When is the best time to teach medical ethics?

Medical ethics education needs a major overhaul. In my view, there is too much medical ethics teaching in the early years of medical school and too little after qualification, when it truly matters.

During a medical conference in London, a neurosurgical trainee approached me after my talk on medical ethics. When I asked him if he was taught the subject at medical school, he answered “Yes, but I can’t remember any of it. We just had to learn things by heart for the exam. Medical ethics is only relevant when you start practising.” This observation, which I had heard many times from other doctors, took me back to the time when, as a Lecturer in Ethics, I had to teach end-of-life ethics to first year medical students. I remember thinking that this was premature, like teaching a student how to do a Whipple procedure. Most of the audience had never seen a seriously ill patient and it would be years before they would have sufficient seniority to be involved in the life-and-death decisions we were discussing.

When I last taught ethics to students in 2009, most of the ethics teaching took place in the first two years of the medical degree. Ironically, the closer students got to qualification the less ethics teaching they received.

This makes little sense. The best time to teach medical ethics is shortly before qualification and, better still, post-qualification, when doctors are in practice and can immediately apply what they learn to their clinical work. Only then does medical ethics, free from the shackles of impending exams, come to life as a relevant, practical discipline.

In medical school, the priority for most students is passing exams. I remember one bold student in a lecture asking, unashamedly, “Will this be in the exam?” I was disappointed at the time but, when it was my turn to learn vast amounts of law as part of my law-conversion course years later, I sympathised with the student. There is so much to memorise that we need to be selective. The average student does not think “I need to learn this to become a better doctor” but “I need to learn this to pass the exam in 3 weeks’ time.” Anything that is not examined is, at best, a distraction from what is essential and, at worst, a waste of time.

There is a place for medical ethics in the undergraduate curriculum. Students must understand that medicine is, at heart, a moral enterprise and the high ethical standards expected of students and doctors. They should also be taught the fundamentals of consent, confidentiality, and issues they are likely to encounter on their placements and their first year of practice.

However, the majority of medical ethics teaching should take place post qualification, with real life cases to illustrate the application of ethical principles or norms to the concrete situation. There should be a minimum number of ethics sessions that doctors should attend. This already exists at the Bar, with the Bar Standards Board requiring all barristers within their first three years of practice to undertake three hours of ethics. If the General Medical Council (GMC) had such a requirement—although with greater hours—Royal Colleges, deaneries, and hospital trusts would arrange more ethics sessions, doctors would benefit from practical ethics education, and the discipline would shed its unfair reputation as dry and impractical.