Ethical interview question

[Cowbell]

Just curious to what your responses are, but what would you do if two individuals needed a liver transplant, and one individual is an alcoholic and/or drug abuser and the other a hard working middle class citizen that does not abuse drugs and/or alcohol, but has been diagnosed with cancer. Who would you give the transplant to granted you only have one liver? One of the individuals will die if they don't receive the transplant. The individual that has a history of abusing drugs pleads that he is wanting to change his life around and he can only do that if he recieves the transplant.

[Mourning Cloak]

Just curious to what your responses are, but what would you do if two individuals needed a liver transplant, and one individual is an alcoholic and/or drug abuser and the other a hard working middle class citizen that does not abuse drugs and/or alcohol, but has been diagnosed with cancer. Who would you give the transplant to granted you only have one liver? One of the individuals will die if they don't receive the transplant. The individual that has a history of abusing drugs pleads that he is wanting to change his life around and he can only do that if he recieves the transplant.

 

Depends on . . .

What kind of cancer? How advanced?

How long has our junkie been sober?

 

http://www.bcmj.org/article/liver-transplantation-current-status-british-columbia

http://www.cmaj.ca/content/154/3/337.abstract

http://www.ncbi.nlm.nih.gov/pubmed/18822078

[ellorie]

In my opinion it all depends on the viability of the transplant - how many years of life can it be expected to give each recipient based on their current medical status and what is the likelihood that each will survive until another liver becomes available.

[rmorelan]

More important than the particular question though I think is the approach. How do you approach ANY ethical question - if you have a system you cannot be broadsided on interviews

 

One key I guess is that any ethics question you are going to get will not have some "sneaky" medical way of deciding (or at least won't if they did it right). The question cannot assume you actually know anything about specifics of the cancer, duration sober etc and the impact on the transplant. If there was then there potentially could be a single "right answer" - there won't be though, or it isn't an ethics question at all. Hence I wouldn't get used to thinking in those terms.

 

So if I was to offer a hint with this it would be with with that in mind how are approaching this? How are you making your decisions and how are you making sure an admin gets an understanding of that approach?

[Legion]

There is no right or wrong answer to this as long as your reasoning is sound. Right? Unfortunately you are forced to pick one over the other based on what I've heard. So you can't really take both sides to the same extent.

[rmorelan]

There is no right or wrong answer to this as long as your reasoning is sound. Right? Unfortunately you are forced to pick one over the other based on what I've heard. So you can't really take both sides to the same extent.

 

No you have to decide - but your decision isn't even really all that important (I have heard someone argue this case very well that the correct answer is actually NEITHER of the patients get the liver and instead you should release the liver to another centre). It is best not to even think of it in terms of getting a "best answer".

 

The answer doesn't matter - how you approach the problem matters, and that is the only thing that matters. You cannot sit on the fence because in the real world you cannot sit on the fence. We all know ethics is a big part of medicine but I sure didn't fully realize how often it comes up (even as a lowly clerk - often multiple times a shift, over and over again). Now I wonder if we teach enough of it Bottom line there aren't wrong answers but there are wrong approaches.

 

If you don't have an approach you will be crushed on the follow up questions because your decision is not based on a solid foundation.

[future_doc]

http://ethics.missouri.edu/Organ-Transplantation.aspx

[rmorelan]

http://ethics.missouri.edu/Organ-Transplantation.aspx

 

Good summary - although I will argue again too much detail for an ethics question and begins to make you think again it is a medical knowledge question - which it isn't

 

There is nothing wrong with actually arguing that somethings they are considering are wrong as well (they mention income and age as factors which arguably shouldn't be).

 

Since organ transplantation is so commonly used as an ethics example it is very unlikely you would see it at an interview (they do not want canned answers to ethics questions). I guess this is way in part I keep coming back to the need for a system to any ethics question.

[Cowbell]

Good summary - although I will argue again too much detail for an ethics question and begins to make you think again it is a medical knowledge question - which it isn't

 

There is nothing wrong with actually arguing that somethings they are consider are wrong as well (they mention income and age as factors which arguably shouldn't be).

 

Since organ transplantation is so commonly used as an ethics example it is probably very unlikely you would see it at an interview (they do not want canned answers to ethics questions). I guess this is way in part I keep coming back to the need for a system to any ethics question.

 

How do you propose we approach answering ethical questions?

[PhoenixFlare500]

How do you propose we approach answering ethical questions?

