Controversies

Role-Playing for Teaching Ethics in Emergency Medicine MARC S. NELSON, MD, MICHAEL

ELIASTAM,

Ethical issues are becoming increasingly complicated. As with all specialties, emergency medicine has ethical dilemmas unique to the field. We describe a method for teaching students to identify and analyze ethical issues in emergency medicine. The course is designed for clinical medical students and house officers and is structured around various situations in which the students role-play. The course requires about 20 to 30 hours and covers a variety of topics from consent to treatment and confidentiality to teaching and education in the emergency department. (Am J Emerg Med 1991;9:370-374. Copyright 0 1991 by W.B. Saunders Company)

This paper describes a method for teaching medical students and residents about ethical issues unique to emergency medicine. Until very recently no articles existed on the teaching of ethics and emergency medicine. The article by Moskop et al’ is the first. This article continues their discussion by focusing on teaching methodology. specifically, the use of role-playing. Medical ethics has been an important part of the practice of medicine since its inception.‘-’ yet only recently has medical ethics become reasonably established as part of the medical school curriculum.6 A survey in 1974 found that only 6% of the medical schools surveyed had a required course in ethics, and only 44% offered an elective.’ By 1989, however, 43 of 127 medical schools had separate required courses in medical ethics and 100 schools covered medical ethics in other required courses.’ Thus, although it is far from being fully integrated into the medical school curriculum, the teaching of medical ethics has come a long way, and is likely to continue to do so.‘.‘-” It is interesting, however, to consider some of the obstacles in teaching medical ethics. Clearly one of the most perplexing is the lack of an effective way to evaluate courses. ‘2-‘4 In most cases it has simply been assumed that teaching ethics will have a positive effect on the future performance of the physician; however, this is unclear with few studies having been done. The work by Self, Wolinsky, and Baldwin’4 is an exception to this as they show quite nicely that by incorpo-

From the Division of Emergency Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, CA. Manuscript received August 3, 1990; revision accepted January 14, 1991. Address reprint requests to Dr Nelson, Emergency MedicineH1250, Stanford University Hospital, Stanford, CA 943055239. Key Words: Ethics, emergency medicine education, curriculum, role playing. Copyright 0 1991 by W.B. Saunders Company 07356757/91/0904-0017$5.00/O 370

MD, MPP rating medical ethics in their medical school curriculum they were able to make significant gains in the level of medical students’ moral reasoning. Their use of Kohlberg’s theory of cognitive moral development and its six stages of moral reasoningI provides a basis for future research in evaluating the teaching of medical ethics. Other, equally relevant questions include, but are obviously not limited to. when ethics should be taught tie. at what stage of the medical career), can clinical ethics be taught outside a clinical setting, who should be doing the teaching and how to train and find good teachers, and what are the best ways of teaching (lectures, case conferences, audiovisual materials, simulated patients, etc). Lack of space precludes in-depth discussion of all these issues. but the reader is referred to the article by Miles et al.’ an excellent state-of-the-art review with 100 references. EMERGENCYMEDICINE As with most subjects, medical ethics should be vertically and horizontally integrated throughout the entire medical school curriculum.h.“.‘h The theoretical foundation can be taught during the preclinical years. Practical skills and judgement can then be developed during the clinical years.“.” Horizontal integration is also critical, because ethical dilemmas may vary in different medical specialties. The problems in perinatology” are quite different than those in family practice”‘.” or geriatrics.‘2 Of course, many issues are germane regardless of the specialty. Emergency medicine is unique, yet medical ethicists have often neglected or exempted emergency medicine from the same careful deliberation that has been given to other specialties.6.‘3.‘4 Only one book exists on ethics in emergency medicine and in her introduction, Dr Mathieu clearly illustrates some of the problems unique to ethics in emergency medicine.” She offers two interesting quotes. The first by Charles Fried examines the concept of an emergency. The concept of emergency is only a tolerable moral concept if somehow we can truly think of it as exceptional, if we can truly think of it as a circumstance that, far from defying our usual moral universe, suspends it for a limited time and thus suspends usual moral principles.”

