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