# Are Doctors Qualified in Medical Ethics?

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At many universities and on various hospital ethical committees, you will find that the resident 'medical ethicists,' who have to have an extremely sophisticated understanding of the legal, philosophical, psychological, and social issues involved in the ethical problems arising in medicine, have training only in medicine. While they may have the technical expertise from their training to know what can be done and what can't be done with the available medical technology, it is typically the case that years of purely technical training -- memorizing biochemic pathways rather than thinking creatively, devoting all their energies to competing fanatically to get into medical school when other undergraduates were busy growing up; and then thinking they know everything about medical ethics because they have extensive experience in the arrogant, uncritical, careless way ethical issues are dealt with in hospitals and clinics -- have combined to make them utterly naive with respect to sophisticated ethical decisionmaking.

Asking a doctor to give advice on medical ethics is like asking an electrician who should be executed for murder at a criminal trial, since after all, the electrician knows more than the judge and jury do about how the electric chair works.

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Doctors also understand better than anyone the risks, benefits, and costs of medical treatment. A professional ethicist won't know the risks of a particular surgery and can't make a good decision.

Incidentally, most medical schools require students to take medical ethics courses.

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At many universities and on various hospital ethical committees, you will find that the resident 'medical ethicists,' who have to have an extremely sophisticated understanding of the legal, philosophical, psychological, and social issues involved in the ethical problems arising in medicine, have training only in medicine. While they may have the technical expertise from their training to know what can be done and what can't be done with the available medical technology, it is typically the case that years of purely technical training -- memorizing biochemic pathways rather than thinking creatively, devoting all their energies to competing fanatically to get into medical school when other undergraduates were busy growing up; and then thinking they know everything about medical ethics because they have extensive experience in the arrogant, uncritical, careless way ethical issues are dealt with in hospitals and clinics -- have combined to make them utterly naive with respect to sophisticated ethical decisionmaking.

Asking a doctor to give advice on medical ethics is like asking an electrician who should be executed for murder at a criminal trial, since after all, the electrician knows more than the judge and jury do about how the electric chair works.

Unless the medical doctor is affiliated with the religion or beliefs (such as the person being a priest, shaman, etc..) of the person having surgery done on, then I'm going to have to say no. You cannot find too many religious figures who are also licensed medical doctors. That would involve a lot of schooling and study.

And yes, the system is corrupt, Marat. Unfortunately, not enough people are intelligent enough to actually take note of that. It would appear that many professionals are booknerds. In the U.S., you can blame the American Medical Association for most problems with the medical community.

Edited by Genecks

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At many universities and on various hospital ethical committees, you will find that the resident 'medical ethicists,' who have to have an extremely sophisticated understanding of the legal, philosophical, psychological, and social issues involved in the ethical problems arising in medicine, have training only in medicine.

Must one have a PhD. in philosophy and ethics to know the difference between right and wrong? I think not. A doctor might not be formally trained, but I bet they more than anyone realize the consequences of their actions, and can decided what the right thing to do is. Also as Capn said I believe that most medical programs either require a course in medical ethics, or definitely go over the topic through out their program.

it is typically the case that years of purely technical training -- memorizing biochemic pathways rather than thinking creatively, devoting all their energies to competing fanatically to get into medical school when other undergraduates were busy growing up;

How does creative thinking have anything to do with thinking ethical? Sure doctors are required to know many different thinks, but there is a good reason why they are required to know how these things. Personally I would rather have my doctor be able to recognize why two medications would be a bad combination because of there pathways rather than being able to "think creatively". I think that the competition and the discipline required of pre-med students definitely forces them to grow up.

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While most medical schools offer courses in medical ethics, they are philosophically primitive to say the least, relying completely on such simple, introductory texts as Beauchamp's or Gillon's and nothing more, for example. Even then, they are usually elective courses, and in the high-pressured environment of medical school, no rational student can afford to waste ten seconds of time on an optional course.

