Bioethical Inquiry (2014) 11:213–221 DOI 10.1007/s11673-014-9520-9


Teaching Medical Ethics to Meet the Realities of a Changing Health Care System Michael Millstone

Received: 17 July 2012 / Accepted: 15 September 2013 / Published online: 6 May 2014 # Springer Science+Business Media Dordrecht 2014

Abstract The changing context of medical practice— bureaucratic, political, or economic—demands that doctors have the knowledge and skills to face these new realities. Such changes impose obstacles on doctors delivering ethical care to vulnerable patient populations. Modern medical ethics education requires a focus upon the knowledge and skills necessary to close the gap between the theory and practice of ethical care. Physicians and doctors-in-training must learn to be morally sensitive to ethical dilemmas on the wards, learn how to make professionally grounded decisions with their patients and other medical providers, and develop the leadership, dedication, and courage to fulfill ethical values in the face of disincentives and bureaucratic challenges. A new core focus of medical ethics education must turn to learning how to put ethics into practice by teaching physicians to realistically negotiate the new institutional maze of 21st-century medicine. Keywords Education . Professional ethics . Health policy . Organizational ethics

Recognizing the Obstacles of Putting Theory Into Practice The practice of medicine finds itself in the throes of a revolution. Three decades ago “medicine was a cottage M. Millstone (*) Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine/Montefiore Medical Center, Office of Residency Training, 3331 Bainbridge Avenue, Bronx, NY 10467, USA e-mail: [email protected]

industry of autonomous artisans … [its hospitals] considered ‘the doctor’s workshop” (Bohmer 2010, 64). Autonomy was built into the system through a network of private and small group practices with little external oversight or accountability. The care provided was variable, performance typically was without evaluation, and standardized models of practice were viewed critically (Swenson et al. 2010). The doctor-patient relationship occupied an insular position. From the treating physician came the diagnosis, treatment, and care plan for each patient. Practitioners sought to personalize care to the unique set of challenges each patient presented (Bohmer 2010). Commentators now recognize that recent changes have culminated in doctors finding themselves in the midst of a post-industrial revolution, moving from a cottage industry to a standardized bureaucratic business model. In the United States, corporate-run health care organizations, private insurance companies, governmental programs, and the tort system interpose a new set of demands, procedures, and protocols on doctors’ encounters with their patients. The cumulative effect of these third-party stakeholders has altered the character of the once insulated doctor-patient relationship of the cottage industry model. These new governmental and corporate third-party stakeholders shape the delivery of health care and promulgate new policies and entities designed to maximize efficiencies in structuring how doctors interact with patients. These stakeholders devise institutions and policies to contain the escalating costs of new medical technologies and treatments. Financial pressures are exacerbated by highly publicized malpractice trials,


rising expectations for access to the best care, and demands for physician accountability. In response, thirdparty stakeholders turn to bureaucratic nostrums. Accordingly, post-industrial doctors work in a world replete with specialization, documentation, written standard operating procedures, protocols, hierarchy, and division of labor (Bohmer 2010). These developments showcase the fundamental changes transforming the context of practicing medicine. In this revolution, doctors find themselves unprepared and illequipped to confront today’s challenges. This paper focuses on one of the challenges: the need for a medical ethics curriculum that incorporates learning the realities and ethical significance of the organizational and policy changes brought about by post-industrial medicine. For decades the medical ethics community has concentrated on how to define the relationship between doctor and patient within the framework of the cottage industry model. Framed as a balance between the values of the physician and patient, commentators focused on the tension between a doctor’s paternalism and a patient’s autonomy (Brock 1988; Katz 1984). Ethical discourse on this fundamental issue proved critical in developing a greater appreciation of ethics among practicing physicians (Emanuel and Emanuel 1992; Furst 1998). To foster a similar understanding of medical ethics in the next generation of physicians, medical schools throughout the country teach ethics courses. Just as physiology and anatomy constitute mainstays in a medical student’s education, theories ranging from utilitarianism to virtue ethics are now part of the standard curriculum (Eckles et al. 2005; Gawande 2002). No matter which ethical theories medical schools choose to teach, a new pedagogy for medical ethics requires a robust and realistic recognition not only of advances in medical science but also of policy and bureaucratic changes triggered by political, economic, and organizational forces. As noted above, these bureaucratic imperatives inform what transpires in today’s doctor-patient relationships. The doctor, as the patient’s healer and caregiver, must now cope with competing obligations imposed by outside stakeholders. These generate the new ethical dilemmas of post-industrial medicine. A heightened awareness and understanding of the issues inherent in these dilemmas must now constitute an essential part of medical ethics education. Doctors-in-training need to comprehend and anticipate the manifold ways the dilemmas of post-industrial medicine can arise. Doctors must balance coping with

