Deception, discrimination, and fear of reprisal: lessons in ethics from third-year medical students.

PURPOSE: To systematically examine ethical conflicts reported by all State University of New York Upstate Medical University third-year students, compare them with conflicts reported in the literature, and identify content areas that compel new or renewed emphasis in national educational objectives, standard curricula, and texts. METHOD: From 1999 to 2002, all third-year students submitted papers for a required bioethics course. These papers depicted ethical issues arising during clinical clerkships. The authors devised a checklist of ethical issues; after analyzing the students' papers, the authors applied the checklist to the papers to create a taxonomy. RESULTS: Three hundred twenty-seven students submitted 688 cases involving 40 ethical issues. The most common issues were deliberate lies or deceptions (n = 68), patients' right to refuse recommended treatment (n = 48), and insistence on futile treatment (n = 46). Students perceived overt and subtle discrimination toward patients, reflected in substandard or excessive treatment. In 81 cases (12%), students expressed reluctance to speak up about moral conflict for fear of reprisal. This fear was expressed in 18 (45%) of the 40 issues-particularly student-specific (36 [52% of 69]) and quality of care (7 [24% of 29])-and most frequently in cases involving surgery (p < .025) and obstetrics-gynecology patients (p < .01). CONCLUSIONS: Students discerned ethical dilemmas in both "usual and customary" and seemingly incidental situations. Students who described fear of speaking up perceived a tradeoff between academic survival and patients' interests. The cases demonstrated that students still lacked the tools to navigate ethical dilemmas effectively. The authors propose that moral courage is within the realm of professional expectations for medical students; its cultivation is an appropriate formal objective for medical education.