|
Phase I Home Page
Phase II Home Page
Phase
I & II
Phase
III
Year 4
Contents
Objectives
Concept
Inventory
Evaluation
of Students
Evaluation
of Curriculum & Faculty
Learning
Opportunities
List
of References
|
|
Introduction to Medical Ethics
for Students at the Medical College of Georgia
Phase
I and Phase II
Ethics is the discipline that
systematically analyzes and rationally justifies our moral choices (Pellegrino).
Knowledge of ethics is critical to the professional development of the physician
(Hafferty).
Ethical decision making
deals with concrete
judgments in situations in which action
must be taken despite uncertainty.
This course of study is designed for all four
years of medical school. The purpose of this course is to teach the skills
necessary for the student to identify, analyze and resolve ethical problems in
patient care situations, and choose among the options that can be done and those
that ought to be done, for a given patient in a given clinical setting. We will
help the student gain insight into the patient-physician relationship from the
patient's perspective as well as the physician's. Finally, by introducing this
course of study in the pre-clinical years, we hope to make the transition from a
morally responsible student to a morally responsible physician more logical,
more meaningful, and more certain.
The course consists of a one-hour group
lecture/interactive discussion for Phase 1 and 2. This will be followed by 6
hour and a half workshops. In these workshops, we will discuss and analyze all
issues described in the course content. Each workshop will have 10-12 students
and one faculty facilitator; and will consist of case discussions, clinical
vignettes, role-playing to enhance the skills of proper physician/patient
communication regarding sensitive issues, and audiovisual presentations modeling
appropriate and inappropriate professional behavior in clinical situations
followed by feedback. In addition, there will be ethical grand rounds and
vertical insertion of appropriate ethical issues into preexisting lectures. For
example, in a neuroscience lecture dealing with brain function/death or
persistent vegetative state, issues regarding care of the dying patient/family,
could be discussed. Finally, ethical issues of specific cases being considered
in preexisting groups such as problem-based learning, problem solving, and the A
standardized patient could be expanded upon through use of prepared packets of
materials.
Phase 3
core clerkships will include monthly one-hour workshops in which each student
would be expected to present an ethical dilemma he/she has faced and a
resolution reached. This format is ideally suited to small-group discussions
(i.e., 10-30 students) and techniques such as role-playing, use of standardized
patients, prepared scenarios, videos of simulated ward teams in action will be
used.
Other venues in Phase 3 include:
- departmental didactic lectures
- departmental grand rounds
- departmental daily ward rounds
Year 4
An elective in Medical Ethics is offered on a monthly basis to medical students.
This course consists of intensive, case-oriented discussion of important issues
confronted by all students in the clinical setting. An interdisciplinary
elective is planned for the spring semester and will include students from
medicine, nursing and the allied health sciences. These students will have the
opportunity to explore a special ethical issue and present their research in a
grand rounds format for the student body/faculty at large.
Contents
Medical students must be prepared and knowledgeable regarding the following
issues:
- Informed consent, including assessment of the
comprehension of the patient and shared decision making.
- Confidentiality and when it can justifiably be
breached.
- Competency assessment-factors of decision
making for the incompetent patient.
- Disclosure and justification for withholding
information.
- Futile versus curative therapy.
- Advance Directives.
- CPR.
- DNR issues.
- Terminating the patient-physician
relationship.
- The non-compliant patient and refusal of
recommended treatment including life-sustaining treatment.
- Quality of life issues.
- Euthanasia and assisted suicide.
- Management of medical resources in relation to
clinical decision-making.
- HIV issues.
- Care of the dying patient and learning the
distinction between: (a) withholding and withdrawing life sustaining medical
intervention, including nutrition and hydration; (b) "Ordinary"
and "extraordinary" care; (c) hastening the death process versus
allowing to die; (d) assisted suicide and euthanasia; (e) brain death and
persistent vegetative state.
