Ethics and moral reflection of the medical student

Intervention in the roundtable Ethics and morals in the current practice of Medicine.
School University of Medicine, University of Alicante, 25 January 1996.

Greetings and thanks.

Introduction

Sometimes we lecturers take some liberties: we are invited to speak on one subject topic and we deal with another. I have been offered the one on Ethics and morality in the current practice of medicine. It is extremely complex. And as I have been told not to speak for more than 20 minutes, better less than more, as people are more inclined to ask questions than to listen to long speeches, I have decided to say two or three things about it, tell a story, and thus give rise to the desired questions and answers, which, God willing, will be accurate and satisfactory.

For some, ethics and morality are and mean the same thing. The two terms, one of Greek and the other of Latin origin, refer to reflection on the right conduct of people, to determining what is good and what is bad. The DRAE says of ethics that it is the part of Philosophy that deals with the morals and obligations of man. It says of morality that it is the science that deals with the good in general, and with human actions in order of their goodness or badness. For these ethics and morals are the same thing.

For others, this is not the case. For them, morality is not the same as ethics. Morality is a set of principles and values, a conception of life and the world, which must be professed and practised in order to lead a dignified and good life. They tend to equate morality with religion or substitutes for religion. And by ethics they mean rather an academic exercise, the art of arguing philosophically about questions of principles and values to be professed and practised, such as whether it is possible to justify such conduct or its opposite. Just as morality tends to be singular, i.e. universal, believed and accepted by all, so ethics are plural, forming parties, groups of opinion, trends, such as utilitarianism, consequentialism, relativism, emotionalism, deontologism, and so on.

In recent decades, and still today, morality has been persecuted and discredited. When someone proposed that the right way to proceed in such and such a circumstance was this or that, they were told to take their moralizing elsewhere, they were branded as cavemen, archaizers or pontificating pedagogues, and were ignored. Today, as we can see, society is strongly de-moralised. And today we are witnessing a prodigious proliferation of changing ethics, of fashions that pass and are replaced by others. A French author has just published a book graduate La valse des éthiques. He says that the points of reference letter have disappeared, the duties have vanished, that we inherit the void. Morality seems to be absent. In its place, ethics are being talked about all the time.

Where do we stand? I leave the semantic issue, whether ethics or morality, there. We could spend hours discussing whether it is possible to live without principles to which one can be faithful, whether there is an order goal that must mark the relations of some people with others, with animals, with nature and with things. Or if it is preferable to take advantage of what is most convenient at any given moment, or if money and things are worth more than people, if people can be classified into different categories, so that there are some lives that are respectable and worth living and others that lack this fundamental dignity and can be eliminated.

I am inclined to think with the former that ethics and morality mean the same thing and that they are two words that can be interchanged. Since ethics is more popular than morals, I will go with the flow of time. Whenever I say ethical or ethics I will be referring to that interlocking set of principles and values that must be professed and practised constantly and sincerely in order to lead a good and dignified life. I will not mean that it is impossible to know what is good, that it is all the same as long as one has good intentions, that no one can boast of having found the truth. I slowly read through John Paul II's Veritatis splendor. And I think it is a wonderful denunciation of the insincerity, the scepticism of the soft ethics that are so dominant in post-modern society.

This is the end of the introduction.

Learning to ask questions

What I want to say now, what I want to say before I run out of twenty minutes, is that medicine is an intrinsically ethical activity. I think that one of the reasons that led almost all of us to take up the risky profession of medicine was the aspiration to do a specific good: to serve the sick in that scientific, professional and humane way that is the practice of medicine.

But is this still valid? contact The initial illusion, with the long preclinical period, with hardly any contact with the patients, tends to be forgotten. After a few years of studying medicine and watching professors and doctors behave, many students come to the conclusion that the only thing that really matters is efficiency, mastery of the molecular and pathophysiological, having a clear idea of how the machinery of the body works. It is above all about obsessively remembering what they can ask at spanish medical residency program. Because of the effect of spanish medical residency program, one tends less to understand and think than to memorise; one does not see the world of medicine as a universe of problems, but as a recipe book of solutions; one prefers simply to retain data to answer them in the exam, not to learn how to look them up and use them in life.

Over the years, the vocation is forgotten and, with it, the idea that we are here to help the sick with that wonderfully living science, as clear-minded people, but at the same time and with the same intensity, as people sensitive to human needs, to the needy and sometimes overshadowed dignity of the sick.

