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Brian Cox
Cardiff By The Sea, CA
United States

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Should medical ethics be taught in medical school?

Over the course of the summer, I am embarking on a fairly comprehensive examination of medical ethics curriculum in the medical schools of the UK, Ireland, Canada, and America. I will be conducting focus groups and distributing surveys to understand how medical students view their competency in dealing with ethical issues, especially those encountered at the end-of-life.

I hope to use this information to make specific curriculum amendments that will allow future doctors to confidently manage terminally ill patients.

However, I need your help.

In order to make my study even more robust, I wish to garner as many perspectives as possible. Please contribute your opinions, your experiences, your attitudes and beliefs. Tell me how doctors deal with end-of-life issues: how they have managed your family and friends.

*The first comment gives a little background on the current state of medical ethics in the UK. It is an excerpt from my proposal earlier this year.

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Feyisayo Anjorin 50+
- 0
Jul 24 2012: It is very important to have people of intergrity in the medical profession.
A lot of factors would contribute to the moulding of an individual; even those in the medical profession. But it would be unwise, and even disastrous, not to try all that can be done, including teachings, laws and regulations, to make individuals better. So that they can be more effective as agents of life.
Alec Chapa
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Jul 11 2012: "You don't have to find an average between short and tall (because you can't)"
I agree that one cannot and this is my point. In order to put the absolute into the words as it *really* is, we would have to synthesize (and bear with me, as it's the best word i can think to use) all of the perspectives on it, as in this case, they are examples or manifestations of the concept, just as Socrates would combine examples (which is similar to the word perspective- an example is in a way a perspective of the concept) to find the concept of just.
Alec Chapa
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Jul 11 2012: "Forms don't have to manifest in a single being to validate their existence. In fact, you'd never find that, because they ARE abstractions."
Yes, exactly. What I'm trying to say is that precisely because instances of these concepts are abstractions, "imperfect" and individuated models of the concept, we cannot and will not arrive at the moral axioms we speak of.
"In other words, what is justice in the abstract sense?"
yes, this is the idea/concept/form i speak of, which produces the examples.
"Don't ideas exist? Ideas are, at the very least, brain energy and energy certainly exists."
It's a tricky thing to say and im not quite sure i can put it into words, but I'll try. When you speak of the concept/idea/form that makes the examples just, can it be, itself, made into an example? Of course not! It is just an idea. And of course it is real, as it may not be tangible or visible but it definitely effects the world, which is in some way real, at least. My point is, when I say "absolute" I associate it with form/idea/concept and since the idea itself can never be modeled perfectly, so, too, can an absolute be modeled perfectly by language. Not to say that language is insufficient, but just that regardless of the means, any way of manifestation will only be an example of the idea, not the idea/form/concept or absolute we seek.
I think that humans can only be inspired by this absolute, to put it poetically, and then put it into their own words, but never be able to put the absolute, without bias or perspective, into words, as everyone will describe it differently.
Patrick Bailey
- +1
Jul 11 2012: Hi, Brian. Yes, ethics should definitely be taught as part of medical school. I'm a professor of philosophy and ethics, and I'm currently pursuing a second degree specifically in bioethics. People often approach ethics with the attitude that studying it is of no real value. As someone who has spent the past 20 years doing just that, I can assure you that's not the case. Philosophy, and by extension ethics, is just like anything else - the more you do it, the better you become at it. Not all explanations are created equal.

