Michael Lowe,
Tutor in clinical ethics

John Hunter Hospital,
Newcastle,
New South Wales,
Australia

Back to cover page

Being learners as well as carers can put medical students into difficult ethical situations. Ian Kerridge and Michael Lowe show you how to stop your ethics being eroded

Do medical students conform to unethical behaviour?

Students and junior hospital staff are often placed in situations where real ethical dilemmas are ignored or denied by those in higher positions. This lack of recognition may lead to students' ethical standards and compassion being gradually eroded by the hospital environment. There are five main areas in which conflicts between the various roles of medical students result in ethical dilemmas: witnessing unethical acts committed by other team members, trying to be a good team player, being evaluated for grades, knowing a patient more personally than the rest of the team, and being subtly coerced to put oneself at risk of personal injury.1

The way that you deal with these issues will shape your future development as doctors. In this paper we discuss ways to deal with ethical concerns and show that you are not alone when you confront the conflicting emotions caused by ethical dilemmas.

Learning "on" patients, learning from patients
Medical students and junior hospital staff often find it difficult to balance the conflicting demands created by being both a learner and a carer. For example, you may hurt patients while learning technical procedures when you and your patients know that others could do the procedure more expertly. This dilemma continues throughout your professional life. In fact, whenever a surgeon performs a new procedure or a physician uses a new drug the patient acts partly as a tool for learning.

We are all patients at some stage in our lives and would probably all prefer to be operated on by the surgeon with the greatest experience or cannulated by the most adept house officer. However, if patients always demanded such standards of care new doctors and medical students would never be able to learn. Who then should be responsible for providing the teaching material for inexperienced doctors?

In countries such as the United States some people consider that patients in public hospitals receive a better standard of health care than they could otherwise afford and that they should pay for their care by allowing themselves to be used for teaching. Few patients would be aware of such justifications, however, as this reasoning is mostly kept hidden. It is more ethical to ask patients' permission, many of whom will say: "Well you have to learn sometime don't you." Patients understand that expert care can be provided only by doctors who have practical experience and clinical wisdom because they have learnt with and from patients. The right to expert medical care therefore depends on a duty that is owed by patients towards medical students and medical training.

Duty of patients
The extent of this duty is not clear. For example, several authors have examined how students learn vaginal examination in different countries. In one study, 70% of American students learnt vaginal examination with non-patient volunteers, 23% with conscious patients, and only 2% with unconscious patients. By contrast, in Britain only 1% of students learnt with volunteers, 41% with conscious patients and 46% with unconscious patients.2 When these figures became publicly known they have provoked public outrage. In a study in inner city Birmingham 54% of women objected to having an internal examination by a medical student and 84% felt that no more than two medical students should be present at a consultation. All patients believed that permission should be sought for a vaginal examination under anaesthetic and all believed that a maximum of one student should be present in a consultation if a vaginal examination is to be performed.3

Although we believe that patients do have a qualified duty towards the training of medical and paramedical students, not all patients feel the same. This duty does not negate patients' rights to refuse to participate in teaching, to full explanation, or to optimal care if they refuse to be involved. Where possible non-patient volunteers should be used. When approaching patients you should tell them you are a medical student and why you wish to see them. You should have supervision for any potentially distressing or hazardous procedure. If patients refuse to see you accept this gracefully and don't try to coerce them.

Witnessing unethical acts
Students act as interested observers, part way between the layperson and the full professional. It is disturbing that in some studies 65% of students felt that they had witnessed unethical behaviour by a member of the health care team to which they were attached and 80% believed that they had acted unethically or wilfully misled patients themselves; 54% of the students who had witnessed unethical behaviour felt that they were in some way an accomplice to these actions.1

Students do not enter medicine with their own sets of values and beliefs and a commitment to caring for patients. The process of learning about medicine directs and perhaps limits this diffuse sense of moral concern. What students learn is to clarify and define their obligations and responsibilities to patients and others.4 This process is analogous to other forms of learning in medicine--you begin with imprecise ideas and gradually modify them in the face of experience.

For many students, exposure to the hospital environment results in an erosion of their ethical values rather than a strengthening. For example, one student stated: "Slowly I'm seeing my classmates become destroyed and it scares me. I've become so cynical that it's just not right.''5 Much of the negative impact that hospitals have on junior doctors may relate to the long hours, poor working conditions, and inadequate supervision; adopting ethically dubious practices is a way of survival. Some students are not displeased that their ethical principles are being eroded, believing that becoming a doctor requires a transformation of character.1

Students often react with a policy of silence when they observe or take part in ethically suspect actions. However it is not enough simply to vow to act if similar situations arise in the future. You need to practise and develop the skills involved in responding to unethical behaviour if they are to be available when needed. Keeping quiet becomes a habit, and it represents a failure in teaching, learning, and caring.

