Should television programs be used to teach health care ethics?

Since the start of my studies in bioethics and continuing into my hospital-based work, this conversation illustrates why I don't watch any of the major networks' medical series. Yet I never watched the adult cartoon show The Simpsons and have come to regret it after reading various chapters in the 2001 book The Simpsons and Philosophy: The D'Oh of Homer! Has my "cease and desist" decision regarding prime time medical dramas been too hasty?

The most recent issue of the Journal of Medical Ethics includes a study about the frequency and manner in which ethical situations appear in 50 episodes of House, M.D. and another popular medical series, Grey's Anatomy. Researchers Czarny, Faden and Sugarman identified 179 bioethical "incidents" in the 50 episodes. Among the 179 incidents are 49 issues about patient consent, 14 patients refusing recommended treatment, 22 deviations from standard medical practice, and 12 problems in accessing health care services. Added to these 179 situations are 396 ethical incidents involving professionalism, 218 of which are between patient and physician, and 178 between physicians or between physicians and allied health staff.

The study concludes that a minority of the incidents involve ethically acceptable actions by physicians. For instance, 60 of the 218 patient-physician issues are evaluated as ethically commendable, and only nine of the 178 interprofessional issues are commendable. Just 21 of the 49 consent incidents are judged ethically exemplary. And only four of the 22 physicians inappropriately deviating from standard clinical practices actually receive some type of reprimand or sanction.

So should television programs be used to teach health care ethics? It is challenging to teach health care students because many are eager to learn and master the scientific and technical parts of nursing, medicine, pharmacy and so on. To say that there is a lot of information to know today is admittedly a sizeable understatement. Compared to other courses in their curricula, many health sciences students consider ethics "lightweight" and therefore a lower priority for their time and energy. Ethics instructors are often encouraged to use innovative and contemporary teaching techniques in the hopes of getting students' attention and promoting reflective discussion. (I recall being asked several years ago to make one of my sessions with first-year medical students funny! Watching The Simpsons may have been helpful then.) Is watching modern prime time programs a promising technique for teaching ethics?

Commenting on a study by Czarny and colleagues about popular medical shows, published in 2008 in the American Journal of Bioethics, White, in that same issue, argues "no," because too few of the other allied health staff have prominent roles in most series. I don't subscribe to a network that has Nurse Jackie or Hawthorne. Perhaps they help balance viewers' understanding of these other health care professionals that viewers will encounter if they are ever hospitalized. In an earlier 2008 issue of the AJB, Trachtman correctly identifies what prime time medical series tend to omit: how frustrating ordinary health concerns are, how varied people's perspectives are, how complex people are, and how health problems unfold erratically for months and years.

Others argue that watching prime time medical shows can be a good teaching technique. Wicclair's commentary in the same AJB issue, features the catchy title "Can a Fictional Unethical Physician Be Used to Teach Ethics?" referring to the larger-than-life character, Dr. Gregory House. Despite saying "It is hard to imagine a worse role model for medical students than House," Wicclair answers the technique question with a cautious "yes," as does Spike in his commentary on Czarny et al.'s 2008 study.

Why "yes"? Spike says -- and I agree -- that the shows frequently offer far richer narratives about the patients, their families and hospital staff than the most common teaching method -- a two- or three-paragraph clinical case followed by the question, "Ethically, what should you do?" Wicclair instead draws hope from Czarny et al.'s 2008 study of 167 nursing students and 207 medical students' television viewing habits. More than 80 per cent said they watch and discuss these medical shows, half of the time with their friends. The study asked students to rate how well ethical situations are portrayed in episodes of House, M.D., Grey's Anatomy, ER and Nip/Tuck. One third of the students thought the portrayals were adequate and two thirds disagreed.

Let's be clear. The primary goal of scriptwriters is to attract lots of viewers in order to increase network and studio revenues. The focus is entertainment, not education. But there is some empirical evidence that television shows actually affect viewers' beliefs and behaviours, according to Valente, Murphy, Huang et al., writing in a 2007 issue of the Journal of Health Communication International Perspectives. So it's important for those of us teaching and mentoring students, as well as interacting with the general public, to be aware of popular media portrayals of lives impacted by illness or injury; relationships between patients, families and health care workers; and the impact of administrators on health care delivery.

Other techniques should therefore be included, namely from the humanities. By "humanities," I mean movies, plays, fictional stories, biographies, autobiographies, art and poetry. An excellent resource is the New York University School of Medicine's Literature, Art & Medicine web site. Another valuable resource is the Washington, D.C.-based Society for Arts in Healthcare, whose mission it is to promote inclusion of the arts in health care settings, given their contribution to healing.

Has my mind changed about prime time medical dramas? Yes. Because over 80 per cent of health care students watch them regularly, I need to, too. And since most of my time is spent with seasoned health care workers, I'm going to find out which medical dramas they watch ...