Kenneth Boyd

Medical ethics and law for doctors of tomorrow: the 1998 Consensus Statement updated

Knowledge of the ethical and legal basis of medicine is as essential to clinical practice as an understanding of basic medical sciences. In the UK, the General Medical Council (GMC) requires that medical graduates behave according to ethical and legal principles and must know about and comply with the GMC’s ethical guidance and standards. We suggest that these standards can only be achieved when the teaching and learning of medical ethics, law and professionalism are fundamental to, and thoroughly integrated both vertically and horizontally throughout, the curricula of all medical schools as a shared obligation of all teachers. The GMC also requires that each medical school provides adequate teaching time and resources to achieve the above. We reiterate that the adequate provision and coordination of teaching and learning of ethics and law requires at least one full-time senior academic in ethics and law with relevant professional and academic expertise. In this paper we set out an updated indicative core content of learning for medical ethics and law in UK medical schools and describe its origins and the consultative process by which it was achieved.

Disease, illness, sickness, health, healing and wholeness: exploring some elusive concepts

Concepts such as disease and health can be difficult to define precisely. Part of the reason for this is that they embody value judgments and are rooted in metaphor. The precise meaning of terms like health, healing and wholeness is likely to remain elusive, because the disconcerting openness of the outlook gained from experience alone resists the reduction of first-person judgments (including those of religion) to third-person explanations (including those of science).

The impact of AIDS on medical ethics

For this special issue of the Journal of Medical Ethics we have assembled articles that reflect some of the newer issues or fresh perspectives. There is a mix of approaches including forward looks, present dilemmas and reflections on the past, now that sufficient time has elapsed to allow a considered view. We are most grateful to our wide range of contributors for their thoughtful analyses of several key areas of contemporary debate. Our own contributions include the following editorials in which each of us has considered, from his own perspective, the impact of AIDS on medical ethics, a case study and a lexicon that allows brief probing of some topics. ### ANTHONY J PINCHING Medical ethics has been matured through being tested and refined through the multifaceted challenge of AIDS. As with the society and social values from which its moral framework is derived, so medical ethics has been subjected to intense scrutiny by the emergence of this new disease. Few areas of ethical discourse have been untouched. This infection is so intensely private in its transmission, the disease so isolating and so personally devastating in its impact, it readily distinguishes the reality of what people are and do, from the rhetoric of what others may feel they should be and do. AIDS has forced us to recognise that respecting individual rights is a critical safeguard for the health of the community, as well as for the person. These issues are well illustrated by the interweaving issues of patient empowerment, respect for confidentiality, and patient advocacy and activism. ### EMPOWERMENT Physicians in this field have been struck by the way in which people affected have wanted to be involved in decision making. While this has often been ascribed to their social groups, it probably was more a reflection of their younger age and a generation change …

HIV infection and AIDS: the ethics of medical confidentiality.

An Institute of Medical Ethics working party argues that an ethically desirable relationship of mutual empowerment between patient and clinician is more likely to be achieved if patients understand the ground rules of medical confidentiality. It identifies and illustrates ambiguities in the General Medical Councils guidance on AIDS and confidentiality, and relates this to the practice of different doctors and specialties. Matters might be clarified, it suggests, by identifying moral factors which tend to recur in medical decisions about maintaining or breaching confidentiality. The working party argues that two such factors are particularly important: the patients need to exercise informed choice and the doctors primary responsibility to his or her own patients.

Medical ethics: principles, persons, and perspectives: from controversy to conversation

Medical ethics, principles, persons, and perspectives is discussed under three headings: History, Theory, and Practice. Under Theory, the author will say something about some different approaches to the study and discussion of ethical issues in medicine—especially those based on principles, persons, or perspectives. Under Practice, the author will discuss how one perspectives based approach, hermeneutics, might help in relation first to everyday ethical issues and then to public controversies. In that context some possible advantages of moving from controversy to conversation will be explored; and that will then be illustrated with reference to a current controversy about the use of human embryos in stem cell therapy research. The paper begins with history, and it begins in the author’s home city of Edinburgh.

Ethnicity and the ethics of data linkage

Linking health data with census data on ethnicity has potential benefits for the health of ethnic minority groups. Ethical objections to linking these data however include concerns about informed consent and the possibility of the findings being misused against the interests of ethnic minority groups. While consent concerns may be allayed by procedures to safeguard anonymity and respect privacy, robust procedures to demonstrate public approval of data linkage also need to be devised. The possibility of findings being misused against the interests of ethnic minority groups may be diminished by informed and open public discussion in mature democracies, but remain a concern in the international context.

