pp. 148-151 in
Bioethics in Asia
Editors: Norio Fujiki and Darryl R. J. Macer, Ph.D.
Eubios Ethics Institute
Copyright 2000, Eubios Ethics Institute
All commercial rights reserved. This publication may be reproduced for limited educational or academic use, however please enquire with the author.
4.4. The Clinical Ethics Education in Saga Medical School
Director, Mitsuse National Health Insurance Clinic
Saga Medical School, Mitsuse, Japan
I spoke about "Medical Ethics Education in Saga Medical School in Japan" in the 1st Congress of the East Asian Association of Bioethics in Beijing. This time I would like to speak about the elective course "Clinical Ethics".
In Saga Medical School, 2 of the mandatory 40 lectures of introductory course to clinical medicine for the 4th year medical students are allotted to "clinical ethics". In this course, in the first lecture (90 minutes), students are taught about the history of clinical ethics and one way of ethical thinking of the case using the 4-Box (Medical Indication, Patient Preference, QOL, Contextual Features) analysis by AR Jonsen (Univ. of Washington) et.al. (Figure 1).
In the second lecture (also 90 minutes), students are to discuss about the clinical case such as "The 40 years old man who had back pain owing to bone metastasis from tumor of unknown origin" What should we do first for this patient as a doctor? "To examine for the tumor origin?h, gInformed consent?h, gPain Control?" There is no one absolute answer. It depends on the case.
In the post lecture questionnaire, there are some supportive comments from the students to this lectures such as; gIt is a good time for us to learn about clinical ethics just before clinical clerkship." "It is very practical and impressive for me to think about not the special case such as organ transplantation but the ethical dilemma in daily case." But there are also some critical comments on this lectures such as; gI understand your eagerness in this lecture, but it is difficult to discuss ethical case in a big lecture room with 100 students.", "It is unable to realize the importance of clinical ethics before I experience clinical clerkship.", "It is a very important things to learn. We need more time to learn."
To reply these comments, we also started the 4 weeks elective course "Clinical Ethics" for the 6th year medical students who want to study further. In this course,
1) The students need to choose the case of ethical dilemma which they have encountered during their bedside assignments.
2) The students summarize the case and analyze the case by 4-box theory (Medical Indication, Patient Preference, QOL, Contextual Features) analysis by AR Jonsen.
3) The students present the topics they want to discuss in the case.
4) The discussion was done not only with the physician in general medicine but also the teachers of law, sociology, philosophy and psychology in general education.
5)The cases and the topics we want to discuss were sent by Internet to the bioethicist and doctors and others who have interest in this field in Japan and also in USA and Canada to ask for their comments, and a number of cases have been published in EJAIB.
I would like to show one case and show how we do this ethical case discussion. The treatment for an old patient who attempted suicide, an 80 year old male. He attempted suicide by drinking agricultural chemicals and was found after he fell down in front of his house by the bill collector. He was sent to the university hospital by the ambulance. (He was suspected to be suffering from organic phosphate poisoning and the stomach and the colon was washed by tube. The next day measures became normal. The chest X-ray film showed consolidation in the Right Upper Lobe.) Aspiration pneumonia was suspected and antibiotics were given to the patient. He was found to have a cataract in both eyes. He was consulted by the Psychiatrist and the Psychiatrist found that the patient was not suffering from depression and highly suspected that he felt loneliness and committed suicide willfully. His general condition recovered and after the talk with his family he was discharged to his home after 10 days stay in the hospital.
The patient is timid and doesn't like to meet others and usually stayed in his house all day. He was married with his wife about 45 years ago. His wife had two children with her former husband who died earlier. He was adopted to his wife's house. He has one true daughter. Now he lives with his wife and the oldest son in law's family who live next to their house. His wife is a very active person and she usually goes out without the patient. But she didn't come to the hospital caring of the public reputation.
(1) Was the treatment in the hospital enough for this patient ?
1) Is it necessary to find out the cause of the suicidal attempt not to try again?
2) Is it necessary to join the patient to the discharge explanation to the
3) It seems that the key person is the patient's wife. But she didn't come to the hospital caring of the public reputation. Owing to his families story, the patient is slightly demented and the wife is always angry at the patient. Isn't it dangerous to commit the suicide again when he will return to the same bad situation with his wife? Isn't it necessary to follow up in the outpatient clinic or refer to the local medical doctor?
(2) How to deal with the older person in daily life?
(3) What makes the elder people feel their gIKIGAI (meaning of life)"
Discussion about this case between students and physician, teachers in sociology and law. In our case discussion we mainly talked about the social support network for this patient. In the emergency room, physical treatment is the main goal for this patient. But it is not enough for this case. The important thing is how to take care of his daily life in his house. In Japan, social support system for the aged people are now being constructed. Home helpers, Community Health Nurse, Local Medical Doctor, and Mental Health Center in the community will help these kind of patients. But the curriculum for the medical students is mainly medical knowledge. Social care system are taught in Medical Sociology, but not enough. So the student didn't understand the network of care system practically.
