The very public emotional and legal battle surrounding the end of Terri Schiavo’s life exemplified what can happen without advance directives and living wills.
Day after day, the world learned likely more than it needed to about family struggles and the death of this previously private 42-year-old.
After Ms. Schiavo’s death, Carol A. Schwab asked the junior and senior medical students taking her elective in legal/medical education to put aside emotion and identify reasons that supported either terminating or sustaining life support.
“We did not second-guess the ultimate decision,” says the assistant dean of legal/medical education in the Medical College of Georgia School of Medicine. “We simply looked at the positions and examined where each side might lead us if we followed it to extremes. We reached a consensus on the value of having both sides of the argument to help maintain a middle ground.”
Such discussions aren’t new on campus, but the increasing complexity of legal/medical issues are prompting more of them.
“In the early 1990s, we had a mini-course on medical ethics,” says Dr. Ruth-Marie E. Fincher, vice dean for academic affairs for the School of Medicine. “We decided medical ethics was so important to all students throughout the curriculum that it shouldn’t be an isolated short course in the beginning of the first year. Rather, it should be extended throughout medical school, emphasizing different points at different points of need for the students. We also wanted to strengthen discussions of medical-legal issues.”
Ethics and legal issues are now embedded in all small-group discussions in the Essentials of Clinical Medicine course that spans the first two years of medical school, Dr. Fincher says. Second-year students’ organ systems-based education will include three weeklong inter-sessions with discussions of legal/medical issues, preparation for end of life and pediatric immunization. Dr. Fincher envisions more explicit placement of medical-ethical and medical-legal issues throughout the curriculum, topics not directly addressed when she was in medical school.
As the school’s first assistant dean of legal/medical education and a lawyer
who spent 16 years on the faculty of North Carolina State University, Ms. Schwab
is spearheading a team exploring which legal and ethical topics to cover and how
they are best taught and evaluated.
The list currently includes the physician-patient relationship, informed consent, medical records, end-of-life issues, risk management, liability issues, legal issues in mental health and communicable diseases. Ms. Schwab already has developed online tutorials for three of the core topics, although she’d prefer the classes be taught in small-group sessions that enable discussion.
The monthlong elective she introduced this year does just that. She uses an informal lecture style along with real-life cases to bring home the topic and trigger discussion among the small group of juniors and seniors for three hours, four days a week. Each student keeps a class journal for further expression.
“These are issues that physicians run into on a daily basis and yet many have no training. There are many of end-of-life issues; it’s not just terminating life support systems, although that is a big part of it,” she says, referencing class discussions about Ms. Schiavo’s case. “It’s also knowing and understanding from a legal and a medical perspective what an advance directive is, what a do-not-resuscitate order is and how to deal with them. Many medical students have never seen these documents.”
MCG has a strong history in covering medical ethics, but a renewed focus on legal/medical issues is needed, she says. “It’s very hard to separate ethics from law. Often ethical rules become rules of law. I show the students the history of these rules.”
Learning about the potential consequences of violating the rules can be depressing to the future doctors who only want to help people get better. “You see it in their journals,” says
Ms. Schwab. “They are studying so hard to be doctors and we focus on lawsuits. I try and pull them back in with a little bit of perspective. So many daily activities involve the potential for liability. Every time you get behind the wheel of a car, you are putting yourself at risk for a lawsuit. Risk management is managing the risk … driving safely, obeying speed limits and other traffic laws and when you can’t eliminate the risk, you insure it. The practice of medicine is no different. My goal is to make students more confident about managing the risk by knowing the rules.”
She and Dr. Fincher agree these need a place within the jam-packed medical school curriculum. “We have been moving in that direction for 15 years and have recognized that we need to do more than role model ethical principles in clinical practice,” says Dr. Fincher, a practicing internist. “We must go beyond the idea that there is no guidance to help us make ethical decisions. While there frequently is not a right answer in terms of what to do in certain clinical situations, there are principles to guide our decisions.”
The team is considering offering a continuing medical education version of the class. “Practicing physician are very enthusiastic when they hear about my course,” Ms. Schwab says. “They express regret that they did not have the same opportunity when they were in medical school.”
Monica McMillan, a third-year student from Macon, Ga., is glad she doesn’t have to wait to learn more. “A lot of the issues we see in the hospital don’t just deal with medicine or science. You are dealing with people,” says Miss McMillan, who took the elective in April.
Long before she ever saw a patient, Miss McMillan remembers discussing with her classmates issues they wished they were learning more about. “The business side of medicine was one of them, legal issues in medicine was another one and public health. When you get into the real world, you are expected to know those things that are not a part of the traditional curriculum, so you end up having to learn as you go.”
Ms. Schwab is happy helping students learn before they go.
--Toni Baker