So You Wanna Be a...Medical Ethicist

We spoke with Joel Frader, MD, MA, Professor of Pediatrics and Professor of Medical Humanities and Bioethics, Northwestern University’s Feinberg School of Medicine, and Division Head, General Academic Pediatrics, Children’s Memorial Hospital, Chicago, IL to learn what it is to be a medical ethicist, the latest issues he faces, and how you too can become a medical ethicist.

What does it mean to be a medical ethicist? What are the requirements? There aren’t any offi cial requirements in the same way that there are for doctors or lawyers. At some level, it means whatever the individual wants it to mean. Most people who are doing something they call medical ethics do it by virtue of some professional background that involves clinical skills or formal education in philosophy, theology, religious studies, or a similar area; that’s been true for 30-40 years. In the last 15 years or so, there have been a number of programs around the country that award students masters-level degrees in medical ethics, bioethics, or related titles. These people spend one to two years—depending on the program, with some clinical involvement or not—learning the philosophical, ethical, moral, and intellectual history relevant to the field. People typically end up doing some combination of clinical consultation and policy development, as well as institutional education.

What issues do you deal with on a day-to-day basis? Is this a full- or part-time position? It’s very much part-time, although 25% of my time is supported by my medical school to be part of a medical humanities and bioethics teaching program for medical students. I teach various topics in medical ethics in a variety of settings, sometimes in the classroom in the first couple years before the students are immersed in the clinical world. But a large part is for students who are doing clinical rotations in various hospitals, getting them together to discuss cases they have encountered that have posed ethical dilemmas for them. In addition, I do ethics consultation here at our Children’s Memorial Hosptial. I teach residents, nurses, and others about medical ethics. I’ve also participated in writing institutional policies, and I do academic work “scholarshipped” in the field of medical ethics (some is empirical, some is post-ethical analysis).

What ethical issues have arisen from use of new technologies in medicine, such as e-mail contact with patients? There have been many issues, although it’s not something I’ve focused on personally. The issues concern privacy—something as simple as knowing whether the person you’re corresponding with electronically is who he or she purports to be. In pediatrics, that’s a big issue, because someone might pretend to be their 14-year-old son or daughter who we’ve promised confidentiality to. And the parent is trying to get around that promise by getting information out of us electronically without our being able to confirm who he or she is. Most of the issues we’ve faced electronically have to do with, in one form or another, privacy confidentiality. On a day-to-day basis, the bigger issues have to do with adequacy of informed consent, end-of-life decision making, limits on medical intervention, and issues around the appropriateness of including patients as subjects in research trials.

In what situations could your expertise be put to best use? Issues come up all the time about whether, in our case, parents or young children really understand what it is that the doctors are telling them and proposing for them. Such things as the doctor saying “we think your child should have x, y, z procedures,” and the parent really doesn’t understand what it is that’s being proposed and goes along with it based on simply trusting the doctor, when in fact if the parent understood, he or she may or may not be really interested in going through with what’s being proposed.

How did you get involved in medical ethics, and how would a physician go about becoming a medical ethicist? At the time I got interested, 30 years ago, there were no formal programs. So, I took advantage of the Robert Wood Johnson Clinical Scholars program, which is still around and takes people who are fi nishing residency programs and allows them to develop their intellectual interests in issues that are non-biomedical (not laboratory science or clinical trials), but that have more of a public health, health services research, or medical economics interest, for example. I was at the University of Pennsylvania, where I happened to get a degree in sociology and worked with people in sociology in ethics and in law at the time, to develop my interest. These days, one can do a fellowship and/or a masters program at some point in one’s medical career and develop interest in ethics that way. At Northwestern, we recently started a masters program that is primarily designed for medical students to pick up an additional degree with typically an extra year of intellectual work.

What else do you feel our readers should know about medical ethics? I think it’s common for medical professionals, perhaps mostly physicians, to think of ethics as something that is sort of on the side, soft, etc., when in fact, if you step back and think about it, the ethical issues have almost everything to do with what’s important about doctor-patient relationships. If you take informed consent as an example seriously, what it means is developing a relationship with patients or their surrogates that allows people to develop a trust that doctors want patients to have in them. It’s not irrelevant at all. It’s at the core of medical practice.