domingo, 29 de noviembre de 2009

Ética clínica para estudiantes

MJA Vol 178 17 February 2003 167
The Medical Journal of Australia ISSN: 0025-729X 17 February
2003 178 4 167-169
©The Medical Journal of Australia 2003
Medical Education
Teacher-clinicians are not always adequate role models
the place of clinical ethics in the education of medical
students.1 A similar appreciation of its relevance has grown in
the UK, North America and Europe.2-4 Recently, a working
group of the Association of Teachers of Ethics and Law in
Australian and New Zealand Medical Schools (ATEAM)
produced a core curriculum for the subject5 that encompasses
the knowledge, skills and attitudes required for students to
appreciate the range and complexity of ethical issues permeating
medicine and the moral principles required to deal with
Who should teach ethics to medical students remains
debatable, with some advocating a role for ethicists and others
seeing the clinician as more appropriate. ATEAM argued that
an optimal program embodies “multiple perspectives and
multiple teachers”.5 As the working group put it: “Teachers
of ethics can play an important role in modeling the very
nature of ethics: the teaching process should be perceived as
being emotionally supportive and academically encouraging,
should be tolerant of multiple perspectives, should be interdisciplinary
and should actively involve clinicians as codeinstructors
and as role models for students. This also underscores
the responsibility of teachers to develop as an ethical
community and be alert to, and respond to, unethical behavior
among themselves.”5
Clinicians who are specifically recruited to teach clinical
ethics are invariably selected on the basis of their sensitivity
and commitment to the ethical dimension of the doctor–
patient relationship; they are likely to serve as appropriate role
models. Regrettably, during the course of their training,
students may encounter other clinicians who lack sensitivity
and manifest a disregard of ethical principles. In a survey of
Canadian medical students, half reported pressure to act
unethically and 60% had observed unethical conduct in a
clinical teacher.6 Moreover, they had felt impotent in the face
of these circumstances because of the teacher’s intimidatory
Having taught clinical ethics for almost three decades and
on three continents, I have compiled a body of evidence of
clinicians demonstrating wholly undesirable qualities and
behaviour to medical students. In the context of case-centred
teaching programs in ethics, students are requested to
observe ethical aspects of practice during their attachment to
a medical or surgical unit and then select an experience which
has provoked their curiosity, generated concern or affected
them in some way. The narrative of this experience is shared
with a group of fellow students, one of whom serves as a
scribe. As a result of this process, I have files containing
dozens of ethically challenging scenarios (Box 1).
The student dilemma
A recurrent theme in these scenarios is the students’ powerlessness
either to challenge the clinician or to intervene on the
patient’s behalf: “How can I, when placed at the very bottom
of the hierarchy, voice my disapproval?” ... “How can I come
to the aid of patients when I am not directly responsible for
them and this could be construed as acting beyond my
remit?” ... “How can I inform the Dean given that my
Medical students and clinical ethics
Sidney Bloch
Department of Psychiatry, University of Melbourne,
Fitzroy, VIC.
Sidney Bloch, PhD, FRANZCP, Professor.
Reprints will not be available from the authors. Correspondence:
Professor Sidney Bloch, Department of Psychiatry, University of Melbourne,
St Vincent’s Hospital, Fitzroy, VIC 3065.
1: Examples of ethically challenging situations faced
by medical students
■ The jocular doctor: In an effort to introduce each patient in a clinic
to the observing students, a consultant either joked about them or
referred to an amusing quality in them. Although the content and
tone were not malicious, the students wondered whether this did
not undermine the principle of respecting the dignity of the
person. The students were sensitised given their experience not
long before of a pair of surgeons talking indelicately about an
anaesthetised patient under their joint care.
■ The slanging match: A group of students were unnerved when
witnessing a feud between a consultant and a ward sister,
conducted in the passage and well within earshot of the patients.
The pair had virtually come to blows over the issue of truth-telling.
The nursing staff were convinced that a patient with advanced
cancer sought the truth about her prognosis, whereas the
consultant was of the view that she would be emotionally harmed
if given an explicit prognosis. The students felt immobilised in the
face of the increasingly acrimonious exchange.
■ The scolding doctor: During the course of a consultation, a patient
complained of a burning sensation in her legs. The clinician briefly
reassured her that this was of no consequence. The pain
appeared to worsen, the patient becoming tearful and distressed.
Expecting further reassurance by the doctor or cessation of the
examination, the students were staggered to hear his litany of
criticisms of the patient for her not exercising or eating
adequately. Later in the staff office, the doctor complained further
about the patient, seemingly insensitive to her suffering.