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the inescapable reality of modern medicine without abdicating their distinctive professional obligation to their patients. As a result, a normative axiom embraced here posits that ethical doctors serve as compassionate and competent caregivers, acting as fiduciaries to cure and relieve the suffering of their patients (Pellegrino 2006). To prepare doctors to realistically translate the norms of medical care into practice, medical ethics education must focus on a reality in which doctors and patients no longer constitute the only players negotiating the meaning of the doctor-patient relationship. Post-industrial medicine presents challenges not only for experienced practitioners but also for third-year medical students, who initially encounter actual patients during third-year rotations or clerkships. Here student doctors confront the disparity between what they were taught in the classroom and the new realities of modern medicine. Empirical studies on medical ethics education shed light on this disparity. In a comprehensive review by Eckles and associates of the literature on medical ethics education, two goals predominate: (1) producing virtuous physicians and (2) teaching practical skills to analyze and resolve real-world ethical dilemmas (Eckles et al. 2005). According to this study, these goals have produced a lack of consensus on the objectives of medical ethics education. The authors stress that biomedical ethics curricula lack sufficient focus and emphasis on how the new realities of medical practice—bureaucratic, political, or economic—demand that doctors have the knowledge and skill-set to navigate these realities in order to put ethics into practice. Reinforcing this finding, a review of the literature by Caldicott and Faber-Langendoen asserts that “[t]he medical ethics education literature documents a persistent mismatch between the issues taught to medical students in required bioethics curricula and texts and the dilemmas students typically face in their clinical experiences” (Caldicott and Faber-Langendoen 2005, 866, emphasis added). Put simply, medical ethics education requires a clearer focus and emphasis on linking theory to the practice of modern medicine. For example, traditionally medical ethicists stressed the importance of physicians having both sufficient training in communicating with patients and the necessary time to clarify each party’s values in the doctorpatient relationship. As the Emanuels cogently argue: [W]e need to implement changes in medical care and education to encourage a more caring approach. We must … educate physicians not just

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to spend more time in physician-patient communication but to elucidate and articulate the values underlying their medical care decisions, including routine ones; we must shift the publicly assumed conception of patient autonomy that shapes both the physician’s and the patient’s expectations from patient control to moral development (Emanuel and Emanuel 1992, 2224). However, the realities of the modern medical system can make this goal difficult to achieve. An example of one such challenge is planning for end-of-life care. The recent debate about the Affordable Care Act 2010 (ACA) (Pear 2011) illustrates the challenges of implementing a “health care financing system that properly reimburses—rather than penalizes—physicians for taking the time to discuss values with their patients” (Emanuel and Emanuel 1992, 2224–2225). The initial version of the bill contained a provision in which Medicare reimbursed doctors’ discussions with patients about end-of-life care, such as advance directives in which patients express their preference on the use of aggressive life-sustaining treatment. Opponents of the bill claimed that the law created “death panels” that allowed government bureaucrats to make decisions about whether geriatric patients on Medicare would live or die. As a result, “Democrats dropped the proposal to encourage end-of-life planning after it touched off [this] political storm [and] … [t]he provision for advance care planning was not included in the final health care overhaul signed into law by President Obama” (Pear 2011, 10–13). This case illustrates how political forces and public policies shape the realities doctors must navigate in seeking to provide ethical care for their patients. Most doctors today still endorse the ethical value and clinical importance of physicians counseling patients on end-of-life health issues. As Medscape Medical News reports: Organized medicine has endorsed end-of-life counseling, also called advance care planning, as the epitome of patient-centered care because its goal is finding out what kind of care, if any, a person wants at life’s end. Having such discussions in advance is crucial, said Roland Goertz, MD, president of the American Academy of Family Physicians (AAFP). “The best time to talk about that is not on your deathbed, but beforehand, when you still can think