Doctors’ orders for language testers: the origin and purpose of ethical codes

Accountability in language testing, as in other professions, requires openness to stakeholders. Professions are increasingly publishing a Code of Ethics which sets out the principles governing the conduct of their members. The long tradition of medicine’s use of a Code of Ethics is discussed and the arguments in that profession with regard to openness is considered. The International Language Testing Association (ILTA) has recently agreed its own Code of Ethics (see Appendix 1). This article considers how far this Code of Ethics makes language testing an open profession and notes the dangers of face validity and of hypocrisy. The article then discusses the need for a Code of Practice to provide detailed guidance to language testers with regard to their professional responsibilities. It is concluded that: • it is unlikely that an international organization could develop one universal Code of Practice, given the demands of enforceability and relativism; and • that the way forward may be to encourage local Codes of Practice. Caution is, however, necessary, given the possibility of tension between relativism and modernity, such that a local Code of Practice could become an alternative Code of Ethics.

The Objective Structured Clinical Examination and student collusion: marks do not tell the whole truth

Objective: To determine whether the marks in the third year Objective Structured Clinical Examination (OSCE) were affected by the collusion reported by the students themselves on an electronic discussion board. Design: A review of the student discussion, examiners’ feedback and a comparison of the marks obtained on the 2 days of the OSCE. Participants: 255 third year medical students. Setting: An OSCE consisting of 15 stations, administered on three sites over 2 days at a UK medical school. Results: 40 students contributed to the discussion on the electronic discussion board. The main points raised were perceived inequity between students who did, or did not, have prior knowledge of the station content, and the lack of honesty and professionalism of their peers. Most contributors claimed to have received, or knew of others receiving, prior knowledge, but none confessed to passing on information. No significant difference (p = 0.16) was observed in the overall mark for the OSCE on day 1 (mean 390 (SD 37)) and day 2 (mean 397 (38)). On day 2, marks were considerably greater for four stations and markedly lower for three stations. It was not obvious why collusion should affect these station marks. A clear indication of the effects of collusion could only be obtained from a single subsection of an individual station (pathology) where 82 students on day 2 incorrectly gave the diagnosis from day 1. Conclusion: Marks do not provide a sound inference of student collusion in an OSCE and may mask the aspects of professional development of students.

The impossibility of informed consent

The problematic nature of informed consent to medical treatment and research, and its relation to autonomy, trust and clinical practice, has been addressed on many occasions and from a variety of ethical perspectives in the pages of the Journal of Medical Ethics. This paper gives an account of how discussion of these issues has developed and changed, by describing a number of significant contributions to these debates which provide examples of ‘doing good medical ethics’ over the 40 years of the Journals publication.

An AIDS lexicon

The sudden appearance of a truly new disease is a wake-up call. A new global pandemic of an infectious agent, transmitted through sexual contact and blood, affecting alienated and/or deprived people and communities, infectious throughout, that causes a slowly progressive breakdown of defence against other infectious diseases, as well as causing dementia in some, and leads to a premature death, occurring in an era of extensive travel and rapid communication, is a veritable tocsin. These crude ingredients of AIDS as a medical and social phenomenon, blended with the poignant personal histories revealed to clinical professionals, spiced — as if this were necessary — by the fear, the prejudice, the wild theorising and the voyeurism, have presented a substantial challenge to practical medical ethics. Familiar ethical debates have been reopened with new perspective and insight, others have been examined thoroughly for the first time. Building on the major developments in medical ethics over recent decades, AIDS has provided an opportunity, indeed a necessity, for its maturation. It continues to present new issues for debate, while those that were present from the outset continue to perplex us, as this issue of the journal should show. In teaching, AIDS offers a plethora of examples to illustrate most of the central tenets and tensions of medical ethics. As an exemplar, it has provided preparation and precedent for addressing some of the issues emerging from new challenges, such as screening for susceptibility to genetic disease. AJP The word comes from the same germanic root as “to be robbed excessively”. Bereavement is an intensely personal and disorienting experience, to which people can react with denial, anger, guilt or depression, sometimes prolonged. In Western countries nowadays it is most commonly experienced in mid-life through the death of a parent, or in old age through that of a …