Primum non tacere. An ethics of speaking up.

During the last five years I have conducted ethics courses, seminars, and case conferences for medical students. I have also had many informal discussions with students at all stages of their medical training. Yet I am still surprised by how many students know and refer to the Hippocratic maxim to do no harm. Some even cite the Latin version: Primum non nocere. I wish, however, that more medical students would also keep in mind a Socratic maxim: Primum non tacere. First, do not be silent. When I encourage students to articulate ethical issues that they face as students, they often describe situations where they must decide whether to speak up or keep quiet. The following are cases that students have described and that I have altered somewhat and then formulated from a student's perspective. 1. Spos (acronym for "subhuman piece of shit").[1] Before I entered medical school I read House of God, but I didn't find it very amusing. I was troubled by the attitudes the characters displayed, and I told myself that I would try to be more respectful of patients. I assumed that speaking about patients in derogatory terms was a fad that would be over by the time I began my clerkships at the hospital. That was not the case. During my first rotation my resident presented me with a new admission: "Here's your patient. He's a forty-year-old Hispanic male, a shooter, a real spos." I wondered whether I should say anything. I didn't like that language and the attitude it displayed, but it wasn't my job to train the house staff. On the other hand, if I didn't say anything, I'd seem to accept the judgments and attitudes I want to avoid. 2. Informed Consent.[2] I always thought that informed consent was integral to the doctor-patient relationship, that it was really one aspect of good communication with patients. Yet some people view it differently, as a bureaucratic hassle imposed by people outside medicine. This difference became painfully clear during my first week in the clerkship. My resident told me to "consent" one of his patients. This was my second day. I had never met the patient and had no idea what the risks of the proposed procedure were. So I politely asked my resident about the risks, but he told me with a slight sense of annoyance that the patient will sign anything. What were my choices? I could say something to the resident I could just get the signature. I could look up the procedure in a textbook. Or I could ask someone who might explain the procedure to me. In fact, I asked another resident who told me a bit about the procedure. An hour later my resident saw me again and said that the team had decided to include a second procedure. He told me to simply write the second procedure onto the form and to use the same pen. I didn't want to be party to this sham, but I also didn't want to jeopardize my grade. 3. Practice Makes Perfect.[3] I understand that this hospital is a teaching hospital and that students, residents, and fellows are here to learn. The fact that we learn on patients means that some patients are subjected to additional pain, inconvenience, and physical examinations. I guess there's a kind of bargain: we learn medicine on people who are mostly poor, and they get care they might not otherwise have access to. Whether or not this arrangement is fair, I've come to accept it. But I never imagined that people would practice a procedure that wasn't medically indicated. Late one night I was working with a resident in the labor and delivery room. The patient was in labor, and the resident decided to do a forceps delivery. I didn't see the indication. The woman didn't seem very fatigued, and there were no apparent complications. I didn't know the exact statistics, but I was sure that a forceps delivery involved some risk to die fetus. I didn't know what to do. If I asked what the indications were, the resident was sure to have some rationalization. If I told an attending physician the next day, I'd create a lot of trouble and no good would come of it. …