Consensus statement in medical ethics
Decision-making in the clinical setting
Although medical schools take different approaches to ethics, in the UK the starting point will usually be the consensus statement. It lists the areas every medical student should learn during their training and also describes competencies that students should develop. The consensus statement in medical ethics is summarized in the following section with some examples. The full version is available on the Institute of Medical Ethics website (
www.instituteofmedicalethics.org). The eagle-eyed will notice that even the summary includes areas in which few, if any, medical students, will be directly involved. Medicine is a mixture of the applied and the arcane. However, it is helpful to think about the relationship between what you are learning and your practice.
For example, in sessions on genome editing or cloning, you can relish (really) the intellectual gymnastics of debates about personhood and identity. In contrast, when you are learning about consent, it is important to think of it both in terms of its conceptual elements and its practical application. What then are the basics of ethics? One way to answer that question is to think about the transition from the lecture theatre to the clinical environment. The ways in which you experience consent, confidentiality, questions of dignity (sometimes yours as well as the patient’s), capacity (ditto), and decision-making are fundamental. These areas have both conceptual and practical meaning. For that reason and given that our time together is limited, let us focus on those.
• Patients: their values, narratives, rights, and responsibilities.
• Consent and refusal in medical decision-making: e.g. the constituent elements of valid consent, proxy consent.
• Capacity: e.g. the Mental Capacity Act, Deprivation of Liberty Safeguards, best interests.
• Confidentiality: e.g. the limits to confidentiality, the role of trust in therapeutic relationships.
• Justice and public health ethics: e.g. resource allocation.
• Ethico-legal aspects of working with children and young people: e.g. the Children Act, Gillick competence, the concept of assent.
• Mental health ethics and the legal framework: e.g. the Mental Health Act.
• Ethics at the beginning of life: e.g. reproductive ethics, neonatal ethics.
• Towards the end of life: e.g. assisted dying, resuscitation decision-making, death certification.
• Medical research and audit: e.g. research governance, research with people who lack capacity, global considerations in research.
• Generic competencies: e.g. awareness of ethical questions or considerations, analytic and reasoning skills, reflective practice.
As a medical student, you will seek consent hundreds, possibly thousands, of times. It is a familiar task, yet it is also the way in which you demonstrate a fundamental ethical commitment, namely your respect for self-determination. For students, consent is particularly important—no one has to talk to a student or let someone who is not qualified examine them—you always have to ask permission. For a patient to make an informed choice, you must explain your student status. The four elements of consent are each experienced differently as a student. First, there is the question of capacity, i.e. can this person understand, remember, and weigh up what is happening or being proposed? If a patient does not have capacity, they cannot agree or disagree to you doing anything. Anything that happens to a patient without capacity should be either on the basis of proxy consent (if there is a valid lasting power of attorney) or best interests. It is difficult to argue that it is in best interests of a person who lacks capacity to have a student, rather than a qualified doctor, perform an examination or provide treatment, although in some settings you may be invited to contribute under close supervision.
Assuming the patient has capacity, he/she has to give consent voluntarily. You need to be clear that it is a choice whether a student is involved. Next, is the question of information: the patient needs enough to make a decision with the emphasis being on what the patient wants to know rather than what the professionals want to tell. Relevant information includes that you are a student and your stage of training. Occasionally, you may be introduced misleadingly (e.g. as a ‘colleague’ or a ‘doctor in training’). It is your job to ensure that the patient understands that you are a student and not yet qualified. Finally, consent has to be continuing which means the patient can change his or her mind.
The excitement of clinical placements can mean that even the best students forget the basics of consent. However fascinating the learning opportunity, the essence of your privileged status as a medical student is trust. And trust depends on your honesty and sensitivity in seeking consent, always. Whatever the pressures, you obtain permission. No exceptions.