My approach in an extremely general sense: look at your choices/alternatives and then look at the short-term as well as long-term outcomes for all the parties involved. This may require some background information, and if you're really in a spot where you don't know what the issue is about then you might be able to ask to get more info, or get someone to clarify the situation for you if need be. Then you have to prioritize which parties can benefit and which get the short end of the stick, if one of them has to (or I suppose all of them), and explain why you prioritized them that way e.g. cost/benefit. You may want to consider how your decision will affect the person involved as well as society as a whole.

 

Four key words in at least medical ethics: beneficence, non-maleficence, justice, and autonomy. Consider applying these to your situation.

[rmorelan]

Everyone has a different system of course - for starters I think it is important to just flat out list all the considerations for the usual two parties affected and also the hidden third party - here we have two people in play and also society at large (no ethical decision made ever just affects the two - there are always broader ramifications. Don't miss that ).

 

As phoenix pointed out beneficence, non-maleficence, justice, and autonomy are key areas to explain. I would add privacy to that list as well since it often comes up. Break down each person's position in these terms (and also the third position as well). Simply explaining to the interviewers you know the terms, can apply them and logically determine all of the factors and all of the players gets you pretty far along in the process.

 

Next with all of the positions out there you are going to have to make a choice based on your personal ethical framework - what do you think is more important (does beneficence trump privacy? How about autonomy? and so on). How much does society get to play a role in this (that third player again - and often that is actually the tie breaker - actually in the case you present people often argue that the impact to society overall tips the scales one way or the other. For instance it might be in society's best interest to not allow for any form of age, race, religious discrimination - sounds good but if truly believed it means that you cannot introduce an age bias in your decision here because the impact overall is a negative one ). Breaking a law by the way impacts yourself, the profession and society - so you can just include the impact of that in any ethical consideration as well. The ability of other doctors' to do their jobs is impacted when any other doctor breaks rules - you still may have to but you also have to factor that in.

 

Once you make your choice they may challenge you - by pushing on some of the pillars of your argument. you can also simply look at things as a new problem, restate the changes to your analysis of key factors and draw a conclusion as well. In any case you show you think through things and don't just fly by the seat of your pants. This prevents you from being inconsistent.

 

Two other considerations - they will always make it sound like you have to act alone in this - that is silly. There is always a hospital ethicist, colleagues, social workers etc to help you - 24/7. Basically pull the big support button. Make sure you are still saying you will make the decision but the advice of others is important to you. It will be in the real world and shows you actually know how the system works.

 

Lastly people just end the discussion without talking about fall out. You don't just abandon the person that didn't get the liver - again optimally manage that care, comfort them, make sure that they are kept alive so they get potentially the next liver. Show some compassion, some knowledge of what is available to help. I call this "going gently" - someone will always not get what they want in any ethics argument but that doesn't mean you cannot help them still. Remember again you are in a hospital - you have supports.

 

This takes practise to get fast and good at. Still I think it is valuable

[Lactic Folly]

rmorelan, you should sticky this in the interview section!

[Cowbell]

Everyone has a different system of course - for starters I think it is important to just flat out list all the considerations for the usual two parties affected and also the hidden third party - here we have two people in play and also society at large (no ethical decision made ever just affects the two - there are always broader ramifications. Don't miss that ).

 

As phoenix pointed out beneficence, non-maleficence, justice, and autonomy are key areas to explain. I would add privacy to that list as well since it often comes up. Break down each persons position in this terms (and also the third position as well). Simply explaining to the interviewers you know the terms, can apply them and logically determine all of the factors and all of the players gets you pretty far along in the process.

 

Next with all of the positions out there you are going to have to make a choice based on your personal ethical framework - what do you think is more important (does beneficence trump privacy? How about autonomy? and so on). How much does society get to play a role in this (that third player again - and often that is actually the tie breaker - actually in the case you present people often argue that the impact to society overall tips the scales one way or the other. For instance it might be in society's best interest to not allow for any form of age, race, religious discrimination - sounds good but if truly believed it means that you cannot introduce an age bias in your decision here because the impact overall is a negative one ). Breaking a law by the way impacts yourself, the profession and society - so you can just include the impact of that in any ethical consideration as well. The ability of other doctors' to do their jobs is impacted when any other doctor breaks rules - you still may have to but you also have to factor that in.

 

Once you make your choice they may challenge you - by pushing on some of the pillars of your argument. you can also simply look at things as a new problem, restate the changes to your analysis of key factors and draw a conclusion as well. In any case you show you think through things and don't just fly by the seat of your pants. This prevents you from being inconsistent.

