Can ethics be taught in a hospital?

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PEDIATRICS Vol. 60 No. 2 August 1977 253

on the concept of a value system and of its development. Withal, we must remain account-able.

It must be better understood that health includes not only the physical but also mental, emotional, and social well-being. This is a redefi-nition that many pediatricians have not yet made and are not willing to. make in terms of their own comfort and anxiety. Such new directions will involve much less Qf the fight against nature and much more of the need to cope with one’s self. Still, there must be forethought. The important must not be supplanted or preempted by the measurable and it must be kept clear that no one discipline has the competence to solve these problems unilaterally.

The compelling theme, however, is that pedia-tricians must examine their future roles. The Academy cannot make them decide the focus, be it the traditional mode of cure or the broader concepts discussed at Wingspread. Certainly, if pediatricians are to become active advocates of the whole child, there must be cohcomitant change in the entire predoctoral and postdoctoral educational system. If the decision is to partici-pate organizationally, then the Academy can define areas of action. The role of an organization is to do just that for those who wish to enter the arena. It cannot, however, mandate that they enter.

Certainly, if there is to be advocacy and a concern for the so-called best interest of the child, pediatricians must be willing to be witnesses at court, and to educate judges, lawyers, and legisla-tors. They must do this for individua’s and for groups, in the community, in the courts, in the hospital, and in the office. If pediatricians can increase their participation and be more broadly available, they might have a unique opportunity to be involved not only in minutely organized particulars and hi personalization but also in a more global effort for the presumed general good. Then, indeed, we might assure that fewer deviant children become deviant adults. Regardless, the

individual pediatrician must come to a personal

conclusion.

HENRY M. SEIDEL, M.D.

The Johns Hopkins University, School of Health Services

Hampton House 105

624 North Broadway

Baltimore, Maryland 21205

The conference, held in Raci#{241}e,Wis., September 24 to 26, 1975, was sponsored by the American Academy of Pediatrics with the support of The Johnson Foundation of Racine, Wis., and the Josephine Kugel Foundation of Omaha.

Participa-tion of faculty members of The Johns Hopkins University was supported by the Lilly Endowment, Inc.

All direct quotations are from the transcript of the conference.

A full report on the conference, “Legal Change for Child Health,” may be obtained by writing the American Academy of Pediatrics, P.O. Box 1034, Evanston, IL 60204. The handling charge is $2.

See NAPS document 03046 for 16 pages of “Legal Change for Child Health: The Report on a Wingspread Conference.” Order from ASIS/NAPS, do Microfiche Publications, 440

Park Avenue South, New York, NY 10016. Remit with order for each NAPS document number $1.50 for microfiche or $5.00 for photocopies for up to 30 pages; and 15 cents per page for each additional page over the first 30 pages. Make checks payable to Microfiche Publications.

Can

ethics

be taught

in a hospital?

No one now doubts that physicians frequently

face difficult ethical questions in the course of medical practice. These questions are often of a

kind that cannot simply be left to await a time when one has greater leisure. Physicians have to act and take responsibility for their decisions, whichever way they decide. Often the ethical decisions are as crucial as the medical ones. Yet most physicians have received no formal training in ethics and many of them have not thought, talked, or read much about the subject either. It is not uncommon for a physician to describe himself as purely a technician, a kind of advanced

plumber who does nothing but respond to

requests from people who come to have defective plumbing put right.

The “technician” approach may be applicable to one or two specialized fields of medicine; it is most certainly not applicable to general practice or to pediatrics. When dealing with young chil-dren, in particular, the physician must take on extra responsibility because the children them-selves are incapable of grasping the implications of medical decisions and parents or guardians cannot automatically be assumed to have the right to decide for their child.

It is therefore appropriate that a program of “Ethics Rounds” has been set up at the Children’s Hospital Medical Center in Boston, and it is useful to have the report of Levine et al. on the

at Viet Nam:AAP Sponsored on September 8, 2020

www.aappublications.org/news

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254 ETHICS

first five years of this program (see page 202). Nevertheless, the report does not resolve the question of whether ethics can be taught in a hospital. The authors present the program in a favorable light and recommend its replication or adaptation for other medical centers, but the evidence of the outcome of the program provided

by the authors does not altogether support this

recommendation.

There are two facts presented by the authors which cast doubt on their recommendation. The first is that a clear majority of those who partici-pated in one ethics session did not return for a second session (a situation somewhat understated by the authors’ remark that of 102 participants “41% were present more than once”). The second is that an even larger majority of participants

stated that the discussions either had no effect on the positions they took on the issues discussed, or merely strengthened the position they had held before the discussion.

In anticipation of these objections the authors state, first, that pressure on physicians’ time made it impossible for them to attend regularly, and, second, that an interdisciplinary forum of this type should seek to “sensitize” participants to the issues rather than to alter their views.

These replies may be enough to rebut any claim that the high dropout rate and limited effect on the attitudes of participants mark the ethics rounds as a failure. The fact that partici-pants themselves generally saw the sessions as helpful is enough to negate that suggestion (unless they were merely being polite). Nevertheless if the ethics rounds were a success, they appear to have been only a moderate success, and so we should consider other and possibly better methods of teaching ethics to medical practitioners.

A clue to the direction in which we might look is provided by the authors’ observation that “College and medical students are particularly responsive to discussions of medical ethics.” While attempts to reach those already in medical practice should certainly be continued, the provi-sion of more and better ethics courses for medical students may prove the most successful means of raising the level of ethical thought and discussion among medical personnel in the long run.

