Teaching ethical decision-making in medicine

Feb 11 2005

When medical students at the University of Iowa Roy J. and Lucille A. Carver College of Medicine learn about ethical decision-making in patient care, one of the things they paradoxically learn is that an "ethical" problem often isn't one.

Doctors routinely learn specific skills from textbooks, multimedia tools and hands-on training -- from diagnosing rare disorders to honing surgical techniques using state-of-the-art instruments. Ethical decision-making can be unsettling to medical students, who are accustomed to seeking out the single correct answer to any question.

And while many people consider a doctor's degree or specialty when choosing a physician, patients rarely wonder how their doctor makes ethical decisions.

Yet a physician's ability to reason ethically can contribute substantially to both the patient-physician interaction and health care delivery, said Lauris Kaldjian, M.D., Ph.D., an assistant professor of internal medicine who teaches second-year medical ethics at the UI Carver College of Medicine.

In an article that appeared online Feb. 9 in the Journal of General Internal Medicine, Kaldjian outlines the training approach developed by himself and two co-authors, Robert Weir, Ph.D., the Richard M. Caplan Endowed Chair in Biomedical Ethics and Medical Humanities at the UI, and Thomas P. Duffy, M.D., professor of internal medicine at the Yale University School of Medicine.

Titled "A Clinician's Approach to Clinical Ethical Reasoning," the article reveals how doctors can be effective in situations involving difficult decisions and differences in judgment.

"One of the challenges in clinical medical ethics is that sometimes a problem arises, and health care professionals believe they have an ethical problem on their hands. In fact, they may not; it may be a problem of communication or trust or insufficient medical information," said Kaldjian, who also is a staff ethicist for UI Hospitals and Clinics.

As an example, in end-of-life care, a family may resist additional treatment for a patient's pneumonia, which is normally not controversial to treat, because they believe the loved one has suffered enough. Yet the doctor may feel additional care is important because pneumonia is treatable with antibiotics. Improved communication may help everyone agree on what the goal of care should be and then understand what may facilitate that goal.

For students in training, the biggest challenge may be handling the feeling of uncertainty when they realize there are different, legitimate answers to the questions they encounter in clinical care settings.

"Students may feel unsettled. However, medical ethics is not only about asking and exploring questions but also about decision-making. Choices have to made one way or another. In clinical care, you can't just sit back and have a discussion with no follow-up action," Kaldjian said.

Instruction focuses on teaching students a way of reasoning that acknowledges there are different ways to judge what is a right answer. The students also are taught how to articulate their reasons for making decisions.

"Ethical decision-making is a complex mix of medical details and ethical values. Doctors have an easier time discussing medical details and are less familiar with articulating ethical values. Our approach helps them with this second task, especially when there are ethical disagreements," Kaldjian said.

"At the very least, we have to let each other know the basis of our disagreements, otherwise decision-making styles can be paternalistic and based more on a physician's position and power than on ethical reasons," he added.

The Hippocratic Oath stressed commitment to the patient and the patient's good -- an important and still meaningful part of today's modern physician oaths -- but it did not promote a patient's autonomy or rights.

"So much of medical ethics today takes seriously patient autonomy, an idea that was foreign to the Hippocratic tradition," Kaldjian said.

Today, patients and their families are involved in processes and choices surrounding medical care. Yet the requests or demands of a patient may put his or her doctor in an ethical quandary. For example, a doctor may have to choose between keeping the diagnosis of HIV infection confidential or reporting it to public health officials to protect the health of other persons who might have been exposed to the infection. The doctor must decide how to balance his or her primary responsibility to the patient with obligations to other persons in society.

For their part, patients and families should be aware that different physicians, based on individual values and reasoning, may respond differently in similar situations, just as different families respond variously to the same situation. Family members should listen carefully when a doctor makes a recommendation and invite the doctor to explain the rationale for the approach if one is not forthcoming, Kaldjian said.

When a patient rejects a doctor's recommendation for seemingly ethical reasons, it may be that those involved simply have not conversed with each other enough to understand each other's thinking and reasoning.

"Physicians are often unsettled by patients who refuse what the physician believes to be a good recommendation," he said. "If that recommendation is made too quickly and not accepted, there can be conflict, and the physician might think there's an ethical problem. In fact, it may be that the exchange was too rushed and that real dialogue has not yet happened."

In other instances, a physician may believe an ethical issue is at hand, when the need for additional facts may really be the issue.

"If a family rejects a physician's recommendation, he or she should review the medical literature and see if all the options were considered," Kaldjian said. "A thoughtful patient or family may raise questions that force the physician to do more homework and check other legitimate options. Then, at the end of the day, it might be possible to reach consensus on an alternative good solution rather than simply agreeing to disagree."

If a breakdown of trust occurs between physician and patient, it may be necessary to involve a third party, such as another physician. Kaldjian said most hospitals also have an ethics committee or a staff ethicist who can assist. In addition, social workers and chaplains can understand the issues at stake and be very helpful.

"Doctors sometimes need to learn to accept decisions they don't agree with. However, there are some situations in which to go along with a decision would compromise their deepest selves," Kaldjian said.

In their approach to ethical reasoning, the authors emphasize the doctor's own ethical integrity by referring to "conscientious practice," meaning that doctors and other health care providers need to be able to practice medicine in a way that does not contradict their deepest personal and professional values.

As an example, a physician at a hospital that will not provide treatment for a patient without insurance might decide that in order to maintain his or her integrity he or she needs to serve as the patient's advocate and find some way to provide care.

"It is a challenging task for a doctor to sustain a professional life that is consistent with his or her deepest beliefs," Kaldjian said.

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