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Spandorfer J, Pohl C, Nasca T, Rattner SL, eds. Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge: Cambridge University Press; 2010.

Video: Principle of Patient Autonomy | Commentaries

A Medical Student Perspective

It is not hard to imagine that helping close the incision would be the easiest choice for the student, as such participation is expected of a fourth year student and would be done at the request of the attending. Closing incisions also gives a student the opportunity to make a more personal contribution to the case while practicing a useful skill. However, if she did so, the student would knowingly break the agreement formed with the patient during rounds. The fact that the student's action would have little impact on the outcome of the operation is not sufficient reason to ignore the patient's preferences. Doing so would place the trust of the patient at risk as well as the patient-surgeon and patient-student relationships.

An appropriate first step is to make Dr. White aware of the conversation from rounds. The student is thus showing respect for the patient and acknowledging his right to make autonomous decisions regarding his care. These are fundamental principles of the informed consent process. Informed consent is considered an ongoing dialogue between patient and surgeon (1), and the resident and student are participants in this process. They have a mutual understanding with the patient regarding their roles in the operation and should honor those expectations. Additionally, the patient's expression of personal preferences before a procedure should be a foremost consideration when making decisions regarding an anesthetized patient.

As medical students on clinical rotations, we see the look of hesitancy some patients express when we ask permission to participate in their care. Most patients are willing to interact with students, but this willingness varies with the clinical setting (2). One survey in an outpatient clinic noted that only 2 percent of patients would not allow students to watch surgery but 59% said they would probably or definitely not allow students to suture incisions (2). As in this case, the appropriate response to patients' concerns is to err on the side of giving more information regarding trainee's roles rather than less. If open discussions do not resolve concerns over student involvement, patients ultimately have the right to choose from whom they receive treatment (3).

Because of their willingness to interact with students, we come to expect patients' consent, even though our involvement may place additional burdens on their care. Medical students have a right to a clinical education, but the obligation to fulfill this responsibility rests with the university, not its patients (4).

In this case, the student must explain to the attending physician why she is refusing a simple request. Speaking up is not without risk, because these actions may affect her evaluation and status on the team. However, patients entrust physicians to exercise moral courage on their behalf (5). Just as technical skills must be sought and practiced by future physicians, so too must habits of character and ethical conduct.


  1. Bernat JL. Peterson LM. Patient-centered informed consent in surgical practice.[see comment]. Arch Surg. 2006;141(1):86-92

  2. Ubel PA. Silver-Isenstadt A. Are patients willing to participate in medical education? J Clin Ethics. 2000;11(3):230-5

  3. Council on Ethical and Judicial Affairs. Opinion E-8.087, Medical Student Involvement in Patient Care. In: Code of Medical Ethics of the American Medical Association: Current Opinions with Annotations. 2006-2007 Edition.;Chicago: AMA Press, 2006. http://www.ama-assn.org/ama/pub/category/8491.html Accessed September 14, 2007

  4. Pelligrino ED. Medical Education. In: WT Reich, ed. Encyclopedia of Bioethics. New York: Macmillan Library Reference; 1995.

  5. Dwyer J. Primum non tacere. An ethics of speaking up. Hastings Center Report. 1994;24(1):13-8

Peter King
Fourth Year Medical Student
Medical University of South Carolina