The current issue of Academic Psychiatry contains two articles on ethics education that complement each other in raising sobering and thought-provoking questions. Roberts et al. (1) surveyed the preferences and experiences of medical students and residents regarding ethics and professionalism education. The ideas and findings in the Roberts et al. article are too numerous to be fairly summarized here, but the essence is that medical students and trainees commonly experience ethical conflicts in their training, believe their training (in ethics or otherwise) is not quite up to meeting the challenges of the ethical conflicts encountered, tend to be optimistic about the value and the achievability of the goals of professionalism and ethics training, and prefer clinically oriented learning (and evaluation) approaches. In short, the portrait of these students and trainees is one of concerned adult learners who feel they need, want, and believe in the efficacy of more ethics education. A highly structured survey such as this, however, is not designed to explore deeply into the possible stories that underlie the largely—although not entirely, as we will see below—optimistic quantitative findings. In this regard, the article by Jinger Hoop (2) raises some less optimistic possibilities.
Hoop thoughtfully raises disturbing yet infrequently discussed ethical dimensions of psychiatric residency training. These are framed as dual role issues, between the role of a physician whose primary fiduciary duty of promoting the welfare of the patient may come in conflict with the roles of a learner, a supervisee, or an employee. She notes that these conflicts are rarely part of the standard ethical curriculum. Indeed, it may be that we are lulled into this neglect by the emerging prominence of ethics curricula in psychiatric training. Further, these ethical conflicts come at a time of high stress and vulnerability for the resident. Hoop suggests a helpful set of recommendations to remedy the situation.
In order to appreciate fully the implications of Hoop's article, it may be worth drawing a further distinction: some ethical tensions or dilemmas are inherent to playing two different roles simultaneously, while other conflicts and tensions happen to arise in the same domains but are not inherent to the roles themselves. For example, the issue of informed consent for treatment in a resident's first psychotherapy case is a tension that is inherent to the role of a physician who is also a trainee. On the other hand, the conflict created by a supervisor who suggests false documentation is not inherent to the resident-supervisor relationship. Sometimes the distinction is not easy to draw without further detail. For example, the cases of clinical disagreement between supervisee and supervisor, as discussed by Hoop, could be an inevitable part of such relationships since psychiatric diagnoses and treatment often involve considerable room for judgment, or they could involve a situation gone wrong as when an impaired or incompetent supervisor suggests a course of treatment that may harm patients.
When the ethical tension is inherent to two distinct but legitimate roles of the physician, the ethics may be more challenging (since there is no way of getting rid of the tensions, only ways of managing them) but in some ways easier to teach since they are clearly problems for the profession as a whole. Such perennial, inherent tensions usually leave a trail of tradition in dealing with them, in the form of professional codes (e.g., dual agency guidelines, conflicts of interest rules), practices, supervisory guidelines, etc. Such traditions provide the familiar contents of professional ethics curricula.
I suspect, however, that by "hidden ethical dilemmas in residency training" Hoop means those cases in which the ethical tensions arise out of the seldom discussed moral failings of supervisors, program practices, and institutions. What she reminds us of is that it is an unpleasant (therefore hidden) subject, even if most of us can tell a few amusing anecdotes.
It is not surprising that our (I assume we are all guilty at one time or another) moral failings remain part of the hidden curriculum. First, most people and institutions who behave unethically do not feel that they are being unethical. We have a need to justify our questionable actions—indeed, we have a need to not even recognize them as questionable—and most of us are very good at it. Second, often the ethically questionable action at issue is not a violation of someone's right or a clear instance of inflicting harm but a failure to live up to an ideal that may cause no visible harm at the level of each individual instance, even if the long-term corrosive consequences are predictable. Finally, to confront someone about his or her allegedly unethical behavior is not pleasant for either the accuser or the accused and is especially challenging for the person with less power in the relationship.
How do our trainees cope with all this? One suspects that the strategies involve some combination of anger, humor, dejected acceptance, and perhaps even cynicism. Roberts et al. found that trainees seem to believe rather strongly that medical training fosters cynicism, although a specific analysis was not performed, there appeared to be a trend of increasing clinical experience leading to greater belief in cynicism caused by medical training. Of course, the trainees' beliefs about cynicism-promoting effects of medical training do not show that they have become cynical. Indeed, their overwhelming recognition of the importance of ethics in medicine and in ethics training shows the opposite. But their answers may inform us that they are witnessing problems that confirm Hoop's thesis, which is that these "hidden" ethical tensions need much more attention. Perhaps this is why there is a consistent and strong belief among those surveyed that the best mode of ethics education consists of "role modeling of ethical reasoning and behavior by faculty, clinical rounds, interactions with patients in routine training, and case conferences"(1).
The comparatively greater openness to further ethics training among psychiatric residents reported in the Roberts et al. article is both sobering and encouraging. It is sobering that this desire for more ethics training may be a sign of relatively greater moral distress experienced by psychiatric residents. Yet, one is impressed by their desire for something better. The two thoughtful papers published in this issue are important steps toward "something better."