- Ward Team Ethics: to help the student prepare
for his/her clinical education (i.e., the ward team experience) where there
is no written curriculum, and to help the student make the transition from
classroom to patient care and to discuss pressures of being a team member.
In particular, the pressure to learn, be part of the team, achieve good
grades, deal with making mistakes, and witnessing other team members making
mistakes, handling differences of opinion among ward team members, and
learning the paramount importance of keeping the welfare of the patient as
first and foremost priority; being perceptive of ethical issues that arise
while on the ward, and, above all maintain and enhance his/her individual
integrity and moral values regardless of the manifold ward team pressures
and influence not withstanding.
- Genetic testing and genetic manipulation
issues.
- Impaired physician issues.
- Ethical, moral, cultural, religious
differences regarding such issues as reproductive technology, abortion,
gender differentiation, contraception and birth control. In view of these
differences the ever present duty to properly fulfill the physician's
fiduciary and moral responsibility to his/her patient in areas of clinical
decision making and counseling; to define the responsibility of the
physician to appropriately help the patient make a reasonable decision as to
his/her course of action regarding these difficult, controversial issues,
regardless of the physician's personal moral preference.
Objectives
At the conclusion of this course, the student should:
- Be thoroughly familiar with the criteria
necessary for him/her to make sound ethical decisions.
- To know the moral aspects of medical practice
and to have a clear decision making strategy for clinical-ethical problems
in medicine. These criteria will include an understanding of: (a)
Beneficence; (b) Non-maleficence; (c) Autonomy; (d) Distributive justice;
(e) Medical indications; (f) Patient preferences; (g) Quality of life
preferences; (h) Other factors.
- Know how to obtain informed voluntary consent.
- Know what to do if a patient refuses
recommended treatment.
- Know what to do about incompetent patients.
- Know when it is morally justified to withhold
information.
- Know when breaching confidentiality is
justified.
- Know how to manage patients with poor
prognoses.
- Know how to manage medical resources wisely.
- Gain detailed knowledge of advance directives
and the legal issues involved (institution, state).
- Understand the basis of the physician's
obligation to care for particular patients
- Become aware of problems related to Afutile@
therapy and the limits of patient's demands for "non-indicated"
therapy.
- Learn distinction between withholding and
withdrawing life sustaining medical intervention; brain death, persistent
vegetative state, and coma; assisted suicide and euthanasia versus allowing
to die.
- Appropriate care of HIV test, notification of
third parties exposed to HIV, and maintaining confidentiality of HIV test
results.
Finally, to teach skills of ethical analysis
essential to making medical moral choices; raise responsibility of ethical
issues in every day clinical practice and enhance critical reflection of one's
personal values and obligations as a physician. In short, to educate students in
proper professional behavior and to endow them with the practice, wisdom, and
informed ability to exercise proper moral and ethical judgment in clinical
management.
Concept Inventory
Level 1: Concepts that the student should be thoroughly familiar with:
- The meaning of professional integrity and
the moral basis of medical practice including conflicting moral values and
importance of patient preference.
- Ethical principles of beneficence and non-maleficience.
- Strategy for ethical clinical decision-making
and ability to apply this strategy with understanding of the principles of
medical indications, patient preference, quality of life factors and other
external factors.
- Voluntary informed consent.
- Patient refusal of recommended treatment
including life-sustaining treatment and making ethical decisions related to
cardio-pulmonary resuscitation and life support.
- Competency and incompetency.
- Moral justification of withholding information.
- Principles of confidentiality and when breaching
confidentiality is justified.
- HIV tests, confidentiality of tests results and
legal/ethical issues regarding third parties exposed to HIV.
- Proper professional behavior in dealing with
patients, colleagues and co-workers.
Level 2: Concepts that the student should be
familiar with but in-depth knowledge is not necessary.
- Advance directives and legal instruments
in the State of Georgia.
- Principles determining futile therapy,
terminal care vs. futile care and understanding the limits of patient demands
for non-indicated therapy.
