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What do medical students experience as moral problems during their obstetric and gynaecology clerkship?
  1. G Olthuis1,
  2. L Dukel2
  1. 1
    Radboud University Nijmegen Medical Centre, Department Ethics, Philosophy and History of Medicine, Nijmegen, The Netherlands
  2. 2
    Radboud University Nijmegen Medical Centre, Department of Obstetrics & Gynaecology, Nijmegen, The Netherlands
  1. Dr G Olthuis, Council for Public Health and Health Care, Centre for Ethics and Health, PO Box 19404, 2500 CK, The Hague, The Netherlands; g.olthuis{at}chello.nl

Abstract

This article reports on moral problems that were raised by medical students as the basis for an ethical case-conference in an obstetrics and gynaecology clerkship. After introducing the issue of teaching clinical ethics, the method of our case-conference is explained. Next, the variety of topics and related moral problems are presented. The article continues with a discussion of three distinct and challenging aspects that characterise obstetrics and gynaecology as a domain for teaching clinical ethics. The conclusion puts forward three significant points our review raises.

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The purpose of teaching ethics in an obstetrics and gynaecology clerkship is to increase students’ awareness of clinical ethical issues, to improve their understanding of ethical concepts and to apply these concepts to the analysis of ethical problems in the field.1 This article focuses on what medical students experience as moral problems during a clerkship in obstetrics and gynaecology. Before we concentrate on this issue, we will briefly summarise the importance of teaching clinical ethics and the way we have put it into practice in the obstetrics and gynaecology clerkship in the Radboud University Nijmegen Medical Centre.

During their clerkships, medical students are confronted intensively by the necessity to deal with moral dilemmas in medical practice on a daily basis. Actual participation in medical practice makes students experience personally the inseparable relation between ethics and clinical medicine.2 Teaching ethics in the clinic aims to enhance the ability of (future) clinicians to reach ethical decisions and thus aims to contribute to an improvement in the quality of patient care.35 Dealing effectively with ethical problems in practice is linked with a variety of skills: recognising the ethical issue, applying relevant knowledge, analysing the problem, deciding on the course of action and implementing the steps that are to improve the situation.5

It is increasingly recognised that the content of clinical ethics teaching needs to be customised to the learner.4 Clinical learners are “doers” who acquire knowledge for its usefulness in practice.5 Moreover, medical students prefer ethics teaching to focus on the actual problems they confront.4 Since possibilities for direct ethics teaching at the bedside seem to be limited, case-based conferences provide an adequate alternative that is still closely linked to clinical care.5 It is claimed that clinicians learn well when they are actively involved in interactive sessions such as case discussions.6

A method that combines the experiences of students in the clinic with interactive small-group teaching is using students’ cases as a basis for teaching ethics. Students often choose cases that have direct emotional impact on them and that arise from their own responsibilities as medical students.7 Providing cases that students experienced themselves invites and encourages them to explore their moral feelings, analyse the values involved and identify the place and meaning of their own values with respect to their professional behaviour.8 We have applied this approach—a case-based conference on the basis of students’ cases—within the context of an obstetrics and gynaecology clerkship.

METHODS

Until recently, all fifth year medical students of the Radboud University Nijmegen Medical Centre did a compulsory part of their obstetrics and gynaecology clerkship in the academic centre itself. The reason for this is the large variety of special patients visiting the centre compared with the non-academic, general hospitals where the students undertook the rest of the clerkship. A fixed item in the two week programme in the medical centre was an ethical case-conference. We have collected the cases students presented in the conference between September 2004 and April 2007. These cases concern ethical problems students experienced in the general hospitals as well as in the university medical centre.

The procedure of our conference was based on an experimental case-conference programme for obstetrics and gynaecology as it was developed by Ten Have and Essed in the late 1980s.9 The ethical conference was scheduled for one hour. The design was largely identical to clinical conferences with which students are familiar. Every two weeks, around 10 new students participated in the academic part of the clerkship. Due to duties at night or commitments in the clinic for some of them, seven or eight students usually attended the ethical conference.