Case history

A fourth year medical student was asked to prepare a long case to present to the professor of medicine. The professor suggested that he examine Mr B, an 85 year old man with alcoholic liver disease and hepatocellular carcinoma. When Mr B was asked for permission he replied: "You can if you have to but I'd rather not, I've just seen three medical students and I'm a bit sore." The student asked the house officer for another patient to examine but was told that he ought to be a bit more persistent. "You'll never get anywhere if you don't push these guys a bit. They'll always say no if you give them a choice."

The duty to speak out
Humans like to conform to expectations. In 1963, a series of experiments designed by Stanley Milgram investigated the reactions of people placed in an environment that encouraged unethical actions. Experimental subjects were asked to give electrical shocks to others as part of an experiment. Unknown to the subjects, those who received the shocks were actually paid volunteers who pretended to be in pain. Milgram advised the subjects to give shocks of increasing severity, to the point where the victims screamed in agony or no longer appeared responsive. When the subjects protested about giving such severe shocks, they were told only: "You have no other choice, you must go on," or "The experiment requires that you continue." Over 60% of subjects were persuaded to give shocks that they believed were severely dangerous or life threatening.5

It is difficult to know exactly when you should speak out in matters of ethics or medical law. As students or junior medical staff you are not obliged to follow commands that are illegal such as inflicting torture or deliberate harm--indeed, there is a legal obligation to speak out against such actions. In addition, a strong ethical and legal case can be made for refusing to participate in actions that you believe to be morally wrong. For example, you do not have to participate in abortions if you have a conscientious objection to them.

Unfortunately, most conflicts do not fall into either category but are characterised by legal and ethical uncertainty. Dwyer stated that in trying to decide whether to speak up in a particular case you should consider the potential harm to patients, your role in the situation, the nature and certainty of your judgments, the probable effectiveness of speaking up, and the likely cost to yourself of speaking up.4

The main factor is the possibility of harm to patients. If patients have been harmed by unethical actions you may have to speak out even if you are only peripherally involved. Students are often unsure of their judgments, either because they do not have enough experience to judge the appropriateness of an action or because they doubt the value of their ethical judgments. You need to find an appropriate threshold for certainty in expressing your concerns.

It is also reasonable to consider the likely efficacy of speaking out and the possibilities for harm to yourself if you speak up. You may not have an obligation to speak out if it will be ineffective or cause you harm that is out of proportion to the benefit to the patient. The relative importance of each of these factors is difficult to judge, but we have found that speaking out can make a difference and need not always require great personal sacrifice.

The American College of Physicians states that "it is unethical for a physician not to report fraud, professional misconduct, incompetence or abandonment of a patient by another physician."6 It also states, however, that it "is unethical for a physician to disparage the professional competence, knowledge, qualifications, or services of another physician to a patient or a third party or to state or imply that a patient has been poorly managed or mistreated by a colleague, without substantial evidence." This second statement is more a statement of professional etiquette. Certainly, it is better to keep speaking out within the usual channels where possible, but it may be necessary to go outside them.

Cases of ethical conflict can be difficult to recognise and you may realise only later that you have participated in or acquiesced to unethical actions. There are several approaches to such situations. Firstly, you should develop a plan of action for future management of similar situations. Secondly, you could seek to stimulate some institutional change to prevent such incidents in future. For example, if placement with a particular physician exposes students to unethical behaviour you may be able to discuss this within the university so that students are placed elsewhere. Finally, you should discuss these issues with your peers and develop a forum where such problems can be discussed in future.

Conclusion
Medical students are both learners and participants in the health care system. As such they will often be exposed to ethical dilemmas. Such issues need to be addressed honestly as they are an integral feature of medicine and medical education. It has been stated that the ideal relationships between colleagues, within the medical profession and between health care professionals generally is one of both mutual support and mutual and honest criticism.7

We have discussed Milgram's experiments about the power of authority and conformity already but it is also worth noting that a few of his subjects refused to shock patients further. In one case the experimenter attempted to bully the subject by stating, "You have no other choice." The subject replied: "I do have a choice. Why don't I have a choice? I came here of my own free will."8 The same is true of students, doctors, and patients.

References

1 Feudtner C, Christakis DA, Christakis DA. Do clinical clerks suffer ethical erosion? Students' perceptions of their ethical environment and personal development. Acad Med 1994;69:670-9.

2 Cohen DL, Wakeford R, Kesssel RWI, McCullough LB. Teaching vaginal examination. Lancet 1988;ii:1375.

3 Bibby J, Boyd N, Redman CWE, Luesley DM. Consent for vaginal examination by students on anaesthetised patients. Lancet 1988;ii:1150.

4 Dwyer J. Primum non tacere. Ethics of speaking up. Hastings Cent Rep 1994;24:13-8.

5 Sutherland S. Irrationality. The enemy within. London: Penguin, 1994.

6 American College of Physicians. Ethics manual. 3rd ed. Ann Intern Med 1992;117:947-60.

7 Campbell A, Gillett G, Jones J. Practical medical ethics. Auckland: Oxford University Press, 1992.

8 Schwartz S. Pavlov's heirs. Sydney: Angus and Robertson, 1987.