Let's Teach Moral Reasoning to the Next Generation of Doctors

Stuart A. Green, MD


January 12, 2009


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Right now, the medical profession is on the ropes. The media and Congress continue to flail away at the unseemly relationship doctors have with drug companies and medical device makers.[1] Accusations of kickbacks for product selection,[2] unearned "consulting" fees, stock options tied to research results,[3] and drug-rep supplied pizza for office staff[4] all imply that our profession puts personal gain ahead of patient welfare.

In medical-legal arena, lawyers and judges realize that favorable testimony can be purchased in a marketplace replete with practitioners of questionable ethical standards.[5]

Likewise, statisticians find that local and regional variation in treatment for common aliments, such as breast cancer and back pain,[6,7] correlate with ownership of imaging equipment, testing devices, and ambulatory or in-patient treatment centers.[8]

Rather than fighting the accusations of unethical conduct with self-righteous assertions by our professional associations, it would be more appropriate to train the next generation of doctors to incorporate high-level moral reasoning in their medical and professional decision making.

Surveys of medical school and residency training programs find that formal education in medical ethics and moral reasoning is sadly deficient,[9] and no wonder: Discussing ethics in the abstract is both boring and ill-focused.

Since doctors in training have turned increasingly towards review articles (both print and Web-based) as sources of information, it occurred to me that such publications should shine a brighter light on ethics issues arising out of topics their authors cover. For instance, assume a submission reviews the treatment of carpal tunnel syndrome and notes that most workers' compensation patients with electrodiagnostically negative CTS do poorly after transverse carpal ligament release. I believe that manuscripts' authors should discuss whether it's ethical to perform surgery on a subset of patients prone to an unfavorable outcome. In this way, we'll incorporate ethical judgment into all facets of medical education.

I'm concerned that our profession, after repeated conflict-of-interest inquiries (whether appropriate or off target), won't be invited to the table when the final structure of America's new healthcare paradigm is considered. While it seems impossible that doctors wouldn't be involved, remember that Hillary Clinton's health plan was drafted without much physician input. Even more remarkably, when Gov. Schwarzenegger's staff crafted California's monumental Workers' Compensation Reform Act, neither doctors nor lawyers were consulted, only labor and business. Perhaps the governor suspected that workers' comp treaters and claimant attorneys milked the system for their own benefit and thus wouldn't serve either the employers' or the injured workers' future interests.

If we continue to burn through our good will by continuous acts perceived by the public as corrupt, we'll get what we deserve!

That's my opinion. I'm Dr. Stuart A. Green, Clinical Professor of Orthopaedic Surgery at the University of California, Irvine.



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