Letter to a new medical student
Whether you are a new medical student or not, this letter from Daniel Sokol hits the mark
Congratulations! How many others would love to be in your shoes, tracing the footsteps of Hippocrates, Jenner, Lister, Osler, Fleming and other greats of medicine. (1) The path ahead is indeed long, but was it not Confucius who reminded us that even a journey of a thousand miles begins with a single step? (2) (3)Why this letter? I have some advice which you may find helpful. A secret? Not really. The talking fox, in The Little Prince, had a real secret: “It is only with the heart that one can see rightly; what is essential is invisible to the eye”. (4)
My simple message concerns the moral dimension of medicine. Medicine is fundamentally about human beings and, whenever humanity is involved, so too is morality. Why? Because, as social creatures, we have duties to each other. I have a duty to treat you in a particular way. I shouldn’t lie to you, or steal from you, or insult you for no good reason. And we also have duties to ourselves. We must treat ourselves with respect and dignity. As a medical student, and later as a doctor, you will be dealing with patients, relatives and colleagues. More specifically, you will strive to help patients who are by nature sick and vulnerable. For the patient, the awkward shift from health to illness is not the only change. The clinical environment itself can be impersonal, unfamiliar and often confusing. (5)
The task is all the more complicated because whenever we try to help patients, whether through words, drugs or procedures, we risk harming them. An aspirin tablet can trigger an anaphylactic reaction; a caesarian uncontrollable bleeding. The sharp sword of Damocles hangs precariously over doctors and their patients. (6) As time is limited and resources scarce, you may also deprive others of needed assistance. If you decide to drain Mr Smith’s abscess now, the injured Mr Jones will have to wait in pain a while longer. More dramatically, giving a heart to a patient with severe cardiomyopathy (an abnormality of the heart muscle) may entail the death of another patient in desperate need of the organ. For all these reasons, medicine is a deeply moral endeavour, often involving conflicting moral principles.
Throughout your training, you will be exposed to the scientific and technical components of medicine. You will wonder at, and on occasion curse, the sheer volume of medical and biochemical knowledge acquired over the centuries. We have come a long way from the days of supernatural explanations of disease, and Galen’s long-standing belief that illness was caused by an imbalance of four humours. The ethical aspect will not feature as much as the technical and the temptation will be to dismiss ethics as irrelevant, unimportant or inconvenient to the immediate task of helping the patient.
My message is this: do not yield to this temptation, however strong, but take the ethical issues in medicine as seriously as you do the technical ones. This doesn’t mean devouring textbooks on medical ethics. It means simply seeing ethics as integral to the proper care of your patients. Just as you want to increase your understanding of the factual aspects of medicine, so should you want to deepen your moral understanding. Your ability to perceive moral issues, to reason through ethical problems in search of a solution, and to act upon your decision is inextricably linked to your future success as a doctor.
I have on occasion heard your peers say that ethics is merely a matter of law. You should of course consider the law when deciding how to act, but the law is no moral panacea. While morals may form the basis of law, there is much that the law permits but that morality forbids. A student who laughs at the misfortune of a dying patient is not acting unlawfully, but may still be morally at fault. Law often represents the lowest acceptable measure of morality. As a member of the medical community, you should be striving for a higher standard. Sometimes, the law is silent, or permits several options. Should you breach a patient’s confidentiality if you believe your silence may endanger someone else? The law offers no easy solution.
You will be faced with many diagnostic and therapeutic mysteries in years to come. Medical journals are replete with case studies involving rare cases of tetanus, typhoid or other diseases whose unusual symptoms stumped the medical team. Biomedicine is a young discipline and much remains to be found. You will also encounter ethical puzzles. What should you do or say if you made a medical error that no one else noticed? How should you deal with patients’ cultural or religious beliefs at odds with your own? How should you handle racist or abusive patients? How should you evaluate a patient’s quality of life or the futility of a given treatment? Like the medical ones, these problems will need to be diagnosed and resolved, and may require skill, creativity, humility, wisdom and courage. In ancient times, whether in Greece or China, doctors were philosophers. Today, a good doctor - and a good medical student - remains a practical philosopher.
So here endeth the lesson. I’m aware that I haven’t discussed how to resolve moral problems. This will, I hope, be taught to you in the coming months. My intention here is more modest: to remind you, at the outset of this lifelong journey, of the profoundly ethical nature of medicine which in this technical age is too easily overlooked. The ethical aspects are neglected because, unlike physical abnormalities, they are difficult to see. The fox was right: what is essential is invisible to the eye.
Daniel K. Sokol L
Lecturer in Medical Ethics and Law
St George’s, University of London
Cranmer Terrace
London SW17 0RE
daniel.sokol@talk21.com
Endnotes
(1) An excellent introduction to the history of medicine is Roy Porter’s Blood and Guts: A Short History of Medicine (2002), published by W.W. Norton and Co.
(2) Confucius was a Chinese thinker living in the 6th century BC. For a concise summary of his life and philosophy, see http://plato.stanford.edu/entries/confucius/
(3) Sir William Osler (1849-1919), while Regius Professor of Medicine at Oxford, addressed medical students as “fellow students”. For Osler, all doctors, however experienced, were students of medicine, always learning more about the many facets of medicine.
(4) For more on this inspiring little book, see http://en.wikipedia.org/wiki/The_Little_Prince
(5) I have written frankly about my own experience as a patient in the British Medical Journal (2004, 328:471. http://www.bmj.com/cgi/content/full/328/7437/471).
(6) The Roman writer Cicero recounts the story of Damocles. In the story, king Dionysius allows the envious Damocles to experience, for a short time, the life of a powerful ruler. As Damocles is enjoying a lavish banquet, he notices, hanging directly above him, a sharp sword suspended by a single horse’s hair. This was meant to represent the illusory appearance of comfort and the ever-present danger that Dionysius faced as a king.
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