Journal ofmedical ethics, 1987, 13, 144-149

Teaching medical ethics symposium

Medical ethics and the clinical curriculum:a case studyLen Doyal with Brian Hurwitz and John S Yudkin, Middlesex Polytechnic, General Practitioner andWhittington Hospital respectively

Authors' abstract

There are very few medical ethics courses in Britishmedical schools which are a formal part of the clinicalcurriculum. Such a programme is described in thefollowing, along with the way in which the long-termcurriculum committee of the University College andMiddlesex HospitalJointMedical Schoolwas persuadedto make it compulsoryforfirst-year students. Pedagogicallessons which have been learned in its planning andimplementation are outlined and teaching materials areincluded concerning student and course assessment whichshould be useful for others engaged in similar work.Finally, some of the institutional obstacles facing suchattempts are discussed, particularly problems concerningtimetabling, different types of opposition and theconsequent importance ofbuilding alliances among clinicalteaching staff.

IntroductionIn September 1985, Brian Hurwitz and I began to teachmedical ethics to first-year clinical students of the newlyformed Joint University College and Middlesex HospitalMedical School. The course consists of 12 sessionscovering the major topics in the field and is taught threetimes a year at the Whittington Hospital, where one thirdof the first-year students are based each term in groupsof around 70. Because of its length, structure and the factthat after a trial period it was approved as a formal andassessed part of the clinical curriculum, the coursemay be unique in the UK. It has met with great successwith students and some staff and led, among otherthings, to a King's Fund Fellowship at the Centre ofMedical Law and Ethics at King's College, London.In the following paper, we will describe thebackground to the development of the course, itscurrent content and method of presentation, theapproach which we have taken to its assessment,details of the student response to it, and some of theproblems encountered in trying to make it a success.In doing so, we shall focus on experiences which have

Key words

Teaching medical ethics.

particular relevance to those who are attempting toget similar programmes off the ground, often no doubtin the face of considerable opposition.

BackgroundIn 1982/3, we began a series of informal and optionalseminars on a weekly basis on social issues withinmodern medicine. The topics we chose werewideranging and covered everything from debatesconcerning prevention v cure to health and safety atwork. Initially, medical ethics constituted only a smallpart of the programme. The innovative character ofthese sessions concerned not so much the originalityof the topics chosen - these were fairly standard farefor any short course in social medicine. Rather it wasthe format of presentation that proved particularlysuccessful in stimulating discussion and interest. Eachsession consisted of a brief introduction to the issuefor that week (for example why so many people smoke)followed by a video - usually from a relevant televisionprogramme - highlighting the concepts and argumentsraised. A discussion then ensued which was designedto elicit responses from as many of those present aspossible and to encourage debate between them. Theresults were often quite electric - excellent interchangewith maximum participation.

Yet there were problems and serious ones. The onlyslot that we could find on the timetable when asignificant number of students were even potentiallyfree was on one afternoon at 4:30 pm. This meant thataudiences were small and inevitably self-selected withall of the dangers of insularity that this can bring.Further, it became clear that some topics were beingdiscussed at too general a level for many of thestudents, who were more at home with traditional casepresentation. In reviewing what might be done aboutthis, three things became clear. First, it was by thatstage obvious that the most popular topics concernedethical issues of one sort or another. For example, theweek devoted to the abortion debate always attractedmaximum attendance. For this reason and spurred onby the General Medical Council (GMC) rulingconcerning ethics teaching in medical schools, wedecided to devote the entire programme to moralissues, including some which are unorthodox by

copyright. on June 20, 2020 by guest. P

rotected byhttp://jm

e.bmj.com

/J M

ed Ethics: first published as 10.1136/jm

e.13.3.144 on 1 Septem

ber 1987. Dow

nloaded from

Teaching medical ethics symposium: Medical ethics and the clinical curriculum: a case study 145

conventional standards (for example the ethicaldilemmas facing doctors in underdevelopedcountries). Second, we had to find another time whenmost students would be available and to ensure thatthey would all be maximally motivated to attend. Andthird, we were convinced that we should retain theformat of a short introductory lecture, video anddiscussion, but with the video being devoted to casesposing specific moral dilemmas.