Medicine is, by its very nature, a moral task, a matter of human relationships. The doctor does not only deal with data from laboratory, with diagnostic imaging techniques, with books: he deals, first of all, with sick men and women. He has to be a specialised and competent expert in diagnosing and repairing the malfunctions caused by illness. But he also needs to be an expert in humanity who knows how to respect the uniqueness of each individual, his integrity staff. financial aid his patient by treating his illness, and, when necessary, by treating also the man who suffers from it.

This is the root of medical ethics. In order to fully assume one's responsibility and face up to problems that are sometimes - not always, of course - fraught with tremendous dilemmas, it is not enough for the doctor to have intuition or that sort of primary instinct, made up of good intentions and a medical sense of smell, that desire to follow the customs of medicine in general. It is necessary, then, for the doctor to stop and think, and to be able to articulate, before himself, a rational basis for his actions.

It is a pity that little or no medical ethics is studied at degree program, that little or no importance is attached to it. Because there seems to be a close correlation between what one will be ethically as a doctor and what one already is ethically as a student. It has been said, humorously and truthfully, that medical students are a population of undifferentiated yatroblasts, acquiring, throughout the stages of their maturation period at School and in the decisive years of their specialised training , the skills and attitudes, capacities and commitments of the profession. And although most moral psychologists think, with Kohlberg, that ethical differentiation, the moral personality, is almost fully forged by the time medical students enter university, and that they cannot be expected to undergo, apart from the infrequent cases of moral conversion - today is the feast of the Conversion of St. Paul - profound changes in their ethical character, profound changes in their ethical character, I think that university age is a formidable time for moral maturation, for strengthening our attitudes, making them richer and more conscious, in order to oppose the ever-present danger of our conscience becoming calloused. It is always possible to sharpen one's conscience in analysis and reflection, in acquiring and maintaining the wonderful habit of recognising and rectifying one's mistakes.

After every mistake, and it is inevitable to make them from time to time, it is not enough to carry on as if nothing had happened. Every blunder a doctor makes requires, even if no one has warned him or her, that he or she stops to reflect, to identify the circumstances that led to it, to study the procedures to ensure that it does not happen again. If the error was manifest, he must also ask the patient's forgiveness. This is the only way to lead a healthy moral life, not to become a hypocritical cynic. That is ethics or morality, something very practical, which makes our life more conscious, more deliberate, more chosen.

For this, it is essential to care for, educate and keep conscience alive and awake. By conscience we can understand the immediate, intuitive, almost visceral capacity to judge the morality of our actions; the privileged gift of knowing, as we go along, as we act, whether our actions and the motives that drive us to act are right or wrong. result This is a great thing, which serves us in ordinary life on condition that this judgement of conscience is the result of a correct training, of a serious reflection, made some time ago, and repeated through application to new and old situations, until it becomes a stable habit, a virtue. The same happens with clinical habits: the good cardiologist no longer has to auscultate tone by tone, analysing every sound and every silence, as the student does: he listens and interprets auscultation as a whole that responds to specific diagnostic patterns. It is not enough to be guided by the ethical "prompt", which may be the result of obfuscation, laziness, prejudice, or unpremeditation, like the student who wants to imitate the seasoned cardiologist and makes a foolish judgement after listening to average a dozen heartbeats: there is subaortic stenosis here. Ethical conscience develops at the pace and to the extent that one questions oneself, stubbornly asks oneself questions, and stubbornly seeks answers to these questions. That is why moral life depends on how awake our conscience is, on our capacity to discover nuances, to ask ourselves questions. Ethical reflection is not a matter for philosophers or experts: it concerns us all. Ethics is as consubstantial to medicine as science itself. This is an intrinsically ethical business .

A story to reflect on

I repeat once again: we must learn to ask ourselves questions. That is how we will find the answers. In the seminars, we always study ethical cases. The most important thing is that before the seminar each one has identified on his own the significant data , put them in order and try to formulate the problem(s) that the case presents. We do a kind of ethical "autopsy" on the case. This financial aid so that each student can more or less determine the level of his ethical sensitivity: he only has to compare the list of data and ethical questions that he had prepared and the one that, among all, we have put on the table.