At the beginning of the two week clerkship in the academic centre students were instructed to select an obstetrics or gynaecology case appropriate for moral deliberation, preferably a case one of them had actually been involved in. Each student suggested a case and the group independently decided which one to use for the conference. A few days before the conference, an outline of the case was emailed to the staff who would attend the conference (an ethicist and a gynaecologist) enabling them to be properly prepared. The presence of an ethicist and a clinician is in accordance with what is recommended in the literature.1 4 9 10 The ethicist chaired the conference, which included a presentation of the case by a student, clinical and ethical comments by the staff and a discussion. See also Ten Have et al.9 Often, the attending students actively started to discuss the case without any stimulation or questioning by the commentators. The commentators monitored the discussion and, in the course of the conference, attempted to draw attention to issues the students seemed to miss by posing questions. These experiences acknowledge one of the characteristics of small group case-conferences: they invite active participation and peer interaction.5 7

RESULTS

We have collected a total of 60 cases over a period of 30 months. These were the cases that were actually discussed during the conferences. The cases that were discarded by the students were not registered. Approximately 480 (60*8 students) medical students attended the conferences in that period. The students raised a large variety of issues which they considered were moral problems. Table 1 reflects the frequency of the different topics.

Table 1 Frequency of topics the students provided in consideration of a moral problem

Moral problems relating to indications for fertility treatment were most common. Moral doubts that stem from the psycho-social situation of the couple (history of violence, very low IQ, mental instability, alcohol/drugs), co-morbidity (HIV infected couple, familiar with Turner syndrome, male has Becker’s disease), or the age difference between the couple (>30 years) were the most common.

The second series of problems were those related to specific categories of patients. Several categories were mentioned. Issues here included: (1) How should we deal with a (healthy) pregnant woman who is very anxious, and occupies a hospital bed for non-medical reasons? (2) What should we do when Jehovah’s witnesses refuse administration of blood? How should we deal with a Muslim couple who refuse to allow the woman to be seen by a male gynaecologist? (3) Should infibulation be restored after giving birth? (4) What should the doctor do when it is noticed that a husband lies to his non-Dutch speaking wife?

The third largest category of moral problems concerned embryo reduction of a multiple pregnancy. One type of question focused on couples who already had children and feared that caring for more than two newborns would be too hard. Other moral concerns in this category had to do with embryo reduction on the basis of prenatal testing (eg, trisomy 21). An extra complication may be the discovery of an imperfect fetus (one of more) after an ultrasound in the third trimester of the pregnancy. Dutch law allows a termination of pregnancy until the 24th week. In the third trimester abortion is only allowed under very strict conditions, for example, when a fetus is not viable.

The fourth category is termination of pregnancy. Ethically speaking, in abortion cases the moral right of self-determination of the mother is weighed against the moral duty to protect unborn life. Cases our students raised varied from unwanted pregnancy of a young woman who already had had two abortions, to abortion requests because of a very poor prognosis of the fetus.

Another category concerned problems relating to the reversal of sterilisation of women. For example, should sterilisation be undone while the woman was sterilised four months before? Or should reversal take place if a woman’s children with a former partner have been put in foster families?

The next category concerned the question of whether physicians should reconstruct the hymen of young girls, mostly from a Turkish or Moroccan origin. This concerns girls, mostly in their early twenties, who are raised in between two cultures: an Islamic oriented home situation and a Western, liberal climate at school and on the streets. For some of them, this situation has been at the cost of their virginity. However, eventually they often intend to marry an Islamic husband, which requires an intact hymen. Should medicine contribute to maintaining a practice that conflicts with the value attached to bodily autonomy, sexual liberty and equality between man and woman?

The next two categories both contain two cases. The first concerns premature births of twins in which one of the fetuses is affected with, for example, trisomy 21. The moral problem involved was the question what to do when the affected fetus requires an active intervention that may be not without danger for the prognosis of the healthy fetus. The other category contains cases involving women who were already deprived of parental rights regarding one child. One of them behaved quite aggressively toward her newborn baby; the other was denied her cocaine addiction while pregnant. Other cases of domestic violence were not mentioned. Whether this indicates an under reporting is not clear in our study. In The Netherlands, the prevalence of domestic violence involving children younger than 10 years is 4–11%, 1–3% of the children of that age has been the victim of sexual violence. The prevalence of domestic violence between partners is 12%.11 A recent study showed that family doctors significantly better recognise and respond to intimate partner abuse after a training.12

The last category (“other”) concerns five single cases on a variety of moral questions: should—if the situation of a pregnant trauma patient deteriorates—the life of the mother be saved at the cost of the fetus? Should a woman be inseminated with the semen of her partner, who is terminally ill? Should a student perform a PAP-smear while the woman in question explicitly requested a gynaecologist? Can a drug be used to terminate a pregnancy which is proven to be effective but is not officially registered? How to deal with a minor boy who will be treated with chemotherapy and whose sperm will be cryopreserved in advance?

