I see that a visitor had been directed to my blog from a web search engine with the question “What is an ethical dilemma?” I am not sure that I have defined this term previously. I would like to do so now. I found a definition noted by T.Y. Lee to which I agree. The examples below, however, are my own. Maybe a valuable mind game would be to think of some other examples.
“What is an ethical dilemma?” It is a Conflict between…
Ones PERSONAL and PROFESSIONAL values
A physician has a duty to his family (go to the football game) but he also has a duty to the patient (admit the patient to the hospital).
Two values/ethical PRINCIPLES
A patient has right to reject a treatment (autonomy) but a physician has a responsibility to protect the patient from a harmful decision (non-malificence)
Two possible actions, each with reasons strongly FAVORABLE and UNFAVORABLE
Treating the patient with a drug which though may have bad side-effects could possibly improve patient’s illness but by withholding the drug the patient has a possible chance of spontaneously improving and not be burdened by the bad side effects of a drug.
Two UNSATISFACTORY alternatives
The patient with terminal cancer who has stopped breathing will die quickly if nothing is done but his family would not be able to arrive soon enough to be with him before the patient’s death. However intubating the patient and putting the patient on a respirator will allow time for the family to come to visit him but only prolong an uncomfortable period of dying.
One’s VALUES/PRINCIPLES and one’s PERCEIVED ROLE
A physician has personal values that define abortion as immoral and yet as an obstetrician in a small community far from medical centers is now asked by a long-time patient to perform an abortion.
The need to ACT and the need to REFLECT
The psychiatrist suspects that his patient might commit a homicide and should notify authorities about his suspicion but he is uncertain that he should divulge to the authorities the patient’s private history without more proof of the patient’s intentions.
An important point about ethical dilemmas to carry away is that it is wise to try to avoid the situation, if possible, where they can occur but also one should be aware that not all ethical dilemmas if they do occur are settled to everyone’s satisfaction. Often in medical ethical dilemmas, it requires some consensus amongst the public and/or physicians, ethicists, lawyers and the courts to provide guidance.
I hope this posting helps those who wonder what are ethical dilemmas. ..Maurice.
ADDENDUM 9-2-2008: Those who would like to "play" ethicist and try to solve some hypothetical ethical dilemmas, after you have, if desired, read the comments or posted here, you may go to the "Ethical Dilemmas:Playing Ethicist: Almost Anyone Can Do It" thread.
Tuesday, March 8, 2005
Monday, March 7, 2005
Standardized Patients, Actors, Acting in Medical School Teaching and Empathy
As a follow-up on the issue of teaching medical students empathy through method-acting, I would like to point out that acting out clinical encounters is going on all the time in medical school teaching. If you don’t already know of the role of “standardized patients” as used for this teaching, read on.
For a number of years, more and more medical schools have incorporated professional actors in their teaching programs related to the first and second year students learning how to take a history and how to perform a physical examination. These actors are trained to provide the students with a simulation of a real patient, a clinical case, but with teaching advantages included. Those advantages include interviewing and examining in a non-threatening environment, with the support of a group of fellow students and the instructor-facilitator. This is in contrast to the experience “on the hospital wards” where the students are often alone with a patient and have to struggle with their own uncertainties and inexperience with no immediate assistance.
With the standardized patient, the student who is doing the interviewing can, when their own ability to know what to say or what to do next fails, can call a “time out”. The interview may abruptly stop, with the standardized patient ignoring what follows and the student can then communicate with his or her colleagues and the facilitator for help. When “time in” is called the interview proceeds as though there was no break. Another advantage for the students is the feedback that the standardized patient actor, who is again trained for this function, can deliver to the students. The actor can express how he or she, in the role they played, reacted to the questions and behavior of the student and provide valuable constructive criticism or encouragement to the student. This kind of feedback is not uniformly available from the real patients the student examines. Standardized patients can also provide a more comfortable environment for the student to practice physical examination. Though often pathologic findings may be absent, nevertheless on occasion a standardized patient with an abnormal physical finding may be discovered this becomes a valuable asset.