Medicine and morality: a course in medicalethics

These changes proved remarkably successful. Withthe help and encouragement of Mr John Cochrane,the Undergraduate Sub-Dean at the Whittington, and DrJohn S Yudkin, Consultant and Senior Lecturer, wediscovered a time on Tuesdays when most studentswere free: 12:30-2:00 pm. Both encouraged us to runour newly formulated ethics course as a trial for oneterm and if successful to propose it as a formal partof the first-year clinical programme. Dr Yudkin hasparticipated fully in its planning and operation.Retaining the format of the earlier course (lecture/video/discussion), its general content was and still isas follows:

Syllabus1. Moral reasoning and medical ethics: Rules ineveryday life. Moral rules: an introduction. Moralrules and medical practice: protect life/health, respectautonomy. The philosophical character of moral rulesand why they do not dictate their own interpretation.Disputes about interpretation and their resolution.Persons v bodies. Video: a case concerning euthanasia.2. The rights and duties of doctors: More onprotecting life and respecting autonomy in practice.The concepts of 'rights' and 'duties'. Moralfoundations of the obligations of doctors. Universalmoral values v contract. Clashes between professionaland private moral commitments. Telling the truth asan example. How much truth are doctors obligated totell? Video: a case concerning terminal care.3. Medicine, autonomy and confidentiality: Why isconfidentiality so important for the practice ofmedicine? The philosophical character of promises.Under what circumstances - if any - can breaking aconfidence be justified? Obligations to patients vobligations to the public. Conflicts of interest and whygeneral practitioners have such a tough time of it.Video: a case concerning venereal disease.4. Morality and scarce resources: Choosing who getswhat in the face of scarcity. The concept of 'entitlement'.Two rival approaches to moral justification:utilitarianism v deontology. Sexism, ageism and scarceresources. The importance of collective decision-making. Can politics be kept out of medicine? Video:a case concerning kidney machines.5. The ethics of medical experimentation: Can theselective treatment of patients for research purposes

be morally justified? What about other forms ofvoluntary participation in potentially hazardousexperiments? Individual autonomy and the problemsof informed consent. The rights of patients and theproblem of expertise. The rights of doctors and theimportance of medical research. The constitution ofresearch ethics committees. Video: a case concerningcancer research with geriatric patients.6. And what is life?: Back to persons. Biological vtheological and social definitions of personhood. Thephilosophical importance of language use in thisrespect. The concept of biological 'viability' and itsdependence on the state of technological advance. Themorality of embryo experimentation and what to dowith the spare embryos. Evaluating the WarnockReport. The importance of public opinion in resolvingmoral disputes in medicine. Video: a case concerninginfertility.7. A woman's right to choose: The question ofabortion. Utilitarian and deontological arguments bothpro and con. The law. Further problems aboutdefining life and autonomy in relation to theimportance of protecting and respecting them (forexample the perils of the 'potentiality' argument).Illustrations of the use of counterexample in moralargument through taking arguments both pro and conto extreme limits. Video: a case concerning abortion.The ethical dilemmas ofsurrogacy. More on Warnock.8. Morality and paediatrics: Giving birth to andcaring for disadvantaged children- who decides? Yetmore on personhood. What constitutes a 'severe'handicap. The social character of criteria of normality.Why plausible individual cases of omission orcommission leading to death can have problematicmoral and legal implications. The Arthur case and thecase of Baby Doe. Determining the rights and dutiesof doctors v the rights and duties of parents. Video:a case concerning neonatal brain damage.9. Morality and mental illness: Defining mentaldisturbance and related debates. Does the lack of aspecific aetiology for mental disturbance lead to ethicalproblems for orthodox psychiatric medicine. More onthe social character of normality and the difficultiesof psychiatric diagnosis. The problem of determiningthe rights and duties of those who suffer from impairedautonomy. The justifiability of behaviour therapy,force and drugs as treatments. Video: a caseconcerning anorexia.10. The ethics of prevention v cure: Theenvironmental context of protecting life. Questioningthe importance of curative medicine in explaining thedecline of the infectious diseases. Back to the politicsof resource allocation. If doctors are morally obligatedto protect life and health collectively as well asindividually, should a larger percentage of the healthbudget and the medical curriculum be devoted to socialmedicine and primary care? To what extent shouldindividuals be held morally responsible for illnesseswhich they could themselves have prevented and towhat extent should they be given treatment? Video:

