Despite my extreme distaste for Forgive and Remember: Managing Medical Failure, I thought Bosk’s discussion about the “Varieties of Normal Action” and the accompanying grid of expectations and outcomes (pg. 116-120) to be were interesting and worth more detail, particularly Cell 4, expected failure. Here, doctors face the difficult situation of knowing that medical intervention will most likely be unsuccessful, but needing to care for their patients in the most ethical and humane way possible. I stumbled across this New York Times article from 1990 that touches on the same idea: http://www.nytimes.com/1990/05/15/science/the-doctor-s-world-despite-many-shifts-oath-as-old-as-apollo-endures-in-medicine.html?src=pm. In a nutshell, the Hippocratic oath, a list of axioms repeated by new doctors that essentially mean they will do no harm, has been phased out in the medical school setting and there’s a question of the validity of its origins. According to the article, it’s quite possible the Hippocratic oath (and accordingly, medical ethics) are not studied in medical school at all, which is detrimental to patients, and that the oath has paternalistic roots that don’t honor a patient’s wishes and hold the doctor above all others. It’s an interesting read, and encompasses bits of our discussions about How Doctors Think, medical ethics and our current reading.
Sunday, April 8, 2012
Medical Ethics
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This was a great article, it was interesting and like you said, relevant to what we're talking about and reading for class. I think that no matter what the origins of the Hippocratic oath, it's a great idea to have doctors have a personal ethical code that they agree to adhere to. It may not seem very useful and some might just go through the motions of it like saying the pledge of allegiance, but if doctors take the time to actually ingrain a moral code that has been agreed upon into their practice, and hold themselves accountable for upholding that code, they'd be less likely to commit errors. That way, in situations where doctors expect failure, there is a protocol for how the patient should be treated as opposed to relying on personal judgement. Maybe the Hippocratic oath is being phased out because morality and ethics are so associated with religion that setting standards for them has been stigmatized because it creates a lot of debate. But ethics don't necessarily have to be based on any sort of religion, and having an ethical code for doctors would be beneficial for many complicated cases in which doctors need to make tough decisions when they're faced with expected failure.
ReplyDeleteI think this is an interesting point. I read the article and one of the statements that caught my attention was “they say in pointing out that medical leaders are now criticizing their own colleagues for greed, fraud, cheating and even stealing the books for their courses on medical ethics.” But is the absence of the oath to blame? I think it’s a shame that medical education doesn’t give more attention to ethics, but at the same time I question how effective it would really be. Is teaching ethics class in business school going to provide the students with a better sense of morality? I’d argue it would not; ethics aren’t something you learn in a classroom. I think the questionable decisions made by doctors, and even businessmen, lawyers, and other professions, are not a result of a failure of the education system, they’re the result of a structural issue. There’s some deeper problem that’s manifesting into a variety of other problems, but that we recognize as failure to provide proper care for patients, for example.
ReplyDeleteI tend to agree with Hagan. I think many medical errors and the questionable decisions doctors make are not due to a lack of ethics, knowledge, etc, but rather the sheer complexity of medicine and the idea that doctors don't know how to reconcile and deal with not being able to further care for their patients and/or death and dying. In his book Checklist Manifesto, Atul Gwande writes about how many medical errors are not due to lack of knowledge of carrying out the correct procedural steps, but rather the complexity of medicine and the carrying out of the procedural steps. He proposes that these errors (i.e. giving a patient the wrong dose of medication or causing a central line to get infected) can be resolved or at least significantly minimized with the use of simple checklists that help ensure that doctors and medical staff follow particular sets of steps to properly complete various procedures. In this case, the correction of error is not done by correcting one doctor, but rather correcting medical teams and the medical system as a whole. The problem is structural. In her book Final Exam, Pauline Chen writes about how physicians are never taught about how to deal with death and dying in medical school. They are not taught how to break bad news, tell their patients that they have tried all possible treatments, or tell their patients that they are dying. They are not taught how to reconcile their feelings about their patients' deaths. They are not taught when to stop trying every possible treatment on a terminally ill patient. Many physicians thus avoid death and dying. They avoid telling their patients that they are dying because of not knowing how to. They avoid telling their patients that their is little chance that a treatment will work because they do not want to be the bearer of bad news. They avoid doing these things because they cannot personally reconcile their own feelings about them. These types of medical practices, judgements, and "errors" while "unethical" can hardly be blamed on the budding physician when the problem lies in the culture and nature of the medical profession. Again, I think the problem is somewhat structural. Integrating the Hippocratic Oath or a medical ethics class into medical education is probably not going to teach medical students how to practice 100%, full-proof, ethical medicine or hot to properly treat dead and dying patients. The hierarchy of physicians above the medical students don't presently formally teach them either either. They're basically never properly learned or taught. All physicians come to deal with ethical practice and judgements in their own ways only after gaining their own experience and after experiencing their first patient death. While I think ethical treatment should be formally taught and emphasized by the hierarchy of physicians, there are some gray areas of ethical treatment that can only be learned with experience. Only after one experiences their first patient death can he/she feel the feelings associated with it, learn how to reconcile these feelings, learn what went wrong and what went right with that patient's treatment and death, understand if he/she treated the dying patient in the proper, ethical, and humane manner, and then prospectively ethically treat their next patient.
ReplyDeleteI am on the fence about the effectiveness of implementing an oath to improve ethical standards in the hospital. I think that the example Vittoria brought up about the Pledge of Allegiance is relevant, because that is something that most people simply recite mindlessly and do not ponder the meaning of it once the pledge is over. However, in the case of an oath taken before one testifies at court, this recitation seems to be held at much more gravitas than the Pledge to Allegiance. Perhaps one of the reasons for this distinction is the frequency in which we undertake the oaths. Since the Pledge of Allegiance is recited every day (at least it was in elementary school), this decreases the effectiveness of it. Perhaps if the Hippocratic Oath was limited to just the most important circumstances, like before a surgery, then it would prove to be an effective way to remind doctors of their ethical obligations.
ReplyDeleteI also agree with Silpa that experience is key for doctors or medical students to learn how to approach certain situations. I feel that much of this field does not only involve heavy academic preparation but also involves emotional tasks. These doctors need to invest in their patients emotionally in order to give them the best care since knowing the disease itself is not enough. Agreeing to Vittoria's comment, ethical codes can get messy since religion can get involved. I think we see even a more messy side since we live in a society where there are so many practiced religions. In the end, it just shows that people are going to stand firm in only what they believe in and in only what they believe is right. And so, an oath for example is only effective to those that agree to it. Therefore, it's very difficult to enforce an oath that everyone can agree on. Overall, I believe that less errors can be made if there are systems that better hold doctors accountable with their peers. With that, doctors or nurses can focus on how to better themselves through their experiences.
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