Medical students and clinical ethics

IN 2000, THE AUSTRALIAN MEDICAL COUNCIL highlighted the place of clinical ethics in the education of medical students.1 A similar appreciation of its relevance has grown in the UK, North America and Europe.2-4 Recently, a working group of the Association of Teachers of Ethics and Law in Australian an New Zealand Medical Schools (ATEAM) produced a core curriculum for the subject5 that encompasses the knowledge, skills and attitudes required for students to appreciate the range and complexity of ethical issues permeating medicine and the moral principles required to deal with them. Who should teach ethics to medical students remains debatable, with some advocating a role for ethicists and others seeing the clinician as more appropriate. ATEAM argued that an optimal program embodies “multiple perspectives and multiple teachers”.5 As the working group put it: “Teachers of ethics can play an important role in modeling the very nature of ethics: the teaching process should be perceived as being emotionally supportive and academically encouraging, should be tolerant of multiple perspectives, should be interdisciplinary and should actively involve clinicians as codeinstructors and as role models for students. This also underscores the responsibility of teachers to develop as an ethical community and be alert to, and respond to, unethical behavior among themselves.”5 Clinicians who are specifically recruited to teach clinical ethics are invariably selected on the basis of their sensitivity and commitment to the ethical dimension of the doctor– patient relationship; they are likely to serve as appropriate role models. Regrettably, during the course of their training, students may encounter other clinicians who lack sensitivity and manifest a disregard of ethical principles. In a survey of Canadian medical students, half reported pressure to act unethically and 60% had observed unethical conduct in a clinical teacher.6 Moreover, they had felt impotent in the face of these circumstances because of the teacher’s intimidatory attitude. Having taught clinical ethics for almost three decades and on three continents, I have compiled a body of evidence of clinicians demonstrating wholly undesirable qualities and behaviour to medical students. In the context of case-centred teaching programs in ethics, students are requested to observe ethical aspects of practice during their attachment to a medical or surgical unit and then select an experience which has provoked their curiosity, generated concern or affected them in some way. The narrative of this experience is shared with a group of fellow students, one of whom serves as a scribe. As a result of this process, I have files containing dozens of ethically challenging scenarios (Box 1).