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Most of us equate “acting ethically” with doing the right thing. For example, you find a wallet with cash and credit cards lying in the street. Do you try to find the wallet’s owner or keep the cash and toss the rest? 

Few would disagree that finding the owner is the right thing to do.  But in the medical field, knowing the right thing to do can be much more complicated.

Medical ethics go as far back as classical antiquity and the Hippocratic Oath ‒ the principle of “Do no harm.” Underlying the ethical practice of medicine today is compassionate care embodied in the more modern version of the oath: “I will remember that there is an art to medicine as well as a science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.”

It’s one thing to take an oath and keep its lofty principles in mind and quite another to put those principles into action when faced with making difficult decisions under pressure.

Consider the following: You realize that unless your patient gets an immediate blood transfusion he will likely die. However, your patient has indicated that under no circumstances does he want a blood transfusion.  Do you ignore your patient’s wishes and hopefully save him? Or do you respect his wishes, knowing that by doing so he will likely die? This scenario incorporates the ethical principle of autonomy, which is backed by law and gives any individual the right to refuse treatment if he or she understands the risks. 

But how does a physician know ethical principles like this, how and where law applies, and be equipped to do the right thing when it really counts?

A big part of the answer is training.

Ethical Training

Medical ethics (also called bioethics) will be a touchstone of the curriculum at the new UNLV School of Medicine as pointed out by Dr. Barbara Atkinson, founding dean of the school. 

“We want students to come out of their medical training with a framework they can use to make decisions that meet the standards of medical practice and fit within ethical and legal boundaries.”

Learning where those boundaries are is very important.  Atkinson notes that “There were research studies done in the 40s and 50s that you would not do today. If you can’t do the research without going beyond the boundaries, you don’t do the research.”

Case-Based Learning

In their first two years of training, UNLV medical students will face ethical issues as part of the school’s case-based (also called problem-based) approach. They’ll be exposed to cases that describe a patient fully, so that they’re learning the basics of medical science and thinking through the legal and ethical issues.

Atkinson cites an example:  “You might have a teenage girl who has a venereal disease. The venereal disease needs to be treated, but the girl doesn’t want to tell her mother that she’s having sexual relations.”

The school’s goal, Atkinson said, is to teach both medical knowledge and decision-making through concrete cases. “We want them to research the literature to learn what they have to do. In the venereal disease case, you have to report to the health district and to do a variety of things that you don’t have a choice about. But you do have some other choices — you just need to know where the boundaries are.”

Starting in their third year, students will deal with actual patients and ethical issues as they come up. Students will have the opportunity to discuss those issues with the attending faculty, and if these are really important cases, with fellow students. This is one reason a diverse student population is a recruitment goal. “Students come to the medical school with very different ethics, but all good ethics. And hearing other students discuss ethics from their personal viewpoint can be very valuable. ”

Why We Teach Bioethics

Ethics-based training at the UNLV School of Medicine will cover the spectrum of issues that patients expect their doctors to understand:

• End-of-life ‒  These are issues that relate to a patient’s care as he or she nears the end of life.  What does the patient want to have done – or not done? How does the patient go about determining want he or she wants done? When can you terminate care? What are the legal issues involved?
• Reproduction ‒ This is perhaps the most controversial area of bioethics. When does life start? What are the implications of abortion? What are the legal standards in the state where the physician is practicing?
• Synthetic biology ‒  This involves the use of genetic material, such as DNA, to change or improve things we eat or use or do. One example is genetically modified corn that is more pest-resistant. It can even involve genetic manipulation of animals. Remember Dolly the Sheep, the first animal to be cloned?
• Research ‒ What can you do during clinical trials? For instance, what approaches are ethical and not ethical in testing a new pharmaceutical drug for cancer? How do you pick a population of test subjects? What should test subjects rightfully expect at each stage of a clinical trial? The ethical principle of patient autonomy plays an important role in research issues as well as in clinical treatment of patients.
• Health disparity ‒ Health disparity evokes the question why do patients in some cultures get better medical care in general than others, and what can physicians do to ensure all patients get appropriate care? Atkinson stresses that “Different cultures have different ethical expectations. So if you’re going to treat patients of different types of ethnic backgrounds, you need to understand what these different cultures think about ethical issues.”

Teaching bioethics in medical school is absolutely essential, but it’s really about learning the framework. As Atkinson points out, “It’s important not so much we teach the ethics, but teach the framework around ethics. (You don't need) to teach people what to think, but to teach them the parameters within which they need to make those decisions. And, of course, we want to present this training in an interesting and challenging way.”

So it’s not so much you know to return that lost wallet, it’s all about knowing the parameters — ethical, legal, cultural, and others — that inform your decision.