Meeting the ethical needs of doctors
http://www.100md.com
《英国医生杂志》
We need clinical ethicists in addition to other measures
A sound knowledge of medical ethics is essential to the good practice of medicine. This belief underlies the integration of medical ethics into the teaching of medical students, the proliferation of articles and textbooks on the subject, the increasing number of clinical ethics committees in NHS trusts, and the BMJ's new series on medico-ethical problems in everyday practice.1-5 These are all indications that medical ethics constitutes an important component of medical practice. But even more conclusive evidence exists that doctors need help with ethical problems.
The BMA receives several thousand enquiries each year from concerned doctors confronted with ethical issues.6 No doubt many more doctors do not make use of the BMA's services through lack of time or embarrassment. Some doctors, especially if junior, may not wish to rock the boat by pointing to an ethically dubious practice. House officers, for example, may not feel comfortable obtaining consent from a patient for an unfamiliar procedure, but they may feel even more awkward raising the issue with a consultant. Others simply fail to identify the ethical problems pervading their day to day work.
Medical ethics is not solely common sense. The 823 pages of Medical Ethics Today, the BMA's latest handbook of ethics and law, is evidence of this.7 To expect medical students to learn more than the bare bones of the subject is unrealistic given that their curriculum is already packed to the brim. Doctors cannot be expected to undergo extensive training in the subject while working full time. The emphasis in the teaching of medical ethics should be on identifying ethical problems, logical thinking, some knowledge of the relevant law, and the importance of seeking help.
About a fifth of NHS acute trusts currently have a clinical ethics committee.4 These provide a valuable service in drafting hospital policies and helping doctors resolve ethical dilemmas. However, most clinical ethics committees are ill suited to respond to the immediate problems that doctors encounter in their daily work. Committees are not as flexible and approachable as individuals. Many doctors are unlikely to present their ethical concerns to a committee for fear of appearing foolish or ignorant. As junior doctors are notoriously loath to flag their ignorance, summoning the hospital's clinical ethics committee to evaluate a situation runs counter to the prevalent ethos.8
In North America, many hospitals have full time clinical ethicists as well as clinical ethics committees. Although not all from a medical background, most ethicists hold postgraduate degrees in subjects such as moral philosophy, theology, medical ethics, and law, and they are increasingly trained specifically in clinical ethics. They can be called on by staff or patients who need help in medico-ethical matters. Some are available 24 hours a day. Although clinical ethicists have no claim to greater virtue than others, their task is to help resolve moral problems by drawing on their knowledge of ethical issues encountered in hospitals, their past resolution, and by using a set of principles for analysing them.
Although few in number, empirical studies have shown that ethics consultations are associated with reductions in time spent on ventilators and days inhospital, and that most doctors and nurses who have used the service find it helpful.9 10 Furthermore, evidence shows that clinical ethicists score higher in moral reasoning tests than clinicians.11
Case example (hypothetical scenario, based on several real cases)
A 26 year old man is run over by a truck and dies in emergency. His wife, also in her 20s, asks the doctors to extract her dead husband's sperm, saying that they have always wanted to have children and gives evidence of their treatment for infertility. The emergency consultant calls the clinical ethicist for advice. The legal situation is unclear. (The author's response to the hypothetical case example is on bmj.com)
Clinical ethicists could also contribute to the continuing education of healthcare staff in medical ethics through lecturing and private consultations. From my own experience in Canada, doctors expressed a greater understanding of the ethical requirements of informed consent and do not resuscitate orders after attending lectures on these topics. Ethicists could teach ethics to students and doctors at the bedside, exploring the links between technical skill and ethical decision making. The hands-on involvement of clinical ethicists in teaching is likely to reduce the occurrence or recurrence of ethical violations by highlighting key ethical issues and drawing lessons from previous cases.
The idea of using clinical ethicists gives cause for some concern. Doctors may offload their ethical problems on clinical ethicists, abnegating their moral responsibilities too easily. This could be avoided through an awareness of this danger. Some sceptics may frown at the suggestion of creating yet another expert, but ethical cases, like medicine itself, are increasingly sophisticated. Questions also exist about the precise role, training, recruitment, and funding of these new professionals. Finally, the introduction of clinical ethicists should be in addition to the training in medical ethics, clinical ethics committees, and the BMA's advice centre.
