Book Review: Ward Ethics: Dilemmas for Medical Students and Doctors in Training
Authors: Miles Little
Journal: Journal of the Royal Society of Medicine (2001)

The first thing to recognize is that Ward Ethics is not about ‘beeper ethics’, the term used by Nancy Dubler to describe the kind of clinical ethics that she and her colleagues practise at ward level in New York. This is a book devoted to something else—the ethical quandaries of students and trainees as they deal with the hierarchies in which they are the ‘bottom feeders’. It examines in great detail the dilemmas created by demands to do things beyond one's level of competence, and the pressure to do things to protect one's career. It uses true stories to generate discussion. As the editors write, ‘The following chapters are based on actual cases solicited internationally from medical students, interns, residents, and now-practicing physicians, who, often for the first time, reveal cases that continue to cause them discomfort and distress, even though in some cases years have passed’. This is essentially narrative ethics. The ethical issues emerge from the stories. The stories are grouped under headings, and the ethical discussion is developed by experts from around the world. There are two parts to the book. The first is on caring for patients, the second on being a team member in the modern therapeutic environment. Each part has many subsections, dealing with specific issues such as blaming the patient, breaking confidentiality, the newly dead, practising surgery on uninformed patients, and sexual harassment.

The multiplicity of authors is a strength, because it allows the development of several approaches to medical ethics, rather than privileging one system over another. George Agich, for example, stresses partnerships between student and patient as an inextricable part of learning, and suggests a focus on principles of vulnerability and respect. This is rewarding because it avoids entanglement with issues of beneficence, non-maleficence and autonomy, pointing out that other principles can be just as important and, at times, more illuminating. Marli Huijer and Gregory Larkin both confront the distorted priorities of students and trainees, which often put patient care and responsibility lower than gaining knowledge, being part of a team and obtaining good grades. Discussions are not constrained by familiar principalism, nor by adherence to virtue ethics, rights and duties, deontology or utilitarianism. This is narrative ethics at its best.

Similarly, there are opportunities to offer cross-cultural comparisons, because the authors come from diverse countries: the USA, Canada, The Netherlands, France, Japan, the UK, Israel and Argentina are all represented. There is, however, a degree of US bias, because 33 authors come from the US, and only 13 from elsewhere. Sometimes this orientation may create barriers for other readers. On p. 51, for example, Robyn Shapiro details US statutes in Illinois and Michigan dealing with the treatment of substance abuse. This is undoubtedly important for those working in the US but is of questionable relevance for outsiders. (One small, pedantic point emerges from this enlightened pluralism. The spelling of familiar words changes according to the country of origin or perhaps the country of editing. The verb ‘to practise’ is sometimes spelt in the English way, sometimes in the North American way. Both will do these days, but it is odd to see them side by side on the page.)

The mode of writing adds appeal and immediacy to the text. Authors frequently tell stories of difficulties during their own training, as Andereck does on pp. 37-39, which complement the stories of the students and residents. These ‘writer stories’ often have a confessional element, as though expiating past shame and unresolved distress. Bennhaum's anecdotes on pp. 74-76 about passing nasogastric tubes in his student days raise painful issues about kindness, trust and authority that resonate down the years. Sometimes the writers are quite critical of those who supply the anecdotes—for example, Lawrence Schneiderman on p. 84, warning against facile judgments of the imperfections of a hospital chaplain.

The authors offer practical advice on what to do and say in many situations. Alan Steinbeck, for example, provides detailed suggestions on how to think about death and resuscitation, and how to deal with what seem to be inappropriate orders. Much of the advice is wise and helpful, and the writers avoid platitudinous suggestions about standing up for ‘the right’ in the face of instructions from seniors and teachers. They also offer reassurance about hostile and threatening emotions that trainees and students may feel toward patients, their seniors and each other.

The book is lightly referenced, but there are enough references to allow a reader to pursue many of the issues. Each section ends with questions for discussion. It would make a useful text for a course in ethics for students and trainees, and a splendid resource for those who supervise and carry out the training. The ‘epilogue’ is brief but pointed. It offers practical suggestions for improvement, by means of regular ward ethics rounds, student seminars, and faculty workshops. It also suggests ward ethics committees, focusing on ethical issues in training, with interdisciplinary membership. It stresses the responsibility of training organizations to do something to address problems which we all acknowledge but about which we tend to shrug our shoulders. We still often reason that medicine is practised in the fires of human interaction, and that coping is still a major skill for doctors. But, as the editors point out, ‘... there is a danger of professional hypocrisy in any system that proclaims a dedication to the goal of producing humane and compassionate physicians while allowing institutionalized behaviors that undermine that effort’.

This review does little justice to a very commendable and very complex piece of work, whose breadth, thoroughness, wisdom and practicality make it readable and valuable. Kushner and Thomasma are to be congratulated for addressing such an important, and usually occult, field of ethics. In this undertaking, trainees and students have found a voice.