ALT-1 The Role of Bioethics in Medical Education
For all the current buzz about bioethical issues, it is worth remembering that bioethics is actually a very young discipline. Before the 1980s, medicine was all about the triumph of science and technology over health problems. Failure - as measured by the battle between disease and technology - was not an option. Yet as modern technology began to win that battle more and more often, it became increasingly apparent that the battleground was a human being.
As the wishes of that human being gradually began to play a relevant role in the battle between disease and technology, the ancient ethical credo of "First, do no harm" began to take on a new meaning. In a world where machines could keep a person's body alive indefinitely even after the complete loss of brain function, the focus of that battle gradually shifted from quantity of life to quality of life.
At this point, bioethics first began to find its place in modern medical education.
Most medical students today are required to take at least one course in bioethics as part of their medical education. That course usually begins with the three basic principles of modern medical bioethics, autonomy (the patient's wishes), beneficence (do no harm), and justice (the patient as part of society). The most basic courses in bioethics begin and end with these definitions and their immediate, practical application. Until quite recently, the whole thing was covered in the equivalent of a weekend workshop.
As bioethics moved from an optional elective to a core part of the medical curriculum, the course expanded as well. Some schools use a historical approach, examining how various philosphers over the ages have explored these principles and the balance between them. A typical course outline of this kind might include virtue (Plato), utilitarianism (Jeremy Bentham), deontology (Immanuel Kant), and some exploration of the social contract (Jean-Jacques Rousseau).
Other schools minimise the philosophical language to focus on the practical, usually as it applies to a series of examples and case studies. Here, students are first introduced to the idea that there actually are human considerations beyond the scientifically optimal treatment: which can be quite a shock for students who have come to medicine from a traditional hard science background. Common examples studied here include confidentiality, consent, prenatal genetic manipulation, and resource management.
At least one medical school examines bioethical principles through empathy, theatre, and roleplaying, along with background reading of selected short stories and poems by physician-authors. Typical questions explored in this approach include patient non-compliance, giving bad news, and physician mistakes.
This is not to say that any given approach looks only at some issues but not others. Most full-year courses try to give a broad sense of the most important bioethics issues today. That being said: medical curriculum time is limited. Consequently, most schools will tend to look at bioethics issues through the dominant lens of their environment without looking too much further afield.
While the news today is full of hot-button bioethical question marks such as stem cell harvesting, genetic manipulation, or the possibility of human cloning: most medical students will never personally run into these issues. These topics are rarely brought up in medical education, or even in medical research education. For the most part, they remain the domain of bioethics specialists.
On the other hand, most medical students will personally encounter end-of-life issues before the end of their residency. Only a couple of decades ago, Do Not Resuscitate (DNR) orders were unheard of. One fought for life as hard as one could, no matter what the circumstances. Yet today, many - but not all - patients with terminal illnesses ask to be allowed to die as peacefully as possible, without the implementation of extreme measures such as feeding tubes and ventilators. Medical students are taught how to discuss these matters with their patients before the time comes, and take their wishes into account in creating a plan for treatment or palliative care.
Perhaps above all, effective bioethics studies teach the prospective physician that, despite everything hard science has to say about it, there will always be background issues which affect any given decision. If an unborn child has been diagnosed with Tay-Sachs syndrome, it will certainly die before its second birthday: yet a woman morally opposed to abortion may wish to bring it to term anyway. A physician who wishes to give the best possible care may also be concerned about the possibility of a malpractice suit, and so prescribe expensive tests beyond what is realistically necessary (just in case).
Inserting bioethics studies into medical education does not guarantee that there will never be a decision making conflict between physician and patient. There will always be differences of opinions, and especially differences over what is most valuable in determining quality of life. Once, the roles were straightforward: patients were sick, doctors treated to the best of their ability, patients cooperated. Today, the abilities and choices are much greater, and the roles are not so simple.
Yet the essence of bioethics is to attempt to act, not only with efficacy but with morality. As long as bioethics education succeeds in teaching medical students to see their patients as fellow and sometimes fallible human beings who are worthy of respect - and the other way around - it cannot go too far wrong.