The second quote is by Justice Cardozo. Written 75 years ago it focuses on decision making, but illustrates that emergencies can be an exception to general ethical rules.

n TEACHING

ETHICS

371

Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable in damages. . . This is true except in cases of emergency where the patient is unconscious and where it is necessary

signed to stimulate thought about a variety of problems before they occur.

NELSON AND ELIASTAM

MEDICAL

to operate before consent can be obtained.” Clearly emergency medicine is different. These differences, however, are not cause to ignore ethical dilemmas, rather they demand a different approach. The decisions that must be made in a busy emergency department often do not leave a lot of time for reflection. A delay of a couple of minutes may mean the difference between life or death for a critically ill patient. When an ethical dilemma arises there is often no time to consult with an ethics committee or even another physician. In addition to the problem of limited time, emergency physicians also face problems unique to emergency medicine (Table 1). The question of whether or not to perform an elective abortion is not in the scope of practice of emergency medicine; the question of whether to give blood to a trauma victim, the child of a Jehovah’s Witness, is. This course is designed to introduce physicians and physicians-to-be to a variety of ethical problems that may confront them not just in an emergency department, but wherever an emergency might arise. Emergencies, by definition, are unexpected. The cases used as examples in this course could occur in a variety of settings. House officers or attending physicians are often called to help treat a cardiac arrest on a patient they are not familiar with or are just covering for the night. Parental consent is a given part of pediatrics. Thus this course, while targeted towards emergency physicians, is in many ways applicable to any physician or physicianin-training. Finally, it must be remembered that ethical problems byand-large often do not have a unique right or wrong answer. There are often many correct answers within morally relevant options. This course does not give answers. It is deTABLE 1. Differences Primary Care Emergency

Between

Medicine

Patient is often brought in by police, ambulance. Patient does not choose physician. Physician does not know patient, family. Anxiety, pain, alcohol and altered mental status are frequent. Decisions are made quickly. Physician makes decisions on his/her own.

Work environment is open and less controlled. Adapted

with permission.25

Emergency

Medicine

Primary

and

Care

Patient chooses to enter medical system. Patient chooses physician. Physician knows patient, family. Anxiety, pain, alcohol and altered mental status are less frequent. Usually there is time for reflection. Physician may consult with family, lawyers, ethics committees, other physicians. Work environment is private and controlled.

The major aim of this course is to provoke thought and to raise the students’ consciousnesses to issues they might not believe are problems, as well as offering a method for approaching the problems that are identified. In addition, using Kohlberg’s theory of moral development” it seeks to raise students to higher levels of moral reasoning. Unlike much of the medical school curriculum, which through rote memorization stifles creative ideas and individual views, this course encourages students to create solutions to problems for which there is no right or wrong answer. This does not, of course, mean that some solutions will not be better than others for almost certainly that will be the case. However, the aim here is not to arrive at the best solution, but to help physicians consider all aspects of the problem so that whatever the physician decides will have been carefully thought out. By the end of the course the students should feel that they understand why the cases presented are complex. The students should develop analytic skills in dealing with ethical issues and become more sophisticated in the way they think. The course should also give the students new frames of reference. They should understand how ethical decisions interact with legal ones. Law is a conglomeration of societal decisions and legal precedent may affect the options a physician has in dealing with a certain situation. Finally students should realize that the cases presented represent only some of the situations that may confront a physician. As technology advances, and situations change, new problems will arise. The physician should begin to anticipate these problems and think about them before they occur. FORMAT Student Level Although the questions posed by the various cases may seem straightforward, thinking about them in anything more than a very superficial way will require a certain degree of medical sophistication. It is therefore suggested that the facilitator or group leader restrict the enrollment to students in their last clinical year or to interns and residents. It also presupposes a basic theoretical background in medical ethics as would be found in a vertically integrated curriculum.6*“S16 Time Frame The course is designed to be given in a series of 10 2-hour blocks; however, a teacher may elect to shorten the course and choose 5 or 8 of the possible topics. Alternatively, the students may select the topics. Class Size The optimal size for the class is 4 to 10 students. More than 10 students will make it difficult for each student to participate in the discussion. Less than four students will make it difficult to role-play (see below).

