Medical ethics and law as a core subject in medical education

In Tomorrow’s Doctors Britain’s General Medical Council initiated a radical and needed reform of medical education. One of the less noticed, yet revolutionary, aspects of this reform is that medical ethics and law have become a core component of the curriculum. Thus all medical students, states the council, must acquire knowledge and understanding of ethical and legal issues relevant to the practice of medicine and be able “to understand and analyse ethical problems so as to enable patients, their families, society, and the doctor to have proper regard to such problems in reaching decisions.”¹ 

Seeking to pool their expertise, most of the academics currently teaching medical ethics and law in UK medical schools—mostly clinicians, philosophers, lawyers, and theologians—hammered out a consensus statement about what should constitute the core academic content necessary to produce “doctors who will engage in good ethically and legally informed practice.” They also agreed some minimal organisational requirements for the subject to be taught successfully.

The consensus statement sees the teaching of medical ethics and law as contributing to the overall objective of medical education—“the creation of good doctors who will enhance and promote the health and medical welfare of the people they serve in ways which fairly and justly respect their dignity, autonomy and rights.” To achieve these goals medical students must be able to understand the ethical principles and values underpinning good medical practice; be able to think critically about ethics, reflecting on their own beliefs and understanding and appreciating alternative, perhaps competing, approaches; and “be able to argue and counterargue in order to contribute to informed discussion and debate.” Students must know the main professional and legal obligations of doctors in the UK, especially those specified by the General Medical Council, and be able constructively to participate in the ethical and legal reasoning needed in everyday practice.

We cannot detail here all the recommendations of the consensus statement. It, and the names of those who created it, are available on the BMJ’s website (www.bmj.com) and will be published in the Journal of Medical Ethics.² The box, however, outlines the 12 agreed themes of the proposed core curriculum, along with an indication of some of the ethical and legal topics encompassed by those themes, all of which the consensus document proposes must be taught.

Core curriculum for medical ethics and law

(1) Informed consent and refusal of treatment—Why respect for autonomy is so important; adequate information; treatment without consent; competence; battery and negligence.

(2) The clinical relationship: truthfulness, trust, and good communication—Ethical limits of paternalism; building trust; honesty, courage, and other virtues in clinical practice; narrative and the importance of communication skills.

(3) Confidentiality—Clinical importance of privacy; compulsory and discretionary disclosure; public v private interests.

(4) Medical research—Ethical and legal tensions in doing medical research on patients, human volunteers, and animals; the need for effective regulation.

(5) Human reproduction—Ethical and legal status of the embryo/fetus; assisted conception; abortion, including prenatal screening.

(6) The new genetics—Treating the abnormal v improving the normal; debates about the ethical boundaries of and the need to regulate genetic therapy and research.

(7) Children—Ethical and legal significance of age to consent to treatment; dealing with parental/child/clinician conflict; child abuse.

(8) Mental disorders and disabilities—Ethical and legal justifications for detention and treatment without consent; conflicts of interests between patient, family, and community.

(9) Life, death, dying, and killing—The duty of care and ethical and legal justifications for the non-provision of life prolonging treatment and the provision of potentially life shortening palliatives; transplantation, death certification, and the coroner’s court.

(10) Vulnerabilities created by the duties of doctors and medical students—Public expectations of medicine; the need for teamwork; the health of doctors and students in relation to professional performance; the General Medical Council and professional regulation; responding appropriately to clinical mistakes; whistleblowing.

(11) Resource allocation—Ethical debates about “rationing” and the fair and just distribution of scarce health care; the relevance of needs, rights, utility, efficiency, desert, and autonomy to theories of equitable health care; boundaries of responsibility of individuals for their own health.

(12) Rights—What rights are, and their links with moral and professional duties; the importance of the concept of rights, including human rights, for good medical practice.

The consensus group states explicitly that its specification of the content of these core issues is not intended to prejudge how they are to be taught, but one way or another “all the topics specified ought to be addressed.” Equally, there was unanimous agreement that, whileteaching of this subject should be widely shared within medical schools, its adequate provision and coordination require at least one full time senior academic in ethics and law with relevant professional and academic expertise—for the subject is “an emerging academic discipline with intrinsic and rigorous standards.” Medical ethics and law can no longer be taught by well disposed clinicians without some consistent interaction with and support from specialists.

The consensus group recommends that medical ethics and law should be introduced systematically, should feature throughout the entire clinical curriculum (right through to the house officer year), and should be fully integrated within it. Such integration should include each clinical discipline addressing ethical and legal issues of particular relevance to that discipline, especially those which students will have personally encountered on their course. Finally, the competence of both students and teachers should be formally assessed, with the same rigour as for any other core subject.

The proposed curriculum is a full one, and each medical school is likely to implement it differently—which to non-hegemonists is one of the strengths of the document. What the consensus group regarded as non-negotiable, however, is the need to implement all of it. The burden must fall on those who reject any component of the proposed core curriculum to explain why a newly qualified doctor does not need to understand it. We have no doubt ourselves that the interests of medical students, the medical profession, patients, and the community at large converge in urging stiff resistance to any attempts to reduce what the consensus group sees as the minimal content of a core curriculum for medical education in medical ethics and law.