Teaching medical ethics: useful or useless?

I seem to be in the minority - although the 'polling' is hardly extensive - here.

In this series of rapid responses J K Anand writes 'I agree with Ms Susanne Stevens - Ethics should trump the Law. A price to pay? Yes. So be it.' and Eugene G Breen writes 'I agree with the other writer who says that good ethics is superior to law, because a law can never make something right that is wrong.'.

As it happens, I agree with both of them, so far as it their statements go.

But, I am interested in end-of-life at home, and a family carer can find himself or herself interacting with not the GP, or even a district nurse, but sometimes with 999 paramedics, police officers or potentially coroner's officers after a death. I have written about this in my earlier piece, in which I explained why I insist it has to be law first (ref 1).

I certainly agree, although exactly how 'good and bad are decided' is very tricky, that a law which is 'clearly ethically bad' is a bad law: the answer, is to get the bad law changed into a good law. But my issue, hinges on how does one create 'proportionate behaviour' when different professionals are involved, and while they might have theoretically acceptable 'ethics', each profession has a different objective ?

Consider a terminally-diagnosed patient, who is at home and shares the home with a single relative. The prognosis for this still-fairly-healthy patient is 'a dreadful-looking degeneration before eventual death', so the patient makes it clear to both his GP and to his relative that 'if I have a cardiopulmonary arrest for any reason whatever, I'm forbidding attempted resuscitation: I would view death from an unexpected arrest as a bit of good fortune'. The ethics and the law, seem to agree: neither the GP nor the relative, should attempt CPR if the patient arrests - and ethically, the relative should surely seek to prevent anyone else from attempting CPR. But if this patient suffers an arrest before he becomes 'very ill' then his arrest would occur outside of 'expected death' status - then if 999 paramedics are involved they tend to attempt CPR, and if the police become involved, because there is no certainty that the death will be certified, the police tend to treat the relative 'as a suspect'. Where is the 'ethics' in treating a relative 'as a suspect' simply because a death couldn't be certified at the time, when the morality of the relative, and the law of patient autonomy, agree that the relative's role should be to support the patient's decisions ?

'Whose ethics' are supposed to 'sit above the law': yours, mine, those of the police - and I cannot be charged, as a family carer, with 'a breach of ethics', can I ?

Ref 1 http://www.bmj.com/content/353/bmj.i2230/rr-7

The biomedical ethics that Sokol discusses are critical to enabling medical students to develop professional, caring and appropriate responses to the medical dilemmas that they are bound to face in clinical practice, and it is important and worthy that we continue to question how effective medical education is and how to improve it. However, it is important to note that Sokol’s discussion takes a narrow view of the content and potential impact of ethics training at medical schools. While ethics has traditionally focused on issues of human autonomy and the wellbeing and rights of individuals, challenges currently facing health and health services have forced issues of population health, global health and the environment into the ethics spotlight.
Global health poses many ethical challenges, including related to the distribution of health resources (workers, medicines, organs for donation) internationally. New sustainable healthcare education learning objectives referenced by in the UK’s ‘Outcomes for Graduates’ ask students to recognise the ethical tension between treating a patient (allocating resources to their care) and impacts of resource use on the environment and public health locally and globally. In the UK, threats to the provision of a publically-funded health service and increased moves to restrict access by requiring proof of identity, may increasingly raise ethical issues about health equity and the right to health which clinicians may need to address. The Global Consensus on Social Accountability highlighted that medical schools have a role in preparing students to face current and future health threats; and that medical schools and medical students need not only talk about, but can also enact partnerships and initiatives to promote health by addressing social and environmental issues. Medical students not only need to understand and discuss ethics, but they can explore ethics by acting on their values and expanding their own views and perceptions.
Just as it is difficult to assess whether teaching about ethics may result in a medical student spending longer with a dying patient, it is difficult to identify any causation between teaching about environmental ethics or social justice and medical students’ advocacy to promote healthy environments or human rights. Anecdotally, however, there is evidence to suggest that students do respond to the opportunity, for example, to explore the intergenerational equity impacts of our current rate of fossil fuel consumption in health services or their own values in relation to ethical procurement by healthcare providers. At the Sustainable Healthcare Education network, educators have found that reflective logs and student evaluation often highlights that students are newly engaged by education about the ethics of sustainable healthcare and plan to take action in their personal or professional lives. Meanwhile, advocacy about global and environmental ethics by medical students appears to be alive and kicking, for example through the Healthy Planet campaign, which is calling on health organisations to divest from fossil fuels and the International Federation of Medical Students’ Associations which is currently campaigning about refugees’ rights to access healthcare.

