domingo, 29 de noviembre de 2009

Ética en medicina interna

Teaching Medical Ethics in Internal Medicine Residencies
Technologic advances, the medical malpractice crisis, and changes in health care reimbursement
pose ethical quandaries for the practicing physician every day. Should the demented patient be
kept alive with tube feedings, antibiotics, and mechanical ventilators? How defensively must the
prudent physician practice? Does the private practitioner have a duty to care for indigent
patients? To resolve these questions, practitioners must understand medical ethics. Medical
ethics teaching should have an important place in residents’ preparation for practice. This
teaching can sensitize residents to ethical issues in patient care, improve their ability to analyze
those issues, and help them make sound management decisions. Yet residency directors who
want such teaching in their programs may feel ill-prepared to plan and implement a medical
ethics curriculum. This chapter reviews recent events in medical education that have emphasized
the importance of medical ethics teaching, outlines the rationale for this teaching, proposes
topics for inclusion in a medical ethics curriculum, and suggests ways to train faculty and teach
medical ethics to residents.
Until the early 1980s, many program directors believed teaching medical ethics was unnecessary
or even counterproductive to resident education. Directors thought three years was barely
enough time for residents to master the many technologies of internal medicine; medical ethics
teaching would merely usurp valuable time from traditional technical education.20 Some
directors doubted that medical ethics could be taught or could have much impact on resident
behavior.37 Others felt that experienced clinicians could teach medical ethics adequately in the
course of conducting good patient care.
Those attitudes began to change with two recent events. In 1983 a special American Board of
Internal Medicine (ABIM) subcommittee issued a statement that excellence in practice requires
the internist to meet high standards of humanistic behavior. This subcommittee identified
integrity, respect, and compassion as humanistic qualities essential for clinical competence. The
subcommittee also concluded that the cognitive aspects of ethics should be taught, that residents
can be sensitized to their own values and their patients’ values, and that “established personality
traits and behavior can be modified.”37 Furthermore, the subcommittee endorsed ABIM’s
attempts to assess humanistic qualities in candidates for board certification. The subcommittee
urged ABIM to continue ethics questions on the certification examination and to advise program
directors about standards and methods for assessing humanistic qualities in residents.22,37
In 1984, the Association of American Medical Colleges published “Physicians for the Twenty-
First Century: The General Professional Education of the Physician Report” (GPEP Report).
Though specifically addressing premedical college and medical school education, the GPEP
Report had clear expectations of ethics and values training in residency. The report stated:
“Ethical sensitivity and moral integrity, combined with equanimity, humility, and selfknowledge,
are quintessential qualities of all physicians.”36 Residency education must nurture
those qualities in residents because residents are particularly susceptible to cynicism and
depression. Residents need medical ethics teaching to help counteract the stresses of overwork
and feelings of inadequacy as well as to bolster residents’ ethical and humanistic development.
Teaching medical ethics in internal medicine residencies is justified for several reasons. First,
residents must learn to recognize the full range of ethical issues that pervade medicine. (A
medical ethics issue is any conflict of values concerning patient care.) Journal articles proliferate
on withdrawal of life support, assessment of patient competence, refusal of recommended
treatment, and decision-making for incompetent patients, and physicians now recognize these
topics as ethical issues (Perkins, HS: unpublished data). Yet many important but less dramatic
issues often go unrecognized. Should physicians order unnecessary tests at patients’ insistence?
Should physicians inform patients about clinical mistakes? Must physicians treat noncompliant
patients? Clouser sees medicine as a conceptual ghetto: a highly educated community with
similar training, language, and goals, but impoverished of other world views.21 This idea may
explain why many ethical issues escape physicians. Physicians may simply not recognize values
different from their own. Ethics teaching sensitizes physicians to the different values patients
may have and to the conflicts of values that create medical ethics issues. For example, one study
demonstrated that interaction with a physician-ethicist on medicine ward rounds at a teaching
hospital more than quadrupled the number of patients whom residents recognized as posing
significant ethical problems.30
Second, residents must learn a sound framework for resolving ethical issues. The framework
provided by medical ethics teaching rests on the primacy of the physician’s loyalty to patients’
wishes and interests. Physician intuition and feelings are insufficient to manage such issues.
