The ethical gift box: suggestions for improving the ethical conduct of doctors

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In a recent issue of BMA News one core trainee who was 28 weeks pregnant recounted how one consultant told her that she would “never achieve consultancy” and how another remarked that there was little point in teaching her as she would forget it all on maternity leave.1

Last month a student came to see me about the possibility of appealing against the result of a failed exam. She told me that some private general practitioners, in exchange for a fee, would compose letters affirming that a student had been depressed when sitting the exam, whatever the truth.

Late last year a former army GP was struck off for not reporting serious injuries inflicted on one of his patients by British forces in Iraq and for lying to investigators about the incident.2 And in February this year the Francis report of the Mid Staffs public inquiry painted a bleak picture of the ethical landscape in healthcare.

There is, in short, much cause for despair for those of us who view the practice of medicine as a noble vocation with integrity at its heart.

All the ill behaved doctors described above breached the guidance of the General Medical Council. I remember one disciplinary hearing where the barrister who was cross examining the doctor opened his questioning with, “Are you familiar with the GMC’s Duties of a Doctor?” and was mightily surprised when the answer came back as “no.” Although knowledge of GMC guidance will not eliminate unethical behaviour, it may well reduce its prevalence. The guidance represents the ethical rule book for doctors. The conclusions of the GMC’s fitness to practise panels, for example, contain statements such as “The panel has borne in mind the duties of a doctor registered with the GMC as set out in Good Medical Practice.” Royal colleges and medical schools may thus wish to place a greater focus on testing candidates’ knowledge of the GMC guidance in their examinations.

The GMC booklets are—with respect to those who drafted the rules—somewhat dull. My hope is that someone will write an engaging, single volume Annotated Ethical Guidance of the GMC, containing explanations, elaborations, and examples that illuminate and entertain.

In an ideal world a copy of this annotated guidance would be offered to every medical student and doctor.

Although useful, such a volume would do little to raise the spirits of the profession, so, to boost morale, the ethical gift box would also contain a volume of essays by William Osler, the Canadian physician and former regius professor of medicine at Oxford. In years past drug companies gave copies of Osler’s Aequanimitas to new medical graduates. The inside front cover of my secondhand copy reads, “Presented by Charles E Frosst & Co, on Graduation 1962.”

Today, sadly, many clinicians have never heard of Osler, except perhaps in the context of Osler’s nodes and infective endocarditis. Yet, more than ever, Osler’s writings are needed. The general mood of the medical profession, at least in the United Kingdom, seems low. Business pressures and targets are affecting the delivery and practice of medicine. Senior clinicians are stifled by administrative demands. Junior doctors, constrained by the advent of the European Union’s Working Time Directive, are perceived by their seniors as lacking in clinical skills and acumen. And the scope of medicine is expanding uncomfortably to encompass aesthetic and other procedures a world away from the medicine of Hippocrates, Sydenham, and Laennec.

Against this chaotic backdrop, Osler’s essays are salutary. “Hard though the conditions may be,” Osler writes, “approached in the right spirit—the spirit that has animated us from the days of Hippocrates—the practice of medicine affords scope for the exercise of the best faculties of the mind and heart.”3

Talk to the members of the Osler Club of London, a historical society of clinicians, lawyers, and others founded in 1928, and each will tell you a different story about how Osler has influenced his or her practice. In an unpublished address Osler said, “The motto of each of you as you undertake the examination and treatment of a case should be ‘put yourself in his place.’” He followed this by listing three simple actions that could make all the difference: “The kindly word, the cheerful greeting, the sympathetic look.”4 Even the busiest doctors cannot say that time is a barrier to these actions.

It is risky to tell medical students to be kind or compassionate. It can sound trite and patronising. Yet, Osler’s formulation has an air of authenticity: “Be careful when you get into practice to cultivate equally well your hearts and your heads.”5 Osler’s own humility counteracts any hint of condescension. Even at the height of his fame he considered himself a student of medicine.

So, in the face of gloomy news about wayward doctors, let us seek enthusiastic authors for the Annotated Ethical Guidance of the GMC, deepen the profession’s knowledge by including a short test of the key guidance in exams, and, instead of mugs, pens, and stress balls, dish out free copies of Osler at conferences.