Teaching medical ethics
Teaching medical
ethics and law
within
medical education: a
model for the
UK
core
curriculum
Consensus statementby teachers of medical ethics and law in UK medicalschools*
The General Medical Council has stated that
medical ethics and law should constitute one of thecore componentsof the medical curriculum.'
The practice of good medicine inevitably raises both ethical and legal issues and demands an
understanding of both.Inthisdocument, teachers of medical ethics and law in medical schools throughout theUK nowoffer theirownconsensus statement about theissues, concepts, arguments,
skills and attitudes that all medical students should understand and know how to apply in practice by the time they qualify. This consensus proposes a minimal core undergraduate pro-grammeof workwhichwebelievetobeconsistent with the stated objective of the General Medical Council that studentsshouldacquireaknowledge andunderstanding of "ethical and legal issues
rel-evant tothepracticeof medicine" andan "ability
tounderstandand analyse ethical problemsso as to enable patients, their families, society and the doctortohaveproperregardtosuchproblemsin
reachingdecisions".' Someorganisational princi-ples are also summarised whichwe believe tobe crucial for the successful implementation ofour
proposed undergraduate programme.
Medicalethics and law in the medical curriculum
Within the traditional medical curriculum, the
teaching of ethics and law has often been both eclectic and scarce. Ifthey were lucky, students receivedafew lecturesduringtheentirety of their clinical studies-sometimesaccompanied bysmall
group discussions. The tutor mightormightnot
havehad academicqualifications orother relevant experience ineither moralphilosophy,moral
the-ology or law. Such teaching was and sometimes stillisoptional,notformally assessedon apar with
other clinicalstudies andnotnecessarilyeven
for-*Thisconsensus statementisalso available atthe British Medical
journalwebsite:www.bmj.com
mally timetabled. Asaresult, attendancewasand sometimes still is poor and audiences self-selected. The impact of such teachingontherest
ofthe clinical curriculum could be - unsurpris-ingly - sub-optimal. At some schools, however,
where teaching has beenmore extensive and
sys-tematic, student feedback is good.
Thecurriculum proposed here demands a bal-anced,sustained, academically rigorous and
clini-cally relevantpresentation of bothethics and law in medicine, and of the relationship and tensions between them. Clinical relevance and the duties and educational needs of students should be stressed. Teaching should reinforce the overall aims of medical education: the creation of good doctorswho will enhance andpromotethehealth and medical welfare of the people they serve in
wayswhichfairly and justly respecttheir dignity,
autonomyandrights. Thesegoalswill beachieved through:
* ensuring that students understand the ethical principles and values whichunderpin the
prac-ticeof good medicine
* enabling studentstothinkcritically about ethi-cal issues inmedicine,toreflectupontheirown
beliefs aboutethics,tounderstand and appreci-ate alternative and sometimes competing
ap-proaches andtobe abletoargue and counter-argue in order to contribute to informed
discussion and debate
* ensuring that students know the main profes-sional obligations of doctors in the United Kingdomasendorsedbythe institutions which
regulateorinfluence medicalpractice-
particu-larly those specified by the General Medical Council
* giving students a knowledge and understand-ing ofthelegalprocess and thelegalobligations
of medical practitioners sufficient to enable
themtopractise medicine effectivelyand with minimalrisk
* enabling students not only to enjoy the intellectualsatisfaction of debates within medi-cal ethics and law but also to appreciate that ethical and legal reasoning and critical reflec-tion are natural and integral components in their clinical decision-makingand practice * enabling students to understand that ethical
and legal issuesarisenotonly inextra-ordinary situations in medicine but also occur in
everyday practice. Corecontent
There is widespreadagreement about the
accept-able ethical and legal contours ofgood and safe medical practice and little debate about the related understanding, attitudes and skills that
this requires. Relevant issues, problems,concepts
andarguments are nowexplored in standard
text-books of medical ethics,inintroductionsto medi-cal law and in much professional literature.
Students must learn sensitively to apply their
growing intellectual understanding ofthe ethical and legal underpinning of good practice in their evolving clinical experience and in their own
professional relationships with patients, other healthprofessionalsand other members of society. The following is a core list of topics which should becovered:
IINFORMEDCONSENT AND REFUSAL OF TREATMENT
* Thesignificance ofautonomy: respect for per-sonsand forbodily integrity
* Competence to consent: conceptual, ethical andlegalaspects
* Further conditions for ethically acceptable
consent: adequate information and
compre-hension, non-coercion
* Treatmentwithoutconsentandproxy consent
-when andwhy morally andlegallyjustifiable * Assault,battery,negligenceandlegalstandards
for disclosureof information
* Problems ofcommunicatinginformation about
diagnosis, treatmentand risks: theimportance
ofempathy.