copyright. on June 20, 2020 by guest. P

rotected byhttp://jm

e.bmj.com

/J M

ed Ethics: first published as 10.1136/jm

e.13.3.144 on 1 Septem

ber 1987. Dow

nloaded from

146 Len Doyal with Brian Hurwitz andJohn S Yudkin

a case concerning smoking.11. Medicine, morality and underdevelopment: Moreon prevention v cure. Ethics, political economy andpatterns of illness in the Third World. Who can besaid to be morally responsible for such high levels ofmortality and morbidity? To what extent can goodhealth be regarded as a universalisable right? Hardchoices: medical resource allocation against thebackground of severe resource constraints. Whyprimary care is an ethical as well as medical issue.Implications for medical education in underdevelopedcountries. Video: the case of Zimbabwe.12. Medical ethics and medical education: Learningto be a moral doctor v getting doctored. The moraltrials and tribulations of being a medical student.Relationships between students and teachers. Theethics of educational authority. Relationships betweenstudents and patients. Encountering moral dilemmasfor the first time and against the background of limitedformal responsibility. Relationships between studentsand students. The ethics of professional andeducational competition. The ethics of the curriculum.Back to prevention v cure. Video: the case of a Londonmedical school.

With the exception of the last, each of the precedingsessions conforms to the mode of presentation alreadyoutlined. We believe that a brief introductory lectureis necessary to outline the philosophical backgroundfor medical students to get the most benefit from thevideo and the discussion which follows. Without suchan overview, only the very best students will feel thatthey have a sufficient conceptual 'take' on the casematerial to say something confidently about it. Sufficeit to say that the specific case presented in each sessioninevitably suggests many others which are mentionedby them, or us, and which together usually cover thespectrum of arguments which need to be engaged.Further, students are always encouraged at thebeginning of each session to try to integrate into thediscussion any relevant clinical material which theyhave experienced or heard about on the wards. Finally,a minimal amount of reading from the establishedtexts is assigned for each session with multiple copiesavailable in the library.

Assessing them and us

We realised from the beginning that if we were to getthe students to take the course and the medical schoolto take us seriously then both they and we would haveto be assessed. For the student evaluation of the courseand our performance, we distributed - and continueto do so - the following questionnaire at the end ofeach programme:

Student Evaluation: 'Medicine and morality'Please answer all of the following:1. Approximately how many of the ethics sessionshave you attended?

2. How interesting did you find the sessions as a whole?(For all questions of this type we structuredthe answers as . . . Very; . . . Fairly; . . . NotVery; . . . Not At All)3. Which were the most interesting sessions whichyou attended?4. How relevant to medical education did you considerthe specific issues comprising the programme?5. Were there any issues which you think should havebeen included but were not?6. Given the small amount of time allocated to thecourse, its presentation was an attempt to combineboth a formal lecture component and a more informaldiscussion component. How successful would you ratethis attempt?7. Do you have any other remarks about thepresentation of the course and/or its balance?8. We also tried to integrate a film component intothe course. How would you rate its success?9. In your syllabus, a small amount of readingwas recommended. How much did you do? (. . . All;. . . Some; ... None)10. Would you like to see further courses on medicalethics in your second and third years?11. Provided that you were convinced that it could bedone objectively, would you be for or against medicalethics becoming a formally assessed subject countingtowards your overall result?12. What were the main factors which prevented youfrom attending sessions?After one trial-term the resulting feedback wasgratifyingly positive. Attendance was high (betweenone half and two thirds on a regular basis) and it wasclear that most of the students enjoyed the course, feltthat it achieved a good balance and thought that itshould be continued - indeed expanded! Aside fromthe intrinsic merits of the programme, it was on thisbasis that the curriculum committee agreed that thecourse should become a formal part of the first-yearcurriculum. Attendance and student evaluations havecontinued to be good during subsequent terms.