Of course a medical ethicist should know the technical aspects of the medical issue he or she is dealing with, and most of them do. The same is true with courts which have to deal with such issues, for which the judges rely on expert medical advisors or testimony. But while humanistically trained medical ethicists and judges can be helped to understand the technical issues involved, purely technically trained physicians seem never to be able to summon the subtle skills of humanistic judgment required to deal with problems in medical ethics in any sophisticated way.

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Still why must someone be a trained ethicist to know the difference between right and wrong? Yes, at times a doctor might find an issue, which they cannot resolve the right decision, but that would be a time where they can seek advice from others.

As an aside do you see a epidemic issue of doctors making unethical decisions? I for one certainly don't. There are bad doctors, just like there are bad cops or judges, but the majority of doctors I have meet make ethical decisions in the best interest of their patients.

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As an aside do you see a epidemic issue of doctors making unethical decisions? I for one certainly don't.

I do, in the form of unnecessary extra tests, performed more for covering their own ass from being sued on the slim chance that the test actually turned out to be necessary, than concern for the patient's well-being. Tests which might slightly harm the patient, as well as his wallet, and also waste the patient's time and that of other medical staff.

Not that I can blame them, given the way patients have been throwing malpractice lawsuits at them if something does go wrong.

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I do, in the form of unnecessary extra tests, performed more for covering their own ass from being sued on the slim chance that the test actually turned out to be necessary, than concern for the patient's well-being. Tests which might slightly harm the patient, as well as his wallet, and also waste the patient's time and that of other medical staff.

Not that I can blame them, given the way patients have been throwing malpractice lawsuits at them if something does go wrong.

I would not call the doctors decision to order extra, and at times unnecessary tests shows is an unethical decision. They are only doing so because the consequences of them missing something are enormous for both themselves and their patients.

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I worked at a dialysis clinic for a number of years where I saw a woman in her 80s brought in from the nursing home three times a week for treatments which caused her to scream her lungs out. She was utterly senile and had no idea what was happening to her or why, but the 'wise doctors' had decided for her that it was their medical duty to keep her alive by continuing the treatments. At that same clinic, a very bright 18-year-old girl was told by the transplant supervisor that she would not be put on the waiting list for a transplant because in the utterly subjective opinion of the supervisor, "You don't seem mature enough." This turned out to be a death sentence for the girl, who had severe hypotension on dialysis, but no criminal charge could be brought, because doctors get to play god, as everyone knows. When working in another clinic I saw an old man weeping after both of his feet had been amputated. The attending physician screamed at him that "We have given you enough morphine to kill a horse, so what are you crying about?!" The old patient said, "It's not the pain," to which the wise and kindly doctor replied, "Then what the f- are you crying about?" The notion that someone might weep on waking up to find himself without feet could not get through the thick skull of someone who had been nothing but a technocrat with no human or humanistic skill-development all his life.

For anyone who needs any more convincing that physicians know nothing about medical ethics, I have ten thousand more stories like that from my personal experience. You can read similar cases in Mendelsohn's book, 'Confessions of a Medical Heretic.'

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The plural of "anecdote" is "anecdotes," not "evidence."

And even if true, it would only enforce that they are good and bad doctors. Big surprise.

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I think you can legitimately infer from the extreme lack of moral sensitivity among physicians in the examples I cite that the average degree of ethical insight for the entire group is fairly low. This should not be surprising, given their education from a very early age in purely technological rather than humanistic matters. I once took a course from a British institution which gives degrees in medical ethics primarily for physicians, and the intellectual level in that group was astonishingly low. As a foreign student at a German medical faculty in the 1980s, I was surprised to find that the medical ethics course had only four students instead of the 300 who were usually present at the hard science courses. I then noticed that all the other students in the medical ethics class were, like me, foreigners, and that we had all made the same 'mistake,' which was to attend a non-required course.

