How to Balance Patient Rights, Safety and Choice of Provider with the Need to Train Future Doctors
Main Article Content
Abstract
There is significant variation internationally in ethical guidance on teaching and involvement of students in patient care. New Zealand is an outlier in requiring consent for teaching which “includes training” for all medical students and post graduate trainees. There is an ethical tension between the patient’s best interests to receive the best available care and the societal need to train new doctors. This tension is hard to resolve if the patient lacks capacity, and the decision is required to be made solely on the best interest of the patient. If this New Zealand standard is applied rigorously no-one would be able to learn a procedure that is only performed on a person lacking capacity. Requiring consent is not usual in the apprenticeship model which is central to the training of doctors. Any standards relating to managing the risks of teaching, and agreement for involvement in care must apply to all students and qualified doctors. Whilst patients retain the right to refuse treatment the value of having students as part of the team should be emphasised and the social norm should be that patients are involved in teaching. Teaching should be an ethical responsibility of all doctors. Particular guidance is needed for teaching/learning with patients who have limited or impaired capacity. This can be modelled on guidance developed for research on vulnerable patients.
Article Details
How to Cite
GRAY, Ben.
How to Balance Patient Rights, Safety and Choice of Provider with the Need to Train Future Doctors.
Medical Research Archives, [S.l.], v. 13, n. 6, june 2025.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6620>. Date accessed: 15 july 2025.
doi: https://doi.org/10.18103/mra.v13i6.6620.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Gawande A. Complications :a surgeon's notes on an imperfect science. 1st ed. ed. Metropolitan Books; 2002:x, 269.
2. United Nations Educational Scientific and Cultural Organization. Universal Declaration on Bioethics and Human Rights. UNESCO. 2021. https://en.unesco.org/themes/ethics-science-and-technology/bioethics-and-human-rights
3. Parsa-Parsi RW. The International Code of Medical Ethics of the World Medical Association. JAMA. 2022;doi:10.1001/jama.2022.19697
4. The Code of Health and Disability Services Consumers' Rights, (1996). http://www.hdc.org.nz/theact/theact-thecode
5. Medical Board AHPRA. Good medical practice: a code of conduct for doctors in Australia. https://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx
6. Singapore Medical Council. Ethical Code and Ethical Guidelines. 2025. https://isomer-user-content.by.gov.sg/77/775548fb-11df-4393-89c5-33717769ccf6/2016-smc-ethical-code-and-ethical-guidelines---(13sep16).pdf
7. Malaysian Medical Association. Code of Medical Ethics. 2025. https://www.mma.org.my/images/pdfs/Link-CodeOfEthics/MMA_ethicscode.pdf
8. Medical Council of New Zealand. Good Medical Practice. 2022. https://www.mcnz.org.nz/our-standards/current-standards/good-medical-practice-2/
9. General Medical Council. Good Medical Practice. General Medical Council. 2024. https://www.gmc-uk.org/-/media/documents/good-medical-practice-2024---english-102607294.pdf
10. American Medical Association Code of Medical Ethics Medical Student Involvement in Patient Care. 2024. https://code-medical-ethics.ama-assn.org/ethics-opinions/medical-student-involvement-patient-care-0
11. Council CnnLM. Guide to Professional Conduct & Ethics for Registered Medical Practitioners. 2024. https://www.medicalcouncil.ie/news-and-publications/publications/guide-to-professional-conduct-and-ethics-for-registered-medical-practitioners-2024.pdf
12. Elendu C, Amaechi DC, Okatta AU, et al. The impact of simulation-based training in medical education: A review. Medicine. 2024;103(27):e38813.
13. Broadmore J, Hutton J, Langdana F. Medical students’ experience of vaginal examinations of anaesthetised women. BJOG: An International Journal of Obstetrics & Gynaecology. 2009;116(5):731-733.
