- Xiaoyang Chen and Tongwei Yang
Medical Ethics Research Center, Medical School, Shandong University,
44, Wenhua Xilu, Jinan, Shandong 250012, The People's Republic of China
Email: chenxy@sdu.edu.cn

Eubios Journal of Asian and International Bioethics 14 (2004), 216-218.

Abstract

There are many ethical issues in clinical teaching. Hospitals do not have right to ask the patients to accept clinical teaching and patients do not have to. The principle of informed consent should be followed to carry out good clinical teaching based on patient's trust and cooperation. Informed consent is a moral premise for clinical teaching, an embodiment for respecting patients and an important guarantee for patient's support.

Key Words: clinical teaching; informed consent; right; obligation

Should patients be the teaching aid when they see the doctor? Should the doctors respect the privacy of patients? These questions have been asked and discussed many times in the media and medical journals in China and elsewhere recently (Coldicott et al., 2003; Nestel and Kneebone, 2003). For example, a doctor explained about a pregnant woman's body including her private parts to his students when the pregnant woman was waiting for her induced abortion. As the teaching aid, a patient with throat pain was asked to open his mouth and vocalize more than 20 times (Yuan, 2003). Some papers opposed what was reported and suggested that hospitals should respect the right of privacy (Jiang, 2003). However, in some people's mind, though not protected by law, it's not only the patient's obligation but also an important reflection of modern civilization to take the patient as teaching aids (Lu, 2002). Some specialists think that as the center of medical treatment, patients should be given more humane care and we should pay more attention to ethics when we apply new technology to patients.

We could centralize our discussion to three questions: (1) is it a patient's obligation to be a teaching aid? (2) do hospitals have the right to request patients to be teaching aids? (3) how could the hospitals be trusted by patients and carry out clinical teaching with patient's cooperation? These are three correlative questions and the third is a central issue that we discuss in this paper. 

Are patient's obliged to be teaching aids?

Patients pay their fee-for-service to get treatment and doctors help the patients with their medical knowledge to get their salary. Whether in the general hospital or in a teaching hospital, the patients have the same aim and request when they see a doctor and they make contract with the doctor only about their treatment, at the same time, the patients have the same rights and obligations in the contract. Patients should not be viewed only as teaching aids in teaching hospitals, nor in the general hospitals.

We can discuss people's rights and obligations and the relation between them. Wang Haiming pointed out in his book titled "New Ethics" that "it is unfair and incorrect for a person if their obligation is not equal to their right" (Wang, 2001), "People should get equivalent rights and obligations from society and it's the radical principle of social justice". In other words, patients should not fulfill the requirements to be a teaching aid in teaching hospitals since they have the same basic right and obligation as in a general hospital.

2.Do hospitals have the right to request patients to be teaching aids?

Personal rights are citizen's necessary benefit protected by the society; the administrator must give the necessary benefits to the members of the society. Personal rights are "valid demands" and thus a type of "qualification".  

Accordingly, there are at least two types of citizen's contribution to the society: The first, as a citizen, they should contribute to the society and other members of the society, however, it's not necessary for them, for example, to be ready to help others at all costs. Evidently, it's not an obligation but almsgiving. The second, as a citizen, he or she must do good to the society and others and also must carry out obligations, e.g., paying income tax. When somebody see a doctor, it's necessary for him to pay a fee-for-service and be treated. It is the "valid request" and "qualification" of patients and the hospitals and doctors must offer proper treatment for the patient. However, it's not necessary for patients to be teaching aids in teaching hospitals, so they help doctors in clinical teaching just from a helpful spirit to society.

3. How could the hospitals be trusted by patients and carry out clinical teaching with patient's cooperation?

Now we have pointed out that patients don't have the obligation to be teaching aids and hospitals don't have the right to order them, how can teaching hospitals carry out their clinical teaching?

We would seek the answer by illation. Our society has seldom asked its citizens to be ready to help others by sacrificing themselves. However, why are there so many people to do so? Why are there so many people with a good spirit? All of these have a high-minded conscience and good social environment. Better the social environment is the more the citizens would contribute to society and others.

In the same way, building a noble moral environment in hospitals is the key to carry out clinical teaching. Patients would like to trade-off their rights and help doctors in clinical teaching if they were given humane care in hospitals. In contrast, the worse the environment is, the more self-protective the patients will be. How could doctors win trust from patients? What should doctors do to make patients sacrifice their rights? These are two core questions and we believe that informed consent, as a discipline, is an very important guarantee to carry out clinical teaching.