This suggestion is not new. There has been a marked increase in the teaching of medical ethics at American medical schools in recent years. According to a national medical school survey based on reports from 107 schools, the number of faculties with major commitments to medical ethics teaching increased by more than 50% (from

19 to 31) between 1972 and 1976.’ These schools

are still, however, in a minority, and it is to be hoped that the rate of increase does not slacken.

In addition to the greater responsiveness of students to ethical issues, a further reason for concentrating ethical teaching at this level is that it is possible to provide a more thorough and more

solidly based course. My own experience in teaching ethics suggests that the case study approach needs to be supplemented by a more systematic discussion of the nature of ethics and the various ethical theories, like utilitarianism and theories based on rights or justice, from which ethical judgments in particular cases can be derived. It is only to be expected that if one invites discussion of a difficult ethical case, without having previously encouraged one’s audience to reflect on the foundations of their ethical views, most will respond by articulating the opinions they already hold. As the study of Levine et al. indicates, a program of this type cannot expect to achieve much more than the identification and clarification of issues.

Identifying and clarifying issues is worthwhile only if it is part of a larger process of encouraging rational reflection on ethical principles. If people are liable to settle issues on the basis of irrational and indefensible ethical prejudices, they may do as well when they are muddled as when they get the issues clear.

Courses based on case studies alone-or on

contentious ethical issues, like abortion, euthana-sia, human experimentation, and so on-have, in my experience, a tendency to go round in circles. With each issue or case study, the same under-lying questions come up: What is it to make an ethical judgment? Are ethical judgments subjec-live or objective? What are rights? What is justice? Are rights to be respected, no matter what the consequences of so doing, or can benefits to society override individual rights? Without sessions specifically directed to them, these ques-tions are not likely to be discussed adequately; and yet the more concrete issues cannot be settled unless one first makes up one’s mind about the more abstract questions.

Courses in medical ethics, then, need to provide some background in ethical theory as well as the opportunity to examine difficult issues and cases. This raises another point, the qualifica-tions of those teaching the courses. According to the national survey of medical schools, teachers of courses in medical schools come in approximately equal numbers from three groups: physicians, hospital chaplains, and ethicists. Those who come from the first of these groups will, except in rare

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PEDIATRICS Vol. 60 No. 2 August 1977 255

instances, lack the grounding in ethical theory

needed to conduct the kind of course I am advocating. Those from the second group are more likely to have been trained in ethics, but their training is liable to have been slanted in a theological direction. Obviously, theologians have a part to play in medical ethics, but equally obviously, ours is a pluralistic society in which the religious can have no monopoly over areas which

vitally affect nonbelievers as well as believers.

The third group, ethicists or moral philoso-phers-some of whom will be religious and some of whom will not be-consists of those who have qualifications specifically in the study of ethical theory. There is, of course, a danger that they will take too abstract an approach, and be ignorant of the complexities of medical practice. This danger can be overcome if ethicists are given short-term internships in hospitals, or are involved in deci-sion-making processes in hospitals on some other basis.

The ethicist who has had experience in the hospital situation would be well qualified to teach a solid and yet practical course in medical ethics. Perhaps it is this kind of course, led by a profes-sional ethicist with some medical experience, that will prove the the most successful means of education in medical ethics.

Victot*z, Australia

PETER SINGER, B. Phil. Philosophy Department, Monash University

REFERENCE

1. Veatch RM, Sollito 5: Medical ethics teaching: Report of anational medical school survey. JAMA 235:1030, 1976.

The pediatrician and children in

foster

care

There are approximately 330,000 children living in foster care under the auspices of public and private social agencies in the United States. The vast majority-approximately 80%-have come into care because of severe personal and social problems that have afflicted their parents. More often than not, they come from households that are headed by women struggling to survive

on public assistance budgets. Minority children are heavily overrepresented in their ranks.

Parental failure leading to breakup of families is usually related to such personal problems of

adults as mental illness, poor physical health, mental retardation, drug addiction, alcoholism, arrest and imprisonment for deviant behavior, and marital discord. Sizable groups of children come into care because their parents have been judged in court actions to have been guilty of abuse or neglect. Others have been voluntarily surrendered for adoption or have been aban-doned. Overall, this is a most severely deprived sector of the parent population of the United States. Their circumstances are replete with a kind of human misery that is extraordinarily

stark.

Parental breakdown is not always the factor which precipitates the need for placement. In recent years, the foster care system has been increasingly called upon to provide care for youngsters who show an inability to adjust in the

community and whose behavioral problems

appear to be beyond the control of their parents. These children represent the remaining 20% who are in care; they require placement for reasons related to their own manifest difficulties. They often come from intact homes where, neverthe-less, severe family pathology has provided the seeding ground for the emergence of predelin-quent behavior or full-blown delinquent careers.

The pediatrician who encounters foster chil-dren early after their entrance into care will find a fairly high proportion among them whose

medical needs have been grossly neglected. This

is not surprising, considering the severe impover-ishment of the homes from which many foster children originate. While the majority are in good health and have somehow managed to overcome the most blatant kind of parental neglect-proof of the remarkable durability of many children in the face of adversity-careful physical screening is required to bring to the fore unmet medical needs that require remedial attention. Many of the children have never been seen by a dentist, had their eyes examined, or received a complete physical checkup. Becoming the ward of a social agency offers the child an opportunity to receive

high-quality medical attention, something not

available to many of the children in their home neighborhoods.

In addition to providing service in the area of physical health, the pediatrician has an important role to play with respect to the child’s emotional needs. Many of the children entering foster care have been traumatized at the hands of neglectful

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1977;60;253

Pediatrics

Peter Singer