AMERICAN

372

JOURNAL

OF EMERGENCY

MEDICINE

n Volume 9, Number 4 n July 1991

Individual Classes

Textbook

Each of the 10 classes is based on an ethical problem that is raised by a true case. The use of case-centered instruction in ethics is widely accepted, especially during the clinical years. 6,13,28,29 Each case (see Table 2 for an example) will involve three or four students playing various roles, eg, patient, doctor, relative, police officer, etc. The other students will observe. Each student should have the opportunity to play the role of the physician at least once. In most cases the role-playing will take 15 to 30 minutes. The remainder of the time should be used for discussion.

The text by Iserson et al entitled Ethics in Emergency Medicine” is a superb reference book for the teacher. It is written at a level appropriate for students or house officers and may therefore be suggested as a reference for students interested in further information. Other textbooks such as those by Abrams,23 Brody.24 and Young3’ are also useful although they are not specifically focused on emergency medicine. Finally the reading list in the article by Moskop et al’ provides a nice source for references.

TABLE 2.

Sample

Case Scenario

Case-Consent to Treatment A40-year-old man is brought into the emergency department after being hit by a car. He has an obvious femur fracture and open tibia/fibula fracture but is otherwise uninjured. During his initial assessment a clerk arrives with a form for him to sign giving consent for treatment. Roles 1. Physician 2. Patient 3. Patient’s Wife 4. Nurse Physician Your role is to treatment. Your lose his leg. You is ready to leave arrives. Patient “Dot,

For each case there will be one handout for each role. The handouts are different and the students playing the roles should not look at each other’s handout. Those students observing should only be told the background of the case and not how the various roles are to be played. For each set of handouts (case) it will be indicated by an asterisk who should start the discussion and what his or her first comment will be. SPECIAL OPTIONS Video Tape

convince the patient that he needs immediate concern is that without an operation he may want the nurse to stay with the patient until he for the operating room or until an orthopedist

you have to give me something

Handouts

If available, the faculty member may want to videotape the role-playing. Videotapes eliminate any question as to what really occurred and what was really said during the interaction. In the absence of a video, the instructor may elect just to record the audio portion of the role-playing session. Case Modification

for this pain!”

You are in excruciating pain. You will do anything the medical team wants as long as they give you something for the pain. You are fixated on this idea and will not listen to anything anyone else says, except your wife whose financial advise you usually follow. Patient’s Wife You realize that it is important that your husband get help, but you also know you do not have insurance and already have many debts. You are insistent on knowing exactly how much this will cost and what they will do if you cannot pay. You want to know if it is cheaper at another hospital. You will not let your husband sign the consent form until this is resolved. Nurse You are busy and have other sick patients to take care of. You do not want to get involved with this patient because he is alert and refusing to sign a consent form to be treated. You are concerned because it is against the law (“assault”) to take care of a patient without his consent. Possible Changes 1. The patient appears to be intoxicated. 2. The patient has an obvious head injury. 3. The patient is mentally retarded and it is unclear legal guardian is.

who the

Data from lserson et aI” and Hiller MD (ed): Medical Ethics and the Law. Cambridge, MA, Ballinger, 1981, pp 197-217.