 

Two other considerations - they will always make it sound like you have to act alone in this - that is silly. There is always a hospital ethicist, colleagues, social workers etc to help you - 24/7. Basically pull the big support button. Make sure you are still saying you will make the decision but the advice of others is important to you. It will be in the real world and shows you actually know how the system works.

 

Lastly people just end the discussion without talking about fall out. You don't just abandon the person that didn't get the liver - again optimally manage that care, comfort them, make sure that they are kept alive so they get potentially the next liver. Show some compassion, some knowledge of what is available to help. I call this "going gently" - someone will always not get what they want in any ethics argument but that doesn't mean you cannot help them still. Remember again you are in a hospital - you have supports.

 

This takes practise to get fast and good at. Still I think it is valuable

 

Thank you very much.

[rmorelan]

Thank you very much.

 

For practice you can try using this or any other approach - if you post it here we can look at it and see if there any any "holes". Really this boils down to practice - get a system, practise so it becomes second nature, and go

[Cowbell]

For practice you can try using this or any other approach - if you post it here we can look at it and see if there any any "holes". Really this boils down to practice - get a system, practise so it becomes second nature, and go

 

Awesome, thanks! Quick question, if you don't mind: I understand that you can't reveal to much about the MMI, but would you be able to elaborate on the types of the questions that are asked? For example, would you say that the majority of questions asked are ethical questions (not necessarily related to healthcare), or are some traditional interview style questions also asked?

[PhoenixFlare500]

Once you make your choice they may challenge you - by pushing on some of the pillars of your argument. you can also simply look at things as a new problem, restate the changes to your analysis of key factors and draw a conclusion as well. In any case you show you think through things and don't just fly by the seat of your pants. This prevents you from being inconsistent.

 

If they do this, I would try to stick to your original argument as much as you can, while compensating for whatever new information or what-ifs they're pushing on you. If you're completely switching sides just from one piece of information that you could've missed, it might be evident that you didn't think enough the whole situation. If it does completely change your perspective, you could just be honest and say "well I never thought about that", and then explain why you're switching (But then that still makes your original argument weak), but the danger there is they could be real tricky and keep giving you what-ifs, and then you could really tie yourself up and not be able to come to any type of resolution.

[PhoenixFlare500]

Awesome, thanks! Quick question, if you don't mind: I understand that you can't reveal to much about the MMI, but would you be able to elaborate on the types of the questions that are asked? For example, would you say that the majority of questions asked are ethical questions (not necessarily related to healthcare), or are some traditional interview style questions also asked?

From what I've heard, this depends completely on which school you're interviewing at. Some questions can be expected, some can be completely random. Every school probably has at least a couple ethical questions in the MMI so it's a good idea to prepare for them anyways.

[future_doc]

rmorelan, you should sticky this in the interview section!

 

It has been stickied as Part 2 of my sticky @ Medical School Interviews forum.

[Illuminant]

Just curious to what your responses are, but what would you do if two individuals needed a liver transplant, and one individual is an alcoholic and/or drug abuser and the other a hard working middle class citizen that does not abuse drugs and/or alcohol, but has been diagnosed with cancer. Who would you give the transplant to granted you only have one liver? One of the individuals will die if they don't receive the transplant. The individual that has a history of abusing drugs pleads that he is wanting to change his life around and he can only do that if he recieves the transplant.

 

I will take a shot,

 

I will give the liver to the hardworking middle class person due to the fact that this individual proved to be hardworking and benefiting society. The other person, who also receive my compassion, will not receive the liver because he could be promising me that he will change his life just so that he would be able to survive. There is 50/50 chance that this person could either stop being alcoholic/drug abuser or not change his life around. While the other person will most likely return to be a hardworking middle class person if he/she survives.

 

Evaluate my answer -> is it good or bad?

[rmorelan]

I will take a shot,

 

I will give the liver to the hardworking middle class person due to the fact that this individual proved to be hardworking and benefiting society. The other person, who also receive my compassion, will not receive the liver because he could be promising me that he will change his life just so that he would be able to survive. There is 50/50 chance that this person could either stop being alcoholic/drug abuser or not change his life around. While the other person will most likely return to be a hardworking middle class person if he/she survives.

 

Evaluate my answer -> is it good or bad?

 

hehehe this is the fun part - really taking things apart and seeing where they go

 

Ok, so your argument is that health resources should be given to those members of society that measurably contribute the most? In extension to the general case should all health care resources be distributed that way? Should we prioritize access to say cataract surgery, hip replacement, dialysis, and wait times in general based on such priorities? How exactly would you compare, evaluate and prioritize that way - what if they were both middle class but one contributed 50% more in terms of tax dollars (I suppose one measure of productivity)? How does all of this contribute to the overall fairness of the health care system?

