Once a month, or the secret to raising the status of medical ethics
BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2883 (Published 02 June 2015) Cite this as: BMJ 2015;350:h2883
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Simon Kenwright (this series of rapid responses 6 June) has commented 'From a clinician’s viewpoint, one might equally think that most decisions about CPR are pretty straightforward but that does not mean by-passing discussion and looking at the problem from the different perspectives of those involved'.
Decisions about CPR are not at all 'straightforward': there is a remarkable amount of confusion centred on the difference between 'CPR could never be successful on clinical grounds' and 'potentially successful CPR is being withheld', and in particular centred on the decision-making and authority for the latter of those two situations. It is even possible to construct a scenario, when it is clearly ethically correct to attempt CPR only if it were absolutely certain to be unsuccessful (ref 1). And many clinicians seem to have a problem with the decision-making authority of attorneys appointed by patients: those attorneys are appointed to make the decisions, not to merely be involved in discussions about the decisions.
But whichever way you go, law or ethics, there is a 'sticky wicket' lurking somewhere. Ethics does not lead to clarity: consider the assisted dying debate, and for example the fact that the pro camp tend to call it assisted suicide whereas the anti camp tend to call it euthanasia. If we instead use law, and return to CPR, the law states that mentally-capable patients can refuse CPR, but it isn't at all clear how mental incapacity can be established if a patient seems lucid. There was a report in The Independent (newspaper), June 24th 2013 (carried on pages 1, 6 and 7), when Sir Mark Hedley, a recently-retired judge, explained that ‘I decided at 10pm that a suicidal man with mental health problems could be allowed to die of an overdose rather than order doctors to pump his stomach ... I decided he had capacity [to refuse treatment], so he died that night. That‘s exactly what he wanted to do... That one never found its way into any report of any sort’. Sir Mark was the out-of-hours Court of Protection judge.
So the law, seems to be clear about patient self-determination, and allows patients to be, to use my phrase, 'self destructive': not an easy thing for clinicians to 'live with'. Medical ethics, seems to be much more concerned with 'good outcomes' but that results in significantly greater ambiguity than is present in a well-drafted law.
Ref 1 Scroll down to my entry at 18/05/14 - 12:14 in the series at:
http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/?obj...
Competing interests: No competing interests
Many of us – perhaps a majority – have spent much time discussing ethical issues on ward rounds and elsewhere. My impression has been very much that doctors are both aware and think about practical ethical issues to an increasing extent. Just what good evidence does Daniel Sokol have that this is not so? This may not be as apparent amongst medical students as is it the clinical relevance that focuses attention and this is why his general thrust is so important. The same arguments can apply in learning anatomy as a student compared with its stark relevance at times later on.
“Most cases are ethically so obvious that no discussion is needed.” From a clinician’s viewpoint , one might equally think that most decisions about CPR are pretty straightforward but that does not mean by-passing discussion and looking at the problem from the different perspectives of those involved. I also recall a conversation with a distinguished philosopher clinician pointing out that he had never made an ethical or moral decision with which he was completely happy. Clinical decisions often have an immediate relevance and implication absent from contemplating the related ethical issues. In his example given , about withholding treatment from the patient deteriorating on ITU , I hope the point would be made that discussion – clinical and ethical – about a DNR decision should have taken place much sooner rather than just waiting until death seems imminent. Practical medical ethics for clinicians must include a pro-active approach not just a reactive (or even retrospective) one.
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Having completed an Intercalated degree in healthcare ethics and law during my undergraduate medical training, I read with great interest Sokol’s article [1]. Following Intercalation I have had a much greater awareness of the importance of recognising and addressing ethical issues in clinical practice. However, it is only since starting Foundation Training that I fully appreciate the complexity and relevance of ethics to daily working life. From the elderly patient acutely unwell in the community with a strong aversion to hospital admission, to the young patient with learning disabilities who requires an urgent capacity assessment on the Emergency Assessment Unit. End of life care in complex situations such as malignancy in young patients, or a patient with such a severe infection that antibiotics were administered for symptom relief during the terminal phase. As well as patient care, our professionalism and relationships with colleagues also have ethical dimensions.
