Narrowing the gap between the rhetoric and the reality of medical ethics

Academic Medicine

Volumn 71, Issue 3, 1996, Pages 227-237

  Silverman, David R ^a,b  

^a STANFORD LAW SCHOOL   (United States)

^b NONE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

CLINICAL EDUCATION; HEALTH CARE QUALITY; LAW; LEGAL ASPECT; MEDICAL EDUCATION; MEDICAL ETHICS; MEDICAL PRACTICE; PATIENT CARE; PHYSICIAN ATTITUDE; PRIORITY JOURNAL; REVIEW;

EID: 0029981881     PISSN: 10402446     EISSN: None     Source Type: Journal    
DOI: 10.1097/00001888-199603000-00010     Document Type: Review

References (123)

1. Report of the Secretary's Commission on Medical Malpractice. DHEW Publ No. (OS) 78-89. Washington, DC: Government Printing Office, 1973:73. Bok D. The Cost of Talent, New York: The Free Press, 1993:67.
2. Report of the Secretary's Commission on Medical Malpractice. DHEW Publ No. (OS) 78-89. Washington, DC: Government Printing Office, 1973:73. Bok D. The Cost of Talent, New York: The Free Press, 1993:67.
3. For an illustration of the (83) clinical skills expected of medical school graduates, see Martin YM, Harris DL, Karg MB. Clinical competencies of graduating medical students. J Med Educ. 1985;60:919-24.
4. Lewis IJ. The Sick Citadel. Cambridge, MA: Oelgeschlager, Gunn & Hain, 1983:140.
5. Rensberger B. The Touchy Issue of Trainee Surgeons Operating without Consent of Patients. The New York Times. 1978 Feb 6; Sect. B:12 (col.1). Holmes MK. Ghost surgery. Bull NY Acad Med 1980;56:412-9.
6. Rensberger B. The Touchy Issue of Trainee Surgeons Operating without Consent of Patients. The New York Times. 1978 Feb 6; Sect. B:12 (col.1). Holmes MK. Ghost surgery. Bull NY Acad Med 1980;56:412-9.
7. Holmes, supra note 4.
8. Seelig CB. Quantitating qualitative issues in residency training. J Gen Intern Med. 1993;8:610-3. Christakis DA, Feudtner C. Ethics in a short white coat: the ethical dilemmas that medical students confront. Acad Med. 1993;68:249-54 (arguing that current medical curricula do not adequately address the ethical issues medical students face as students).
9. Seelig CB. Quantitating qualitative issues in residency training. J Gen Intern Med. 1993;8:610-3. Christakis DA, Feudtner C. Ethics in a short white coat: the ethical dilemmas that medical students confront. Acad Med. 1993;68:249-54 (arguing that current medical curricula do not adequately address the ethical issues medical students face as students).
10. Greganti MA, Drossman DA, Rogers JF. The role of the attending physician. Arch Intern Med. 1982;142:698-9.
11. Roberts CM. Doctor and Patient in the Teaching Hospital. Lexington, MA: Lexington Books, 1977:54.
12. Report of the Secretary's Commission on Medical Malpractice, supra note 1.
13. Dworkin G. the 'student doctor' and a wary patient: commentary. Hastings Ctr Re. 1982;12:27-8.
14. Brennan TA, Herbert LE, Laird NM, et al. Hospital characteristics associated with adverse events and substandard care. JAMA. 1991;265:3265-9 (finding that primary teaching hospitals have a lowet rate of adverse patient events due to negligence than do non-teaching hospitals). Dailey TH, Leff EI. Resident surgery - is it safe? Dis Colon Rectum. 1978;21:85-8 (finding that patients operated on by residents under direct attending supervision have surgical results comparable to those of patients operated on by attending surgeons).
15. Brennan TA, Herbert LE, Laird NM, et al. Hospital characteristics associated with adverse events and substandard care. JAMA. 1991;265:3265-9 (finding that primary teaching hospitals have a lowet rate of adverse patient events due to negligence than do non-teaching hospitals). Dailey TH, Leff EI. Resident surgery - is it safe? Dis Colon Rectum. 1978;21:85-8 (finding that patients operated on by residents under direct attending supervision have surgical results comparable to those of patients operated on by attending surgeons).
16. Richardson PH, Curzen P, Fonagy P. Patients' attitudes to student doctors. Med Educ. 1986;20:314-7. King D, Benbow SJ, Elizabeth J, Lye M. Attitudes of elderly patients to medical students. Med Educ 1992;26:360-3. Linfors EW, Neelson FA. The case for bedside rounds. N Engl J Med. 1980;303:1230-3.
