Residents Need Better Ethics Training

After serving on the ethics committees of both my district branch and the national APA, I concluded that many ethics breaches could easily be prevented if doctors received the proper teaching on ethics during their residency.

Ethics is such an important issue that it should be a major component of residency education. Despite the need for a comprehensive ethics curriculum, however, there is little uniformity from program to program, with some programs all-inclusive and some barely touching on the topic. Moreover, there is minimal research to guide residency programs in selecting the most effective strategies for teaching medical ethics.

Some practitioners feel that teaching ethics does not necessarily create ethical residents, and doctors should know right from wrong before they even enter medical school. This view suggests that a doctor who commits an ethical transgression would probably do so no matter what he or she is taught in medical school or residency. This argument maintains that the only way to have ethical residents is to screen candidates and pick those who appear to have an appealing moral fiber and value system. There is some validity to the argument that moral and ethical development comes from experiences that start in early childhood and are a result of the individual's upbringing. However, I would argue that we need to select residents who appear to have good pre-existing values, but augment these values by making a conscious effort to teach ethics in residency.

There are not many absolutes in medical ethics. Principles of medical ethics such as beneficence, autonomy, nonmaleficence, and justice can be at odds with one another, and in adhering to one principle a physician may violate another. For example, in psychiatry we are sometimes faced with a conflict between autonomy—patients' freedom to make their own decisions—and beneficence, that is, the psychiatrist's obligation to do what is best for the patient. This happens, for example, every time we sign involuntary hospitalization papers. But physicians are not born understanding ethical principles, they must be taught. A resident who is fluent in his or her understanding of ethics will know that there are rarely absolutes in ethical decisions and will carefully weigh all options. Attainment of this ability requires skill and careful contemplation that can best be fostered through didactics and open discussion during training. Furthermore, talking about ethics is stimulating and leads to the most heated debates residents encounter during training.

It is naïve to take for granted that residents already know, or can teach themselves, basic ethical principles. Residents are exceedingly busy and often do not read unless specifically instructed to do so by their supervisors. So to assume residents will read The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry may be overly optimistic. Furthermore, this 35-page document, which outlines the principles upon which residents and doctors should base their practice, was never handed out during my internship, nor was I told by my senior residents, “Read this; it will guide you.”

In 1996, APA formed a task force to develop curricular material in psychiatric ethics titled “A Basic Model Ethics Curriculum for Psychiatric Residents.” This included a comprehensive list of topics that should be covered as well as methods to assess the resident's skills, attitudes, and professionalism. In 2001 APA published an ethics primer, and 7,000 copies were sent to residents across the country. These tools were helpful, but more needs to be done to build on this base, since they did not offer much practical guidance for training directors or others in the department on how to create an ethics curriculum. This leads to omissions and considerable variability from one residency program to another.

The New York County District Branch, on whose ethics committee I served, surveyed the didactic portion of the various ethics programs in New York, and in reviewing what the residencies shared about their curriculum, we discovered a wide inconsistency in the way ethics was taught. The range of topics in most programs varied, and most lacked the breadth of knowledge needed to assist psychiatrists in facing the difficult ethical issues that will inevitably arise in their practice.

While I am not suggesting that we impose a very rigid curriculum upon psychiatry residencies, there is a clear need for thoughtful guidelines to help elevate the standards of most programs.

What needs to be included are basics such as the number of ethics-related sessions a program should have, important readings, and sample cases for discussion. I would suggest developing a model curriculum that contains a 12-session lecture series, which should contain topics such as core ethical principles, allocation of scarce resources, ethical issues in research, confidentiality, the insanity defense, and ethics in pharmaceutical-industry interactions. Readings should be assigned from multiple sources, such as the Bloch and Chodoff text, as well as articles from the lay press. Sample cases should highlight specific ethical principles, and these should be topics for discussion. Residents should be encouraged to bring cases that they have encountered in clinical practice to stimulate discussion.

I challenge the profession to create a first-rate ethics curriculum that will enable residents to make difficult decisions with competence and conviction. ▪