DISCUSSION

Since obstetrics and gynaecology functions within a complex ethical, social and cultural environment that includes both specialty-specific issues and reflects medical practice in general, it provides a challenging domain for clinical ethics teaching.7 The topics mentioned in our overview of cases confirm this characterisation of obstetrics and gynaecology and the challenge this domain provides to teaching clinical ethics. We will briefly discuss this observation on the basis of three distinct features that arise above.

First, besides ethical issues that play a part throughout clinical practice (eg, issues on consent or withholding treatment), obstetrics and gynaecology as a specialty incorporates a unique and complicating ethical characteristic: the interest of a third party, that is, the fetus. In our overview deliberations about this are strongly prompted in half of the cases, for example, when it involves the indications for fertility treatment (is this couple able to care for a child? Should a physician pronounce judgment on that?) The interests of the child also plays a major part in discussions on the reduction or termination of pregnancies, and in cases of abuse. From an ethical perspective, the interest of the fetus sharply delineates at least three issues that are worth discussing in a conference: the limitations of autonomy (can a pregnant woman determine the course of her life regardless of the interest of the fetus?), the moral status of the embryo (should we consider embryos as persons?) and quality of life (is the life of a child affected by Down syndrome worth living?)

Second, our collection of cases clearly shows that the dynamics of the patient population mirrors that of society. Not only do patients from all segments of society enter the consultation room of the gynaecologist, the composition of the population has become increasingly culturally varied. This shift entails specific ethical problems, also in the domain of obstetrics and gynaecology. Typical in our overview are the cases on hymen reconstruction, issues involving female circumcision and divergent opinions on healthcare provision because of differences in male-female relationships.

Third, technological possibilities in medicine in general and gynaecology in particular develop rapidly. One of the consequences is that reproduction is increasingly considered a process that can be controlled by human intervention. Furthermore, pregnancies have been drastically medicalised in the last few decades. In the wake of these developments, healthcare is more and more approached as a commodity. Although these issues are far too broad for an extensive discussion in the current article, several related moral questions can be recognised in the students’ cases. A few examples: whose responsibility is the application of new techniques? Only the clinician’s, or society at large? For example, how should one deal with psycho-socially unstable couples whose capabilities to raise a child can be questioned but who request reproductive assistance? Next, on the one hand the possibilities to treat infertility seem to have changed views on childlessness: having a child is increasingly considered a right and infertility an individual problem for which a medical solution exists. On the other hand, students raised cases concerning the reduction of multiple pregnancies. This paradoxical development shows that medical techniques play a growing part in the way people plan and construct their lives, which entail new moral problems. The last example involves cases on reversal of sterilisation of women, which strikingly illustrates the way healthcare interventions are increasingly considered a commodity.

CONCLUSION

Although we have to be modest in drawing general conclusions from our analysis (based on 60 cases that originate from students of one academic centre over a period of 30 months), our review of what medical students experience as moral problems during their obstetrics and gynaecology clerkship identifies at least three significant points.

  • Medical students prove to be able to provide a wide variety of ethically problematic cases for teaching purposes during their clerkship. This indicates a certain moral sensitivity towards clinical practice. Furthermore, most of them were—in our experience as teachers—actively involved in the discussions and appreciated the possibility to dedicate a full hour to moral deliberation on clinical-ethical issues.

  • The cases provided were appropriate for teaching clinical ethics and showed the practice of obstetrics and gynaecology to be a complex ensemble of ethical and socio-cultural factors. Casuistry showed that clinical practice is embedded in an ever changing societal dynamic, in which thinking about moral issues is subject to continual revisions.

  • The two points above allow medical students to become acquainted with the necessity to continuously reflect on what obstetrics and gynaecology is capable of and on the moral issues that are at stake in that domain.

An unanswered key question that remains open is whether or not clinical ethics actually improves the quality of patient care.4 13 However, we believe that the points above indicate that the ethical case-conference as we have organised it made a significant contribution to medical students’ awareness of clinical ethical issues in the field of obstetrics and gynaecology, and that it provided a good opportunity to practise their skills to analyse and deal with these issues.

Acknowledgments

The authors are grateful to all the medical students who provided the cases. A Braunack-Mayer is acknowledged for her English language editing.

REFERENCES

Footnotes

  • Competing interests: None declared.

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