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Keywords:

  • ethics;
  • biomedical ethics;
  • law;
  • health law;
  • teaching;
  • education

Abstract

  1. Top of page
  2. Abstract
  3. BIOETHICS IN THE MEDICAL SCHOOL CURRICULUM
  4. ETHICS AND LAW AT THE UNIVERSITY OF IOWA
  5. GOALS, METHODS, AND CORE THEMES
  6. IT'S ETHICAL, BUT IS IT LEGAL?
  7. CONCLUSION
  8. LITERATURE CITED
  9. Biographical Information

While Western medical ethics has ancient roots in the teachings of Hippocrates, its standing in the undergraduate medical curriculum is a distinctly modern development. Today, all of the 127 accredited U.S. medical schools offer formal biomedical ethics instruction, and nearly all offer instruction in the related discipline of health law. This article describes how biomedical ethics and health law are taught at the University of Iowa College of Medicine, one of 12 medical schools that offers separate required courses in both ethics and law. Often ethics and law overlap; often, to act ethically is to act legally. But medical students and practicing physicians also regularly confront dilemmas that pose the question, “It's ethical, but is it legal?” This article discusses the goals, methods, and core themes of teaching issues at the intersection of medicine, ethics, and law, and how the approach to this instruction is designed to offer students a tool kit to begin to deal effectively with these complex issues in professional life. Anat Rec (New Anat) 265:5–9, 2001. © 2001 Wiley-Liss, Inc.

A patient with HIV/AIDS refuses to tell his spouse of his condition. His physician feels morally bound to warn her, but is directed by law to stringently safeguard confidentiality.

A patient with amyotrophic lateral sclerosis (ALS, or Lou Gehrig disease), dying a slow, agonizing death, asks her physician to prescribe analgesics so that she may die with dignity. Her physician feels that complying would be compassionate and humane, but knows that the law makes physician-assisted suicide a crime, allowing comfort care for pain and other symptoms but punishing actions intended to hasten death.

A physician calls the patient's health plan to complain that its refusal to authorize a longer hospital stay will be harmful to the patient. The health plan remains steadfast, the patient is discharged and subsequently is readmitted for emergency surgery that results in loss of a limb.

Dilemmas such as these are not just tools of the classroom; they occur in the real world of the practicing physician. Not infrequently, physicians are called upon to examine both the ethical and legal dimensions of problems in patient care, and to ask: “It's ethical, but is it legal?” or conversely, “It's legal, but is it ethical?” Each question calls us to explore the common, and uncommon, ground between two disciplines that have been instrumental and closely intertwined in the emergence of biomedical ethics and health law (more generally bioethics) as critical components of contemporary medicine (Annas, 1993; Capron and Michel, 1993). In turn, each discipline has also earned an important foothold in the training of future physicians in undergraduate medical education.

This article describes how biomedical ethics and health law are taught at the University of Iowa College of Medicine. As someone who is formally trained and teaches in both areas, my particular focus will be on how the approach to this instruction is designed to offer students a tool kit to prepare themselves to deal effectively with issues at the intersection of medicine, ethics, and law in professional life. First, I offer a brief overview of the place of ethics and law in medical school curricula, past and present.

BIOETHICS IN THE MEDICAL SCHOOL CURRICULUM

  1. Top of page
  2. Abstract
  3. BIOETHICS IN THE MEDICAL SCHOOL CURRICULUM
  4. ETHICS AND LAW AT THE UNIVERSITY OF IOWA
  5. GOALS, METHODS, AND CORE THEMES
  6. IT'S ETHICAL, BUT IS IT LEGAL?
  7. CONCLUSION
  8. LITERATURE CITED
  9. Biographical Information

While Western medical ethics has ancient roots in the teachings of Hippocrates (the Hippocratic oath, or some variation of it, is still recited by the entering class at many medical schools), its standing in the undergraduate medical curriculum is a distinctly modern development. In 1974, 97 of 107 (90.6%) medical schools reported teaching medical ethics, but only six (3.5%) of these schools made ethics education a requirement (Veatch and Solitto, 1976). The next decade saw rapid expansion in humanities and human values curricula, with 43 of 127 (40.2%) medical schools reporting separate required courses in ethics (Miles et al., 1989). Today, all of the 127 accredited U.S. medical schools offer formal biomedical ethics instruction. A closer look reveals that 63 (50%) teach ethics as a separate required course. Of all institutions, 102 teach ethics as part of an existing required course and 60 offer elective courses on ethics (Association of American Medical Colleges, 1998–1999).

