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Ethic issues pose dilemmas for medical students

By Chelsey Baldwin
College of Medicine

Chelsey baldwinEditor's note: Chelsey Baldwin of Little River is a second-year medical student. This column follows the journey of her class in becoming doctors.

"Are you going to let her starve to death?" our patient's adult son questions us during a scenario constructed to test our ability to apply ethical theory to clinical settings. The harshness of the question induces a transient episode of blank stares and ruffled brows in our group classroom.

We progress to muddling over definitions of futility, best interests, positive and negative rights. We eventually decide that allowing the patient to die because of a lack of nutritional supplementation was an ethical course of action guided by the principle of medical futility. In this scenario, we discuss an 82-year-old woman with end stage dementia who is no longer able to take nutrition orally. Given the patient's grim prognosis, we rationalized that there was no medical benefit to placing a percutaneous endoscopic gastrostomy (PEG) feeding tube, which would merely be a medical intervention applied to prolong the inevitable without the hope of improving the patient's quality of life or chances of survival.

This decision is supported by the literature, yet despite this support net, how would we possibly convey this morbid conclusion with mortal implications to our patient's son? Does our mastery of definitions and pockets full of literary support translate into promises of genuine intentions for a grieving family member?

I had often wondered how a physician might come to be competent in such ethical matters and not surprisingly have come to discover that we take a course on this, too. As a part of the second year curriculum, we have been introduced to medical ethics, a course which will continue for the remainder of medical school. The course aims to increase the medical student's competency, not only regarding our moral duties to our patients, but also the legal restraints that may alter the way we practice medicine. In an attempt to obtain these goals, my teammates and I debate the correct course of action in practice scenarios.

As we move toward approaching the family with our medical conclusions, we aim to not only give them advice. We also want to incorporate family and those who feel they have a close relationship with the patient. Integration of the family fits with the latest medical theories of patient- and family-centered care. According to the Institute for Patient And Family-Centered Care, "Patient and family-centered practitioners recognize the vital role that families play in ensuring the health and well-being of infants, children, adolescents, and family members of all ages. They acknowledge that emotional, social, and developmental support are integral components of health care."

Our discussion leader asks the group, "how will you proceed when an agreement cannot be reached despite your best attempts at eliciting the family's understanding of the situation and presenting them with needed information?"

The answer is seemingly clear, since the law has set forth the order by which surrogates will resume the power of making decisions. However, this too can be muddied by our perception of the surrogate's intentions. If the surrogate is not acting in the best interest of the patient, we are obligated to intervene. This creates yet another complicating layer as the group discusses the possibility of causing the patient more harm by informing them of the suspicious intentions on the part of the surrogate.

Our scenario is further complicated by the patient's depleted financial support. We are then asked how this should shape our decisions about treatment. Our sole philosophy major spouts off theories pertaining to the allocation of resources for the greater good.

Even I, as a biology major, am not foreign to these theories of utilitarianism; however, the thought of them being applied at the bedside is cringe-worthy. These concepts demanding consciousness of the masses are overwhelming when staring into the face of a patient. No, this is not our job, and we must grant ourselves leeway from such social burdens and be a doctor to our patient.

By the end of our student discussions, we have talked in circles and come to few, if any, solid conclusions. It is the journey through this process that our preceptor says is the most important. Dr. Joseph John, an internist at the veteran's hospital and clinical professor of medicine and microbiology, is a physician well-seasoned in our ethical dilemmas. He assures us that the process has produced physicians before his eyes and guarantees that we too will follow in their footsteps.

While our minds swim in the sea of our future responsibilities to make the morally correct decisions, for now it is a relief to know the fallback answer remains: Answer Choice C. Consult the Ethics Board.



Friday, March 30, 2012

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