My experience with teaching first and second year medical students, even when they are role-playing the doctor and patient, is that we never encourage their “acting” out a certain behavior toward the patient except to keep in mind the requirement to be professional in their relationship with their patient with the goal of caring, being empathetic, therapeutic and beneficent.
Teaching “light empathy” as described in the literature, is essentially acting to maintain an emotional posture which is acceptable by the patient even though the student is upset with the patient or has moral differences of opinion but with no real understanding of the patient’s motivations and no intent to change the student’s own attitude or emotions, This may be effective and financially rewarding if the student was going into a non-medical care business but I think is unacceptable in medicine.
If anything, “deep empathy” is worthy of teaching where there is no acting in a theatrical sense. With “deep empathy”, the student is encouraged to pay attention to and try to understand what the patient is going through and try to understand his or her own emotions based on a previous similar personal experience. For example, for a patient complaining of pain, the student might remember some injury long ago which caused pain but the student didn’t know the severity of the injury or how long it would last or whether there would be residuals. Would there be some similarity of how the student felt with that the patient is feeling currently? With this contemplation, the student may be able change his or her own feelings about the patient and the patient’s perhaps disturbing reaction to pain.
So this is what I can tell you about “acting” as a part of the teaching clinical medicine in medical school. I hope it has given those visitors who have not been involved in such teaching an idea of what is going on these days. ..Maurice.
For a number of years, more and more medical schools have incorporated professional actors in their teaching programs related to the first and second year students learning how to take a history and how to perform a physical examination. These actors are trained to provide the students with a simulation of a real patient, a clinical case, but with teaching advantages included. Those advantages include interviewing and examining in a non-threatening environment, with the support of a group of fellow students and the instructor-facilitator. This is in contrast to the experience “on the hospital wards” where the students are often alone with a patient and have to struggle with their own uncertainties and inexperience with no immediate assistance.
With the standardized patient, the student who is doing the interviewing can, when their own ability to know what to say or what to do next fails, can call a “time out”. The interview may abruptly stop, with the standardized patient ignoring what follows and the student can then communicate with his or her colleagues and the facilitator for help. When “time in” is called the interview proceeds as though there was no break. Another advantage for the students is the feedback that the standardized patient actor, who is again trained for this function, can deliver to the students. The actor can express how he or she, in the role they played, reacted to the questions and behavior of the student and provide valuable constructive criticism or encouragement to the student. This kind of feedback is not uniformly available from the real patients the student examines. Standardized patients can also provide a more comfortable environment for the student to practice physical examination. Though often pathologic findings may be absent, nevertheless on occasion a standardized patient with an abnormal physical finding may be discovered this becomes a valuable asset.
My experience with teaching first and second year medical students, even when they are role-playing the doctor and patient, is that we never encourage their “acting” out a certain behavior toward the patient except to keep in mind the requirement to be professional in their relationship with their patient with the goal of caring, being empathetic, therapeutic and beneficent.
Teaching “light empathy” as described in the literature, is essentially acting to maintain an emotional posture which is acceptable by the patient even though the student is upset with the patient or has moral differences of opinion but with no real understanding of the patient’s motivations and no intent to change the student’s own attitude or emotions, This may be effective and financially rewarding if the student was going into a non-medical care business but I think is unacceptable in medicine.
If anything, “deep empathy” is worthy of teaching where there is no acting in a theatrical sense. With “deep empathy”, the student is encouraged to pay attention to and try to understand what the patient is going through and try to understand his or her own emotions based on a previous similar personal experience. For example, for a patient complaining of pain, the student might remember some injury long ago which caused pain but the student didn’t know the severity of the injury or how long it would last or whether there would be residuals. Would there be some similarity of how the student felt with that the patient is feeling currently? With this contemplation, the student may be able change his or her own feelings about the patient and the patient’s perhaps disturbing reaction to pain.
So this is what I can tell you about “acting” as a part of the teaching clinical medicine in medical school. I hope it has given those visitors who have not been involved in such teaching an idea of what is going on these days. ..Maurice.