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At many universities and on various hospital ethical committees, you will find that the resident 'medical ethicists,' who have to have an extremely sophisticated understanding of the legal, philosophical, psychological, and social issues involved in the ethical problems arising in medicine, have training only in medicine. While they may have the technical expertise from their training to know what can be done and what can't be done with the available medical technology, it is typically the case that years of purely technical training -- memorizing biochemic pathways rather than thinking creatively, devoting all their energies to competing fanatically to get into medical school when other undergraduates were busy growing up; and then thinking they know everything about medical ethics because they have extensive experience in the arrogant, uncritical, careless way ethical issues are dealt with in hospitals and clinics -- have combined to make them utterly naive with respect to sophisticated ethical decisionmaking.

First let me say that I am a physician, so I do have person experience with ethics committees, ethical issues in medicine, being utterly naive with respect to "sophisticated decision making", competing fanatically to get into medical school and not "growing up" in the process, being wholly uncreative, and hating human beings in general (as evidenced by your anecdotes which most certainly represent all physicians).

Many ethical committees, including the one at my own training university / hospital system, are composed of multidisciplinary teams which include a physician, nurse, chaplain, lawyer, somebody specifically trained in medical ethics, and often times a member of the community; plus or minus other disciplines which are situation dependent. If a case actually goes before an ethics committee, it is discussed by this multidisciplinary team and any recommendations or advisories that come from the committee represent the collective opinion of these members, not the point of view of the physician on the committee. That being said, ethical committees are generally considered fairly toothless. In my personal experience, and in the experience of many of those I work with, they rarely come out with a clear answer to a proposed question. And at the end of the day, after all the philosophizing is over with, a physician still has to write the order and is wholly liable for the decision made, regardless of the ethics committee position. Thus, the system is set up such that a physician will always act in what he or she feels is the best decision.

And in the United States, the best decision for the physician is heavily influenced by family wishes happen to be. I currently work in the medical intensive care unit, which as I'm sure you are aware, involves treating very sick individuals usually with life-sustaining treatments. Recently I cared for a young lady with end-stage liver disease. She was intubated, unresponsive, her blood is so thin that she is bleeding from her eyes, her ears, her vagina and rectum, the capillaries in her skin are leaking blood, every mucous membrane in her body is oozing blood. She requires blood transfusions twice a day. Her blood pressure is so low that we have to use medications to augment her blood pressure -- were we to stop them she would die. We are pouring fluid into her to help keep her blood pressure up, but the fluid leaks out of her blood vessels into her tissues because she's lost all of the oncotic pressure (the liver is responsible for many of the proteins which maintain this pressure). This means that she was swollen up like a water balloon. Even her conjunctiva was edematous. She had a raging bacterial blood infection because her gallbladder was necrotic. Her pancreas had already failed. Her liver had failed. Her lungs had failed. Her kidneys were beginning to fail -- it was multisystem organ failure and there was no way she was going to survive. Yet the family firmly believed she would walk out of the ICU one day. And for this reason they wanted us to dialyze her.

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The senile old woman at the dialysis clinic I was discussing had no living relatives and was being kept alive by orders of the chief of nephrology, who at 65 was still the champion of making the fastest rounds of anyone on staff. This was because the payment schedule gave each nephrologist \$60 per patient visited, and the only way to increase hourly rates was to see as many patients as possible per hour. He was so bad at rushing past patients in desperate need of a consultation that the nurses used to interpose themselves in front of him to prevent him walking away from patients without answering their questions. During rounds the clinic looked more like a football blocking practice session than an exercise in renal medicine.

I am sorry to hear that such a thing has occurred, but I would like to point out what Blike and Swansont said:

As to your anecdotes, they are merely that: anecdotes. For every one you can produce about some physician who knew nothing about human emotion and human suffering, I can produce three anecdotes of the opposite. I, and most other physicians, have cried for and with my patients. We are humans too.

The plural of "anecdote" is "anecdotes," not "evidence."

