An ethical dilemma

[icedoverfire]

Hi gents,

I was recently posed this question in a practice interview (for med school), and I couldn't think of a response. I'm hoping a few good B&B members could help me out.

"As a surgeon you are asked to separate 'Siamese twins' (conjoined twins) and realize that one of the children will probably die. Discuss what process you would go through in making the decision whether to operate or not?"

After much consideration (now) I think I would operate to save the one child at the risk of losing the other, rather than let them both die.

- ice

 

[AdrianR]

This is a non sequitur - the ultimate decision belongs to the parents of the children involved which they would, hopefully, base upon your expert, professional advice.

 

[icedoverfire]

I agree - the final (extremely difficult) decision would lie with the parents, but I would strongly advocate for "harm reduction", if we could call it that, in the sense of saving at least one child.

- ice

 

[DanOK]

Very seldom is a physician asked out of the clear blue to make such a decision in a vacuum. In almost all cases there are family members who are involved and they make the decision. So my response would not be what your decision was but who, and what school, asked you such a arrogant question. My first response to such a question would be is the family aware of the options and what course of treatment are they advocating.

I am continuity amazed at the medical community's assumption that they are making these decisions. Both my parents and one brother-in-law passed away in their home. In each occurrence, as they approached the end of life care, a doctor or staff member decided a procedure was warranted or a transfer to a nursing home was the next course of action, which was complete outside of my family members wishes. Each time the medical facility and staff had to be reminded that it wasn't their decision to make. In one case the arrangements for a transfer had already been made.

I hope that my doctor can keep his ethical dilemma's out of my care. I expect them to provide me and/or my family with a clear set of options based on sound medical practice and I will make the decisions based on what I want.

 

[icedoverfire]

I also agree that such a decision is impossible to make in a vacuum for exactly the reasons you stated: familial considerations absolutely must be taken into account.

That being said, a lot of medical school interviewers LOVE to ask these "chicken and egg" kind of ethical dilemma questions, although it's impossible to make a sort of snap judgment decision.

EDIT: This particular question was actually given to me by my undergrad institution as an example of the kinds of questions to be aware of in interviews.

- ice

 

[DanOK]

Your right of course. Schools are becoming more competitive all the time in the search for the best and brightest. I am just getting more cynical as I age out and have more interaction with the medical system in the US.

Hey from the schools stand point the best and brightest will donate more money as alumni.

Take good care,

Dan

 

[Go West Young Man]

I think y'all are missing the point. The key part of the question is "As a surgeon you are asked to separate..." which to me suggests that that family has made their decision already.

The question is designed to get the student to go into the ethical gray zone and examine his own beliefs and motivations and decide where the line is for him/her. Would you kill one child to save the second, or let them both either die or live painful and limited lives? You could also have been asked to choose between saving a pregnant woman's life or her unborn child, but not both, or maybe would you perform a life saving procedure on a child that their parents object to?

These are all pretty standard "there are no right answers" type questions. The questioner is looking more at your thought process than about the answer you arrive at.

 

[Never2Late]

this is a non sequitur - the ultimate decision belongs to the parents of the children involved which they would, hopefully, base upon your expert, professional advice.

+1

 

[mdevine]

Having done these interviews many times, it is important to realize that there isn't a definitive answer to the question. We are looking at how someone answers and how they defend their argument. Further, difficult questions give you a chance to assess someone's composure under pressure. I prefer to hear the applicant say that they would defer to the families wishes. I actually don't want someone who is arrogant and looking to impose their wishes on the patient. That said, I personally don't like this type of question and the most recent interviews that I've done have changed the format. We have switched to standardized case studies designed to let the applicant talk about more generalized topics. There is less variability between interviewers and applicants and seems to be a more fair approach. Honestly, I do these on a volunteer basis at a medical school near me (and not where I went). Obviously, any interview process is designed to get the candidates best suited to do the job (intelligence, empathy, social skills, work ethic) and how much money they will generate for the school has nothing to do with it.

 

[DE Shaver]

These are all pretty standard "there are no right answers" type questions. The questioner is looking more at your thought process than about the answer you arrive at.

I agree with this perspective. The point of these questions is to ascertain an applicants rationalizing skills and provoke an applicant's deliberating abilities to ultimately come to a reasoned conclusion. However, to add a bit of contrariness to this issue, I'll say there is a wrong answer to these types of questions, which is "I don't know." However, even that can be debated.

 

[garyg]

I think y'all are missing the point. The key part of the question is "As a surgeon you are asked to separate..." which to me suggests that that family has made their decision already.

The question is designed to get the student to go into the ethical gray zone and examine his own beliefs and motivations and decide where the line is for him/her. Would you kill one child to save the second, or let them both either die or live painful and limited lives? You could also have been asked to choose between saving a pregnant woman's life or her unborn child, but not both, or maybe would you perform a life saving procedure on a child that their parents object to?

These are all pretty standard "there are no right answers" type questions. The questioner is looking more at your thought process than about the answer you arrive at.

This is the "right answer", that there is no right answer .. I'd rather a doc that ponders for a bit than one who instantly does a Marcus for me. Same for the mechanic on the car, who gives me options & probabilities rather than The Answer

 

[BladeRunner001]

Having done these interviews many times, it is important to realize that there isn't a definitive answer to the question. We are looking at how someone answers and how they defend their argument. Further, difficult questions give you a chance to assess someone's composure under pressure. I prefer to hear the applicant say that they would defer to the families wishes. I actually don't want someone who is arrogant and looking to impose their wishes on the patient. That said, I personally don't like this type of question and the most recent interviews that I've done have changed the format. We have switched to standardized case studies designed to let the applicant talk about more generalized topics. There is less variability between interviewers and applicants and seems to be a more fair approach. Honestly, I do these on a volunteer basis at a medical school near me (and not where I went). Obviously, any interview process is designed to get the candidates best suited to do the job (intelligence, empathy, social skills, work ethic) and how much money they will generate for the school has nothing to do with it.

HUGE +1 to this. This is clear case of "there's no right answer"...it is based on extracting the "arrogance factor" in a potential candidate.

 

[closer]

This is a non sequitur - the ultimate decision belongs to the parents of the children involved which they would, hopefully, base upon your expert, professional advice.

I agree with the comments made by others in this thread that the question is designed to explore the applicant's thought process. However, want to point out that some of these issues are not purely ethical decisions, there can be legal ramifications. Parents who wilfully ignore a doctor's advice, or don't even seek medical care for their kids when they should, can be held criminally responsible for their actions. There are various such state and local laws that deal with parental responsibility.

 

[LarryAndro]

... Discuss what process you would go through in making the decision whether to operate or not?" ...

All responses talking about the need to consult with family and others is appropriate and within the scope of the question. I hope IcedOverFire doesn't object, but what if YOU had to make the decision yourself with no help form others?

Speaking for myself, I am a pragmatist, and I believe I would make the decision much like a medic triages on the battlefield, or health care providers triage in disasters. How to maximize the positive, and minimize the negative for the widest number of people would be my primary guide.

I do not believe biological life is holy. I believe lived and experienced life is holy.

 

[icedoverfire]

@ LarryAndro - In real life, I would talk to the parents of the children and lay out everything for them, no bull**** e.g. "we can save one child but we will lose the other, preferable to losing both". I'm an advocate for harm reduction in a situation like this. Quality of life for the surviving child would also factor in to what I would discuss with the parents. If it was the case that I could save one child, but that child's life would consist of watching him or her slowly waste away and eventually die, I might seriously suggest the option of allowing both children something of a dignified death at my hands.

- ice