Yet it was also obvious that we had to evaluate thestudents. Here the aim was to devise a diagnosticassessment which would give us and them some ideaof how much of the course they had understood. Inorder to convince the medical school that this waspossible, especially against the background ofarguments to the effect that moral understanding couldnot be evaluated 'objectively', we also created a trialassessment for the first group to do the course and aspecimen answer paper which could in principle beused by any assessor. These are outlined below andhelped to convince the curriculum committee to agreeto similar assessments being incorporated into thecourse on a compulsory basis.

Student assessment: 'Medicine and morality'

Below you will find two fictitious cases (only one willbe described here) adopted from real events which

copyright. on June 20, 2020 by guest. P

rotected byhttp://jm

e.bmj.com

/J M

ed Ethics: first published as 10.1136/jm

e.13.3.144 on 1 Septem

ber 1987. Dow

nloaded from

Teaching medical ethics symposium: Medical ethics and the clinical cumrculum: a case study 147

raise a number of issues which we considered on thecourse. Please read each of them and choose whichone you find the most interesting. Then answer all ofthe questions that follow in not more than oneparagraph each. In your responses, be sure to argue -to give reasons for what you say - and not just to assert.Case 1: 'John K, a 32-year-old lawyer, worried forseveral years about developing Huntington's chorea,a neurological disorder that appears in a person'sthirties or forties, bringing rapid uncontrollabletwitching and contractions and progressive,irreversible dementia, leading to death inapproximately ten years. John K's mother died fromthis disease, which is autosomal dominant and afflicts50 per cent of an affected parent's offspring. Oftenparents have children before they are aware that oneof them has the disease. John K and his wife have achild because of contraceptive failure and anunwillingness to have an abortion because of his wife'sreligious convictions.John K has indicated to many people that he would

prefer to die rather than live and die as his motherlived and died. He is anxious, drinks heavily and hasintermittent depression, for which he sees apsychiatrist. Nevertheless, he is a productive lawyer.John K first noticed facial twitching three months

ago, and two neurologists independently confirmed adiagnosis of Huntington's. He explained his situationto his psychiatrist and requested help in committingsuicide. When the psychiatrist refused, John reassuredhim that he did not plan to attempt suicide any timesoon.

But when he went home, he ingested all his anti-depressant medication, after pinning a note to his shirtto explain his actions and to refuse any medicalassistance that might be offered. His wife, whom hehad not told about the diagnosis, found himunconscious and rushed him to hospital withoutremoving the note'(1).

1. Employing a fictitious example other than theabove, illustrate the two most important principlesguiding ethical judgements in medicine - protect life/health and respect personal autonomy - and thetensions which exist between them.2. Discuss how these same principles and tensions areillustrated by your chosen example.3. Assume that in Case 1, John K was successfullytreated with a stomach pump by the physician inauthority after reading and understanding the note.Now outline at least two ethical arguments for thecourse of action which was followed.4. Outline at least two ethical arguments against thiscourse of action.5. Is there anything which you should never do inarriving at a medical ethical judgement about aparticular patient? Why?6. Assume that you are a member of a hospital clinicalethics committee - assuming that such things existedin Britain - which considers cases and issues like the

above. Who should be represented on this committeeand why? What should its powers be and why?There is not sufficient space to repeat the whole ofthe specimen answer which convinced the sceptics thatobjective assessment of answers to the above wasfeasible. Readers will be familiar with the sorts ofreplies which would be appropriate for the questionsasked. However, it might be of interest to include oursample answer to question 5 because of its speculativecharacter and since it gives a sense of the moral valuesabout which a consensus often emerges by the end ofeach course.

5. 'There are three things which should not be done.First, doctors should not knowingly break the law.Second, they should not make ethical decisions purelyon the basis of an individual evaluation without, wherepossible, consulting relevant colleagues. And third,they should not act on judgements which are solelyderived from religious or moral dogma. Again, theyshould consult with colleagues who are known to haveother views, should inform patients of their ethicalconvictions and offer an alternative consultation if itis desired. The reasons for all three guidelines aresimilar. We have seen on the course that rules do notin themselves determine their varying individualinterpretations and therefore cannot in themselves bereferred to for guidance. One needs others for the sortof collective instruction which is enshrined in law andin the judgements of colleagues'.

