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When Teachable Moments Become Ethically Problematic

  • ELIZABETH DZENG
Abstract:

There is frequently tension in medical education between teaching moments that provide skills and knowledge for medical trainees, and instrumentalizing patients for the purpose of teaching. In this commentary, I question the ethical acceptability of the practice of providing cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) to dying patients who would be unlikely to survive resuscitation, as a teaching opportunity for medical trainees. This practice violates the principle of informed consent, as the patient agreed to resuscitation for the purpose of potentially prolonging life rather than to futile resuscitation as a teaching opportunity. Justifying futile resuscitation in order to practice normalizes deceptive and nonconsensual teaching cases in medical training. Condoning these behaviors as ethically acceptable trains physicians to believe that core ethical principles are relative and fluid to suit one’s purpose. I argue that these practices are antithetical to the principles espoused by both medical ethics and physician professionalism.

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Notes

1. Dzeng, E, Colaianni, A, Roland, M, Chander, G, Smith, TJ, Kelly, MP, et al. Influence of institutional culture and policies on do-not-resuscitate decision making at the end of life. JAMA Internal Medicine 2015;21, 287:18.

2. Dzeng, E, Colaianni, A, Roland, M, Levine, D, Kelly, MP, Barclay, S, et al. Moral distress amongst american physician trainees regarding futile treatments at the end of life: A qualitative study. Journal of General Internal Medicine 2016;31(1):93–9.

3. AMA Code of Medical Ethics. AMA, 2016; available at http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page. (last accessed 21 Mar 2016).

4. Hafferty, F, Franks, R. The hidden curriculum, ethics teaching, and the structure of medical education. Academic Medicine 1994;69:861–71.

5. See note 1, Dzeng et al. 2015.

6. Berger, JT. Moral distress in medical education and training. Journal of General Internal Medicine 2013;29(2):395–8.

7. Carrese, JA, Malek, J, Watson, K, Lehmann, LS, Green, MJ, McCullough, LB, et al. The essential role of medical ethics education in achieving professionalism: The Romanell Report. Academic Medicine 2015;90(6):744–72.

8. Kant I. Groundwork for the Metaphysic of Morals. 1785.

9. Swick, HM. Toward a normative definition of medical professionalism. Academic Medicine 2000;75:612–6.

10. Rosenbaum, JR, Bradley, EH, Holmboe, ES, Farrell, MH, Krumholz, HM. Sources of ethical conflict in medical housestaff training: A qualitative study. American Journal of Medicine 2004;116:402–7.

11. Ubel, PA, Jepson, C, Silver-Isenstadt, A. Don’t ask, don’t tell: A change in medical student attitudes after obstetrics/gynecology clerkships toward seeking consent for pelvic examinations on an anesthetized patient. American Journal of Obstetrics and Gynecology 2003;188(2):575–9.

12. See note 2, Dzeng et al. 2016.

13. Hildebrandt, S. Developing empathy and clinical detachment during the dissection course in gross anatomy. Anatomical Sciences Education 2010;3(4):216.

14. Pawlina, W, Hammer, R, Strauss, J, Shaun, G. Heath, S, Zhao, K, Sahota, S, Regnier, T, Freshwater, D, Feeley, M. The hand that gives the rose. Mayo Clinical Proceedings 2011;86(2):139–44.

I thank Alexander K. Smith, MD, MPH for his insightful comments to the manuscript and Stephen Barclay, Bm, BCh, MD; Michael P. Kelly, PhD; David Levine, MD, MHS, ScD; Martin Roland, Bm, BCh, DM; and Thomas J. Smith, MD for their mentorship during the doctoral project from which the data from this article were obtained. The data cited in this study were funded by the Health Resources and Service Administration T32 HP10025-20 Training Grant and the Gates Cambridge Scholarship. Ethical approval was granted for the study by the Johns Hopkins School of Medicine Institutional Review Board (NA_00080529, 1/28/2013).

The aim of this section is to expand and accelerate advances in methods of teaching bioethics.

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Cambridge Quarterly of Healthcare Ethics
  • ISSN: 0963-1801
  • EISSN: 1469-2147
  • URL: /core/journals/cambridge-quarterly-of-healthcare-ethics
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