(1) what is the meaning of "informed consent"? 

The modern informed consent came after the World War II. Western countries came to an agreement that nobody can do any medical experiment without the patient's informed consent in 1946 when global people condemned Nazis and passed the "Nuremberg Code". From then on, the scope of informed consent was expounded from experiment to therapy and was included in patients' rights (Churchill, 1986). Informed consent includes two correlative parts: information and consent. It is not  just a legal document by doctors and patients, but also a thought with influential ethical meaning, which means someone ratifies that the professionals do something for him or her  with understanding, free will and without compelling force (Huo, 2004).

(2) The significance of informed consent to clinical teaching.

  Most doctors have recognized that ethics as a discipline is important for medical experiments and clinical therapy, however, they have not paid much attention to it. In the author's opinion, to understand patients' rights and obligations adequately and be supported by patients, doctors must carry out the principles of informed consent in clinical practice.

 Without patients' help and support, doctors can't make progress. Patients make a large contribution to medical students' on their way to becoming a good doctor! Shouldn't doctors thank and respect their patients? Shouldn't hospitals carry out informed consent in their clinical teaching? Yes , of course!

  As a citizen, sufferers have the right of self-determination and privacy. Patients should decide whether to accept the therapy or not by themselves, whether to take part in the clinical experiment or not by themselves and whether to help clinical teaching or not by themselves. The right of privacy means that as a natural person, our personal information must be protected. Privacy is limited to something individual but is not common, and is something that others cannot invade. Patients can volunteer to show their privacy to doctors when they see a doctor and just break their privacy to special doctors but not others. The doctors will infringe patients' privacy right if they break patients' privacy. Patient just release their private details to special interns but not to others when a patient shows their private parts and private information to an intern in clinical teaching. In a word, hospitals could carry out clinical teaching based on patients' releasing their private right and the hospital would infringe patients' right if they carry out clinical teaching without informed consent. Informed consent is the moral premise for carrying out clinical teaching and the embodiment for respecting patients.

(3) Some methods to carrying out the principle of informed consent.

 The basic thinking of informed consent in clinical teaching is that a patient should decide whether or not to accept clinical teaching after he/she is provided enough information. In fact, it is people's right to control their body, protect their privacy and decide whether or not to accept clinical teaching.

 Whereas, these methods to carry out informed consent include the following. As teaching aids, patients should know what will they do or show to interns. Doctors should introduce the interns to patients, including the number and gender of the medical students. Doctors should promise to keep thepatients' privacy and assure them that clinical teaching would not affect their therapy. Doctors should treat patients as persons and not make them sick. Patients have freedom to choose whether or not to accept clinical teaching.

4. Discussion and Conclusions

 No matter whether in general hospitals or in teaching hospitals, patients have the right of privacy and informed independent decisions. Hospitals shouldn't request patients to be merely teaching aids and patients do not have the obligation. Informed consent is the moral premise and a guarantee for carrying out clinical teaching. Patients contribute to clinical teaching only because of their nobleness.

 As teaching hospitals, training medical students is a very important work, however, not by force but by contribution. The authors believe that (a) citizens will abide by a law of their own accord only when the law accords with ethics. (b) more patients would contribute to clinical teaching if they could be taken as the center of medical treatment and were given more humane care.

References

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Coldicott Y, Pope C, Roberts C. 2003. The ethics of intimate examination – teaching tomorrow's doctors.  British Medical Journal. 2003; 326: 97-101.

Huo, X. 2004. Informed consent in China. Health Paper. February 24, 2004.

Jiang, N. 2003. Patients should't take part in clinical teaching without free will. South City Paper. October 20,2003

Lu, G. 2002. Discussion on the value and protection of privacy right. Chinese Bioethics. 2002; 5.

Nestel D and Kneebone R. 2003. Please don't touch me there: the ethics of intimate examinations: integrated approach to teaching and learning clinical skills. British Medical Journal. 2003; 326: 1327.

Wang, H. 2001. New Ethics. Shangwu (Business) Press. Beijing. 2001.

Yuan, H. 2003. A women became teaching aid when she had gynecology examination.  Qilu Evening Paper. October 18,2003.