Critical Examination of Ethical Issues

Photo by Leah Gourley Dan Brock

The head of the pediatric ICU at Children’s Hospital Boston faced a daunting dilemma. The ECMO machines used to assist sick newborns were all occupied, yet another infant who needed one was due to arrive. What was the ethical thing to do—turn away the incoming child or accept him and bounce another tiny patient off a machine? What considerations should govern such rationing—the differing survival chances of the babies? Simple first-come-first-served?

This real-life conundrum of one of the faculty members teaching medical ethics at HMS ended without a child being taken off one of the machines, but with the newcomer being rejected. Students in HMS’s elective Medical Ethics in Clinical Practice ponder the case as one of the inevitable ethical tripwires of a doctor’s life. The new curriculum makes such philosophical wrestling mandatory. Medical Ethics and Professionalism will be required for first-year students in their very first semester, said Dan Brock, HMS professor of medical ethics and director of the HMS Division of Medical Ethics. He coteaches the elective and is heading up the planning for its mandatory successor.

Only 30 students or so take the elective course each year. Requiring it was timely, Brock said: “As difficult ethics issues become more and more common in medicine, all students should be exposed to critical examination of them.”

Students will be divided into four or five sections, each taught by a different faculty member. All groups will study 10 core topics. There will also be three or four elective topics undertaken at the discretion of each instructor. Core topics will include informed consent and surrogate decision-making for incompetent patients, confidentiality and truth-telling, end-of-life care issues, conflicts of interest in medicine, reproductive issues, genetic testing, and rationing. Ethics also will be one of the options for students to fulfill the new requirement for an in-depth scholarly concentration, with as yet undetermined advanced electives to be offered, as well as independent study on specific topics.

“We want students to be able to identify ethical issues when they arise, because you’re not going to deal with them well if you don’t even notice them,” said Brock. “We want students to be able to carefully and rigorously think through and analyze what they’re going to do in the situation when they confront it.”

One challenge, he noted, will be teaching students with no clinical experience and thus no personal run-ins with ethical dilemmas. “They don’t have a good feeling for what the pushes and pulls are on you—what it’s like to deal with a family member who’s making very problematic decisions for an incompetent patient, for example.” To compensate, ethics teaching will be incorporated into some pilot third-year clerkships after students hit the wards.

“We can have students responsible for identifying cases that raise difficult issues that they’ve been struggling with,” said Brock. There will also be efforts to coordinate with other courses—to discuss genetic-testing issues when students take genetics, for instance.

“This year, I just did a session on reproductive issues, and one of the students asked, ‘We’re just doing OB–GYN now. Did you coordinate it?’ Well, actually, I hadn’t. It turned out serendipitously that it was coordinated. What we’re going to be trying to do is do it less serendipitously and with more planning.”

—Rich Barlow

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