Alcoholics and drug addicts may repulse the resident, but his or her feelings do not justify
denying these people full medical care. Medical ethics examines clinical decisions for their
assumptions, logic, and implications. Furthermore, ethics teaching requires more than
demonstrations of good patient care. Actions can be ambiguous. The resident may not
understand that the attending physician stops the vegetative patient’s respirator not to save
money for the hospital but to comply with the patient’s presumed wishes. Ethics teaching
emphasizes the importance of stating reasons to justify actions and understanding how those
reasons derive from a comprehensive ethical framework.
Third, medical ethics teaching can have its greatest impact during residency because those are
professionally formative years. For the first time in their careers, residents must take
responsibility for patients’ medical care. Residents must learn decision-making under
circumstances of incomplete knowledge, predictive uncertainty, and their own and patients’ high
expectations. This weighty responsibility often daunts residents, and their anxiety will prompt
them to adopt whichever problem-solving methods appear useful. As one such method, medical
ethics can prove itself useful to residents in conducting patient care.29,32 In addition, medical
ethics can shape practice habits most during residency because residents’ habits are not yet
In July 1983, the DeCamp Foundation invited the nation’s leading medical ethicists to a
conference to define a core curriculum in medical ethics. They identified seven fundamental
ethical skills that every resident should know:27
1. Know the moral aspects of medical practice. The resident should realize that medical
practice requires choices based on values. Because such value-laden choices determine
how physicians will treat patients, medicine has a distinct moral dimension. Sometimes
values conflict, and residents must be able to recognize those conflicts and resolve them
in ways that promote patients’ interests. Patients’ wishes are usually the best indicators
of patients’ interests. A lung cancer patient requests full cardiopulmonary resuscitation
despite the resident’s recommendation against it. The resident sees resuscitation merely
as wasting valuable medical resources and prolonging the patient’s suffering. The
patient, however, wants more time with his family. The resident should recognize the
conflict between his values and the patient’s and resolve it by honoring the patient’s
2. Know how to obtain informed, voluntary consent. The resident should clearly
understand that the fundamental purpose of informed consent is to facilitate the patient’s
informed participation in decisions about his own care, not to protect the physician or the
hospital. The resident should also know the ethical (and often legal) standard of
disclosure—what what a reasonable patient would want to know in such circumstances—
and be able to communicate medical information in language the patient can understand.
For example, most patients want to know important side effects of medication. Thus,
before starting clonidine for hypertension, the resident should inform a young man about
possible fatigue and impotence.
Proper consent must also be voluntary, i.e., free from coercive influences causing the
patient to choose against his true wishes. When patients’ decisions appear illogical, the
resident should probe for possible coercive influences. The resident recommends adding
nifedepine to a Medicare patient’s antihypertensive regimen. Agreeable at first, the
patient refuses after the resident explains the high cost. The resident probes and
discovers the patient is afraid he cannot afford nifedepine on his pension. The resident
asks the social service department to apply to Medicare for drug reimbursement and then
the patient agrees to take nifedepine.
3. Know what to do if a patient refuses recommended treatment. The resident
ordinarily should honor patient refusals of treatment if probing reveals no
misunderstanding or coercive factors influencing the patient’s judgment. A man with
bilateral lower extremity weakness from a midthoracic spinal stenosis refuses
recommended decompressive surgery. The neurology resident probes for the reasons
behind the patient’s refusal. The patient says he understands the doctors have good
intentions in recommending surgery, but he does not want to risk becoming more
disabled from the surgery. Without compelling evidence that misunderstandings or
coercion influence the patient, the physicians correctly choose to honor the man’s refusal.
4. Know what to do about incompetent patients. The resident should know how to
identify incompetent patients and how to secure valid consents to treat these patients.
Incompetence means the inability to understand information relevant to a decision,
deliberate about options logically, make a choice consistent with one’s own values, and
communicate that choice. Simply refusing recommended therapy does not by itself prove
incompetence. (Patients, such as the man with spinal stenosis, may validly refuse
recommended therapy because it violates their personal values.) The vegetative, the
comatose, and the severely demented are the clearest examples of incompetent patients:
they meet all four conditions in the definition of incompetence.
