Using medical drama to teach biomedical ethics to medical students

Abstract

Nowadays, clinicians are faced with multifaceted ethical concerns, and it is often argued that students of medicine should be well trained in clinical ethics and have a minimum level of ethical sensitivity and critical analysis. Consequently, most medical colleges have introduced programs in biomedical ethics. It is often pointed out that there is a gap separating ethical theories from concrete moral dilemmas. This problem became less pervasive as case-studies started being used. Nevertheless, vignettes are mostly presented as an addendum to a unit and often engage the students only “temporarily.” It is my contention that this can be remedied if students were given a venue that will allow them to appreciate as many particulars of the situation as possible, to engage in the case not merely as inactive spectators, rather to get entangled in the case just enough to be involved yet remain sufficiently detached to be able to exercise critical analysis. This is possible through medical drama which, I will argue, is a narrative genre that enhances emotional engagement, cognitive development, and moral imagination allowing for a more ethically sensitive student in training. To do that, reference will be made to the medical drama “House MD.”

Introduction

Mrs. Sloan was 42 years old and five months pregnant when she was rushed to the hospital suffering from what seemed to be a stroke. The attending physician and his team concluded that serious medical problems with the fetus are causing the mother's illness. Thus, unless the pregnancy is terminated, she will die. Mrs. Sloan however refused that option and her decision was supported by the Dean of Medicine.

Can the several approaches to ethics help us in knowing what the right thing to do in this case is? This seems a little thorny simply because we have no information as to how different players view the case. Each has a different lens that allows him/her to see and judge matters differently. Imagine three hypothetical consultants: A utilitarian, a deontologist, and a virtue ethicist. Each will rightly argue that he/she is at a loss of what to do in the absence of more information or data. We do not know if the mother is competent, if the fetus is viable, the true nature of the illness of both, how much time do we have, etc.

Human beings are complex individuals whose emotional reactions play a role in the way they perceive and judge the world around them and, consequently, the way they reason about it. The setback is in the presentation of the case. A closer look allows one to notice that the important aspects that permit one to see the narrative as a whole are left out. Notwithstanding, similar case vignettes are often used for discussions as part of biomedical ethics education. However, they do not allow discussants to see how the various characters perceive and understand different events.

In this article, I will argue that the use of medical drama as a narrative genre (hereafter md-narrative) is an important venue to be used in the teaching of biomedical ethics. It offers an opportunity to bring to bear theories that have been dismissed as too remote and to connect theoretical ethics to everyday medicine. I will argue that the use of md-narrative enhances emotional engagement, cognitive development, and moral imagination which allow for a more ethically sensitive student in training. To do that, and perhaps oddly, reference will be made to the medical drama House MD that portrays a famed diagnostic physician whose legendary gaze suggests that narratives are futile. Cases will be drawn from the purportedly anti-ethics hero to show precisely how we can use narratives to teach ethics to medical trainees.

Nowadays, clinicians are faced with multifaceted ethical concerns in their medical practice. These include disagreements between patients, relatives, and healthcare professionals over treatment options, difficulties in obtaining informed consent, medical error, confidentiality, and others. As such, it is often argued that students of medicine should be well trained in clinical ethics and that practicing physicians should have at least a minimum level of ethical sensitivity and critical analysis that allows them to deal with complex cases. In an attempt at ensuring that, most medical colleges around the world have introduced courses and programs in biomedical ethics. These include lectures on the nature of moral discourse and in moral theories. Students of medicine and bioethicists often remark that there is a gap separating theories offered in ethics from concrete moral dilemmas faced on the wards. Thus, statements like “how will deontology help me decide on whether the life of the baby is more important than that of the mother?” or “ethics is great but really, it is high up there” are becoming catchphrases that reverberate every time biomedical ethics courses are given. This problem became less pervasive as case-studies started being used in an attempt to add to the abstract theories taught to medical students hoping to enhance their ethical reasoning and moral sensitivity. Nevertheless, these vignettes are mostly presented as an addendum to a unit or a theory and often engage the students “temporarily” and do not allow room for a convincing rational conclusiveness. Students leave the debate confused, often forgetful, if not skeptical, of ethics and its bearing.