Sunday, March 6, 2005
Should Doctors Cry? (3)
No. Doctors may shed one tear as part of the empathetic understanding of the patient's situation. But frank crying represents true sympathy and sympathy is not a therapeutic behavior for a physician towards a patient.
Read this poem by George Elliot, the English novelist, titled "Empathy" detailing a relationship which could represent what a patient sees in an empathetic physician.
Oh, the comfort, the inexpressible
Comfort of feeling safe with a person,
Having neither to weight thoughts,
Nor measure words--but pouring them
All right out--just as they are
Chaff and grain together,
Certain that a faithful hand will
Take and sift them,
Keep what is worth keeping,
And with the breath of kindness
Blow the rest away.
..Maurice.
Read this poem by George Elliot, the English novelist, titled "Empathy" detailing a relationship which could represent what a patient sees in an empathetic physician.
Oh, the comfort, the inexpressible
Comfort of feeling safe with a person,
Having neither to weight thoughts,
Nor measure words--but pouring them
All right out--just as they are
Chaff and grain together,
Certain that a faithful hand will
Take and sift them,
Keep what is worth keeping,
And with the breath of kindness
Blow the rest away.
..Maurice.
Friday, March 4, 2005
Leading Questions Make for Questionable Answers
It is not unusual to hear about the use of a leading question (where the answer is implied in the question) as a physician or nurse or family member attempts to get an advance directive regarding “do not resusitate” or “no intubation” statement or some other treatment decision from a sick hospitalized patient. The leading question may come in the form of “You don’t want to be intubated and suffer the discomfort, do you?” or “You don’t want them to pull the plug”, “You want everything done, don’t you?” Often there might not be a whole lot more of an explanation to a patient who is more concerned at the moment with the discomfort and suffering of the illness or who is in a somewhat mentally obtunded state. Use of these questions, in this way or even if given as a direct question such as “Do you want everything done?” is hardly the way to ask a sick patient to make a decision. It really comes down to “what is everything?”, “what is going to be done and how effective will it be to achieve the goals of the patient?” “What does pulling the plug actually mean? Is it to terminate unwanted treatment that is keeping the patient alive or is also to terminate needed comfort care?” Unfortunately when these decisions are left to the last minute, there doesn’t seem to be enough time, enough knowledge or just plain not enough understanding about how to communicate to be certain that the patient’s answer is what the patient really wants. And if answers to these questions are acted on as valid, well.. someone is fooling themselves.
These questions which may be requesting life and death decisions on the part of the patient deserve first a careful evaluation of the patient’s mental capacity to make medical decisions. Secondly it requires the questioner to provide some reasonable detail of the clinical situation so that the patient can make an informed decision. And finally, questions should be presented to the patient in non-coercive ways with the absence of leading questions. Leading questions are acceptable in the courtroom but never in medical communication. I want to emphasize that the proper communication with the patient should apply not only to the healthcare workers but also to family members who quiz the patient about their wishes.
As I have noted above, the first duty of anyone trying to obtain a medical decision from a patient is to verify that the patient has the mental capacity to form that decision for themselves. This is best determined by the patient’s physician. It is usually not necessary to request a psychiatric consultation to make the determination. The method is relatively simple. The patient should be alert, oriented and able to communicate. The patient should be able to demonstrate at least good short-term memory so that when information is presented or questions asked by the examiner, the patient will be able to recollect at the time of making a decision. The next step is to test the patient’s judgment. “You find an envelope on the sidewalk which has an address printed on it and bears an uncancelled stamp, what should you do?” What would you do? The examiner knows the correct answer, does the patient? If the patient passes this far, the next steps would deal with the clinical situation. I would suggest the following questions to see if the patient understands the significance of a personal medical decision. The examiner might not use these exact words but the request should be used in these contexts: 1) “Tell me what you know about your illness, treatment, result of treatment or no treatment” 2) Then instruct the patient regarding the illness, treatment and the result of treatment or no treatment.