14. Cartwright Sylvia. Report of the committee of inquiry into allegations concerning the treatment of cervical cancer at National Women's Hospital and into other related matters. Accessed 12/3/13, https://www.womenshealthcouncil.org.nz/the-cartwright-inquiry
15. Rowland P, Anderson M, Kumagai AK, McMillan S, Sandhu VK, Langlois S. Patient involvement in health professionals’ education: a meta-narrative review. Advances in Health Sciences Education. 2019/08/01 2019;24(3):595-617. doi:10.1007/s10459-018-9857-7
16. Rassie K. The apprenticeship model of clinical medical education: time for structural change. The New Zealand Medical Journal (Online). 2017;130(1461):66.
17. Bagg W, Adams J, Anderson L, et al. Medical Students and informed consent: A consensus statement prepared by the Faculties of Medical and Health Science of the Universities of Auckland and Otago, Chief Medical Officers of District Health Boards, New Zealand Medical Students' Association and the Medical Council of New Zealand. The New Zealand Medical Journal. 2015;128(1414):27.
18. Lave J, Wenger E. Situated learning: Legitimate peripheral participation. Cambridge university press; 1991.
19. New Zealand Medical Council. Kevin Morris, ed. Cole's Medical Practice in New Zealand. 14th ed. 2021. Accessed 10/9/22. https://www.mcnz.org.nz/assets/standards/08588745c0/Coles-Medical-Practice-in-New-Zealand.pdf
20. Bunniss S, Kelly DR. ‘The unknown becomes the known’: collective learning and change in primary care teams. Medical education. 2008;42(12):1185-1194.
21. Caldwell G. Whatever happened to apprenticeship learning? The Clinical Teacher. 2011;8(4):272-275.
22. Moffitt TE, Caspi A, Ambler A, et al. Deep-seated psychological histories of COVID-19 vaccine hesitance and resistance. PNAS nexus. 2022;1(2):pgac034.
23. Health and Disability Commissioner. Case 19HDC01260. 2024. Accessed 16/10/24, https://www.hdc.org.nz/decisions/search-decisions/2024/19hdc01260/
24. Silber JH, Rosenbaum PR, Niknam BA, et al. Comparing outcomes and costs of medical patients treated at major teaching and non-teaching hospitals: a national matched analysis. Journal of general internal medicine. 2020;35:743-752.
25. Nestel D, Kidd J. Peer assisted learning in patient-centred interviewing: the impact on student tutors. Medical teacher. 2005;27(5):439-444.
26. Stone S, Ellers B, Holmes D, Orgren R, Qualters D, Thompson J. Identifying oneself as a teacher: the perceptions of preceptors. Medical education. 2002;36(2):180-185.
27. Schaefer GO, Emanuel EJ, Wertheimer A. The Obligation to Participate in Biomedical Research. JAMA. 2009;302(1):67-72. doi:10.1001/jama.2009.931
28. Ballantyne A, Schaefer GO. Consent and the ethical duty to participate in health data research. Journal of medical ethics. 2018;44(6):392-396.
29. Bagshaw P, Potter JD, Hornblow A, et al. The common good: reviving our social contract to improve healthcare. 2025. p. 9-13.
30. Te Whatu Ora Health New Zealand, Te Aka Whai Ora Māori Health Authority. Finding a place to learn in health. https://www.tewhatuora.govt.nz/whats-happening/consultations/a-new-system-for-student-placements/
31. Medical Council of New Zealand. Fact Sheet Strengthening our Workforce. 2025. https://www.mcnz.org.nz/assets/Uploads/Fact-sheet-PR.pdf?vid=9
32. General Medical Council UK. The State of Medical Education and practice in the UK Workforce Report. 2023. https://www.gmc-uk.org/-/media/documents/workforce-report-2023-full-report_pdf-103569478.pdf
33. Yeomans ND. Demographics and distribution of australia's medical immigrant workforce. J Migr Health. 2022;5:100109. doi:10.1016/j.jmh.2022.100109
34. Nagarajan KK, Atul B, Varun MS, and Adhikari R. Prevalence of US-trained International Medical Graduates (IMG) physicians awaiting permanent residency: a quantitative analysis. Journal of Community Hospital Internal Medicine Perspectives. 2020/11/01 2020;10(6):537-541. doi:10.1080/20009666.2020.1816274
35. Briana Northey. Outsourcing health care risks the next generation of specialists. Accessed April 11 2025, https://www.thepost.co.nz/nz-news/360631419/outsourcing-health-care-risks-next-generation-specialists
36. Ministry of Health. New Zealand Health Survey 2022/23. 2024. https://www.health.govt.nz/publication/annual-update-key-results-2022-23-new-zealand-health-survey
37. Walker S, Reid P, Anderson L, et al. Informed consent for medical student involvement in patient care: an updated consensus statement. The New Zealand Medical Journal (Online). 2023;136(1579):86-95.