 

Or is your argument that self inflicted injuries shouldn't get as high a priority in the system? Setting aside the possibility that addiction could be considered a disease with even a genetic component, again where does this position reach in the grand scheme of things? Should smokers be deprioritized compared to non smokers for lung cancer treatments? What about people with HTN or CAD due to inactivity? What about those that refused basic preventative care - breast exam/mammography, colon cancer screening and so on? health care resources are always finite so these are not artificial problems - people do get worse waiting for treatments in Canada and by extension some will die as a result.

 

What if the person in question could prove they were not going to change their life? Can we use general facts (like say a 50% success rate) to automatically extrapolate to all cases and base decisions on that? If you do what if you really believed this person really was going to change? Can you bend a policy based on that belief? Is that fair? If you cannot do you really have an advocate role or are you merely and extension of the government's policies (i.e. do you work for the patient's interests primarily or something else)

 

Remember when I mentioned the possibility of the adcoms pushing back a bit - this is one form that pushing can take. They start to dig down and pull out the core values of your ethical framework and see if they are logical and consistent. They get to ask a lot questions, just like I did - notice I didn't answer any of them - neither will they

[Illuminant]

what if you really believed this person really was going to change? Can you bend a policy based on that belief? Is that fair?

If this person is going to change, then he will be receive the liver as opposed to the other person. The other person have cancer, and so a chemotherapy treatment will cost the hospital's resources. The death of this person is in the interest of maintaining the finite resources of the hospital.

 

Remember when I mentioned the possibility of the adcoms pushing back a bit - this is one form that pushing can take. They start to dig down and pull out the core values of your ethical framework and see if they are logical and consistent. They get to ask a lot questions, just like I did - notice I didn't answer any of them - neither will they

I never knew any of that, thank you!

[Porsche]

At the end of the day, I think the right thing to do would be to provide the transplant to the individual what would benefit from it the most. Many of these organs are highly scarce.

 

Now despite your political views, look at the controversy that arose when former vice president Cheney received a heart transplant at the age of 70 or 71. Granted he did wait 20 months for it, but the question is, could a younger individual who also needed the organ benefited from it more? To which I answer: yes.

 

I think the same holds true for the drug/alcohol addict and the regular middle class individual. Assuming they are of the same or similar age, I think the right thing to do would to be provide a new liver to the middle class man. Not because he contributed, contributes, and will continue to contribute towards society (i.e. in terms of paying taxes, etc), but simply because he is much healthier. What is to say that the drug addict won't go back to old habits? I understand that is also a chance they won't, but I'd put my money on middle class man with no prior drug/alcohol abuse to not start new habits.

 

If you are in a situation where you have two individuals that both have great health, both young (i.e. no highly significant gap), and one does not need it more then the other, then I think it all comes down to who came in through that door first (hence the reason for a wait list). As sad as it may seem that the individual that won't receive transplant may ultimately die, I think we need to come to the realization that as doctors, you can't always save everyone. We should try, but I don't think we should expect. If you have one liver, then you have one liver.

 

I think a big key to rmorelan's strategy that I found important is to expand the network of people you consult when deciding who receives an organ. I may be a doctor, but as was said before, there are people who dedicate their entire career towards ethics. Consult them.

[rmorelan]

If this person is going to change, then he will be receive the liver as opposed to the other person. The other person have cancer, and so a chemotherapy treatment will cost the hospital's resources. The death of this person is in the interest of maintaining the finite resources of the hospital.

 

You seem very focused on just the resource issues - lets through another wrinkle, what if any particular one of them was able to donate 300K to the hospital (well in excess of the cost of treatment). What would you do now?

[future_doc]

Irrelevant. And buying organs (directly or indirectly) is unethical and certainly illegal (directly).

[PhoenixFlare500]

At the end of the day, I think the right thing to do would be to provide the transplant to the individual what would benefit from it the most. Many of these organs are highly scarce.

 

Now despite your political views, look at the controversy that arose when former vice president Cheney received a heart transplant at the age of 70 or 71. Granted he did wait 20 months for it, but the question is, could a younger individual who also needed the organ benefited from it more? To which I answer: yes.

Should this apply to all cases where the age difference is significant? i.e. Say a 65 year old who's been on dialysis for 15 or 20 years decides he wants to get a kidney transplant. Should a 45 year old who's only been on dialysis for 5 years get it first? Should we begin to withhold any type of medical care from elderly people and always give younger people priority when resources are limited? Or should older people get kicked out of hospital beds only to make room for younger patients?