That being said, the current trends in spirituality and medicine (where spirituality isn't defined as exclusively "religious" but merely as whatever is at the core of one's source of meaning in life...family, appreciation of nature, altruistic acts, etc.) begin from the idea of treating patients as a person (i.e. a being with a set of beliefs, values, ideals, hopes, concerns, personality traits, etc.) rather than merely treating an illness or a symptom. Ethics is about how we weigh values, often in relation to a conflicting sense of duty. If we can consider such things in advance, it makes it easier to know what to look for, think about, and consider before we have to do so when we're interacting with people when it really matters. Two things I tell my own students at the beginning of every semester are that if we're going to even attempt to do philosophy well, we need to always keep in mind 1) make no assumptions (or as few as possible) and 2) just because you've heard something all your life doesn't make it true. Most of the students in my current graduate courses are medical students and my program is in the school of medicine, not philosophy; and they all the time make assuptions that philosophers wouldn't simply because of their background. If we combine the two disciplines, everyone benefits. Philosophers who attempt bioethics without any medical science are at an equal disadvantage as doctors who have no exposure to ethics.
Adriana Mackay
- 0
Jul 6 2012: They definitely should.
dean crawford
- 0
Jul 5 2012: How do brian
Quick question why would anyone let a doctor manage there family? Unless he was part of it. And what make you think that a doctor handles there death different from any one else? Please tell me if there is good money desinging a curculum for group that has almost no potential for being ethical.
Now with all that said the medical profession is a bloated pig that has as much use as tits on a boar hog.
Stancy Kelly
- +2
Jun 30 2012: Hi, I am a final year medical student from NZ. We have been taught medical "ethics" throughout our clinical years. I put the ethics part in quotation mark as I do think that there is a component of ethics that stems from the morals and values that we develop from childhood. Our teaching was based around autonomy, non-malificence, beneficence and justice. From this base we were encouraged to build discussions and arguments around case. We were always challenged to bring our own views and to try to look at things from all angles. There were many learning points were based around autonomy and competence. I found the teaching really useful in that it has helped me to develop my thinking and has given me a structure to refer back to when I come across a challenging case. We didn't have much teaching specifically about end of life care but I feel that with the base that I have I will have some confidence in my approach to such problems. Separate to out ethics teaching we have had a few sessions on breaking bad news which I found helpful but nothing can compare to witnessing it being done. But it was really nice to have a palliative care physician talk to us about his experiences. I have had a quick glance though the previous comments and see that someone suggested that you include australia. I imagine that aus and NZ have a similar curriculum. Let me know if you want to know more about my medical school and I can give you more details.
- Brian Cox 20+
  - 0
  Jul 5 2012: Hey Stancy, sorry for the delayed reply, I've been conducting and transcribing focus groups with medical students. I'm very interested in what appears to be an apparent difference in Australia/NZ and UK teaching, especially considering the two countries are British colonies. I probably will not be examining Australia/NZ this time around, but I'm on elective next summer. It would be interesting to followup some of this data through the Medical Ethics Institute out by you guys. If you can send me a message, I'd like to ask you just a few questions. I'm pretty wary about putting my email up on a public forum, but if you'd like, you could message me via facebook https://www.facebook.com/brian.k.cox. If not, no worries. Thanks for the comprehensive reply!
Ann Jaimi Alexander
- +2
Jun 28 2012: I'm pursuing my masters in education and we learned medical ethics as part of one of our courses. The purpose of learning this in education was because we deal with vulnerable children, as is the case with doctors too - dealing with vulnerable patients. It's important for people in these professions (that deal with a vulnerable people) to know how to empathize and understand that their role in their these peoples lives isn't just something in passing.

From my experience of learning medical ethics as an education student I can say that it is highly valuable and concur that ethics is something that is engrained from childhood and home life. If you don't have an ethically sound upbringing then learning about medical ethics can be quite surprising and new, and difficult to grasp. Ethics can also vary culture to culture.
- Brian Cox 20+
  - 0
  Jul 5 2012: Yes, definitely. I'm looking into improving the curriculum through an examination of cultural differences and how to respond empathetically to a diversity of groups.
  