coherently and discuss these things with your family,” Dr. Goertz told Medscape Medical News. Busy physicians are more likely to broach the subject if they are financially rewarded for it, he added. “In our country, incentives work extremely well” (Lowes 2010, 2–3). Despite the medical community’s preferences, health care policy can hinder the ability of doctors to put ethical principles into practice. Nowhere is this problem clearer than in geriatric medicine.

Geriatric Medicine: How Policy Shapes Putting Ethical Principles Into Practice A growing elderly population combined with public policy constrains doctors’ ability to encourage and support an ethics of caring for this vulnerable patient population. In 2009 about 40 million Americans were 65 years or older. They comprised 12.9 percent of the U.S. population, about one in every eight Americans. Notably, trends show that by 2030 about 72.1 million older persons, more than twice their number in 2000, will constitute the potential patient population (American Hospital Association 2007; Administration on Aging 2011). Those 65 and older occupy a singular position. When they reach 65, Medicare guarantees them health care for the rest of their lives (Eastman 2007). When it comes to health care for the elderly, Medicare policy shapes doctor-patient interactions. It serves as the key to understanding the advantages and disadvantages imposed on those patients 65 and older. Finding doctors willing to treat them has become a serious challenge. Reimbursement rates for physicians have been stagnant or even decreasing when compared with inflation. With further budget cuts likely, increasing numbers of doctors have declined to take on new Medicare patients (Doherty 2010). This pattern of disincentives for physicians caring for the elderly is especially evident in primary care, where the reimbursement rates are far lower than those of the more procedure-based specialties and subspecialties, such as surgery, cardiology, and gastroenterology (Bodenheimer, Grumbach, and Berenson 2009). Notably, primary care doctors often do not take on new Medicare patients in order to avoid incurring the additional expense and paperwork that accompany these patients. This trend leaves the 65 and older population


without primary care, which eliminates essential screenings and management of their chronic conditions. The uncertainties and obstacles for Medicare patients in finding a primary care physician will only worsen as the “baby boomers” begin to enter the 65 and older patient pool. The number of primary care providers has simply not kept pace with the demand (Bodenheimer, Grumbach, and Berenson 2009). The influence of programs such as Medicare reveals how policies shape the challenges physicians confront when attempting to put ethical principles into practice. While well intentioned, such policies, whether public or private, produce widespread change, foster frustration among patients and doctors, and transform the organizations that deliver health care.

The Post-Industrial Medical Revolution: How Organizations Shape Putting Ethical Principles Into Practice In the current medical environment, practitioners are forced to maneuver within an increasingly complex maze of organizational directives. This bureaucratic side of medicine, as described above, often lies outside a doctor’s training. Modern medicine has “become too costly to escape diligent, bureaucratic oversight, and those … in medicine increasingly find [themselves] asked to justify … valuable services” (Crenner 2007, 24). Student doctors are not being prepared for a workplace rapidly evolving from a cottage industry to a standardized bureaucratic business model. Evidence of a lack of proper training of medical school graduates can be found in a recently published study. The researchers analyzed the Association of American Medical Colleges’ (AAMC) annual Graduation Questionnaire for the years 2003 to 2007. The authors found that the percentage of students reporting “appropriate” training in the “practice of medicine,” using the AAMC content areas of medical economics, health care systems, managed care, practice management, and medical record keeping, was only 40 percent to 50 percent (Patel, Lypson, and Davis 2009). From these results, the authors concluded that “such deficiencies in training during medical school have consequences for physicians’ later practice, affecting their efforts to navigate the complex world of medical costs, comparative effectiveness, and medical decision

