by Craig Klugman, Ph.D.
Last week I attended the second annual meeting of the Academy for Professionalism in Medicine. This group of scholars is trying to define professionalism and examine how to effectively bring ethics and humanities into medical school classrooms and residency programs. A new study, however, suggests that we should forget about poetry, principles, values, and reflection. All we really need is coffee.
Researchers at the Universities of Arizona, North Carolina and Washington examined the effects of caffeine on sleep-deprived subjects when confronted with social pressure to deceive another person. In the experiment, subjects were kept awake for 24 hours. They were then asked to send a deceptive message. People who were sleep-deprived and uncaffeinated were more easily influenced to send that message. Those who were sleep-deprived and had caffeine were less likely to send the message, even under social influence.
As it turns out, there is a lot of research that shows a lack of sleep decreases a person’s ability to self regulate. And among those tools of self-regulation is ethical behavior. People with lowered self-regulation are more likely to perform unethical behaviors at work. If you feel rested, you can resist pressure to behave unethically. But it you are tired, you are more likely to go along with the request.
Researchers suggest that such a phenomenon may explain why people working at a corporation may go along with an authority that encourages actions that most people would consider to be unethical, or even illegal.
In the recently published study, researchers gave caffeine in the form of gum to subjects. The results show that caffeine not only helps you feel more awake, it reinstates your self-regulation and you can resist pressure to perform unethical behavior.
Although the authors looked at the arena of business practices, might the same finding also hold for the world of medicine? Medical students, residents, and even some attendings are famous for being sleep-deprived. Studies have shown that not only do overtired medical professionals make more errors, but they are also more likely to abuse drugs and even to get into motor vehicle accidents (driving tired can be as dangerous as driving under the influence). Such problems were the impetus for the much-despised work hour rules.
Thus, by the theory discussed above, these sleep-deprived medical professionals likely have lowered self-regulation. Add in a little social pressure and suddenly there is the potential for lots of ethical behavior. A patient adamantly states that you do not enter a diagnosis in the chart. A director asks that you “fudge” your work-hours log. An attending tells a medical student to close a wound even if he or she does not know how, and the student does so. A student is told to perform a pelvic exam on a woman under general anesthesia who has not been asked to consent for this. And telling a patient to return to the hospital for a visit not because such a visit is medically necessary, but because he or she is a good teaching case.
The answer to such issues usually incorporates renewed enforcement of regulations, new trainings, additional lectures on the topic, or an investigation when a patient is harmed. Perhaps the alternative is adding caffeine or another stimulant. Caffeine increases central nervous system activity which then “attenuates [the] effects of sleep deprivation.” A caffeinated person who is sleep-deprived has improved reaction to tasks and increased self-regulation. Who needs work hour limits when a little stimulant will bring that person back up to normal functioning? Military pilots have used stimulants for a long time to put off sleep so they could function better. Then when they have time, they crash and sleep. Why not have the same expectations of medical personnel?
Is it right to ask people to medicate themselves to do their job? Might taking stimulants become a requirement to success in medical training? Should residents be required to take caffeine or other stimulants to improve their ethical behavior? Is ethics simply reducible to the ability to refuse pressure to do the unethical? Should I consider replacing my lectures on privacy with a caffeine tablet? Perhaps talks on Kant should be augmented by coffee tasting. Or perhaps a medical system that requires people to live in a state of sleep deprivation should be altered to be more humane. This is not the current state of our society: When people cannot physically or mentally adapt to social expectations, we medicate those people rather than thinking about changing the environment and circumstances that are incompatible with some humans’ functioning.
What this study does suggest is that knowing the right thing and an awareness of ethical theories are not enough. Being tired may compromise an individual to the point where he or she lacks true capacity to make autonomous decisions. Good decisions and ethical behavior require an environment and circumstances that provide people with the freedom to make conscious, ethical choices even in the face of authority telling them otherwise. And if that doesn’t work, then there’s always java.