Getting ethics into practice

In their day to day practice, clinicians make not only scientific judgments about the effectiveness of one intervention in comparison with another but also value judgments. Sometimes such judgments are explicit—for example, when a doctor reflects on his or her own moral views about the permissibility of abortion. In most cases, however, value judgments in medical practice are implicit in what seem, at first glance, to be “clinical” decisions.

Thus doctors may not think of themselves as making value judgments when, for example, considering what would be in an incompetent patient's best interests, weighing up whether harm to a third party is serious enough to justify a breach of patient confidentiality, or assessing quality of life in intensive care. Yet these decisions do indeed entail the making of value judgments, as do others—such as those in priority settings. Good medical practice requires that such value judgments are properly analysed and assessed, just as scientific and technical evidence should be properly evaluated and evidence based. It requires too that, when asked, doctors can justify both the value judgments and the scientific judgments informing their practice. To do so, they need education, support, and guidance, as well as opportunities to share models of good ethical practice in discussion with their colleagues. This week the BMJ starts a new occasional series on “Ethics in practice,” which aims to describe cases in which value judgments are needed and to discuss the sort of ethical analysis that might underpin those judgments (p 165).¹

The belief that decision making in medicine has an important ethical component has been apparent for as long as medicine has been practised. Nevertheless, the ethical dimensions of practice have become more prominent recently, initially in the 1970s and 1980s in the United States and subsequently elsewhere, for several reasons.² Firstly, public attitudes to the professions have changed to a welcome willingness to require of professionals that their decisions are based on good reasons rather than simply tradition or authority. Secondly, technological developments such as organ transplantation, critical care, and assisted reproduction have created new ethical problems and intensified old ones. Thirdly, several high profile scandals in medicine, from Tuskegee (where prisoners were infected with syphilis and left untreated) to Alder Hey (where children's organs were retained after autopsies without the parents' consent), have led to increased scrutiny of medicine and to calls for health professionals and managers to justify their practice in ethical terms.

This increased awareness of the ethical dimension of medicine has led to three major developments: laws and guidelines designed to regulate medical practice in ethically sensitive areas, innovative forms of ethics support in clinical settings,³ and an increased emphasis on ethics in the medical curriculum.⁴ Although these developments are welcome, they are not enough.

Law and guidance can provide frameworks for good practice but cannot determine what is good practice in individual cases. Similarly, while providing important sources of education, case consultation, and policy development, clinical ethics committees cannot provide day to day ethics support in all clinical situations. In the United Kingdom the role of clinical ethics committees and the comparative merits of different forms of clinical ethics support are being considered by a Royal College of Physicians working party, due to report at the end of 2004. It is clear, however, that just as laws and professional guidelines need to be complemented by the development of appropriate skills and awareness in doctors themselves, so too will any form of ethics support. Doctors still need to be able to recognise the value judgments implicit in their practice, assess the merits of various competing courses of action, and be able to justify their decisions, at least in part, in ethical terms.

This shows that providing ethics teaching in medical schools is central to developing and maintaining good medical practice. Ethics is increasingly taught to all medical students, and textbooks covering the core topics in ethics have been developed.⁵ Many doctors currently practising will, however, have received little or no ethics education. This implies the need for continuing professional education in ethics. The BMJ's new series is aimed at contributing to that continuing education by helping practising health professionals think more deeply about the ethical aspects of their practice.