17. Richardson PH, Curzen P, Fonagy P. Patients' attitudes to student doctors. Med Educ. 1986;20:314-7. King D, Benbow SJ, Elizabeth J, Lye M. Attitudes of elderly patients to medical students. Med Educ 1992;26:360-3. Linfors EW, Neelson FA. The case for bedside rounds. N Engl J Med. 1980;303:1230-3.
18. Richardson PH, Curzen P, Fonagy P. Patients' attitudes to student doctors. Med Educ. 1986;20:314-7. King D, Benbow SJ, Elizabeth J, Lye M. Attitudes of elderly patients to medical students. Med Educ 1992;26:360-3. Linfors EW, Neelson FA. The case for bedside rounds. N Engl J Med. 1980;303:1230-3.
19. Richardson, supra note 12.
20. Kapp MB. Legal implications of clinical supervision of medical students and residents. J Med Educ 1983;58:293-9.
21. See John F. Kennedy Hospital v. Heston, 279 A.2d 670 (N.J. 1970) (noting the patient can not demand "mistreatment," by rejecting a specific procedure).
22. Joint Commission on Accreditation of Hospitals. Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Hospitals, 1994.
23. American Medical Association Council on Ethical and Judicial Affairs. Code of Medical Ethics: Current Opinions with Annotations. Chicago, IL: American Medical Association, 1994.
24. American College of Surgeons. Statement on principles, § I.A, 1981, cited in Rich BA. Malpractice issues in academic medical centers. J Coll Univ L. 1986;13:149-77.
25. Massachusetts, for example, has incorporated a statutory code section titled "Patients' Rights." This code explicitly requires explanation of the educational role of the teaching hospital and provides patients with a non-waivable right to refuse educational examination. Mass. Gen. L. ch. 111, § 70E (1985).
26. Schoendorff v. New York Hospital, 105 N.E. 92 (N.Y. 1914).
27. Academic medical centers were for the most part insulated from litigation by the law's charitable institution immunity until the landmark case, Darling v. Charleston Memorial Hospital, 211 N.E.2d 253 (Ill. App. 1965).
28. Inderbitzen v. Lane Hospital, 12 P.2d 744 (Cal. App. 1932).
29. Ibid.
30. Canterbury v. Spence, 464 F.2d 772 (D.C. Cir 1972), cert. denied, 409, U.S. 1064.
31. Edwards SL. Failure to inform as medical malpractice. Vand L Rev. 1970;23:754-74.
32. See Blaskas v. Murray, 646 P.2d 907 (Colo. 1982) (holding that a physician who falsely represented to a patient that he had experience in ankle replacement surgery was liable for negligent misrepresentation).
33. Perna v. Pirozzi, 457 A.2d 431 (N.J. 1983) (holding that a physician who did not adequately advise a patient that his group practice treated all patients collectively was guilty of medical malpractice).
34. Dubois RW, Rogers WH, Moxley JH 3d, Draper D, Brook RH. Hospital inpatient mortality: is it a predictor of quality? N Engl J Med. 1987;317:1674-80.
35. All the states bar the unlicensed practice of medicine, usually with a broad statutory provision that includes a restriction on the use of the terms "doctor" and "physician." New York, for example, stipulates that "Anyone not authorized to use a professional title regulated by this title, and who uses such professional title, shall be guilty of a class A misdemeanor." N.Y. Education Law §6513 (McKinney Supp. 1984).
36. Massachusetts Board of Registration in Medicine, Rules and Regulations, VI.3 (1977).
37. Dworkin, supra note 10. Kapp, supra note 14. Simpson CL. Misrepresentation in teaching hospitals. Med Trial Tech Q. 1977;23:233-69.
38. Dworkin, supra note 10. Kapp, supra note 14. Simpson CL. Misrepresentation in teaching hospitals. Med Trial Tech Q. 1977;23:233-69.
39. See, e.g., Kern v. St. Luke's Hospital Association of Saginaw, 273 N.W.2d 75, 82 (Mich. 1978).
40. Fjerstad v. Knutson, 271 N.W.2d 8, 13-14 (S.D. 1978) (noting that an intern's use of the title "doctor" may violate the state's illegal practice of medicine statute because interns are not yet licensed physicians).
41. Simpson, supra note 31, citing Stulberg SD. The legal status of medical students in the state of Michigan. Univ Mich Med Cent J. 1970;36:77-83.