■ “All must palpate”: Having examined a patient with an abdominal
mass who was obviously in severe pain, the doctor instructed all
eight students in the tutorial group to palpate her abdomen after
the ward round. Half the group felt so intimidated by the clinician’s
“overbearing personality” that they examined the patient despite
her request for the process to cease. The others felt it
disrespectful to impose on the patient, but then had to lie to the
teacher that they had “felt the mass”.
■ The “difficult” patient: The patient screamed out in pain when the
doctor examined her pelvis. The observing student was startled to
hear the doctor then reprimand the patient for acting “hysterically”
and losing control. Later, but still at the bedside, he explained to
the student that she was a “difficult personality” and had always
responded in this “exaggerated” way.
168 MJA Vol 178 17 February 2003
quandary may well be divulged to the clinician himself?”
Although these sorts of questions have been posed many
times, I have always found it difficult to provide a rational
response. After all, any advice to take action could well place
students in professional jeopardy.7
When asked what factors inhibit students from speaking out,
fear heads the list. Teacher-clinicians exert a strong influence
over the student’s future. They may be examiners or a source
of references. Another commonly cited factor is the dominance
of a professional culture which makes it taboo to question the
clinical or professional conduct of a senior colleague. Mention
is often made of an ethos whereby doctors should protect one
another, especially in the face of a censorious environment and
a siege mentality regarding the legal profession. Students note
that “whistle blowing” is frowned upon and that the discloser
of “medical secrets” is often ostracised.8
Students may not always feel confident that their critical
reaction to an unethical clinician is justified: “Perhaps I am
not able to tease out all the aspects?” ... “Surely consultants
with much more clinical experience and knowledge than
myself must know what they are doing.” ... “Perhaps it is the
best way of dealing with the situation.”
Other factors are probably rationalisations to justify retreating
from a potential confrontation. For instance, are students
justified in levelling criticism when they themselves may act
unethically in the future, whether deliberately or inadvertently?
Leeway is also given to the common plight which
doctors, especially junior staff, face — working under great
pressure with limited resources. Is it not understandable that
a doctor may sometimes, in a state of frustration or fatigue,
fail to maintain optimal ethical standards?
Finally, questioning a consultant’s clinical decision is akin to
a student asking a teacher to clarify an objective position, but
raising questions about an ethical judgement may penetrate
more deeply and imply an attack on the personal qualities of
the clinician. In minor instances, issuing this challenge may
not seem worth the offence it may cause. In extreme cases,
where a student surmises that a teacher is habitually unethical
by dint of inherent deficiencies, the corollary may follow that
“Such doctors unfortunately do exist and we have no choice
but to tolerate them”.
If a series of teachers fail as ethical role models, students
may well become disillusioned with their chosen profession.
Instead of having an eager, energetic approach to medical life,
they may become cynical and embittered. If insufficient good
role models are available, students may miss the opportunity,
at a formative period in their development, to enhance their
own ethical capabilities.
Students are well placed as members of an observant,
intelligent peer group to contribute to the promotion of
ethical standards by raising issues with their teachers. By not
speaking out, avoidable patient distress may persist. The
distress may be amplified by a sense of disillusionment that
the “next generation” of doctors merely imitates the undesirable
behaviours of their seniors. Students’ acquiescence could
be seen to maintain the status quo.
James Dwyer7 captures the essence of the problem: “… the
failure to speak up in certain situations is a failure of learning
and caring.” Moreover, the risk prevails that moral sensibility
becomes eroded.
Suggestions for change
Given the adverse repercussions of negative ethical role
modelling, I have sought the views of student groups over
recent years as to how they may act. What follows is the
product of these discussions.
The cardinal change required is to remove the taboo on
students “speaking up”. Dwyer7 encapsulates this appositely
by calling on students to subscribe to the Socratic maxim
primum non tacere (“first, do not be silent”) to fulfil their
responsibilities to patients, colleagues and the medical profession.
Abolishing the taboo depends on a number of overlapping
factors. Altering the nature of the teacher–student
relationship is paramount. The traditional hierarchical character
of not only that association but of all the tiers of
medicine embodies so many limitations that it ought to be
ditched at the earliest opportunity. A more equitable link,
similar to a partnership, is bound to be much more rewarding
to both parties by permitting everyone to learn from each
other’s perspective.9 Here, the teacher must obviously modify
well-entrenched habits and come to regard students as creative
and curious. The learning process can be so much richer
when it encompasses this interactive quality.