38. Gray B. (Bio)Ethics in a Pluralistic Society. Challenges. 2019;10(1):12.
39. New Zealand Law Commission. Review of Adult Decision-Making Capacity Law. https://www.lawcom.govt.nz/assets/Publications/IssuesPapers/NZLC-IP49.pdf
40. Te Ara Tika: Guidelines for Māori Research Ethics: a Framework for Researchers and Ethics Committee Members (Health Research Council of New Zealand) (2010).
41. Manson NC, O'Neill Onora. Rethinking informed consent in bioethics. Cambridge University Press; 2007.
42. Davey LMMD. The Oath of Hippocrates: An Historical Review. Neurosurgery. 2001;49(3):554-566.
43. New Zealand Medical Association. Code of Ethics for the New Zealand Medical Profession. New Zealand Medical Association. 2021. https://assets-global.website-files.com/5e332a62c703f6340a2faf44/5fbd645fe15640fa981fa469_Code%20of%20Ethics%20Redesign%202020%20version%204.pdf
44. Brown A, Kassam A, Paget M, Blades K, Mercia M, Kachra R. Exploring the global impact of the COVID-19 pandemic on medical education: an international cross-sectional study of medical learners. Can Med Educ J. 06/30 2021;12(3):28-43. doi:10.36834/cmej.71149
45. Tolsgaard MG, Cleland J, Wilkinson T, Ellaway RH. How we make choices and sacrifices in medical education during the COVID-19 pandemic. Medical teacher. 2020;42(7):741-743.
46. Murton SA, Pullon SRH. Assessment of training capacity in New Zealand general practices: a stocktake in the lower North Island and South Island. The New Zealand Medical Journal (Online). 2017 Sep 22-2022-11-08 2017;130(1462):11-26.
47. New Zealand Medical Students Association. NZMSA Statement on Graduating Doctors Without Jobs. 2025. https://www.nzmsa.org.nz/_files/ugd/137253_9ae9b1640239468b9fd05c11861324b1.pdf
48. National Ethics Advisory Committee. National Ethical Standards for Health and Disability Research and Quality Improvement. https://neac.health.govt.nz
2. United Nations Educational Scientific and Cultural Organization. Universal Declaration on Bioethics and Human Rights. UNESCO. 2021. https://en.unesco.org/themes/ethics-science-and-technology/bioethics-and-human-rights
3. Parsa-Parsi RW. The International Code of Medical Ethics of the World Medical Association. JAMA. 2022;doi:10.1001/jama.2022.19697
4. The Code of Health and Disability Services Consumers' Rights, (1996). http://www.hdc.org.nz/theact/theact-thecode
5. Medical Board AHPRA. Good medical practice: a code of conduct for doctors in Australia. https://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx
6. Singapore Medical Council. Ethical Code and Ethical Guidelines. 2025. https://isomer-user-content.by.gov.sg/77/775548fb-11df-4393-89c5-33717769ccf6/2016-smc-ethical-code-and-ethical-guidelines---(13sep16).pdf
7. Malaysian Medical Association. Code of Medical Ethics. 2025. https://www.mma.org.my/images/pdfs/Link-CodeOfEthics/MMA_ethicscode.pdf
8. Medical Council of New Zealand. Good Medical Practice. 2022. https://www.mcnz.org.nz/our-standards/current-standards/good-medical-practice-2/
9. General Medical Council. Good Medical Practice. General Medical Council. 2024. https://www.gmc-uk.org/-/media/documents/good-medical-practice-2024---english-102607294.pdf
10. American Medical Association Code of Medical Ethics Medical Student Involvement in Patient Care. 2024. https://code-medical-ethics.ama-assn.org/ethics-opinions/medical-student-involvement-patient-care-0
11. Council CnnLM. Guide to Professional Conduct & Ethics for Registered Medical Practitioners. 2024. https://www.medicalcouncil.ie/news-and-publications/publications/guide-to-professional-conduct-and-ethics-for-registered-medical-practitioners-2024.pdf
12. Elendu C, Amaechi DC, Okatta AU, et al. The impact of simulation-based training in medical education: A review. Medicine. 2024;103(27):e38813.