The teacher may wish to change certain details of a case after the initial discussion to make the case more difficult. Examples follow each case. Invited Guests The role of persons trained in medical ethics their background cannot be overemphasized. notes, “Trained ethicists bring a degree of knowledge of the literature of ethics, and the lytical thinking that are not part of the education.“”

regardless of As Pelligrino objectivity, a skills of anaphysician’s

ROLE-PLAYING The concept of role-playing is designed to stimulate the students and place them in situations in which they must examine not only the patient’s point of view, but also that of the family member, police officer, or nurse. These different perspectives should be taken advantage of in the ensuing discussion by asking such questions as, “How did you, as the wife, feel when the doctor said . . .” or “How did you, as the nurse, feel when the doctor ignored your comments?” The use of simulations as a method of teaching has become increasingly common over the past few decades, largely as a result of an increased interest among medical educators in teaching students problem-solving skills.3’ Of

NELSON AND ELIASTAM

n TEACHING

MEDICAL

ETHICS

the many variations that exist, such as paper simulations,32 computer simulations,3’“3 and simulated patients,34”6 the use of role-playing37 is particularly well suited for this type of course. Although most students will probably enjoy the sessions, others may be more reticent and need encouragement from the teacher. With each session it should get easier for the students. Encouraging reluctant students to participate will occasionally require some creativity on the part of the teacher, but with persistence it is usually possible. ROLE OF THE TEACHER The teacher’s role during the course mainly involves two things. First, the teacher needs to ensure that the role playing session of each class goes smoothly (see the prior section on role playing for further details). Second, the teacher must act in such a way as to facilitate a valuable discussion following the role playing. CONTENT The following encompass the group of issues we chose to present. Obviously many other salient issues exist. 1. Consent to treatment. 2. Holding patients against their will. 3. Parental consent. 4. Research in the emergency 5. Teaching ment.

and education

department. in an emergency

depart-

6. Confidentiality. 7. The right to die. 8. Triage. 9. The impaired physician. 10. Medicine and the law. Each case is designed to illustrate different ethical principles. CONCLUSION Ethical considerations are becoming increasingly important in the practice of medicine. It is important that curricula are designed to emphasize medical ethics as it relates to emergency medicine. This course provides a way for medical educators in emergency medicine to sensitize students and residents, and develop their ability to think critically about ethical issues.* REFERENCES 1. Moskop JC, Mitchell JM, Ray VG: An ethics curriculum for teaching emergency medicine residents. Ann Emerg Med 1990;19:187-192 2. Wanzer SH, Federman DD, Adelstein SJ, et al: The physician’s responsibility toward hopelessly ill patients: A second look. N Engl J Med 1989;320:844-849 3. President’s Commission for the Study of Ethical Problems