  The world needs great teachers, wish you the best in your pursuit!
Swadesh Deepak
- +1
Jun 28 2012: My own understanding(I am a Doctor myself) is that Medical ethics or any ethics can't be taught in medical schools... it's something that has to be inculcated since childhood... at home, in junior school, senior school, higher education.... and "life". All Doctors sign the "Hippocratic Oath" at the time of registration, but do most Doctors follow them?
- Brian Cox 20+
  - 0
  Jul 5 2012: It's difficult to know whether ethics should be taught as apparently as math, english, and science, or whether it should "informally" be taught through experience and reflection. Surely we know right from wrong, but in the complicated world of medicine, it is sometimes not a question of what "can" we do, but what "should" we do? The Hippocratic Oath is a reflection of the ethical tenets, but it may not always govern our actions. "Doing no harm" can have many interpretations, unfortunately.
- Patrick Bailey
  - 0
  Jul 11 2012: Ethical theory can definitely be taught. I spend every day of the week doing it. The idea that something can't be taught simply because there are no strict answers, as one expects to find in sciences and other disciplines, is mistaken. Philosophy is about abstract critical thinking, not memorizing empirical facts. They're just two different ways to approach knowledge, and each has its own purpose, function, and merits. And ethics is always about what we ought to do, if you're talking about what we "can" do, then you're no longer talking about ethics. That's the difference between normative (evaluative) and non-normative (purely descriptive) statements. Ethical considerations are always normative, because they attempt to assess or evaluate. For example, one theory (often mistaken as an ethical theory) is psychological egoism, which simply states we observe that humans tend to act in self-serving ways. That's a purely descriptive statement, it doesn't attempt to prescribe anything. Its "sister" theory is ethical egoism, which states that if we do, in fact, observe people to behave as such, then people "ought" to do so, because they're simply acting on human nature. The latter of these two statements is normative, because it's prescribing what one ought to do...that's the realm of ethics.
Salim Solaiman 50+
- +2
Jun 28 2012: With my shallow knowledge I am aware of that all medical students go through Hippocratic oath at least, which is pretty good base for medical ethics till today.....how much of those ethics are practiced in real professional life setting as a whole ?

My feeling is, it is better to think how can we bring ethics in practice what we learnt whether from familial , societal or institutional setting............
- Brian Cox 20+
  - 0
  Jul 5 2012: The idea of "auditing" ethical practices is an interesting idea. I've written it down to research whether it has been done before.
  - Salim Solaiman 50+
    
    0
    Jul 6 2012: Thanks for your compliment......would love to know your findings of such research as well......
    My feeling is how to get right response from the respondents can be a challenge....as the most unethical person in practice seems most ethical in talking that's what my experience is.......I have no doubt you have the expertise to unmask respondents tactically to get real answer.....
    
    All the best with your research.
Stevan S.
- +2
TED Translator

Jun 28 2012: It is not a question IF Ethics should be studied. It's rather HOW, or in which manner should the matter be presented to students.

The presentation of seemingly impossible dilemmas to students who are at the beginning of their medical education (f.e. 1st year of medical school) leads to fruitless discussions.

However, students at a later stage of education should be stimulated to utilize their acquired knowledge, therefore ethical discussions can be infused with actual medical facts. In addition, experienced doctors could be invited to share their own stories and views on certain subjects.
- Brian Cox 20+
  - 0
  Jul 5 2012: You nailed it. Currently ethical teaching is considered to be formal, informal, or hidden. Formal teaching is comprised of lectures, seminars, etc. while informal teaching is the reflective aspect of some tutorials and discussions. The "hidden" curriculum is the idea that medical ethics is pervasive throughout the hospital, and students witness good ethical practice subconsciously. However, it appears there is a drive to make teaching substantial and lasting but in a more formal manner. Medical students need to be engaged in the discussion of medical ethics early, but discussions (as you said) which do not lead to impossibly "grey" outcomes.
Robert Winner 50+
- +1
Jun 28 2012: In a manner of speaking it is already covered. Your bedside manner is critiqued and discussed. If I could suggest ... hospitals have staff that counsel and refer families in death situations. I would be there for the announcement of the cause and answer medical questions and then sincerly offer condolences on the passing and turn them over to the professionals. You have a speciality and so do they each of you should respect the areas of the other.

