Doctor's virtues

Compassion and benevolence are two of the doctor role virtues particularly relevant to situations like Nicole's. The good doctor acts for the benefit of the patient, recognising and addressing his or her individual suffering. A third relevant virtue is humility. The good doctor uses medical technology and his or her power only in ways that benefit patients. As Oakley and Cocking highlight, the good doctor is willing to concede that treatment has failed.3 It seems clear that the doctor acting with compassion, benevolence and humility would not choose the second hip replacement undergone by Nicole's patient nor the other continued interventions. In a situation where the patient or family members were requesting treatment that the doctor believed would not benefit the patient, compassion might perhaps direct the doctor to act differently. But in Nicole's story, because no relatives were asking for the treatment and the patient was resisting the interventions, the doctor's role virtues point away from proceeding with treatment.

These virtues of the good doctor require the doctor to advocate against a treatment plan that is not beneficial to the patient. However, it is crucial that a doctor faced with an apparently futile intervention investigates the decision-maker's reasons for choosing such a treatment. The questioning doctor could be wrong in his or her assessment of the potential benefit offered by the treatment, owing to inexperience or lack of information (either about the clinical nature of the intervention or about the patient's wishes and values). This is particularly the case for junior doctors, with their limited experience. The questioning doctor needs to understand the rationale behind the decision-making doctor's (or doctors') choice, in order to judge that the proposed treatment is not beneficial for the patient and is therefore genuinely incompatible with the role virtues of benevolence and compassion. This would most probably involve discussion with the senior doctor to identify his or her reasons for choosing the intervention. Additional research may also be useful, drawing on the expertise of other senior doctors or publications. However, as discussed further in the next section, the junior doctor needs to ensure that information is sought in a way that is sensitive to, and respectful of, their senior colleagues.

If the questioning doctor continues to believe that the treatment is futile having sought this additional information, the characteristics of the good doctor require him or her to argue against the treatment. For the junior doctor in this position, he or she must speak to the registrars and consultants. In order to have any chance of altering the course of the patient's treatment, the junior doctor needs to express his or her concerns to the senior doctors, particularly those with decision-making power. In Nicole's case, the doctor role virtues point to speaking up, with the aim of preventing the operation and stopping the other burdensome interventions.

Team member's virtues

Superficially, the role virtues of the team member seem to point to simply complying with the seniors' decision as the appropriate action in a situation like Nicole's. Being cooperative, role-sensitive and trusting of fellow team members, it appears initially that the good team member would acquiesce in the seniors' decision and implement the treatment plan without delay or question. However, on closer analysis, two aspects of the team member role virtues indicate that they in fact support junior doctors speaking up in this type of situation.

First, the good team member is communicative. Junior doctors often spend more time with patients than their senior colleagues do and thus can have additional information and insights to contribute to decision-making about patients' care. Communicating his or her concerns on this type of value-based question could further be seen as an attribute of the good team member, be they junior or senior. Such questioning serves as a warning light function for the team, prompting reflection on the appropriateness of the team's direction. If the good team member is communicative, then he or she does not remain silent when faced with apparently futile treatment.

Second, the team member role virtues are in fact compatible with the action-option suggested by the doctor role virtues—namely, investigating the decision-maker's rationale and discussing concerns with senior doctors. Questioning the treatment plan can be done in a way that is compatible with being a good team member, thus satisfying the virtue sets of both the doctor and team member roles. With appropriately timed and respectful questioning, it is possible to seek seniors' reasons and discuss concerns without causing offence or disrupting team functioning.

Medical learner's virtues

The role virtue set of the medical learner also points to investigating the rationale and discussing concerns as the appropriate action-option in a situation like Nicole's. Being curious, reflective about his or her own learning and motivated to improve his or her clinical skills, the good medical learner would want to understand the reasons behind the senior doctor's decision in order to improve his or her own decision-making. The virtue of being vocal similarly points to asking questions about that decision and discussing one's concerns. Junior doctors, with their limited clinical experience, may have an unwarranted level of conviction about a patient's imminent death. They are yet to have the sobering experience, reported by more senior doctors, of patients recovering after a hasty death appeared inevitable. Seeking further information about why a more experienced colleague sees pursuing treatment as appropriate would therefore be the choice of the good medical learner.

1. Always investigate rationale

Junior doctors ought always to pursue their concerns rather than implement without question the treatment decisions made by their senior colleagues. It is crucial that they first find out more about the rationale behind a decision to proceed with treatment that appears to be futile, in a way that is respectful to the decision-making doctor.

2. If concern remains, engage seniors in discussion sensitively and with an open mind

Having sought this additional information, if the junior doctor still believes that the treatment chosen by colleagues is of no benefit to the patient then he or she ought to discuss these concerns with senior team members in a sensitive and respectful way. Junior doctors ought to initiate and engage in this type of discussion open-mindedly. The aim of the discussion, at least initially, ought to be increasing their understanding rather than necessarily persuading the consultant. This openness ought to apply to ethical values as well as medical knowledge. Junior doctors ought to enter such a discussion willing, for example, to alter their own view of what constitutes futile treatment. It is well-accepted that, alongside their medical knowledge, junior doctors' and medical students' ethical views are shaped by their colleagues.4 Making these discussions explicit and reflective means that the views are more likely to be well-justified and ethically sound.

