everyday ethical dilemmas in residency training · moral identity can be seen as being a crucial...

EVERYDAY ETHICAL DILEMMAS

INRESIDENCY TRAINING

LAWRENCE R. FISCHETTI, PHD, LP, MFT

MARLA ROWE-GOROSH, MD, FACH

REALIZING OUR BEST INTENTIONS. SEMCME. 10-18-2019.

PLAN FOR TODAY

Ethics Instruction in UME & GME

Discussion of Ethics Teaching

Gap Between Ideals and Behavior

Rest’s Four-Components of Moral Behavior

MEDICAL SCHOOL ETHICS INSTRUCTION

Ethical Theories, Ethical Decision Making

Informed Consent, Giving Bad News, DNR

Values & Moral Development

Didactics, Small Groups, Case-Based, Active Learning

Interdisciplinary

Integration Across Settings & Time

Fox, Arnold, Brody. Medical ethics education: past, present, and future. 1995.

BROADER VIEW OF ETHICS INSTRUCTION

Medical ethics is an integral part both of every clinical

interaction and of each physician’s professional and

personal identity.

Fox, Arnold, Brody. Medical ethics education: past, present, and future. 1995.

TEACHING PROFESSIONALISM IN GME

Professional Values & Behavior

Physician Well-Being, Ethical Decision Making

Small Group Discussion

Didactics, Reflection, Simulations, Balint Groups

UME: Role Modeling & Reflection Most Effective

Berger, Ginsburg, et al. Academic Medicine (pre-publication)

ETHICS INSTRUCTION YOUR PROGRAM

Focus, Methods, Challenges, Outcomes

10 Minutes

Group Discussion

THE GAP BETWEEN PROFESSIONAL & ETHICAL

IDEALS & BEHAVIOR

What the literature and rhetoric of medicine lacks is a clear

recognition of the gap between these widely recognized

manifestations of virtue in action and what we actually do

in the circumstances in which we live our lives.

Inui. A Flag in the Wind: Educating for Professionalism in Med. 2003.

BEHAVIORAL ETHICS

PREDICTION

“I should behave ethically … therefore I

will”

RECOLLECTION

“I should have behaved ethically … therefore I

did!”

DECISION TIME

“I don’t see the ethical implications of this decision …

so I do what I want to do”

Bazerman & Tenbrunsel Blind spots: Why we fail to do what’s right and what to do about it. 2011.

BEHAVIORAL ETHICS

System 2 Thinking Prediction

Slow, deliberate, CS, effortful, logical

Predictions reflect Ideals

System 1 Thinking Behavior

Fast, automatic, UCS, effortless, implicit, emotional

Influenced by desirability, feasibility, self-interest

Vulnerable to Bias

DECISION MAKING UNDER STRESS

“… consistent with Janis and Mann’s (1977) theory, results

showed that decision making was affected negatively by

pressure [and] that participants relied little on legal

guidelines in making responses to ethical conflict

dilemmas.”

Hinkeldey NS, Spokane AR. Journal of Counseling and Development 1985; 64:240-245.

DOING LESS THAN ONE BELIEVES ONE SHOULD

[Mental health] “… professionals acknowledged laws

and ethical codes when identifying what they should do

but more often identified personal values and practical

factors when determining what they actually would do

when faced with a dilemma.”

Smith et al. Clinical ethical decision making. Professional Psychology: Research and Practice 1991; 22:235-239.

ONE’S TRUE IDEAL SELF

“… distal future thoughts are likely to activate a strong desire

to become like one’s true ideal self, whereas proximal future

thoughts cue more instrumental and pragmatic selves, with

the power of the situation having an inhibitory role on

whether or not people behave according to their true,

inner self.”

Monrouxe. Identities, self and medical education. 2013.

MORAL IDENTITY

Moral identity can be seen as being a crucial area for

understanding within medical education as it lies at the

intersection of moral development and identity formation:

one’s moral identity is seen as the motivating force

operating between moral reasoning and behavior.”

Monrouxe. Identities, self and medical education. 2013.

MAKING ETHICS RELEVANT

It is in making decisions and living with their

consequences that ethics ceases to be only a theoretical

discipline and begins to become a professional code of

conduct.

Christakis & Feudtner. Ethics in a short white coat. 1993.

RECURRING DILEMMAS IN ETHICS EDUCATION

Education Versus Patient Care/Safety

The “Allure” of Being a Team Player

Challenging Medical Routines/Hierarchy

Boundaries, Identifications, Allegiances

Deception, Substance Use, Irresponsibility

Christakis & Feudtner. Ethics in a short white coat. 1993.

FOUR-COMPONENTS OF MORAL BEHAVIOR

Moral Sensitivity

Moral Judgment

Moral Motivation & Commitment

Moral Character & Competence

Rest, Narvaez, Bebeau, Thoma. Post-conventional moral thinking. 1999.

RECALLING ETHICAL DILEMMAS FROM TRAINING

Describe an Ethical Dilemma From Your Training:

Describe the Event

Nature of the Ethical/Professional Dilemma

Thoughts Regarding the Outcome

RECALLING ETHICAL DILEMMAS FROM TRAINING

Discussion & Exploration:

Moral Sensitivity

Moral Judgment

Moral Motivation & Commitment – Ideal Self

Moral Character & Competence