In a busy clinical role how important it is to take a step back and view our patients and the situations we encounter in context. In doing this, arguably there are ethical issues to be found in all the patient pathways we are part of. As Sokol highlights, no area of medicine or surgery is immune from ethics [1]. The involvement in, and impact of, ethics on clinical practice and on medical research is profound.
I wholeheartedly agree that ethics should be viewed as ‘interesting and useful’ and that there is a need to convey the message of its ‘relevance and importance’ to clinical practice [1]. In keeping with Sokol’s simple solution I have made a conscious effort during Foundation Training to incorporate ethical issues into teaching sessions, and to carry out case-based discussions and reflections for my ePortfolio on cases involving pertinent ethical issues.
The beauty of ethics is that it fosters debate, encourages us to consider that ‘what is’ does not necessarily translate into ‘what ought to be’. The Hippocratic Oath reminds us that there is art to medicine as well as science, and that we treat not disease nor investigations, but a sick person whose illness must be viewed in context. As I approach the end of Foundation Training, the cases that have involved key ethical issues are undoubtedly some of the most memorable. I hope that Sokol’s simple solution is adopted by many, and that his article sows the seed for portraying the key role that ethics has to play in medicine and surgery.
References:
[1] Sokol DK. Once a month, or the secret to raising the status of medical ethics. BMJ 2015; doi 10.1136/bmj.h2883.
Competing interests: No competing interests
As a layman who discusses end-of-life, I find the difference between law and medical ethics problematic.
I admit that law and ethics/morality are linked: 'ethics' are considered while a Bill is being considered by parliament, and 'ethics' are sometimes considered by judges when unclear aspects of an Act are involved in a ruling (and even more so, if the ruling is about 'common law' as opposed to statute). But if an Act comes into force, 'the necessary ethics should logically be contained within it'.
Medical ethics, 'cross legal boundaries' and are presumably best understood by medics: but the law, should be understandable by means of reading an Act, if there is an Act covering the issues in question. It doesn't need a medic, to read an Act - and if medics 'read into an Act their own pre-existing understanding of medical ethics', instead of deducing from the wording of the Act the 'ethical position it contains', there is an inevitable clash between medical opinion and lay opinion. There is a similar issue, if judges interpret an Act by relying on their superior grasp of legacy case law, instead of concentrating on the wording of the Act itself.
I come across this issue, repeatedly: doctors will present an argument in terms of medical ethics, and I will point out 'there is a law covering this - and if the law differs from your medical ethics, and the law is clear enough, the law takes precedence'.
Basically, I'm saying that what doctors need is a better understanding of the law, as opposed to undue concentration on medical ethics.
And 'ask a lawyer' doesn't work - lawyers argue the case for whichever side of an argument, is paying them !
Competing interests: No competing interests
Re: Once a month, or the secret to raising the status of medical ethics
As medical students, we agree with Daniel Sokal [1] that ethics is a vitally important subject for doctors. Decisions involving medical ethics are pervasive throughout medicine for clinicians at all levels, from antibiotic prescribing to complex end of life decisions. We also agree that (unfortunately) ethics has a poor reputation, and is generally a low priority for medical students.
We are delighted that Sokal has offered a simple solution to this problem: ward-based discussions led by senior clinicians that highlight an ethical dimension to a patient case. This will give students the opportunity to apply basic ethical principles, and to better understand how ethics is fundamental to every day clinical practice. Our own experience of such discussions has been very positive, and we urge our busy clinical mentors to try and incorporate these opportunities into their teaching where possible.
In addition to clinicians leading the discussion, we believe that students should also take an active role in developing their ethical education. At Warwick Medical School, we have gone one step further than the article recommends; students have developed a monthly clinical ethics committee to practise forming decisions around real patient cases. Not only has this proven to be an effective forum to develop our ethical reasoning, but it has also generated a great deal of interest in the subject among fellow students. This final point is perhaps the most important one and, as Osler himself said, "the very first step towards success in any occupation is to become interested in it." [2]
[1] Sokol DK. Once a month, or the secret to raising the status of medical ethics. BMJ 2015; doi 10.1136/bmj.h2883.
[2] Osler W. An Address On The Master-Word In Medicine: Delivered to Medical Students on the Occasion of the Opening of the New Laboratories of the Medical Faculty of the University of Toronto, October 1st, 1903. Br Med J. 1903;2(2236):1196-200.
Competing interests: No competing interests