The practice of teaching Ethics in the classroom is waste of time. Further, medical ethics differ in different societies. There is no such thing as the Universal Truth.
I agree with Ms Susanne Stevens - Ethics should trump the Law. A price to pay? Yes. So be it.
The medical profession in the UK is composed of individuals with disparate antecedents and a very limited knowledge of what is " acceptable" .
It would be far more useful if in the medical schools ( in the UK) the students in the clinical years were to learn medical ethics as practised here these days. It would take longer. But at least the students would learn the practical issues and discuss them. Here, the patients AND their relatives and friends, would be " honorary teachers".
Doctors who qualified abroad and go straight in to hospital junior grades will need help and guidance from long serving nursing and other staff including the consultants.
Did I hear someone say that my suggestions are superfluous?

Just for once, I cannot agree with Susanne Stevens (response 8 December) that 'Law should not trump ethics'.

Law and ethics are 'entangled', but where the law has been explained in an Act, the Act will 'incorporate' the 'ethics' which have been retained, and discard those regarded as obsolete. For my own area of interest, which is end-of-life especially when the patient is at home and is being supported by both family carers and also professionals, I am faced with the issue that the family carers are legally required to follow the Mental Capacity Act itself, but are under no legal obligation to even look at the MCA's Code of Practice. But the professionals must obey the MCA, 'have regard to' the MCA's Code of Practice, and are also 'bombarded' by other guidance and other impositions ('safeguarding' being particularly problematic, with respect to EoL).

How can family carers and clinicians, work together to provide the supportive team which the patient needs, if the family carers are being guided by just the law itself, while the clinicians [who must also obey the law itself] are strongly influenced by other things - things which family carers are not, legally, required to pay any attention to ? That cannot work - so it has to be 'we all follow the law unless the law isn't clear, in which case we can introduce other considerations, such as 'ethics' and 'logic' and, crucially I believe, 'perspective-balanced behaviour''. It is very awkward indeed, if bodies such as the GMC apply ethics which run counter to law - which makes life difficult for the professionals.

There seems to be a problem with clinicians and the law - put bluntly, in my view many clinicians seem to understand the law very poorly. Listening to an episode of 'We need to talk about death' on BBC Radio 4 yesterday evening, the 'doctrine of double effect' cropped up. The clinician explained the doctrine, but was more interested in arguing that strong pain-relief does not necessarily shorten life, and might extend life. But, I think that misses the point. Surely now that we have the MCA and the Montgomery ruling, it is legally clear that it is for the patient to decide whether or not to accept the risks associated with an offered treatment (and this is a crucially important point - who decides about risk, is really fundamental) - so the doctor must explain that 'the level of morphine necessary to adequately relieve your pain, might hasten your death' and then the patient makes the decision. The 'doctrine of double effect' seems obsolete, because it appears to carry an implication that the doctor decides whether the risk is acceptable: and these days, that type of risk, is for the doctor to describe, but for the patient to consider [so we only need to avoid a dose of morphine which would almost certainly promptly kill the patient - that would be illegal, and assisted suicide: whereas a future shorter but pain-free life, compared to a longer and agonising one, is something the law surely now allows the patient to decide about ?]. The radio programme, also seemed less than legally clear, about a capacitous end-of-life patient who is refusing pain relief but who is obviously in great pain, describing this as being difficult for clinicians. Well, yes it is difficult - for the family as well - but administering pain-relief against the wishes of a capacitous patient, even if the patient is clearly in agony, is surely a clear case of assault !

It is unusual for me to disagree with Susanne Stevens - but I do disagree, about this.