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making” (Patel, Davis, and Lypson 2011, 695). Doctors’ responses on surveys reveal a disturbing trend about the consequences of working without the necessary training. Specifically, doctors report the personal toll this deficiency can have on their psychological health and professional commitment. As described by Levine and Wallach: Physician surveys document disillusionment, depression, and a sense of powerlessness. Blame is sought in “bureaucracy,” a litigious society, or from diminished patient “loyalty.” Doctors flee practices or choose specialties distant from patient contact. Palpable resentments surface when doctors talk privately (Levine and W. Wallach 2011, 2). In response, one may argue that such attitudes are isolated cases, restricted to a small group of disgruntled physicians, unhappy with change. But new empirical findings show that such attitudes among physicians are more widespread, further contributing to changes in the organizational structure of American medicine. In 2010, hospitals in the United States employed 211,500 physicians, a 34 percent increase since 2000. During this same period, doctors involved in patient care and other health care roles only increased 17 percent to 858,000. Meaning today, one out of every four active physicians is employed by a hospital. “[D]roves of physicians are seeking the shelter of a hospital to escape the bad weather of independent practice: long hours, atrisk revenue streams, and government prodding to adopt expensive electronic health record systems, to name a few turn-offs” (Lowes 2012, 5). But many hospitals are no longer “the doctor’s workshop” of the cottage industry model. Hospitals are quickly adopting an organizational model utilizing a standardized protocol-driven system of care. Intermountain Healthcare Network (Bohmer 2010) typifies this new direction in health care delivery. Intermountain consists of a series of hospitals working within its own network, whose doctors are a mix of salaried practitioners and independent physicians. The organization has adopted a standardized “business model” of care. As described by Bohmer: In contrast to the loosely worded clinical guidelines that have been common in health care, Intermountain’s clinical processes are defined by protocols: detailed descriptions of the sequence of tasks and decisions that lead to the resolution of

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a patient’s health problem … At Intermountain, each protocol is drafted by a small team of paid clinical experts who review the scientific literature and Intermountain’s own experience. The team defines each variable—symptom, physical observation, or laboratory result—and the expected timeline for the patient’s diagnosis, treatment, and recovery. This information is translated into a sequence of yes/no check boxes and specific test and treatment choices laid out to mirror the order in which a doctor usually does his or her work. A larger team of general practitioners, nurses, and information-systems and administrative personnel then ensures that the protocol is workable in practice (Bohmer 2010, 64). Most remarkable is how this health care organization relies on these protocols to direct 90 percent of its caseload (Bohmer 2010). The movement away from cottage industry to a postindustrial model of care focuses on protocol-based care, measured outcomes, and accurate reporting, as found at Intermountain Healthcare Network (Swenson et al. 2010). In the past, physicians had autonomy and seemingly limitless sources of funding from government and insurers. Today, doctors work in health care organizations shaped by public and private initiatives that require maximum efficiency and cost-effectiveness. These organizations create new moral dilemmas for doctors. As Shale explains in a recent analysis of health care organizations: [P]roviding care for individual patients and organizing care for populations of patients are closely related and yet differing tasks. A doctor’s duty is to make the needs of his patient his first concern. Similarly, ethical health care organizations aim to provide the best possible care for each of their individual patients. But the reason health care organizations exist is to provide better care for individuals through providing shared resources for groups of people. Providing for an entire patient population confronts health care organizations [and doctors] with ethical challenges different from those that typically confront individual doctors [in the cottage industry model] (Shale 2008, 38–39). The autonomy physicians have long enjoyed is becoming a thing of the past. As seen with Intermountain, the future of medicine relies on an evidence-based,