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My general point is basically the one I stated at the outset: It is an arbitrary assumption that just because someone has training and experience in medical technology, he must also know all about medical ethics. It is just like leaving the decision to execute someone by electrocution to an electrician rather than to a judge and jury: the technical dimension simply has nothing to do with the ethical dimension. Of course a medical ethicist should have some basic knowledge of medicine or access to a medical advisor on certain technical points, such as whether certain conjoined twins can safely be separated (as in the case of (Re A (Children) House of Lords, 2000), but the focus of expertise on these matters should be on ethics, not on medicine.

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I think the other point you're missing is that, just because someone does something wrong, doesn't mean they didn't know it's wrong. Do you seriously believe that the nephrologist in your story doesn't know that what he's doing is wrong? You'd think he'd notice what with the nurses blocking his exit. It's wrong and everyone knows it; the trouble is that their payment system is also wrong.

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Blike, at any point does a physician have a duty to step in, and stop family members from demanding or withholding treatment? If they do is do they really have an course of action in this matter?

In my opinion the only time a physician has the duty to do so is when the physician knows and has documentation that said treatment is against the wishes of the patient, or in the case of withholding treatment from children. These are the only two circumstances I have ever seen physicians act against the wishes of a family. And believe it or not, even in the case of children, it usually goes through ethics committee channels first. Physicians rarely act solo on these matters unless its an urgent decision.

I worked at a dialysis clinic for a number of years where I saw a woman in her 80s brought in from the nursing home three times a week for treatments which caused her to scream her lungs out.
The senile old woman at the dialysis clinic I was discussing had no living relatives and was being kept alive by orders of the chief of nephrology

And there is the missing piece of the puzzle. A senile woman is not competent to make her own medical decision, and since she has no living relatives, there is no one to make the decision to stop using the life-saving intervention. You would be hard pressed to find a physician who would actively stop this life-sustaining treatment just because it was uncomfortable for her. That is very shaky grounds. There is also the question of whether or not she chose to start dialysis while she was competent, or whether or not some relative at some point made the decision to start dialysis. In that case, the physician may be ethically obligated to keep providing treatments.

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I saw this topic when it was first posted but meandered on by since it seemed to me like a thinly disguised doctor bashing thread and while I might have gleefully participated 10 to 5 years ago on some days back when I used to work in the medical field, time has tempered such thoughts and emotions. But it is the last day of my vacation and I am feeling deeply philosophical this afternoon and since I cannot post in either the ethics or philosophy forums on this site yet, I feel like my raison d'être at this moment, at this time, is to post on this thread in order to contribute to the discussion at hand since I do have a different perspective based on a unique experience with regard to the OP.

I used to work as a CNA III back in the day when I was under the very misguided notion that I thought I wanted to be a nurse and as cardiovascular technician when I came to my senses. (Nothing against nurses by any stretch of the imagination, they are gems, just not for me and I had the self-awareness to recognize this.) I can somewhat empathize with Marat to a point, as far as dealing with the arrogance of some doctors but I think that this is the exception rather than the rule and so don't fall prey to broad sweeping generalizations. The negative experiences was usually with first year residents, who would be rotating services in the hospital that I worked and were going into the field of something like podiatry and would dismiss my EKG and patient care assessments despite being taught in my spare time by the department head of arrhythmia (I think that he was just delighted about my desire and enthusiasm to learn, so we would sometimes lunch together and I would just soak up everything he said.) and the three years that I worked in that department. So I do have 5 years of experience of working in the medical field and can come at this discussion from that particular perspective.

Somewhere during this time, my late husband developed profound heart failure due to a congenital birth defect (transposition of the great vessels) and a Mustard procedure. (A little background info...Mustard procedures used to be standard procedure for correction for a relatively brief amount of time, now they correct the problem at birth. A Mustard procedure is where they reroute the blood so that the left ventricle becomes pulmonary and right becomes systemic). Since he wasn't a good candidate for a heart transplant due to the amount blood transfusions he had over the years, it was thought that the Mustard procedure cold be reverse, by a doctor who had only done it unsuccessfully once, but Mustard procedures were rare and the only other option was to move to Chicago away from the support of our families to attempt the reversal by a doctor who had to successfully done it twice. We opted to stay and have the doctor who had not yet done it successfully due it as he seemed to be an excellent doctor with an excellent reputation (he did do the arterial switch in babies all of the time).

