The Ethics of Teaching Hospitals

I can’t imagine what the patient was thinking. Seeing my trembling hands approaching the lacerations on his face with a sharp needle. I tried to reassure him that I knew what I was doing, but the pair of residents who stood behind me discredited that notion. The procedure took twice as long as a more experienced practitioner, but the end result was – in my perhaps biased opinion – comparable.

Suture Practice
Yes sir, I’ve done this before.

Patients at teaching hospitals, perhaps unknowingly, take a large role in the education and development of every stage of trainee in every area of practice. They will likely be interviewed and examined multiple times; their plans of care may change as their case makes its way up the chain of command; and they may undergo supervised procedures performed by less experienced trainees. However, I believe that patients receive superior treatment at teaching institutions as a direct result of the supervised care of trainees who are more curious, active and generally have fewer responsibilities and are able to spend more time with their patients.

Let’s explore the ethics of patient care at teaching institutions, examining how it may affect each of the major principles of medical ethics.

  1. Autonomy: Individuals have the right to make decisions about their health and what happens to their bodies.
    I think there is some infringement on autonomy in teaching hospitals, as patients should expect to be fully informed in order to make reasonable decisions. While patients receive information about the hospital and consent for treatment during registration, it is unlikely that this information is either read or explained appropriately.
    I have been guilty of this as well. For example, I intentionally withheld from a patient the fact that I had never performed a particular procedure outside of relatively low-fidelity simulations and had just watched a video explaining how to do it.
    It does not respect the patient’s autonomy to hide these facts, as the patient has a right to know and potentially refuse treatment.
  2. Beneficence: The practitioner must act to improve the patient’s health.
    The application of this principle is unaffected in teaching institutions.
  3. Non-maleficence: First, do no harm.
    It is possible that the participation of less-experienced trainees leads to more errors and the possibility of causing unintended harm. However, the requirement for hands-on experience for trainees is unavoidable. Patient safety should be ensured with continuous supervision and graded responsibility.
  4. Justice: All patients should be treated equitably. All resources should be distributed equitably.
    Different teaching institutions vary in their levels of insistence on trainee participation (should a patient refuse that students not participate in his or her care). A violation of this principle would occur if certain populations were more likely to be required to work with trainees. Another possible conflict is if teaching institutions are predominantly located in low-income areas where patients have fewer options.

In summary, I believe that trainee participation in teaching institutions is critical to the development of competent physicians and is therefore an essential component of medical care. The participation of trainees supports the overarching goal of helping people, and the risk of harm can be mitigated by adequate supervision. Finally the principles of autonomy and justice can be upheld if all patients are adequately informed of the ways that trainees may participate in their care and none are allowed to refuse such participation without reasonable concerns.

Have you ever been treated or hospitalized at a teaching institution? What was your experience like?

  1. I had a cavity filled at a dental school.
    My understanding is that the work was much better than what I would have received at a dentist’s office. The reason is that the excavation of the cavity according to the textbook had to be according to very strict standards which were inspected prior to my cavity being filled. At the dentist’s office, these standards would not be so closely adhered to in the interest of shortening the time it takes to fill a cavity, and therefore, increasing profitability of the dentist’s office. The dental school did not labor under that constraint of profitability.

    Charles Perkins

    Nov 11, 05:54 AM #

  2. Firstly, a very interesting post which I very much enjoyed reading, and certainly one that raises an interesting question regarding the ethics of medical treatment. The way I see it is like this: ultimately, as a patient, you want to be treated by the best doctor who makes the fewest mistakes; hypothetically, if this was possible everyone would see one doctor in each specific field of medicine depending on their ailment. As a result fewer competent doctors would exist because other doctors wouldn’t be able to gain experience, and when that ‘best doctor’ finally retired you would be in a much worse position to be treated than if compared to the current system.

    I live in the UK and our health care is free. I take it as part of the package to be treated by anyone who is qualified to treat me, even if they are relatively unexperienced. I think that the majority of patients are accepting of the fact that doctors need hands on training before they are able to call themselves experienced doctors, but at the same time, I would expect trainee doctors and nurses to start at the basics before, oh I don’t know, having to perform complicated heart surgery.

    I think supervision is obviously important and if any complications were to occur then it would be important for those complications to be safeguarded against by the amount of supervision and extra ‘help’ available. In conclusion, not only do I feel as though trainee doctors are crucial, but I would welcome being treated by a young and enthusiastic doctor who wanted to further his career by doing the best job possible. Even the best doctors have to start somewhere and wouldn’t be able to perform as well as they do without having had adequate levels of hands on training.

    Adam Egarr

    Jan 31, 12:48 PM #

  3. UK NHS Medical ethics – is it unethical for patients to be used for training purposes without consent.
    If such a patient be harmed during a non consensual training procedure, and a lack of ‘duty of care’ was established – should that patient be recompensed ?

    John Follon

    Dec 6, 03:47 AM #

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