#I can't cite the textbook i pulled the excerpt from because it was a pdf excerpt :(

[salt-baby]

prev said "elaborate", you ask I will deliver!

so what do premed and med students actually receive as ethical education?

my main grievances with basic medical ethics courses mostly has to do with autonomy and paternalism.

paternalism is essentially the concept that because doctors understand the medical science better than the patient does, they have a responsibility to guide patients through their medical care and towards the best treatments. In the same way a father does for their child, the doctor has authority to decide things if they think it's in the best interest of the patient.

The idealistic version of this is that a doctor is suggesting to a patient what they think will be the best medication or procedure, because the doctor is educated to think about things like niche drug interactions and how a patient's health may affect treatment efficacy and that sort of thing. Patients get told the basics of their diagnosis and the next steps, so as not to overwhelm them with the technical stuff.

However, this falls apart when it comes to things like informed consent. Patients have to understand what they're getting into when they accept a treatment. Overly paternalistic doctors may skip giving patients a proper explanation, telling them that "I'm a doctor, trust me on this". But doctors never have a full picture of all the things that factor into a patient's medical decisions, and patients often have other goals than achieving best health in pursuing medical treatment. Especially in the case of disabled people, who often aren't ever going to return to best health.

Newer medical ethics textbooks will include more autonomous models in place of paternalism, but it's not as ideal as it seems. Per those textbooks, the principle of autonomy obliges doctors to give their patients the freedom to make medical decisions, even against advice. But doctors aren't advised to do this in cases where they deem a person unable to make a decision, and this isn't based on the legal definition. If a doctor thinks a patient is unable to make a calm and rational choice, they don't necessarily have to respect a patient's autonomy. And how much doctors can persuade a patient varies from source to source.

Worth noting? The book usually associated with the introduction of autonomy in place of paternalism, "Principles of Biomedical Ethics" was published in 1980. Paternalism was presumably taught at least up until that point, and even if its not promoted anymore, it's still introduced as part of medical education.

Both of these principles can be seen in medical ethics courses, as seen in this reading written in response to the introduction of autonomy, which was actually used at my university. The reading is introduced by the textbook as follows:

"Respect for patient autonomy is distorted when autonomy is understood as mere noninterference, says Ackerman. On this prevalent hands-off view, "the doctor need be only an honest and good technician, providing relevant information and dispensing professionally competent care." But this approach fails to respect the autonomy genuinely, he argues, for it does not recognize that many factors can compromise autonomy, including illness and a host of psychological, social, and cultural constraints. At times, true respect for autonomy may require the physician to intervene, to deviate from the patient's stated preferences. The goal of the physician-patient relationship should be "to resolve the underlying physical (or mental) defect, and to deal with cognitive, psychological, and social constraints in order to restore autonomous functioning."

Think I'm kidding? Here's flashcards on this reading, and a student's essay on it.

Ackerman himself doesn't necessarily advocate for forcing patients into the choices doctors feel are best for their health at the expense of their free will. His point is more that beyond simply educating a patient on their condition and their best options, doctors should consider factors impeding a patients decision, like the opinions of their family members. The problem is that Ackerman asserts that illness itself can be a factor, and that the mental strain and sudden change in life habits or plans from adjusting to being ill causes patients to be less able to make decisions clearly. And he means ALL patients. This is an incredibly dangerous concept to be introducing.

This reading encourages doctors to second-guess a patient's decision, and is very firm in that illness can make a patient unable to make a decision, even if that illness doesn't affect cognition at all. It's true that the sudden news of a diagnosis, especially a chronic one, can be world-shattering. But that doesn't mean a patient isn't making a valid decision.

This reading has its purpose, and I don't totally disagree with Ackerman (obviously I do on the effects of illness). But along the way, a very risky concept has been introduced. This is why I say ableism is being taught in classes, because while the reading itself is useful, a very subtle ableism is introduced alongside it. If the ableism in this reading isn't named and discussed, then students often take the content as fact, because on the exam that's how it'll be treated.

Additionally, all of these concepts place the doctor in a clear position of power over the patient. I get the idea, that because doctors know more, that education places them over the patient. But in reality, when it comes to the core problem of diagnosing and treating the illness at hand, the patient is still bringing valuable knowledge to the table. The patient is the one who first notices something is wrong, the patient is the only person who can explain what's happening with their body, and the patient has the ultimate say with their consent.

And I don't believe these ideas are being critically engaged with by students. They're just learning the buzzwords and the right things to say in medical school interviews. Because the school has introduced this bias, the student now has to go above and beyond to unlearn it. Understanding ethical theory is important, but serious thought needs to be given to the language used and how concepts are presented.

Ultimately, when patients are judged to be incapable of a decision is governed by hospital or state policy, and so is who the doctor involves in patient care. Don't let me scare you here - your doctor can't just decide you're too anxious and force you into something you don't want to do. But these ideas still affect how doctors talk to patients in a more subversive way, and there's still real harm in that.

yes, doctors suck, but also "the medical ethics and patient interaction training doctors receive reinforces ableism" and "the hyper competitive medical school application process roots out the poor, the disabled, and those who would diversify the field" and "anti-establishment sentiment gets applications rejected and promotions requests denied, weeding out the doctors on our side" and "the gruesome nature of the job and the complete lack of mental health support for medical practitioners breeds apathy towards patients" and "insurance companies often define treatment solely on a cost-analysis basis" and "doctors take on such overwhelming student loan debt they have no choice but to pursue high paying jobs at the expense of their morals" are all also true

none of this absolves doctors of the truly horrendous things they say and do to patients, but it's important to acknowledge that rather than every doctor being coincidentally a bad person, there is something specific about this field and career path that gives rise to such high prevalence of ableist attitudes

and I WILL elaborate happily