II THECLINICAL RELATIONSHIP-TRUTHFULNESS,
TRUST AND GOODCOMMUNICATION
* The ethical limits of paternalism towards patients
* Thesignificance ofhonesty,courage,prudence
and facilitative attitudes:virtues inthepractice
ofgood medicine
* Legal andethicalboundaries ofclinical discre-tion towithhold information
* Practical difficultieswithtruth-tellingin medi-cine:inter/intraprofessionalconflictsand other
barrierstogoodcommunication
* The ethical and legal importance of good
com-munication skills and the significance of the patient's narrative (as distinct from other professional narratives) in building relation-shipsoftrust.The importanceof cultural,
gen-der, inter-generational, religious and racial
sen-sitivity.
IIICONFIDENTIALITY AND GOOD CLINICAL PRACTICE
* Professional information, privacy and respect
forautonomy
* Trust, secrecy and security in the sharing of information: the practical demands of good
practice.
* The patient and the family: potential moral and legal tensions
* Disclosure of information: publicversus private
interests
* Compulsory and discretionary disclosure of confidential information: professionaland legal
requirements.
IV MEDICAL RESEARCH
* Historical and contemporary examples of abuses of medical research
* Individual rights and moral tension between theduty ofcare to the individual and the
inter-ests of others. Therapeutic and non-therapeuticresearch
* Professional and legal regulation of medical research.
* The ethical significance of the distinction between research, audit and innovative and standard therapy as well as between patients andhealthy volunteers
* Research and vulnerable groups: ethical and legal boundaries of informed and proxy con-sent
* Researchon animals: ethical debates andlegal requirements.
VHUMANREPRODUCTION
* Ethical debates about, and the legal status of, theembryo/fetus
* The maternal-fetal relationship: ethical
ten-sions
* Abortion:professional guidelines, legal
require-mentsanddebatesabouttheuseof tissuefrom
aborted fetuses
* Sterilisation: ethicalandlegalissues
* Pre andpostnatal screeningandtesting:ethical issues concerning informed consent and the
determination of the interests of the future
child
* Assistedconception:legal boundaries and
VITHE'NEWGENETICS
* Gene therapy: ethical issues concerning the
distinction between treating the abnormal and improving the normal
* Somatic versus germline treatment and
re-search: ethicalandlegalarguments * Eugenicsversuspatient-centred care
* Genetic counselling: responsibilitiestopatients
versusresponsibilitiestofamilies
* Benefits and dangers of genetic testing and
screening after birth: the risks of unwelcome information andof geneticstigmatisation * Cloning: genetic versus personal identity
-ethical implications.
VIICHILDREN
* Respectfor the rights of children: evolution of
currentethical issues
* The relevance of age in the determination of
competence to consent to orrefusetreatment * Ethical debates about legal boundaries of
con-sultation with younger and older children as
regards consent to treatment
* Thedoctor/parent relationship:proxy decision-makingand protecting children's interests
* Good ethical and legal practice in reporting suspected child abuse.
VIIIMENTALDISORDERS AND DISABILITIES
* Definitions of mental disorders, mental inca-pacity, (including mental illness, learning disability andpersonality disorder)
* Ethical andlegal implications of serious mental illness: civil incapacities, vulnerability and reducedresponsibility
* Treatment,legal detention of, and researchon,
theseriously mentallydisordered withor
with-out consent
* Patient, family and community: ethical and
legaltensions.
IXLIFE,DEATH, DYINGANDKILLING
* Palliative care, length and quality of life and goodclinicalpractice
* Attemptingethicallytoreconcilenon-provision oflife-prolonging treatment with the duty of
care:killingandletting die, doubleeffect, ordi-naryandextra-ordinarymeans
* Withholding and withdrawing life-prolonging treatment-and potentially shorteninglife -in
legallyacceptableways
* Euthanasia and assisted suicide: ethical and
legalarguments
* Transplantation: ethical andlegalissues
* Deathcertificationand theroleof thecoroner's
court.
XVULNERABILITIES CREATED BY THE DUTIES OF DOCTORS AND MEDICAL STUDENTS
* Public expectations of medicine: difficulties in dealing with uncertainty and conflict. Ethical importance of good inter- and intra-
profes-sionalcommunication and teamwork
* The General Medical Council. Professional regulation, standards, and the Medical Regis-ter.Implicationsfor students and their relation-ship with patients
* Responding appropriately to clinical mistakes:
personal, legal and ethical responsibilities. Unethical and unsafe practice in medicine: "whistleblowing"
* The law ofnegligence, NHS complaints and disciplinary procedures
* The health of doctors and students and its
relationship toprofessionalperformance: risks,
sourcesof help and dutiestodisclose.
* Medical ethics andthe involvement of doctors in police interrogation, torture and capital
punishment.