A complete copy of the curriculum thors on request. l

is available

from the au-

373

in Medicine and Biomedical and Behavioral Research. Deciding to forego life-sustaining treatment. A report on the ethical, medical and legal issues in treatment decisions. Washington, DC, Government Printing Office, 1983 4. Senate Special Committee on Aging. A matter of choice: Planning ahead for health care decisions. Washington, DC, Government Printing Office, 1987 5. Executive Board of the American Academy of Neurology. Position of the American Academy of Neurology on certain aspects of the care and management of the persistent vegetative state patient. Minneapolis, MN, American Academy of Neurology, 1988 6. Miles SH, Lane LW, Bickel J, et al: Medical ethics education: Coming of age. Acad Med 1989;64:705-714 7. Veatch RM, Sollitto S: Medical ethics teaching: report of a national medical school survey. JAMA 1978;235:1030-1033 8. Barzansky B, Personal Communication, American Medical Association, September 1989, cited in Miles SH, Lane LW, Bickel J, et al, op tit 9. Pellegrino ED, Hart RJ, Henderson SR, et al: Relevance and utility of courses in medical ethics: A survey of physician’s perceptions. JAMA 1985;253:49-53 10. Self DJ, Wolinsky FD, Baldwin DC: The effect of teaching medical ethics on medical students’ moral reasoning. Acad Med 1989;64:755-759 11. Bickel J: Integrating human values teaching programs into medical students’ clinical education. Project report to the AAMC. Washington, DC, Association of American Medical Colleges, November 1986 12. Pellegrino ED: Teaching medical ethics: Some persistent questions and some responses. Acad Med 1989;64:701-703 13. Brody 8: The Baylor experience in teaching medical ethics. Acad Med 1989;64:715-718 14. Self DJ, Wolinsky FD, Baldwin DC: The effect of teaching medical ethics on medical students’ moral reasoning. Acad Med 1989;65:755-759 15. Kohlberg L: Essays on moral development, Vol 2. In The Psychology of Moral Development. San Francisco, CA, Harper and Row, 1984 16. McElhinney TK. Pellegrino ED: The humanities and human values in medical schools: A ten year overview. Washington, DC, Society on Health and Human Values, 1982 17. Culver CM, et al: Basic curricular goals in medical ethics. N Engl J Med 1985;312:253-256 18. Brody H: Teaching medical ethics: Future challenges. JAMA 1974;229:177-179 19. Fleischman A: Teaching medical ethics in a pediatric training program. Pediatr Ann 1981;10:411-413 20. Sun T, Self DJ: Medical ethics programs in family practice residencies. Fam Med 1985$7:99-l 02 21. Self DJ, Lynn-Loftus GT: A model for teaching ethics in a family practice residency. J Fam Pratt 1983;16:355-359 22. Cassel CK, Meier DE, Traines M: Selected bibliography on recent articles on ethics and geriatrics. J Am Geriatr Sot 1985;30:394-409 23. Abrams N, Buckner MD: Medical Ethics: A Clinical Textbook and Reference for the Health Care Professions. Cambridge, MA, MIT Press, 1983 24. Brody H: Ethical Decisions in Medicine. Boston, MA, Little-Brown, 1981 25. lserson KV, Sanders AB, Mathieu DR, et al: Ethics in Emergency Medicine. Baltimore, MD, Williams & Wilkins, 1986 26. Fried C: Rights and healthcare_Beyond equity and efficiency. N Engl J Med 1975;293:241-245 27. Schloendorff V: New York Hospital, 211 NY 125, 127, 129; 105 NE 92, 93 (1914) 28. Thomasma DC: Humanities training for health professionals. Mobius 1982;2:72-80 29. Siegler MA: A legacy of Osler: Teaching clinical ethics at the bedside. JAMA 1978;239:951-956 30. Young E: Alpha and Omega: Ethics at the Frontiers of Life and Death. Reading, MA, Addison-Wesley, 1989 31. Dinham SM, Stritter FT: Research on professional educa-

374

AMERICAN

JOURNAL

tion. In Wittrock MC (ed): Handbook of Research on Teaching (ed 3). New York, NY, Macmillan Publishing, 1986, pp 960-961 32. McGuire CH, Solomon LM, Bashook PG: Construction and Use of Written Simulations. New York, NY, Psychological Corp, 1976 33. Friedman RB: A computer program for simulating the patient-physician encounter. J Med Ed 1973;46:92-97 34. Friedman RB, Korst DR, et al: Experience with the simulated patient physician encounter. J Med Ed 1978;53:825-830 35. Norman GR, Tugwell P, Feightner JW: A comparison of

OF EMERGENCY

MEDICINE

n Volume 9, Number 4 n July 1991

resident performance on real and simulated patients. J Med Ed 1982;57:708-715 36. Stillman PL, Rutala PJ, Stillman AE, et al: The use of patient instructors to evaluate the clinical competence of physicians. In Lloyd JS (ed): Evaluation of Noncognitive Skills and Clinical Performance. Chicago, IL, American Board of Medical Specialties, 1982 37. Cassata DM, Conroe RM, Clements PN: A program for enhancing medical interviewing using video-tape feedback in the family practice residency. J Fam Prac 1977;4:673-677