During this same period, health law (often denominated law and medicine, or medical jurisprudence) made parallel gains in visibility and acceptance. In the mid-1970s, 40 of 101 (39.6%) U.S. medical schools reported a required course in this area, with 33 additional schools offering an elective. By 1987, a course in law and medicine was offered at 54 of the 127 (42.5%) medical schools and was a required course at half of those institutions (Williams and Winslade, 1995). Today, health law is offered at all but 13 U.S. medical schools. In contrast to the historical trend toward a free-standing required course in ethics, legal issues have increasingly been subsumed within broader curricular offerings. Students' exposure comes as part of an existing required course at 95 (74.8%) U.S. medical schools, and as an elective in 54 curricula. Only 12 (9.4%) schools offer a separate required course in law and medicine (Association of American Medical Colleges, 1998–1999).

ETHICS AND LAW AT THE UNIVERSITY OF IOWA

  1. Top of page
  2. Abstract
  3. BIOETHICS IN THE MEDICAL SCHOOL CURRICULUM
  4. ETHICS AND LAW AT THE UNIVERSITY OF IOWA
  5. GOALS, METHODS, AND CORE THEMES
  6. IT'S ETHICAL, BUT IS IT LEGAL?
  7. CONCLUSION
  8. LITERATURE CITED
  9. Biographical Information

The University of Iowa College of Medicine is among the relative few to offer separate required courses in both ethics and law. Both courses are directed by faculty in the Program in Biomedical Ethics and Medical Humanities (PBEMH). Formally established in 1992, the PBEMH grew out of the merger of three related but administratively distinct programs: Biomedical Ethics (established 1988), Medical Humanities (1983), and History of Medicine (1989). As currently constituted, the program faculty includes a director trained in religious studies and five additional faculty collectively trained in medicine, history, clinical psychology, communication studies, religious studies, philosophy, bioethics, and law. While the second-year courses in Biomedical Ethics and Health Law form the core required exposure to ethical and legal issues, medical students also encounter various aspects of ethics and medical humanities through a required course entitled “Death, and the Dying Patient.” Students may also choose an elective course on the history of medicine, and they receive a series of lectures from program faculty in their first semester. Physician-faculty facilitate “ethics teaching moments” on the floor for students and residents.

Like many of its sister medical colleges, the principal subject matter taught at the UI College of Medicine attends to ethical issues at the heart of the physician-patient relationship.

An initiative to formalize and integrate ethics and law education for students and residents in the clinical clerkship years is currently in its formative stages.

As at many medical schools, ethics and law are taught in the pre-clinical years, coming in the third and fourth terms, respectively. Both are taught through a combination of didactic sessions given by program faculty and small group, case-based discussions, with time evenly divided between the two formats on the topic for that week. The total number of contact hours is 30 (20 for ethics, 10 for law). Ethics discussion groups are team taught, typically pairing a physician and non-physician to lead each group. Among non-physicians, nursing and social work are the most frequently represented of the course faculty. The complement of physician and health professional faculty places important expertise and experience in the classroom (though not of course, a trained ethicist in every room), and attests to the clinical relevance of ethics.

Taking a slightly different approach, each small group for health law is led by an attorney, typically drawn from university faculty, university and hospital counsel, and private practice. More than half practice or teach health law. Beyond development of a knowledge base, students' exposure to “real-life” attorneys hopefully serves as well to alleviate familiar disquiets about law and lawyers found among many medical students (mirroring many practicing physicians) and to foster more positive attitudes about the legal profession.

Like many of its sister medical colleges, the principal subject matter taught at the UI College of Medicine attends to ethical issues at the heart of the physician-patient relationship, including confidentiality, informed consent, patient autonomy, decisional capacity, the role and authority of families, and decisions at the beginning and near the end of life. Matters of social policy and responsibility (for example, allocation of scarce life-saving donor organs) receive some, though comparatively less, attention, though matters of the physician-professional's role in society frequently emerge in group discussions.

Health law, also focused on the physician-patient relationship, turns to several of the same general topics (confidentiality, informed consent, right to refuse treatment) and reinforces some core themes, emphasizes legal aspects of common and uncommon clinical problems, and stresses points of difference between ethical and legal approaches. In addition, students are exposed to more traditional medico-legal issues, such as patient abandonment, malpractice, and duties of care in emergencies. Recognizing the changing face of health care, questions of patient advocacy in a managed care environment are addressed from the standpoint of both disciplines.

