Program in Bioethics and Humanities

  • Course Reflections 

     Word Cloud

    Anonymous Student Reflections

     This cloud of words gives a suggestive snapshot of the values, ethics, and concerns raised by students in their reflections at the end of the 2013 Bioethics and Humanities Seminar at the Carver College of Medicine.  Below are some insightful (and anonymous) excerpts from their reflections which they have kindly agreed to share.

    AVOIDING CYNICISM 

     “I don’t want to be cynical or skeptical or jaded already….  I want to consciously develop my own voice in medicine – one which is ethical and moral and aligns with not only the way I was raised, but also is congruous with the way I want to practice medicine.”  

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     LEARNING HUMILITY 

    “There has been an underlying theme throughout that seems to me to represent that most valuable ethical trait and important ethical lesson: humility. This concept first occurred to me during our discussion of cultural sensitivity. I wanted so badly to create for myself a set of rules by which I could act consistently and without self-doubt and I was certain that my goal was achievable with a reasonable amount of foresight and consideration. However, through the rhetoric of class discussion, I found myself increasingly frustrated at my inability to create a “catch-all” code. I was, in fact, being humbled by my own desire to behave ethically. I was being forced to recognize the significance of specific circumstances in ethical decision making and reluctantly letting go of my previous belief that with that appropriate set of guidelines, I would always be able to do the “right” thing.”

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     WHICH ETHICAL VALUES WILL I FOLLOW? 

    “The idea of a hidden value system frankly puts me on edge; I don’t relish the idea of being remolded and changed by an unacknowledged force. How am I to be a moral and ethical being if my morals and ethics are chosen for me by my profession? Or, to reflect on Veatch’s article, which authority comes first? Professional? Religious? Cultural? Personal? …. Altruism is explicitly valued, yet the workload and schedule is such that it is almost impossible to be anything but selfish if one hopes to get through it all, let alone be at the top of the class. How is that ethical? How is it possible that explicit and implicit values are allowed to be so contradictory?”

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     HOW DO WE DEAL WITH THE HIDDEN CURRICULUM? 

    “New research comes out all the time that doctors are more depressed, stressed, and disillusioned with the medical profession than ever before, and recently I have been prone to doubts about my chosen career path. Our discussions on the hidden curriculum helped clarify the source of this trend, and offered potential solutions which I may attempt to utilize when on rotations in order to counteract the cognitive dissonance which the hidden curriculum reinforces. For example, we have often been told of the importance of establishing a strong relationship with a patient and of performing a comprehensive physical exam with no mention of the time, money, and paperwork pressure that will prevent us from being thorough and effective practitioners. The explicit values prevent us from openly acknowledging the tension between altruism and self-interest….

    What especially stood out to me in the Coulehan article was the assertion that medical students and professionals relieve the conflict between tacit and explicit values by adopting a professional identity in which one unconsciously bases their behavior on tacit values while convincing themselves they are acting out explicit values. This is a classic response to cognitive dissonance, and one which may prove impossible to avoid when hospital requirements overpower altruistic intentions. I hope to develop the compassionate professional identity Coulehan describes, one in which I embody a reflective professional identity, though I imagine this will be a lifelong struggle which will require effort to maintain in the midst of external agendas by for-profit institutions.”

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     WHERE SHOULD ETHICS BE IN THE MEDICAL CURRICULUM?

    “What is the role of medical education in biomedical ethics? What can it be? What should it be? Is a school responsible for instilling ethical values and behavior in its students? If so, how? Should we all be required to read ethical theory and write papers? Should ethical instruction be entrusted to the “hidden curriculum?” I think we focused on these questions in part because we are in a very classroom-oriented phase of our education and we have a difficult time seeing how sincere coursework in ethics could be shoe-horned into our science-and-clinical-skills-heavy curriculum. On the other hand, a more modest incorporation of ethical instruction might come off as lip service. As a group I think we were perplexed by this problem – we affirm the importance of ethical thinking but are unsure when or how health care trainees might best learn and practice it. This seminar has been excellent practice for a handful of us, but what about the rest of our class? Do they already have it figured out?”