After having identified an incompetent patient, the resident should ensure that the patient
has a suitable proxy who knows the patient well and can make decisions promoting the
patient’s wishes or interests. A severely demented Alzheimer’s patient is admitted to the
hospital for a urinary tract infection. The patient has no family. While treating the
infection, the resident approaches the patient’s best friend and longtime neighbor to be
his guardian, and the friend agrees. Guardianship will officially designate the friend as
the decision-maker for the patient in the future. The resident asks the social service
department to initiate the guardianship proceedings.
5. Know when it is morally justified to withhold information. The resident may
understand that professional tradition has allowed the physician great discretion to
withhold from patients information that might harm them. The law calls this doctrine
“therapeutic privilege.” Yet the resident must understand that patients need medical
information to make important life decisions, and that this information rarely harms
patients. Physicians can almost never justify withholding important medical information
from patients. Claiming the patient would lose hope and faith, the family asks the
resident not to tell a very religious, elderly woman her cancer diagnosis. Without more
convincing evidence of severe harm to the patient, the resident correctly insists he must
disclose the diagnosis.
6. Know when breaching confidentiality is justified. The resident must understand that
maximum therapeutic benefit often depends on the physician’s duty to maintain
confidentiality. If a patient cannot expect the physician to keep sensitive information
confidential, the patient may hesitate to request medical help or to disclose information
that may be necessary for accurate diagnosis and effective treatment. Yet this duty is not
absolute. The law specifies three exceptions to the physician’s duty to keep
confidentiality: (1) reporting communicable diseases, child abuse, elder abuse, and
gunshot wounds; (2) testifying in court; and (3) disclosing serious danger the patient
poses to specific others. The first two exceptions are self-explanatory, but the third
requires clarification by example. The Tarasoff case in California involved a rejected
lover who confided to his therapist that he intended to kill his former girlfriend.
Although the therapist notified the police and the police detained the patient briefly, they
eventually released him for insufficient proof that he would commit murder. The patient
then killed the girl, and her parents sued the therapist for not warning the victim. The
California Supreme Court ruled in favor of the parents by declaring: “The (patient’s)
protective privilege ends when the public peril begins...”.1
7. Know how to manage patients with poor prognoses. The resident must know how
terminal care differs from curative care. When terminal care is indicated, the resident
must be able to focus on physical comfort, avoid excessive monitoring, and attend to the
patient’s emotional needs. Meeting those needs sometimes requires special staff effort
and modifications in hospital routine. A young woman’s surgical, radiation therapy, and
chemotherapy treatments for breast cancer have failed, and her physicians conclude she is
dying. The patient requests comfort care and permission to see her preschool children.
The resident stops all laboratory tests and monitoring of vital signs. He writes a noresuscitation
order. He also persuades hospital administration to make an exception to
normal policy to allow the children to visit their mother in her room.
After the DeCamp conference had defined the seven ethical skills above, the federal
government and private insurance companies introduced strong cost containment
measures, including reimbursement by diagnosis-related groups. These measures justify
an eighth ethical skill every resident should know:
8. Know how to manage medical resources wisely. The resident must learn to use
medical resources only when they will benefit patients.
On the one hand, the resident should adhere to cost containment measures by not wasting
resources. The technologic imperative—the tendency for physicians to overuse
technologies because they exist—has considerable power over residents and other young
physicians. Lacking confidence in his or her own clinical judgment, the resident often
relies too heavily on technology to reassure himself. Most patients with congestive heart
failure can be adequately diagnosed and treated on the basis of history, physical
examination, and chest x-ray. Few patients require expensive echocardiographic studies
or multiple gated scans. The resident should resist the temptation to order such tests
On the other hand, the resident should realize that cost containment measures can set
physician and hospital interests against patient interests. The resident must never allow
these measures to compromise important patient interests. Residents must be sure
patients get the medical attention and resources they require. The family of an elderly
demented woman controls her Social Security checks but has failed to pay several
months’ rent to the nursing home where she lives. When the patient is hospitalized for
pneumonia, the nursing home refuses to take her back until the family pays the
outstanding bill. The family refuses. When the inpatient days allotted under Medicare
run out, the hospital administrator urges the physicians to discharge the patient
immediately to the family’s home. The physicians, however, believe that this would
seriously compromise the patient’s interests: a family unwilling to use the patient’s
Social Security checks to pay her nursing home bills is unlikely to give her adequate care
at home. Even though the hospital may suffer a financial loss, the physicians decide to
keep the patient hospitalized until proper placement is arranged.
