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How to be a “good” medical student
  1. D K Sokol
  1. Medical Ethics Unit, Department of Primary Health Care & General Practice, Imperial College School of Medicine, London W6 8RP, UK; daniel.sokolimperial.ac.uk

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    The public revelation in 2003 that medical students perform intimate examinations without patient consent has engendered much debate in the press and scientific journals. Using this case as a springboard for discussion, I will argue that medical schools should encourage students to raise their ethical concerns and call for a change of policy making it easier for students to do so. I will also address the question of medical students’ moral obligations towards their patients, and conclude that medical students ought to express their discontent when faced with unethical practices or attitudes.

    In early January 2003, a study appeared in the British Medical Journal revealing that nearly a quarter of rectal and vaginal examinations on anaesthetised patients were performed by medical students without patient consent.1 Although the study did not generate the firestorm of controversy many expected, it engendered much discussion on ethical issues surrounding informed consent and patient autonomy, as well as stressing the need for greater ethics training for medical students. As an ethical problem, however, the case of intimate examinations is, to my mind, relatively uninteresting. If we agree that it is wrong for doctors to perform a vaginal examination on a conscious person without their consent, then it follows that it will still be wrong if that same person is merely asleep. Society would be somewhat chaotic if a person suddenly lost his rights when unconscious. The argument that the anaesthetised patient is unaware of the examination and so cannot be harmed is, at best, questionable. Suppose a newspaper revealed tomorrow that sociology students had placed hidden cameras in the cubicles of public toilets to study urination habits. Most people would be understandably outraged by this violation of privacy, even though the victims were not harmed by it at the time. This is based on the belief that a person’s rights can be violated without that person’s knowledge.

    As for the conflict between the educational need of students and the respect for patient autonomy, it would only arise if an overwhelming number of patients refused to be examined. This is an unlikely scenario. In a commentary on Dr Coldicott’s study, Britt-Ingjerd Nesheim, a professor of obstetrics and gynaecology in Norway, affirms that obtaining patient consent to student examinations is not difficult, as long as the patient feels comfortable with the arrangements.2 Yet for me the study raises a more interesting question which extends beyond the recondite sphere of intimate examinations. It concerns the moral obligations of medical students faced with ethically dubious situations. In short, what should a “good” medical student do?

    In an article on the scope of medical ethics, Professor Raanan Gillon recounts two experiences from his days as a medical student.3 The first describes his teacher’s refusal to grant an abortion to a 14 year old girl on the grounds that she was “a slut”; the second his own refusal to examine a scrotal lump on a patient whose testicles had already been examined by five other students. Gillon’s objections were very much the exception. When these events took place in the 1960s, medical students were simply expected to follow their teachers’ orders and to absorb their evident wisdom without question. Since then, medical ethics has developed from an ill defined embryonic subject to an academic discipline in its own right, with specific journals and associations, and a place in the medical curriculum.

    Judging from some of the comments from students at Bristol, however, the growing emergence of medical ethics has not dispelled the awkward climate of unquestioned reverence towards teachers. Many of the students felt uneasy about the examinations, but were too intimidated to voice their concerns: “You couldn’t refuse comfortably. It would be very awkward, and you’d be made to feel inadequate and stupid”, commented a fourth year student who participated in the study. It seems clear that medical schools should strive to foster a climate more conducive to open discussion on ethical issues between students and teachers. Students should not have to perform heroic acts of courage to raise ethical concerns. In light of medical ethics’ place in the curriculum, the situation is deeply paradoxical. Students may be taught the importance of respecting the patient’s autonomy one day, but witness an obvious violation of this principle by their teachers the next. For the subject to be of any use, students must not only be allowed, but positively encouraged to put into practice their knowledge without the fear of appearing “inadequate and stupid”. If a student’s ethical concerns remain unresolved after discussion with the teacher, there should be formal methods of complaint, perhaps through a committee specifically set up for that purpose, or through the school’s medical ethicist, who would then investigate the matter thoroughly. Medical ethics is, after all, an applied discipline.

    It is nonetheless all too easy to blame the medical establishment and individual teachers for the unethical behaviour of students, as if the appellation “medical student” shielded individuals from moral fault. In Nick Hornby’s novel “How to be good”, the narrator, an adulterous GP and mother of two, resolves her moral conundrums by mechanically repeating “I must be good. I’m a doctor”.4 It is only later that she acknowledges that her justification is too facile: “it’s not enough to just be a doctor, you have to be a good doctor”. Students, however wide eyed or intimidated, are still capable of independent thought. Their personal values should not vanish as they put on the white coat, just as a patient’s rights should not evaporate when under anaesthetic. Although the reluctance of many Bristol students to perform the examinations is comforting, it seems that none acted on their qualms by declining to perform the procedure or asking that proper consent be obtained. Neither the diminished responsibility of the medical student, nor his status as an apprentice, removes the need for ethical reflection in daily proceedings. Indeed, far from absolving him from moral inquiry, these factors should encourage a process of ethical questioning. This exercise is, to my mind, crucial to a student’s flourishing as a morally responsible future doctor. To paraphrase Nick Hornby: “it’s not enough to just be a medical student”.

    Acknowledgments

    The author thanks Raanan Gillon, George Freeman, Richard Ashcroft, and Anna Smajdor for their helpful comments and suggestions.

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