All the best. Bob.
- Brian Cox 20+
  - 0
  Jul 5 2012: But is it too late if you're practicing the art of breaking bad news at the bedside?
Barry Palmer 50+
- +1
Jun 27 2012: I see end of life issues being mentioned a lot in these comments. While those issues are dramatic, ethics is involved in every aspect of an industry that should be centered around care. Any issue that negatively affects the quality of care is an injustice to the patient. Examples: the relationship of care giver to third parties such as drug companies, equipment suppliers and especially insurance companies; the doctor nurse relationship; mistakes that cause patients to get new infections in hospitals, many of them dying. When medical care is so expensive that many people can't afford needed care, the compensation of the care givers is an ethical issue.

I think that ethics should be taught as a separate class in each year of medical school and in every class it should be emphasized that quality of care is an ethical issue.
Lejan . 30+
- +1
TED Translator

Jun 27 2012: Isn't it taught in medical school already? If it isn't the question may then start with 'why'...

I think any end-of-life situation - where possible - should be based on 'free will' from inside and outside the sick-bed to keep both parties in their very own dignity at any time.

Teaching medical ethics may help the student to learn about it, yet it does not and should not prevent him and her to reflect and decide for themselves on this issue. May this decision be general or case specific later on. But to feel comfortable with whatever decision one makes, it will probably have helped to have learned about it. And if it doesn't it would not do any harm.

The conflict caused by the hippocratic oath in those situations lays in the oath istelf, which could be changed if it proofs
obstructive in finding a personal decision for a doctor. It has been written by men, it could be changed by men if it helps avoiding moral conflicts out of itself.

I can only say that if I ever have to make a decision for myself to end my life because I wan't it to, I would be grateful and honored if my doctor agreed on helping me by this. Also I have to honor and respect if he or she choses not to, yet knowing who would, would be helpful at that pont in time.
Debra Smith 200+
- +1
Jun 27 2012: Dear Brian, teach me how to help and I will.
I hope you feel well today (and every day)
Debra
thomas le calvé
- +1
Jun 27 2012: Maybe medecine should be taught in elementary schools (at least the basic). The medical industry is too big to be ethical.. and cost an arm to develop, while some simple knowledge and a peaceful environment could be much more proficient !
- Brian Cox 20+
  - 0
  Jun 27 2012: Classes in ethics are surely forgotten until a high school/collegiate level. I think academic administrators view ethical understanding is a purely philosophical pursuit rather than an integral part of communication, empathy, and integrity. Starting early is a great idea!
  - Patrick Bailey
    
    0
    Jul 11 2012: Exactly, Brian. Ethics could easily be characterized as the most practical branch of philosophy, because it addresses social behaviors, which is a subset of human behaviors.
Barry Palmer 50+
- +1
Jun 27 2012: Of course it should, and so should medical systems.
- Brian Cox 20+
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  Jun 27 2012: AGREED. System management is another major source of problems.
Terry Haynes
- +1
Jun 27 2012: I am a believer in medical ethics . I also support dying with Dignity. I am not a doctor, but if I was one, My primary goal would be to save lives,not end lives. But if I could not save the patient, I would try to help the patient die with dignity and grace. I would be respectfull, compassionate and professional to the highest degree.
- Brian Cox 20+
  - 0
  Jun 27 2012: I agree with you wholeheartedly. However, finding a way to 'respectfully, compassionately and professionally' allow a patient to die with dignity while maintaining medical principles of 'do no harm,' presents a tremendous challenge. If you can figure out how to balance all elements of this problem, you would win a Nobel Prize.
  - Terry Haynes
    
    0
    Jun 28 2012: Hello Brian
    My answer is what I already have, And that is a Living Will ( Advance directive ). Which states that I am not to be resucitated or put on life support. It allows the doctor to respect my wishes ethically and legally. Its not a nobel prize winner. But in my case it is the right answer.
Alec Chapa
- +1
Jun 27 2012: I believe there is a solution. I think that people are all on different planes of thought, though we may be perceiving the same thing (glass half empty or half full.). I compare this to different denominators but the same idea. So, let's say I'm 1/2 and you are 2/4 . We have a different way to explain the same thing. The easily solution is to find a common denominator and work from there, thus allowing solutions to be in both yours and my terms.
The same principle i illustrated here is apparent in Hegels philosophy: the synthesis is finding the common denominator of the thesis (your viewpoint) and the antithesis (my viewpoint).

