Appetiser.

One of the things I originally said I wanted to use this blog for was the sharing and discussion of interesting articles... something which I haven't actually done yet.

Seeing as it's exam period I've dug something out which is both interesting and informative for medics and non-medics alike, as well as providing some useful inspiration for any Psychology students reading. Yup, we're talking ethics.

The following extracts are taken from an article published in the BMJ last year by Daniel Sokol. Entitled 'What to tell junior doctors about ethics' it's essentially a brief discussion of how ethics often aren't as transparent as we initially think.

It's probably one of my favourite articles from my scrapbook. I think at this point I should mention my medical scrapbook; I was advised by a lovely anaethetist to keep a record of any medical articles I find interesting, as they can provide useful memory joggers. Once you start looking it's amazing what you can find - and how you can relate it to broader discussions on current issues such as euthanaesia, obesity surgery and the state of the NHS. It's something I'd recommend to any budding medical student as interviews are very focused on hot topics and contentious issues which test your ability to reason and empathise.

Aside from using it as interview ammunition, I've regularly quoted this when talking with people about my interest in medicine, and I think it can be enjoyed by most people, as it really does make you question what we mean by ethics and fair treatment of patients. I think it also gives us, as patients, a sense of the difficulties our doctors face when asked an awkward question - and how negotiating the minefield of ethics can be just as difficult as providing a diagnosis. These rules aren't just for medicine - all social research and interactions are based on ethical codes, hence why psychology students may be particularly interested.

You can pay for and read the full article here and to avoid being sued I'll just take quotes and add my own commentry.

What to tell junior doctors about ethics by Daniel Sokol
Commentary by me, Shannon Hilton.

Consent is probably the most obvious ethical issue that arises in medical care. Informed consent is always preferable and in medicine,patients should always be fully aware of the risks and expected outcomes of any procedure before agreeing to it, free of pressure from medical staff. Realistically it appears that

"some junior doctors are asked to obtain consent for unfamiliar procedures; and. although some politely decline to do so, others do not want to make a fuss and acquiesce"

This represents a warped sense of what consent is: whilst the patient feels like they're fully informed, surely this is voided if a doctor has unknowingly missed out a few key aspects of the procedure or it's after-effects. And if you're thinking "well surely it doesn't matter if they get it a little bit wrong" the example quoted by Sokol goes as follows

"on the trolley heading for the operating theatre, one patient at a colleague's hospital told the porter that she was relieved at finally having the operation as she was looking forward to starting a family. She was about to undergo a hysterectomy"

Not meaning to patronise you (that means talking down to people*) a hysterectomy involves removing the patients womb (as well as possibly other bits and pieces). Clearly, this could prove problematic for baby-making.

Another common (but I guess under-appreciated) ethic is that of confidentiality. Easy, surely? Don't tell your colleagues, don't leave notes lying around. Slightly trickier issues arise when calling patients to discuss,for example, blood tests, where the spouse can't technically be told who or why, they're calling. Potential domestics may arise concerning the 'mystery woman' calling after a curious wife's husband. The example offered is pure brilliance.

"the story this time will be of the patient who dies from a ruptured cerebral aneurysm during overzealous intercourse with his mistress. The distraught wife asks the medical team what happened. Discuss."

And I think that discussion could extend way past the ethics of the situation. However, practicalities and specific definitions of "overzealous sex" aren't really relevant. Either way, an interesting thought-provoker. Break the doctor's oath of honesty, or break the patient's confidentiality. And consider the third-party here, the spouse, which option benefits her most? Is the patient's confidentiality renounced due to his death? Interesting.

Another topic that has often made me ponder is that of operating in the 'patient's best interests'. The definitions of a doctor's role often rely on semantics; most people are happy to believe a doctor's role is to preserve life and ease suffering. When do these come into conflict? For instance, a patient riddled through with cancer and in immense pain - preserving life involves keeping the patient alive by whatever means. Easing suffering could mean pumping a weak and vulnerable patient full of morphine to the point of removing all consciousness, or in many people's opinion the most humane option may be euthanasia.

Other related issues occur on a daily basis for sports doctors - rugby players often insist on continuing a match with minimum pain relief or dressing for deep gashes, boxers finish the round with a broken rib. What is the best interest of the patient? Personal ones, or health ones? And as Sokol offers

"a prison doctor may also face a dilemma when she knows that a patient requesting diazapam is being coerced by some rough types to ask for the drug. The patient will not be treated kindly by the requestors if he fails to get some"

The article goes on to discuss work-place related ethical dilemmas, such as the safety of locums whose English may by substandard or the classic case of the 'incompetent colleague'. To be honest, as a student with the tiniest experience of clinical settings I think my opinion is irrelevant here, but the comments offered by Sokol certainly provides some interesting stimulus.

I think the summary paragraph encapsulates the purpose of the article well

"the purpose... is not to provide junior doctors with a solution to their problems... but to whet their ethical curiosity and provide them with a deeper appreciation of the pervasiveness of medical ethics. Most importantly... what other profession can boast such a fascinating range of challenges and opportunities? That, perhaps, should be the essential message"

And I think 'pervasiveness' is an excellent term for any pre-interview candidate to have prepared for an ethics discussion.

*Jimmy Carr, possibly my favourite one-liner ever.