Between a Rock and a Hard Place

MMIs are often centered around a specific ethical dilemma or scenario. Although that might sound intimidating, it’s also a benefit for you because there are no right answers. However, while there may be no right answers, there are better or worse ways to answer an MMI prompt.

In this article, I’m going to give some tips on how to approach MMI interviews, with an emphasis on ethical problems. I won’t give any solutions, but I will equip you with the right questions to ask yourself. These questions should act as a framework that will guide your thoughts towards crafting a robust and thoughtful answer to any prompt you’re given. Remember, it’s more about your approach than your answer.

Here’s a general tip to start: Relax. Look, I’ve tried to cram philosophy papers the night before they’re due; but, frankly, that approach never turns out well. Some situations require a calm, slow thought process; philosophy and MMIs are some of those instances. If you’re frantic, you won’t be able to form coherent thoughts. Take a deep breath — the goal is not to convince your interviewers of your particular viewpoint, or even to fix the problem at hand. Your goal is to show your values and how you approach problems. Remember, as Dr. Jessica Friedman, a former medical admissions committee member at Mt. Sinai School of Medicine, says: there’s no wrong answer to an MMI prompt.

These questions should act as a framework that will guide your thoughts towards crafting a robust and thoughtful answer to any prompt you’re given.

Medical Ethics and the MMI

To start, let’s examine an important bioethical problem (and personal interest of mine) that often shows up in MMI questions: resource-allocation in times of scarcity. Often, we have a shortage of resources and a preponderance of need. Unfortunately, this means that not all those who need help will receive it. But how do we choose who does?

Organ transplantation is a classic example. Let’s say you’re a transplant surgeon, and you have one available liver. You alone get to decide who will receive it. (Note: this is not a plausible scenario, but an interesting one to ponder nonetheless.)

You have two patients in front of you: a 50-year-old man (Patient X) whose liver has degraded due to alcoholism. There are no complications; if he receives the liver, he will almost certainly recover and his system will regain full functioning capacity.

Next to him is another 50-year-old man (Patient Y): a father of three whose liver is riddled with cancer. His daughter is about to graduate from high school and is planning on attending university next year. Patient Y will definitely improve with a liver transplant, but there’s no guarantee he’ll be cancer-free.

To whom do you give the liver? On the one hand, we have a man who will certainly recover, but may have “deserved” his illness in the first place. On the other, we have a man who did nothing to merit his disease, but has uncertain chances for recovery.

The Four Principles of Medical Ethics

The best way to appraise a medical dilemma is to analyze it using the four principles of medical ethics. These principles were developed by Dr. Tom Beauchamp and Dr. James Childress and were published in their book Principles of Biomedical Ethics (1985). As America’s first significant bioethics text, this book soon became a standard reference, and its approach to medical ethics is widely accepted today.

Beauchamp and Childress’s methodology emphasizes approaching each situation with regard to four medical principles, now often called the “Four Pillars of Medical Ethics.” These include (1) autonomy, (2) beneficence, (3) non-maleficence, and (4) justice. They are defined as the following:

1. autonomy: the patient controls the right to body and future
2. beneficence: the doctor seeks to do good
3. non-maleficence: the doctor avoids doing bad
4. justice: the doctor treats all patience equally

Let’s start with Principle 1. In this case, both patients have successfully maintained their autonomy. Each has requested an organ, and it now falls upon you, the doctor, to attempt to provide it. You are not forcing the organ on either patient, nor are you ignoring the patients’ wishes. Thus, this situation does not violate principles of autonomy.

Next, let’s talk about Principle 4. This organ allocation dilemma is an ongoing medical debate that hinges upon the concept of justice. Many ask the question: Isn’t it unjust to give a liver to a patient who self-inflicted his own suffering when it could be given to a patient whose illness was tragically random?

In my opinion, that is not a fair question for a doctor to consider. As medical professionals, we serve justice. But be careful not to conflate justice with revenge. It is not up to the physician to mete out punishment; you are neither the judge, nor the jury, and especially not the executioner. Our duty is not to make sure people “get what they deserve”; it is to ensure all are treated justly, i.e. with equity.

Of course, your opinion may differ from mine. If you disagree, be prepared to justify why your motivations are not vindictive, and how they actually serve a greater good. One such way to approach this is to argue that an alcoholic is more likely to continue abusing alcohol and damage his liver all over again; thus, a cancer patient would be more deserving. In this way, giving the liver to a cancer patient would maximize the liver’s utility. Regardless of whether you agree, let’s examine the other facets of this dilemma.

Regardless of which option you choose, make sure you have examined the situation in regards to all four principles and be ready to demonstrate how each relates to your decision.

The remaining principles—beneficence and non-maleficence—often go hand-in-hand. Here, doing good can be seen as providing the liver to the person with the greatest potential for a full recovery. In this case, Patient X is most likely to make a full recovery, provided he stops drinking. Because Patient Y may suffer a relapse, his chances are lower. From this perspective, I can do more good and less bad by giving the liver to Patient X.

Thus, after putting all emotion and bias aside, it seems to me that the doctor ought to give the liver to Patient X, the alcoholic. My argument hinges on Principles 2 and 3 (Beneficence and Non-Maleficence), and posits that Principles 1 (Autonomy) and 4 (Justice) are less relevant.

If you disagree, you’re likely to cite Principle 4 as the basis of your argument. Regardless of which option you choose, make sure you have examined the situation in regards to all four principles and be ready to demonstrate how each relates to your decision.

Summary

This is only one example of how you should approach a bioethical dilemma.

To re-cap:

• Summarize the issue in all its ethically relevant facets
• Analyze the situation in respect to each of the four Principles of Medical Ethics
• State the conclusion, mentioning which principles justify your decision

Armed with this methodology, you won’t be so nervous when you face an MMI and questions about medical ethics problems. Remember, as long as you’re consistent in your principles and keep patient welfare foremost in mind, there are no wrong answers. Take a breath, speak with confidence, and go impress your interviewers!