GOALS, METHODS, AND CORE THEMES

  1. Top of page
  2. Abstract
  3. BIOETHICS IN THE MEDICAL SCHOOL CURRICULUM
  4. ETHICS AND LAW AT THE UNIVERSITY OF IOWA
  5. GOALS, METHODS, AND CORE THEMES
  6. IT'S ETHICAL, BUT IS IT LEGAL?
  7. CONCLUSION
  8. LITERATURE CITED
  9. Biographical Information

Bioethics instruction should emphasize realistic goals within the larger context of a predominantly clinical, scientific educational model, and should strive to impart and cultivate practical problem-solving tools that students can “take home” (Pellegrino, 1989; Williams and Winslade, 1995). Thus, beyond expansion of a core knowledge base and a general familiarity with new concepts and vocabulary, our biomedical ethics course emphasizes the development of basic skills and abilities to recognize ethical issues in clinical cases and daily practice; identify multiple perspectives (economics, law, politics, religion) that shape medical practice; reason about acceptable alternatives and choose the “best” course of action; and interpret and discuss some of the complex professional and societal issues confronting medicine and society. Most of these objectives resonate with the course of legal instruction as well, where stress is placed on beginning skills of legal reasoning and sensitivity to the ways in which law shapes the rights and duties of patients, families, and physicians and the nature of the physician-patient relationship.

Students should come to appreciate a range of lessons about what counts as acceptable professional behavior (for example, having a patient's informed consent before surgery, recognizing the rights of families at the bedside of dying patients). However, no pretense is made to teach students to be virtuous, nor to produce more ethical or law-abiding physicians. Such aspirations invoke assumptions about the translation of knowledge and reasoning into habits of behavior that reach well beyond the classroom (Koppelman, 1999). If the intellectual and reasoning skills to which students are exposed are internalized as habits of reflection and sensitivity to the role of values in medicine— a first step on the path to habits of conduct— this would, of course, be a welcome dividend. Though not a question that has been widely researched, several studies suggest that ethics education (and by implication, legal education) can in fact have this effect, attesting to the contributions of these disciplines to the undergraduate curriculum. Medical ethics education has been shown to improve students' moral reasoning skills (Self et al., 1989), and can increase physicians' ability to recognize and address ethical and legal issues in patient care (Markson et al., 1997). Many physicians perceive their own ethics education in medical school to have had substantial practical benefit (Pellegrino et al., 1985).

Pedagogical choices of methodology are directly related to the goals and expectations for the course of instruction. Biomedical Ethics is taught as applied ethics. The prevailing emphasis, particularly in small group discussions, is on employing the established principles of bioethics— autonomy, beneficence, nonmaleficence, and justice— to analyze problems presented by clinical cases. This principle-based approach to “doing bioethics,” in which principles frame the analysis and reasoning proceeds back and forth between the facts of the case and the relevant principles, is the prevailing model of bioethics discourse. As a teaching method, it also finds an easy fit with a time-honored pattern of legal reasoning that begins with cases and looks to the rule of law (constitution, statutes, and case precedent) to adjudicate disputes between patients and physicians. Applied ethics and applied law share important commitments to the reasoned deployment of rules and principles in problem-solving, offering a framework for thinking through a range of clinical dilemmas that lie ahead for the future physician. At the same time, students in the ethics course are exposed to alternative analytical approaches (casuistry, narrative, an ethic of care) and to the leading ethical theories (deontology/respect for persons, utilitarianism/consequentialism, virtue theory). Group discussions often explore these different ways of “seeing” the problem, and both ethical and legal case analyses bring out the contextual features of cases that are sometimes overlooked in a rigidly principle-based (or in law, a rule-based) approach.

Applied ethics and applied law share important commitments to the reasoned deployment of rules and principles in problem-solving, offering a framework for thinking through a range of clinical dilemmas that lie ahead for the future physician.

IT'S ETHICAL, BUT IS IT LEGAL?

  1. Top of page
  2. Abstract
  3. BIOETHICS IN THE MEDICAL SCHOOL CURRICULUM
  4. ETHICS AND LAW AT THE UNIVERSITY OF IOWA
  5. GOALS, METHODS, AND CORE THEMES
  6. IT'S ETHICAL, BUT IS IT LEGAL?
  7. CONCLUSION
  8. LITERATURE CITED
  9. Biographical Information

The medical-ethical-legal landscape enjoys shared commitments to a number of foundational norms at the heart of the physician-patient-family relationship, among them informed consent, confidentiality, respect for autonomy, and family authority to decide for incompetent loved ones near the end of life. Often, to act ethically is to act legally. At the same time, one of the most significant challenges of teaching ethics and law arises from the fact that in other areas, and in particular cases, the ethically appropriate response is not necessarily supported by the law, nor is legal compliance always synonymous with morally licit behavior. Making the transition from ethics to law, and acquiring the tools to bridge the gap, is a central theme of our health law course. The brief scenarios that begin this article illustrate some of the important messages.

