'No one right answer:' Exploring medicine's toughest ethical questions

By Grace McOmber
School of Medicine

Weeks after finishing her first year of medical school at Virginia Commonwealth University, Megan Castle moved into a Yale dorm suite with total strangers: a prelaw student from Florida, a philosophy major from California, a conflict mediator from New York and an ICU nurse from Italy.

Over the next several weeks, the four roommates shared more than a living space - brought together by the Yale Summer Institute in Bioethics, they spent their days exploring complex ethical questions and how their different backgrounds and beliefs shape the way they approach those questions.

For Castle, the summer program was an opportunity to broaden her medical education and learn from the experiences of professionals outside of medicine. Now that she's back at the VCU School of Medicine for her second year, she's eager to continue studying bioethics and help her peers explore how these principles will factor into the decisions they'll make every day as physicians.

"Ethics shouldn't ever be an afterthought," Castle said. "We should incorporate it into everything we do and ask questions about why we do the things we do. I want to get people thinking in that direction."

Digging deeper into bioethics in medicine and other fields

Bioethics, as defined by the National Institutes of Health, is the study of "ethical, social and legal issues that arise in biomedicine and bioresearch." Four main principles - autonomy, beneficence, nonmaleficence and justice - guide the numerous frameworks from which bioethicists approach moral dilemmas in a range of fields, including biotechnology, law, the environment, research and medicine, among others.

A key component of bioethics is its evolution alongside technological advancements, cultural attitudes and the recognition of past wrongs. For example, the 1950s saw the invention and widespread usage of mechanical ventilators that can sustain vital bodily functions in patients with a total loss of brain activity. This advancement necessitated conversations on when a patient can and should be declared dead, the role of next-of-kin in that decision and how to balance differing opinions on maintaining life support.

"Bioethics is different from any other field of study I've engaged with, because the goal isn't to find one right answer," Castle said. "The goal is to ask questions and present differing opinions on a given issue."

"I'll likely not ever be fully prepared for circumstances with the hardest ethical quandaries, but having experience sitting in that space can provide guideposts for navigating it," Castle said. "If you only care about ethics in the abstract, you don't really care about ethics."

At the School of Medicine, medical students formally engage with bioethical concepts during the longitudinal Physician, Patient and Society course, also known as PPS, beginning in their first semester of medical school. Across the preclinical curriculum, students sit for lectures on the foundational principles of medical ethics and hear directly from patients whose identities have historically been marginalized in healthcare, like people with sickle cell disease, substance use disorder and disabilities.

Meera Pahuja, M.D., an assistant professor in the Department of Internal Medicine and co-director of PPS, said the course not only encourages students to be curious about their patients' values, but it also challenges them to interrogate their own values.

"We're aiming to teach students that being a physician isn't just about knowing all this information, it's also about understanding why a patient may have different values and makes different choices than you do," Pahuja said.

Castle credits PPS, in part, for sparking her interest in bioethics and its role in medicine. At the seven-week Yale program, Castle was in a cohort of 35 students and professionals representing a wide range of professions and backgrounds - including medical students from Spain, a Romanian researcher living in Singapore, an embalmer and a pediatrician. She attended morning lectures highlighting some of medicine's most pressing questions, such as how to allocate medical resources, using AI responsibly and the ethical considerations involved in advancing biomedical research. Optional afternoon lectures featured more niche topics like space exploration, animal welfare and the U.S. legal system.

Field trips introduced the group to individuals and organizations that explore bioethics in their industries, like a chef and farmer outside of New Haven, Connecticut, who prepared several dishes made from invasive plant species and discussed the intersection of agriculture, environmentalism and food sustainability. Another seminar took place at the Cushing Center, a medical library on Yale's campus that houses more than 2,200 human brain specimens, where the group discussed the educational value of the exhibition and ethical considerations of displaying patient remains.

"In medical school, there is very often a 'right' answer, and I found myself grappling for them at times throughout the summer," Castle said. "Exploring ethics forces you to sit in an uncomfortable area of ambiguity."

Tackling ethical dilemmas in the medical school environment

When she returned to Richmond in August, Castle stepped up as president of the medical ethics student interest group she joined during her first year. Her goal in leading the group is to create opportunities for her peers to explore tough bioethical questions through open discussions.

"I think there can be some hesitation in medical students when it comes to having these conversations, because there is usually no one right answer," Castle said. "I want to make an environment where that is okay."

To facilitate those open discussions, Castle and her co-leaders collaborate with other student interest groups and invite experts from a range of professions to host learning sessions open to all medical students. Last year, the group hosted a joint lunch lecture with the Medical Spanish Student Student Interest Group to discuss linguistic and cultural barriers when providing care to immigrant communities. This semester, the group is collaborating with the Student Psychiatry Society to host a faculty-led lecture on how children develop their morality.

Medical Ethics meetings mirror the final M1 session of the PPS course, where students work in small groups to discuss an ethical dilemma. In both settings, the goal isn't to arrive at a single right answer, but to explore the perspectives and experiences that shape how people approach complex ethical questions.

"They hear differing opinions and learn from each other," Pahuja said. "It gives students, including students with minority opinions, a chance to talk about how and why they came to their stance."

According to Julie Kraft, a second-year medical student and vice president of the Medical Ethics group, these discussions help prime medical students to prioritize ethical considerations in their decision-making. The events and discussions also help students get more comfortable asking what she calls "deceptively simple questions" - questions that may seem straightforward on the surface but reveal layers of complexity the more they are explored.

"Talking about ethics challenges us, especially as preclinical students, to use a different part of our brains," Kraft said. "Technology and medicine are advancing so quickly, and I think having ethics at the forefront of our minds can help us consider how to best use these new tools, as well as the limits of them."

For Castle, the lessons she learned over her summer at Yale are already shaping how she thinks about her future as a physician. As she prepares to enter the clinical setting, she's bringing a greater appreciation for the value of sitting in discomfort, asking difficult questions and making space for perspectives outside her own - skills she hopes will help her and her peers navigate the ethical complexities that will inevitably arise throughout their careers in patient care.

"I'll likely not ever be fully prepared for circumstances with the hardest ethical quandaries, but having experience sitting in that space can provide guideposts for navigating it," Castle said. "If you only care about ethics in the abstract, you don't really care about ethics."

This story was originally published on the School of Medicine website.