Figure 1: 4-Box Theory of Clinical Ethics
The comments received by Internet
Sizue Sato (old female doctor,Japanese )
I am also an aged person. I want to thinking about this case as an aged who lived the same age. Thinking about his age, the patient must have worked hard during difficult days in post World War. His wife (who lost his husband with two children) might thank him and also he might feel happy when he grow up his children. But when he becomes old and retired from his work, he has no hobby and no friends and he became depressed in his house. In contrast to his depressive state, his wife became energetic and go outside with her friends. I think the best treatment to this patient is to listen to his story. "Feeling loneliness" in the family is harder than the "loneliness". Who can treat this person? Counselor? Kind Psychiatrist? The same age friend? Please ask him "what is the best thing for me to do for you?" Cataracts should be treated. When I suffered cataract, I thought "my career
as a doctor finished."
Comments from Tom McCormick (Univ. of Washington)
The goals of medical treatment must be broad enough to include, not just the immediate organic threat to the patient, but the overall condition of the patient. Dr. George Engels calls this the "bio-psycho-social model" of medicine. In this country, sometimes social workers visit weekly, and bring a dog or cat, so the patient can also pet the animal while talking with the social worker. This has been found to be very beneficial. spiritual (some add to bio-psycho-social-spiritual): Where does this patient find "meaning" in life. Is there any religious background? Are there grandchildren? Is there a small garden to care for? A key issue for human individuals is the question: "what gives meaning and purpose to my life." Each of us must answer this in some way---the social worker, or chaplain should feel comfortable talking with the patient about these questions.
This case is an important reminder that the goals of medical treatment must be broad enough to include, not just the immediate organic threat to the patient, but the overall condition of the patient. Dr. George Engels calls this the "bio-psycho-social model" of medicine.
1) Bio: He certainly needed immediate emergency treatment to save his life from the chemical poisoning. Since it is discovered that he has some dementia, the biological model would also require that we find out more about this condition, does he have Alzheimerfs disease, organic dementia, or depression? This would help us discover "medical indications for intervention."
2) psycho: His biological threat (poisoning) seemed to arise from his underlying psychological condition. From all descriptions, he sounded clinically depressed to me. Unless this condition is treated, he is likely to repeat his attempt at suicide. Thus, "medical indications" seem to indicate treatment for depression.
3) social: In part, his loss of meaning in life seems to stem from his isolated social situation. Perhaps there is conflict with his wife, or a feeling of "abandonment". Social workers should address this situation, and might provide weekly home visits to address his loneliness. In this country, sometimes social workers visit weekly, and bring a dog or cat, so the patient can also pet the animal while talking with the social worker. This has been found to be very beneficial.
4) spiritual (some add to bio-psycho-social-spiritual): Where does this patient find "meaning" in life. Is there any religious background? Are there grandchildren? Is there a small garden to care for? A key issue for human individuals is the question: "what gives meaning and purpose to my life." Each of us must answer this in some way---the social worker, or chaplain should feel comfortable talking with the patient about these questions.
The comments from the participant of this case discussion
From the students
1) This discussion on the case we experienced was so impressive and practical.
I think it is meaningful for us and for the patient care to think about ethical aspects. I hope to continue to think about this in the future as a physician. 2) Using 4 box theory, I noticed there are many other fields rather than Medical Indication to think about. 3) We understand the importance of team approach. To do a better treatment, we doctor's cannot do everything by ourselves. We understand its importance by this interdisciplinary and international discussion.
From the teachers
1) We can learn the practical aspect of ethical thinking by these real case discussion. (Teacher of philosophy)
2) I thought this discussion is not only a ethical discussion of a clinical case, but also a case management for this patient.(Teacher of sociology)
3) It is very attractive for me to know what is the important things to teach for the medical students in the general education.(Teachers of law)
4) The comments sent by Internet shows difference and similarity. They made our sight wide and sometimes made us to notice the cultural difference. The important things are pointed out by different commentators. (Physician)
For the future education of clinical ethics
1) We hope to widen this discussion not only to western but also to Asian people. The people who have interest in this discussion, please send us E-mail. We will send new ethical case we want to discuss.E-mail:HQC00330@niftyserve.or.jp Perhaps our Japanese culture and feeling is similar to Asian people.
2) Now we use the ethical analysis (4- box theory) by Western people. I think it is also useful to analyze Japanese case. But I think there are some difference between Japanese and Western culture. So we hope to revise this way of thinking fit Japanese case more easily.
4. FutilityQOL gWell-beingh
1. Definition and evaluation of QOL (Physical, mental, psychological)
2. Who and how to decide
- How to avoid prejudice
- What is the best interest for the patient
3. Factors influencing QOL
CF: Contextual Features gJustice-Utilityh
1. Family and persons concerned
3. Cost, public interest
4. Policy & care system, research & education
5. Law and custom
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