standardized care model. While working within this new business-like organization, physicians will have to be able to recognize and overcome ethical dilemmas in a challenging new bureaucratic environment. To deliver care to their patients, doctors will require moral leadership skills to deftly navigate modern health care organizations. Teaching medical ethics must keep pace with these new challenges of medical practice, as exemplified above. Through this process, ethical discourse in medicine furthers the exploration of the values, policies, and training that will reconcile the noble ethical precepts of the traditional doctor-patient relationship with the realities of working within modern health care organizations. Over the last 30 years, an important challenge required striking a balance between patient autonomy and physician paternalism. Today, to implement ethical standards requires teaching medical ethics in a manner grounded in the new demands of medical practice, such as those faced in treating the elderly and working within changing bureaucracies.

Teaching Medical Ethics to Negotiate the Obstacles of 21st-Century Medicine The physicians most often admired are those possessing the virtues of leadership, courage, and dedication to serving their patients in the face of bureaucratic obstacles. As forcefully asserted by Swensen and colleagues, this “often means swimming upstream against the system, rather than relying confidently on it” (Swenson et al. 2010, e12(1)). Unfortunately, as the system becomes more complex and fragmented, doctors find themselves unable to maneuver under the weight of today’s new health care delivery systems. Worn down by these systems, doctors often display a deficiency in these virtues (Caldicott and Faber-Langendoen 2005). The remainder of this paper explores how, through a process of understanding health policy and developing medical professionalism through practice and example, tomorrow’s doctors can step up where today’s practitioners stumble. The curriculum in medical school and residency training aims to include the latest scientific and clinical developments. But, as noted above in the study of “Medical Student Perceptions of Education in Health Care Systems” (Patel, Lypson, and Davis 2009), when it comes to a curriculum in health care policy, more needs to be done


to match what doctors face in modern practice with what they are taught. To best serve their patients, experienced doctors appreciate how critical it is to know the inner workings of health care organizations and the policies that govern them. These physicians recognize that their patients require more than proper diagnosis and treatment (Chervenak and McCullough 2001). Many patients also require assistance in obtaining the medical resources necessary to achieve positive long-term outcomes (Ernest, Wong, and Federico 2010). In the United States, those patients fortunate enough to be insured through their employers, or who can afford to purchase health insurance, often pose a variety of moral dilemmas for physicians. Consider this hypothetical: A private practice specialist in pain medicine strives to serve her patients with compassionate, competent, evidence-based care. In keeping current with the professional literature, she reads a respected medical journal related to her specialty. She is impressed by an empirically based meta-analysis of randomized controlled trials, which demonstrates that ultrasoundguided nerve blocks are more likely to be successful, take less time to perform, have faster onset, and produce longer duration than nerve blocks utilizing electrical neurostimulation (Abrahams et al. 2009). Even though our hypothetical pain doctor was originally trained in electrical neurostimulation, she elects to commit the time and expense to remain up-to-date with the most recent evidence-based practice, to train in ultrasoundguided nerve blocks, and to purchase the equipment to perform an ultrasound-guided nerve block for her patients. A patient comes to her clinic where it is determined he requires a brachial plexus nerve block. In light of the high risk of puncturing the jugular vein or carotid artery in this area of the body, the physician believes an ultrasound-guided nerve block is strongly indicated. However, the doctor, on review of the patient’s insurance, realizes only electrical neurostimulation nerve blocks, not ultrasound-guided nerve blocks, are covered by this particular insurer. Even after explaining her reasoning behind this necessary treatment approach to the insurance representative, it is confirmed the physician will not be reimbursed if she elects to utilize the safest and most efficacious treatment for her patient. The insurance company’s authorized treatment, neurostimulation, imposes a moral dilemma on the doctor. On the one hand, she risks a negative clinical outcome, the danger of a malpractice suit, and a possible failure of her principal directive to do no harm. On the other hand, she performs

