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Bridgeport, CT
Dr. Manthous is Associate Clinical Professor of Medicine, Yale University School of Medicine.
Correspondence to: Constantine A. Manthous, MD, FCCP, Bridgeport Hospital and Yale University School of Medicine, Bridgeport Hospital, 267 Grant St, Bridgeport, CT 06610; e-mail: Pcmant{at}bpthosp.org
A 55-year-old man with hyperlipidemia and hypertension has an uncomplicated myocardial infarction. You are writing his prescriptions, preparing for hospital discharge.
Clinicians are likely to differ considerably on their approach to this patient. Why? Differing medical knowledge and experience account for some of the variability. But knowledge of ethics and its application also contribute. What is ethics? Webster’s Seventh Collegiate Dictionary defines ethics as "the discipline dealing with what is good and bad and with moral duty and obligation." How we have come to define good and bad is complex. Most behaviors described as ethical or good are those that respect or aid others. Some would argue that God has given or instilled ethics in us. Or, as with Ralph Waldo Emerson’s Oversoul, our unity with God and nature can allow us to intuit right and wrong. Even nonreligious ethics suggest that discrimination of good and evil can be found within. For example, Immanuel Kant suggested his "categorical imperative," ie, taking an action for its own sake, is derived using reason.
Ethics is also a social construct (eg, laws, religious rules) that maintains order from a "state of nature." Despite abundant differences, nearly all religions and cultures simultaneously and, to some degree, independently developed similar definitions of good vs bad. There are no cultures or religions in which killing, stealing, or disrespect of others are deemed good. So it is reasonable to ponder why so many dissimilar traditions share core values. Perhaps ethics is rooted in our neurologic evolution. It is not unreasonable to posit that evolved man’s concept of "good" is the phenotype of genes that promote appreciation of social order, cooperation, and thus genetic propagation. Insofar as inappropriate behaviors are not ultimately accepted by reasonable people, natural and social selection gradually eliminates "bad" traits from the herd, leaving brains that value cooperation and respect for others... features present in most religious and cultural definitions of "good." Neuroimaging techniques are beginning to decipher functional differences of those with immoral behavior,12 supporting that wiring and function affect behaviors including ability to gate good and bad. Nonetheless, available evidence supports that both nature and nurture contribute to our ethical self-expression.3
By the time we have reached adulthood, parents, social institutions, and life experiences have molded us into increasingly independent ethical agents, the foundation on which our medical training is built. However, as we enter medical schools, most have had little or no exposure to medical ethics per se. Applied ethics in medicine, dating back to the Hippocratic Oath, have been taught by formal (eg, didactic) and informal (eg, modeling) methods. The study of medical ethics allows the student to consider and explore, in the safety of hypothetical cases and with peers as sounding boards, principles that aid in navigating ethical issues that arise in everyday practice. It is not tenable to expect that our heterogeneous indoctrination before entering medicine will provide a sufficient compass for complex decisions of daily medical practice. Medical ethics must be cultivated actively if we expect "good" results.
In this issue of CHEST (see page 1684), Carrese and Sugarman4 describe the lack of uniform standards for ethics education in US medical schools and residencies. In addition, we have no data about ethics training and cultural competency of the 40 to 45% of internists who were raised and educated outside the United States. Finally, there are no "outcomes" data to examine whether physicians graduating from residency have acquired a sufficient ethical toolbox and if/how ethical principles are applied to patient care. Meanwhile, news media highlighting unethical behaviors of some suggest that there is need for improvement. Continuing medical education requires that we learn new medical treatments as they arise, while we consolidate and polish core skills that are relatively unchanging. Mastery of medical ethics is a career-long pursuit, honed with practice.
While transparent to most of us, medical ethics play out in our patient interactions hundreds of times each day. Returning to the case example above, consider the ethical implications inherent to the simple transaction of prescribing an aspirin for secondary prevention following myocardial infarction. Some clinicians do not offer because they have forgotten or do not know. All-too-common errors of omission fail to satisfy the ethical principle of beneficence (and the professional principle of due diligence). A middle ethical ground would sound something like, "I’m going to suggest that you take an aspirin a day to help protect your heart." While ostensibly respecting the patient’s autonomy (ie, the patient could refuse), this approach does so incompletely by failing to approach the transaction as one of informed consent, with compliance contingent on patient "buy-in." Finally consider a more diligent approach in this ethical spectrum:
Aspirin is a medicine that reduces risk of another heart attack or stroke by roughly 25%. Aspirin predisposes to uncommon but potentially serious bleeding, from ulcers or into the brain if you have head trauma. It may rarely cause reversible kidney dysfunction. We’d have to work together to recognize early symptoms of complications, like heartburn or black stools. The alternative is not to take aspirin and accept the higher risk of a future heart attack.
While fully respecting the patient’s right to informed self-determination, to take or not take the aspirin, the third approach demonstrates concern, team spirit, and diligence. It is not a stretch to qualify in ethical terms this common activity, informed consent, and most everything we do in our professional lives.
Over the next 3 years, CHEST will publish a series of refresher articles on medical bioethics. We each possess varying moral compasses and previous formal education, so the series will emphasize core principles of medical ethics. Every 3 to 4 months, recognized scholars will contribute concise reviews to CHEST. The first article appears in this issue4 and is the foundation of a curriculum, or primer, that will include:
Each article will offer wisdom for students and physicians at all levels of precedent ethics education. Applied ethics will not solve all of the ills of modern medicine. But medical ethics requires that we choose to be and do good for our patients, which is surely medicine for us.
Acknowledgements
I remain grateful to Joseph (Jay) Healey, JD, who introduced a generation of University of Connecticut students to medical ethics, a legacy that has informed and enhanced the care of countless patients.
Footnotes
The author has reported to the ACCP that there are no conflicts of interest related to this article.
References
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