There is a tension between what you learn about confidentiality and dignity and the realities of clinical practice. Attending to the dignity and privacy of a patient is essential. People reveal themselves at their most vulnerable and they do it because they assume you will respect their dignity and protect their privacy. Yet, there is much about healthcare that can compromise privacy and dignity. Many of these things are systemic. Curtains round the bed can (usually) be pulled to protect others seeing what is happening, but sound travels easily whether the curtains are closed or not. Ward rounds share personal information within a group that continues its conversations as it moves through the hospital. Teams meet in the canteen partly because everyone is craving coffee and partly because there is no spare room. Whiteboards, visible to all, aid clinical care, but are less effective at protecting confidentiality. You cannot be an ethical superhero and defend against all these systemic failures, but you can think about your own behaviour. Beware of lunchtime conversations with friends in public spaces. Think about ways you can protect a patient’s dignity. For example, you can cover them up after an examination, check that they are comfortable, and give them quiet space to talk through the implications of their diagnosis with their family. Students often describe feeling powerless as if there is ‘nothing they can do’. Yet, sensitivity to privacy and dignity can be transformative and these small ethical acts are valuable.
People often assume that students do not make any decisions, ethical or otherwise, until they qualify. In fact, students make ethical choices every day: how to introduce themselves, whether to put their own learning before the patient’s comfort, and what to do when they are concerned about a peer or a superior. Nonetheless, it is true that students are rarely the ones making decisions about clinical care. However, you can learn much from watching the ways in which decisions are being made, particularly ethical decisions. Sometimes they will be implicit—you observe no discussion, yet everyone appears agreed on the next steps. Other times, you will see explicit decision-making both with patients and their families and within clinical teams. Whatever the subject, from safeguarding to resuscitation and from the determination of best interests to information sharing, you have a unique opportunity as a student to observe decision-making. Try to make your observations count. Does it reflect what you have learnt? Why has this decision been taken? Do you agree with it? Who was involved in making the decision? Will it be reviewed? If so, how, when, and by whom? What was written in the notes about the decision? How is it going to be communicated both to the patient and his or her family and to other professionals? These are not just prompts for the incurious—they are the basis of ethical practice both as a medical student and a doctor.
Do not be afraid to ask politely about why and how decisions have been reached. These conversations provide the foundations for the day when you are the one making the decisions.
You will meet a range of people in your training. Some will inspire you and become role models. Others will be more cautionary tales than role models. There is something to learn from everyone you meet, although it may not always be what they claim to be teaching. Role models are essential, especially when times get tough. Everyone has moments of doubt in medical school, particularly after bruising days. Role models are invaluable for helping you get through those moments. Find people who remind you why you want to do medicine and what kind of a doctor you want to become. Notice what it is about them that inspires you and hang on to it in your own practice. They have; you can too.
What of the cautionary tales? Those whom you would dread becoming or even simply just dread? They are important too. They represent your ethical boundaries and identity. You respond to them negatively because something is at odds with what you believe or know to be right. That is the hidden gem in these horrid encounters. In rejecting their approach, you affirm your own commitment to ethical practice and maintaining your integrity. Now, that is all well and good, but how does that get you through the day when you are working with someone who is causing you distress? You do not need to struggle on alone. All medical schools will have members of staff who will support students who have concerns about the practice they encounter in the clinical setting and most will also have systems to allow for confidential feedback about student experiences. I know that the perceived ‘risk’ of confiding in someone about a senior is significant, but there are safe ways of speaking out and getting some support. Please find and use them.
Whether it is in a lecture theatre, an OSCE, or a real clinical setting, you will encounter ethics in many ways. Sometimes, you will need to hit the books and get to grips with specific knowledge. Sometimes, you will practise how to apply conceptual learning to clinical situations. Sometimes, you will experience ethics in ways that seem far removed from what you have encountered in the classroom or examination room. Whether you love or loathe the subject, it is inescapable and how you respond is often, in itself, a moral choice. As you shift between types of learning in different places, perhaps the most important thing is to remember what brought you to medicine in the first place. Although motivation will vary, you will never meet anyone who entered medicine wanting to do a poor job.