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67% of residency directors reported that a lack of faculty expertise in medical ethics was a significant barrier to their attempts to provide a more comprehensive educational process. I have a proposal for a solution to these problems: Teaching about the “house of ethics” in ob/gyn, as we do at Vanderbilt University.
Dr Boehm is a professor in the Department of Obstetrics and Gynecology, Vanderbilt University, Nashville, Tennessee.
The results of a 2015 survey of residency directors on medical ethics in ob/gyn residency programs may be news to some in our specialty but they are not a surprise to me. Published in the American Journal of Obstetrics and Gynecology the data reveal that medical ethics is a part of the core curriculum in 50% of ob/gyn residency programs but is taught in an unstructured manner, with 57% of programs dedicating 5 or fewer hours per year to the subject.1 In addition, 73% of the survey respondents stated that they would like “more” to “a lot more” ethics education for their program and 85% indicated that they believed medical ethics education should be required.
Interestingly, 67% reported that a lack of faculty expertise in medical ethics was a significant barrier to their attempts to provide a more comprehensive educational process. I have a proposal for a solution to these problems: Teaching about the “house of ethics” in ob/gyn, as we do at Vanderbilt University.
When I served as Chair of the Vanderbilt Medical Center Ethics Committee from 1990 to 2004, I came to understand that ethics is the study of standards of conduct and moral judgment as well as a code of behavior. I also came to realize that the question of what is “right” is at the center of most of our ethical discussions and debate. I came to believe that the issues surrounding medical ethics were pervasive and ubiquitous throughout the day-to-day practice of medicine.
Medical ethics issues involve much more than whether it is appropriate to perform an abortion or to allow a patient to refuse treatment. It also involves each and every patient encounter, whether in an outpatient setting or within the confines of a hospital.
Because of this, I began to teach our ob/gyn residents that in our profession, we practice in what I call a “house of ethics” and each time we undertake a patient encounter, we enter this domicile. I tell them that the foundation of this house comprises 4 principles of medical ethics first introduced by Hippocrates: beneficence, non-maleficence, autonomy, and justice. I explain that the walls of the house are made of the many virtues of medical professionalism and the roof comprises the informed consent process. This metaphor frames understanding and stimulates an encompassing concept of medical ethics.
We teach our residents that beneficence is the duty to do good on behalf of the patient; non-maleficence is the duty to refrain from harming the patient; autonomy is the respect for self-determination for patient and physician; and justice is the patient’s right to be treated fairly and to receive a fair distribution of the burdens and benefits of healthcare. They are taught further that the walls of professionalism are defined as the principles of how we conduct ourselves while serving our patients and include such virtues as confidentiality, truthfulness, compassion, sympathy, promptness, reliability, a nonjudgmental attitude, absence of conflicts of interest, lifelong learning, integrity, honesty, humility, and collegiality.
Finally, the residents learn that the roof of our ethics “house” is informed consent. In 1992, the Committee on Ethics of the American College of Obstetricians and Gynecologists stated that informed consent is an ethical concept that has become integral to contemporary medical ethics and practice, and that it is a requirement for medical treatment.2 Therefore, if our patients are not appropriately and thoroughly informed about the medical care that we recommend, we are violating a basic ethics principle of medicine. Informed consent allows patients to profess their autonomy in an educated manner, and it allows a sense of trust to build between patient and physician.
We stress that trust is the glue that binds medical providers to patients and enables providers to exercise their professional authority. A thorough and complete informed consent process increases communication between patient and physician, which then can lead to a more trusting relationship. Without adequate informed consent, our ethics house is at risk of collapsing; without it, patients will not have the trust that is imperative for dispensing beneficence, non-maleficence, autonomy, and justice.
Students of the practice of medicine need to understand that each and every encounter with a patient involves at least one of the foundational ethics principles, as well as many of the aspects of professionalism. For example, the principles of beneficence and non-maleficence are practiced each time we explain to a patient the risk-benefit ratio of a recommended procedure or treatment. Writing a prescription, explaining symptoms, and recommending care all involve one or more aspects of professionalism and foundational ethics principles. It is not just the lofty and difficult ethical issues that arise in the care of seriously ill patients that require a medical ethics consultation. It is, rather, everyday encounters with patients that lead to consideration of the many basic ethical and professional principles.
The “house of ethics” is a teaching tool that is simple to learn and teach. It can be taught without extensive training. Students and residents can easily understand it and, when applied to the many circumstances that arise on most days in the practice of medicine, it can lead to an expanded understanding of the complexities of patient care.
Abortion, multifetal pregnancy reduction, end of life, refusal of care, management of pregnancies with serious fetal anomalies or conditions, sterilization, the dispensing of contraception, discussions of risk-benefit assessment, access to care, and explanations of unexpected outcomes are but a few of the many issues that arise in an ob/gyn practice. These and many others are ideal instances for in-depth teaching of ethics and professionalism. In that context, the teaching of medical ethics is ingrained in the everyday practice of medicine similar to traditional bedside teaching of the art and science of medical care.
Teaching medical ethics does not require hiring ethics experts or introducing numerous didactic sessions on complicated issues. It requires incorporating the basic principles of medical ethics-professionalism and informed consent-into the daily routine care of patients. This way, our residents will complete their training with a better understanding of the importance of bringing ethics to each and every patient encounter.
1. Byrne J, et al. Evaluation of ethics education in obstetrics and gynecology residency programs. Am J Obstet Gynecol. 2015; 212:397.
2. Ethical Dimensions of Informed Consent. ACOG Committee Opinion: Committee on Ethics, No. 108, May 1992. Int J Gynaecol Obstet. 1992:39(4)346-355.