I’ve recently decided to pursue the medical ethics track here at Baylor, and I’m thrilled to have discovered that there is an official department that oversees this field and certifies physicians-in-training in this discipline. I just finished up the required first-year course last week (hoping I passed that ridiculous exam! my hand still aches when I think of how much writing I did), and while I have a few elective courses and a research project to complete before I get certified, I wanted to jot down my thoughts while they’re fresh about what exactly makes for a good medical ethicist. This is more for later reflection than anything else, but I do hope you’ll take a moment to comment with your thoughts–I’m always looking to see what others think and improve.

1) Think of the patient. No, really. Think of the patient. This is so stupidly obvious, yet it’s overlooked all the time thanks to the easy boilerplate of “It’s hospital policy.” It’s amazing how many will blindly follow words on paper instead of the needs of a fellow human being. I’m thinking of a case where a pediatric patient with a terminal condition was on his deathbed. His father was a psych patient, and admittedly not entirely right upstairs, so for security reasons based on his mental condition, he was not allowed into his son’s room to spend the final hours together.

See what’s wrong with this scenario?

Someone took the general hospital rule that psych patients are not to have extended visiting hours, and denied a young boy in his final hours the gift of holding his father’s hand as he went. If this doesn’t strike you as a great injustice and move you to anger/tears, please don’t be a part of the healthcare field until it does.

Fortunately in this case, a physician intervened, and demanded that extra security be called up to the ward and the father be allowed in the room. The end result? The physician got in trouble for violating hospital policy. For thinking of the boy’s feelings. Incredible. Thank goodness for being able to rely on tenure…?

Now, with this rule, it’s a bit broad. Think of all the patients in a case. If you’ve got a pregnant mother, you’ve got two patients, particularly if she’s passed the X-week mark (dictated by your state laws) past which the fetus is considered viable. If you’ve got a pediatric patient, you’ve got to take care of the parents too. If you’ve got a man who tested positive for TB, you need to get his family in for testing and preventative therapy too. It goes on and on–cast the net wide, no matter what the law minimally requires.

2) Never stop asking questions and communicating. I don’t know where in the busy life of medicine some doctors stopped being inquisitive and became robots processing information and technicians performing a trained skill. A case came in where a developmentally mentally challenged woman gave birth to a healthy baby. Heated debate ensued about whether the baby should be given to the care of the state and foster care to give it a more competent set of parents, or whether the baby should be allowed to stay with the mother, given that the mother was competent enough to take care of herself and had managed through pregnancy without the help of the father, who was no longer in the picture.

Amidst the flying arguments which began to lean toward giving the child to foster care, a medical student went into the room, and a few short questions later, discovered that this mother apparently had an aunt who had already agreed to take care of both her and the baby once the child was born. The aunt was called, and she immediately came to the hospital.

See what went wrong in this scenario?

Not a single other person had bothered to ask the patient if there might be other family who could help. Not the attending, not the residents, not the nurses. It took a curious student to stymie the possibility of giving away a child to the mercy of the foster care system. That student saved that baby’s life by simply taking a moment to speak with the patient and wondering if there was anything else that could be done. This brings me to the next rule…

3) Be creative. Brainstorm. A large, large part of being a medical ethicist is thinking up alternative solutions. Free your mind and forget the notion of good idea/bad idea. You can always sort your thoughts in order of best-to-worst later. The test prompt for my ethics exam presented a case where a mentally challenged young man was brought in by his parents for a vasectomy after they heard that one of his classmates had impregnated another classmate the week before. They were concerned that he wouldn’t be able to control his sexual impulses and do the same. This young man clearly lacks the mental capacity to be a father, so his parents wanted to prevent the possibility altogether.

What questions are popping up here?

Sure, it’s legally kosher in a lot of states for parents to sterilize their mentally disabled children. Should it really be the first thing to come to mind, though? What about psych therapy to see if he can develop restraint? What about transferring him to an all-boys school? What about home schooling with tutors? Most importantly, if he’s really so mentally incapable, why are they leaving him unsupervised for periods of time long enough that the possibility of him impregnating someone exists?

The parents’ wishes are clearly driven by fear, and a physician that simply goes with their will and performs the procedure is one who isn’t using his/her brain. In the end, a vasectomy may indeed be called for, but hopping straight to it without giving some pause to other solutions is on par with negligence, IMHO.

4) Bend/break rules when needed. Let’s be real, we’ve all justifiably broken rules before. It happens. An interesting case was presented to us in class where a patient concerned about his sexual promiscuity wanted to be tested for HIV. He tested positive…but did not want his girlfriend to find out. The girlfriend is also your patient. The girlfriend is also pregnant. Telling her that her partner is HIV-positive is a clear breach of patient confidentiality. Turns out the law only prevents you from being sued by the man in the event that you tell his spouse, not a significant other.

Do you tell her…? Would it be any different if she wasn’t pregnant?

I would hope there is general consensus that any modern-day physician needs to be an advocate for women’s rights and tell the girlfriend that she is at risk for HIV, regardless of whether or not she’s pregnant. That said, basic respect for the patient-physician relationship calls for informing the boyfriend that you’re going to do this regardless of what he wants, and give him a chance to change his mind and deliver the bad news himself. In the event that he still refuses to budge and you tell the girlfriend, limit the confidentiality breach as much as possible–only deliver the news that her partner has HIV, and her options to protect both herself and the fetus; how her boyfriend acquired HIV is something for the pair to discuss, and it’s not something that needs to come from a doctor. Don’t be nosy.

5) Be prepared to pay for it. Self-sacrifice is a hallmark of the medical profession; whether its reputation or money, the possibility of repercussions is always there. In the above case, you might lose the man as a patient, the man might spread negative rumors about you to his cohorts and damage your business, you might get sued (although it turns out that monetary damages in this type of scenario are typically quite minimal), etc.

So do you just sit there and deal with lawsuits left and right…?

Hell no. The tenet of open communication goes a long, long way in preventing people from getting mad at you. An attending told me a methodology he follows, and it’s quite genius: whenever he absolutely needs to go against a patient’s wishes, he carefully takes the time to explain to them why exactly his medical judgment calls for it, and then he gives them the phone number of the best malpractice lawyer in the city, and quietly says that if necessary, he would be willing to defend his actions under oath in a court of law. He’s yet to be sued by a patient who he’s said this to–they get that he’s entirely serious, and that he’s focused on what’s really important, and willing to fight for it. Kinda cool, no?

5 tenets of medical ethics