3) Now discover whether the patient has learned from the examiner’s explanations. “Can you tell me what you now understand about your illness, treatment, result of treatment or no treatment?” 4) “What is your hope, goal or wish?” 5) “What would you want to be done about your illness?” 6) “Tell me why you decided as you did.” Notice that none of the questions are leading questions and the question 5 which requests a decision is open-ended in that it doesn’t give any hints of what could or could not be decided. From the answers to these questions and particularly question 6, the examiner might sense some significant depression. In this event, consultation with a psychiatrist might be helpful.
All of the above discourse is my own personal opinion and my way of thinking of how to make for a medical decision by the patient that one can feel confident that it will represent a truly autonomous and informed decision and that one has confidence that acting on it will be fair and ethical. I would appreciate reading any visitors views of this important part of medical care based on their own past experience. ..Maurice.
These questions which may be requesting life and death decisions on the part of the patient deserve first a careful evaluation of the patient’s mental capacity to make medical decisions. Secondly it requires the questioner to provide some reasonable detail of the clinical situation so that the patient can make an informed decision. And finally, questions should be presented to the patient in non-coercive ways with the absence of leading questions. Leading questions are acceptable in the courtroom but never in medical communication. I want to emphasize that the proper communication with the patient should apply not only to the healthcare workers but also to family members who quiz the patient about their wishes.
As I have noted above, the first duty of anyone trying to obtain a medical decision from a patient is to verify that the patient has the mental capacity to form that decision for themselves. This is best determined by the patient’s physician. It is usually not necessary to request a psychiatric consultation to make the determination. The method is relatively simple. The patient should be alert, oriented and able to communicate. The patient should be able to demonstrate at least good short-term memory so that when information is presented or questions asked by the examiner, the patient will be able to recollect at the time of making a decision. The next step is to test the patient’s judgment. “You find an envelope on the sidewalk which has an address printed on it and bears an uncancelled stamp, what should you do?” What would you do? The examiner knows the correct answer, does the patient? If the patient passes this far, the next steps would deal with the clinical situation. I would suggest the following questions to see if the patient understands the significance of a personal medical decision. The examiner might not use these exact words but the request should be used in these contexts: 1) “Tell me what you know about your illness, treatment, result of treatment or no treatment” 2) Then instruct the patient regarding the illness, treatment and the result of treatment or no treatment.
3) Now discover whether the patient has learned from the examiner’s explanations. “Can you tell me what you now understand about your illness, treatment, result of treatment or no treatment?” 4) “What is your hope, goal or wish?” 5) “What would you want to be done about your illness?” 6) “Tell me why you decided as you did.” Notice that none of the questions are leading questions and the question 5 which requests a decision is open-ended in that it doesn’t give any hints of what could or could not be decided. From the answers to these questions and particularly question 6, the examiner might sense some significant depression. In this event, consultation with a psychiatrist might be helpful.
All of the above discourse is my own personal opinion and my way of thinking of how to make for a medical decision by the patient that one can feel confident that it will represent a truly autonomous and informed decision and that one has confidence that acting on it will be fair and ethical. I would appreciate reading any visitors views of this important part of medical care based on their own past experience. ..Maurice.
Thursday, March 3, 2005
Should Doctors Cry (2): Empathy vs Sympathy
In the Fall 2003 issue of the Permanente Journal, James Hardee, M.D. presents what I feel is a very good overview of empathy and how it is different from sympathy. I have extracted the following from the Conclusion. Please read the entire article.
One of the difficulties written about in becoming truely empathetic is how we can "borrow" the true feelings of the patient, if physicians themselves have never experienced the same or similar stories. And even if the physicians did, might not their own individual past history, their own strengths and weaknesses affect their understanding of their patient's suffering? It is difficult but there is no doubt that not to provide empathy to a patient represents a great absence in the relationship and can have consequences for the patient's health. Empathy is the way to therapeutically and spiritually "connect" to the patient. This connection, if and when it occurs, is felt both on the part of the patient and also the physician. In fact, physicians will tell you that at the moment of this connection the physician may experience "goose-bumps", this event having such a physiological effect.