An effective medical ethics curriculum requires three resources from the department:
endorsement, faculty, and funds. The department chair and program director must openly
endorse ethics teaching and actively promote it to residents. Non-ethics faculty must reinforce
ethics instruction by using ethical concepts in their own clinical teaching.36 Without strong
department-wide endorsement for medical ethics teaching, residents will view ethics as
Effective medical ethics teaching also requires trained faculty able to devote sufficient time to
develop and teach the curriculum. The department should recruit at least three people—a
professional ethicist or theologian and two physicians—to serve as medical ethics faculty. The
department should commit 20-25 percent of each ethics faculty member’s work week to the
ethics teaching program. The ethicist must have a strong commitment to medical ethics. He or
she should be willing to teach residents on the wards and in the clinics. Many medical schools
and hospitals already employ ethicists, and some of these ethicists may be available to the
department of medicine on a shared basis. Ideally, the physicians recruited as ethics faculty
should command respect as clinicians and also have strong motivation to study medical ethics.
These physicians will need formal training in the subject. Medical ethics fellowships, lasting
from several months to two years, are available at the following institutions:
Center for Clinical Medical Ethics, The Pritzker School of Medicine, PO Box 72, The
University of Chicago Hospitals, 5841 South Maryland Avenue, Chicago, IL 60637
The Institute for Medical Humanities, The University of Texas Medical Branch,
Galveston, TX 77550.
The Hastings Center, 255 Elm Road, Briarcliff Manor, NY 10510.
The Kennedy Institute of Ethics, Georgetown University, Washington, DC 20057.
The Robert Wood Johnson Clinical Scholars Program, c/o the Robert Wood Johnson
Foundation, College Road and US Route 1, PO Box 2316, Princeton, NJ 08543-2316.
The Department of Medicine at the University of Texas Health Science Center at San Antonio
offers an intensive, one-month seminar covering the most influential books and articles on
medical ethics. This seminar also offers participants the opportunity to conduct in-hospital ethics
consultations under supervision. A residency program’s ethics faculty should conduct ongoing
research about medical ethics and publish their results. The department chair should assure the
ethics faculty that their teaching and research will receive proper recognition in promotion and
tenure decisions. Assessment of that work should include consultation with comparable ethics
faculties at other medical schools or hospitals.
Effective medical ethics teaching uses the following forums: teaching conferences, teaching
rounds, ethics consultations, and participation on appropriate committees. First, four to six
departmental teaching conferences per year should focus on ethical issues. The conferences
might include medical grand rounds, morbidity and mortality conferences, and house staff
conferences. Almost all medical ethicists recommend that these conferences address specific
cases to demonstrate to residents the importance of ethics to actual patient care. Conferences use
the ethics faculty’s time efficiently, but one-hour, case-oriented conferences provide little time to
develop a basic theoretical framework for understanding ethical issues. Thus, residents may
sometimes feel the solutions are arbitrary.
Second, ethics teaching rounds should occur on the oncology wards, in the intensive care units,
and in other patient care areas where ethical issues arise frequently. These rounds should require
residents to present cases posing ethical issues. In this way, residents will gain experience at
identifying and articulating ethical issues. These rounds otherwise share the advantages and
disadvantages of teaching conferences.
Third, ethics consultations are also a key part of ethics teaching. Ethics consultations help
residents recognize ethical issues involving their patients, change management in many cases,
and boost residents’ confidence in their final management plans (Perkins HS: unpublished data).