13. Broadmore J, Hutton J, Langdana F. Medical students’ experience of vaginal examinations of anaesthetised women. BJOG: An International Journal of Obstetrics & Gynaecology. 2009;116(5):731-733.
14. Cartwright Sylvia. Report of the committee of inquiry into allegations concerning the treatment of cervical cancer at National Women's Hospital and into other related matters. Accessed 12/3/13, https://www.womenshealthcouncil.org.nz/the-cartwright-inquiry
15. Rowland P, Anderson M, Kumagai AK, McMillan S, Sandhu VK, Langlois S. Patient involvement in health professionals’ education: a meta-narrative review. Advances in Health Sciences Education. 2019/08/01 2019;24(3):595-617. doi:10.1007/s10459-018-9857-7
16. Rassie K. The apprenticeship model of clinical medical education: time for structural change. The New Zealand Medical Journal (Online). 2017;130(1461):66.
17. Bagg W, Adams J, Anderson L, et al. Medical Students and informed consent: A consensus statement prepared by the Faculties of Medical and Health Science of the Universities of Auckland and Otago, Chief Medical Officers of District Health Boards, New Zealand Medical Students' Association and the Medical Council of New Zealand. The New Zealand Medical Journal. 2015;128(1414):27.
18. Lave J, Wenger E. Situated learning: Legitimate peripheral participation. Cambridge university press; 1991.
19. New Zealand Medical Council. Kevin Morris, ed. Cole's Medical Practice in New Zealand. 14th ed. 2021. Accessed 10/9/22. https://www.mcnz.org.nz/assets/standards/08588745c0/Coles-Medical-Practice-in-New-Zealand.pdf
20. Bunniss S, Kelly DR. ‘The unknown becomes the known’: collective learning and change in primary care teams. Medical education. 2008;42(12):1185-1194.
21. Caldwell G. Whatever happened to apprenticeship learning? The Clinical Teacher. 2011;8(4):272-275.
22. Moffitt TE, Caspi A, Ambler A, et al. Deep-seated psychological histories of COVID-19 vaccine hesitance and resistance. PNAS nexus. 2022;1(2):pgac034.
23. Health and Disability Commissioner. Case 19HDC01260. 2024. Accessed 16/10/24, https://www.hdc.org.nz/decisions/search-decisions/2024/19hdc01260/
24. Silber JH, Rosenbaum PR, Niknam BA, et al. Comparing outcomes and costs of medical patients treated at major teaching and non-teaching hospitals: a national matched analysis. Journal of general internal medicine. 2020;35:743-752.
25. Nestel D, Kidd J. Peer assisted learning in patient-centred interviewing: the impact on student tutors. Medical teacher. 2005;27(5):439-444.
26. Stone S, Ellers B, Holmes D, Orgren R, Qualters D, Thompson J. Identifying oneself as a teacher: the perceptions of preceptors. Medical education. 2002;36(2):180-185.
27. Schaefer GO, Emanuel EJ, Wertheimer A. The Obligation to Participate in Biomedical Research. JAMA. 2009;302(1):67-72. doi:10.1001/jama.2009.931
28. Ballantyne A, Schaefer GO. Consent and the ethical duty to participate in health data research. Journal of medical ethics. 2018;44(6):392-396.