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an outdated procedure for which she will be reimbursed, permitting her practice to remain open for the good of her patients and professional career. There are no simple answers. Doctors, and especially doctors-in-training, at the very least should recognize that struggling with these kinds of problems strikes at the very core of what it means to be virtuous in modern medicine. This type of dilemma may appear to be commonplace, but studies show the knowledge and skills needed to cope with these sorts of issues typically are not included in medical education (Patel, Davis, and Lypson 2011), let alone medical ethics courses. Doctors-in-training need to be empowered with these skills and knowledge. They need to be better prepared to serve their patients and to take on the organizational maze of insurance representatives, formularies, preferred networks, cost-benefit analyses, maximized efficiencies, and effective decision-making. Medical educators must begin to incorporate policy topics into the curriculum to equip student doctors and practitioners with the know-how to effectively maneuver within the modern health care system. This goal underscores that health policy training should occur throughout a doctor’s medical education: from medical school to residency and throughout one’s career. Undergraduate medical school curricula must establish a solid foundation to understand policy issues and to acquire the analytical skills to meet the challenges of being a medical doctor. Building on this background, attending physicians need to train student doctors and residents to understand and to navigate the bureaucratic maze of health care. Experienced physicians in clinical practice will require reinforcement in continuing medical education programs (Patel, Davis, and Lypson 2011). It is only by such preparation and continual education that doctors can acquire and maintain the tools needed to recognize and understand the new political, bureaucratic, and economic realities of medicine. But while the ability to recognize and to understand such challenges is a necessity, physicians must also have the medical professionalism and moral courage to overcome these challenges (Chervenak and McCullough 2001). Displaying the virtues physicians strive to manifest in practice highlights the essence of medical professionalism: the leadership, courage, and dedication to translate ethical principles into practice (Chervenak and McCullough 2001). The Charter on Medical Professionalism identifies “the primacy of patient welfare, patient autonomy, and social justice as the three core principles of professionalism in medicine” (West and Shanafelt

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2007, 2). Professionalism constitutes such a core competency for physicians that the Accreditation Council for Graduate Medical Education mandates residency programs to train about, and to measure the development of, professionalism in resident doctors (West and Shanafelt 2007). Empirical studies show the influence professionalism has on quality of care and patients’ satisfaction with their care (West and Shanafelt 2007). But the demands of bureaucratic imperatives and public policies can conflict with the principles of professionalism. To be a virtuous doctor, as noted above, requires leadership, courage, and dedication. Doctors confront the challenge of preserving their professional role as compassionate and competent caregivers in the face of increasing demands from third-party stakeholders. Too often, this process transforms doctors into cogs of a larger “health industry” that dispenses “impersonal care”—an oxymoron (as discerned by noted medical educator Dr. T. Byram Karasu) that eliminates compassion from medicine (Karasu 2003). For example, even within the confines of the academic medical center, these changes shape the delivery of health care. “[D]ecreased government funding of research and education, increasing patient care costs, and decreased reimbursement for medical care have [led to] greater collaborations with industry” (West and Shanafelt 2007, 4). This movement away from a mission devoted to “the primacy of patient welfare, patient autonomy, and social justice” toward one focused on profit represents a serious conflict of interest. A number of studies have shown how this collaboration leads to problems, such as the withholding of research results from colleagues, encouraging research in areas with greater commercial applicability, and lowering academic productivity (Blumenthal et al. 1996). Reduced financial resources also produce greater clinical responsibilities for academic clinicians. These demands threaten to limit academic faculty’s energy to devote to medical education and academic research, threatening their function as role models to doctors-in-training (West and Shanafelt 2007; Lachman 2009). The effect of these changes on medical education cannot be overstated. A cynicism about the ideals of professionalism has crept into the student culture of academic medicine. As explained by West and Shanafelt: Trainees report that the values exhibited by their teachers and institutions directly impact their own professionalism. Unfortunately, a significant percentage of physicians and medical students are