Moral theories are thus seen as far from being able to capture the complexities of ethical life on the wards. A deontologist's take on the case of Ms Sloan might not appeal to that of the utilitarian. Either might not appeal to the doctor who sees in them remote theories suspended in space, mere exercises in futility. Herman maintains “the difficulty with a conception of morality that ties moral judgment to rules is that it ignores details (particular facts about individuals and case) that are morally relevant. (…) People draw meaning and value from the particular” (Herman 1985). Moral theories, she continues, comprise “rules of moral salience” (Herman 1985). These select particularities of situations that warrant consideration and sift out extra ones that are considered morally irrelevant. The manner in which a case is presented or dealt with might be a result of theoretical bias. It depends on which particulars of the case are emphasized or remain undeveloped.

While it is important for physicians to know the principles and the different theories of medical ethics, this knowledge alone will not help them in disentangling complex cases they will often face. In addition to an analytic approach which reduces human quandaries to rational problems, physicians must see in these dilemmas something other than mere ethical quandaries in need of solutions and be able to identify a relevant humane occurrence: A narrative in need of interpretation. It is my contention that these loopholes can be remedied if students were given a venue that will allow them to appreciate as many particulars of the situation as possible, to engage in the case not as inactive spectators for a short time, rather to get entangled in the case just enough to be involved yet remain sufficiently detached to be able to exercise a good amount of critical analysis. This is possible through medical drama. Md-narrative allows the use of what Charon (2001) called narrative competence which “human beings use to absorb, interpret, and respond to stories.” This competence “enables physicians to practice medicine with empathy, reflection, professionalism and trustworthiness” (Charon 2001). Narrative relates events that occur over time following a certain progression. Novels, patient stories, and poems are narratives and television dramas are the narratives of our times. As Kozloff pointed out, “our ancestors used to listen to tall-tale spinners, read penny dreadfuls, tune in to radio dramas, or rush to the local bijou each Saturday, now we primarily satisfy our ever-constant yen for stories by gathering around the flickering box in the living room. Television is the principal storyteller in contemporary (…) society” (Kozloff 1992). Television dramas allow us to enter into narratives and the world they depict in a way that we become caught up in the action. Herein lies their power. As Volandes argues, “by providing vivid details with images, film vignettes offer rich and textured details of cases, including the patient's perspective and the clinical reality” (Volandes 2007). If the problem with teaching ethics is that it cannot be tangibly grasped, md-narratives translate ethics into a living experience.

Numerous nights every week, a great number of medical students watch medical dramas like Scrubs, Chicago Hope or ER. According to Jeffrey Spike, associate professor at Florida State University College of Medicine, “there should be no shame in admitting that sometimes professional scriptwriters can write a better script than a small team of doctors and ethicists working in isolation at a medical school as if it were a cottage industry” (O’Reilly 2009). He even contends that “the mass media can provide an invaluable supplement to the ethics education of students in medicine, and ethics professors who ignorant that fact (or worse, condemn it) are not doing their job” (Spike 2008). The medical drama is becoming a popular genre and has a specific appeal to students of medicine. Such is the case of Fox's medical drama House MD whose hero, Dr House, is a maverick who communicates with diseases instead of patients. Now showing in its fifth season, he remains an acerbic physician who practices doctoring on the white board instead of by the bedside. In the pilot episode, a notorious conversation takes place between this tragic hero and his aid, which sets the pace of the episodes to follow:

Foreman: Isn’t treating patients why we became doctors?

House: No, treating illnesses is why we become doctors. Treating patients is what makes most doctors miserable. (Pilot, Episode 101)

A key feature of the series is the bitter and paradoxical character of the protagonist. House is an antisocial drug addict (he consumes Vicodin for his chronic leg pain) who employs notorious means of diagnosis and treatment. He habitually risks the lives of patients in an attempt at saving them. His “epiphanies” are paved with what are judged immoral resolutions and he is often contrasted with Wilson, the kind oncologist, who is ironically1 everyone's favorite physician. Put plainly, House's hubris is tragic. Notwithstanding, the enormous popularity of the show cannot be denied as recent ratings indicate an average of 14 million viewers (Colin 2006).

