Med Students Now Get Daily Dose of Bioethics
Quynh-Nhu Nguyen knows she will face a steady stream of ethical decisions when she becomes a physician: “I’ve thought about them often,” she said. But as a first-year student at the George Washington University School of Medicine, she doesn’t believe she is yet preparing for them.
Nguyen is wrong. And her professors are delighted that she is; it means that they have been introducing bioethics into the curriculum seamlessly, and the students don’t even realize they are being exposed to it.
George Washington and most of the nation’s other medical schools have made the study of bioethics a standard part of their programs for more than 25 years. But as recent advances in medical technology have catapulted such issues as end-of-life care, doctor-assisted suicide, medical rationing and fertility choices into the front lines of daily health-care delivery, medical schools have begun transforming their approach.
No longer isolated as it was in the 1970s, the study of biomedical ethical dilemmas is now melded into the education that medical students receive every day.
“It is part and parcel of our program,” said Dr. Robert Keimowitz, dean of George Washington’s medical school. “It is not taught as a separate course.”
The idea is to make it as much a part of their experience as student doctors as it will be when they become practicing doctors.
“There are all kinds of societal issues that physicians deal with every day, many of them related to the beginning or the end of life,” said Dr. Michael Whitcomb, senior vice president of the Assn. of American Medical Colleges. “We are confronting them daily: Look at the recent debate, for example, over the birth of those septuplets,” referring to the delivery of septuplets by Bobbi McCaughey in Iowa.
Schools now integrate ethical decision-making into all their teaching: in classroom discussions of case studies, in role-playing of specific patient-doctor situations and even with students’ exposure to patients, which begins during their first weeks of medical schooling.
“It is here that they begin to experience, live and unrehearsed, the ethical issues, dilemmas and responsibilities of the practicing physician,” said Dr. Morgan D. Delaney, director of George Washington’s first-year course in the practice of medicine. “It is here that the ethics of medicine begins to intrude upon the student’s consciousness.”
George Washington’s first-year students, for example, study the case of an elderly woman with severe osteoporosis who fractures a hip. She is the principal caregiver for her young grandchildren, a role that will be greatly impeded by her disability.
“This case is a starting point for discussions of the developmental stages of human life, family responsibilities and the ‘sick’ role and the burdens it imposes upon a patient and her family,” Delaney explained.
Dealing with such concerns is an important element of delivering health care today, he said, yet it would have been unthinkable at an earlier time, when physicians believed that their responsibility was only to heal the body, not to become involved in more complicated issues of psychosocial dynamics.
Dr. Albert Jonsen, professor of medical ethics at the University of Washington and a pioneer in introducing the subject into medical education, hails the new approach.
“When you get to the end of medical school, you will have learned your ethics in a way that’s painless,” he said, “and it will be integrated into the very kinds of things you will do as a physician.”
Firsthand Experience With Painful Choices
After her sophomore year at UC Irvine, Quynh Nguyen (pronounced Quinn Hwinn) spent the summer training to become a volunteer at a hospice program run by St. Joseph’s Hospital in Orange. But ultimately she chose not to participate.
“Initially, I thought it would be valuable for me to have the experience of spending time with patients in the final moments of their lives,” she recalled. She finished the training because “I wanted to be aware of my own strengths and weaknesses, and know what to focus on.”
But she dropped out of the actual volunteering. “I found that it was hard for me emotionally. It was tough, very tough. I couldn’t do it.”
The emotional strain that Nguyen felt was compounded by a personal tragedy that was unfolding outside school. A close friend of her mother’s--a woman who was 40 years old and pregnant--had been diagnosed with advanced colon cancer, and Nguyen became drawn into discussions of the painful choices confronting the woman’s family.
“I was in that room when my mother’s friend died,” she remembered with a shudder. “They were feeding her through a tube. They had to make the decision to take the tube out.”
Complicating her approach to matters of medical ethics is that she is heavily influenced by her religious beliefs. Born in Vietnam in 1974, she was 18 months old when her parents brought her and her four older brothers and sisters to Southern California, eventually settling in Irvine. Her father, who owns a landscaping business, and her mother, an electrical technician, reared their children as Buddhists.
Nguyen says she would be reluctant to suggest anything that would tarnish her reverence for life. She opposes the concept of physician-assisted suicide, for example--”I would never assist a patient seeking to take his or her own life”--and would refuse to perform an abortion “unless it was to save the life of the mother.”
“This is not for me,” she said of abortion, although she realizes that “in training, I probably will need to learn how to do one.”
“These are all issues I know I’m going to have to think about in the coming years,” she said. “Things are never black or white. There are always exceptions; I realize that. And I realize these are issues I will have to face at some point. I’ve thought about many of them. But I’m not sure I have any answers.”
Nguyen, 23, and midway through her first year in medical school, knows that, as a physician, she will have to strike a delicate balance between becoming too professionally detached from her patients and becoming too emotionally involved. She is concerned that she will not succeed.
The experience with her mother’s friend “made me really put things into perspective,” she said. “It was difficult for me to be emotionally detached. It’s so hard not to get involved, especially when you’re there during their last moments of life.
“As a doctor, you have to be able to confront these issues and talk to your patients about them, particularly when it is the end of life and there are decisions that have to be made. But it’s still hard for me. I think, as I go through the various rotations with patients, I’ll eventually be better at it. At least I hope so.”
Keimowitz, George Washington’s medical school dean, describes Nguyen’s apprehension as perfectly normal for this stage of her education. He said first-year students worry about everything down to drawing blood and conducting their first pelvic examination. Whatever it is, “they’re convinced they can’t do it,” he said.
There are no clear answers to the most troubling medical issues facing society today, he said. All doctors can do is approach every issue honestly and examine every facet of it.
Even that, he said, represents a radical departure from the past. During the school’s alumni reunion this fall, Dr. Felicia Cohn, of George Washington’s Center to Improve Care of the Dying, described to the older physicians the need to discuss terminal illness openly with patients.
“They were absolutely shocked,” Keimowitz recalled. “Many of them felt that you simply can’t have doctors talking to patients about dying.
“Doctors don’t change very quickly,” he said. “There has been a real generational change, and it is very important.”
Technology Has Raised Host of New Questions
Ethics has been a formal part of medical education since about 1970, and the first subjects--such as professional ethical behavior and patient confidentiality--were relatively tame. Since then, rapid advances in the technology of prolonging life--and even creating it--have raised a broad range of ethical questions.
In 1972, Jonsen introduced one of the first ethics courses in the nation at the UC San Francisco School of Medicine. The two-week course, for fourth-year students just before their internships, dealt mostly with DNR (do not resuscitate) orders and the termination of life support.
In recent years, managed care has added an additional layer of difficult choices for doctors as they grapple with their changing relationship with patients.
Today, the ethics theme at most schools runs virtually throughout the four-year programs. At George Washington, for example, Nguyen and her first-year classmates will not only deal with real-life patients but also dissect case studies in the classroom.
In addition to the elderly woman with the hip fracture, they will consider a 14-year-old girl who is newly diagnosed with diabetes. Central to her case, Delaney said, is the interaction between the adolescent and her mother: How, for example, should the doctor treat the usually confidential doctor-patient relationship when the patient is a minor?
“We continue to build upon these foundations as the year progresses,” he added, “returning periodically to more formal discussions of medical ethics, but always based in case studies.”
This concept is widely embraced today as medical schools, in Jonsen’s words, “try to find the things every practitioner should be familiar with.”
“The real skill of ethical judgment is to know what your basic stance is,” Jonsen said, “and to have the discretion to move away from it when you see a very good reason to do so.”
