Appendix 50 - Ethical Compromise

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]

The majority of 1800 third year medical students surveyed reported doing something they believed was unethical.[564] One student admits, "What I learned was how to survive as a medical student by forcing myself to believe that what I was doing was all right, when deep inside I knew it was not."[565]

Sixty-seven percent felt "bad or guilty" about something they had done in third year. Of these students, three quarters had, "succumbed to that pressure against their better judgment." Sixty-two percent believed that some of their ethical principles had been "eroded or lost."[566] Another student: "I live in a world in which I do not trust or believe in what I am doing, and where I have grave doubts about what I am inflicting on other human beings."[567]

"At present it is a rare person that emerges from medical training with his or her humanity intact."[568]

In studies of third year medical students, ethical dilemmas mostly hinged around subservience to authority. One article elaborates:

The students' conflicts with their teams were most often couched as violations of personal values or principles. The student 'took the patients' side against the doctors, who took their own side.' So, to the students, becoming a doctor was problematic. It meant compromising one's principles in order to fit in, or join the team....

Whereas the students operated according to their values (compassion, caring, respect and fairness to patients), the teams appeared to operate at the lower level of doing right to please others and function within the system....

What are the implications of the perceived need to regress to a developmentally more primitive level in order to function? It may account for the difficulty acculturating. Not only were principles being violated, but some students were being pushed into childish behavior. It would be astounding if medical students eventually regress to a morally lower level themselves, but the evidence at hand suggests they may...."

[Evidence] suggests we will not encounter many students willing to adopt civil disobedience in response to compromising their principles.[569]

Always do right. This will gratify some people and astonish the rest - Mark Twain

From an article entitled "Speak No Evil: Physician Silence in the Face of Professional Impropriety":

For many medical students, the most disturbing aspect of their ethical lives arises from the troubling divide that separates knowing what they should do from actually doing it. These approaches fail because, for many ethical dilemmas, surmounting the barriers that separate belief from action involves confrontation, either between people or within one's self.[570]

Martin Luther King, Jr.: "It is neither in comfort nor convenience that a man's self-worth should be judged, but in his reaction to conflict and controversy."

More troubling, of course, are the students who postpone confrontation - 'I'll stand firm on my ethical beliefs when I am a resident or an attending, but not right now' - or revise their values or degree of sensitivity (for example, the transformation of a student who, during his first patient encounter, feels awkward and even impudent when asking about bowel habits, but then matures into the fourth-year clinical clerk who believes that 'Actually, it's all right to have five students perform rectal examinations on the same patient; this is how we learn').

From a study of common themes in medical student essays:

Sadly, some of the essays voiced helplessness and fear. Most distressing to them, they testified, was the indecision and powerlessness they felt when they witnessed what they considered to be ethically dubious actions of residents or faculty. Fearing their teachers' reprisals - poor evaluations, bad grades, or ridicule - students maintained 'structured silence,' unable either to stop the behavior or to extricate themselves from it. About these failings, they reported extreme guilt.[571]

A doctor in one article asserts that a, "civilizing sensitizing model for postgraduate medical education... can only be achieved if humanity, compassion, and ethical concerns are not considered peripheral subsidiary distractions."[572] From an article in JAMA: "What students therefore need is not more ethical theory but better guidance on how to act ethically in the face of adversity." Learning this art of ethical confrontation would require a style of teaching that emphasizes, "discussions and role playing among small groups of students with a trusted facilitator, allowing students to air their common dilemmas, brainstorm potential solutions, and rehearse how to confront difficult situations."[573] And, perhaps, "Before all else, each of us must take a fundamental risk - to be true to ourselves" - Jim Webb.



[564] Feudtner, C, et al. "Do Clinical Clerks Suffer Ethical Erosion?" Academic Medicine 69(1994):670-679.

[565] Journal of the American Medical Association 266(1991):3422.

[566] Feudtner, C, et al. "Do Clinical Clerks..." Academic Medicine 69(1994):670-679.

[567] Harrison, M. A Woman in Residence New York: Random House, 1982:176.

[568] Zeldow, PB and DC Clark. Letter. Journal of the American Medical Association 261(1989):2066.

[569] Branch, WT. "Professional and Moral Development in Medical Students." Transactions of the American Clinical and Climatological Association 109(1998):218-230.

[570] Jones, TR. "Speak No Evil: Physician Silence in the Face of Professional Impropriety." Journal of the American Medical Association 276(1996):753-754.

[571] Charon, R and RC Fox. "Critiques and Remedies." Journal of the American Medical Association 274(1995):767, 771.

[572] Noonan, WD. "Must an Internship be Miserable?" The Pharos 1995(Summer):19-23.

[573] Feudtner, C, D Christakis and P Schwartz. "Ethics and the Art of Confrontation." Journal of the American Medical Association 276(1996):755-756.



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