Founding Document of the Program from Dr. James A. Knight, 1974
Program in Medical Ethics and Human Values in the Delivery of Health Services
While the student enters medical school with humanistic concerns and a deep social consciousness, the medical school does not make much of a conscious effort to nurture and reinforce these values. During his/her years in medical school, the student loses some of his/her idealism, social consciousness, and primary commitment to the service of the patient. He/She often becomes disillusioned and cynical through the years of struggle, for his/her feelings of caring and compassion can be beaten out of him/her. Society, educators, and government feel great concern as they anticipate increasingly dehumanizing developments in medicine and medical education. A counter-balancing emphasis on ethics and human values is imperative.
The aim of this program is to make a consideration of ethical issues and human values an integral part of the medical education process and relevant to the delivery of health services. More important than an exposition of ethical issues is the concern with the student's awareness of these issues in his/her day-to-day activity and specifically the value systems which may bear on his/her attitudes, decisions, and goals in patient care.
An effort will be made to raise each student's level of competence in the examination of the ethical and social problems arising out of advances in the health sciences. The student is not at present given the necessary training to cope with the issues in their full complexity or understand the threat to human values that is implicit in the technology of medicine. The medical student stands in the midst of great advances and the ethical and social dilemmas they create. His/Her response relates to human values that touch on the nature of man, his/her dignity, and his/her future. He/She must learn to achieve footholds from which he/she can question the assumptions, values, implications, and meanings of his/her training and actions. The explosive power of new knowledge and techniques forces constant alterations of professional practice and a re-examination of many traditional values in the care of patients. Thus, the student's medical education must be deepened to include those experiences in which he may gain clarity regarding the values he/she holds, internal consistency between his/her values and actions, and an adequate conceptual framework for decision-making. His/Her adaptive capabilities should include a tolerance for ambiguity, an openness to the plural-ism of his/her world, and an aversion to oversimplification and reductionism.
Such a program will exist to help the student examine the value issues arising in his/her care of patients, research, and health planning. Also, it will exist to sharpen his/her awareness of the priorities, ethical positions, role expectations, and methodologic assumptions in his/her and his/her patient's activity.
lt has been well established that if the value orientations of students are to be influenced, a direct rather than an indirect approach holds the greatest potential. In other words, students can be changed over the course of four years, but these changes in nontechnical orientations can only be brought about by conscious and direct efforts. Little is accomplished by hoping that medical students will develop the “right” attitudes by being placed in the “right” situations. On the other hand, much is accomplished by discussing the “right” attitudes directly, in relation to specific medical contexts. Since many attitudes in medicine are based on religious and philosophic considerations rather than medical ones, these issues should be discussed openly as religious and philosophic issues, not disguised as medical ones.
Any effective teaching of humanistic perspectives to medical students must be centered around the problems and practices of health care. In centering such teaching in health care, one does not call the student away from his/her primary concerns or work against the reward system in which he/she lives.
Lectures on medical ethics have limited value in effecting behavioral change. The seminar approach involving reading in depth, reflection, and discussion is a good method but one that should be used in conjunction with other approaches. The case conference method, with the presentation of patients when appropriate, has been shown to be exceedingly effective as a teaching-learning instrument. Also, ward rounds and grand rounds furnish impressive opportunities for demonstrating ethical decision-making.
Thus, the major educational tool is clinical in nature — the individual case situation. This approach avoids abstractions and emphasizes the uniqueness of each ethical or value-oriented decision as it relates to a specific patient and a specific set of circumstances. Since the patient and his /her situation are presented, the student will not be dealing with the theoretical in ethics but with the concrete.
- Approaches in ethical decision-making as related to clinical situations with patients.
This would include a critical delineation and examination of the conceptual framework of ethics. Selected moral problems in medicine, such as these, would be emphasized: human experimentation, “extraordinary” means in prolonging life, genetic counseling and control, abortion, sterilization, civil disobedience, and value imposition. Concepts such as natural law, natural rights, consent, self-determination, autonomy, authority, and value will be included.
- An examination and analysis of moral and philosophic aspects of issues related to health care delivery.
Among the issues to be included are: principles and problems of professional responsibility; the concept of person in the physician-patient relationship and in the health-care setting (privacy, dignity, confidentiality, truth-telling, informed consent, and so on); value judgments regarding sexuality, fertility, and the family; and the use and role of persuasion in health care.
- Death and dying.
This area will include studies of the conceptual and behavioral models needed in dealing with death, dying patients, and their families. Also, the student must be given opportunities to work with his/her own feelings about death so that he/she will be free to care for his/her patients, and not be in bondage to his/her fears and defensive behavior. Keeping company with the dying can be a rich and rewarding learning experience for the student. With the help of such patients, he/she can begin his/her own preparation for death.
- The internalization of professional obligations.
A serious inquiry must be made into the various ways in which professional obligations are internalized by the medical student. The process of socialization or professional maturation is a value-oriented endeavor and deserves serious attention, with ethics and human values in mind.
- Role of religious beliefs in the responses of patients.
Patients’ responses to both health and illness should be recognized and appreciated. many of these responses are religious and philosophic in nature. Man is a product of his/her total environment, and disease is a protest of the whole man/woman. Disease is more than a matter of invading germs or hardening of the arteries, for more universal factors play an immense role in the production of disease and in the recovery from it. The student must learn to face the conflict between his/her pragmatic education and his/her spiritual inclination to feel religious awe, as he/she faces the marvels of the human body and mind.