In light of the accepted importance and relevance of medical ethics to everyday practice, the demand for ethical support by doctors in the United Kingdom,6 12 the impossibility of training medical students and doctors to sufficient levels of proficiency in ethics, and the success of clinical ethicists in North America, we now need to introduce clinical ethicists in hospitals in the United Kingdom. Doctors cannot possibly deal with all the ethical problems they encounter in their professional lives, nor can they be expected to analyse complex ethical issues, and to know how similar cases were handled elsewhere. Clinical ethics committees cannot alone cope with the demands of ethically troubled doctors at the coalface. The use of clinical ethicists would represent an important step forward.
Daniel K Sokol, doctoral candidate in medical ethics
Medical Ethics Unit, Department of Primary Health Care and General Practice, Imperial College, London W6 8RP (daniel.sokol@imperial.ac.uk)
The author's response to the hypothetical case example is on bmj.com
Competing interests: None declared.
References
Consensus Group of Teachers of Medical Ethics and Law in UK Medical Schools: Teaching medical ethics and law within medical education: a model for the UK core curriculum. J Med Ethics 1998;24: 188-92.
Hope T, Savulescu J, Hendrick J. Medical ethics and law: the core curriculum. Edinburgh: Churchill-Livingstone, 2003.
Sokol D, Bergson G. Medical ethics and law: surviving on the wards and passing exams. London: Trauma Publishing, 2005.
Slowther A, Johnston C, Goodall J, Hope T. Development of clinical ethics committees. BMJ 2004;328: 950-2.
Parker M. Getting ethics into practice. BMJ 2004;329: 126.
BBC. Doctors make medical ethics plea. BBC News 2 December 2003. http://news.bbc.co.uk/1/hi/health/3253786.stm (accessed 11 Feb 2005).
British Medical Association Ethics Department: Medical ethics today; the BMA's handbook of ethics and law. 2nd ed. London: BMJ Books, 2004.
Smith R. Medical mishaps. studentBMJ 1998;10: 6. (October.)
Schneiderman L, Gilmer T, Teetzel H, Dugan D, Blustein J, Cranford R, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting. JAMA 2003;290: 1166-72.
Gacki-Smith J, Gordon E. Residents' access to ethics consultation: knowledge, use, and perceptions. Acad Med 2005;80: 168-75.
Self D, Skeel J, Jecker N. A comparison of the moral reasoning of physicians and clinical medical ethicists. Acad Med 1993;68: 852-5.
Slowther A, Bunch C, Woolnough B, Hope T. Clinical ethics support services in the UK: an investigation of the current provision of ethics support to health professionals in the UK. J Med Ethics 2001;27: i2-i8.
A sound knowledge of medical ethics is essential to the good practice of medicine. This belief underlies the integration of medical ethics into the teaching of medical students, the proliferation of articles and textbooks on the subject, the increasing number of clinical ethics committees in NHS trusts, and the BMJ's new series on medico-ethical problems in everyday practice.1-5 These are all indications that medical ethics constitutes an important component of medical practice. But even more conclusive evidence exists that doctors need help with ethical problems.
The BMA receives several thousand enquiries each year from concerned doctors confronted with ethical issues.6 No doubt many more doctors do not make use of the BMA's services through lack of time or embarrassment. Some doctors, especially if junior, may not wish to rock the boat by pointing to an ethically dubious practice. House officers, for example, may not feel comfortable obtaining consent from a patient for an unfamiliar procedure, but they may feel even more awkward raising the issue with a consultant. Others simply fail to identify the ethical problems pervading their day to day work.
Medical ethics is not solely common sense. The 823 pages of Medical Ethics Today, the BMA's latest handbook of ethics and law, is evidence of this.7 To expect medical students to learn more than the bare bones of the subject is unrealistic given that their curriculum is already packed to the brim. Doctors cannot be expected to undergo extensive training in the subject while working full time. The emphasis in the teaching of medical ethics should be on identifying ethical problems, logical thinking, some knowledge of the relevant law, and the importance of seeking help.
About a fifth of NHS acute trusts currently have a clinical ethics committee.4 These provide a valuable service in drafting hospital policies and helping doctors resolve ethical dilemmas. However, most clinical ethics committees are ill suited to respond to the immediate problems that doctors encounter in their daily work. Committees are not as flexible and approachable as individuals. Many doctors are unlikely to present their ethical concerns to a committee for fear of appearing foolish or ignorant. As junior doctors are notoriously loath to flag their ignorance, summoning the hospital's clinical ethics committee to evaluate a situation runs counter to the prevalent ethos.8
In North America, many hospitals have full time clinical ethicists as well as clinical ethics committees. Although not all from a medical background, most ethicists hold postgraduate degrees in subjects such as moral philosophy, theology, medical ethics, and law, and they are increasingly trained specifically in clinical ethics. They can be called on by staff or patients who need help in medico-ethical matters. Some are available 24 hours a day. Although clinical ethicists have no claim to greater virtue than others, their task is to help resolve moral problems by drawing on their knowledge of ethical issues encountered in hospitals, their past resolution, and by using a set of principles for analysing them.
