The axis of ethics

Surgeon, Paolo Macchiarini, conducted unethical implant procedures

Twice recently I’ve asked medical students whether they’d heard of this year’s report into Gosport War Memorial Hospital. Of the sixty or so, only a couple had; with most unaware that perhaps tenfold their number perished at Gosport, amidst a “disregard for human life”.

This means neither the students nor their clinical teachers have discussed Gosport and the issues arising. Or if there has been discussion, it’s been in a way that’s made almost zero impact. Either way it falsifies the platitude that lessons have been learned.


Ethics is often seen as peripheral to medicine; most relevant to niche questions – like when life begins, or when measures to prolong it should end. This is reflected in medical school curricula and postgraduate exams with their emphasis on bioscience and technology.

Yet medical careers can span four decades, during which much of the bioscientific detail will change or become redundant.

[Empires devoted to peptic ulcer surgery have crumbled. The Krebs cycle comes round rarely in daily practice].

In contrast, the ethical questions endure quietly in the everyday.

We consider the best course of action, with patients, for ourselves, for our service and for society; which treatments are warranted or worth it; how to balance the needs of a few against those of the many; whose treatment has become futile; who’s responsible when things go wrong. Unlike the bioscientific curriculum, these issues have been present since before the definition of medicine, and will endure even when diagnosis becomes the job of artificial intelligence (AI).

In that sense, ethics isn’t the icing on the cake. It is the cake. It’s the core and substance of medical practice; the axis around which the bioscientific details swirl. Hence the fundamental relationship between doctor and patient is still founded on ethical issues like consent, confidentiality and trust. The fundamental failures of medicine are also anchored to ethical issues. At Alder Hey, Bristol and Gosport, organs and / or lives were taken from people who didn’t give their consent.

Medicine has also to meet the challenges put by Ivan Illich; that it often harms patients; that it becomes a self-serving business; that it turns us into consumers of healthcare rather than creators of our own health. Consider these illustrations. Medical injury is now a leading cause of death in the US. Healthcare fraud in the US alone is of similar order of magnitude to the sums spent on the entire NHS. Genomics, big data and AI will deliver health products for us to consume, even as we neglect age-old abilities to create health through e.g. relationships, food and our environment.

The General Medical Council may be starting to recognise the primacy of ethics over bioscientific minutiae. The British Medical Association continues to lag, acting too often with secrecy, and without members’ informed consent. Such paternalism is redolent of the past, but hopefully not the future of medicine.

The response of University medical schools has been patchy. They’re monuments to bioscience, maintained by the big money brought in by medical students and research. But little of that funding goes to ethics teaching. Instead, medical schools often depend on volunteers, drawn from the NHS (where ethics training may likewise be scarce). This may reflect a dismissive attitude across Universities and the NHS. Despite the harms of unethical research, from Wakefield (MMR) to Macchiarini (“engineered” implants), ethics checks can still be seen as a chore, rather than respected as a chance to improve.

Conclusion

Ethical reasoning isn’t a luxury. It isn’t about moralising or blame. Instead, it’s a core skill whose need arises from curiosity about our imperfections and quandaries. It’s a natural necessity in the pursuit of best practice. Without it, medicine ceases to be a profession; habitually losing its bearings; becoming overly certain in what Illich might describe as doing, selling and controlling.

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