Searching for medical RumpolesBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c42 (Published 06 January 2010) Cite this as: BMJ 2010;340:c42
- Daniel K Sokol, honorary senior lecturer in medical ethics, Imperial College London
This time last year around 100 teachers of medical ethics assembled to thrash out a new consensus statement on the ethicolegal training of future doctors. The existing statement, published in 1998, was showing signs of age.1 Consultation was thorough, involving the General Medical Council, the British Medical Association, and many other stakeholders. This month the Journal of Medical Ethics published the new statement.2 It is ambitious and admirable. (As a signatory I am, admittedly, biased.) Students, at the end of the revised course, should be familiar with a number of key topics, from professionalism to medical research; be able to “consider, apply and reflect critically on the ethical and legal bases for clinical decisions”; and “identify values of different stakeholders,” including their own. In an accompanying editorial Søren Holm and John Harris note that any medical student who has achieved all the learning outcomes will have “a solid basis in ethics and law.”3
Solid indeed, for I doubt that many professional ethicists would be able to tick all the boxes. Only now, after studying law formally, do I realise how little I understood. Only after spending time in a hospital did I realise that much of what is essential in clinical ethics could not be learnt in books. Still, it is better to aim high than to aim modestly, even at risk of falling short, and the revised curriculum is an upgrade of its prior incarnation.
Arriving at a consensus statement is a hard grind, but tougher still is getting it implemented in the medical school curriculum. Implementation will require work and perhaps, in some cases, a radical overhaul of current arrangements. The authors of the statement emphasise the need in a medical school’s staff for at least “one full-time senior academic in ethics and law with relevant professional and academic expertise.” Several medical schools do not currently satisfy this condition.4 A related problem is finding good teachers. The most fascinating of subjects will seem arid in the wrong hands. A splendid curriculum is wasted if it is improperly delivered—whether too theoretically, too practically, or too boringly.
I now come to that most uncomfortable question. Does teaching medical ethics and law make a jot of difference? If so, is it a positive one? A key challenge in assessing the value of teaching ethics and law lies in the difficulty of knowing how to measure its impact on clinical practice. It would be unethical to teach the subject to one batch of students but not to another and then compare the two groups several years later, perhaps in terms of complaints filed against them. This would also be of dubious value, for the most saintly of doctors can be subject to complaints. The bioethicist Judith André was surely right when she said that teaching ethics to medical students was an act of hope.5 Teachers simply do not know whether their efforts will make a positive difference to students. Without conclusive evidence the only way to maintain our enthusiasm, as teachers, is to hope that it does. In any event, even if we were tempted to stop teaching the subject, we can be pretty sure that patients and members of the public would these days insist on it.
Are doctors today more ethical than those of 50 years ago, who had no formal training in ethics? How can this question be answered? What test would we apply? Doctors nowadays seem more frightened of medical malpractice claims. Any benefits from this heightened sense of accountability may be offset by a change of attitude at odds with the Hippocratic concern for the patient. To some doctors the patient as person in need is morphing into the patient as perilous object.
Ask medical school candidates what they have been reading and the answer will usually be some scientific magazine. Where is the medical equivalent of Rumpole of the Bailey, that famous creation of the late John Mortimer? Rumpole is a wise, unassuming barrister who strives to uphold the tenets of justice. If a fiction writer were to compose a medical version, he or she might show Dr Rumpole motivated not by career progression, money, or esteem but by the welfare of his patients and their relatives. With understated wit, he would illuminate the flaws in the medical establishment, challenge the status quo, and seek without effusive sentimentalism the golden thread running through the heart of medicine: an unwavering commitment to sick people. And for that he would be chided as a trouble maker by the great and the good of the profession.
Would Dr Rumpole have studied the revised core curriculum in medical ethics and law? Probably not, yet his critics would be fewer and less self assured had they studied it. It would be foolish to expect miracles from the teaching of ethics and law: there will always be indecency and poor judgment, whatever the teaching. But to dismiss the activity as pointless because its impact cannot be shown conclusively is to discard a large swathe of worthwhile human activity. Throughout the revised curriculum, amid the dozens of specific learning objectives, shines the golden thread that binds all healthcare professionals. For that reason alone the new consensus statement deserves to be widely implemented.
Cite this as: BMJ 2010;340:c42
Many thanks to Ronald P Sokol and Raanan Gillon for helpful comments on earlier drafts.
Competing interest: DKS is a signatory of the revised consensus statement in medical ethics and law.