Yes, I think debates would work, as it is basically allowing a synthesis between the students, but then what happens when two people did not attend the same class or school? I think this is when ethics of a time period (bigger scale, no longer just in terms of an individual) comes into play. If we can get on common terms as a generation, we may teach ethics in that generation. Though, this would be very difficult...
- Brian Cox 20+
  - 0
  Jun 27 2012: Thank you for your insight into Hegel's philosophy and the idea of a common denominator for consensus' sake.
Sebastian R.
- +1
Jun 26 2012: I am not a medical student, but I think the responsibility of a Doctor is very important topic.I think that a Doctor can not be personally held responsible for every mistake because in such an environment he will try not do admit any mistakes. If he does not admit them, others cannot learn from them so they will happen again. In a lot of cases mistakes are even not realized because the patient is passed to the next doctor. For plane accidents every country has a institution dealing with every single accident or close accident. (NTSB). There is a video series on youtube which then brings the human side back to the accident story: Example: http://www.youtube.com/watch?v=DyuSmPYF0YM

The Pilots can talk about it and the passengers profit from this practice. I think is is a major issue in medicine. However it is not as easy to do "the right thing".
- Brian Cox 20+
  - +1
  Jun 27 2012: Have you watched the TED talk about doctors admitting mistakes?
  
  http://www.ted.com/talks/lang/en/brian_goldman_doctors_make_mistakes_can_we_talk_about_that.html
Debra Smith 200+
- +1
Jun 26 2012: Absolutley!
Fritzie Reisner 100+
- +2
Host

Jun 26 2012: I assumed medical ethics are already part of medical curricula. Don't most professions include training in the ethics of the discipline?
- Brian Cox 20+
  - 0
  Jun 26 2012: Medical ethics is part of a curriculum, but teaching is not universal nor is it comprehensive.
  
  As a result, many individuals receive "informal" or "hidden" teaching. That is, you learn as a witness and through reflection. However, the eventuality of this practice may lead to the adoption of bad habits. It is therefore necessary for students to receive more "formal" teaching. Scripted scenarios and tutorial based learning are essential if medical students join the workforce with competency in end-of-life issues.
  - Fritzie Reisner 100+
    
    +1
    Host
    
    Jun 26 2012: Case studies seem like an effective vehicle for such a curriculum. In a business school, a law school, a teacher training program, a public affairs school... ethics is often addressed by putting forward case studies for discussion.
John Dunbar 10+
- +1
Jun 26 2012: Although this isn't related to end of life issues I have to bring up an issue that is related. The prescription pill epidemic in the United States has far surpassed the carnage of the crack epidemic. A multitude of doctors have been arrested for illegally prescribing prescription opiods, benzodiazapenes, and others.

As a 24 year old living in NH,(which sits on the border of massachusetts, which has the highest opiod overdose rate per capita in the country) i have many friends who went from college students, to full blown addicts in a matter of weeks due to this scourge.

Doctors need to have a better understanding of what it is they are actuality prescribing and how potentially addictive it is. The psychiatric community is also under siege for over medicating children with narcotic stimulants. I can count the number of people on my hands that don't take adderall to write a paper. Yes, at the end of the day the people taking the medication need to be responsible for what they put in their system.

To me, it seems as though many doctors seemed to be happily deceived by patients who doctor shop. Kickbacks, rigged studies, and false marketing have been shown by numerous sources in regards to pharmaceutical companies.

I can't tell you how much I agree that rigorous ethics should be taught in medical school. Something must be done to curtail the abuse of prescription medication and although profit seeking doctors seem to be only one part of the equation, it doesn't lessen the role it has played in this ongoing tragedy.
- Brian Cox 20+
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  Jun 26 2012: Couldn't agree with you more. We live in a finger pointing society where everyone passes the blame.
  
  It is the responsibility of all parties involved - the patient, doctor, lawyer, judge, and pharmaceutical company - to ensure profits do not come before safety.
  
