Weeding the Unethical Out of Medicine
This year I decided to lay sod in the yard. Not only a major expense, it goes against a whole industry based on seeding and reseeding the lawn every spring. Four weeks and $500 in water bills later, the Bermuda is "established,” and other than mowing it once a month, I thought my work was done. No such luck: crabgrass has taken hold, and just as it can grow in the narrow cracks of a sidewalk, legions of it crisscross the yard, sprouting between every strip of sod. I was told to spray, but that the herbicide might leave my yard looking like a checkerboard of brown lines. Plus, it’s been in the 90s so the same stuff that kills crabgrass will likely ruin the Bermuda. So, my best option was to pull the crabgrass up by hand: a slow and laborious process that required me to get down on my hands and knees to weed out the crabgrass one plant at a time.
While weeding last weekend, a volunteer was going door to door collecting canned goods to help stock the local food pantry. Thirty minutes later, she couldn’t help but notice how little I’d weeded and how much I had yet to go. She laughed and said, "That’s hopeless. ” I wanted to say, "Not as hopeless as expecting to solve world hunger with a couple cans of green beans.”
I was just flustered because I knew she was right. In the past hour I’d weeded about 200 square feet and had about 8000 square feet to go. It was pointless. I kept pulling weeds while my mind did the mental gymnastics: 8000 divided by 200…is the same as 80 divided by 2…is 40 hours of pulling weeds…at about 2 hours a day…is 20 days! By the time I would finish, if I’d finish, new weeds would be sprouting. It occurred to me that the task off pulling weeds was an excellent metaphor for my life.
Whenever anyone asks me what I do for a living, I say I teach ethics. The most common response to that is "I didn’t know ethics can be taught.” Apparently, many believe that a person is either born ethical or not, kind of like athletic ability. When I tell them I teach medical ethics to aspiring health practitioners, the response is invariably, "Sounds hopeless”: as hopeless as pulling weeds.
Basically, there are three ways to insure the health profession remains ethical: 1. Prescreen student applicants, 2. Provide ethics education, and 3. Weed out the unethical ones. To belabor my lawn metaphor this means: 1. Use pre-emergent herbicides, 2. Use post-emergent herbicides, or 3. Pull out each weed by hand. Laying sod is similar to establishing an ethics curriculum. Unlike seeding, which is a way of starting all over again each year, sod is scientifically and esthetically designed to provide a foundation for future growth. Likewise when an ethics curriculum is based on sound pedagogy, it provides the foundation for future growth and an opportunity for life-long learning. In teaching ethics, we don’t start with a tabla rasa, we start with standardized goals and objectives that are met though individual and collaborative efforts. Yet, despite these efforts, weeds pop up now and then. Some instructors blame the admissions department or interviewing committees for accepting students who are not suited for the health professions. The problem is that there are no "pre-emergent” herbicides that we can spray on all applicants to guarantee only ethical students are admitted. Under the right (or wrong) conditions, as television’s Dr. House says, "Everybody lies.”
So, similar to the idea of using post-emergent herbicides in lawn care, schools and their accrediting bodies mandate ethics education. This is done to protect future patients as well as the integrity of the academic institution, which is the first place most malpractice defense attorneys try to lay the blame. "No one ever taught my client how to conduct ethical and legal informed consent.” Will an ethics education prevent unethical behavior? Not by itself. A gardener can spray post-emergents all year long and still find a resistant weed, not to mention the damage that subjecting harsh and unnecessary herbicides can have on a healthy lawn. I once saw a course syllabus for an ethics class that was two-thirds plagiarism warnings, all set in bold red type. Likewise, the use of policing tools such as turnitin.com seems counterproductive to me, especially when the goal in an ethics class is to encourage ethical behavior for its own sake and not out of fear of penalties and punishment. Daniel Pink, author of Drive: The Surprising Truth About What Motivates Us, emphasizes the value of intrinsic motivators, such as enjoyment and enthusiasm, over extrinsic motivators, such as punishment or external rewards. Post-emergents for ethics education, whether threatening students with a stick or enticing them with a carrot, cannot guarantee that everyone will recognize the obligation medical professionals have to behave well.
Pulling weeds seems like an endless task because it is an endless task. As to whether it is a "hopeless” one, well I guess that depends on the perspective. The process of weeding out students who are ill-suited for the health professions can be one of the most challenging tasks for an instructor. Many instructors balk at the responsibility, justifying their hesitancy with claims that they can’t catch everyone, or that it is too much trouble to file a complaint, or that their referrals always seem to get pardoned anyway. It is easier to blame the admissions department or the learning environment, but the only way healthcare will ever stand a chance of greener pastures is if we use all three approaches to help weed the unethical out of medicine. That means selecting reputable candidates, providing effective ethics education throughout the curriculum, and demonstrating the courage it takes to get down on our hands and knees to weed out those who do not recognize patient care as the highest calling.
Holub P. Weeding the Unethical Out of Medicine. The Internet Journal of Allied Health Sciences and Practice. 2010 Jul 01;8(3), Article 2.