During your medicine clerkship, you will be offered two
experiences which relate to ethical and humanistic issues in
internal medicine. These two sessions will constitute the medicine
component of the third year Dilemmas in Clinical Medicine (DCM)
course. These will be incorporated into the regular Friday
medicine sessions at the CFS site.
Session 1.
Decision Making for the Incapacitated Patient and the Physician's
Responsibility Toward Hopelessly Ill Patients:
This introductory session will be presented early in the clerkship
and will provide an overview of the problem of medical decision
making when a patient is no longer capable of making decisions. A
major focus of this process will address the dilemmas of medical
care for patients who are hopelessly ill. The student should
prepare for this session as follows:
a. Read the Wanzer et. al. article. This overview by a
group of eminent clinicians attempts to deal with a wide range
of issues relating to hopelessly ill and dying patients. The
article cites changes in attitudes and practices since its
"first look" edition in the mid-80s. One must now question
how many of this 1989 article's recommendations are accepted
and what still remains controversial. The student should
approach this article in light of his or her own attitudes as
well as observed clinical practices. One of the main
objectives of the session will be to identify and discuss any
of the article's recommendations that the student finds
troublesome or unacceptable, and be prepared to explain why.
b. Read the Emanuels' article on The Medical Directive, and
review the New York State pamphlet on the Health Care Proxy.
These reflect the two general approaches to decision making
for incapacitated patients. The Medical Directive focuses
upon the precise wishes of the (presently) competent person,
in anticipation of future clinical scenarios. The goal of
this tool is to carefully document the specific wishes of a
given individual, so that future medical decisions can be made
in accord with these statements.
The alternative formulation, represented by the Health Care
Proxy, stresses the complexity of the clinical circumstances
at the time the patient becomes incapable of deciding. By
appointing and empowering a trusted person to make decisions,
the proxy approach attempts to deal with the nuances of a
particular case with a "real time" decision-maker. These two
approaches are complementary, as they each stress a different
aspect of the problem. The student should also fill out a
copy of the Directive, and choose a proxy decision-maker. If
either of these exercises makes the student uncomfortable, he
or she should be prepared to explain his or her reticence in
this regard.
Required reading:
1) Wanzer SH, et. al.: "The Physician's Responsibility
Toward Hopelessly Ill Patients: a second look", New England
Journal of Medicine, (March 30, 1989) 320: 844-849.
2) Emanuel LL, and Emanuel E: "The Medical Directive". JAMA,
(June 9, 1989) 261: 3288-3293.
3) New York State Department of Health: "Appointing Your
Health Care Agent: New York State's Proxy Law" (1990)
Session 2.
Case Reports:
Each student will select an actual case from his or her own
experience in the clerkship that poses a significant ethical
dilemma, and provide a written report of the case. The written
report should conform to the instructions in the protocol below.
The papers will be handed in before the second session so that they
can be reviewed and graded by course faculty (the time and place
will be announced at the first session). At the time of the second
meeting, The class will break up into smaller groups to facilitate
discussion. Although each case may not be discussed, every student
should be prepared to discuss his or her case upon request. When
this occurs, the student should summarize the details of the case
briefly to permit maximum time for questions and discussion.
Course Objectives:
1. The student will be able to recognize and categorize an ethical
dilemma, and clearly characterize the problem, as well as define
the roles of the various parties involved.
2. The student will be able to analyze such cases with the goal of
resolving the dilemma. In many cases, this resolution will consist
of a statement of recommended action. In others it will be a clear
plan for gathering specific information needed to take the proper
action.
3. The student will be able to articulate the relevance of values
and value judgements in any given clinical case, whether or not it
is identified as an "ethical dilemma".
4. The student will have the ability to assess decision making
capacity. When a patient is deemed to lack such capacity, the
student will be able to clearly define the process for decision
making in such individuals.
5. The student will be familiar with the various types of advance
directives, and will be able to counsel patients in the choice and
preparation of each.
6. The student will enhance his or her sensitivity toward the
problem of hopelessly ill patients. This includes identification
of those clinical situations in which a patient's probability of
recovery is in a downward spiral. Furthermore, the student should
be able to "switch gears" and assist colleagues in developing a
palliative care plan which is individualized to fit the patient's
values.
Student responsibilities:
The student is required to attend both sessions and submit the
written report at the designated time. The write-ups will be
graded on the basis of their written character, but attendance at
both sessions is required for a passing grade in the course.
Students are reminded of the DCM final examination at the end of
the third year, in addition to the 5 clerkship components of the
DCM course.