More on empathy later. ..Maurice.
Despite some divergent opinion on the matter, we may propose a subtle but important distinction between empathy and sympathy.
Whereas empathy is used by skilled clinicians to enhance communication and delivery of care, sympathy can be burdensome and emotionally exhausting and can lead to burnout. Sympathy implies feeling shared with the sufferer as if the pain belonged to both persons: We sympathize with other human beings when we share and suffer with them. It would stand to reason, therefore, that completely shared suffering can never exist between physician and patient; otherwise, the physician would share the patient's plight and would therefore be unable to help.
Empathy is concerned with a much higher order of human relationship and understanding: engaged detachment. In empathy, we 'borrow' another's feelings to observe, feel, and understand them--but not to take them onto ourselves. By being a participant-observer, we come to understand how the other person feels. An empathetic observer enters into the equation and then is removed.
Harry Wilmer (Wilmer HA. The doctor-patient relationship and issues of pity, sympathy and empathy. Br J Med Psychol 1968 Sep;41(3):243-8.) summarizes these three emotions--Empathy, Sympathy, and Pity--as follows:
* Pity describes a relationship which separates physician and patient. Pity is often condescending and may entail feelings of contempt and rejection.
* Sympathy is when the physician experiences feelings as if he or she were the sufferer. Sympathy is thus shared suffering.
* Empathy is the feeling relationship in which the physician understands the patient's plight as if the physician were the patient. The physician identifies with the patient and at the same time maintains a distance. Empathetic communication enhances the therapeutic effectiveness of the clinician-patient relationship.
One of the difficulties written about in becoming truely empathetic is how we can "borrow" the true feelings of the patient, if physicians themselves have never experienced the same or similar stories. And even if the physicians did, might not their own individual past history, their own strengths and weaknesses affect their understanding of their patient's suffering? It is difficult but there is no doubt that not to provide empathy to a patient represents a great absence in the relationship and can have consequences for the patient's health. Empathy is the way to therapeutically and spiritually "connect" to the patient. This connection, if and when it occurs, is felt both on the part of the patient and also the physician. In fact, physicians will tell you that at the moment of this connection the physician may experience "goose-bumps", this event having such a physiological effect.
More on empathy later. ..Maurice.
Wednesday, March 2, 2005
Should Doctors Cry? (1)
Go to retired doc's thoughts where James writes his views of the article in the March 2, 2005 issue of JAMA by E.B. Larson and X. Yao who suggested that method acting be part of the training and use by physicians in creating effective empathy in the patient-doctor relationship. I wrote a comment there but I also wanted to extend the issue a bit here on my blog.
One of the emotional issues which my first year medical students experience and are concerned about is what should they do if the story related by the patient in the bed in front of them is causing the student to feel so sad that tears are welling up in the student's eyes. They ask because they have experinced this reaction. The students ask me "should doctors cry?"
In view of the article, the question arises should doctors be actors and train to supress any emotional unsupportive response on their part whether sadness or anger or any form of irritability? And in the other direction, should they act fresh, composed, in tip-top mental and physical condition, happy and encouraging even when the doctor feels just the opposite? After all, shouldn't the doctor always be therapeutic in their behavior to the patient and wouldn't showing the wrong emotion be not helpful for the patient?
Before I go on any further, I would like to read the views of my visitors, both as a patient or as a physician, on this subject. ..Maurice.
One of the emotional issues which my first year medical students experience and are concerned about is what should they do if the story related by the patient in the bed in front of them is causing the student to feel so sad that tears are welling up in the student's eyes. They ask because they have experinced this reaction. The students ask me "should doctors cry?"
In view of the article, the question arises should doctors be actors and train to supress any emotional unsupportive response on their part whether sadness or anger or any form of irritability? And in the other direction, should they act fresh, composed, in tip-top mental and physical condition, happy and encouraging even when the doctor feels just the opposite? After all, shouldn't the doctor always be therapeutic in their behavior to the patient and wouldn't showing the wrong emotion be not helpful for the patient?
