[MOL] Ethics matters..... [00970] Medicine On Line

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[MOL] Ethics matters.....

Ethics Matters

Patients for Practice?

January 25, 2000
Web posted at: 3:52 p.m. EST (2052 GMT)

by Jeffrey P. Kahn, Ph.D., M.P.H.
Director, Center for Bioethics
University of Minnesota

Physicians can only learn so much from books, journals, classrooms and computers. Someone has to be their first patient for every procedure. This includes everything from taking a medical history, to drawing blood, to performing more complex and invasive procedures.

But there is a practice in medicine where new and inexperienced doctors may learn by working with patients who have recently died or are not expected to recover. A survey examining this little-known aspect of medical training was recently published in the New England Journal of Medicine, and it found that it is not at all uncommon. How should we balance the need to train doctors against the rights of patients not to be misused?

More practice means better doctors

I don't want to be the first patient for any doctor -- his first case of a particular disease, her first surgery of a particular type, or the first time he takes a particular sample. I'd just as soon my doctor practiced on someone else first. While that view is universal, how and when are doctors supposed to get the practice we patients want? Medical students practice looking in each other's ears or listening to their classmates' hearts, and there are actually professional "model patients" who allow doctors-in-training to use them to practice examination techniques. And when it comes to more invasive procedures, there are even special mannequins for practicing drawing blood or inserting tubes. But these are merely second best, and there always has to be a first live patient.

Getting more than you expect

We can be somewhat comforted by the fact that first-timers will be at least trying to help their patients. Also, students and trainees are taught to inform patients that this is the first time they've drawn blood or sewn up a cut. Patients mostly accept this because they are informed on admission that medical training is part of what goes on in teaching hospitals or clinics, and that trainees may be present and even participate with supervision in patient care. All this is well and good. It is acceptable because it serves both the interests of training future health care workers and the medical care of patients.

But practice on patients who are dying or have recently died doesn't meet this standard, since such training has nothing to do with what patients need and for which consent is not obtained. And it is difficult to imagine that anyone would or could give consent through a blanket statement saying that care in a teaching hospital includes trainees practicing techniques that won't help you once it has been determined that you are likely to die.

Whose interests come first?

Trust between doctors and patients is already under assault -- managed care organizations seem to be intruding in medical decisions, and prestigious medical research is being halted for taking advantage of research subjects. Like in the argument made against physician-assisted suicide, will patients trust their physicians to do the most they can for them if they know that physicians also help kill people, or practice medical procedures on patients who don't need the procedures? It cannot help to have one more reason to wonder whether physicians will do only what is in patients' best interests. Patient welfare must be re-established as the touchstone and guiding principle in medical care to restore that trust. The practice of medicine must include practice, but not at the expense of patients treated like training dummies without their knowledge or consent.

Warmly, lillian
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