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August 3, 2018

Why this doc wants to ditch ethical case studies—in favor of fiction

Daily Briefing

    Ethical case studies used to teach medical students how to handle ethical dilemmas often "miss the point," and future doctors instead should read fiction, according to a recent paper published in Literature and Medicine, Sam Kean writes for The Atlantic.

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    About ethical case studies

    Ethical case studies provide a short summary of a conflict that occurred during medical treatment, Kean writes, and students are generally prompted to come up with next steps for the provider or identify what the provider did wrong. "The idea is to get students thinking about problems they might face in the future, before they actually confront these issues in a pressure-filled clinical situation," Kean writes.

    Fiction over case studies

    But in a paper published in Literature and Medicine, Woods Nash, a medical-humanities researcher at the University of Houston, argues that ethical case studies are too short and place a greater emphasis on action than characterization. As a result, Nash argues case studies lack nuance and have limited usefulness.

    However, Nash argues fiction presents students with the opportunity to better under the patient and get to the root of the patient's concern. To demonstrate his argument, Nash's paper extracts a 215-word ethical case from a 10-page short story "Fetishes," written by Richard Selzer, a physician and writer.

    In the story, a middle-aged woman named Audrey needs a hysterectomy. The night before her surgery, Audrey is told by a male anesthesiologist that prior to surgery she has to remove her dentures. But Audrey objects, saying that her husband doesn't know she has them and having him see her without them would shatter her "dignity." The anesthesiologist doesn't acknowledge her concerns and informs her that her dentures must be removed for her own safety.

    Audrey then meets a younger resident with a limp and tells him of her predicament. The resident agrees to slip her dentures back in during her recovery so her husband doesn't see.

    Nash then critiqued the case study using principalist ethics—a common ethical framework in medicine.

    Nash wrote that based on the condensed form, bioethicists would likely criticize the anesthesiologist for dismissing Audrey's concerns, but he argues that there are more subtle dynamics to the story that should be considered. Rather than this being a story about a woman with a lack of autonomy, he argues, it's a story about a woman whose male doctors are condescending toward her.

    Nash argues that Audrey "perceives [the doctors] as behaving smugly, belittling her because she is a woman, and relishing the power they wield over her. Until these underlying issues are resolved, recommendations to communicate more openly, respect patient autonomy, and reduce risks would remain insufficient." He added that these recommendations "do not penetrate to the problem's roots."

    How to use fiction to teach ethics

    To get to the roots of these problems, Nash recommends doing a simple exercise that he's used for three years. He instructs each of his students to read a short fictional story and summarize it into a case study. He then has his students read each other's summaries and discuss how they differ. The exercise teaches students that "the style of a case is not ethically neutral" and that "there can be no definitive statement of a case," Nash said.

    In general, Nash said he'd prefer to "jettison" all ethical case studies. "The real world is messy, of course, and ethics cases often teach us (implicitly) to clean up that mess by oversimplifying it," he said, adding that case studies "are themselves a byproduct and reflection of clinical practice's overemphasis on efficiency. Not just in primary care, but in many areas of medicine, doctors spend far too little time really listening to patients and trying to appreciate the depths of their patients' problems."


    Some scholars, like Leslie McNolty and Matthew Piecha—program associates at the Center for Practical Bioethics—agree with Nash that ethical case studies are limited, but cautioned against a total condemnation of their usefulness. "In nearly every discussion of real ethical issues, you'll hear someone say [things such as], 'I wish I knew more about her husband,' or 'why's she so afraid of dementia,'" said McNolty.

    Similarly, Piecha said "people actually using [case studies] in ethics committees in hospitals" instead of exclusively in a classroom "are aware of how austere and truncated they are." According to Pjecha, ethics committees generally view case studies "as an important first step, but then you unpack it further, and it spins into a story."

    But Nash maintained that short stories are "more effective means of teaching students and [health care] professionals to wrestle with the mess, to pay attention to narrative perspective and detail, and to become more comfortable with ambiguity." He added, "Why continue to use ethics cases if short stories are better at inviting realistic reflection and more enjoyable to read and discuss?" (Kean, The Atlantic, 7/30).

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