Consultations, however, are quite time-consuming for ethics faculty and may foster in residents
an unhealthy reliance on the consultants. Fourth, participation on the hospital ethics committee,
the institutional review board, the intensive care units committee, and other committees
addressing ethical issues provides an opportunity for ethics faculty to teach other faculty and
Furthermore, effective medical ethics teaching requires adequate financial and material
resources. Because almost no outside funding exists for teaching medical ethics, the department
should allocate enough funds to cover all reasonable curriculum-related expenses. These
expenses might include subscriptions to the Hastings Center Report, the American Journal of
Law and Medicine, and Law, Medicine & Health Care; teaching videotapes; Bioethicsline (a
computerized literature searching program like Medline); guest speakers; and secretarial help.
The department chair and the residency program director should commit these resources
generously—endorsement, faculty, and funds—with the conviction that medical ethics must
become a key element of residents’ education. Medical ethics teaching enriches and balances
residents’ technical education by addressing the important human dimension of medicine.
Harry S. Perkins, MD, Professor, Department of Medicine, University of Texas Medical
School at San Antonio
Books and Monographs
1. Beauchamp TL, Childress JF. “Principles of Biomedical Ethics”, Oxford University
Press, New York, 1983. This book presents systematically the four fundamental
principles of bioethics — autonomy, beneficence, normaleficence, and justice — and
illustrates the application of the principles to actual cases.
2. The Hastings Center. “Guidelines on the Termination of Life-Sustaining Treatment and
the Care of the Dying”, Briarcliff Manor, New York: The Hastings Center, 1987. This
book summarizes the scholarly literature on the life support decisions, emphasizes
prospective planning for them, and specifically discusses decisions about
cardiopulmonary resuscitation, nutrition and hydration, antibiotics, and pain relief.
3. Jonsen AR, Siegler M, Winslade WJ. “Clinical Ethics: A Practical Approach to Ethical
Issues in Clinical Medicine”, MacMillan Publishing Co. Inc., New York, 1986. This
handy pocket-sized book presents a framework for analyzing and resolving common
medical ethics issues. The framework has four components: medical indications, patient
preferences, quality of life judgments, and socioeconomic factors.
4. President’s Commission for the Study of Ethical Problems in Medicine and Behavioral
Research. “Deciding to Forego Life-Sustaining Treatment”, US Government Printing
Office, Washington, DC, 1983. In this report, a presidential commission lays down
sensible guidelines for making life support decisions based on patients’ wishes and
interests. The report differentiates decision-making procedures for competent and
incompetent patients, and deals extensively with three especially problematic topics:
permanently unconscious patients, severely ill newborns, and resuscitation decisions.
5. President’s Commission for the Study of Ethical Problems in Medicine and Behavioral
Research. “Making Health Care Decisions”, US Government Printing Office,
Washington, DC, 1982. This commission report identifies personal well-being and selfdetermination
as the two values underlying the informed consent doctrine and considers
this doctrine and the “ethical imperative.” Thus, health care professionals should ensure
patients are properly informed and allowed to participate as much as possible in decisions
about their care.
6. Reich WT, Ed. “Encyclopedia of Bioethics”, MacMillan Publishing Co., Inc., New
York, 1978. Though a little dated, the Encyclopedia remains an important scholarly
reference on topics from abortion to zygote banking.
Journal Articles
7. Annas GJ. “Not Saints, But Healers: The Legal Duties of Health Care Professionals in
the AIDS Epidemic”, Am J Public Health 1988, 78:844-9. Despite established legal
duties for physicians to treat in emergencies, to refrain from discriminatory patient care
practices, and to avoid abandonment, professional societies and state legislatures have not
uniformly upheld a physician’s duty to treat AIDS patients.
8. Brett AS, McCullough LB. “When Patients Request Specific Interventions: Defining the
Limits of the Physician’s Obligation”, N Engl J Med 1986, 31:347-51. Patients who
demand useless or even harmful therapies present a common ethical problem for
physicians. These authors propose that the physician has no ethical obligation to fulfill a
patient’s wish for a particular therapy unless that therapy has potential benefit for the
9. Jonsen AR. “Do No Harm”, Ann Intern Med 1978, 88:827-32. Jonsen cites four
meanings of the medical maxim “Do no harm”: (1) Medicine is a moral enterprise
intended to benefit patients; (2) Physicians should exercise due care in attending patients;
(3) Patients should ordinarily be allowed to determine which medical risks are acceptable
to them; and (4) Patients should be allowed to determine when treatment’s harm
outweighs its benefits.
