Chapter 31 Medical ethics has seen a remarkable development in the last three decades everywhere in the world, mostly in the UK, Europe and the United States, but also more widely. There is international consensus that it should be an important part of any medical curriculum (WHO 1995, WMA 2005) As the field ‘comes of age’ (Goldie et al 2000, Miles et al 1989), there is now wide acceptance, firstly, that medical ethics is no longer the concern of a single profession or academic discipline but has to be multidisciplinary and multiprofessional; secondly, that it should be academically rigorous and, like other academic subjects that are taught in the medical curriculum, related to current research and ongoing debates in its field; and thirdly, that ethics education must be fully integrated into the medical curriculum, both horizontally and vertically, so that there is seamlessness between what is being taught at any given time and pertinent ethical issues, along with continuous reinforcement for professional growth. However, medical ethics education today faces pressing questions about the effectiveness of what is currently offered in medical schools. Although the vast majority of medical schools teach medical ethics to some extent, there is a broad range in terms of how it is taught, who teaches it and how frequently. These findings were reported by Mattick and Bligh (2006) in a survey of medical schools in the UK where, in spite of having a well-accepted core curriculum in medical ethics, there is wide diversity in teaching, assessment methods and staffing levels (GMC 1993, Consensus Statement 1998 [updated in Stirrat et al 2010]). There is no clear and consistent picture in the current literature of the efficacy of existing forms of ethics education (Campbell et al 2007). Systematic approaches to teaching and assessing legal literacy in relation to ethical thinking should also be developed for the formation of professional identities inclined and confident to engage with the law as a means to guide, protect and empower patients (Preston-Shoot & McKimm 2011, Preston-Shoot et al 2011). In the last 20 years, international trends to privatize medicine have nurtured a ‘healthcare industry’ aimed primarily at profit. This has created role conflicts for medical practitioners, who are caught between their responsibilities to patients, on the one hand and, on the other, the notion of ‘entrepreneurship’ that encourages personal business success combined with loyalty to corporate employers (Breen 2001). Thus, the search for new standards by the medical profession has to focus on those values that distinguish medicine from business, that define fiduciary responsibilities to the vulnerable sick and that bind doctors together as a committed body of persons with judgement and stewardship of knowledge and skill (Pellegrino 2002, Working Party of the Royal College of Physicians 2005). To meet this challenge, medical ethics education must put an emphasis on qualities that all patients look for in a practitioner: they seek a trustworthy advocate, committed first and foremost to patient welfare, empathetic, reflective and able to face up to the complexity of the rapidly changing world of medical practice. But today’s doctors also have to be stewards of scarce resources. They have to seek just uses of finite healthcare budgets that provide the best available healthcare for patients, balancing fee-for-service care to meet growing (and at times unrealistic) consumer demands with publicly provided healthcare (Michels 1999); and to do this, they have to create effective relationships with corporate administrators that preserve rather than absolve or diminish professional responsibility (Breen 2001). This stewardship will also involve assessing the effectiveness of new healthcare delivery channels, including ‘disruptive’ technologies such as telemedicine and internet medicine. Globalized societies must deal with bewildering questions about the translation of standards and ethical paradigms across diverse cultural contexts. No wholesale application of global standards is possible. The importance of culture has been illuminated by Canadian philosopher Charles Taylor. Taylor emphasized the truth that people are self-creating and culture-bearing individuals whose unique identities are formed through integration, reflection and modification of their heritage in response to, and in dialogue with, others (Taylor 1994). One implication of this for medical ethics is that patients will differ in their beliefs concerning matters such as the meaning of life, human suffering and illness, obligations to others in decision making or the extent of interventions upon nature. Today’s doctors must be prepared to test their own ethical beliefs and cultural assumptions against other cultural frameworks. But how will ‘ethical contours’ be discerned in a world that is increasingly flattened by late capitalist imperatives of individualism, universalism, commodification and unrelenting conquest of, and dissociation from, the natural world? Some considerations that are emerging include greater attention to deep and longstanding cultural values that put limits upon medical intervention for ethically and ecologically important reasons; the relationships of family and community in the lives of individuals and their impact on decisions; the avoidance of cultural stereotypes and genuine embrace of an ethics of virtue that commands trust and values true autonomy or ‘self-rule’, as contrasted with a mere ethics of obligation that emphasizes only procedural requirements in dealing with disagreement or outright conflict of values (Irvine et al 2002). It has been clearly established that extracurricular factors can have harmful effects on the ethical development of medical students and junior doctors (Hafferty & Franks 1994). However, there continues to be a mismatch between the pedagogical efforts of medical schools and the challenge of reforming environments that impair ethical development (Hafferty 2000). It has been observed that while medical education professes explicit commitment to traditional values such as compassion, empathy and altruism, the reality is that its underbelly is a tacit, nonreflective acceptance of detachment and professional self-interest (Coulehan & Williams 2001). This easily leads to a narrowing of professional identity to that of the competent technician, devaluing relationship-centred approaches to medicine. Patients are seen as objects of technical services and medical students as apprentice technicians or trainee medical scientists. It is commonplace that medical graduates’ spirits can be broken by the tough discipline of hospital managers and senior clinicians, and fair to say that the educational model of most hospital internship programmes may often be likened to a hierarchical ‘militaristic’ command structure (Leeder 2007). The ‘soft’ influence of pharmaceutical companies in undergraduate medical education is also an area of concern, particularly its effects on the practice of evidence-based medicine. Students’ interaction with industry is found to be associated with positive attitudes towards industry marketing, including the reception of gifts, and scepticism about possible negative influence on their prescribing patterns (Austad et al 2011).
Ethics and attitudes
Introduction
Critical challenges
Challenge 1: The changing doctor–patient relationship
Challenge 2: Cultural pluralism
Challenge 3: The power of the hidden curriculum
Current accepted standards of medical ethics education:
Challenges for medical ethics education:
The changing doctor–patient relationship
Multiculturalism
Hidden curriculum – teaching teachers