XIRESOURCE ALLOCATION
* Inadequate resources and distributive justice within the National HealthService (NHS): the law
* Theories andcriteriafor equitable healthcare:
needs, rights, utility, efficiency, desert, au-tonomy
* Debates about rationing: personal, local,
na-tional and international perspectives. Markets and ethical differences between competing healthcare deliverysystems
* Boundaries ofresponsibility of individuals for theirownillnesses and ethicalimplications.
XIIRIGHTS
* Conceptions ofrights-whatarethey?
* Linksbetween rights and duties and
responsi-bilities
* Internationaldeclarations of humanrights * The importance of theconceptof humanrights
for medical ethics
* Debates about the centralityofrightsforgood professionalpracticeinmedicine
* Rights andjusticeinhealthcare.
Thespecification ofthesecoreissuesis innoway meanttobegquestions abouthowtheyare
intro-duced, discussed and analysed throughout the curriculum. For example, some teaching pro-grammes will be more directed towards ethical thanlegalanalysis; others more focusedon some
issues (for example, informed consent) than
others (resource allocation). Which foci are selected will and should depend in part on the interests of lecturers and their clinical colleagues.
In the specification of the "core" it would be
wrong excessively to determine its specific con-tent.For example,nospecifictexts orreadingsare
recommended, but all the topics specified ought
tobeaddressed.
The generalorganisation of clinical teachinginethics and law
Success in presenting such a core programme
withina general clinical curriculum entails more
than getting the content right. There are also organisational prerequisites:
* Ethics and law applied to medicine is now an
emerging academic discipline with intrinsic and rigorous standards. While teaching of this subject will and should be widely shared within medical schools, its adequate provision and coordination requires at least one full-time senior academicinethics andlaw with relevant professional and academic expertise.
* Ethics and law shouldbe introduced
systemati-cally in ordertoprepare studentstomeettheir
own professional and legal responsibilities when working with patients.
* Ethics and law teaching should be features of the whole curriculum, should begin early and bereinforced throughout thecourse.It should
fullybe integratedwith therest of the curricu-lum.
* Ethics and law teaching should also be integrated with the rest of the curriculum
through provisionofcoursesandworkshopsfor teachers, including house officers.
* Ethics and law should be formally assessed as are all other core subjects within the curricu-lum. The details of such assessment will vary
between schools but formalassessmentshould
occurandshould have thesameimportanceas assessment inany othercore subject. Without such assessment, ethics and law applied to
medicine cannot be taughtsuccessfully within the medical schools. Theteachingitself should
also beassessed in thesamewayas isteaching
inother coresubjects.
* Ethics and law should have sufficient
curricu-lum time and resources explicitly allocated to itsteachingtoachieve thepreceding goals.
Aspartofits fullintegrationinto thecurriculum,
teaching in ethics and law should feature in the students' clinical experience, consistently forging links with good medical and surgical practice. Each clinicaldiscipline should addressethicaland legal issues of particular relevance to it and its
students should be subjectto assessment as they would be forany other teachingin thatspecialty.
Students should be encouraged to present prob-lems which they have personally encountered in theircourse.
TEACHING METHODS
A variety of teaching methods is consistent with
achieving the preceding goals. Ideally, these will
entail a mix between large and small groups,
exploring issues inacase-based fashion. Coverage ofcorematerial in ethics andlaw, however, should
not falter in the face of insufficient teaching
resources for small groups.Interactive workwith
large groups can still be effective and should always be considered rather than opting for little
or no cover. The key is to make all teaching of whatever sizedgroupsbothclinically relevantand
pitchedtotheacademic background and ability of the audiencetaught.
Conclusion
We have outlinedacorecurriculum for the
teach-ing of ethics and law applied to medicine and
indicatedorganisational conditions for its
success-ful teaching. We believenotonly that it will helpto create good doctors, but that it will help themto
enjoy a morefulfilling practice of medicine in a
worldof diverse values and beliefs. We thus
com-mend this consensus statement to the medical schoolsforadoptionasthe basisfor their teaching of ethics and law and to the General Medical Council. Weemphasise that this proposed model
sets out conditions deemed to be minimal for
achieving the aim of creating doctors who will
engage in good ethically and legally informed practice. Many schoolsmaywishtodomorethan
wehave outlined and this istobe commended. We believe thatthey shouldnotdo less.