House's famous exhortation that “everybody lies” implies that it is more conducive to the truth if one were to stay away from patient encounter, as patients will take you further from the truth. Accused of having a “disdain for human interaction” (The Mistake, Episode 208), House argues that he can cure his patients without an encounter. Patients are objectified and turned into their disease. All through the four seasons and a half, we continue to see series of objectifications that do not fail to reveal fantastic narratives that constitute marvelous educational opportunities for teaching biomedical ethics.

Emotional engagement and critical thinking

Ms Sloan's case vignette alone, although an example of case-studies used to illustrate the application of ethics and its relevance on the wards, does not allow for deep and serious deliberations. More information is needed to understand (1) why the attending of the case took the decision he took, (2) the patient's refusal of a decision that will save her life, and (3) the reason why the Dean of Medicine refused to back up the scientific judgment of the attending physician and thus to formulate our own ethical rational reflection on the case. The personal narrative of the mother that made her refuse the life-saving operation is lacking. We infer that the attending physician is someone who deems that the life of the mother is more important than that of the baby; hence, it is worth sacrificing the latter to save her life. We have no idea as to why the Dean of Medicine took her position and we might spend time throwing assumptions there as well. What are the values and preferences from which the different agents operate? What discussions occurred? What emotional reactions developed?

This is, in fact, one of House's cases (Fetal Position, Episode 317). As viewers watch the narrative unfolding over 45 minutes, the above questions start to find their answers: Ms Sloan is 42 and single. She suffered miscarriages and failed IVFs and sees this IVF pregnancy as her last chance. The attending physician is House, whose character we already know: Atypical views of right and wrong, “arrogant”, often calls patients “idiots” or “morons.” He does not see a “baby” but a “fetus”, a “tadpole”, a “parasitic growth”, a “dangerous tumor” and concludes that termination of pregnancy is the way to save the patient's life. The Dean of Medicine, Dr Cuddy, identifies with the patient who is approximately her age. She too was trying to get pregnant by IVF and considers the fetus as a baby-patient. This impels her to push for risky exploratory fetal surgery to save the life of the unborn baby. During the surgery, the hand of the unborn child squeezes House's finger.2 Unexpectedly towards the end of the episode, and for the first time, House refers to it as a “baby.”

The use of analogous md-narrative in teaching enhances emotional engagement and cognitive development. Viewers get involved in the life of the agents, and the cognitive development of learners is improved through group deliberations, creative thinking, and questioning which happens effortlessly in an ambiance of involvement. As the different pieces of the narrative progress, as we witness physical findings, catch sight of the gazes, smiles, fears, and values of the different parties, particulars start to have more meaning. As we hear them talk of their personal stories, the reasons for their decisions, issues make more sense. We may not agree, but at least we understand the reasons as to why persons took the position they took. Discussions become rich and moral contradictions start to unfold. Arguments become oriented and targeted even heated. References to values, facts, and theories become solid and contextual because we are aware of the particulars and perspectives. Moral exercise ceases to be abstract. Physicians, patients (as well as other participants and stakeholders) are seen in context, within the situation and in relationship to each other. According to Nussbaum (1990), “[a] novel, just because it is not our life, places us in a moral position that is favorable for perception and it shows us what it would be like to take up that position in life. We find here life without possessiveness, attention without bias, involvement without panic.” The same can be said of md-narratives. They offer a new element needed to enhance teaching of biomedical ethics: Surgeons without a scalpel and patients without a disease, the discussants are engaged enough to argue and take a stand, yet detached enough to make critical deliberation and reflective judgment. While the role of emotion in morality has been disputed, this depends largely on whether they are viewed as pure impulses or as having some kind of cognitive content. While this is an interesting issue, it falls beyond the scope of this article. According to Aristotle, emotion is not only a manner of reacting; it is also a manner of perceiving, of being involved, and then reacting in a particular situation. Thus, to act rightly involves acting rightly in affect as well as in conduct and emotions thus play a role. While some aspects of the case, and not others, are discerned depending on the viewers’ emotional susceptibility, this can be used positively in class discussions as different aspects are brought to light and emotions are educated. Md-narratives appeal to both mind and heart. Sherman argued that emotions are an essential source of information and prepare for moral reflection. They are “modes of attending and conveying value” in that they allow us to notice relevant salient information and have a revelatory function and a motivational one as they reveal information and move a person to action (Sherman 1997). This has bearing on ward ethics and moral decision making.

