Conflicts between residents and attending physicians over ethical issues often occur and residents must attempt to navigate these perilous waters. A brief description of a conflict concerning informed consent and professional role expectations in a neonatal intensive care unit is presented. The discussion then explores contextual features that often shape such ethical conflicts and presents ways of understanding ethical conflicts that occur in the course of medical training. Constructive approaches for residents to engage in conflict resolution are offered.
Get full access to this article
View all access options for this article.
References
1.
1. AMA Council on Ethical and Judicial Affairs. Disputes between medical supervisors and trainees. JAMA. 1994;272:1861-1865.
2.
2. Black PM. Moral disagreements during residency training. JAMA. 1985;254:3467-3468.
3.
3. Branch WT Jr.The ethics of caring and medical education. Acad Med. 2000;75:127-132.
4.
4. Crook E, Weiner J. Resolving conflicts when residents and attendings disagree. Am Coll Physicians Observer. 1994;14:5-5,11-11.
5.
5. Diekema DS, Shugerman RP. An ethics curriculum for the pediatric residency program: confronting barriers to implementation. Arch Pediatr Adol Med. 1997;151:609-614.
6.
6. Jones TR. Speak no evil: physician silence in the face of professional impropriety. JAMA. 1996;276:753-754.
7.
7. Morris M. When loyalties are divided between teachers and patients. J Med Ethics. 1992;18:153-155.
8.
8. Nelson RM, Shapiro RS. The role of an ethics committee in resolving conflict in the neonatal intensive care unit. J Law, Med Ethics. 1995;23:27-32.
9.
9. Winkenwerder W. Ethical dilemmas for house staff physicians: the care of critically iii and dying patients. JAMA. 1985;254:3454-3455.
10.
10. Marcia Gray v. State of Rhode Island Dept. Mental Health, 697 F. Supp. 580: U.S. District; 1988.
11.
11. Brophy v. New England Sinai Hospital, Inc., 497 N.E.2d 626: Mass; 1986.
12.
12. Coordinating Council of the National Center for State Courts. Guidelines for State Court Decision Making in Life-Sustaining Medical Treatment Cases. Revised 2nd ed.St. Paul: West Publishing; 1992.
13.
13. Meisel A. The legal consensus about forgoing life-sustaining treatment: its status and its prospects. Kennedy Inst Ethicsj. 1992;2:309-345.
14.
14. AMA Council on Ethical and Judicial Affairs. Persistent vegetative state and the decision to withdraw or withhold life support.JAMA. 1990;263:426-430.
15.
15. American Nurses Association. Position Statement in Forgoing Artificial Nutnition and Hydration. American Nurses Association; April 2, 1992.
16.
16. AAP Committee on Bioethics. Guidelines on forgoing life-sustaining medical treatment. Pediatrics. 1994;93:532-536.
17.
17. AAP Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics. 1995;95:314-217.
18.
18. AAP Committee on Bioethics. Ethics and the care of critically iii infants and children. Pediatrics. 1996;98:149-152.
19.
19. AAP Committee on Bioethics, AAP Committee on Hospital Care. Palliative care for children. Pediatrics. 2000;106:351-357.
20.
20. AAP Committee on Fetus and Newborn. The initiation or withdrawal of treatment for high-risk newborns. Pediatrics. 1995;96:362-363.
21.
21. Levi BH. Withdrawing nutrition and hydration from children: legal, ethical, and professional issues. Forthcoming.
22.
22. Fost N. Decisions regarding treatment of seriously ill newborns. JAMA. 1999;281:2041-2043.
23.
23. Whittier G. The ethics of metaphor and the infant body in pain. Lit Med. 1999;18:210-235.
24.
24. Gustaitis R, Young EW. A Time to Be Born, A Time to Die: Conflicts and Ethics in an Intensive Care Nursery. 1st ed.Reading, Mass: Addison Wesley Press; 1986.
25.
25. Lantos J. The difficulty of being anti NICU. Lit Med. 1999;18:237-240.
26.
26. Guillemin JH, Holmstrom LL. Mixed Blessings: Intensive Care for Newborns. New York: Oxford; 1986.
27.
27. Hefferman P, Heilig S. Giving “moral distress” a voice: ethical concerns among neonatal intensive care unit personnel. Cambridge Q Healthcare Ethics. 1999;8:173-178.
28.
28. Martin DA. Nurses' involvement in ethical decision-making with severely iii newborns. Issues Comprehensive Pediatr Nursing. 1989;12:463-473.
29.
29. Mehren E. Born Too Soon. New York: Doubleday; 1991.
30.
30. Muraskas J, Marshall PA, Tomich P, et al. Neonatal viability in the 1990s: held hostage by technology. Cambridge QHealthcare Ethics. 1999;8:160-172.
31.
31. Sammons W, Lewis J. Premature Babies: A Different Beginning. St. Louis: C.V. Mosby Co.; 1985.
32.
32. Stinson R, Stinson P. The Long Dyingof Baby Andrew). Boston: Little, Brown, & Co; 1979.
33.
33. Jameton AL. Paediatric nursing ethics. In: Goldworth A, Silverman W, Stevenson DK, Young EWD, eds. Ethics and Perinatology. New York: Oxford Medical Publications; 1995:427-443.
34.
34. Pinch WJ, Spielman ML. The parents' perspective: ethical decision-making in neonatal intensive care. JAdvanced Nursing. 1990;15:712-719.
