April 2001
A medical intern doing volunteer work in Sri Lanka. Source: Projects Abroad.
During the past decade, biomedical ethics (commonly called bioethics) has become a popular topic for media coverage. This is largely due to increased complexity of caring for patients and the difficult decisions that new technologies demand. Examples include high-visibility issues like the completion of the human genome project, cloning, patenting of human tissue products, and transplants. However, doctors worry (or should worry) more often about less visible but more common issues such as ensuring patient self-determination and proper informed consent for medical procedures, end-of-life decision making, research ethics, reproductive medicine, and managed care and related economic issues.
Despite the trendy nature of cloning and other hot issues, there are numerous ways in which the knowledge that practicing physicians have about medical ethics and law can have a more direct impact on the type and quality of care that the average patient receives. In order to provide medical care in an ethical and humane way, physicians need to be better educated about specific aspects of ethical medical practice and learn to think critically about the increasingly complex world of medical practice. Routine bioethics education for medical students and resident physicians, and continuing medical education for practicing doctors, are the best ways to accomplish this goal.
What skills and characteristics in physicians (in addition to scientific expertise) are necessary for them to practice good medicine?
- It is vital that physicians understand basic aspects of law and the legal system in order to practice good medicine.1 This means that knowledge of law has profound ethical implications for patient care and well-being. My own research suggests that physicians know substantially less about medical law when they get such legal information from other physicians.2 This is not to suggest that all physicians are ignorant of relevant law but rather, that there is great variability among physicians in knowledge of law (and ethics). Thus bioethicists, who are trained in specific aspects of medical law (and who may themselves be physicians), are appropriate persons to supplement physicians’ knowledge in this area. Other research has demonstrated that how people think about risk (like the risk of malpractice lawsuits) affects the way they react to it, creating ethical consequences.3 Because risk management is an issue that concerns most physicians, improving doctors’ knowledge of medical law can help them better understand and estimate risks, as well as learn where they may be unconsciously overestimating certain risks in ways that have negative effects for patient care. Thus, law and ethics are inevitably intertwined in clinical medicine.
- Understanding social and institutional aspects of health care delivery is also vital. Doctors should know how hospitals and other medical institutions function and how different health care providers and administrators work together. These relationships include physicians’ interactions with nurses, respiratory therapists, physical therapists, occupational therapists, nurses’ aides, and members of hospital administration in the areas of finance and risk management. Bioethicists can assist physicians-in-training to understand how such institutional relationships may function differently from those to which they are accustomed and help them assimilate to new institutional structures. Good physician-role-models also play a significant part in this process.
- Practical application of bioethics concepts is essential for the well-being of both patients and physicians. The integration of bioethics into clinical medicine through the practice of “clinical ethics” is a major part of many bioethicists’ jobs. This usually occurs in at least two ways, first by educating physicians-in-training, and second, by conducting clinical ethics consultations, which have both an educational role and are designed to assist with a particular ethical problem in a clinical setting. In this setting, the bioethicist provides services that assist specific patients and their families, as well as health care providers. By modeling good clinical ethics practice, bioethicists can teach physicians ways to better perform these functions.
- Understanding health policy and the legislative process is an important part of delivering good health care in the modern world. Some good examples of issues from the realm of health policy, of which physicians should be aware, include: state and federal regulation of health care financing; public health and health promotion efforts; legislative action on end-of-life decisions and pain control; pharmaceutical regulation; and the impact of emerging genetic testing and other biotechnology. Physicians having a strong interest in one or more of these issues may wish to become active in advocating a particular piece of legislation or other policy. Because many physicians do not ordinarily think in these terms, bioethicists can make them aware of ways that health care providers can become more active in the public policy process.
- Knowledge and experience of the humanities is a key element of caring for patients as persons. For example when physicians read poetry or fiction that explores aspects of human illness and suffering, it provides them with exposure to the human experience of health care that may become lost in the daily activities of technological medicine. The humanities can thus add to the richness of both patients’ and physicians’ experiences. Many bioethicists are trained in particular disciplines of the humanities, and some bioethicists have specific training in “medical humanities.” Thus, the bioethicist is the ideal person to provide such background for aspiring physicians.
- With academic medicine becoming ever more dependent on the private sector in health care, the ability to think critically about ethical issues and take appropriate action in response is a key element of academic physicians’ work. A good example is the increasing impact of conflicts of interest.4 As research physicians increasingly have a direct financial interest in the outcome of their research, bioethicists can provide a sensitivity to the public perceptions that may emerge from such financial relationships. Critical thinking is the stock-in-trade of bioethicists and they can foster it in many ways with physicians.
Why are bioethicists the best persons to accomplish this educational mission?
Bioethicists are generally trained in philosophical ethics and law, as well as the social sciences and humanities. However, the level and type of training among individuals varies to a significant extent, so physicians seeking bioethics consultations should be aware of the particular type of expertise they need and search out a bioethicist with proper background when possible.
