Learning for lifeBMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7536.0-f (Published 02 February 2006) Cite this as: BMJ 2006;332:0-f
- Fiona Godlee, editor ()
As doctors, how much should our moral values influence our clinical decisions?
When the footballer George Best was given a liver transplant for alcoholic liver disease, there were many dissenting voices. His continued drinking after the transplant further inflamed the moral outrage. A precious resource had been wasted, so people said, on a man who had brought his condition on himself and failed to change his lifestyle.
Commenting on his own similar case in our interactive case report, the patient, A Bond, doesn't think he should receive a transplant if he continues to drink, or even if he stops drinking (p 277). But as Paul Haber writes in an accompanying commentary (p 277), much adult illness is due to failure to change high risk behaviours. Clinicians must strike a balance between avoiding futile treatment and protecting recidivist patients from being stigmatised. In a rapid response (http://bmj.bmjjournals.com/cgi/eletters/332/7532/33), Mark L Willenbring advises doctors to “do whatever is medically indicated and is consistent with the patient's wishes, and be wary about covert moral judgment coloring decision-making.”
If moral judgments are to be avoided, judgments based on religious values should also be kept apart from clinical decisions, says Julian Savulescu in his essay against conscientious objection in medicine (p 294). As the state of Wisconsin considers a bill allowing doctors to opt out of a broad range of clinical activities, Savulescu takes a hard line. “If people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors.”
Conscientious objection may be acceptable, he says, where there are enough other clinicians willing to do a procedure such as abortion. But the doctor must make sure that the patient knows about and gets the care they are entitled to from another doctor. Doctors who don't do this should lose their licence to practise. He concludes that different values should be debated by society, not during patient care.
How then can we best prepare young doctors for the difficult balancing acts they will need to perform? Ed Peile praises case based learning as one important tool (p 278). It is “real, complex, and convoluted,” forcing us to put the ethical and psychological aspects of care alongside the clinical. Naomi Lear tells us about Dr Ipp, the Jewish doctor who inspired her to take up medicine (p 311). “In his dealings with people he would remind me, ‘Being a doctor is about more than the physical exam.’” Now a medical student in Canada, Lear feels the lack of such guidance and starved of spiritual development and critical thinking. “Medical students cannot become healers,” she says, “if a focus on their emotional and spiritual development is confined to a limited lecture series.” It's a reminder that we all need a few Dr Ipps in our lives. The hardest thing may be realising that we may also need to be that person for someone else.
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