This is the case with which I started this year's classes. It is taken from JAMA 1985;254:3314. It is entitled From the Bridge, and it reads:

One very busy Saturday work, late one night, almost at midnight, during my placement in the emergency department, a young woman was brought in who had tried to commit suicide. She had cut her radial artery. We put a tourniquet on her, cannulated a vein, started her on saline and, as soon as we had her haematocrit, we transfused her blood. Once she was stabilised, the surgical resident came in and I helped her suture the separated ends of the artery.

I was devastated as I helped, because I could see the despondency and hopelessness in the face and eyes of this young woman. Every now and then, she would burst into tears and say that life sucks, that it's not worth living. I imagined that she had had a bad heartbreak or something terrible, and that was why she had decided to end her life. The resident suddenly said to her: "Next time, why don't you jump on the train? And now stop whining, it's annoying me". When I heard that, I think I was as devastated or even more devastated than the patient: I couldn't open my mouth.

The resident finished the artery repair, which he did with great skill skill, and left without saying a word to the woman. I tried to console her, and also told her to understand, that the man was exhausted, that he had had too much work, and that he was like this because a patient had just died. But that he hadn't really meant what he said. She seemed to understand.

When I later told the resident about this, he told me that who was I to correct him, that he had believed me: that yes, he had said what he had said to purpose, and that he had no regrets. That there was no right for him to have to waste his talents on fixing people who were so busy ending their lives, and that he didn't even know how to do that well. He told me that it was a shame that there were people who felt desperate, who were floundering through life, and who saw death as the only escape from their problems. I could not move his convictions one iota. When, the next day, I discussed all this with the head of department, the incident did not seem to interest him in the least.

The resident violated the Hippocratic injunction to first do no harm. But why did he do it? Is he so self-centred and insensitive that he doesn't give a damn about the suffering of others? Was he so exhausted and emotionally drained that the woman's crying finally got on his nerves? I don't know why he did it. Will I too one day be incapable of understanding pain like that woman's and offend my patients at purpose ?

Reflections

This is the end of the story. The student of our story closes it with a series of questions. That is the essence of it. That is the secret of ethical growth. He asked himself, and logically we ask ourselves, why did the resident behave like that? What could his motives have been? And more importantly, why did he do it, with what purpose, what purpose did he seek? And who was the surgical resident: a racist, a subject possessed by his own self-importance, a petty philosopher of power, who despises the weak? Or simply an element, much more wretched than the young woman, and a victim of an unbearable inferiority complex, who covers himself with the shell of arrogance to hide and protect his weakness?

But the most serious thing is that he did not regret doing what he did. This means that in a similar status , he would act in the same way again. Why does a doctor who has made a mistake not want to repent of his mistake? How long does it take for one's conscience to become calloused and say that wrong is right? How long is it possible to go back and rectify it? This is essential, because the mere fact of not recognising mistakes predisposes us to continue making them.

But in the scene told, we cannot forget that it is not the Resident who is the main protagonist. It is the young woman. Hearing the story may not be enough. An ethical story requires getting into the scene, not reducing the characters to abstract, unreal entities, mere examples. In fact, this was a woman of flesh and blood, an unfortunate human being. It is necessary to make the effort to give her a face, to turn her into a real person: she could be a human wreck, a great person who has come down to earth, destroyed by drugs. Or a poor unfortunate being, a victim of depression. She could be an AIDS patient, or an immigrant from the Dominican Republic, or a black woman, or, for that matter, a young doctor desperate because she had not passed the spanish medical residency program for the second time.

And the other protagonist is the Resident. We have already thought a little about him, but we must continue with the questions: what does it mean, for any doctor, to be tired after a whole shift full of emergencies and shocks? Are we not demanding a superhuman effort from a human being, a flesh and blood one too, someone who may be going through the humiliating crisis of not being as good as he thought he was, of being emotionally depressed because he has just lost a patient? And also, what is the part of the blame that, in his case, could be due to the poor organisation of the hospital, to the shortage of staff, to the fact that our lifestyle causes, at weekends, when it is most needed, a shortage of staff in hospitals and emergency departments? Many ethical resolutions can be deduced from such a case study, some of them impossible for the time being, such as reforming the emergency care system. Other solutions may be costly, such as regulating the maximum hours of work of the on-call resident. The conscientious physician does not leave for good once he has sutured the artery. He realises that it is just as urgent to help the woman overcome her life crisis and thus prevent a further suicide attempt.

Ethical analysis is always fruitful: the core topic is in asking questions and seeking answers. Concern for medical ethics makes us better.