Teaching medical ethics: useful or useless?
BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6415 (Published 08 December 2016) Cite this as: BMJ 2016;355:i6415
Probably for the first time in history, UK trained doctors at all levels, and in all specialties, now receive formal ethics training at medical school. This raises an important but uncomfortable question for those who teach the subject: has it made any difference? If not, should we replace it with another course on pharmacology, clinical skills, or the interpretation of scans?
An “ethics” sceptic will point to the vast increase in numbers of complaints against doctors to the UK General Medical Council in the past 10 years and the growth of clinical negligence claims in that same period. More ethics, more complaints and law suits.
This sceptic may say that any improvement in “ethics” arises not from any teaching in medical ethics but from changes in the law, such as the recent case of Montgomery for consent,1 Tracey for “Do not attempt cardiopulmonary resuscitation,2 and the statutory duty of candour for truth telling and honesty.3 In fact, the sceptic may add, the existence of these cases and the very need for a statutory duty of candour indicate that ethics training has made little difference to actual practice.
Using anecdotal evidence, the sceptic will point to the low status of the subject among most medical students, who deem it “irrelevant,” “impractical,” “unclear.”
No obvious link
In response, the ethics supporter would seek to dissociate the increase in complaints and litigation from the general levels of ethical behaviour, pointing to changing expectations among patients and relatives, the role of the media (including social media) in encouraging complaints, rapacious lawyers, and a greater awareness of complaint processes and the role of the GMC. There is no obvious link between the rising number of complaints and falling standards of clinical or ethical competence, the supporter would say.
Nor does the supposed unpopularity of ethics among medical students indicate a lack of value. Many doctors say that it is only once they start working that they appreciate the subject’s relevance. The ethically trained doctor possesses the tools to escape from the occupational hazard that is clinical myopia.
The answer, of course, is that we do not know whether teaching ethics to medical students makes any long term difference to their clinical practice. The effects of the teaching may impinge positively on a student’s outlook, attitude, or character but may not be tangible or measurable. If a doctor who would otherwise have seen a dying patient for a few seconds before moving on decides out of kindness and compassion to stay a little longer with the patient, to comfort and reassure, is this attributable to ethics teaching at medical school, the doctor’s upbringing, a natural disposition, or last night’s episode of Casualty? It is too complex a situation to draw out cause and effect.
Act of hope
The bioethicist Judith Andre wrote that teaching ethics is “fundamentally an act of hope.”4 We usually have no idea whether such teaching matters. No doubt skewed by the incessant stream of clinical negligence contained in my cases, I have become less certain over time of the effect of ethics teaching at medical school on the future behaviour of doctors, especially if it is delivered in the early years.
The bulk of this teaching should take place after qualification, in the clinical setting. Before then, most students care about one thing only: passing exams.
Yet, the very presence of ethics in the curriculum is important. It sends a message that ethics is an intrinsic and valued part of medical practice. The teaching of ethics, even if its worth can’t be proved, is consistent with common sense and may reassure members of the public that the medical profession, for all the changes since the Oath of Hippocrates, has not lost its moral compass.
Footnotes
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.