Thoseresponsible for creating thecore
consensus statementonmedical ethics and lawteaching
Dr RichardAshcroft,Lecturer, Ethicsin Medi-cine, Universityof Bristol
Professor Dennis Baron, part-time tutor in
Medical Ethics(Rtd),StMary's HospitalMedical
School
Professor Solomon Benatar, Visiting
Co-Director, Centre for Medical Ethics, University College Londonand RoyalFree Hospital School ofMedicine; and Professor ofMedicine,
Univer-sity ofCape Town,Republicof South Africa
Dr Susan Bewley, Director of Obstetrics/ Honorary Senior Lecturer, United Medical and
Dental Schools ofGuy'sand St Thomas's
DrKenneth Boyd, SeniorLecturer in Medical Ethics, University of Edinburgh
TheRev'dJeremyCaddick,Deanof Emmanuel College, University of Cambridge
Professor Alastair Campbell, Professor of Eth-ics inMedicine, UniversityofBristol
Dr ACattan, LecturerinMedicine, University of Newcastleupon Tyne
Dr Graham Clayden, Reader in Paediatrics, United Medical and Dental Schools of Guy's and St Thomas'sHospitals, London University
Dr Albert Day, Senior Medico-Legal Adviser,
MedicalProtection Society
Dr Maria Dlugolecka, Consultant in Public Health Medicine andHonorary Senior Lecturer, University of Edinburgh
DrDonnaDickenson, Leverhulme Senior Lec-turerinMedical Ethics andLaw,Imperial College School ofMedicine, London University
Professor Len Doyal, Professor of Medical
Eth-ics, St Bartholomew's and The Royal London School of Medicine and Dentistry, London University
DrHeatherDraper,LecturerinBioethics, Uni-versity of Birmingham
Dr Bobbie Farsides, Lecturer in Medical Ethics, King's College School of Medicine and Dentistry, London University
Dr Martinvon Fragstein, Lecturer inGeneral Practice, Queen's Medical School, University of Nottingham
Professor Ken Fulford, Professor of Philosophy and MentalHealth, Oxford and Warwick
Univer-sities
Professor Raanan Gillon, Professor of Medical Ethics, Imperial College School of Medicine, London University
Dr Dane Goodman, Medical Educational Ad-viser,United Medical and Dental Schools ofGuy's
andSt Thomas'sHospitals,LondonUniversity
MsVivienneHarpwood,SeniorLegal Lecturer, CardiffLawSchool,University of Wales
Professor John Harris, Sir David Alliance Professor ofBioethics, Institute of Medicine, Law
andBioethics,ManchesterUniversity
TheRev'dPeterHaughton, AdviserinMedical Ethics and Law, United Medical and Dental Schools of Guy's and St Thomas's Hospitals,
LondonUniversity
Dr Peter Healy,Honorary Tutor, Department ofBiomedical Science and Ethics, University of Birmingham Medical School
Professor Roger Higgs, Professor of General Practice andPrimaryCare,King's CollegeSchool of Medicine andDentistry,LondonUniversity
DrAnthonyHope, UniversityLecturerin Prac-ticeSkills, University of Oxford Clinical School
Dr Jennifer Jackson, Senior Lecturer,
Depart-mentof Philosophy, University of Leeds
Dr Ian Jessiman, Elected member of General Medical Council
Professor Alan Johnson, Professor of Surgery,
University of Sheffield
The Rev'd Dr Jennifer King, Honorary Lec-turerinEthics, St Bartholomew's and The Royal London School of Medicine and Dentistry, LondonUniversity
Dr StevenLutrell, Senior Registrar, University College, London University
Professor Eric Matthews, Professor of
Philoso-phy,University of Aberdeen
DrRichard Meakin, Senior Lecturer in General Practice, Royal Free Hospital School of Medicine, LondonUniversity
Dr Michael Parker, European Coordinator for Biomedical Research Project, Imperial College School of Medicine, London University
Dr 0 Portsmouth, Honorary Senior Clinical Lecturer,University of Birmingham
Dr Lisa Schwartz, Lecturer in Philosophy of Medicine, University of Glasgow
Dr Francoise Shenfield, Clinical Lecturer in
Obstetrics and Gynaecology and Honorary
Lec-turer in Medical Ethics, University College LondonMedical School, London University
DrDavidSnashall, SeniorLecturer in Occupa-tional Medicine, United Medical and Dental Schools of Guy's and St Thomas's Hospitals,
London University
Ms Ann Somerville, Head of Medical Ethics,
BritishMedical Association
DrTimothy Steiner, Reader inNeurosciences, Imperial College School of Medicine, London
University
The Rev'd Bryan Vernon, Lecturer in Health CareEthics, University of NewcastleuponTyne
Mr Christopher Ward, Consultant Plastic Surgeon and Honorary SeniorLecturerin Medi-cal Ethics, Imperial College School ofMedicine, London University
Dr Luke Zander, Senior Lecturer in
Depart-ment of General Practice, United Medical and Dental Schools ofGuy's and St Thomas's
Hospi-tals, LondonUniversity
Dr Paquita de Zulueta, Lecturer in Medical Ethics,Imperial College, LondonUniversity References
1 General Medical Council. Tomorrow's doctors. London: General MedicalCouncil 1993:14,26.
