ETHICS DISCUSSION OUTLINE      Daniel Pasquale Frouman

I.   Case Presentation        10/22/08

II.  Ethical Questions

III.  Principles of Medical Ethics

IV. Review of Literature

I.  CASE PRESENTATION

Ms. X is a Caucasian female in her thirties who presented to Parkland for an intense burning pain in her right eye.  She denied any recent trauma.  The pain was localized and did not radiate.  She described the pain as being worse than giving birth to two infants at once.” She reported no alleviating or exasperating factors. She reported feeling “hot and clammy,” which she attributed to generalized anxiety. She denied fevers, chills, and headaches. She has had a history of three Staphylococcal infections in the past three years and reported a past history of hypertension, heart murmur, asthma, bipolar disorder, and generalized anxiety. Her family history is significant for a father and mother with diabetes.  She smokes ½ a pack of cigarettes per day and does not drink. She is a full-time single- mother of two with no college education.  Ms. X and her two children live with her parents. She was diagnosed with a Staphylococcal infection in her right eye for which she received surgical and antibiotic treatment.

When we first approached the patient we explained that we were medical students developing our history and physical exam skills and asked for her permission to be interviewed and examined.  Ms. X was not aware that she would be acting as a teaching patient and said that she did not want to be interviewed nor examined at that time. However, she later obliged, provided that we finished promptly. The fact that the patient was hesitant to be interviewed and examined by medical students prompted the following questions for discussion:

II. ETHICAL QUESTIONS

Question 1

Does the patient have the right to refuse the role of teaching patient in a teaching hospital?

Question 2

Is the indigent patient obligated to act as a teaching patient in exchange for medical care from clinical teaching institution?

Question 3

Does the patient have a moral obligation to be a teaching patient given the critical role of   the teaching hospital in the education of future physicians as well as the advancement of medical  knowledge?

III. PRINCIPLES OF MEDICAL ETHICS

• Beneficence  The obligation of health care providers to help people in need
• Nonmaleficence The duty of health care providers to do no harm
• Autonomy  The right of the patients to make choices regarding their health care
• Justice   The concept of treating everyone in a fair manner

1.  Beneficence

i. Beneficence in terms of the healthcare provider is straightforward. The individual health  care providers and the teaching hospital as a whole have made a commitment to aid patients in  need and are, thus, obliged to assist the patient.

ii.  The patient’s obligation, however, is not straightforward.  Has the patient made a  commitment to participate in the education of future physicians?

iii.   If one argues that the patient has made such a commitment by accepting services at a  teaching hospital would this be a legal obligation or a moral obligation?

iv. If the patient signed a consent form when entering the teaching hospital that clearly stated  that she would be participating as a teaching subject in a teaching hospital, is she not obliged to  participate as a teaching patient?

The following questions could be asked:

a. Did the patient completely understand the consent form she signed when entering Parkland?

b.   Does the patient completely understand the meaning of being treated at a teaching hospital?

c.   Did the patient’s illness and/or associated discomfort limit her understanding of  the consent form when admitted?

If the answer is “yes” to anyone of these three questions, then one could argue that the patient  did not give adequate informed consent and is thus not obligated to participate as a teaching   subject.

2.  Nonmaleficence

i. Medical students should refrain from performing unsupervised potentially dangerous procedures since they may harm the patient.

ii. The patient history and physical exam is noninvasive and should pose no treat to the  patient’s health.

iii. The patient may be uncomfortable or embarrassed to serve as a teaching subject.

iv. The patient’s illness and/or associated pain may deem a procedure, performed purely for    educational purposes, unnecessary.

3.  Autonomy

“Autonomy is founded in the overall desire of most human beings to control their own destiny,  to have choices in life, and to life in a society that places value on individual freedom. In medical  ethics, autonomy refers to the right of competent adult patients to consent to or refuse treatment.”

(Access Medicine—Lange Health Policy. Chapter 13. “Medical Ethics and the Rationing of  Health Care.” McGraw Hill Companies. 2008)

i. In order for the patient to be autonomous she must be given a choice and her decision    must be honored.  We allowed the patient the opportunity to choose whether she wanted    to be interviewed and examined or not.  Did we honor her decision? Did she feel     pressured to go along with the H&P?

ii. Does the indigent patient really have a choice?  If the only health care available to the    patient is via the teaching hospital, the patient has no choice but to sign the informed    consent form and participate as a teaching subject.  The indigent patient has no autonomy   in this scenario and I would argue that the only way to restore the patient’s autonomy in    this scenario is by allowing her the right to refuse acting as a teaching subject.

