swept under the rug). This goal involves using those experiences and learning from them.

The fourth goal is a variation on the famous “Primum non nocere,” and is “Primum non tacere,” which means “first, be not silent.” There is real risk to patients in silence in the setting of ethical conflict, and the most sensitive student or resident may do his or her patients a great service by speaking up and seeking open discussion, either to the team or to the institutional ethics committee. There is also great risk for the trainee, for seeing ethical breaches in the practice of medicine and remaining silent greatly raises the risk of burnout and departure from the practice of clinical medicine.

The students have a defined curriculum in ethics on the medicine clerkship and have sessions on advance directives and surrogate decision-making, informed consent and on medical error. Every month on the medical service includes a “ward ethics rounds.” These resident and student sessions allow the medical teams to bring forward ethical situations or conflicts they have encountered on the wards for open discussion, community ethical deliberation and problem solving. The preventive ethics review is incorporated here.

In addition, both categorical and primary care residents have sessions devoted to medical ethics in the ambulatory block months (which are) dedicated to the goals of medicine and models of the doctor-patient relationship, informed consent, confidentiality, physician as gatekeeper and other outpatient ethical issues and topics.

A classic conundrum in medical ethics is whether creating ethical physicians is possible, or whether it is the admissions office’s responsibility to accept ethical individuals, who then are trained as physicians. We believe that our trainees are ethical, but that they need to be taught to trust their instincts when a medical situation makes them uncomfortable, that they need to know where to turn for help and guidance in these situations, and that the ethical practice of medicine gives them the best hope for a long, satisfying and rewarding career in medicine.