The patient who refuses to inform his spouse of his HIV-positive status places the physician on the horns of an ethical and legal dilemma. Presented as an ethical issue, most medical students conclude (by a show of hands) that the magnitude of the potential harm to the wife, together with the possibility of preventing transmission or initiating early testing and intervention, justifies breaching the duty of confidentiality owed the patient, even at the expense of the patient's trust. On the other hand, the picture changes when presented as a legal issue. Where the state statute governing HIV/AIDS imposes a strict duty of confidentiality, the physician (student) must confront the call of conscience and conviction when the ethically licit choice puts him or her at legal risk for breaching confidentiality. Complicating the matter, to hold confidentiality dear may expose the physician to the risk of liability from third parties alleging a duty to warn, at least if the law does not clearly confer immunity for maintaining the patient's confidence.

When another approach in force in some states— a legal permission (not a duty) to warn at-risk third parties— is introduced, a key point differentiating ethics from law comes into view. Having emerged from the laboratory of the states more so than from federal enactments, health law is oft-distinguished by state boundaries, the many areas of consensus notwithstanding. Hence, it can vary from state to state. By contrast, ethics knows no jurisdictional limitations. Ethics is universal, or we might say universalizable in ways that law typically is not.

If extant law on physician-assisted suicide (PAS) is uniform (it is illegal in all states save Oregon), it is hardly “settled.” Whatever one's position on PAS, the very public controversy surrounding it puts at center stage the moral basis of law, pressing us to ask how ethical positions are translated into legal rules and whether the law itself can be immoral. The ALS patient's plea for compassion opens a window on a related lesson. Law does not simply happen to medicine. Professional values, in particular through the voice of organized medicine, can play an essential role in shaping public policy in the legislature, before the judiciary, and in the court of public opinion. Returning to the bedside, those who find the patient's entreaty ethically compelling confront a stark reminder of the power of law. Law has the teeth of enforceability (liability and punishment) in ways that ethics (disapproval) does not.

The third illustration regarding managed care travels into largely new waters where ethics, and to a greater extent law, are in a nascent stage of development. Ethical pronouncements from the American Medical Association and other professional associations admonish physicians to be vigorous patient advocates in the face of the new demands of managed care (American Medical Association, 1998-1999; American College of Physicians, 1998). Yet, to follow this advice may also put the physician at risk of “retaliation” from the managed care organization. The law has barely begun to address how far physicians must go to reverse denials of coverage. And state law nationally offers only a patchwork of protections for physicians in managed care contracts (Miller, 1997). How should prospective physicians respond in the face of significant legal uncertainty? Like PAS, the case example opens a vista to a larger set of important questions, including the patients' rights movement in the laboratory of the states (at the end of 2000, federal interest continued to be stalled in Congress), provider protection laws (less common than those concerned with patients' rights), and again the variability of law from state to state. Both ethical and legal discourse offer important opportunities for medical students to voice and explore their attitudes and perceptions about the managed care environment in which many of them will make their careers.

These are but a few of the cases in which physicians must come to grips with the interrelationships among medicine, ethics, and law. Each emphasizes the place of values in medical practice, and reminds us that medicine is not an insular profession. Rather, the physician's calling is embedded in a larger set of ethical, legal, and societal norms. Substantial common ground between ethical and legal conduct offers important lessons regarding professional expectations. Conscientious reflection on instances where ethics and law may well diverge adds to the prospective physician's tool kit for the practice of good —ethically defensible and legally compliant— medicine.

CONCLUSION

  1. Top of page
  2. Abstract
  3. BIOETHICS IN THE MEDICAL SCHOOL CURRICULUM
  4. ETHICS AND LAW AT THE UNIVERSITY OF IOWA
  5. GOALS, METHODS, AND CORE THEMES
  6. IT'S ETHICAL, BUT IS IT LEGAL?
  7. CONCLUSION
  8. LITERATURE CITED
  9. Biographical Information

In the words of several well-known clinician-ethicists, “[t]he necessity for the teaching of clinical ethics rests in the immutable fact that any serious medical decision involves two components—a technical decision requiring the application of knowledge of basic and clinical sciences to the patient's present problems, and a moral component demanding that the technically correct decision is also morally defensible” (Pellegrino et al., 1990). Much the same may be said of the role of law in medical decisions and of the imperative that decisions be legally defensible.