4.  Justice

“The principle of justice as applied to medical ethics is newer, more controversial, and harder to define than the principles of beneficence, nonmaleficence, and autonomy.  In a general sense, people are treated justly when they receive what they deserve.  It is unjust not to grant a medical degree to someone who completes medical school and passes all the necessary examinations.  It is unjust to punish a person who did not commit a crime.  In another meaning, justice refers to universal rights: to receive enough to eat, to be afforded shelter, to have access to basic medical care and education, and to be able to speak freely.  . . . justice connotes equal opportunity . . . (and) differential treatment . . . is unjust…”

(Access Medicine—Lange Health Policy. Chapter 13. “Medical Ethics and the Rationing of Health Care.” McGraw Hill Companies. 2008)

i. It would be unjust if only certain patients (e.g., indigent patients) were asked to be    teaching subjects.

ii. It would be unjust if only certain patients (e.g., wealthy, insured patients) were allowed    to refuse being teaching subjects.

iii. It would also be unjust to society as whole if clinical education were limited to only a    given subset of the population. The physician must treat patients within the entire     spectrum of humanity, irrespective of socioeconomic status, race, ethnicity and sexual    orientation.  Given the wide range of human diversity it is only logical that clinical    education encompass this diversity.

V. REVIEW OF LITERATURE

i. Patients usually sign a consent form when entering a teaching hospital. However, many patients  have not been given adequate informed consent.

a. Serious illness at the time of admission

b.  Some patients may not completely understand the meaning of being cared for in a     teaching hospital

c. Some patients may not understand the different levels of healthcare providers, i.e.,    medical students, interns, residents, fellows, and attending physicians

d. Patients may not be aware of the possible tension between the need to train new     physicians and provide quality care

ii. Patients should be informed of procedures that are being done purely for educational purposes.

iii. Noninvasive procedures (i.e., auscultation, percussion, palpation) performed by students are  allowed even if they are unnecessary.

iv. Patient participation should be requested politely and “refusal should be accepted graciously.”

v. Most patients are more than willing to participate in the educational process and the occasional  patient who refuses should not be pressured.

vi. Patients are not obligated to participate in the training of future society’s physicians. Physicians  should be “grateful for their generosity.”

vii. The teaching hospital is vital to patient care, clinical research, and clinical education.  The best  medical education is done by the bedside. Extensive studies have shown that teaching hospitals,  when compared with non-teaching hospitals, provide better care not only for patients with rare  and complex diseases but also for patients with common conditions.  Teaching hospitals provide  better care for elderly patients and are capable of providing advanced services (i.e., complicated  surgeries and bone marrow transplants) that may not be available at other hospitals.

viii. High quality patient care, state-of-the-art clinical research, innovations in clinical care, and   clinical education come with a high fiscal burden. Before Medicare and Medicaid (1966), most  funding for medical education in the U.S came from the NIH in the form of research grants not  intended for medical education.  The mergence of academic medicine with indigent and elderly  patient care began as an effort to fund medical research and education.  The idea was to treat  indigent and elderly patients in teaching hospitals, have the government fund it via Medicare and  Medicaid, and use the income for clinical research and clinical education.

ix. The public is unaware of the teaching hospital dynamic.  Educating the public may encourage  patients to participate as teaching subjects.

References

Lo B. Ethical dilemmas students and house staff face. In: Resolving Ethical Dilemmas. 3^rd ed.    Baltimore: Lippincott Williams and Wilkins; 2005: 226-234

Christakis Da, Feudtner C. Ethics in a short white coat: The ethical dilemmas that medical    students confront. Acad Med 1993; 68: 249-254.

Relman, Arnold S. Who will pay for Medical Education in Our Teaching Hospitals? Science Vol. 226, No. 4670 (Oct. 1984), pp. 20-23

Ayanian, John Z. and Joel S. Weissman. (Harvard Medical School) Teaching Hospitals and    Quality of Care: A Review of the Literature. The Milbank Quarterly, Vol. 80, No. 3    (2002), pp. 569-593

Access Medicine—Clinical Ethics. Chapter 4. “Clinical Teaching.” McGraw Hill Companies.    (2008)