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The clinical vignette remains the standard means by which medical ethics are taught to students in the healthcare professions. Although written or verbal vignettes are useful as a pedagogic tool for teaching ethics and introducing students to real cases, they are limited, since students must imagine the clinical scenario. Medical ethics are almost universally taught during the early years of training, when students are unfamiliar with the clinical reality in which ethics issues arise. Film vignettes fill in that imaginative leap. By providing vivid details with images, film vignettes offer rich and textured details of cases, including the patient's perspective and the clinical reality. Film vignettes provide a detailed ethnography that allows for a more complete discussion of the ethical issues. Film can serve as an additional tool for teaching medical ethics to members of the healthcare professions.
Walk into any school or university where ethics are taught to healthcare professionals and you will encounter the familiar means of teaching medical ethics to students: the clinical vignette. Using clinical vignettes to spark ethical discussions parallels the recent restructuring of the teaching of medical students by using less memorisation and more real patient cases. Students no longer memorise the pathophysiology of broken plaques impeding cardiac blood flow using a textbook, but instead learn the constellation of symptoms for a heart attack by using real patient cases. These allow students to uncover the rich details of having “chest discomfort” and “jaw pain”, while simultaneously learning about cholesterol plaques clogging arteries. Education in medical ethics has taken much the same approach. Instead of rote memorisation of the pillars of medical ethics, students uncover the principles by reading patient cases where values like autonomy and beneficence are discussed and imprinted more concretely.
Although wonderful pedagogic tools for teaching ethics, vignettes, which are usually written or verbal, can be limiting. Medical ethics are almost universally taught during the early years of training, when students have the least clinical experience. Vignettes present ethical conundrums in a medical context that students are still unfamiliar with. Some may see this as a benefit, since students will not be overwhelmed by the medical facts of a case; however, once clinical experience is added to the medical facts, the ethical insights may fall by the wayside.
Film offers a powerful and underutilised medium in which clinical vignettes come alive in their rich and textured details, both medical and non‐medical. In this paper, I argue for the use of film in teaching medical ethics. Film vignettes, or what I term “film ethnography”, better captures the foreign medical terrain and ethical issues that students are still unfamiliar with early in their career, while preserving the inherent ethical drama of seeking to do the right thing. Film can improve the present method of using clinical vignettes to teach medical ethics to healthcare professionals.
One of the first distinctions students learn in medicine is that between disease and illness. Disease is the biologic pathology, while illness is the social experience of having a disease.1 Two patients can have the same disease but experience it differently. And much of our individualised experiences of disease derive from our unique and individual values. Ethical discussions of cases often derive from patients having different value systems, which may lead to different ethical decisions in the clinical context.
Consider the value of autonomy, the foundational pillar on which much of medical ethics rests. A commonly used clinical vignette that students often find jarring is one in which a decisionally capable person prefers not to have a particular medical procedure in the context of a terminal disease. For instance, a 66‐year‐old woman with widely metastatic breast cancer and pneumonia declines medical interventions, including antibiotics. Being of sound mind, she—or any patient, for that matter—can decide not to have further interventions, even if they are potentially life‐saving. Students reading the written vignette learn one of the implications of autonomy for the practice of medicine: refusing and giving consent for procedures.
But many of the rich details that are essential for ethical analysis are lost in the written or verbal description presented to students. Many of the students simply have never seen a patient with metatstatic breast cancer, or any type of cancer. During the first year of healthcare education, most students have yet to meet a patient, let alone one who is dying. Clinical vignettes lack the rich details that fill in the experience of the disease and the individual values of the patient, integral ingredients for the ethical analysis. Both the medical facts of the case and the experience of the patient are often vital for the ethical analysis and discussion that follow the vignette. Verbal and written vignettes may appear deaf to these considerations. Is there another medium in which to present the same story?
The visual medium brings the clinical vignette alive. Film ethnography engages students by bringing the medicine—what got them interested in healthcare—to the fore, and presents the sometimes overlooked patient's perspective and voice, considerations gaining increasing prominence in the medical ethics literature. The faceless woman with breast cancer now has a face, a voice, a value system that were not readily accessible through words alone. Such details are not overlooked by ethnography, which attempts to systematically detail the qualitative aspects of a clinical case.