In DNR (Episode 109), Giles, a renowned jazz trumpeter, was paralyzed by amyotrophic lateral sclerosis (ALS) and acquires pneumonia. House doubts the diagnosis, but the case is given to Foreman. Giles signs a do not resuscitate (DNR) form to escape a lingering death. However, as he arrests, House violates the order and revives him. He gets a restraining order and is sued. Other doctors are called to pull the plug, yet, surprisingly, Giles lives. House has his team perform risky surgery to fix the paralysis of Giles's arm. His arm and legs improve. Eventually, the cause underlying the paralysis is dealt with and the patient is cured. Towards the end, in an emotional moment, Giles thanks the attending physician who disrespected his wishes and gives him his trumpet as a token of gratitude. Viewers are left perplexed, in awe and leave the episode thinking further about the moral issues it raises.

The episode offers visual imageries that enrich the narrative and grab the discussants. Viewers partake in Giles’ life and those of the people involved in it through the dialogue that takes place (as Giles describes how his music is the thing that hits him hard and true), the arguments (it's the patient's decision, he signed the DNR 'cause he didn’t want a slow and painful death from ALS), the facial language (pain, fear, and angst) and even the music. Without worrying about the consequences, viewers witness what making choices entails. Had the DNR been respected, Giles would have died: A moral conundrum. At the same time, not respecting the wish of a competent patient led to the restraining order and a lawsuit. All through, viewers see the agony of Giles, the trumpeter, whose quality of life has been taken away allegedly by ALS and how this had an impact on his decision. Giles is not a number, but a person with a past, and a future to whom one can relate. He is objectified by House and by the viewers only to be made a particular hero in a series of particulars and hence a person with a life and plight worthy of thought and reflection, not simply a case. Case-studies objectify patients and render them soulless while md-narratives objectify them to bring them to life. In a way, they offer the viewer a chance to mature emotionally and “of feeling specific emotions finely – in the right way, in the right circumstances, for the right reasons (…) [this] marks the cultivated emotional tendencies constitutive of virtue” (Sherman 1997). Was it not Aristotle who believed that attending tragedies was part of adult education of characters? Emotions can be educated in considerable ways even when we are past childhood years (Sherman 1997). One might ask: Are emotions necessary at all? A Kantian would argue that emotions are fickle and one cannot base one's moral decisions on such capricious bases. Looking at it from an Aristotelian perspective, for a phrominos (a person of practical wisdom), the kind of physician we hope our medical student will eventually become, emotions function like a microscope that allow the student to see what lies behind the fear that a patient feels when he says “I am scared.” The hidden information here that emotions allow the student to perceive is the fear of death, of dependence, and a sense of loss. Angst denotes suffering and pain. Emotions become keys that open the gates for newer understandings. So, in a way, they help students see things they might have missed!

There are always various sides to a moral conundrum. But this is what ethics is about and this is what makes a discussion fruitful and healthy. Unlike Dr Cameron in the series who frequently portrays the viewpoint that ethics is black or white, moral quandaries are usually the gray area in between. Spectators are taken and caught up by the emotional tension; yet, their emotions are detached enough for them to be able to make critical reflections on what the right action is. It is not their patient. Their deliberation will not have immediate repercussions. They can be the champions of unrestricted autonomy and patient rights. Yet, Giles is not on the wards. Thus, he is their “virtual patient/teacher” who explains to them in many ways that at times, blind adherence to principles is dictatorship. They have the time to deliberate, to think, to rethink, and to weigh things out. Their judgment need not be suspended under the pressure of strong emotions or time. Emotional engagement is heightened when participants start relating to the characters of the narrative. In addition, this identification allows for moral imagination to be nurtured and to play a role in ethical decision making.

Table

Practice points

Case vignettes are often used for discussions as part of biomedical ethics education; yet, they do not allow discussants to see how the various stakeholders perceive and understand different events. Medical drama as an md-narrative is an important venue to be used in the teaching of biomedical ethics. The use of medical drama in teaching enhances emotional engagement, cognitive development, and moral imagination which allow for a more ethically sensitive student in training. Case-studies objectify patients and render them soulless while medical drama narratives objectify them to bring them to life.

