Medical ethicsBMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7214.2 (Published 02 October 1999) Cite this as: BMJ 1999;319:S2-7214
Not so much a specialty as a way of thought. Trisha Macnair reports on opportunities for career development through training in medical ethics
One of the few things that everyone in the field of medical ethics agrees on is that it's a boom industry. This is good news for those interested in developing their career in that direction, although if it is true it's hardly an endorsement of the history of our profession. The rising interest in medical ethics reflects changes in the doctor-patient relationship and the increasing number of moral challenges thrown our way by new technology and the dilemma on how to spend limited resources.
Medical ethics has been defined as “the analytical activity in which the concepts, assumptions, beliefs, attitudes, emotions, reasons and arguments underlying medico-moral decision making are examined critically.”1 That's a hot potato for debate, and anyone hoping that ethics will provide simple straightforward answers will be disappointed.Ethics is central to every branch of medicine, although there are still plenty of cynics out there. If you are a control freak who doesn”t need anyone else's views cluttering up your certainty in your own practice, or a statistics fan who needs a meta-analysis of randomised controlled trials to convince you of the right way to practise, then medical ethics may seem irrelevant.Fortunately, most doctors are aware of the need to back their clinical work with careful thought about how they reach important decisions. Many relish the challenge that medical ethics offer, and postgraduate study and qualifications in medical ethics can lead to a variety of career opportunities, especially in the shape of part time work among a wider portfolio. But others feel hopelessly bogged down by
the complexities of moral arguments and uncertain how to begin to address complicated ethical issues. For them, further study of ethics can greatly enrich clinical practice.The importance of medical ethics and, in particular, the need for more teaching at both undergraduate and postgraduate level have been recognised by the General Medical Council. In Tomorrow's Doctors the GMC stated that medical ethics and law should constitute one of the core components of the medical curriculum.2 Before this, scant attention was given to ethics in the curriculum, and philosophers, theologians, and healthcare workers other than doctors were more likely than doctors to help shape ethical practice. Since the GMC's recommendation, teachers of medical ethics have produced a consensus statement setting out the minimum content of ethics teaching for medical students.3 Despite this comprehensive proposal, some medical schools seem to have been slow to take the recommendations seriously, but change is under way. In some schools, such as Manchester and Bristol, medical students even have the option of spending an intercalated year studying ethics.Not only doctors have become aware of the need for a better understanding of ethical debate. Ethics and healthcare law are becoming matters of general interest, and there are still relatively few doctors willing or able to present the medical profession's view to the media.All these changes have meant that career possibilities are opening up, but if you're dreaming of a job stalking the wards supporting patients in a battle against arrogant consultants then you've been watching too many television dramas. Most career openings in ethics are part time and form part of a career portfolio.
Clinical ethicists (often, but not always, doctors) do exist in many hospitals in the United States, but it will be a long time, if ever, before we see the equivalent in Britain. The US ethicists lurk around the hospital armed with a bleeper waiting to be called whenever a moral dilemma crops up. Then they may be given as little as 15 minutes to provide the definitive ethical answer on problems such as whether to remove the organs from a brain dead patient or if a 12 year old child has the right to refuse lifesaving surgery. But their role has been criticised as being more a part of the risk management business prevalent in US medicine than a genuine desire to do the right thing.
In Britain full time ethicists are almost exclusively based in academia, buried in teaching, research, and expert reports, although they may often be asked to help with difficult clinical cases or provide comment on ethical issues in the media. Some British hospitals do employ ethicists (St Christopher's Hospice is currently setting up such a post), but most hospitals already have or are setting up ethics committees to hammer out difficult issues rather than relying on the advice of one individual. Although not mandatory, ethics committees are generally accepted as a mark of good practice.
As medical schools begin to implement the GMC recommendations for including ethics in the medical curriculum, the demand for people able to teach the subject will increase. Much of the teaching is best done in small groups, so part time opportunities are opening up for doctors with an ethics training to help take tutorials and seminars for medical undergraduate and for postgraduate professional training.
Teaching jobs in ethics are occasionally advertised in the Times Higher Education Supplement and similar places. They may also be advertised locally in postgraduate centres associated with medical schools.
The public is deeply concerned about many ethical issues related to health, and the media are well aware of this growing interest. People who can speak in an intelligent and informed way on the topic (ideally in 30 second soundbites) are hotly pursued these days. One well known academic ethicist I spoke to gave me a run down of his diary, which featured more media interviews each week than most celebrities or cabinet members could dream of. It is possible to make an important contribution to the arguments and even (claim some ethicists) to help to shape government policy.
Medical litigation is a thriving business, and there is a growing demand from law firms for those doctors trained in both ethics and law. Nurses and midwives are often employed in the process of discovery because they know what to look for and make good notes.
Personal professional development
Few practising doctors will make a real mark on ethical issues through their career, but a deeper understanding of ethical debate can make an immense contribution to personal professional development, and to greater job satisfaction. An ability to think through ethical issues can improve decision making and develop confidence in rational argument, which are transferable skills. A further benefit of studying ethics is the opportunity to debate the issues with people from different professions as doctors are in minority on many ethics courses.
There are now many different courses on ethics on offer around the country. Study of medical ethics often goes hand in hand with medical law, and many courses cover both areas.For those interested in academic study, a Masters degree, PhD, or even MD can be taken at a number of universities and colleges, including the Centre for Law and Medical Ethics at Kings College London, the Institute of Medicine Law and Bioethics at Manchester University, Preston University, the University of Birmingham, and the Centre for Philosophy and Health Care at the University of Wales Swansea. Many of these schools also offer diploma courses.Study may be full time, part time (usually over two years), or even by occasional attendance or distance learning. The MA course at Swansea, for example, is taught as a combination of distance learning and five residential teaching blocks of three nights. The Ethics Unit at Imperial College's School of Medicine runs an intensive five day course each year.Some centres run specialist courses for those working in particular fields. For example, both Kings College London and the Centre for Ethics in Medicine at Bristol University run training for people involved in research ethics committees or running clinical trials, while others run courses focusing on the ethics of psychiatric care and on palliative care. In addition, many centres run public lecture programmes.
The Institute of Medical Ethics, based in Edinburgh, comprises a network of people involved in ethics. It is involved in the undergraduate curriculum and publishes the Journal of Medical Ethics in collaboration with the BMJ Publishing Group.
The Wellcome Trust's Medicine in Society programme supports research into the ethical consequences of developments in medicine and biology and provides training and other fellowships to attract academics into the area.Ethics journals:
Journal of Medical Ethics (BMJ Publishing Group)
Bulletin of Medical Ethics (ourworld.compuserve.com/homepages/Bulletin_of_Medical_Ethics/)
Core topics in medical ethics
Informed consent and refusal of treatment
The clinical relationship, truthfulness, trust, and good communication
Confidentiality and good clinical practice
The new genetics
Health care and those with mental disorders and disabilities
Life, death, dying, and killing
Vulnerabilities created by the duties of doctors and medical students