35.
35. Fleishman AR, Arras J. Teaching medical ethics in perinatology. Clin Perinatol. 1987;14:395-402.
36.
36. Culver G, Fallon K, Londner RB, et al. Informed decisions for extremely lowbirthweight infants. JAMA. 2000;283:3201-3202.
37.
37. Buchanan JM. The Demand and Supply of Public Goods. Chicago: Rand McNally; 1968.
38.
38. Eckenfels EJ, Daugherty SR, Baldwin DC. A socio-cultural framework for explaining perceptions of mistreatment and abuse in the professional socialization of future physicians. Ann Behav Sci Med Educ. 1997;4:11-18.
39.
39. Urbach JR, Levenson JL, Harbison JW. Perceptions of housestaff stress and dysfunction within the academic medical center. Psychiatric Q. 1989;60:283-296.
40.
40. Bissonette R, O's hea RM, Horwitz M, Route CF. A data-generated basis for medical ethics education: categorizing issues experienced by students during clinical training. Acad Med. 1995;70:1035-1037.
41.
41. Cook DJ, Liutkus JF, Risdon CL, et al. Residents' experiences of abuse, discrimination, and sexual harassment during residency training. Can Med Assoc. 1996;154:1657-1665.
42.
42. Daugherty SR, Baldwin DCJr, Rowley BD. Learning, satisfaction, and mistreatment during medical internship. JAMA. 1998;279:1194-1199.
43.
43. Elnicki DM, Linger B, Asch E, et al. Patterns of medical student abuse during internal medicine clerkship: perspectives of students at 11 medical schools. Acad Med. 1999;74(10 Suppl): S99-S101.
44.
44. Hundert EM, Hafferty F, Christakis D. Characteristics of the informal curriculum and trainees' ethical choices. Acad Med. 1996;71:624-633.
45.
45. Kassebaum DG, Cutler ER. On the culture of student abuse in medical school. Acad Med. 1998;73:1149-1158.
46.
46. Sheehan KH, Sheehan DV, White K, et al. A pilot study of medical student abuse: student perceptions of mistreatment and misconduct in medical school.JAMA. 1990;263:533-537.
47.
47. Silver HK, Glicken AD. Medical student abuse: incidence, severity, and significance.JAMA. 1990;263:527-532.
48.
48. Richman JA, Flaherty JA, Rospenda KM, Christensen ML. Mental health consequences and correlates of reported medical student abuse. JAAIA. 1992;267:692-694.
49.
49. Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion?: students'perceptions of their ethical environment and personal development. Acad Med. 1994;69:670-679.
50.
50. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medicine. Acad Med. 1994;69:861-871.
51.
51. Bleller L. In word and in deed: effective communication and commitment to action propel medical professionalism. Ward Rounds. 2000;17:23-29.
52.
52. Stern DT. The development of professional character in medical students. Hastings Cent Rep. 2000;30:S26-S29.
53.
53. Cohen JJ. Lining up with students against abuse. Acad Med. 1999;74:45-45.
54.
54. Zweibel EB, Goldstein R. Conflict resolution at the University of Ottawa Faculty of Medicine: The Pelican and the sign of the triangle. Acad Med. 2001;76:337-344.
55.
55. Dwyer J. Primum non tacere: an ethics of speaking up. Hastings Cent Rep. 1994;24:13-18.
56.
56. Brock DW, Wartman SA. When competent patients make irrational choices. N Engl JMed. 1990;322:1595-1599.
57.
57. Dubler NN, Marcus L. Mediating Bioethical Disputes: A Practical Guide. New York: United Hospital Fund of New York; 1994.
58.
58. Novack D, Suchman A, Clark W, et al. Calibrating the physician: personal awareness and effective patient care. JAMA. 1997;278:502-509.
59.
59. Johnson D, Wilson M, Cavanaugh B, et al. Measuring the ability to meet family needs in an intensive care unit. Crit Care Med. 1998;26:266-271.
60.
60. Goold SD, Williams B, Arnold RM. Conflicts regarding decisions to limit treatment: a differential diagnosis. JAMA. 2000;283:909-914.
61.
61. Cassell EJ. Practice versus theory in academic medicine: the conflict between house officers and attending physicians. Bull NYAcad Med. 1984;60:297-308.
62.
62. Farber NJ,Weiner JL,Boyer G, Robinson EJ. How internal medicine residents resolve conflicts with attending physicians. Acad Med. 1990;65:713-715.
63.
63. Green RA. Medical whistle blowing. In: Basson MD, ed. Ethics Humanism, and Medicine. New York: A.R. Liss; 1980:117-126.
64.
64. Marcus LJ, Dorn BC, Kritek PB, et al, eds. Renegotiating Health Care: Resolving Conflict to Build Collaboration. San Francisco: Jossey-Bass; 1995.
65.
65. Stone D, Patton B, Heen S. Difficult Conversations: How to Discuss Vhat Matters Most. 1st ed.New York: Penguin Books; 1999.
66.
66. Kritek P. Negotiating at an Uneven Table: A Practical Approach to Working with Difference and Diversity. San Francisco: Jossey-Bass; 1994.
67.
67. Dewey J. Human Nature and Conduct. New York: The Modern Library; 1957.
68.
68. Dewey J. Art As Experience. New York: Perigree Books; 1980.
69.
69. Camus A. The Stranger1st ed.New York: A. A. Knopf; 1946.