10. LaPuma J, Schiedermayer DL, Toulmin S, Miles SH, McAtee JA. “The Standard of
Care: A Case Report and Ethical Analysis”, Ann Intern Med 1988, 108:121-4. Using a
case to illustrate, the authors propose that the standard of care should include technical
competence at managing disease, the general legal duty to possess and use the skills of a
reasonably well-qualified physician, and the ethical obligation to promote patients’
11. Lo B, Dornbrand L. “Guiding the Hand That Feeds: Caring for the Demented Elderly”,
N Engl J Med 1984, 311:402-4. The authors state four questions to consider in deciding
whether to give tube feedings to the elderly demented: (1) Will the feedings relieve
hunger and thirst? (2) Will the feedings prolong life? (3) Will the feedings cause
suffering? (4) What psychosocial effects will the feedings have? The decision to
withhold tube feedings should be grounded in patients’ wishes or interests.
12. Lo B, Jonsen AR. “Ethical Decisions in the Care of a Patient Terminally Ill With
Metastatic Cancer”, Ann Intern Med 1980, 29:107-11. This article addresses questions
physicians often ask about euthanasia. The authors point out the important difference
between giving high doses of narcotics to alleviate pain and giving equally high doses to
kill the patient.
13. Lidz CW, Appelbaum PS, Meisel A. “Two Models of Implementing Informed Consent”,
Arch Intern Med 1988, 148: 1385-9. The authors describe two models for implementing
informed consent: (1) the event model that involves presenting information to the patient
only once shortly before treatment; and (2) the process model that involves giving
patients information, discussing it with them, and negotiating about decisions throughout
the therapeutic encounter.
14. Lynn J. “Ethical Issues in Caring for Elderly Residents of Nursing Homes”, Primary
Care 1986, 13:295-306. Institutionalization often deprives the elderly, demented, and
disabled of much control over their lives. Physicians should try to restore some control to
these patients by inviting their participation in medical decisions. Furthermore,
physicians should steadfastly serve as the patients’ advocates despite current pressures to
ration resources and to contain costs.
15. Lynn J, Childress JF. “Must Patients Always Be Given Food and Water?”, Hast Cen Rep
1983, 13:17-21. Lynn and Childress say that the incompetent patient usually should
receive food and water. A few instances, however, justify not giving food and water: (1)
whenever feeding cannot improve the patient’s nutrition and hydration; (2) whenever the
patient would not consider the improved nutrition and hydration beneficial; and (3)
whenever the patient would consider the burdens of feeding to outweigh its benefits.
16. Morreim EH. “The MD and the DRG”, Hast Cen Rep 1985, 15:30-8. Cost containment
programs based on diagnosis related groups (DRGs) threaten to destroy the physician’s
traditional loyalty to the patient. While affirming the importance of this loyalty, Morreim
urges physicians to eliminate wasteful practices.
17. Perkins HS. “Ethics at the End of Life: Practical Principles for Making Resuscitation
Decisions”, J Gen Intern Med 1986, 1:170-6. This article outlines three principles for
making resuscitation decisions: (1) Give cardiopulmonary resuscitation (CPR) unless
compelling reasons indicate the patient would not want it; (2) Give no CPR if the patient
has refused it; and (3) Give no CPR if it would not serve therapeutic goals the patient
would choose.
18. Steinbrook R, Lo B. “Artificial Feedings: Solid Ground, Not Slippery Slope”, N Engl J
Med 1988, 318:286-90. Arguing from five recent legal cases, the authors propose that
nasogastric and intravenous feedings be used only if their benefits for the patient
outweigh their burdens. If benefits do not outweigh burdens, the physician may
justifiably withhold the feedings.