Phrases often appearing in written vignettes, such as “aggressive procedures” and “futile care”, lose their amorphous qualities as students see and experience ventilators and medical emergencies on the screen. The details in ethical cases ought to matter in the analysis, and the clinical vignette's deafness to these aspects of a case deter students from fully engaging with the material and exploring the ethical questions. Film ethnography avoids these limitations.
Consider another case: a 70‐year‐old man with a severely disfiguring case of neurofibromatosis presents to the emergency room with severely infected fibromas (skin lesions). He has had numerous previous admissions to the hospital for these infections, including sepsis, but has decided that he no longer wishes to have the infections treated with antibiotics. He is aware that he may die from these infections but is willing to take that risk. He has had a difficult life, full of stigmatisation and incessant medical interventions, but now wishes to forgo any further aggressive medical care. A psychiatrist has determined that the patient is not depressed and is fully competent.
This vignette raises the issues of autonomy, competence, consent and individual preferences. Students are often engaged with these topics, since it is usually the first time they have explored these values in the medical context. But how effective are these discussions in raising the relevant ethical dimensions of the case? Consider the patient with neurofibromatosis described above, but now seen in an ethnographic film. In the clip taken from a documentary,2 the patient gives insight into how neurofibromatosis has affected his life. He describes a typical trip to the supermarket, which is anything but typical. The film clip also includes the perspective of his physician, who has been taking care of him for well over 40 years. (The film clip is available on‐line at http://homepage.mac.com/avolandes/MovieTheater34.html.)
The visual image of the patient and his doctor adds a textured understanding to the facts and diverse perspectives of the case, aspects usually absent from the traditional vignette. What was once left to the imagination of the clinically inexperienced student is now completed by the images and ethnography of film. Students no longer view the case as an academic fictional exercise but instead appreciate the conviction and genuineness of an individual's value system and ethical decision‐making. Film ethnography allows for a deeper understanding and appreciation of the individual experience of having a disease.
Patients' stories on film may be a more engaging and complete method of raising ethical dilemmas that arise in the practice of medicine. Although there has been a movement towards more detailed narrative discussions of ethical cases,3 students live in an image‐saturated society that transmits stories with pictures, not with words. Clinical vignettes with film ethnography adapt medical ethics to a visual and more accessible medium for students.
There is already an abundance of films that can serve this ethnographic role for teaching medical ethics. Two film documentaries that have already been used in medical ethics are the film Please let me die4 and the subsequent Dax's case.5 These narrate the tragic case of Dax Cowart, a young man who had severe burns over most of his body. The films offer a first‐hand narrative of the excruciatingly painful chlorine baths that Dax underwent daily and his desperate pleas to let him die. The viewer also sees interviews with family members and the physicians who cared for him. In the follow‐up documentary filmed a number of years later, the older Dax, now severely disfigured, argues that he should have been allowed to die and that his autonomy was violated. Despite being married and an accomplished attorney, Dax insists that his autonomy was not respected and that he should have been spared the chlorine pools even if that resulted in his death. Students viewing the film are exposed to the issues of autonomy and beneficence while appreciating the different viewpoints brought to the ethical analysis by the patient, the clinician and the surrogates.
Film makes the illness experience and the relevant ethical values more available for inclusion in the analysis than vignettes. Consider Gretchen Berland's riveting documentary Rolling.6 In this film, three quadriplegics offer a multidimensional understanding of living life from a wheelchair. The viewer experiences life from a radically different perspective: from three feet above the ground. A ubiquitous sense of optimism, satisfaction and resilience quickly dispels the dire stereotypes of quadriplegics that all too often creep into analyses of a “life worth living”. Not to add these perspectives to ethical discussions—for instance, in ethics cases exploring hypothetical preferences in states of paralysis—overlooks an important dimension that is crucial to the discussion.
