Students whose behaviour causes concern: Ethical perspective

doi:10.1136/bmj.a2882

Published 29 December 2008, doi:10.1136/bmj.a2882
Cite this as: BMJ 2008;337:a2882

Analysis

Ethical Debate

Students whose behaviour causes concern: Ethical perspective

Deborah Bowman, senior lecturer in medical ethics and law

¹ Centre for Medical and Healthcare Education, St George’s, University of London, London SW17 0RE

dbowman{at}sgul.ac.uk

What should you do when you see a fellow student behaving inappropriately?After a group of students wrote to the BMJ about their experienceduring an elective (doi:10.1136/bmj.a2874), we sought the opinionsof an ethicist, a dean (doi:10.1136/bmj.a2884), a GMC representative(doi:10.1136/bmj.a2876), and a lecturer from an African university(doi:10.1136/bmj.a2875)

This account captures well the contrast between defining standardsof behaviour and navigating effective implementation of thosestandards. Four issues arise. Firstly, even when standards aredefined, application of those standards is a moral enterprisethat can be confusing and frustrating. Secondly, cultural relativismmay be seductive when working overseas. Thirdly, students haveto discharge significant responsibilities in a system wherepower imbalance and complex role delineation prevail. Finally,the question of who owns a problem is a bar to effective resolution.

Were the authors correct to identify this student’s behaviouras unacceptable? Yes. Although matters of ethical behaviourare redolent with uncertainty, the student was acting improperly.The authors cite guidance from the General Medical Council whichdescribes behaviour expected from medical students.¹ They mightalso have noted that, under domestic law, the student committedassault(s). But what of the location—should we acknowledgethat norms differ in societies? Ethicists do indeed argue aboutcultural relativism, but here it is a red herring. To claimthat ethical practice in Africa differs is to overlook fundamentalmoral precepts. The behaviour showed apparent disregard forhuman dignity, trust, and vulnerability. The student prioritisedhis interests over those of the patients. He was not learningwith, or from, patients but on them and by misrepresentation.The authors suggest that patients may defer to a white person,potentially rendering the therapeutic relationship even moreunbalanced. Default trust and socially determined deferencedemand that the ethical student responds with humility and honesty.Taking advantage of the vulnerable and dependent is wrong, andremains so even if this student were technically brilliant atchest drains, lumbar punctures, and hernia operations.

Moral challenges

The authors’ predicament elucidates the unique moral challengesfor medical students. Medicine has always differed from otherdegrees. Clinical experience, with variable supervision, isa privilege and with privilege comes responsibility. Recently,the focus on student conduct has been considerable. Janet Smithidentified the undergraduate years as a formative period whereprofessional norms are learnt, role models (positive and negative)observed, and choices made.² The GMC has defined how studentsshould behave and the implications for fitness to practise.Undoubtedly, the authors were correct to conclude that theyhad to prioritise the interests of patients. Yet, the accountalso reflects the challenges for students who are aware of theirresponsibility to "do something" but ultimately can depend onlyon their seniors.

The authors seem to have done everything right. They did notjump to conclusions but identified specific behaviours. Theytried to discuss their concerns with the individual himself.They sought advice and involved seniors. It seems that the authorswere let down by the systemic response to their demonstrationof integrity. Once concerns had been expressed the authors wereentitled to rely on a thorough and accountable investigation.Although the supervisor did later report the medical studentto his medical school, the authors did not know that until muchlater. Opportunities were lost. This situation offered an opportunityfor senior staff and medical schools to model a thorough, fair,and accountable response to questionable behaviour. I hope thatthe student who was apparently breaching professional guidanceand the law was given the opportunity to learn, change, andto develop into a doctor who will thrive rather than becomeanother "problem doctor" statistic a few years hence.

Most medical schools have included ethics in their core curriculumfor over a decade,³ ⁴ but this rarely engages with student experience.The apparently simple issues of introductions, conflicts thatarise from an eagerness to learn and impress while having regardfor patients, and the difficulties of responsibility but limitedpower in a hierarchical environment are matters that challengestudents daily yet are at best implicit, and at worst absent,from many curriculums. This account shows how medical studentsgrapple with moral choices and dilemmas throughout their training.Students must be able to rely on staff to support them.

Cite this as: BMJ 2009;338:a2882

Competing interests: None declared.

References

General Medical Council. Medical students: professional behaviour and fitness to practise. London: GMC, 2008.
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