Case Summary

You are a pediatric resident seeing a 4-month-old female who is post-op from pyloric stenosis repair. The child presents with a high fever and no obvious focus of infection. Because of her post-op status, the general surgery resident is seeing the patient along with you in the ED. Both of you believe the child needs to have a catheterized urine specimen collected, but you have been unsuccessful at performing the procedure (as have the nurses) because the child has labial adhesions.

As you both stand over the baby, the surgical resident looks at you and says, "We need the urine sample, and there is an easy way to fix this." He grasps the labia and pulls them apart, leaving a raw, bleeding labial surface. He then walks out of the room.

  • Has the behavior of the surgical resident resulted in harm to the patient?
  • Do you have an obligation to the family to notify them of this harm?
  • What is your obligation to make sure the surgical resident understands the implications of his behavior?
  • Does this need to be documented in the chart?
  • How do you handle the situation if your attending tells you to simply "walk away"?

Learning Objectives

After participating in this module, the student should be able to:

  1. Recognize that one has obligations to patients when harm has been witnessed
  2. Define the extent of one's duties to the patient and to the other parties involved when a colleague has acted incompetently or inappropriately
  3. List strategies for dealing with situations in which an authority figure makes a request that may be wrong or inappropriate
  4. Understand the implications of "whistleblowing" and the factors that should be considered before deciding to do so
  5. Develop strategies for informing other physicians about concerns you may have regarding management of a patient

Suggested Reading for Students

Bok S. Secrets: On the Ethics of Concealment and Revelation. New York: Random House (Vintage Books); 1983.

Council on Ethical and Judicial Affairs, American Medical Association. Disputes between medical supervisors and trainees. JAMA. 1994;272:1861-1865.

Dwyer J. Primum non tacere: an ethics of speaking up. Hastings Center Report. 1994: 24 (1):13-18.

Frader J. Referral back to an incompetent primary care provider. In: Iserson KV, Sanders AB, Mathieu D, eds., Ethics in Emergency Medicine. Second ed. Tucson, Arizona: Galen Press, Ltd.; 1995:276-278.

Knight JR, Palacios JN, Shannon M. Prevalence of alcohol problems among pediatric residents. Arch Pediatr Adolesc Med. 2000;154 (Jan):1181-1183.

Morreim H. Am I my brother's warden? Responding to the unethical or incompetent colleague. Hastings Center Report. 1993;23:19-27.

Weiner J, Snyder L. The impaired colleague. In: Snyder L, ed., Ethical Choices: Case Studies for Medical Practice. Philadelphia: American College of Physicians; 1996:79-84.

Shreves JG, Moss AH. Residents' ethical disagreements with attending physicians: an unrecognized problem.Acad Med. 1996;10:1103-1105.

White BD. The questionably impaired health care professional. In: Iserson KV, Sanders AB, Mathieu D, eds.,Ethics in Emergency Medicine. Second ed. Tucson, Arizona: Galen Press, Ltd.; 1995:284-292.

This student's guide was developed by Douglas S. Diekema, MD, MPH, director of education, Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital.

In addition to the copyright notice set forth in the link below, permission to display, cache and print unlimited copies of the Case-Based Teaching Guides referred to on this page is hereby granted, solely for educational purposes, without charge (other than charges solely to cover the costs of copying), and without alteration of the Materials in any way.

1. Instructor's Guide 2. Student's Guide 3. Case Discussion