Medical ethics and the undergraduate curriculum
In their day-to-day practice, medical practitioners are called upon to make clinical and value judgements about which among a range of available options is the best for the particular patient. Value judgements might include those about which course of action would be in the best interests of a patient lacking capacity; about the quality of life of patients in intensive care; about whether a foreseeable harm to a third party is sufficiently serious to justify a breach of patient confidentiality; or about whether and to what extent it is acceptable, or even required, for a doctor to encourage a patient to change their mind about a course of action which the doctor considers to be mistaken. Good practice requires that decisions about the choice of particular courses of treatment be justified on the basis of good evidence; it also requires that doctors are able to provide good reasons for the value judgements that inform their clinical decisions.
The Royal College of Physicians (RCP) has been at the forefront in highlighting the important ethical dimensions of day-to-day medical practice and has seen the development of high ethical standards in clinical practice and medical research as central to its mission. Research on healthy volunteers and Research involving patients were among the first guidelines on the ethics of medical research to be published in the UK.1,2 These publications have been highly influential and were recently updated by popular demand.3
In 2005, the RCP was the first national body to publish a report and guidelines on the important role of ethics advice and support to health professionals in their day-to-day clinical practice.4 This report argued that ‘wherever healthcare is provided, we believe, on the basis of current trends and our findings, that there will be a need for formal ethics support which is both timely and informed’. It concluded that there is an important role for clinical ethics committees and other forms of ethics support and advice in guiding individual health professionals and in maintaining high ethical standards in practice more broadly. Partly as a consequence of the influence of this report there are now more than 90 clinical ethics committees in the UK offering advice and support to practising health professionals.
These complementary developments in the ethics of research and clinical practice have taken place against the background of the RCP's ongoing commitment to the encouragement of medical professionalism. They highlight the fact that professionalism is not merely a question of practising high quality technical medicine but is also simultaneously about maintaining high ethical standards.
It is clear from its publications that the RCP believes ethics to be an important but difficult part of clinical practice and medical research. This inevitably has implications for how we think about the place of ethics in both undergraduate medical education and in education throughout the professional life of doctors.
We wish to highlight two implications of the RCP's views. First, that ethics education needs to be closely related to practice and second that it should be a component of education throughout the professional life of a doctor. This leaves open, however, several questions about what is the best way of preparing medical students for this lifelong learning. To what degree should ethics education focus on the realities of ethics in current practice? To what extent should it focus on key ethical principles, and how should it provide students with the experience of developing the reasoning skills which will enable them to engage effectively with the (as yet unforeseen) ethical problems which will arise in their future practice?
At the heart of an effective ethics education is the need to provide medical students with opportunities to practice during their training the skills of practical ethical judgement that they are going to need for the future. This suggests that ethics education should be close to practice from the start.
There is much debate about the design of ethics courses for medical students. Some of the questions concern how ethics education should be assessed. There is currently a great deal of interest in multiple choice questions and computer-marked approaches to assessment. But how appropriate are these as a way of assessing the kinds of skills required for ethics? Ethics in practice is about thinking through a problem, making an argument, being able to give good reasons for the chosen way forward and so on. It is in essence about argument and judgement. Is it appropriate to assess these skills using these methods? No philosophy course would be examined in this way. While having a number of practical advantages, such approaches may have a narrowing effect on the curriculum leading it to be focused more on facts and less on the development of the skills and attitudes that doctors are going to need. A second set of questions in ethics education, given the importance of practice, is how much should teaching be around real cases and close to practice and how much should it be focusing on principles, literature, theory and so on? Finally, there is the question of who should be teaching ethics? Should it be taught by experienced clinicians, by people with an academic training in ethics, by people at the cutting edge of bioethics research, or by some combination of all of these?
While there is still much debate on these questions, there are other issues that attract broad agreement. It has been largely agreed, for example, that ethics should be considered as part of practice and of the care and treatment of patients. There is also broad agreement on the topics that should, ideally, be covered in core teaching for example consent, confidentiality, decision-making at the end of life, reproductive medicine, medical research, resource allocation and so on. There are now a number of textbooks addressing these core topics. This core teaching is often supplemented in the medical curriculum by the provision of student-selected modules allowing trainees to study ethics in greater depth. Some agreement has also been reached about methods, for example that ethics is best taught in small groups or seminars which allow students to develop their practical ethics skills and judgement and enable them to develop their own views on core ethical issues.
Ethics education of medical students is well developed and there are many examples of good teaching. Less attention has been paid, however, to the area of continuing professional education in ethics. This suggests, particularly in the context of the rapidly changing face of medicine highlighted by Carol Black (a former president of the RCP) that there is a need for consideration of what should be the features of a programme of continuing ethics education capable of providing health professionals with the skills they need to help them deal appropriately and effectively with the ethical dimensions of their day-to-day practice throughout their professional lives:
The increasing complexity and therapeutic possibilities of medicine, the changing relationships between physicians, patients and other professionals, the advent of consumerism in the ward and the consulting room, debates about values themselves in a profession that draws its membership from a variety of cultural backgrounds: all these factors make ethical judgements harder.
Ethics in practice highlights a further issue: that wherever medicine is practised there is a need for high-quality advice and support.4 A comprehensive ethics strategy requires the development and integration of continuing education, to provide doctors with the appropriate skills, and of appropriate systems of support.
- © 2009 Royal College of Physicians
References
- ↵Royal College of Physicians. Research on health volunteers. London: RCP, 1986.
- ↵Royal College of Physicians. Research involving patients. London: RCP, 1990.
- ↵Royal College of Physicians. Guidelines on the practice of ethics committees in medical research with human participants. London: RCP, 2007.
- ↵Royal College of Physicians. Ethics in practice. London: RCP, 2005.
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