When is the best time to teach medical ethics?
BMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o504 (Published 25 February 2022) Cite this as: BMJ 2022;376:o504
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Dear Editor
I am puzzled by Daniel Sokol’s suggestion that ethics should not be taught too early. Ethics might, in some ways, be in a different category to other medical abilities but, as with complex practical skills, we have to master the basics before we can learn and perform the more difficult stuff.
Are ethics not the threads running through everything a clinician says and does? As the word’s derivation suggests, ethics have to be in our nature and values, not simply to be grafted onto a body of medical knowledge. Yes, students are unlikely to face the most complex ethical dilemmas until later in their careers but they must quickly establish basic, everyday ethical behaviours such as how they speak to and of patients and colleagues as well as ingraining habits of confidentiality about what they see and hear. With this approach it’s difficult to imagine that that learning ethics can come too early. Having it discussed day-to-day in context is likely to be more effective than by didactic teaching. It can be assessed but, again, by discussion rather than multiple-choice exam.
Aldo Leopold said, “ethical behaviour is doing the right thing when no one else is watching – even when doing the wrong thing is legal”. This seems to be a useful starting point and the caveat about legality has important implications if behaviour comes to be questioned or when practicing outside one’s own country when ethics might have to transcend differences in national laws. In another rapid response, Shyan Goh suggests that “no single society has the right to call another archaic…” but this might imply that all ethics should be considered relative. Have we not moved beyond this for many areas of human rights?
Competing interests: No competing interests
Dear Editor,
Sokol describes that ethics is taught too early in the undergraduate medical course and should instead be taught later where it is more relevant, can be applied to practice, and does not conflict with exams (1). Rather than shifting the timeline of ethics teaching, we suggest that the focus should be on the alignment of content with assessments to improve engagement.
In our personal experience of ethics teaching, lectures were poorly attended. Indeed, in a survey of medical students, only 40% expressed an interest in learning about medical ethics despite 82% considering it an important issue (2). Therefore, there is a need for change. However, post graduate doctors arguably have more time commitments and still have membership and fellowship exams. As such any additional teaching may be ignored as well. Instead of avoiding exams, we could ensure ethics teaching is in ‘constructive alignment’ with them. This is an educational principle where the teaching students receive aligns with intended learning outcomes and assessment (3). This alignment helps students to construct meaning from their learning, increases the focus of students and trainees, and permits a valid assessment of learning (4,5). This is particularly important in medical education where there is limited time to learn a wide range of material.
Through the constructive alignment of ethics teaching with assessment we can ensure that it complements rather than conflicts with other educational materials. This will improve engagement from students and trainees, and help focus how ethics is integrated within curricula.
References
(1) Sokol D. When is the best time to teach medical ethics?. BMJ. 2022;:o504.
(2) H. Saied N. Medical students' attitudes to medical ethics education. Annals of the College of Medicine, Mosul. 2013;39(2):101-106.
(3) Biggs J. Enhancing teaching through constructive alignment. Higher Education. 1996;32(3):347-364.
(4) Biggs J. Aligning teaching for constructing learning | Advance HE [Internet]. Advance-he.ac.uk. 2022 [cited 26 February 2022]. Available from: https://www.advance-he.ac.uk/knowledge-hub/aligning-teaching-constructin...
(5) Biggs J., Tang C. (2015) Constructive Alignment: An Outcomes-Based Approach to Teaching Anatomy. In: Chan L., Pawlina W. (eds) Teaching Anatomy. Springer, Cham. https://doi.org/10.1007/978-3-319-08930-0_4
Competing interests: No competing interests
Dear Editor,
The question ‘When is the best time to teach medical ethics?’ begs the question ‘What is the role of ethics in educating tomorrow’s doctors?’ As the World Medical Association’s makes clear, ‘[t]he physician’s knowledge and conscience are dedicated to the fulfilment of [her] duty’ ‘to promote and safeguard the health, well-being and rights of patients’ [1]. There should be no separation in the teaching of science, medicine, and ethics to tomorrow’s doctors. Society rightly expects that every occupation or engagement associated with the doctor’s profession is informed by a life dedicated to ‘the service of humanity’, to respecting the ‘autonomy and dignity of [her] patient’ [2]. Within the mind of a doctor there must be no room for an activity not having regard firstly to human dignity, for an appeal to a higher interest outside of a patient’s (or patients’) health, or for a lapse in conscience.