29. Bagshaw P, Potter JD, Hornblow A, et al. The common good: reviving our social contract to improve healthcare. 2025. p. 9-13.
30. Te Whatu Ora Health New Zealand, Te Aka Whai Ora Māori Health Authority. Finding a place to learn in health. https://www.tewhatuora.govt.nz/whats-happening/consultations/a-new-system-for-student-placements/
31. Medical Council of New Zealand. Fact Sheet Strengthening our Workforce. 2025. https://www.mcnz.org.nz/assets/Uploads/Fact-sheet-PR.pdf?vid=9
32. General Medical Council UK. The State of Medical Education and practice in the UK Workforce Report. 2023. https://www.gmc-uk.org/-/media/documents/workforce-report-2023-full-report_pdf-103569478.pdf
33. Yeomans ND. Demographics and distribution of australia's medical immigrant workforce. J Migr Health. 2022;5:100109. doi:10.1016/j.jmh.2022.100109
34. Nagarajan KK, Atul B, Varun MS, and Adhikari R. Prevalence of US-trained International Medical Graduates (IMG) physicians awaiting permanent residency: a quantitative analysis. Journal of Community Hospital Internal Medicine Perspectives. 2020/11/01 2020;10(6):537-541. doi:10.1080/20009666.2020.1816274
35. Briana Northey. Outsourcing health care risks the next generation of specialists. Accessed April 11 2025, https://www.thepost.co.nz/nz-news/360631419/outsourcing-health-care-risks-next-generation-specialists
36. Ministry of Health. New Zealand Health Survey 2022/23. 2024. https://www.health.govt.nz/publication/annual-update-key-results-2022-23-new-zealand-health-survey
37. Walker S, Reid P, Anderson L, et al. Informed consent for medical student involvement in patient care: an updated consensus statement. The New Zealand Medical Journal (Online). 2023;136(1579):86-95.
38. Gray B. (Bio)Ethics in a Pluralistic Society. Challenges. 2019;10(1):12.
39. New Zealand Law Commission. Review of Adult Decision-Making Capacity Law. https://www.lawcom.govt.nz/assets/Publications/IssuesPapers/NZLC-IP49.pdf
40. Te Ara Tika: Guidelines for Māori Research Ethics: a Framework for Researchers and Ethics Committee Members (Health Research Council of New Zealand) (2010).
41. Manson NC, O'Neill Onora. Rethinking informed consent in bioethics. Cambridge University Press; 2007.
42. Davey LMMD. The Oath of Hippocrates: An Historical Review. Neurosurgery. 2001;49(3):554-566.
43. New Zealand Medical Association. Code of Ethics for the New Zealand Medical Profession. New Zealand Medical Association. 2021. https://assets-global.website-files.com/5e332a62c703f6340a2faf44/5fbd645fe15640fa981fa469_Code%20of%20Ethics%20Redesign%202020%20version%204.pdf
44. Brown A, Kassam A, Paget M, Blades K, Mercia M, Kachra R. Exploring the global impact of the COVID-19 pandemic on medical education: an international cross-sectional study of medical learners. Can Med Educ J. 06/30 2021;12(3):28-43. doi:10.36834/cmej.71149
45. Tolsgaard MG, Cleland J, Wilkinson T, Ellaway RH. How we make choices and sacrifices in medical education during the COVID-19 pandemic. Medical teacher. 2020;42(7):741-743.
46. Murton SA, Pullon SRH. Assessment of training capacity in New Zealand general practices: a stocktake in the lower North Island and South Island. The New Zealand Medical Journal (Online). 2017 Sep 22-2022-11-08 2017;130(1462):11-26.
47. New Zealand Medical Students Association. NZMSA Statement on Graduating Doctors Without Jobs. 2025. https://www.nzmsa.org.nz/_files/ugd/137253_9ae9b1640239468b9fd05c11861324b1.pdf
48. National Ethics Advisory Committee. National Ethical Standards for Health and Disability Research and Quality Improvement. https://neac.health.govt.nz