42. Simpson, supra note 31, citing Stulberg SD. The legal status of medical students in the state of Michigan. Univ Mich Med Cent J. 1970;36:77-83.
43. Annas GJ. The hospital: a human rights wasteland. Civil Lib Rev. 1974;1:9-29.
44. Louis Harris and Associates. Views of Informed Consent and Decision Making: Parallel Surveys of Physicians and the Public. In: President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Managing Health Care Decisions: Volume Two. Washington, DC: Government Printing Office, 1982.
45. Holmes, supra note 4.
46. Annas, supra note 35. Cohen DL, Kessel RWI, McCullough LB, Apostolides AY, Hiderich KJ, Alden ER. Pelvic examinations by medical students. Am J Obstet Gynecol. 1989;161:1013-4.
47. Annas, supra note 35. Cohen DL, Kessel RWI, McCullough LB, Apostolides AY, Hiderich KJ, Alden ER. Pelvic examinations by medical students. Am J Obstet Gynecol. 1989;161:1013-4.
48. Louis Harris and Associates, supra note 36.
49. Ibid.
50. Sade RM. Private patients and surgical training. JAMA. 1977;238:2180.
51. Shultz MM. From informed consent to patient choice: a new protected interest. Yale L J. 1985;95:219-99 (citing Katz RL. Informed consent: is it bad medicine? West Med. 1977;126:426-28).
52. Shultz MM. From informed consent to patient choice: a new protected interest. Yale L J. 1985;95:219-99 (citing Katz RL. Informed consent: is it bad medicine? West Med. 1977;126:426-28).
53. Bosk CL. Forgive and Remember. Chicago: University of Chicago Press, 1979:56 and no. 5, 218-19. C.f. Hill v. Seward, 470 N.Y.S.2d 971 (1983) (holding that an attending surgeon [but not the resident] may be liable for malpractice if the resident fails to obtain proper/adequate informed consent for a procedure done by the surgeon).
54. Bosk, supra note 43.
55. Cohen DL, McCullough LB, Kessel RWI, Apostolides AY, Alden ER, Heiderich KJ. Informed consent policies governing medical students' interactions with patients. J Med Educ. 1987;62:789-98.
56. Cohen DL, McCullough LB, Kessel RWI, et al. A national survey concerning the ethical aspects of informed consent and role of medical students. J Med Educ. 1988;63:821-9.
57. Ibid.
58. Although this is, of course, understandable from the student's perspective, it seems particularly perverse with respect to the patient's interests.
59. Cohen, supra note 38.
60. Kapp, supra note 14.
61. Rush v. Akron General Hospital, 171 N.E.2d 378, 381 (Ohio App. 1957).
62. Harrigan v. United States, 408 F. Supp 177, 185 (E.D. Penn. 1976) (quoting language from McPhee v. Reichel, 461 F.2d 947 [3rd Cir. 1972]).
63. Pratt v. Stein, 444 A.2d 674, 708 (Penn. 1982); c.f. Dent v. West Virginia, 129 U.S. 114 (1888) (upholding a state health board's expulsion of a medical college graduate due to incompetence because in Justice Field's words, "no one has the right to practice medicine without necessary qualifications of learning and skill").
64. McBride v. United States, 462 F.2d 72, 74 (9th Cir. 1972).
65. See e.g., Solomon v. Presbyterian University Hospital, 530 A.2d 85, 99 (Penn. 1987) (discussing the requirements imposed by Pennsylvania's Medical Practice Act of 1974 and Medical Practice Act of 1985); but see New York State Hospital Code Section 405.4, discussed infra note 83 and accompanying text.
66. Williamson HA, Glenn JK, Spencer DC, Reid JC. The development of clinical independence: resident-attending physician interactions in an ambulatory setting. J Fam Pract. 1988;26:60-4. Bosk, supra note 43, at p. 41.
67. Kapp, supra note 14. Cavenar JO, Rhoads EJ, Sullivan JL. Ethical and legal aspects of supervision. Bull Menninger Clin. 1980;44:15-22 (citing Tarasoff v. Regents of the University of California, 131 Cal. Rptr. 14 [1976]). See, e.g., McCullough v. Hutzel Hosp., 276 N.W.2d 569 (Mich. App. 1979); Orezco v. Henry Ford Hospital, 290 N.W.2d 363 (Mich. 1980); Powers v. United States, 589 F. Supp. 1084 (D. Conn. 1984).
68. Kapp, supra note 14. Cavenar JO, Rhoads EJ, Sullivan JL. Ethical and legal aspects of supervision. Bull Menninger Clin. 1980;44:15-22 (citing Tarasoff v. Regents of the University of California, 131 Cal. Rptr. 14 [1976]). See, e.g., McCullough v. Hutzel Hosp., 276 N.W.2d 569 (Mich. App. 1979); Orezco v. Henry Ford Hospital, 290 N.W.2d 363 (Mich. 1980); Powers v. United States, 589 F. Supp. 1084 (D. Conn. 1984).