Bibliography:
1. Databases:
MEDLINE contains a number of Medical Subject Headings (MeSH) in the
field of clinical ethics including: Ethics, Life Support Care,
Euthanasia, Informed Consent, Resuscitation, Patient Participation,
Confidentiality, Physician Patient Relations, and Bioethics.
BIOETHICSLINE is available on-line in many hospital libraries as is
a printed version for each of the past few years (Bibliography of
Bioethics).
2. Medical Journals:
Most mainstream medical journals regularly publish articles related
to ethical issues including some very useful review articles.
These include New England Journal of Medicine, Annals of Internal
Medicine, Archives of Internal Medicine, and JAMA.
3. Specialty Journals:
A number of specialty journals deal with ethical issues in
medicine. The most readable are Hastings Center Report, and
Journal of Clinical Ethics. Others include Journal of Medicine and
Philosophy, Kennedy Institute of Ethics Journal, and Journal of
Law, Medicine & Ethics.
4. ACP Annotated Bibliography:
An excellent annotated bibliography is regularly prepared by the
American College of Physicians. The 1984 edition was published in
Annals of Internal Medicine (101:129-137; 263-274), and the 1988
edition is available as a separate booklet through the ACP (Medical
Ethics: an annotated bibliography). Many libraries have it.
5. Books:
a. Jonsen AR, Siegler M, Winslade WJ (1992): Clinical Ethics: a
practical approach to ethical decisions in clinical medicine,
New York, Macmillan.
Although best taken with a grain of salt, this "manual"
of medical ethics makes specific comment and has
recommendations on many issues in the field.
b. Beauchamp TL, Childress JF (1994): Principles of Biomedical
Ethics, New York, Oxford University Press.
This theoretical review of the principle-based approach
to medical ethics also includes a number of case
discussions (including many classic cases of historical
interest).
c. Gorovitz S et. al. (1983): Moral Problems in Medicine,
Englewood Cliffs, Prentice Hall.
d. Abrams N, and Buckner MD (1983): Medical Ethics: a clinical
textbook and reference for the health care professional,
Cambridge, MIT Press.
These two books are comprised of (classic) articles with
commentary.
e. President's Commission for the Study of Ethical Problems in
Medicine and Biomedical and Behavioral Research.
f. New York State Task Force on Life and the Law.
These two commissions each published a series of well
referenced reports largely dealing with public policy on
the issues we are dealing with.
DCM Case Report Protocol
Protocol for Case Reports:
Case reports should be drawn from the student's own experience during the Medicine clerkship; the report should be kept to a maximum of two sides of a single sheet of paper and, as long as it is legible, may be handwritten.
A. Selecting a Case.
The case should be selected from the student's experience on the clinical rotation, since ethical analysis should be a routine part of medical management. The student should be familiar with all aspects of the patient's medical condition as this is necessary for a meaningful analysis. The case should pose an ethical dilemma for the physicians on the case (that is, a difficult decision involving ethical issues or principles). This ordinarily represents a conflict over values; patient and family, patient and physician, etc. Specifically, you should exclude cases that focus on clearly inappropriate, unprofessional, or immoral behavior.
There is sometimes a tendency to focus upon high profile issues involving seriously ill hospitalized patients (such as withdrawal of life sustaining treatment). While such cases certainly may present serious ethical dilemmas, one must not lose sight of dilemmas in less dramatic settings. Chronic illness, or well-patient encounters are often the backdrop for dilemmas relating to the Doctor-Patient Relationship, particularly in the ambulatory setting. These dilemmas can be just as vexing, and are certainly more common.
B. Writing Up a Case
The write-up itself should begin with a brief summary of the medical facts of the case. This summary should be brief, although the student should be sufficiently familiar with the case to answer more detailed questions at the time of the presentation in class. Particular attention should be paid to clinical details which relate to the ethical issue (e.g. mental status or prognosis).
Following the clinical data, the dilemma itself should be identified. This is a 3 step process in which you identify the issue, a problem and a specific question:
For example, a student's case concerned a patient whose urine was sent for drug screening without the her permission. The issue here would be: "Informed Consent."
Possible problems for the above example might be:
[You only need to provide one problem in your write-up]
Again using the same example, a "should question" might be:
Should we cancel the test, and/or ignore the lab results when they arrive
for this patient?
Once you have an issue identified, a problem to solve and a specific question to answer, you can begin to analyze the case. There are a number of different approaches, but they tend to conform to the outline in the Lo textbook. This approach is explained in detail in the first 2 chapters of the book (pages 3-18). Although not required for the write-ups, relevant citations are welcome, particularly when the student has found them helpful in discussing the case.
A sample write up is available for reference.
Gathering Information
Clarify the Ethical Issues
Resolve Dilemmas
Contact Dr. Jack Freer to discuss any questions or unclear directions.