19. Steinbrook R, Lo B, Tripack J, Dilley JW, Volverding PA. “Ethical Dilemmas In Caring
for Patients With the Acquired Immunodeficiency Syndrome”, Ann Intern Med 1985,
103:787-90. The authors recommend fully aggressive therapy for all AIDS patients who
want it unless the patients are terminal and therapy has virtually no prospects for success.
The authors also recommend that patients who want to limit their therapy discuss those
wishes with their physician and execute advance directives.
Books and Monographs
20. Bickel J. “Integrating Human Values Teaching Programs Into Medical Students’ Clinical
Education”, American Association of Medical Colleges, Washington, DC, 1986. This
survey reveals that human values teaching programs have widely varied objectives.
Common problems for these programs include insufficient funding, general faculty
disinterest, and lack of institutional support.
21. Clouser KD. “Teaching Bioethics: Strategies, Problems, and Resources”, The Hastings
Center, Briarcliff Manor, NY, 1980. Clouser champions medical ethics teaching that
develops students’ analytical thinking as well as sensitizes them to moral issues.
22. Subcommittee on Evaluation of Humanistic Qualities in the Internist, American Board of
Internal Medicine (ABIM), 1985. This monograph identifies and defines three
humanistic qualities the ABIM requires of board-certified internists: integrity, respect,
and compassion. The monograph also presents strategies for assessing these qualities in
residents and emphasizes the importance of assessments based on direct observation.
Journal Articles
23. Arnold RM, Povar GJ, Howell JD. “The Humanities, Humanistic Behavior, and the
Humane Physician: A Cautionary Note”, Ann Intern Med 1987, 106:313-8. The authors
describe humane physicians as possessing technical competence, humanistic attitudes,
humanistic behavior, and knowledge of humanistic concepts. To train such humane
physicians, the authors favor residencies that teach communication skills and cognitive
aspects of medical ethics, medical anthropology, and the other medical humanities.
24. Barnard D. “Residency Ethics Training: A Critique of Current Trends”, Arch Intern Med
1988, 148:1836-8. Barnard argues that ethics training during residency should include
retreats, discussion groups, and other experiences designed to encourage residents to
develop a sound philosophy of practice and to learn good relationship-building skills. In
this way residency programs will acknowledge and nurture “the humanness of the
25. Carson RA, Curry RW. “Ethics Teaching On Rounds”, J Fam Pract 1980, 11:59-63.
Carson and Curry use three cases to illustrate the value of ethics teaching on ward rounds.
Ethics teaching facilitates physicians’ decision-making by “challenging assumptions,
clarifying issues, making distinctions, pointing out deficiencies in reasoning, asking for
reasons, and then probing (those reasons) to see whether they withstand scrutiny.”
26. Clouser KD. “Medical Ethics: Same Uses, Abuses and Limitations”, N Engl J Med 1975,
293:384-7. Clouser claims medical ethics’ primary purpose is to structure disputed issues
by analyzing concepts, applying relevant principles and precedents, and drawing out
implications of actions. He also says medical ethics may not specify one “right” answer
for every issue.
27. Culver CM, Clouser KD, Gert B et al. “Basic Curricular Goals in Medical Ethics”, N
Engl J Med 1985, 312:253-6. At a conference the nation’s leading medical ethicists
agreed on the following beliefs about teaching ethics in medical schools: (1) Medical
ethics cannot change students’ basic moral character but helps students give good
character “the best behavioral expression;” (2) Medical ethics cannot be taught piecemeal
as students rotate through the clinical specialties; (3) Successful teaching programs may
vary considerably; and (4) The content of medical ethics instruction should be “rigorous
and precise.”
28. Jonsen AR. “Leadership In Meeting Ethical Challenges”, J Med Educ 1987, 65:95-9.
Jonsen notes that most physicians remain quite inarticulate about medical ethics, and a
gap separates medical ethics teaching and actual patient care. He urges university
medical centers to maintain faithfulness to the suffering patient and to exercise leadership
in assuring proper care for all.
