AMA Journal of Ethics^®

Case

Emily, a medical school candidate, had high grades and MCAT scores and extensive volunteer experience. The committee members who interviewed her reported that Emily had spoken movingly about her desire to become a primary care physician in a rural setting.

The committee’s student member, Jason, looked up Emily on Facebook to see whether they had any friends in common. There he found a link to a blog post that attributed rising rates of contagious disease and unemployment to illegal immigrants. Emily had added: “I couldn’t agree more. People whose mothers just happened to sneak over the border at the right time are called ‘citizens’ when they’re just driving down wages, straining our infrastructure, and taking jobs that rightly belong to honest, hardworking taxpayers. Why should we take care of them?”

Emily’s Facebook post revealed a side of her that Jason knew the admissions committee hadn’t seen, and he wondered what he should do with this information.

Commentary

Below are a few of Jason’s journal entries starting the day he interviewed Emily.

Oct 19, 2010

I never thought I would regret having a half day off from the wards to be a student interviewer for medical school applicants. But right now, I wish I had never interviewed Emily. I wish I had never looked at her Facebook profile. I wish I were never put into this situation.

When I first met the faculty on the admissions committee today, there was something said that stood out to me. One of the clinicians was on a diatribe about how to put a number on a MCAT score, GPA, and interview performance combination. The other interviewer, Dr. Schwartz, leaned towards me and said, “it’s all about what type of feeling you get after talking to the applicants. And if we are all truthful to each other about what we really think, then there will be no problem in making the right decision.” Why did he have to use the word “truthful”? He slipped that lexicon dagger right in the middle of the compound sentence.

So do I have a duty to my fellow members of the admission committee, my so-called colleagues of the day, to be honest about what I truly think of Emily? I remember reading about philosopher Margaret Gilbert’s views on the idea of a plural subject, which in this case would be the admissions committee. She explains that each member of the plural subject is obligated to all members of the whole. For a plural subject to succeed, there must be an “interdependence of commitment” [1]. Even the AMA Code of Medical Ethics states that “physicians’ relationships must be based on mutual respect and trust” [2]. If I follow the same train of thought, I must be truthful to my colleagues.

It’s getting late, and I still have to read about my patient, Mr. Suarez, whom I admitted today. He’s a 51-year-old with significant alcohol abuse who presented with a history of epigastric pain and weight loss. A history professor from Bolivia, he is actually one of the nicest patients I have yet to meet. During my physical exam, he continued to quiz me on Latin American history, about which I, of course, knew nothing. Generally happy appearing, his eyes gave the only clue to his true fear. That uneasiness must have been amplified toward the other members of the medicine team because he failed to mention his past alcohol problem to everyone else. He told me he didn’t mind the team knowing, but he did not believe it was important.

I’m glad I was truthful to my team about his alcohol abuse because it will directly affect his care. Did I just use the word truthful? I guess my subconscious has a better sense of humor than the conscious me does. Nevertheless, I did fulfill my duty to my colleagues and team regarding Mr. Suarez’s alcohol history. Likewise, I should respect my responsibility to my fellow committee members and tell them about Emily’s Facebook post. Well, I’ll sleep on it for a couple of days.

Oct 22, 2010

Mr. Suarez has not gotten better these last few days, but at least he is not worse. The idea is that he has pancreatitis that just needs rest and waiting to heal. Well, that’s my idea, or more realistically my hope now. During rounds today, pancreatic cancer was tossed around as casually as orders for lunch. But of course, the team decided that I should tell him we need a CT scan to “further differentiate etiologies of his epigastric pain.” I wondered all day if I could just use that quote and sprint out of the room before he asks any questions. Given that I was cut from JV track in high school, I figured I should search for other ideas. In the end, if his autonomous right as a patient is to be respected, then he needs full disclosure in order to make informed decisions regarding his care. I told him we need the scan to see whether he has cancer. The room fell silent, and I just sat there wondering if I had made the right decision.

Looking back on the day, I am more confident in my decision for transparency with Mr. Suarez. On another note, I still haven’t told the admissions committee about Emily’s Facebook post. They will not discuss her application for another few weeks—so I still have time. Thinking back to Mr. Suarez, does the medical school have a duty to be completely transparent in its admissions procedures to Emily? She knows that she will be judged on her grades, MCAT score, application essays, other activities, and the interview. However, there is nowhere any mention of Facebook to be one of the judging criteria. Transparency and truthfulness are such basic moral tenets that the best way I can think about them is by referring to Plato’s and Aristotle’s thoughts on virtue ethics. Basically someone with strong moral character will naturally be completely truthful and open because it emanates from his character. There should be no need for a motivation to be transparent; it is inherent in one’s moral fiber [3]. A modern virtue ethicist, James Wallace, believes that truthfulness and transparency are a “condition of communication” [4]. So what type of moral character do I have by not being transparent with Emily about my own judging criteria?

