Stone Throwing in the Glass House

A small girl with a unique genetic syndrome lies in bed since birth. Her brain does not work. She is in a persistent vegetative state. Recurrent seizures punctuate her intractable epilepsy. She shows no meaningful interaction. Her breathing is insufficient. Upper airway obstruction, repeated aspiration events, chronic lung disease, and scoliosis make her struggle to breathe. Her parents never wanted her to suffer. Two years ago, they agreed to a Physician Orders for Life-Sustaining Treatment (POLST). Their daughter would not undergo resuscitation. Death did not come, however. With meticulous medical care, her body grew. Her breathing worsened. Offered either palliation or a tracheostomy tube, her parents chose “trach.” With easier breathing, the girl expended fewer calories. She continued gastrostomy tube feeds and gained 10 pounds in 3 months. Now she is rehospitalized with respiratory distress. Her weight rises another 2 pounds. We put off calorie reduction for the outpatient setting. For the first time, we discharge the family home with a mechanical ventilator. Our collective health-care efforts have set up a protracted course whose likely end will come in overwhelming sepsis or ARDS, rather than allowing natural death with palliative care. How many ethical issues were raised by this case? I count more than 40 (Table 1). Physicians make ethical decisions constantly in health care without formal training in moral practice. Consequently, we leave most moral issues unaddressed. Instead, we concretize and categorize patient complaints into physical and mental issues to be addressed functionally (1). For instance, I may not be able to help a boy dying of cancer with his existential loneliness, but I can prescribe morphine for his respiratory distress. As a doctor trained in physiological intervention, this essentialization of clinical questions is justified by the ethical principle of beneficence. We focus on how we can help patients. However, this practice dehumanizes patients and leaves important overarching questions unaddressed. As Agledahl et al. wrote, “Even if your clinically sound decision is morally motivated, it may not necessarily be the morally good thing to do” (1). What is the effect of practicing medicine without addressing moral issues? Does clinical practice diminish our own humanity? Studies of our medical trainees may shed some light. Remarkably consistent studies have observed that empathy declines in medical students and resident trainees during their clinical years, but not during preclinical education (2). Students are subjected to mistreatment by mentors, loss of idealism when faced with clinical realities, isolation from social supports, high workload, lack of sleep and personal time, and a fragmented patient–physician relationship (2). Furthermore, the evolving electronic medical environment may be reducing trainees’ time spent in patients’ rooms. Pediatric interns and residents now spend only 12% of their time with patients, but 21% on computers and 35% communicating with colleagues (3). One could argue that limited empathy can improve problem-solving ability and competent health care (4). But what about the moral aspect of medicine? Unfortunately, clinical training impairs moral development. Repeated studies over the past 20 years observed that medical students fail to attain normal moral development and may even decline in moral reasoning capacity during their 4 years of medical school (5–9). Ethics lectures and clinical experience fail to