A medical journal has published a report by University of Iowa professor Doctor Lauris Kaldjian on ethical decision-making in patient care. The doctor says medical students need to be convinced that medicine and ethics are inseparable, and the first requirement is to sympathize with patients and their values. Kaldjian says if you want to be a very good doctor you must understand what it’s like to be human, and “what it is to be a suffering human being.” He says to gain the confidence and trust of patients and their families the doctor must understand them and value them as human beings. One hurdle, he explains, is that many “ethical” decisions are not — it’s just that the values of a doctor and his or her patient may differ. Of course there are professional standards for physicians, but he says there will always be a connection between you who are as a person and who you try to be as a professional. Sometimes the doctor’s personal opinions about transplants, aggressive treatment, end-of-life care or other medical choices will clash with the personal, family or cultural beliefs of a patient — and they can’t agree. Sometimes, and hopefully only rarely, the doctor and patient, or patient’s family, will have to accept the fact that they disagree on something fundamental and the doctor will make arrangements to get another doctor to care for that patient. In extreme and rare circumstances, he says there can come a time when a physician says “My good friend, my patient, I have to part company with you, for these reasons.” Kaldjian says he’s never done it and only saw one case, which was handled well and accepted by the patient. When they simply don’t agree, the patient won’t follow doctor’s orders, and the doctor won’t give the patient the care that sick or dying person wants. It can be tough for a young doctor to accept that there are different opinions on a course of care, or a strong personal preference.Often, his students are unsettled to realize “there is no one clear or ‘right’ option or alternative” and they have to discuss it intently and think about it hard. Kaldjian says there are cases like a massive stroke, where it’s not clear how serious the outlook is, in which a patient’s family and a doctor may differ over whether it’s best to let go, or to “hang in there and treat things thoroughly so more time can be purchased.” He says they also might differ over how to treat a condition like chronic pain. Dr. Kaldjian’s article was published in this week’s on-line edition of the Journal of General Internal Medicine.
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