It is said that events often occur without being planned. My involvement with the Committee for Ethical Issues in Medicine (CEIM) is a good illustration of this point. My journey into the realms of medical ethics began when I was successfully elected to the Royal College of Physicians (RCP) New Consultant Committee as the North Trent representative in 2007. It was an exciting stage of my career. I was keen to make changes and improvements to existing clinical services as well as creating a niche that defined my clinical interest and individuality. This drive was given a further boost when I was competitively selected to participate in the RCP Leading Clinical Services for New Consultants and Managers Programme designed to enhance leadership and management skills. Yet, there is more to being a consultant than just pushing forward the frontiers of service delivery. The saying ‘the buck stops here’ could not be more relevant. Negotiating the intricacies of the political and organisational structure of the NHS to enhance service development is a different proposition to dealing with the frontline of patient care. I arrived at this conclusion based on the experience from my role as a full-time consultant physician in one of the largest and busiest acute medical units in the UK. Possessed with the ultimate responsibility of making important and difficult clinical decisions, one often encountered grey areas of clinical practice intertwined between medical facts, emotions and moral values, an ingredient which makes the clinician's role challenging and interesting. The feeling of uncertainty frequently pervaded followed by periods of inner reflection and I was keen to gain the knowledge of the guiding principles that may help to resolve these issues.
The New Consultant Committee has representations in various RCP committees with the primary objective to encourage the involvement of young consultants in College activities. At the first meeting, a volunteer was sought to represent new consultants in the CEIM. As I was already a member of the research ethics committee for my local trust, I saw this as an excellent opportunity to gain insight into the ethical issues involved in the practice of clinical medicine within my own sphere and, in the wider context, ethical issues of national interest and importance.
Principles of ethics in clinical medicine
Clinical ethics is a practical discipline that provides a structured approach for identifying, analysing and resolving ethical issues in clinical medicine. Medicine, even at its most scientific and technical, is an encounter between human beings and the physician's work of diagnosing disease, offering advice and providing treatment is embedded in moral context. The willingness of physician and patient to endorse moral values usually ensures a sound ethical relationship between patient and physician.
Occasionally, physician and patient may disagree about values or may face choices that challenge them leading to ethical issues. Clinical ethics concerns both the ethical features that should support every clinical encounter and the ethical problems that occasionally occur in those encounters. It relies on the conviction that even when perplexity is great and emotions run high, all parties involved can work constructively to identify, analyse and resolve many of the ethical problems that occur in clinical medicine. In essence, quality in healthcare is not only a question of technical and scientific proficiency, but also of the professional's attitude and ability to identify and handle value conflicts.
The Beauchamp and Childress' Four Principles is one of the most widely used frameworks to provide general guidance in the broad consideration of medical ethics.1 This is based on a group of moral principles:
autonomy (enabling individuals to make reasoned informed choices)
beneficence (balancing the benefits of treatment against the risks and costs)
nonmaleficence (avoid causation of harm)
justice (distributing benefits, risks and costs fairly).
At first glance, these principles sound rather theoretical. However, clinical medicine is, in essence, practical. It consists of individual cases, each one with a variety of medical facts, differing circumstances, controversies and values. In each case, decisions should be taken with a desirable resolution of ethical matters using, with varying emphasis, the guiding principles above.
The Committee for Ethical Issues in Medicine
The Committee for Ethical Issues in Medicine analyses, negotiates and responds to medical issues of an ethical nature. This responsibility is reflected in the CEIM's terms of reference:
to identify and advise the RCP on matters of ethics of particular concern to physicians and the public they serve
to respond to requests from individuals and public bodies for guidance on general ethical issues in medicine.
Since every clinical encounter, scenario and policy will involve some element of ethical dimension and require judgement of such nature, it is not surprising that the breadth of issues discussed by the CEIM is wide ranging. This remit encompasses a spectrum of actions from giving opinions and critique on official documents from the General Medical Council (GMC) to providing responses to circumstances pertaining to specific clinical scenarios. In recent times, issues discussed included co-payments, personal faith, organ donation, pandemic flu, the end-of-life care pathway and health needs of asylum seekers.
Given the diverse controversies and associated complexities encountered, optimal functioning of this committee requires certain elements. The main strength of CEIM is the strong leadership from the current chair, John Saunders, who has a keen interest and in-depth knowledge in medical ethics. This is further augmented by contributions from varied and distinguished medically lay and professional representations from patient and carer networks, law, media, academic ethics, theology, the Department of Health, the Medical Research Council and the British Medical Association. CEIM is able to provide objective and balanced views on complex ethical issues in healthcare settings and equally, if not more importantly, provide an external independent perspective unbiased by medical influence and culture.
Role of ethics in clinical practice and its challenges
In recent times, biomedical ethics has become a popular topic for the media coverage. This is largely due to increased complexity of caring for patients and the difficult decisions that new technologies demand. However, doctors worry more often about less visible but more common real life issues such as informed consent, end-oflife decision making, research ethics, reproductive medicine and healthcare rationing. A good example is the issue of assisted suicide for those with terminal illness. In recent times, the media has reported on UK nationals who ended their lives in the Swiss clinic, Dignitas, which highlighted the assisted suicide debate in the House of Lords with the eventual rejection of the Assisted Dying for the Terminally Ill Bill.
The type and quality of care that a patient receives can be influenced by the knowledge that practising clinicians have about medical ethics and law. In order to provide medical care in a more humane and ethical way, clinicians need to be better educated about specific aspects of ethical medical practice and to think more critically. Routine bioethics education for medical students and junior doctors and continuing medical education for practising clinicians are the best ways to achieve this goal. In the UK, medical ethics and law have been included in the undergraduate medical education since 1993 when the GMC published Tomorrow's doctors which stated that ‘graduates must know about and understand the main ethical and legal issues they will come across’.2 From personal experience, however, reinforcing and maintaining ethical knowledge has not been a routine component of the working life of clinicians.
What skills and expertise in clinicians (in addition to clinical knowledge) are necessary for them to practise good medicine? Familiarity with basic aspects of medical law is useful as it has profound ethical implications for patient care and well being. In my experience, clinicians' knowledge in this area is often lacking although this does not suggest that all are ignorant of the relevant law. Understanding healthcare policy, system and its legislative process is also an important part of delivering good clinical care in the modern world. With medicine becoming increasingly intertwined with the pharmaceutical industry for funding of various clinical and research initiatives, the ability to think critically about conflict of interest is crucial to provide sensitivity to the public perceptions that may emerge from such financial relationships.
My time in the CEIM
I will step down from the New Consultant Committee in 2010. It has been a privilege to be part of the high level intellectual discussions and debate between individuals from different backgrounds who are clearly extremely knowledgeable in their respective fields. In many instances, the solutions to ethical dilemmas are not straightforward. To arrive at thoughtful and sensitive responses to controversial issues often requires considerable consultation, reflection and discussion. It is the collective, rather than individual, effort guided by the able leadership from the chair that makes the most effective impact and influence in the work of the CEIM. Although my term is drawing to a close, my journey in the realm of medical ethics will undoubtedly continue with enlightened vigour as I progress into the next stage of my consultant career.
- © 2010 Royal College of Physicians
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