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     THE STRUGGLE BETWEEN HUMANISM AND EFFICIENCY IN MEDICAL SCHOOL 

    “I enjoyed participating in this course as it addressed many of the difficulties and problems I have encountered with the medical school education philosophy. From our beginnings as pre-medical students, we sought to enter medical school via excellent grades and test scores, volunteering opportunities, student leadership positions, various shadowing encounters, and other facets that made us into well-rounded individuals: excellent candidates to become future physicians. Once admitted to medical school, many of those opportunities still exist for our participation, but there is overall less attention or effort directed towards remaining well-rounded as a medical student. Yes, there is less time and more material to learn, but is that really the reason for less humanistic involvement? It seems the hidden curriculum began to take effect after we received our acceptance letters.

    I have had many conversations with fellow students experiencing the hidden curriculum and our struggles to define ourselves through medical school. There is an overall feeling that one should not lose themselves in the process, but the process definitely changes you. The system may undervalue many characteristics that would make great physicians, and in general it seems to have dissected away our former humanistic inclinations in favor of efficiency.

    My fear is that as we continue with our education, the hidden curriculum may continue to shape our individual virtues, our decisions, or our lack of moral reflection.

    I do not want to become like Tolstoy’s Ivan Ilych, who sometimes experienced ethical discord with what was expected of him, and chose to conform to the standards of others rather than truly living according to his personal virtues:

     At school he had done things which had formerly seemed to him very horrid and made him feel disgusted with himself when he did them; but when later on he saw that such actions were done by people of good position and that they did not regard them as wrong, he was able not exactly to regard them as right, but to forget about them entirely or not be at all troubled at remembering them. (Tolstoy: The Death of Ivan Ilych)"

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     ADDRESSING THE BIOLOGICAL AND SPIRITUAL NEEDS OF PATIENTS

    “Another theme that formed a framework for much of our discussions was the role of the physician both in society and in the patient-physician relationship. Our discussion of Tolstoy’s The Death of Ivan Ilych hit on many points related to this theme that I believe will be very meaningful to my future career. The physician acted mostly in the biophysical realm of medicine in the story and did not address the psychosocial or spiritual needs of Ivan Ilych. In this regard, the physician was focused on a definable, measurable outcome--the time at which Ivan Ilych would expire. I strongly believe that doctors must take into account these other realms of life and adjust their practice to reflect reality. Though we do not have to perform the duties of, for example, a social worker, we must be cognizant of the vital role they can play in managing a person’s care. By removing ourselves from focusing on outcomes (the biophysical realm), we can begin to appreciate our role in validating the significance of the journey through life.”

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     RECKONING WITH UNCERTAINTY 

    “I think the training and culture of medicine does impart a sense of confidence in self or in medical sciences that does not leave room for uncertainty in when and how to treat, and a large part of bioethics is reintroducing this uncertainty. I realized during the course that teaching ethics to physicians is partially a task of teaching acceptance and comfort in uncertainty. The articles on approaches to narrative ethics and virtue ethics all attempt to address the problem of how to comprehend and accept uncertainty. I think the virtues approach to ethics is a way to connect the physician to a value system that is not based in evidence, and in effect forcing physicians to consider that value systems differ between individuals. Basing ethical arguments from a value system stages a discussion based on beliefs, which acknowledge that there is uncertainty between the parties – because beliefs are unique to each individual. The narrative approach expands on this and forces physicians to approach patient-based care by using narrative to place the physician into the context of a patient’s beliefs and understanding of their experience. The class discussion highlighted that narrative ethics can be taken to its negative extreme in stereotyping, but at its core it provides a means of engaging with the patient and replacing physician uncertainty with some degree of understanding. Narrative as a way to insight and understanding of others’ experiences can be clearly seen in Tolstoy’s The Death of Ivan Ilych. It’s this uncertainty that fuels this continuous consideration and dialog between parties that leads to ethical behavior. This uncertainty does not invalidate chosen answers to ethical questions, but it creates a responsibility to continue evaluating and reassessing the ethics of the current answer.”

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