The host environment, whether it be a hospital, a clinic or
general practice, is another crucial variable in enabling the
student to raise ethical questions. An institution whose ethos
encourages ethical enquiry and is open to the challenge of
optimising clinical care will listen carefully to the student’s
The student may contribute to this spirit of ethical openness
in at least two ways. Firstly, questions about ethical
aspects of a clinical situation should be raised respectfully,
avoiding judgementalism or personal denigration. Secondly,
students should take care to broach delicate matters, which
may well involve patient care, in a suitable setting. Thus, if
distressed by an encounter between doctor and patient, they
should refrain from questioning the teacher until in the
private surroundings of the tutorial room.
In proposing these two requirements of students, we have
depicted them as individual protagonists. They may hesitate
to raise an issue lest they are “out on a limb”, their views
stemming from an idiosyncratic source. Students would
2: Principles from the Australian Medical Students’
Association Code of Ethics — preliminary draft
Medical students should:
■ respect the needs, values and culture of patients they encounter
during their medical training;
■ never exploit patients or their families;
■ hold clinical information in confidence;
■ obtain informed consent from patients before involving them in
any aspect of training;
■ appreciate the limits of their role in the clinical setting and in the
■ respect the staff who teach and assist them in their clinical
■ when involved in clinical research adhere to the ethical principles
in the appropriate national and international guidelines;
■ maintain their personal integrity and well being.
MJA Vol 178 17 February 2003 169
therefore do well to ventilate their concerns to their fellows
and then share the task of questioning the clinician.
The advantage of fellowship can be reinforced by reference
to a code of ethics. A draft code for medical students
published in 2002 by the Australian Medical Students’
Association is an exemplary document comprising eight
principles (Box 2), each of which is elaborated upon and
clarified in a series of annotations.10 In the event of an
experience with a negative role model, students can readily
compare what they have observed with corresponding principles
in their code. This comparison can then embolden them
to challenge the teacher.
If students experience difficulty because the teacher resists
their enquiry they may feel helpless. The third annotation of
Principle 6 of the AMSA code anticipates this by stipulating
that: “When medical students experience difficulty with staff,
they should discuss this with their academic mentor or
supervisor.” This is sound advice, although the student may
be reluctant to follow it lest he or she be labelled a “whistle
blower”. Again, the notion of “security in numbers” applies.
Fellow students who share a concern would no doubt find it
easier to raise this as part of a group with a clinical dean or
clinical supervisor.
No matter how comprehensive and systematic the teaching of
medical ethics, the acquisition of relevant skills and the
cultivation of desirable attitudes will take place mainly in the
clinical arena and be influenced by doctors who model an
appreciation of the myriad ethical questions that pervade
medical practice. Role models of good ethical conduct will
always loom large in guiding the student to acquire a sense of
moral integrity.11 Clinician-teachers share a duty to do all
they can to expedite the process. Negative modelling is a
destructive force which has no place in the learning environment.
We all have a responsibility to confront and eradicate it.
1. Australian Medical Council. Goals and objectives of basic medical education.
Guidelines for assessment and accreditation of medical schools. Canberra: AMC,
2. Teaching medical ethics and law within medical education: a model for the UK core
curriculum. J Med Ethics 1998; 24: 188-192.
3. Jennett PA, Crelinsten GL, Kinsella TD. Advanced training in biomedical ethics: a
curriculum in clinical specialty programmes. Med Educ 1993; 27: 484-488.
4. Holm S, Nielsen EH, Norup M, et al. Changes in moral measuring and the teaching
of medical ethics. Med Educ 1995; 29: 420-423.
5. Braunack-Mayer AJ, Gillam LH, Vance EF, et al. An ethics core curriculum for
Australasian medical schools. Med J Aust 2001; 175: 205-210.
6. Hicks LK, Lin Y, Robertson DW, et al. Understanding the clinical dilemmas that
shape medical students’ ethical development: questionnaire survey and focus group
study. BMJ 2001; 322: 709-710.
7. Dwyer J. Primum non tacere: An ethics of speaking up. Hastings Cent Rep 1994; 24:
8. Morreim EH. Am I my brother’s warden? Responding to the unethical or incompetent
colleague. Hastings Cent Rep 1993; 23: 19-27.
9. Kushner TK, Thomasma DC, editors. Ward ethics. Dilemmas for medical students
and doctors in training. Cambridge: Cambridge University Press, 2001.
10. “Draft” code of ethics, 2002. Australian Medical Students’ Association. Available at:
AMSA_ethics.PDF (accessed Nov 2002).
11. Paice E, Heard S, Moss F. How important are models in making good doctors? BMJ
2002; 325: 707-710.
(Received 30 Oct 2002, accepted 30 Oct 2002) ❏

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