The teaching of medical ethics has become an integral aspect of medical education. These courses aim to prepare students for future issues they may face involving informed consent, futility, and conscientious objection as well as aiding us in forming our own moral beliefs for future practice. However, there exists a whole subset of issues faced by medical students as medical students. We occupy the lowest rung on the hospital hierarchy—the bottom of the totem pole. This places us in a vulnerable position with its own unique ethical dilemmas. A study of third-year students in Toronto found that 47% had, at some point during their clerkships, felt pressure to act unethically. One particularly common problem reported involved the sacrifice of proper patient care for the sake of furthering medical education. One student commented:
Once, when I was on call, there was a patient who…was in a vegetative state. The resident….I was working with decided that this would be a good opportunity for me to learn how to do a femoral stab, even though it was not necessarily medically required. The patient was not expected to [recover] from his current condition, and wasn’t in a position to argue….It was more or less for the exercise in education on a non-consenting patient. It struck me as so at the time too, but we don’t really get a lot of opportunity to practise [sic] those types of procedures.
Other situations described by students included practicing pelvic exams on patients under anesthesia or having a patient return for a follow-up visit solely for teaching purposes without the patient being aware that this visit was unnecessary. After spending a small amount of time in clinic, I can see how easily these situations can arise. They are not brought about maliciously, with intent to deceive or take advantage of a patient. Instead, it seems more likely to be a preceptor attempting to provide a positive learning experience for a student. This places the student in a tough place. Our eagerness to excel pushes us to take advantage of all opportunities to improve as future physicians. We are often motivated by a desire to impress our attending physicians, perhaps in the hopes of receiving a letter of recommendation or earning a place in a desired residency program. The competitive atmosphere in which we students live further enhances this need to excel. Being surrounded by so many intelligent, ambitious, and talented individuals creates a pressure to jump at each opportunity in the hopes of proving ourselves amongst our peers.
However, this very eagerness to succeed may cloud our judgment and push us into situations where we may be inclined to ignore the best interests of the patient. As stated by the Toronto student above, the practiced medical procedure was not medically necessary and could have potentially caused harm to the patient. Nonetheless, these facts were set aside because “we don’t really get a lot of opportunity to practice those…procedures.” Furthermore, students may often feel fear or anxiety at expressing this discomfort to those in power. Stating that we do not want to perform a procedure may be perceived as disinterest and lack of commitment. This may be a particularly strong fear when rotating through a specialty in which the student is interested, driven by the “Pass with Honors” grade that seems so important.
In the classroom, we may know the correct answers to USMLE-style ethics questions. When given a brief clinical vignette, the right option may just stand out to us—my personal favorite is “(C) Consult the Ethics Committee.” However, the situations that we face during clerkships do not offer the same safe multiple-choice answers. We may not have the option to seek second opinions or discuss our reasoning. Our decisions must be made in the moment, and there may not always be a correct answer.
Carmen Hoffman is a medical student in the Class of 2018. She is a native of Arizona and attended Arizona State University, where she received a Bachelor of Arts in philosophy. When she has finished school (in the far, far-off future), she hopes to pursue a career in medical ethics. To contact Carmen, please e-mail her at carmenhoffman[at]email.arizona.edu.