This is precisely the sort of answer that many of thestudents regularly reproduce. Indeed, the workproduced by a large percentage of those who attemptthe assessment - creative and rigorous argument of ahigh standard - has been gratifying.

ProblemsSince its inception, the difficulties which we haveconfronted with the course have fallen into threecategories: institutional, attitudinal and logistic.Beginning with the latter, it is notoriously difficult tofind a time during the week when all clinical studentsare free. At the Whittington, we were lucky, althoughwe also suspect that the legendary inflexibility of theclinical timetable has more to do with institutionalinertia than reality. For example, many studentscomplain bitterly about the amount of time which theyspend on their firms 'standing around and waiting forsomething to happen'. No doubt it can be argued thatthis experience is part of the apprenticeship characterof medical education. Students have to learn that being'on call' requires patience as well as expertise. Equallywithout question is the fact that a schedule based onward work within firms makes finding a time whenstudents can be sure to be exempt from medical dutiesextremely problematic. For example, they can hardlydown tools in the middle of assisting in surgery todash to their medical ethics class! However, the

copyright. on June 20, 2020 by guest. P

rotected byhttp://jm

e.bmj.com

/J M

ed Ethics: first published as 10.1136/jm

e.13.3.144 on 1 Septem

ber 1987. Dow

nloaded from

148 Len Doyal with Brian Hurwitz andJohn S Yudkin

comeback surely is that if medical ethics really isbelieved to be an integral part of clinical medicine - if itis accepted that the practice of medicine inevitably has amoral dimension to it which students should also betrained to understand - then the small amount of timerequired for a proper course in the area can surely befound for most students most of the time. Timetablingdifficulties do pose administrative problems which canbe daunting in their complexity. However, in ourexperience of other types of educational institutions,these are usually solvable provided that there is notsome other reason for not trying. Which brings us toattitudes.Even though many of the students were willing to

miss or curtail their lunch break to attend the course,their questionnaires revealed that some of theirconsultants actively discouraged them from doing so.They did this without discussion with us and afterhaving been reminded by the Sub-Dean that the coursewas a formal part of their students' clinical training.Since no further action has been taken to correct thissituation, many students who want to participatecannot - at least on a regular basis. In order to try tocorrect this, we have invited staff to the sessions butwith only limited success. Interestingly, those doctorswho have attended or who have been willing to discussthe course with us have almost always had their doubtsallayed. In short, there can be no doubt that manydoctors are distressed by the idea of ethics being'taught' rather than 'observed in practice' on thewards. The paradox is that until they experience suchteaching, along with its practical relevance to theirown work, it is extremely difficult to win them over.With this in mind, we have contributed to some ofthe mainstream clinical teaching through discussingethical dilemmas raised by cases presented at sessionsof both the staff round and junior 'circus'. But webelieve that one ofour chief failings at the Whittingtonhas been not spending enough time in discussing theseissues with clinical colleagues. We hope to remedythis in the future. A further problem with attitudesconcerns the course assessment. As it stands it is'compulsory' in the sense that anyone who does notdo it has this fact entered into their record. However,since most of the students know that the attitude ofsome of the authorities of the medical school towardsthe course is at best ambiguous, this is hardly a causeto take the assessment as seriously as they might -despite the praise with which they otherwise speak ofthe course. The same problem leads to even the beststudents doing very little of the assigned reading. Inorder to correct this situation, we see no alternativebut to assess ethics in the same way as other clinicalsubjects, with grades which count towards students'final results.

Finally, despite the endorsement of the course bythe curriculum committee of the Joint School, theinstitutional status of the course remains both unclearand insecure, both from the perspective of long-termfunding and as regards the clear support of the

respective deans and others. The reasons for thisare obscure, although they will no doubt be clarifiedin a committee which has been constituted to discussthe overall teaching of ethics in both the pre-clinicaland clinical years. Such confusion is particularlysurprising in the light of the popularity of the courseand the interest which it has generated in other medicalschools and in the profession generally. We suspectthat the reasons may be specific to the internal politicsof the formation of the Joint School which appear tobe highly complex and to the fact that we actuallyteach the course at neither of the constituent medicalschools. Of course, they are also in part due to someof the attitudinal factors referred to above. The futureof the course seems by no means assured.