dissatisfied with their formal training in professionalism and report experiencing a culture of cynicism during training. A majority of students and residents report witnessing peers and supervising physicians refer to patients and colleagues in a derogatory manner, and also report being personally mistreated by peers, educators, and patients. Perhaps related to these experiences, multiple studies have found that humanistic attitudes, particularly empathy, decline throughout medical school and residency training, and levels of anger and depression increase (West and Shanafelt 2007, 5). Professionalism is largely taught through modeled behavior and observing the culture of an organization. Unfortunately, cynical thinking increasingly permeates the medical student community as they perceive a disconnect between the curriculum of professionalism they are taught in the classroom and the behavior they observe among faculty in research labs and hospitals. The core principle of “the primacy of patient welfare” is often lost as fear of disrupting the culture around them silences their concerns. Consider a study involving the next generation of physicians at the State University of New York Upstate Medical University (Caldicott and Faber-Langendoen 2005). From 1999 to 2002, third-year medical students submitted papers explaining ethical issues encountered during their clerkship rotations. A total of 327 students submitted 688 cases involving 40 ethical issues. In this study, the researchers found that one theme was shared across “all ethical issues and specialty services: student’s avoidance of speaking up for fear of reprisal” (Caldicott and Faber-Langendoen 2005, 866, emphasis added). When compared to other ethical issues, students described this fear as justification for their choices when describing the ethical dilemmas they encountered, but not as the dominant ethical issue within the case itself (Caldicott and Faber-Langendoen 2005). As Caldicott and Faber-Langendoen report: “Explicitly cited in 81 [of the student submitted] papers (12 %), fear of speaking up was mentioned in cases depicting 18 (45 %) of the 40 specific ethical issues on our checklist, and seven (24 %) of all cases depicting quality of care” (Caldicott and FaberLangendoen 2005, 870). These results bear witness to how fear in a culture of cynicism can extinguish the virtues physicians strive to manifest in practice. What remains is the silencing of professionalism.


The authors in this study conclude that one essential component of medical ethics education must be moral courage. Only with moral courage can one turn principles into action and put virtues into practice. The authors contend: While administrative, instructional, and curricular interventions may facilitate students’ speaking up, all personal risk cannot be eliminated: courage is required. The essence of courage is action in the face of fear. Based on our data and those of others, we assert that moral courage is an essential ingredient in medical training and practice. We submit that learning and displaying moral courage is well within the realm of professional expectations for medical students and is an appropriate explicit addition to the formal objectives for medical education. … [L]earning objectives and standards specific to professional behavior can be articulated for all in the medical hierarchy so that students can see that even deans, program directors, faculty, and housestaff—along with students—will be held accountable for the courage to implement moral behavior (Caldicott and Faber-Langendoen 2005, 870, emphasis added). Students must begin to develop the virtues of leadership, dedication, and courage to overcome their fears through pragmatic actions (Kidder 2005; Lachman 2009). Ethical principles have little meaning unless physicians can put them into practice (Bloche 2011).

Conclusion: A New Focus for Medical Ethics Education For doctors, medical ethics embodies an applied, practical ethics. It links theory and practice in an amalgam of character-building, professionalism, and organizational skills (Eckles et al. 2005; Bryan and Babelay 2009). Simply studying about medical ethics rings hollow if ethics education fails to prepare doctors with the savvy and strength of character necessary to put these ethical values into practice. Given the changing context of modern medical practice, I recommend that the new core focus of medical ethics education turn to learning how to put ethics into practice by teaching physicians how to realistically navigate the institutional maze of 21st-century medicine. Physicians need to learn to be morally sensitive to ethical dilemmas on the wards,

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learn how to make professionally grounded decisions with their patients and other medical providers, and develop the leadership, dedication, and courage to fulfill ethical values in the face of public policy disincentives and bureaucratic challenges. Disclosure and Funding The author of this manuscript does not have any financial or professional relationships that may pose a competing interest. There is no funding support for this manuscript.

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Teaching medical ethics to meet the realities of a changing health care system.

The changing context of medical practice--bureaucratic, political, or economic--demands that doctors have the knowledge and skills to face these new r...
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