It is worth noting that Nicole did express her view about the futility of the second hip replacement. She spoke to the registrar, clearly expressing her opinion that the operation was futile. However, this did not change the trajectory of the patient's treatment nor resolve her feeling of discomfort. Her experience suggests that consultants need to be involved when junior doctors are expressing concerns about futile treatment. Shreves and Moss' findings about junior doctors' ethical disagreements with consultants indicate that consultants are ‘largely unaware’ of junior doctors' concerns despite believing that it is important to involve junior doctors in treatment decision-making.5 These researchers suggest that ‘residency directors need to encourage house staff (ie, junior doctors) to discuss their ethical conflicts with attending doctors (ie, consultants)’.5 Considering the consultants' position as the key medical decision-makers, junior doctors will, in many cases, need to discuss their concerns about futility with colleagues at this level.

These first two steps may seem a radically minimal obligatory action for junior doctors faced with involvement in futile treatment. However, evidence about junior doctors' behaviour in relation to speaking up about issues in their workplace suggests that it is in fact quite a demanding position from their perspective, asking significantly more than many feel comfortable doing. This reticence about speaking up aligns with Shreves and Moss' finding that most junior doctors do not express their ethical concerns to their senior colleagues.5 Further evidence for junior doctors' unwillingness to discuss concerns with seniors comes from several studies suggesting that medical students are strongly disinclined to speak up, even when they believe that they should.6–8 Discussion of concerns with seniors is thus a substantial and, for many junior doctors, quite demanding action to posit as morally obligatory.

3. Decide whether further action is required

A junior doctor may be morally required to go beyond these first two steps. Depending on the particular circumstances, further action such as approaching senior hospital staff outside the team or refusing to participate in a futile intervention may be appropriate. In some cases, the junior doctor may legitimately decide not to take further action despite his or her concerns. Motivated by the effective functioning of the team (rather than by, for example, self-preservation), the junior doctor may judge that ethically he or she ought to concede. Such yielding is an appropriate part of membership of most kinds of teams; if all team members pursued all of their own views doggedly, a team could not function. While it is always appropriate for team members to express their views and thus contribute their perspective to the team's deliberations, refusal to consider any form of compromise would quickly cripple most teams. The difficulty is, of course, judging which views are appropriate targets of compromise and which are sufficiently important to justify steadfast insistence.

Compassion for patients is not a value that should readily be compromised by junior doctors. Doing more will be morally required, particularly when the burden of the treatment for the patient is substantial and where further action could be taken without causing massive disruption to the team's work. If a junior doctor, having spoken open-mindedly with his or her seniors, still considers a proposed treatment futile then further action is likely to be morally appropriate in a high proportion of cases. Further action by the junior doctor will generally be morally required, particularly when his or her opposition to the treatment is grounded in compassion.

One form that further action could take is refusal to participate in the futile treatment. Refusal to participate differs from avoidance, which could be criticised as cowardly. Where a junior doctor decides to refuse to participate in a procedure for ethical reasons, his or her behaviour should be guided by the role virtues. Refusal to participate should be overt and public within the treating team (in contrast, for example, to avoiding involvement through deception), and limited to the problematic treatment. When attempts to advocate for the patient through discussion have failed, making other team members aware of his or her belief that the treatment compromises patient well-being is a way that the junior doctor can continue to advocate for the patient's interests. Merely avoiding involvement does not achieve this. Making other team members aware of one's views also aligns with the team member role virtue of being communicative. A junior doctor refusing to be involved in a procedure will, in many cases, burden other staff. In line with the team member role virtues, the objecting junior doctor should act so as to minimise this burden—for example, by swapping tasks with other junior doctors on the ward rather than simply avoiding the problematic procedure. Again, openness about objection is important in facilitating this. The junior doctor who decides to refuse to participate also needs to consider carefully which aspects of the proposed treatment are in conflict with the core ethical value at stake, and limit refusal to these aspects. Nicole, for example, could refuse to book the operating theatre for the second hip replacement or to assist in the operation, but ought not to refuse to care for the patient postoperatively. It is the operation itself that is contrary to the patient's well-being. Too wide a scope of refusal runs the risk of compromising the value that the junior doctor is trying to promote.

This analysis points to a need for junior doctors to be trained in effective communication with colleagues, including appropriate questioning of seniors. Many medical schools currently emphasise the importance of doctors' communication with patients and spend considerable time and resources equipping students with this skill. Although less widespread in medical curricula, communication with colleagues is a similarly essential element of medical education. It too is necessary for effective patient care and facilitates doctors' ongoing clinical learning. Just as communicating with patients can be challenging and requires the development of a particular set of attitudes and strategies, communication with colleagues can be similarly demanding and thus requires a specific learnable set of skills. Senior doctors involved in training juniors may also need encouragement to see as appropriate juniors' questioning and skills in responding in ways that address juniors' needs.