Deborah Bowman

The Moral of the Tale: Stories, Trust, and Public Engagement with Clinical Ethics via Radio and Theatre

Trust is frequently discussed with reference to the professional–patient relationship. However, trust is less explored in relation to the ways in which understanding of, and responses to, questions of ethics are discussed by both the “public” and “experts.” Public engagement activity in healthcare ethics may invoke “trust” in analysing a moral question or problem but less frequently conceives of trust as integral to “public engagement” itself. This paper explores the relationship between trust and the ways in which questions of healthcare ethics are identified and negotiated by both “experts” and the public. Drawing on two examples from the author’s “public engagement” work—a radio programme for the British Broadcasting Corporation and work with a playwright and theatre—the paper interrogates the ways in which “public engagement” is often characterized. The author argues that the common approach to public engagement in questions of ethics is unhelpfully constrained by a systemic disposition which continues to privilege the professional or expert voice at the expense of meaningful exchange and dialogue. By creating space for novel interactions between the “expert” and the “public,” authentic engagement is achieved that enables not only the participants to flourish but also contributes to trust itself.

What is it to do good medical ethics? Minding the gap(s)

This paper discusses the character of medical ethics and suggests that there are significant gaps that warrant greater attention. It describes ways in which the content and form of medical ethics may exclude or marginalise perspectives and contributions, thereby reducing its influence and its potential impact on, and value to, patients, students, carers and society. To consider what it is ‘to do good medical ethics’ suggests an active approach that seeks out, and learns from, contributions beyond the traditional boundaries of scholarship.

Who Decides Who Decides? Ethical Perspectives on Capacity and Decision-making

Capacity1 is at the heart of ethical decision making in healthcare. For those who subscribe to a principled approach to moral reasoning (Gillon, 1985; Gillon and Lloyd, 1993; Beauchamp and Childress, 1994), autonomy is often said to be pre-eminent amongst the four principles of medical ethics2, or at least “first amongst equals” (Gillon, 2003). For those who prefer methods of ethical analysis other than the influential “four principles” approach, there remains a fundamental assumption that self-determination is afforded moral value and priority (Campbell, 2003; Harris, 2003; Cowley, 2005). To deny a capacitous person the freedom to make decisions about his or her own treatment and healthcare is fundamentally unethical whether one attributes the moral precept for such a conclusion to autonomy or virtuous practice or respect for others. Conversely, where a person lacks the capacity to make decisions, healthcare professionals have a responsibility to protect his or her interests3. It is remarkably easy to acknowledge the sense of the preceding statements; however, they belie the moral complexity of assessing capacity implying a satisfying but artificial binary certainty in which ethical practice constitutes an informed choice by the professional between affording his patient full entitlement to make his or her own decisions or acts without reference to the patient’s preferences because he or she has not met the demands of the “test” of capacity.

Should psychiatrists ‘Google’ their patients?

Since its beginnings in the 1980s the internet has come to shape our everyday lives, but doctors still seem rather afraid of it. This anxiety may be explained by the fact that researchers and regulatory bodies focus less on the way that the internet can be used to enhance clinical work and more on the potential and perceived risks that this technology poses in terms of boundary violations and accidental breaches of confidentiality. Some aspects of the internets impact on medicine have been better researched than others, for example, whether email communication, social media and teleconferencing psychotherapy could be used to improve the delivery of care. However, few authors have considered the specific issue of searching online for information about patients and much of the guidance published by regulatory organisations eludes this issue. In this article we provide clinical examples where the question ‘should I Google the patient?’ may arise and present questions for future research.

Ethics teaching for clinical practice : a student perspective

Medical ethics and law is now an established part of the curriculum at UK medical schools, and a requirement for graduation under Tomorrow’s Doctors. Recent research has determined that most schools were teaching, to some extent, all the areas from the UK Consensus Statement on the medical ethics curriculum, though the authors acknowledge that there is still some way to go to ensure that all topics are being covered thoroughly.

Medical students and mental health : the UK perspective

In the general population, one in four adults experiences significant mental disorder at some point in life, and the majority (with the exception of dementia) commonly present as young adults. Table 1 shows the relative population prevalence of some common disorders. Medical students are not representative of the general population, even where widening participation programmes have been particularly successful. People with established serious mental health problems are less likely to achieve the academic and social success required for medical school, and high achieving people are less likely to have been exposed to the chronic childhood adversities associated with more severe personality disorders or substance misuse.

Students whose behaviour causes concern: Ethical perspective.

What should you do when you see a fellow student behaving inappropriately? After a group of students wrote to the BMJ about their experience during an elective (doi:10.1136/bmj.a2874), we sought the opinions of an ethicist, a dean (doi:10.1136/bmj.a2884), a GMC representative (doi:10.1136/bmj.a2876), and a lecturer from an African university (doi:10.1136/bmj.a2875)

Vulnerability, survival and shame in Nina Raine’s Tiger Country

Shame in healthcare remains relatively underexplored, yet it is commonplace and its impact is significant. This paper explores shame in healthcare using Nina Raine’s 2011 play Tiger Country. Three manifestations of shame are explored, namely (1) shame in relation to professional identity and survival in the clinical workplace; (2) shame and illness as experienced by both patients and doctors; and (3) the systemic and organisational influences on shame within healthcare systems. I suggest that the theatre is particularly well-placed to elucidate shame, and that Tiger Country demonstrates the prevalence and impact of shame on clinical work. Shame has a fundamental and overlooked relationship with damaging and well-documented phenomena in healthcare, including moral distress, ethical erosion, compassion fatigue, burnout, stress and ill health. Attention to shame is essential for those interested in medicine and healthcare and must, I propose, include the experiences and perceptions of those who provide care, as well as attending to those who receive care.

New perspectives in Medical Humanities

It is a pleasure and a privilege to be able to introduce this guest-edited edition of Medical Humanities on the theme of the ‘Critical Medical Humanities’. The issue is the result of outstanding leadership by William Viney, Felicity Callard and Angela Woods who have demonstrated their commitment to both intellectual originality and unforgiving editorial deadlines throughout the process. Their work has brought together a collection of papers that are exciting, stimulating and engaging. There are a number of ways in which this special edition offers rich, and perhaps new, ways of conceptualising and contributing to the field known as the medical or health humanities. The first noteworthy point is the identities of the authors and the way in which they were persuaded to become involved in writing for this journal. Many of the authors are at the earlier stages of their academic careers. A significant number of them might not have considered themselves as working in, or having a relationship with, the ‘medical humanities’. Yet, thanks to the imagination and the inclusive approach of the team at Durham who have guest-edited this issue, these scholars were encouraged to reflect on whether and how their work might inform and enrich the medical and health humanities. In …

Teaching Ethics in Psychiatry

The process of teaching and learning ethics is constant in psychiatry. This chapter discusses the content, process and methods of facilitating education in ethics. It is argued that although the process of teaching and learning in ethics can be overlooked in attempts to develop and deliver a ‘core curriculum’. Specifically, it is suggested that undue focus on a series of ethical ‘topics’ to be covered risks losing the essence of an education in ethics, namely to equip doctors with the moral imagination, confidence and courage to practise with integrity. It is proposed that attention to emotion, role modelling and ethical erosion via innovative educational interventions may offer all those involved in medical education a more relevant, effective and enjoyable way to change the learning culture and to contribute to the professional development of students and junior doctors.