By even looking on Facebook for Emily’s post, I have broken a trust between the applicant and the committee. I broke the rules implicitly agreed upon by both sides. There is no way I can tell the committee about her post. I should have never looked at it in the first place.

Oct 23, 2010

Mr. Suarez’s lab values are improving, but he continues to look about the same. Now we are just waiting on the results of the CT scan. With nothing really new to report, I figured I would just see how he was doing after rounds today. He quizzed me again on Latin American history, and, again, I amazed him with my utter lack of knowledge. He then turned serious and spoke about the privilege I have as an aspiring physician and how I should not take that responsibility lightly. He said, “You know, as a doctor you are allowed into the most intimate and important moments in a person’s life. From an infant being born, personal secrets, true fears, to a loved one’s death, your patients will allow you to see them at their most vulnerable. Your words have the power to change someone’s life. Cancer or not, right? As a relative stranger, you automatically become a most trusted confidant just by your title.” He paused for a moment, as to gather his thoughts or hold back the tears. “So you must honor your profession. We as patients assume you will be caring, gentle, understanding, and above all else, we assume you will genuinely work your hardest to care for the sick no matter what.” Hearing this directly from my patient—my friend—spoke volumes to me.

If I have this duty to my medical profession, then am I being responsible by being silent about Emily’s Facebook post? As a member of the medical community, I have an obligation not only to my profession’s principles but also ultimately to future patients. I am reminded of ethicist Michael Pritchard’s thoughts on professional integrity. He states, “Although no one may have the right to steal something from me, professionals in my service provide me special assurance that I can trust them not to do this. They do this, not by explicitly saying so, but by presenting themselves to me as professionals” [5]. So the question is: Is Emily ready to join the medical profession where implicit assumptions about caring are placed on her?

Reading Emily’s Facebook post again, I do not really believe that she will “be caring, gentle, understanding and above all else, genuinely work her hardest to care for the sick no matter what.” I know I have been going back and forth about telling the admissions committee about her post. But if I truly want to respect my profession, it is my duty to tell.

Oct 25, 2010

As bad as today was for me, I am sure it was infinitely worse for Mr. Suarez. The preliminary report for his CT scan came back as negative for pancreatic cancer. I was ecstatic, and before even running it by my team, I told Mr. Suarez. He let out a huge sigh as if this enormous weight was lifted from his shoulders. I wish I could have just stayed in that moment. More importantly, I wish I had spoken to my attending or the radiologist before I jumped to a conclusion. But I did not. In short, the final CT scan report came back “inconclusive to rule out cancer.” Then the MRI confirmed the impossible to me, but the inevitable for Mr. Suarez—a mass on the pancreatic head. I can’t even write how the conversation between the team and Mr. Suarez went without shaking. My embarrassment being covered by my sorrow created a blur of the events.

It was my misinterpretation of the validity of the CT report that caused Mr. Suarez to gain false hope. If I had been more thorough in my investigation, the already bad news would have not been worse.

I still have not told the admissions committee about Emily’s post. Today’s events have shaken my confidence in my judgments. Is it possible that I could be misinterpreting Emily’s post as I did the CT results? Misinterpretation is inherent in our medical culture. Earlier this year in the Journal of the American Medical Association, I remember reading an article that reviewed the validity of other journal articles. It concluded, “The reporting and interpretation of findings [in a majority of journal articles in 2006] was frequently inconsistent with the results” [6]. If I cannot read a scholarly article from one of my colleagues without scrutiny for validity, then how can I not give the same in-depth examination to Emily? There is a possibility that she is being ironic or that someone else went onto her Facebook account and wrote that. Without actually giving her the opportunity to defend herself, it is unfair to place judgment. I misinterpreted information already once today that resulted in devastating consequences. I do not want to make the same mistake again. I will keep Emily’s post to myself.

Nov 2, 2010

The intense and exciting rollercoaster of my internal medicine clerkship is finally over. Mr. Suarez forgave me for my mistake and I’m actually going to be with him tomorrow during his surgery to remove the mass. Also, the admissions committee will meet in a couple of days to discuss Emily’s application.

Thinking more about it, the medical school application process is inherently unfair. How can we know what type of doctor someone will be? I am sure people are rejected who would have been phenomenal, while current medical students will prove to be less than ideal physicians. Over 40,000 people apply to medical schools each year, and only 18,000 actually matriculate [7]. At my medical school, we only interview 11 percent of the applicants and accept far fewer [8]. There is a possibility that, by Emily’s being accepted, someone deserving will be rejected.

Today, I received an evaluation from my attending. I generally did well, but the last question on the assessment struck me. It asked, “Would you allow this student to care for one of your loved ones?” Though a simple question, it encompasses how physicians should be judged. In the past few weeks I have weighed the pros and cons of telling the admissions committee about her post. But ultimately it boils down to that straightforward question. Would I let Emily care for one of my loved ones? No, I would not. Tomorrow morning I am letting the admissions committee know about Emily’s post.