Perhaps, just perhaps, there should be no course with the title Medical Ethics in the curricula of our medical schools. Rather we might better consider that the complexities and challenges of ethics be taught as belonging to the very sciences, practices, and engagements already having found a place in our medical schools’ curricula. This is, indeed, the proper time and place to teach the intricacies of medical ethics: as part and partial, as intimately bound to, each and every activity of a medical doctor. Such an employment of ‘medical ethics’ in the curricula might just lead to a less technocratic, less pharmaceutical, less economic, and a more conscience-driven approach in tomorrow’s doctors’ engagement with patients and communities. It will undoubtedly also lead a deeper grasp and appreciation of ‘medical ethics’ by the practitioners of this august profession.
The best time, the required time, to teach ethics to tomorrow’s doctors begins Year 1, Day 1, Lesson 1. Ethics should be integral to the whole of medical education. This is what the General Medical Council (GMC) should be promoting. This is what will make ethics the most engaging, practical, and valued aspect of a medical education.
[1] World Medical Association. Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects. 1964-2013. https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-pr...
[2] World Medical Association. Declaration of Geneva: The Physician’s Pledge. 1948-2017. https://www.wma.net/policies-post/wma-declaration-of-geneva/
Competing interests: No competing interests
Dear Editors
Mr Sokol's latest opinion piece is an interesting one; he appears to pitch the idea that medical ethics can be taught without mentioning the medico-legal framework.
Of course he could easily have meant for the medico-legal matters to be naturally included, part and parcel, within the medical ethics, but in my opinion, medical ethics has to do with "moral principles that govern a person's behaviour or the conducting of an activity" which is highly influenced by individual outlook and societal expectation, whereas medico-legal issues have more to do with healthcare workers navigating employment, statutory, regulatory and legal requirements of their clinical practice. While medical ethics and medico-legal principles are frequently taught together, they are conceptually distinct. Specifically some laws and legal precedence can be trailblazing and forward looking while other can be outdated and not consistent with current expectation of society. Similarly the laws in one land may not match those in another, but no single society has the right to call another archaic, particularly when the laws do reflect the majority views of that community.
But I digress.
I have always taken an interest in ethical and medico-legal issues, having read my first newsletter (from the Medical Protection Society, I recall) in medical school describing the (then) recent implications of the Rogers and Whitaker judgement (ref 1) on medical practice. Even now, 30 years down the track, I am confident that most clinicians (both young and old), as well as many medical students, have no idea what that case has meant to healthcare, nor have any firm concept what "informed consent" truly meant.
Such is the state of knowledge of medico-legal principles and medical ethics in our fraternity.
Mr Sokol considers that medical ethics "should take place post qualification, with real life cases to illustrate the application of ethical principles or norms to the concrete situation"; I would presume here that he had intended also to include medico-legal knowledge in the term "medical ethics". While I agree that teaching medical ethics to a clinician may make more sense, this may be based on weak assumptions. Post qualification, the doctor in the first few years is trying to learn real medicine, survive the day at work and basicially the ultimate responsibility for all things that were done in the name of the consultant, were shouldered by that consultant. In many ways the issue of ethical and legal matters is upon the most senior clinician of the team rather than shared.
As doctors progress in their career, they then have to juggle that work-training-life balance; whatever energy that is left from work and studying for the fellowship is used on building relationship with their family, particularly with life partners and children. Unless personally faced with (or more importantly, personally vested in) ethical issues at work, these matters are considered "non-essential", "not examinable" and "can be postponed to another time".
By the time doctors finished their training, they found themselves again the small fishes in another bigger pond as soon as they received their fellowship papers, competing for jobs, prestige and building a career if family life allows.
In other words, there is always an excuse or reason not to get to learn about medical ethics, if clinicians want to find one.
It is then they get a big mental shock, where some of them realise the buck stops with them in the eyes of society, the workplace and the law. Interestingly others just kept on working, thinking that continuing to do what they learnt in training (and other doctors do) will confer some form of protection and comply with current ethical values.
So, in the end, those who will get to know about medical ethics will either be those who are interested in their medical education/ early in their career, or learn it the hard way when personally faced with an ethical matter, or worse a medico-legal one at work.
I would surmise that Mr Sokol is preaching to the converted; I wonder how many of regular BMJ readers will read this column, and this may be reflecting their attitude and interest in this matter in clinical practice.