29. LaPuma J. “Consultation In Clinical Ethics: Issues and Questions In 27 Cases”, West J
Med 1987, 146:633-7. LaPuma reviews one year’s ethics consultations at the University
of Chicago hospitals. Of 27 consultations, 18 concerned withholding life support, 3
concerned costs or scarce resources, 3 concerned patient autonomy, and 3 concerned
other issues.
30. Lo B, Schroeder SA. “Frequency of Ethical Dilemmas In a Medical Inpatient Service”,
Arch Intern Med 1981, 41:1062-4. The percentage of patients recognized by attending
physicians and residents as causing significant ethical problems rose from 4 percent to 17
percent when a physician-ethicist attended medicine ward rounds at a teaching hospital.
31. Loewy EH. “Teaching Medical Ethics to Medical Students”, J Med Educ 1986, 61:661-
5. Medical ethics requires instruction in order that students learn necessary information
about ethics, acquire important analytic skills, and practice these skills under supervision.
Loewy favors using patient vignettes and clinically I instructors to teach medical ethics.
32. Pellegrino ED. “Relevance and Utility of Courses in Medical Ethics: A Survey of
Physicians’ Perceptions”, JAMA 1985, 253:49-53. Of 1,023 physicians who responded
to a mailed questionnaire survey, only 314 (30.7%) had had any ethics courses in college,
medical school, or postgraduate education. Yet 82 percent of these 314 reported that
these courses helped them identify value conflicts; 79 percent said these courses
increased their sensitivity to patients’ needs; and 73 percent said their courses improved
their ability to deal openly with ethical issues.
33. Pellegrino ED. “Educating the Humanist Physician: An Ancient Ideal Reconsidered”,
JAMA 1974, 227:1288-94. Pellegrino argues that all practicing physicians must be
technically competent and compassionate. In addition, some physicians must command a
broad humanistic education in order to place medicine in its proper relation to culture and
society. Excessively weighted toward the technical for many years, medical curricula
should re-emphasize compassion and humanism.
34. Purtilo RB. “Ethics Consultations in the Hospital”, N Engl J Med 1984, 311:983-6.
Purtilo raises important procedural questions about an ethicist’s doing clinical
consultations: (1) Should the ethicist record his consultation in the medical record? (2)
Should the ethicist be paid for the consultation? (3) Should the ethicist have access to the
patient, family, physician, and other informants in the case? and (4) Should the ethicist
have a hospital staff appointment?
35. Siegler M. “A Legacy of Osler: Teaching Clinical Ethics At the Bedside”, JAMA 1978,
239:951-6. Siegler believes teaching ethics from actual cases at the bedside maximizes
personal accountability, reinforces the relationship between technical competence and
ethical decisions, involves the entire health care team, and decreases medicine’s
resistance to ethics instruction. Physicians, assisted by clinically informed philosophers,
should take the responsibility for teaching ethics at the bedside.
36. Report on the Working Group on Personal Qualities, Values, and Attitudes. Physicians
for the Twenty-First Century. Report of the project panel on the general professional
education of the physician and college preparation for medicine. J Med Educ 1984,
59:177-89. This working group identified attitudes a physician should have “to recapture
the human spirit in medicine.” Medical education, however, often undermines the
development of these attitudes. Therefore, the group challenged medical school faculties
to: (1) choose students with the potential to develop those attitudes; (2) demonstrate
those attitudes to students, and (3) design educational experiences and student evaluations
to reinforce those attitudes.
37. Subcommittee on Evaluation of Humanistic Qualities in the Internist, American Board of
Internal Medicine (ABIM). “Evaluation of Humanistic Qualities in the Internist”, Ann
Intern Med 1983, 99:720-4. This article states the purpose of the subcommittee and some
of its initial findings. Citation 22 summarizes the subcommittee’s final report.
38. Winkenwarder W. “Ethical Dilemmas for House Staff Physicians”, JAMA 1985,
254:3454-7. Winkenwarder offers suggestions for managing the ethical issue created by
disagreement between attending physicians and residents: (1) recognize the value
differences present and discuss them; (2) use consultants or “recognized sages” to help
resolve such disagreements; (3) minimize misunderstandings by maximizing
communication among the staff; and (4) teach more medical ethics.

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