Moral imagination

What does it feel to be like the patient? What goes on in the mind of the patient or the members of the healthcare team when they make decisions that are not solely evidence-based medicine? Following her recovery from tonsillectomy, the philosopher Wittgenstein called his Russian language teacher Pascal Fania inquiring how she felt. Like a dog that has just been run over, she answered. He was “disgusted”: “you don’t know what a dog that has been run over feels like” (Pascal 1994). It is irrelevant to our purposes whether Wittgenstein was truly disgusted. The point is whether one can imagine what another being feels like. When asked what does it feel like to be old? Thirty-three-year-old Ms Ramirez replied: Painful and frustrating. She partook in a 3-hour training program entitled Extreme Aging intended to imitate the weakened capacities linked with old age (Leland 2008). Forty-six-year-old Kim Hansen who also took the course conveyed that the toughest part in the experience was her having to suffer losing people who filled her life: “I gave up my parents first (…) then it was between my husband and my kids. (…) I got very emotional with that” (Leland 2008). Exercises like this trigger a person's imagination which, in a way, allows one to come close to what the other feels like. They allow one to experience Nussbaum's empathy: An “imaginative reconstruction of the experience of the sufferer” (Nussbaum 2001). Ethical thinking cannot remain descriptive. It has to move a little further into the realm of moral imagination and, for the student of medicine, try to think what life might be like for the person on the other side of the stethoscope. The phrase “moral imagination,” says Russel Kurk, was originally coined by Burke and signifies “that power of ethical perception which strides beyond barriers of private experience and events of the moment” (Fraust 2003). According to Johnson, moral reasoning is “basically an imaginative activity, because it uses imaginatively structured concepts and requires imagination to discern what is morally relevant in situations, to understand empathetically how others experience things, and to envision the full range of possibilities open to us in a particular case” (Johnson 1993). He goes on to say that “[m]oral principles without moral imagination become trivial, impossible to apply, and even a hindrance to morally constructive action” (Johnson 1993). Fesmire argues that when one faces dilemmas, options “are tested in thought as we imaginatively envision them carried out” awaiting a solution (Fesmire 2003). Md-narratives offer rich emotive and tangible situations that allow for moral imagination to guide ethical deliberation in the hope of finding this solution. Viewing and reflecting on md-narratives in a classroom environment compel the viewers to respond to the particular experiences the character faces: What should this person have done? What alternatives did she have? What would I have done if I were she? etc. Students are given the chance to change hats and perspectives. They can be the patient, the brother, the physician, the administrator, etc. The fictitious element allows for a free exercise of moral imagination and the discussants to view things from different perspectives, to weigh the pros and cons of different alternatives knowing that no one's life is at stake at this particular instant. Moreover, new relevant considerations might upsurge that might not have been thought of before and consequently, a process of positive critical self-reflection about one's previous ethical standpoint might ensue. The narrative is seen as developing and discussants are part of it. It is not an inert case-study with missing elements. Discussants live it from a distance yet, they, so to speak, feel involved in the narratives of the lives of particular human beings. Herein lies the difference. Md-narratives cultivate our moral imagination by enriching it. They nurture our ethical sensitivity and moral sense by challenging existing moral values and beliefs and making us more perceptive of particulars. In episode 307, a young man, Kyle, who visits his father Gabe in the hospital, who is in a persistent vegetative state (PVS), develops kidney and liver failure and slides into coma. House's idea that this is genetic is rebuffed as the test comes negative. Consequently, he decides to awaken the father in order to know more. An ethical quandary arises: Is it morally acceptable to awaken a patient who will inevitably relapse into a coma merely to ask him a few questions? Meanwhile, the son's health is deteriorating and he needs a heart transplant. We also learn that he is an alcoholic and hence has no chance of getting onto the transplant list. To save the life of his son, the father has to donate his heart: He will have to kill himself. House advises him on the feasible means to do so. Several ethical issues arise: Do alcoholics deserve an equal allocation of resources? Should doctors advise patients on means to kill themselves? Should doctors do that in such situations?

