AMA Journal of Ethics^®

Case

As Priya, a third-year medical student, and the urology resident wait for the anesthesiologist to sedate the middle-aged patient scheduled for a prostatectomy that afternoon, the attending surgeon enters the operating room and announces that he has brought music to be played during the procedure. This is not atypical; many surgeons prefer to have some music playing in the room while they operate, and Priya expects to hear the classic rock or jazz that has accompanied other operations that she has seen.

She is startled when she hears police sirens and profanities being shouted from the CD player. As the bass line of a gangster rap song starts, the attending surgeon steps out to scrub. While Priya washes and prepares the patient, she is shocked by the liberal use of profanity and racial slurs in the lyrics of the song. She reads the reactions of other members of the operating team as they go about their work, shaking their heads or rolling their eyes. Priya decides that she is not the only one who finds the choice of music inappropriate and turns down the volume of the CD player. Priya would rather have turned the music off all together but hesitates to do so because this was the selection of the attending surgeon on the case.

When the attending surgeon returns to the room, he asks in a confrontational tone, "Who turned down my music? Does this offend someone? If you are offended, just stand up and say so, and I'll turn it off." He looks around at the anesthesiologist, the resident, the scrub nurse, and Priya, who all stand in silence. Priya finds it hard to believe that he cannot sense the discomfort sitting heavily in the room. She cannot believe that he really thinks this music is appropriate. But no one speaks up. No one asks that the music be changed. Seconds later, the surgeon asks the circulating nurse to restore the volume on the radio as he dresses for the procedure.

Commentary 1

Though the details of this clinical scenario are unique, the fundamental nature of this student's conflict is not. Priya believes that the attending surgeon has created an environment that is profoundly disrespectful to the patient and operating room team but is unsure how best to respond. As the person with the least experience and knowledge, Priya is expected to defer to the clinical expertise of more senior doctors. Because Priya is accustomed to this passive position, she feels uncomfortable questioning the judgment of an attending surgeon. Priya feels pressure to accept his ethical standards and may even doubt the validity of her own reaction.

Initially, Priya turns down the volume of the gangster rap because it violates her professional values. The profanities and racial slurs are obviously destructive to the environment of mutual respect most conducive to team work and patient care. Members of the operating team, likely a diverse group, may feel demeaned, humiliated, or infuriated by the surgeon's choice of music. Some will interpret the lyrics as reflective of the surgeon's personal views. Priya worries that these emotions will interfere with the concentration and spirit of cooperation essential to a successful surgical procedure. Priya also understands that, by allowing an invasive surgical procedure to be performed on him, this patient has placed great trust in the surgeon and operating room team. The team should acknowledge this trust by maintaining a respectful, dignified environment, even while the patient is unconscious. Finally, Priya objects to the gangster rap on a personal level. She is offended by the lyrics and resents their negative influence on her learning environment.

Despite her sound ethical reasoning, Priya does not admit to turning down the music. Instead, she doubts the appropriateness of criticizing the antagonistic surgeon. If she chooses to assert her own professional standards she will overstep the clearly defined student's role characterized by unconditional deference to more senior professionals. Altruism is tempered by self-interest as fears of humiliation, punishment, and negative repercussions discourage Priya from voicing her disagreement. Though she suspects that similar fears underlie the anesthesiologist's, resident's, and scrub nurse's silence, the possibility remains that others do not find the music equally ethically objectionable. Furthermore Priya wonders if, by publicly confronting the surgeon, she will anger the more senior members of the operating team who deem Priya's reaction inappropriate for a medical student. Clearly, confrontation may not be in her best interest.

As the nurse restores the volume and the surgeon dresses, Priya has a final opportunity to consider possible courses of action. Each option strikes a different balance between respect, patient care, altruism, and self-interest. The path she ultimately chooses will be a reflection of her personal and professional values. A solution that would be tolerable to one person may be intolerable to another, and for any given person subtly different situations might call for radically different courses of action. Confronting the surgeon directly would be tantamount to accepting equal responsibility for the operating room environment. If Priya's personal ambitions require the support of this surgeon or the good opinion of the operating team, the cost of public confrontation may be too high. Priya might consider discussing her concerns with this surgeon or another faculty member privately. Such actions would permit Priya to protect her interests and partially defend her professional values. While this particular patient and team will not benefit, future improvements remain a possibility. Ultimately, Priya may decide to say nothing and follow the lead of the rest of the team.

Though the cost of confrontation is readily appreciated, the long-term price of silence is often overlooked. If moral and ethical integrity are traits highly valued by the medical community, then the development of professional values needs to be an important goal of medical education. Unfortunately the hierarchical structure of medical education, designed to tie responsibility to clinical knowledge, infantilizes its students. Though there is no relationship between moral reasoning and clinical knowledge, students do not feel empowered to confront more senior doctors about unprofessional behavior. Because deeply felt conviction requires a forum for expression, there should not be unconditional deference to medical hierarchy in the realm of professionalism and ethics. However, professional identity and ethical maturity will only become fully integrated when moral responsibility is fully assumed at the beginning of clinical training.