69. See Hill v. Seward, 470 N.Y.S.2d 971 (1983) (holding that the plaintiff has an action to recover against a surgeon for performance of surgery without informed consent when it is alleged that his resident failed to properly consent the patient).
70. Maxwell v. Cole, 482 N.Y.S.2d 1000, 1001 (1984).
71. See, e.g., Schoening v. Grays Harbor Community Hosp., 698 P.2d 593 (Wash. App. 1985); Hardy v. Brantley, 471 So.2d 358 (Miss. 1985); Paintsville Hosp. Co. v. Rose, 683 S.W.2d 255 (Ky. 1985); Darling v. Charleston Community Mem. Hosp. 211 N.E.2d 253 (Ill. 1965).
72. County of Riverside v. Loma Linda University, 173 Cal. Rptr. at 382 (Ct. of App. 1981)
73. Mizrahi, T. Managing medical mistakes: ideology, insularity and accountability among internists-in-training. Soc Sci Med. 1984;19:135-46.
74. Bucher R. Becoming Professional. Beverly Hills, CA: Sage Publications, 1977. Mizrahi, supra note 62.
75. Bosk, supra note 43, at pg. 188.
76. Telephone interview, January 9, 1995.
77. Williamson, supra note 56.
78. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265:2089-94.
79. Boutros A, Della Ratta RK. Internal medicine program directors' perceptions of resident work rounds. J Comm Health. 1994;19:231-8.
80. Wu, supra note 67.
81. Ibid.
82. Short JP. The importance of strong evaluation standards and procedures in training residents. Acad Med. 1993;68:522-5.
83. Schueneman AL, Carley JP, Baker WH. Residency evaluations: are they worth the effort? Arch Surg. 1994;129:1067-73. Short, supra note 71 (finding that despite the heterogeneity of clinical skills and competencies among residents, very few (1.8%) are ever weeded out and dismissed from training programs).
84. The perceived lack of feedback is endemic throughout the whole cycle of medical education, starting with medical students reporting problems on clinical clerkships. Gil DH, Heins M, Jones PB. Perceptions of medical school faculty members and students on clinical clerkship feedback. J Med Educ. 1984;59:856-64.
85. Short, supra note 71.
86. Mizrahi, supra note 62.
87. Ibid.
88. Ibid.
89. Yedidia MJ, Lipkin M, Schwartz MD, Hirschkorn C. Doctors as workers: work-hour regulations and interns' perceptions of responsibility, quality of care, and training. J Gen Intern Med. 1993;8:429-35 (a very interesting discussion of the implications of this conflict in the context of New York's regulations limiting residents' work hours; with critical findings regarding the law's effectiveness in enhancing patient supervision).
90. Millman M. The Unkindest Cut. New York: Morrow, 1977:129.
91. Helms LB, Helms CM. Forty years of litigation involving residents and their training: II. Malpractice issues. Acad Med. 1991;66:718-25. [Since the Helms study was published there have been only two reported opinions addressing the issue of malpractice that involved residents or medical students, Centman v. Cobb, 581 N.E.2d 1286 (Ind. Ct. App. 1991), and Jackson v. Oklahoma Memorial Hospital, No. 83, 924, 1995 Okla. LEXIS 127, (Sup. Ct. Oct. 17, 1995). Neither decision strayed from the existing lines of legal precedent.]
92. Surprisingly, one study found that the malpractice claim rate is actually related positively to experience until the physicians is 27 years out of medical school. Adams EK, Zuckerman S. Variation in the growth and incidence of medical malpractice claims. J Health Pol Policy L. 1984;9:475-88.
93. Asch DA, Parker RM. The Libby Zion case: one step forward or two steps backward? N Engl Med. 1988;318:771-5.
94. New York State Hospital Code Section 405.4. Adopted by the New York State Hospital Review and Planning Council, June 9, 1988.
95. Levinsky NG. Compounding the error. N Engl J Med. 1988;318:778-80.
96. Glickman RM. House-staff training - the need for careful reform. N Engl J Med. 1988;318:780-2.
97. Boutros, supra note 68. (finding that among internal medicine program directors "patient management" was perceived to be the first goal for resident work rounds).