Before I go on any further, I would like to read the views of my visitors, both as a patient or as a physician, on this subject. ..Maurice.
Tuesday, March 1, 2005
Putting “Baby” to Rest
My visitors may have wondered why I needed to write four days of postings for a movie. After all isn’t a movie just a movie. I suppose what that expression could mean is that a movie is valuable for its financial benefit to the producers, for its “escape” value to its viewers who want to get into another life for an hour or two and for the ego and perhaps for the pocket books of its staff and casts if the result is to win an Oscar. Do you think I missed something else of value? Sure. A movie can be a life-moment teaching/learning experience if it brings to the screen what the viewer appreciates as a bit of his or her life or experience or awareness. When the viewer can fully understand and identify with the life of the characters as one easily can in “Baby”, what goes on around the character and what happens to the character is significant to bring about that learning moment, adding something new and important to the viewer’s life experience and knowledge. That is why it is important that what the viewer carries away is something of value for their own life and experience. I think that “Baby” missed the opportunity to do that very thing.
Well, you might say, many movies, maybe even the previous ones that Clint played in, nobody cares about unethical or illegal behavior within the film or at the ending. It’s a “shoot-em up” story. But “Baby” is different. The film is so powerful that I am sure the vast majority of the audience felt personally understanding and emotionally attached to each of the major characters. And when it came to the very ending, what was taken away was something not in keeping with the power of the rest of the film but something tawdry and misleading. What are all those viewers who are or have family members who are severely disabled or who are in a medically terminal condition going to think about what ethical and legal alternatives there are available for them?
Look.. one of the biggest problems physicians face when caring for critically ill patients is ignorance but also misunderstanding by the public about the facts and options in the management of the seriously ill. This misunderstanding is derived from a number of factors including poor physician communication but also by distortions presented on TV medical programs and stories, direct to consumer advertising and the comments of the over-the-fence neighbor amongst others. This lack or misinformation leads to ethical conflicts often between patients, their families and the healthcare providers. As a chairperson of a hospital ethics committee, I can tell you that this provides work for us but I would like to see ethical issues that have already been solved years ago not to arise again and be brought to the ethics committee for the conflict resolution. The newer issues where there is no ethical consensus.. those are the ones we want!
So this why I and others interested in medical ethics would have been pleased if there was a more simple, ethical, legal and realistic ending to such a fine motion picture as “Million Dollar Baby”. And with this final commentary, I will put “Baby” to rest. ..Maurice.
Well, you might say, many movies, maybe even the previous ones that Clint played in, nobody cares about unethical or illegal behavior within the film or at the ending. It’s a “shoot-em up” story. But “Baby” is different. The film is so powerful that I am sure the vast majority of the audience felt personally understanding and emotionally attached to each of the major characters. And when it came to the very ending, what was taken away was something not in keeping with the power of the rest of the film but something tawdry and misleading. What are all those viewers who are or have family members who are severely disabled or who are in a medically terminal condition going to think about what ethical and legal alternatives there are available for them?
Look.. one of the biggest problems physicians face when caring for critically ill patients is ignorance but also misunderstanding by the public about the facts and options in the management of the seriously ill. This misunderstanding is derived from a number of factors including poor physician communication but also by distortions presented on TV medical programs and stories, direct to consumer advertising and the comments of the over-the-fence neighbor amongst others. This lack or misinformation leads to ethical conflicts often between patients, their families and the healthcare providers. As a chairperson of a hospital ethics committee, I can tell you that this provides work for us but I would like to see ethical issues that have already been solved years ago not to arise again and be brought to the ethics committee for the conflict resolution. The newer issues where there is no ethical consensus.. those are the ones we want!
So this why I and others interested in medical ethics would have been pleased if there was a more simple, ethical, legal and realistic ending to such a fine motion picture as “Million Dollar Baby”. And with this final commentary, I will put “Baby” to rest. ..Maurice.
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