Conclusion

Given the preceding, we believe we have learned fourkey lessons about setting up and teaching a course inmedical ethics to clinical students. First, if the courseis to be successful, it must immediately strike studentsas relevant to what the practice of medicine both isand should be like. It should be geared to specificcases and designed to encourage maximumparticipation in discussion of those who attend. Itshould not, in short, take the form of simply a lectureor of a discussion dominated by professionals. Second,its success must be publicly evaluated by the studentsand any other medical staff who can be encouragedto attend. Without such assessment, even with a fewkeen supporters to begin with, it will be hard toconvince those who believe that medical ethics cannotbe taught but must be gleaned through a sort of moralosmosis of apprenticeship with the right sort ofconsultant. Such opponents will obviously be highlysuspicious of outsiders (especially non-doctors!)purporting to fill this role. Third, it is crucial thateverything about a new course be seen by both studentsand staff as 'formal' and on a par with other clinicalwork. One can always put together a course that willbe reasonably successful for a - usually small - self-selected audience. The real trick is to reach those whofear the subject, for whatever reason, and who willlook for an excuse not to attend and to minimise itsimportance. This is why graded compulsoryassessment is so crucial. It is also why deans mustinsist that all consultants allow the students on theirfirms to attend scheduled ethics teaching and continueto do so in the face of opposition. We do notunderestimate the difficulty of this given both thetraditional structure of the clinical curriculum and thepower of individual consultants in its operation. Thus,fourth and finally, for an ethics course to achieve long-term stability within a medical school it is not enoughfor it to be successful with students. It is crucial toforge alliances with as many people on the clinicalstaff as possible and certainly to meet with critics fordiscussion as soon as one hears of them.

All of the above takes time and can be as frustrating

copyright. on June 20, 2020 by guest. P

rotected byhttp://jm

e.bmj.com

/J M

ed Ethics: first published as 10.1136/jm

e.13.3.144 on 1 Septem

ber 1987. Dow

nloaded from

Teaching medical ethics symposium: Medical ethics and the clinical curriculum: a case study 149

as it can be demanding. Yet the rewards are immense:all those involved agree that we have neverexperienced such exciting teaching with so much realgratitude and appreciation at the end of the day.

After graduating in Philosophy and Sociology at GeorgiaState University, Len Doyal BA MSc came to the UKas a Fulbright Fellow and gained an MSc in Logic andScientific Method at the London School of Economics.He is Principal Lecturer in Philosophy at MiddlesexPolytechnic where he teaches moral and politicalphilosophy and politics of the natural and social sciences.He is also currently an Honorary Research Fellow in theCentre of Medical Law and Ethics at King's College,London.Brian Hurwitz MRCP, MRCGP trained in medicineand the history and philosophy of science at CambridgeUniversity. He is a general practitioner in Islington inNorth London and a Research Fellow at UniversityCollege Hospital Medical School. Aside from medicalethics, his research interests include the primary care ofpatients with chronic disease.

John S Yudkin MD, MRCP trained in medicine atCambnidge University and at University College MedicalSchool. He is a consultant physician in general medicineand diabetes at the Whittington Hospital in North Londonand is a Senior Lecturer in the Department of Medicineat University College, London, and at the MiddlesexSchool of Medicine. He has published widely on clinicaltopics related to diabetes and on medicine,underdevelopment and the pharmaceutical industry. Heand Brian Hurvitz are currently engaged in research onshared hospital and primary care for diabetics.

AcknowledgementWe would like to take this opportunity to thankProfessor Ian Kennedy for the advice andencouragement he has given in all stages in theevolution of our course.

References(1) This case is taken directly from Beauchamp T and

Childress J. The principles of biomedical ethics. Oxford:Oxford University Press, 1983.

copyright. on June 20, 2020 by guest. P

rotected byhttp://jm

e.bmj.com

/J M

ed Ethics: first published as 10.1136/jm

e.13.3.144 on 1 Septem

ber 1987. Dow

nloaded from