Response by Susan MacRae

The case of Ms Robertson raises three important questions in my mind. The first is whether the case raises a clinical issue or an ethical issue. The second is the question of --at what point do students have the clinical skills necessary to independently advocate for certain treatments on a patient's behalf? And thirdly is the question of how to manage professional disagreements.

As a general rule, it is essential that we ground our clinical work in the best medical outcomes research that is available. Our goal should be to estimate the probability of occurrences for all outcomes that matter to the patient, taking into consideration in as great a detail as possible, both the patient preferences as well as the patients' medical situation e.g., age, sex and severity of illness. Only recently, are we starting to recognize the importance of such data and information to support better treatment decisions. If we have clear medical evidence for a treatment decision and it coincides with a patient's values, rarely do conflicts seem to emerge. And if they do, it is often between the professional preferences based on the medical evidence, and the patient values. But that is not the case here. Much more often, conflict seems to emerge in cases where the science is unclear and for a number of reasons, the patient is unable to contribute any preferences. This may leave us in a situation very similar to the one we have with Ms R, where two clinicians disagree about what is "best" for her. How can decisions be made in this case?

There are no clear rules about whose opinion should take precedence in cases where there is no definitive guidance from science or from the patient (which I take to be the case here). But it is surely the case that this becomes further complicated in cases involving students and their supervisors. Students are not blank tablets. There is literature that suggests that beginning nursing students think critically and act ethically during their first clinical nursing course. The same is surely true across professions. But it is also the case that beginning students are early on in their journey. When each student has the skills necessary to independently advocate for a certain treatment on a patient's behalf is unique to the student.

But what if a student disagrees with their supervisor? Students will disagree with their supervisors and their peers throughout their careers. Hopefully some of that will be minimized by relying more on outcomes data and patient preferences but there will always be this dilemma. I think in cases where a student has evidence (either data or patient preferences information) to suggest a different treatment plan, other than the one that is being proposed, I believe that student has an obligation to do his/her best to advocate for that patient. Ideally this would be done by approaching the supervisor directly with the evidence in hand. In other cases, it may be necessary to invite another perspective, from another clinician or an ethics committee for example.

In many other cases however, what is "right" is unknown. This may be because for example, there is a fundamental difference of opinion about goals (e.g., length of life vs. quality of life), or a difference of opinion about limits of professional responsibility (e.g., should these clinicians be making recommendations about Ms R's swallowing disorder?), or a difference regarding a clinicians understanding of community's health versus individuals health. In cases such as these, it is often difficult to come up with one "right" answer. In these circumstances, often the best thing a student can do is seek support from others who understand the complexity inherent in the clinical environment, and seek opportunities to hear other perspectives on complex issues. One approach I have seen very useful in dealing with these issues is the use of an informal student discussion group. If students from a variety of perspectives and levels of experience can be brought together in a non-threatening environment, the students seem to learn to embrace these multiple perspectives through a process of growth, as they simultaneously learn to identify more clearly with their own voice.

Case Study

Responses

• Julia Ferre' Shuler
• Sara Gambs   

Annotated Bibliography