Faculty bioethics day 2/2

II – Professionalism

“Not the casual observer: What happens when medical students encounter unethical conduct during clinical rotations?”
Maya Jaffer

This talk was given by a sixth year medical student who had an interest in bioethics. This talk talked about the ethical conduct of students and how it changed during their medical career and the possible reasons and responses to the situations. She started off relating it has been shown, in social experiments, that people are willing to violate their own ethical standards if they are told to by an authority figure. This is a problem that is particularly important with medical students because they are at the bottom of the hospital hierarchy and their actions have a direct impact on patients. She also observed that the apprenticeship structure of medical school might also contribute to students going along with unethical conduct purely to fit in.

Following on there she explained that a loss of ethics was definite phenomenon in medical school, with a large decrease in ethical responses to questionnaires once students started clinical rotations. This might have stemmed from an erosion of the students’ ability to empathise with patients or the ethical and empathic erosion might have both come from somewhere else. For example it might just be that the clinical environment is particularly cynical, leading to a lack of compassion.

On that note, I remember someone telling me an anecdote about someone who did become very disillusioned when he became a doctor. He went into it to help people and make a difference but it really began to wear him down when he’d have to go from examining a rape victim to then treating the rapist or from operating on an innocent harmed in a gang shoot-out and then have to work on an injured gangster. I’m sure that sort of story can’t be that uncommon and it would certainly start to erode one’s connection to humanity.

Possible solutions were discussed, both in the talk and afterwards though I didn’t make notes on anything other than the talks. Proposals such as ethics committees to give guidance or advise such as going to a senior figure for mediation or advice seem nice but turn out to be impractical. If you’re working late at night and see unethical conduct it’s quite possible that there will be no one around for you to go to. If unethical conduct happens during an operation of some sort, an example was given of a midwife shouting at a mother, it’s not possible to go outside and discuss the matter. Other possibilities were to provide ethics courses tailored to students so that they would have been taught how to respond or to have ethical reminders. This stemmed from findings that people will behave more ethically if they are reminded of an ethical code.

Obviously a big part of the problem is the behaviour of the doctors or lecturers themselves who are giving a bad example but it’s much harder to change their ingrained attitudes and responses. That’s not to say it shouldn’t be attempted and as I recall a lot of the discussion focussed on that aspect of this situation.

III – Circumcision

“Circumcision, public health and children’s rights”
Professor David Benetar

I was particularly interested in this talk after the German courts decision that circumcision of children amounted to bodily harm. In the end I was a bit disappointed with this talk but I think our thoughts on the matter were fairly similar.

Prof. Benetar began by reminding everyone that the issue of circumcision is highly polarised and quite emotional. It’s also an issue wehre he thinks the empirical questions of harm vs benefit are are particularly important. He deemed the biggest harm to be pain, particularly in cultural and religious settings where no anaesthesia is used and that it is overlooked as if babies do not feel pain. The second harm pointed out was of complications which are relatively rare but can result in the loss of the penis, I think particularly in cultural circumcisions, and could even result in death. The benefits highlighted were reduced risk of penile cancer, urinary tract infections, sexually transmitted diseases and protection from HIV (which was treated as a separate benefit).

It is obvious that there are risks and benefits but the risks are generally not too serious and the benefits are usually small or the conditions they act on are very rare themselves or easily treated. Taking this into account he found that there was no obvious reason to perform childhood circumcisions but the benefits were modest enough that it wasn’t an unreasonable request for a parent to make. In a sense I’ve taken a similar position. I don’t see it being particularly harmful or having a huge benefit but I think without the clear benefit it is not justified from the child’s point of view. Rather than pushing for one or another view, Prof. Benetar instead decided to go after what he saw as flaws in the reasoning of both sides.

Circumcision is mutilation argument: He criticised this argument by saying it took advantage of two different meanings of “mutilation.” There is the meaning where mutilation is a harmful occurrence that ruins a body and the meaning where mutilation is changing the body but in a value neutral way. More simply put, mutilation is not necessarily wrong. This was illustrated with the idea of a patient with a gangrenous limb. If you remove the limb you are mutilating the body in the sense that you are chopping part of it off but the action is not wrong because you are helping the patient who would otherwise die. The point was that just because circumcision is mutilation does not necessarily mean that it is wrong, there has to be more to it than that.

Absent consent argument: He criticised the view that circumcision doesn’t have the child’s consent, the position I take, in that it’s the parents’ responsibility to make choices for their child until they are able to do so themselves. The argument used here was that vaccination is done without consent but is not wrong even though it has no immediate benefit. The big objection there would be that circumcision is not necessarily beneficial on balance whereas vaccination has a very clear benefit. He tried to counter this by saying that vaccination is also not always beneficial, for example herd immunity means that even without vaccination a child could be fine and if they never get infected the vaccination was for nothing. I don’t think that’s a good counter though because although it means the vaccine is not beneficial to that child in isolation, the benefit is from an aggregate effect. The elimination of diseases from a population is a benefit to every member of that population and that benefit requires a certain level of vaccination so even those that are not directly infected or are protected by herd immunity the benefit is the consequence of vaccination.

Culture argument: Some people claim circumcision is a cultural or religious practice and so should be protected but that is an extremely poor argument. As pointed out there are many cultural practices that are just plain wrong. Cultural practices may be beneficial, neutral or even harmful but tradition does not make a practice acceptable.

Public health argument: Some people, and organisations like the South African Department of Health and World Health Organisation, advocate circumcision as a public health policy, particularly for it’s supposed HIV/AIDS benefits. However we don’t have long term studies of circumcision and HIV and it’s possible that risk compensation might negate any benefits. If you know you are protected then you will be more willing to take risks, particularly in cases of adult circumcision, and if you don’t wait until the wound is healed you will actually be more vulnerable. Those problems would be averted with infant circumcision. For example, we know that circumcision is not as effective as a condom but it is more effective than no protection at all.
I should probably take this time to again mention that I’m not sure how effective circumcision is against HIV. I know some groups promote it but others have claimed the studies are flawed. Prof. Benetar says that the original studies actually addressed their criticisms but I can’t really say as I haven’t read the original studies.

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So that’s the summary of the bioethics day. It was really interesting for me and hopefully I have been able to accurately convey the speakers messages.

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