- Specific gender, cultural and ethnic issues;
religious beliefs and sexual preferences that affect medical decisions.
- Statutory law and legal restrictions for
surrogate decision-making, including treatment of minors. MCG policies and
procedures.
- Impaired physician issues.
- Genetic testing, genetic manipulation issues.
- Multi-cultural, multi-religious, multi-ethnic
differences regarding abortions, contraception, in vitro procedures of
conception and birth control.
Level 3: Concepts that the student should know
exist but need not know in-depth.
Evaluation of
Students
1. Knowledge
- Written evaluation by faculty, following case
discussions, workshops, etc.
- Self-evaluation.
2. Practice Skills
- Written evaluation by clinic faculty,
following direct observation.
- Written evaluation by faculty ethicists
following role playing in workshops.
- Written evaluation by faculty attending on the
in-patient service.
3. Attitudes, values, habits
- Written evaluation by faculty following direct
observation in clinics, in-patient ward service and in-patient rounds.
- Self-assessment.
- Nursing survey.
- Record number of formal and informal bioethics
consultations and ethical dilemmas submitted.
Evaluation of
curriculum and faculty
- Written and oral feedback from students.
- Survey students regarding faculty role modeling of practice
skills, attitudes, values, and overall performance behavior.
- Survey of students after several years following completion
of medical school as to how well they have put into practice what they have
learned.
Learning
Opportunities
- Lectures
- Group workshops for interactive discussion,
role-playing, problem-oriented.
- Seminars and case presentations.
- Audio-visual depictions of professional
behavior scenarios followed by feedback sessions.
- Handouts, referral to specific reference
material.
- Ethical grand rounds.
- Bedside ethical rounds.
- Submission in writing of an ethical dilemma
faced by a student with interactive group discussion and resolution.
- Simulated patient encounters.
- Standardized patients.
- Problem-Based Learning.
Literature Cited
- Hafferty, F. W. and Franks, R. The Hidden
Curriculum, Ethics Teaching, and the Structure of Medical Education, Academic
Medicine, Vol. 69, No. 11 (Nov. 1994), p. 861-871.
- Pellegrino, E. Ethics and the Moment of
Clinical Truth, JAMA, Vol. 239, No. 10 (March 6, 1978), p. 906-96.
List of References
- Bowen, J. L. A Curriculum in Ethics.
Prepared for the Association of Program Directors in Internal Medicine, 4th
Annual Precourse of Education, April 18, 1994.
- Culver, C. M., et al. Special Report Basic
Curricular Goals in Medical Ethics, The New England Journal of Medicine,
Vol. 362, No. 4 (January 24, 1985), p. 253-256.
- Miles, S. H., et al. Medical Ethics Education:
Coming of Age, Academic Medicine, 64 (December, 1989), p. 705-714.
- Perkins, H. S. Teaching Medical Ethics During
Residency, Academic Medicine, 64 (May, 1989), p. 262-266.
- Self, D. J., et al. A Model for Teaching
Ethics in a Family Practice Residency, The Journal of Family Practice,
Vol. 166, No. 2 (1983), p. 355-359.
- Siegler, M. Teaching Clinical Ethics at the
Bedside, JAMA, Vol. 239, No. 10 (March 6, 1978), p. 951-956.
- Siegler, M. Decision-Making Strategy for
Clinical Ethical Problems in Medicine, Archives of Internal Medicine,
Vol. 142 (November, 1982), p. 2178-217.
- Jansen A, Seigler, M and Winslade, W. J. Clinical
Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine,
McGraw-Hill Inc. 3rd Ed. (1992).
- Fletcher J. C., Hite C. A., Lombardi P. A.,
and Marshall, M. F. Introduction to Clinical Ethics, University
Publishing Group Inc., Frederick, MO. (1995).
- Principles of Biomedical Ethics,
Beauchamp & Childress.
- Practical Ethics for Students, Interns, and
Residents, Junkerman and Schiedemayer.
|