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Last Updated: Monday, 4 December 2006, 10:02 GMT
The changing nature of medicine
By Dr Daniel Sokol,
Keele University

Mrs Jones is a 75-year-old woman with a malignant cancer of the colon.

Giving medication can cause ethical dilemmas

She also suffers from uraemia, a toxic condition caused by kidney damage. Although surgery is possible, it will only prolong her life for a few weeks and her death, from metastatic cancer, is likely to be painful.

For her doctor, foregoing surgery will lead to a more peaceful death. With her best interests at heart, he strongly recommends this option to Mrs Jones. Mrs Jones disagrees. She wants surgery.

Dr Stevens, a junior doctor, has accidentally given the wrong dose of medication to an elderly patient.

Thankfully, the mistake is benign. The patient is uncomfortable for a few hours but there are no long term medical consequences. The patient appears unaware of the mistake.

Mr Fildes, a 60-year-old man and life-long heavy smoker, is dying from metastatic lung cancer.

To control his severe pain, he is put on a morphine drip. A week later, Mr Fildes is unresponsive.

The distraught family ask the doctor to increase the dose to "let nature take its course".

'A safe distance'

For a long time, medical ethics was synonymous with etiquette.

As members of a learned and distinguished profession, doctors had to behave in a gentlemanly manner.

How should they ask their patients for payment? How should they examine a lady's abdomen?

In the early 19th century, for example, it was relatively uncommon for doctors to examine the body of their patients.

One of the main advantages of the flexible stethoscopes that appeared in the 1830s, beside reassuring the doctor that he was probably a safe distance from the sick patient, was that it could be used on respectable ladies with a much reduced risk of offending them.

Even a few decades ago, the thought of studying medical ethics formally was unthinkable. One learnt ethics by watching and copying one's seniors.

'Recent addition'

Professor Raanan Gillon, a renowned medical ethicist and retired GP, remembers the time when, as a medical student, he saw one of his teacher's refuse an abortion to a 14-year-old girl because she was a 'slut'.

On another occasion, he recalls standing last in a line of six medical students, each waiting to examine the testicles of a clearly embarrassed patient. When, as a junior doctor, he approached his consultant with the idea of doing a PhD in medical ethics, his project was dismissed with an incredulous laugh: "you can't study medical ethics!'.

Many practising doctors have never received any training in resolving ethical dilemmas
Daniel Sokol

Today, every medical school in the UK must teach the subject to medical students.

However, this is only a recent addition to the already packed curriculum, and medical schools vary greatly in how much emphasis they put on medical ethics teaching.

Many practising doctors have never received any training in resolving ethical dilemmas, despite the fact that developments in medical technology have made such dilemmas more common than ever.

Although some doctors do not see this as a problem, many others voice concerns about their ability to provide sound arguments to justify their ethical decisions.

They operate by intuition, hoping they get it right. They might be at ease when performing a delicate medical procedure, but lack confidence when discussing the thorny concept of futility.

Recognising the significance of ethics to good clinical practice, a recent report by the Royal College of Physicians (RCP) recommended that key medical staff have training in clinical ethics.

Professional help

In response to the RCP's report, Imperial College last week launched the UK's first course in Applied Clinical Ethics (ACE) for clinicians.

The course tackles the central ethical issues in medicine: when is it morally acceptable to withdraw life-saving treatment?

When should doctors consider do-not-resuscitate orders? What happens when patients or relatives disagree with doctors? How should they handle mistakes or deal with problem colleagues?

What role should culture and religion have in decision-making? The aim of the course is simple: to turn clinicians into budding clinical ethicists.

In North America, clinicians can call on professional ethicists for help in resolving moral dilemmas.

Based in hospitals and armed with PhDs, these clinical ethicists are trained in analysing and resolving complex ethical problems in medicine.

Like other healthcare professionals, they can be bleeped and called onto the wards to visit clinicians, patients or relatives, and are considered members of the multi-disciplinary medical team.

In the UK, such a profession does not yet exist. Clinicians are on their own.

When people think of medicine, they think of science and technical miracles, but it is a deeply moral enterprise.

Questions of value, of good and bad, right and wrong, pervade the practice of medicine.

The focus of clinicians' training should not fall exclusively on the technical side, but also on the long-neglected ethical dimension. In the end, clinicians, patients, and society itself will benefit from this broader approach.

Daniel Sokol is a medical ethicist at Keele University and Director of Imperial College's Applied Clinical Ethics course.


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