Although few in number, empirical studies have shown that ethics consultations are associated with reductions in time spent on ventilators and days inhospital, and that most doctors and nurses who have used the service find it helpful.9 10 Furthermore, evidence shows that clinical ethicists score higher in moral reasoning tests than clinicians.11
Case example (hypothetical scenario, based on several real cases)
A 26 year old man is run over by a truck and dies in emergency. His wife, also in her 20s, asks the doctors to extract her dead husband's sperm, saying that they have always wanted to have children and gives evidence of their treatment for infertility. The emergency consultant calls the clinical ethicist for advice. The legal situation is unclear. (The author's response to the hypothetical case example is on bmj.com)
Clinical ethicists could also contribute to the continuing education of healthcare staff in medical ethics through lecturing and private consultations. From my own experience in Canada, doctors expressed a greater understanding of the ethical requirements of informed consent and do not resuscitate orders after attending lectures on these topics. Ethicists could teach ethics to students and doctors at the bedside, exploring the links between technical skill and ethical decision making. The hands-on involvement of clinical ethicists in teaching is likely to reduce the occurrence or recurrence of ethical violations by highlighting key ethical issues and drawing lessons from previous cases.
The idea of using clinical ethicists gives cause for some concern. Doctors may offload their ethical problems on clinical ethicists, abnegating their moral responsibilities too easily. This could be avoided through an awareness of this danger. Some sceptics may frown at the suggestion of creating yet another expert, but ethical cases, like medicine itself, are increasingly sophisticated. Questions also exist about the precise role, training, recruitment, and funding of these new professionals. Finally, the introduction of clinical ethicists should be in addition to the training in medical ethics, clinical ethics committees, and the BMA's advice centre.
In light of the accepted importance and relevance of medical ethics to everyday practice, the demand for ethical support by doctors in the United Kingdom,6 12 the impossibility of training medical students and doctors to sufficient levels of proficiency in ethics, and the success of clinical ethicists in North America, we now need to introduce clinical ethicists in hospitals in the United Kingdom. Doctors cannot possibly deal with all the ethical problems they encounter in their professional lives, nor can they be expected to analyse complex ethical issues, and to know how similar cases were handled elsewhere. Clinical ethics committees cannot alone cope with the demands of ethically troubled doctors at the coalface. The use of clinical ethicists would represent an important step forward.
Daniel K Sokol, doctoral candidate in medical ethics
Medical Ethics Unit, Department of Primary Health Care and General Practice, Imperial College, London W6 8RP (daniel.sokol@imperial.ac.uk)
The author's response to the hypothetical case example is on bmj.com
Competing interests: None declared.
References
Consensus Group of Teachers of Medical Ethics and Law in UK Medical Schools: Teaching medical ethics and law within medical education: a model for the UK core curriculum. J Med Ethics 1998;24: 188-92.
Hope T, Savulescu J, Hendrick J. Medical ethics and law: the core curriculum. Edinburgh: Churchill-Livingstone, 2003.
Sokol D, Bergson G. Medical ethics and law: surviving on the wards and passing exams. London: Trauma Publishing, 2005.
Slowther A, Johnston C, Goodall J, Hope T. Development of clinical ethics committees. BMJ 2004;328: 950-2.
Parker M. Getting ethics into practice. BMJ 2004;329: 126.
BBC. Doctors make medical ethics plea. BBC News 2 December 2003. http://news.bbc.co.uk/1/hi/health/3253786.stm (accessed 11 Feb 2005).
British Medical Association Ethics Department: Medical ethics today; the BMA's handbook of ethics and law. 2nd ed. London: BMJ Books, 2004.
Smith R. Medical mishaps. studentBMJ 1998;10: 6. (October.)
Schneiderman L, Gilmer T, Teetzel H, Dugan D, Blustein J, Cranford R, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting. JAMA 2003;290: 1166-72.
Gacki-Smith J, Gordon E. Residents' access to ethics consultation: knowledge, use, and perceptions. Acad Med 2005;80: 168-75.
Self D, Skeel J, Jecker N. A comparison of the moral reasoning of physicians and clinical medical ethicists. Acad Med 1993;68: 852-5.
Slowther A, Bunch C, Woolnough B, Hope T. Clinical ethics support services in the UK: an investigation of the current provision of ethics support to health professionals in the UK. J Med Ethics 2001;27: i2-i8.