98. Annas, supra note 35.
99. Wood VC, Markert RJ, McGlynn TJ. Internal medicine residents' perceptions of the balance between service and education in their night-call activities. Acad Med. 1993;68:640-2. Roberts, supra note 8, at p. 45.
100. Roberts, supra note 8, at p. 45.
101. Ibid. at p. 50.
102. McLeod PJ, Tamblyn R, Benaroya S, Snell L. Faculty ratings of resident humanism predict patient satisfaction ratings in ambulatory medical clinics. J Gen Intern Med. 1994;9:321-6 (lamenting the "overemphasis on the cognitive and technical aspects of medicine at the expense of the interpersonal skills and humane qualities of practicing physicians").
103. Linfors, supra note 12 (criticizing the lack of patient interaction by attending physicians conducting rounds, and citing Engel GL. The implications of changes in medical education. Hosp Pract. 1971;6(12):109-16, for the observation that some faculty members, "too often are people who themselves never really have been interested in patients").
104. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Managing Health Care Decisions: Volume One. Washington, DC: Government Printing Office, 1982;33.
105. Linfors, supra note 12.
106. The term was drawn from Dostoyevsky F. The Brothers Karamazov. Middlesex, England: Penguin Books Ltd., 1964.
107. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavior Research, supra note 92, at no. 21 p. 135.
108. Katz J. Informed consent - a fairy tale?: law's vision. U Pitt L Rev. 1977;39:137-74.
109. Katz J. Disclosure and consent: in search of their roots. In: National Symposium on Genetics and the law. Annas GJ, Milunsky A (eds). Genetics and The Law II. New York: Plenum Press, 1980.
110. Louis Harris and Associates, supra note 36.
111. Richardson, supra note 12.
112. For an interesting interpretation of the clash of professional cultures, see Gibson, Schwartz. Physicians and Lawyers: Science, Art, and Conflict. In: Furrow BR, Johnson SH, Jost TS, Schwartz RL (eds). Bioethics: Health Care Law and Ethics. St. Paul, MN: West Publishing, 1991:404.
113. Hiatt HH, Barnes BA, Brennan TA, et al. A study of medical injury and medical malpractice. N Engl J Med. 1989;321:480-4.
114. Shultz, supra note 42.
115. Siegler M. Searching for moral certainty in medicine: a proposal for a new model of the doctor-patient encounter. Bull NY Acad Med. 1981;57:56-69.
116. Katz, supra note 97.
117. For an interesting, although somewhat inconclusive, discussion of these findings and their prescriptive meaning, see President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, supra note 92, at pp. 153-5.
118. Lidz CW, Meisel A. Consent and the structure of medical care. In: President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Managing Health Care Decisions: Volume Two. Washington, DC: Government Printing Office, 1982.
119. Lidz CW, Meisel AM, Zerubavel E, et al: Informed Consent: A Study of Decision Making in Psychiatry. New York: Guilford Press, 1983. Lidz CW, Appelbaum PS, Meisel A. Two models of implementing informed consent. Arch Intern Med. 1988;148:1385-9.
120. Lidz CW, Meisel AM, Zerubavel E, et al: Informed Consent: A Study of Decision Making in Psychiatry. New York: Guilford Press, 1983. Lidz CW, Appelbaum PS, Meisel A. Two models of implementing informed consent. Arch Intern Med. 1988;148:1385-9.
121. Lidz, supra note 106.
122. Cassell EJ. The 'student doctor' and a wary patient: commentary. Hastings Ctr Rep. 1982;12:27-8. Pernick MS. The patient's role in medical decision making: a social history of informed consent in medical therapy. In: President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Managing Health Care Decisions: Volume Three. Washington, DC: Government Printing Office, 1982.
123. Cassell EJ. The 'student doctor' and a wary patient: commentary. Hastings Ctr Rep. 1982;12:27-8. Pernick MS. The patient's role in medical decision making: a social history of informed consent in medical therapy. In: President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Managing Health Care Decisions: Volume Three. Washington, DC: Government Printing Office, 1982.