Md-narratives allow discussants to get involved. We see Kyle constantly visiting his father who did not care for him. Gabe thought his son was a drunkard who caused the fire that killed his wife and rendered him comatose. As the narrative unfolds, we realize that Kyle had ragged-red fiber, a disorder of mitochondrial metabolism characterized by myoclonic epilepsy and ragged-red muscle fiber. Realizing this, Gabe feels bad, wishes he had time to see his son (“I wouldn’t get to see him even if we got in a car right now and broke the speed limit, driving back, would I?”), and wants to give him his heart. House appreciates the usefulness of a heart that will go to waste unless harvested.

Nevertheless, md-narratives as venues to teach biomedical ethics will inevitably have their critics. One might argue that the intellectual passivity medical dramas offer can be dangerous. This, however, can be resolved by emphasizing that they be an in-class group activity with a moderator. Arras who argues that narrative is a “crucial element in ethical analysis” worries whether it “will ever be in a position to supplant an ethic also undergirded by principles and theory” (Arras 2007). It is not my contention though, that md-narratives should or can do such a thing. Rather, they serve as a supplement to illustrate the relevance of moral theory and principles on the ward. Also, moral imagination can be thwarted by a number of factors all of which can be witnessed on the wards. These factors will be mentioned briefly as they merit an in-depth consideration on their own which falls beyond the scope of this article.

1. The habitual states of the discussant and physicians who are not used to engage in such ventures and who might need further training.

2. Students might feel that it is better if they were to obey unfettered authorities instead of engaging in an act of moral deliberation that involves moral imagination if it ensures a better evaluation and will not upset their superiors.

3. Many students and attending physicians tend to appeal to the authority of what Jonsen and Toulmin (1988) called the “tyranny of principles.”

4. The need to promote one's self interest, particularly in an atmosphere where it pays to do so and where checks and balances are wanting.

MD-narratives offer creative ways to meet the objectives of biomedical ethics education which consist of introducing principles and theories of medical ethics, enhancing ethical sensitivity, offering participants a chance to challenge their beliefs, and give examples of role models (to mention but a few). They are in line with modern brain-based learning theory, and they raise bioethical issues that are encountered on the wards of almost every hospital (many of which can be discussed through, and extrapolated from, House MD), they help students understand the issues, relate to them, argue their positions, and defend them. Most importantly, they allow them to see that moral theory is not suspended in space, rather, that it has important bearing in everyday ward life.

Will this work? Will md-narratives actually enhance emotional engagement, cognitive development and moral imagination? We aim to launch this method of teaching as a pilot project with our MED III students at the American University of Beirut teaching hospital in what we have called the Physicians, Patients and Society-2 course. Several episodes from House MD will be used in lieu of clinical vignettes. Some will be screened in class and interrupted on the go for questions, debates, and reflection. Others will be divided into segments and placed online via a Learning Management System (Moodle) and be used as entrance and exit activities for a number of units.

Why the arrogant House and not the metamorphosed Dr Mackie from the film The Doctor or another character that is less controversial? There are three main reasons for this: (1) The character, the cool rugged physician with his cane, appeals to contemporary young minds, (2) House is a series, the link it offers plays an important role in its being a narrative, and (3) it is my conviction that House cares. He epitomizes the physician who dares to break the rules when rules need to be broken, who cares for his patients but does not want to be seen caring, whose sole aim is the cure, not the applause. This, however, is another story, another narrative.

Experience has shown us that case vignettes in fact objectify patients and rob them of the details that render them alive and soulless. Time will tell whether md-narratives, used the way we suggested, will bring patients and everyone involved in their care to life and hence will allow the students to mature emotionally and ethically.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Notes on contributors

Thalia Arawi

THALIA ARAWI is a clinical bioethicist and the director of Bioethics and Professionalism Programme at the American University of Beirut, Faculty of Medicine and Medical Center. She is a member of several international Bioethics Associations.

Notes

1. Dr Wilson is portrayed as very kind, putting the good of the patient before his own. Yet, his kindliness is an impediment: He writes prescriptions to his friend, has affairs with depressed patients, etc.

2. Reminiscent of the famous Samuel Armas’ story: A fetus with spina bifida who underwent a successful fetal surgery in 1999 by a surgical team at Vanderbilt University in Nashville.