An Ethical Issue in Medical Education of Obstetrics and Gynecology.

There are four principles of medical ethics; Beneficence, Respect for autonomy, Non-maleficence, and Justice. It is not easy to apply to principles of medical ethics in the special circumstances of obstetrics and gynecology. Student doctors must learn to be familiar with principles of medical ethics tailored to the special circumstances while the obstetrics and gynecology practice.

Student doctors in hospital training are required to be mindful of several issues. In every field of medicine, the student doctor should comprehend not only specific techniques such as lung sound auscultation, but also distinct ethics of the department. In obstetrics and gynecology, students should have medical knowledge on pregnancy in women and menopausal women.1234 Ethics cannot but be overemphasized due to the peculiar nature of the department. Ethics are particularly highlighted in obstetrics and gynecology, together with the difficulties involved. Moreover, the student doctors are often faced with a situation in which the ethics and other important values for medical students are incompatible. It is necessary to understand general medical ethics for student doctors in advance of the discussion on characteristic circumstances of obstetrics and gynecology. There are 4 principles of medical ethics i.e., Beneficence, Respect for autonomy, Non-malfeasance, and Justice. First, "Beneficence" signifies that whatever is done or said is to be for the patients' good; e.g., a student doctor is able to converse with patients and help them feel at ease. Next, "Respect for autonomy" refers to respect for the decision-making capacity of the patients and empowering reasoned informed choices. Thus, when a student doctor asks a patient about his/her condition, the student doctor should identify him/herself as a student doctor and obtain consent for a physical examination. If the patient refuses, respect for autonomy requires that the student should decide between abandoning the physical examination and enquiring later when the patient is ready. "Non-malfeasance" can be confused with beneficence. However, non-malfeasance simply means, "Do not harm". Since most treatments cause some side effects, doctors always take the risk of going against this principle. Medical students who normally do not perform certain procedures themselves might violate the principle in other ways. For example, a prior relationship between a student doctor and patient could hinder the therapeutic relationship between physicians and patients, due to misinformation on treatment or acquired prejudice against the doctor. Thus, student doctors have to be careful in their communication with patients. Finally, "Justice" is the fair distribution of benefits, risks and costs. A student doctor is not commonly confronted with a situation that requires most justifiable decision making. However, they should be prepared to make moral decisions on allocating the limited resources based on the principle of justice. Among the principles of medical ethics, respect for autonomy and non-malfeasance can be easily infringed by student doctors undergoing training in obstetrics and gynecology. Thus, student doctors and their instructors have to consider these 2 principles. Doctors should get "informed consent" from patients before the procedures. Obtaining consent from patients for student observation of medical procedure is not fulfilled thoroughly and can infringe on patient autonomy. In emergency cases, such as pregnant women in labor, or gynecologic emergency patients, it is difficult to obtain consent.5 Besides, mandatory consent in every obstetric or gynecologic procedure could result in reduced training opportunities for the student doctors that could result in deterioration of the quality of medical education.6 These reasons can intrude on patient autonomy. Furthermore, observation by the student doctors can do harm to patients. Obstetrics and gynecology involves thorough inspection of female genitalia. So observation of inspections itself can cause the patients to feel sexually humiliated, especially transsexuality.7 Based on the rule of double effect, if the action accords with 4 conditions that are mentioned below, it can be ethically justified, despite the negative result of the action. First, the action must be morally good itself. Second, the intention of action must be morally good. Third, good ends do not justify evil means. Fourth, the good effect must be larger than or at least equivalent to the bad effect. Educating student doctors can be considered as good intention and may benefit the entire society. However, if the good effect to the present patient does not surpass the bad effect, the observation by the student doctors is not justified. Because obstetrics and gynecology deal with female genitalia, it is inevitable that male student doctors meet some delicate situations. Therefore, the male student doctors ought to consider the characteristics of the department while setting high ethical standards. Above all, a patient is never a sexual object. The student doctors should not capitalize on the patient-doctor relationship to satisfy their own sexual curiosities. Abuse of their status as student doctors could damage the therapeutic relationship between the patient and her obstetrician or gynecologist, as well as cause humiliation. Next, male student doctors have to consider that they might lack empathy for fears associated with gynecology visits or the void after hysterectomy. Keeping the patients perspective in mind, they would be able to avoid sham, embarrassment, or emotional pain during medical examinations. It is not easy for student doctors to behave for the good of a patient at all times. Sometimes, when a patient refuses a visit of a student doctor due to preconceptions of such visits as troublesome and not helpful for his/her own treatment, the student is confronted with issues such as optimal patient care and education. Offering practical help as a student is challenging. Nevertheless, the student doctors should attempt to benefit both the present patient and entire society at all times. Consequently, upholding the 4 principles of general medical ethics including Beneficence, Respect for autonomy, Non-malfeasance, and Justice, should be the constant goals. In addition, if students encounter special circumstances like dealing with female genitalia in obstetrics and gynecology, specific ethical standards are necessary for making the most proper judgment whenever needed.