Although many films may have clips that are relevant to discussions of medical ethics, few go into the depth needed to expose students to the ethical analysis that they need to learn. But with the ready availability of digital video equipment and the ease with which clinicians can edit their own films, a new library of video vignettes can be created to explore numerous cases in medical ethics. Consider the video clip of advanced dementia that was created by clinicians to incorporate into ethical discussions about patients with the disease (the video clip is available on‐line at http://homepage.mac.com/avolandes/AlzheimersVideoiMovieTheater18.html).
After viewing the video, advanced dementia is no longer a faceless memory disorder but is transformed into a lived experience, one that spares little detail and forces a recognition of the social experience of the disease, vital information for the ethical analysis. The lived experience of the disease is brought to the fore and not hidden for some later time when the medical student is exposed to the clinical environment. Moreover, the lived experience of disease is readily available for the student to incorporate into the ethical analysis. The complete video vignette would include testimonials from the patient's family members and clinicians. The various perspectives on the disease and the values involved in caring for such patients are quickly introduced and examined in the ethical discussion.
Film vignettes are a powerful addition to the teaching tools available to train healthcare professionals in medical ethics. The medium of film offers a more complete picture of the ethical dimensions of a case than a solely verbal or written vignette. However, it has important limitations.
Film clips can be manipulated to favor a particular perspective. Consider the manipulation of the public's sentiments in the Terri Schiavo case, in which a 6‐second video clip was shown attempting to portray her as more cognitively aware than her diagnosis of persistent vegetative state would suggest. (For links to the various videos of Schiavo, see http://en.wikipedia.org/wiki/Terri_Schiavo#External_links.) Editing and digital effects can introduce bias in the filming of cases. Even the choice of surroundings—for instance, a nursing home or a hospital bed—can influence the impression a film clip leaves.
In order to minimise the introduction of bias in filming cases, close collaboration with expert physicians, nurses and other healthcare professionals is crucial. In the two video clips of the patient with neurofibromatosis and the patient with advanced dementia, the producers we solicited the suggestions and opinions of geriatricians, dermatologists, neurologists, social workers and nursing staff. We also used the cinéma vérité style of documentary film‐making to film and edit the clips, avoiding the use of special effects or staging. Nonetheless, the use of video inherently involves aesthetic biases.
Aesthetic biases are not, however, unique to film; writing clinical vignettes also introduces biases. Consider the choice of words often used in written vignettes, such as “aggressive care” and “futile care”. Word choice is also a potential bias laden with values. Film should not be viewed as more or less objective than the written word, but additional precautions ought to be taken over the final visual clip presented to healthcare professional students.
Clinical vignettes have been the predominant means of teaching medical ethics to students in healthcare professional schools. Despite being conducive to ethical discussions, written and verbal vignettes are limited in that they may neglect some of the pertinent facts important for ethical analysis, namely the experience of the illness and the patient's perspective. Film vignettes are able to overcome these shortcomings and supplement this traditional means of teaching ethics.
Film is an increasingly more affordable and accessible medium to implement. New technological advances in digital filming and digital editing programs make the use of film vignettes both logistically possible and financially affordable for all health professional schools. The increasingly available video capabilities of the internet also make film vignettes widely accessible. We have already incorporated the use of film vignettes in our own ethics teaching and have made the clips available on‐line.
In this paper, I have explored the use of film for teaching medical ethics. Film ethnography provides a more complete understanding of the relevant ethical considerations for students in the early part of their careers. Ethnography presents a more nuanced understanding of the social experience of illness and places the patient's perspective at the center of the discussion. Clinical vignettes will always be an integral part of teaching medical ethics to students. Film may be able to supplement the traditional clinical vignette by providing information that is not readily accessible to students in the early junctures of their medical lives. Film is an engaging and readily accessible medium that students are already familiar with. Supplementing written vignettes with film assists students to grasp a more complete understanding of clinical vignettes, a better position from which to engage in ethical analysis.
I would like to think Muriel Gillick for comments on an earlier draft of this paper.
Competing interests: None declared.