Anyway, to try to make a long story short, after a series of two bandings on the pulmonary artery to develop the strength of the left ventricle, the main procedure to perform the switch. The switch itself was a success, but the right ventricle was struggling from the shock of the surgery and we were having a rough time weening him off of the ventilator. On day 5 after the surgery, I noticed some black stuff in his vent tubing. I mentioned it to the nurse and she said she would let the respiratory know. 3 days later I am becoming convinced that it doesn't look like he hasn't been bathed, even though the nurse checked the assessment sheet in the computer and it had been signed off as complete, and I could have sworn I was looking at the same black stuff in his tubing that I had noticed prior, even though the nurse it was signed as being changed.

Frustrated, I went and dragged director of nursing (did I mention that this was the same hospital I had worked at eight months but had quit because I had gone back to school for massage therapy out of frustration with the general assembly line approach that I felt specialized healthcare had become? The director was a friend.) So we bathed him, changed his tubing, (during the bath we noticed a decub the size of a dime) and the director of nursing in the ICU assured me and his parents that his care would improve. During this time, my husband is still as lucid as one would could be on a fentanyl drip, but that weekend I noticed a definite deterioration in his mental state as well as a decrease in body temperature (some people may know where this is going.) I let the nurse know, who was one of the hospital's PRN floaters, and she said that she had just given him pain meds. I asked for a chest x-ray to be ordered, she said she would let the DOD know of my concern when they did their rounds in the morning and then I was hustled out because visiting hours were over even though visiting hours never applied to me before since I used to work there and a couple of the staff knew me.

Frustrated, I managed to chase down one of the residents I had a good working relationship with (several hours later), who ordered a chest x-ray and yes he had pneumonia, he was in septic shock and he had lost his kidneys. When the pneumonia cleared up, he was diagnosed with ARDS. (And he was still classified as alert and oriented. He communicated through writing.)

5 months later, multiple nosocomial infections, a couple of surgeries, tearful consultations with the surgical attending, any DOD at the time his bowel finally died and the decision to take him of the vent was made. It was that or have him undergo another surgery that didn't look like it do much benefit. We opted for the former. The family was called, everyone said their good-byes, he was taken off of the ventilator, and DOD who had all of the personal warmth of a turnip (he was going into plastics) but had the good moral judgement to give the order for enough morphine to kill him. I am very grateful to that doctor for not dragging it out.

So back to the Op I think that if you are going to make a case for the established presence of a medical ethicist than really it shouldn't just be there for the doctors but for the entire healthcare staff.

I feel like I should also include that the hospital during this time was short staffed due to the high turnover after the staff's increase in co-payments and health insurance. And it was much cheaper to hire PRN nurses who wouldn't demand decent healthcare coverage. I also feel like I should mention that three years later there was a class action suit against the hospital by the employees, since the hospital had investments in the insurance company that we were forced to be provided. I had cobra-ed my insurance so we still had it at the time my late husband was hospitalized. So the medical bills that I couldn't afford to pay were settled out of court through the class action suit that I barely remembered signing during the second year that I worked their. I almost believed in the bastardized westernized version of karma on that day, I tell you; almost, but not quite.

So I am really not sure what the benefit would be to have medical ethicists involved except to create more paperwork and to give someone a job who wanted to be a medical ethicist. I dunno? Maybe they could teach a continuing education class that healthcare workers would be required to take? But I think they have to do this already? Except the class would be led a medical ethicist rather than what someone could be classified as a peer.

Anyway, I suspect the problem with healthcare has become systemic and so there no real one-size fits all solution.

Just my 2¢.