  And you may not have realized it, but opioids play a large role in patient management at end-of-life. There is something called the "Doctrine of Double Effect" (DDE). DDE states that although opioids are used to prolong life by reducing personal suffering, they are also simultaneously reducing respiratory rate and increasing side effects. Though the net result is a prolonged life, the argument is that life is prolonged at a cost.
Obey No1kinobe 50+
- +1
Jun 26 2012: All professions should cover the legal and ethical considerations that are relevant.

Given education is more centralised than working. This is a good place to start.

Places of work (hospitals) also have an obligation to provide a policy framework and training in this regards etc. Ideally appropriate ethics should be built into the culture of all organisations.

Personally, I support teaching ethics at school with an age appropriate curriculum.
- Brian Cox 20+
  - 0
  Jun 26 2012: You very insightfully point out that education is centralized. I never thought of that before. It would be interesting to examine whether medical programs with similar curricula produce equivalent ethical competencies.
peter lindsay 30+
- +1
Jun 26 2012: Maybe you should include Australia in your investigation. An ethics class is a requirement for the first four semesters.
- Brian Cox 20+
  - 0
  Jun 26 2012: In medical school? Can you describe what is covered? Many medical schools attempt to cover the topics of beneficence, malevolence, autonomy, etc. Additionally, they have classes on "breaking bad news" and talking to family members, yet many junior doctors still report apprehension in dealing with end-of-life issues. I am trying figure out why this is.
  
  I would be very, very interested to hear from you if you have time.
  - peter lindsay 30+
    
    0
    Jun 27 2012: Sorry Brian I have no knowledge of course content. I'm a highschool teacher so often have discussions with students regarding thier future after highschool. We get a book that lists the subjects studied for all courses offered at Australian universities so I looked up medicine and found ethics listed as a mandatory subject for 4 semesters. I'll see if I can find out a bit more.
    This page is a descrition of the course from the University of Queensland
    http://www.courses.uq.edu.au/student_section_loader.php?section=1&profileId=48085
Linda Taylor 50+
- +1
Jun 26 2012: It is somewhat disconcerting to think that physicians would not be educated in medical ethics. There is so much involved in medicine that surrounds ethics. I also do not think it should be a comprehensive education in ethics but adequate information to make decisions and to be able to competently address an ethics board.

There are medical ethicists who study ethics and who can be sought out as consults for complex cases. Much like there are medical specialists. But the truly complex cases need to be deliberated by a board or a community of care providers.

Every physician has a set of ethics under which he/she operates. Two physicians can disagree about the same exact case. Over time, they learn about how other physicians practice and if they run into an ethical dilemma, they can refer.

One person was requesting continuing futile medical treatment which one physician was uncomfortable initiating. That physician referred the patient to a research hospital physician who had no issue continuing treatment. Explained that he could not help but he knew someone who could.
- Brian Cox 20+
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  Jun 26 2012: At that stage, medical ethical principles are often quite clear to the physician in question. What I am trying to examine is whether we need to start learning the complexities of medical ethics earlier in our career.
  - Linda Taylor 50+
    
    0
    Jun 26 2012: I don't think you can arrive at that level of practice without the proper educational base from which to make decisions. Yes I think we all need it early in our careers.
Virginia Arsenault
- +1
Jun 26 2012: As a nurse who has dealt for many years with dying patients, I have one important idea to mention. Physicians have a moral responsibility to tell a patient when they are nearing the end of their life.
I have been in the unfortunate position of being the bearer of this news. Frequently I feel that I often do not have all the details, while the person who did have the information, chose not to share them with the patient. Come on, doctors! Don't you think your patients deserve to hear the most important information in their lives from you? Just because it's something you can't fix, doesn't make it essential for you to deal with.
- Brian Cox 20+
  - 0
  Jun 26 2012: It is a shame that you have been placed in such a position. These types of situations should not occur, but frequently do. Doctors need to feel comfortable and competent delivering bad news regardless of the circumstance so that individuals like yourself are not forced into an unfamiliar situation.

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