To the Editor: I am a recent medical school graduate and new intern in the field of psychiatry at a large academic medical center. My intern year thus far has been quite thrilling and quite terrifying—even more so than I had expected—and I do notice myself reflecting frequently on my recent transition and new role as a young doctor.
While applying the vast medical knowledge required to provide quality care for patients with psychiatric illness has been a challenge, even more challenging have been the complex ethical scenarios that have presented on the units. I have felt unprepared to answer questions such as, Should we pursue involuntary electroconvulsive therapy (ECT) for a patient with severe depression and psychosis with fluctuating capacity who has historically opposed ECT when not depressed? Similarly in the past few weeks, my co-residents have encountered similarly perplexing and ethically debatable questions: Should we force nutrition on a young adult patient with treatment-refractory anorexia who has the capacity to deny nutrition? Should we pursue lifesaving oncologic treatment for a schizophrenic patient without capacity who is refusing?
The cases outlined above present the most difficult of bioethical scenarios, and as an intern, I have found that these ethical questions have been pivotal not only in determining a plan of care but also in developing my own professional identity and values. The nature of these ethical cases is often so multifaceted that disagreement frequently occurs among providers and across specialties, even given the common end goals to uphold bioethical obligations and help patients. Additionally, these cases are often emotionally charged and resonate strongly with physicians, as our primary interest in beneficence towards the patient can be at odds with patients’ autonomy regarding their own care.
While I did receive some basic bioethics training during medical school, one recommendation is to embed clinical ethics education much more robustly within undergraduate medical curricula, possibly implementing the practical guidelines outlined by Giubilini and colleagues1 in 2016 regarding a four-year bioethics curriculum. Further, we as residents and educators must act—even beyond reforming the written curriculum—to provide a nurturing clinical atmosphere on the wards to encourage medical students to critically approach these ethical issues and take action. Emphasizing and practicing bioethics principles early in training will only enable better holistic care for patients.
The author would like to thank Dr. Jason Jalil and Dr. Paul Aronowitz for their guidance and contributions to this letter.
Sophie Rosseel, MD
First-year resident, Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, California; email@example.com.
1. Giubilini A, Milnes S, Savulescu J. The medical ethics curriculum in medical schools: Present and future. J Clin Ethics. 2016;27:129145.