Clearly ethics and law can be successfully taught as complementary disciplines in the pre-clinical years. Introductory courses can begin to stock the tools needed for future physicians to deal with complex, interdisciplinary problems they will inevitably face in both primary and tertiary care. It must also be acknowledged that in order to consistently demonstrate their clinical relevance and reinforce habits of reflection upon the broader dimensions of the real problems of the practicing physician, bioethical issues and reasoning need to be fully integrated into the medical curriculum spanning all four years (Miles et al., 1989; Brody, 1989). The process of meeting this challenge has just begun at our college of medicine.

LITERATURE CITED

  1. Top of page
  2. Abstract
  3. BIOETHICS IN THE MEDICAL SCHOOL CURRICULUM
  4. ETHICS AND LAW AT THE UNIVERSITY OF IOWA
  5. GOALS, METHODS, AND CORE THEMES
  6. IT'S ETHICAL, BUT IS IT LEGAL?
  7. CONCLUSION
  8. LITERATURE CITED
  9. Biographical Information
  • American College of Physicians. 1998. Ethics Manual, fourth edition. Ann Int Med 128: 576594.
  • American Medical Association, Council on Ethical and Judicial Affairs. 1998–1999. Code of Medical Ethics: Current Opinions with Annotations. Chicago: American Medical Association.
  • Annas GJ. 1993. Standard of care: the law of American bioethics. New York: Oxford Univ. Press.
  • Association of American Medical Colleges, Curriculum Directory, 1998–1999. Wash, DC: Association of American Medical Colleges.
  • Brody BA. 1989. The Baylor experience in teaching medical ethics. Acad Med 64: 715718.
  • Capron AM, Michel V. 1993. Law and bioethics. Loyola LA Law Rev 25: 2540.
  • Koppelman LM. 1999. Values and virtues: how should they be taught? Acad Med 74: 13071310.
  • Markson L, Clark J, Glantz L, Lamberton V, Kern D, Stollerman G. 1997. The doctor's role in discussing advance prefer ences for end-of-life care: perceptions of physicians practicing in the VA. JAGS 45: 399406.
  • Miles SH, Lane LW, Bickel J, Walker RM, Cassel CK. 1989. Medical ethics education: coming of age. Acad Med 64: 705714.
  • Miller TE. 1997. Managed care regulation in the laboratory of the states. JAMA 278: 11021109.
  • Pellegrino ED. 1989. Teaching medical ethics: some persistent questions and some responses. Acad Med 64: 701703.
  • Pellegrino ED, Hart RJ, Henderson SR, Loeb SE, Edwards G. 1985. Relevance and utility of courses in medical ethics: a survey of physicians' perceptions. JAMA 253: 4953.
  • Pellegrino ED, Siegler M., Singer PA. 1990. Teaching clinical ethics. J Clin Ethics 1: 175180.
  • Self DJ, Wolinsky FD, Baldwin DC. 1989. The effect of teaching medical ethics on medical students' moral reasoning. Acad Med 64: 755759.
  • Veatch RM, Sollitto S. 1976. Medical ethics teaching: report of a national medical school survey. JAMA 235: 10301033.
  • Williams PC, Winslade W. 1995. educating medical students about law and the legal system. Acad Med 70: 777786.

Biographical Information

  1. Top of page
  2. Abstract
  3. BIOETHICS IN THE MEDICAL SCHOOL CURRICULUM
  4. ETHICS AND LAW AT THE UNIVERSITY OF IOWA
  5. GOALS, METHODS, AND CORE THEMES
  6. IT'S ETHICAL, BUT IS IT LEGAL?
  7. CONCLUSION
  8. LITERATURE CITED
  9. Biographical Information

Robert S. Olick, J.D., Ph.D., is Associate Professor in the Program in Biomedical Ethics and Medical Humanities and Department of Family Medicine, University of Iowa College of Medicine, where he teaches both biomedical ethics and health law. He also holds an appointment as associate professor in the University of Iowa College of Law. Dr. Olick's current areas of research and writing include ethical, legal, and policy issues in decisions near the end of life; genetic information and research; managed care; and the physician-patient relationship.