Reference
1. https://pubmed.ncbi.nlm.nih.gov/11648609/
Competing interests: No competing interests
Dear Editor
I agree that medical ethics has attracted an unfair reputation as “as dry and impractical”[1]. Combining medical ethics training with medical law relating to law of negligence in particular, could be a more attractive option for doctors. In a climate of rampant litigation, broader knowledge of such topics would not only allay disproportionate anxieties of doctors but empower positive decision making in a timely manner. Further such combined post qualification training regularly, is likely to improve personal and professional resilience of clinicians. Without waiting for GMC to mandate such training, NHS Trusts and Royal Colleges should proactively make arrangements to provide a greater level of training in medical ethics and law. Judgment/case-based discussions among groups of doctors along the lines of a Balint group might be an attractive learning option.
References
[1] https://www.bmj.com/content/376/bmj.o504
Competing interests: No competing interests
Dear Editor
I agree with the author that there is place for teaching ethics in undergraduate curriculum. However it should not be taught only in first two years. It should be taught in multiple sessions spread over all course. It should not be didactic but through case studies and then discussion among peers with supervision by mentors. First year could be basic introduction. Clinically related ethical issues related to malpractices, organ donations etc may be taught in final years. In India we have introduced AETCOM module ( case scenario based model) since 2015 and has worked well
Competing interests: No competing interests
Medical students' exposure to ethically complex realities of medicine is inadequate
Dear Editor,
During medical school, there is an insufficient focus on confronting ethically challenging issues. Students feel much less prepared for common ethical problems than for common medical problems (Silverman et al. 2013 “Perceived comfort level of medical students and residents in handling clinical ethics issues”), and we are encouraged to observe complex surgical cases more than ethical ones, despite the latter’s broader applicability and immediacy. Doctors lacking confidence in their ethical judgement risk patient safety, making the gap between ethics in medical school and practical reality astounding.
Teaching students about ethics is more complicated than the sciences: Medical students typically come from a scientific background, and focus on medicine’s clearer aspects; in PBL scenarios concerning detaining patients under the mental health act, students focus on the legal or diagnostic aspects of the case, rather than the abstract ethical elements (Donaldson et al. 2010 “Case-based seminars in medical ethics education: how medical students define and discuss moral problems”). Students also face pressures of imminent examinations and must economise on that which is tested, with ethics falling by the wayside.
How is one prepared to contend with these issues as a doctor? What can one do when confronted with a case like euthanasia, or operation denial? The responsibility of care is, by practising medicine, done willingly. “The question is”, says Atul Gawande, “having accepted the responsibility, how one does such work well” (“Better: A Surgeon’s Notes on Performance”. New York: Metropolitan, 2007). With this maxim in mind, we can recontextualise our professional lives in healthcare systems.
Our role in ethical issues at this stage of medical education is similar to that in surgery; with consent, we ought to observe most procedures, the difference being we aren’t encouraged to observe complex ethical situations. This viewpoint supports students for three reasons: it doesn’t propose that students be taught ethics formally (in the same way students are not taught to perform endoscopic third ventriculostomies), as the value comes from increased readiness and exposure to ethical aspects of medicine. Secondly, students are ideally placed to overcome apprehensiveness towards ethical situations in practicevia their diminished responsibility. Finally, this doesn’t add to the volume of information students need for exams, but still prepares them to deal with situations they face imminently after graduation.
We should orient ourselves towards our future professional roles, ensuring our ethical, as well as clinical, judgement is developed. It is too simplistic to view such judgement as the preserve of seniors; have you ever thought ‘I’m glad I’m not making that decision’, or ‘that’s for them to decide’? Perhaps more pertinent are situations of interpersonal conflict, common on placement. Considering these things is uncomfortable, but deference here ultimately stunts professional growth.
By observing the current state of ethical debates among clinicians and thinking critically about their arguments, we begin to hone our own ethical judgement. The result could be a generation of clinicians who aren’t scared of asking difficult questions, in the right context and with respect to patients. Both Scottish and UK Governments will imminently debate bills legalising medical assistance in dying , and organ donation is already the norm, so the opportunity for us to learn the intersection of medical practice with the moral complexity of the real world shouldn’t be ignored, and this learning should begin at school.
Competing interests: No competing interests