Bioethicists can provide a more objective and balanced view of complex ethical issues in health care settings. In other words, bioethicists can often provide an outside perspective on medical care. However, as bioethics practice becomes a more routine part of medicine there is a danger of bioethicists being co-opted by the system they are charged with improving. For this reason, bioethicists should be scrupulous in maintaining their objectivity where possible.
Many bioethicists have extensive experience in analyzing and resolving actual dilemmas in clinical medicine. In fact, “clinical ethics” has become an unofficial sub-specialty of the field.
Educational efforts specifically targeted to teach bioethics issues to physicians are effective. Recent research suggests that after a course in bioethics, physicians have a more subtle understanding of ethical issues and are better able to analyze relevant issues critically.5
What is a good example of the ways that these factors converge?
An excellent example of the importance of all these factors is the ongoing debate over control of severe pain in terminally ill patients.
First, because of the risk of diversion of narcotic medications into illegal markets, there are strong legal restrictions placed on prescribing of these drugs. Fear of overly-zealous government enforcement of these laws may cause many physicians to err on the side of caution and prescribe lower doses of these medications than necessary to relieve patients’ pain.6 Thus, regulations affecting pain relief medication can have unintended consequences of diminishing patients’ ability to obtain legitimate relief. Improved legal knowledge among physicians may reduce fear and misunderstanding and may increase prescribing of appropriate levels of medication for pain relief.
However, knowledge of these unintended effects is also necessary among policy makers and legislators. The misnamed Pain Relief Promotion Act of 1999 is but one example of how policy and medical care may collide in ways that have negative effects on patient care. This recently-proposed bill was designed to override the physician-assisted suicide law currently in effect in Oregon and to prohibit other states from enacting similar laws.7 Expert bioethicists believe that if this bill were to pass, palliative care could be compromised due to the fear of criminal prosecution of physicians.7 Thus, physicians concerned about being able to prescribe appropriate pain control for their dying patients should take an active role in the legislative and process to ensure that patients’ interests are upheld. As part of this effort, physicians could be active in public education about the impact of such legislation as well as contacting legislators directly to voice the concerns of the health care community and make clear the possible unintended consequences.
Finally, but not least in importance, viewing cases through the lens of medical humanities can better enable physicians to understand their patients’ experience of pain and alleviate suffering to the extent possible.
Thus, legal, social, institutional, policy, and humanistic factors all play a role in such analysis.
What are barriers to these goals and what are their implications?
- The most critical barrier to achieving uniform bioethics education in the medical curriculum is financial constraints. Most bioethics programs in medical schools are not funded in a way that ensures their continuation. Instead, bioethics programs usually depend on funds set aside by the dean or other discretionary sources such as federal grants that could rapidly dry up.8 One source of such discretionary funds is overhead money from scientific grants. For example, when the department of biochemistry receives a grant from the National Institutes of Health some of the overhead money from that grant may be used to benefit bioethics program. The risk in this approach is that bioethics may come to be viewed as marginal to the mission of the medical school and therefore expendable.8
- Another barrier to bioethics implementation throughout medical curricula is that there remains substantial variation in the quantity and quality of curriculum.9 Because the field is fairly new and remains underfunded, less effort has been expended in developing programs than in other aspects of medical education. However, the proliferation of graduate programs awarding Ph.D.s in bioethics means there will soon be a good supply of well trained persons able to fill this gap.
- Another barrier is giving bioethics lip service but not substance. Although accrediting organizations require institutions to address ethics issues to some extent, the compliance bar is set fairly low. Institutions with ethics programs that only satisfy the minimum requirement of accrediting agencies do not have adequate services to ensure ethical patient care. Physicians who are mentors and teachers must indicate to students and trainees that ethics is an crucial part of what they are learning. This message must permeate the educational environment. In all these efforts, however, the role of the bioethicist should be one of a colleague possessing specialized knowledge and skills, who is working with doctors, rather than an outside professional seeking to monitor physician behavior.
- The most important implication of these barriers is for patient well-being. If young physicians are not taught the importance of bioethics issues for their clinical practice, patients may suffer needless pain, their legal rights of self-determination may be disregarded, and their experience of health care will be less than optimal. If this is to be avoided, bioethics must receive a higher priority in medical education in the future than it has occupied in the past.
One way to convince medical institutions that bioethics is necessary may be to appeal to their bottom line. If having an excellent bioethics program in a medical school and affiliated teaching hospitals can reduce exposure to legal risks, then administrators may begin to view it as more important. Myra Christopher, the President of Midwest Bioethics Center in Kansas City, Mo. has noted that when viewed in this light “good ethics is good business.”8 If appealing to the benefit for suffering patients is insufficient to foster the development and continuation of good bioethics programs, approaching the issue from a legal perspective should provide ample alternative justification. Whichever rationale is more persuasive, bioethics education should emerge as a permanent and routine part of medical education.
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