Teaching and Learning > DISCOURSE

Why medical ethics should not be taught by Philosophers

Author: Christopher Cowley

Journal Title: Discourse

ISSN: 1741-4164

ISSN-L:

Volume: 5

Number: 1

Start page: 50

End page: 63

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In many UK medical schools,1 the ethics content seems to be delivered, or at least co-ordinated, by academic philosophers. Presumably philosophers are considered most qualified for this role in virtue of their particular training in analysis and exploration of ideas and in clarifying concepts, assumptions and consequences; and there seems to be no apparent reason why such training cannot be brought to bear on the problems that characterise the world of medicine. Philosophers are obviously the best people to teach moral philosophy to philosophy students. But I want to suggest that they are not the best people to teach medical ethics to medical students and that medical ethics is not best conceived of in philosophical terms. Instead, I shall briefly sketch some alternative directions that medical ethics could take.2

In philosophy departments, philosophical skills are developed over a three-year undergraduate programme. Honours students will typically write at least twenty essays before they graduate. Understandably, there is much less room for philosophy and ethics in the medical curriculum, and so the question arises of how best to use the space available.

Now there are certain things that ought to be taught, and that philosophers can teach, but which have little to do with ethics: critical thinking, for example. However, there is no particular reason why natural or social scientists couldn't teach this, since they make use of the same sort of principles and skills in their own work. Similarly, there certainly ought to be some basic elements of the philosophy of science and the philosophy of mind in a medical curriculum, but again, these could perhaps be adequately taught by scientists who are already involved. But if a philosopher is handy to teach the above, then all well and good.3

The legislative and dramatic

This paper is only about the medical ethics content, however. And I shall claim that teaching medical ethics to medical students ought not to be a scaled-down version of teaching moral philosophy to philosophy students. The main reason for this is because of the essential double-aspect nature of ethics, making it unlike any other scientific subject (not controversial), but also unlike any other philosophical subject (more controversial). The two aspects are familiar under a number of labels, but I want to call them the 'legislative' and the 'dramatic' aspects. The legislative process involves discussion about, for example, the ethically best option from among those available in a generalisable situation, or the ethical duty that one person might have toward another; this is what philosophers do in the philosophy seminar. I choose the word 'legislate' in a Kantian spirit, because of the essentially impersonal and universalisable nature of the process and the outcomes, insofar as they aspire to recognised philosophical legitimacy. In moments of ethical perplexity, any decision about what I ought to do, claim the legislative enthusiasts, must be preceded by a discovery of what ought to be done.

What I call the dramatic process, on the other hand, involves the cultivation of appropriate behavioural dispositions, of ethical sensitivities to the relevant situational features, of the capacity to imaginatively engage with the likely consequences, and of a rudimentary grasp of ethical concepts; and this process is most familiar to those responsible for the day-to-day care of children. The successful cultivation of such dispositions and sensitivities will result in the adult knowing what to do in many situations without experiencing ethical perplexity. I call it 'dramatic' because the theatre seems to be a closer model than the parliament.

Most philosophers concentrate on the legislative aspect and leave the dramatic aspect to educationalists, psychologists and parents. However, a close look at what actually happens in ethical disagreement and ethical persuasion among adults reveals a much greater role for the dramatic than philosophers assume. Certainly I will sometimes be persuaded to change my ethical opinion on the basis of another's good reasons; but I am equally disposed to change my mind when presented with a compelling portrait of, say, the suffering that would necessarily follow from holding a particular opinion. As such, Dickens is as great a moral philosopher as Kant; and it would not be embarrassing for a social activist to reveal that he had first been moved (rather than persuaded) toward activism by reading Bleak House.4

It is true that some philosophers have rediscovered 'virtue ethics', but again they are involved in discussing the virtues and their cultivation, rather than in trying to actually cultivate them among their students. The ideal of the (university-level) philosophy course remains to teach the adult students how to deliberate over, discuss and write about philosophical problems as well as the tutors do. The goal of a medical ethics education, they will say, is to improve (adult) students' ability to deliberate and discuss as much as the time available will allow, in order to help them to discuss and deliberate over ethical issues better once they become doctors.

The dramatic aspect of ethics seems to have been neglected, and I want to argue that this is a mistake: indeed, I believe the dramatic aspect should predominate over the legislative aspect in a restricted curriculum. This is of course not to deny the important place of law in the medical curriculum, and this will lend itself to the didactic and legislative model, and many legal problems will turn on important ethical questions. Interested students can also be encouraged to discuss medical ethical issues legislatively with a philosopher in an 'after-school club'. In what follows, however, I discuss the nature of the core ethics elements of the medical curriculum, and eventually adumbrate possible structures for dramatic teaching.

The medical world

In many ways, medicine is just another university course, and just another career. The medical training occupies no special place in the university prospectus, and the hospital staff are organised along the same bureaucratic lines as any large institution. Off-duty, doctors and nurses dress and speak and drive like the rest of us. But this similarity occludes striking dissimilarities, and it is easy to forget just how extraordinary medicine is in so many respects. Consider the GP: only in one other context (sexual pursuit) would we undress in front of a complete stranger, and allow him to touch us, sometimes intimately. Some of the information requested by the GP we wouldn't give to our closest friends or family, let alone a stranger: drinking problems, sexual problems, problems with continence. This represents a huge amount of trust, and gives the GP a huge amount of power, whether he wants it or not.

Consider the surgeon: in no other social context would a competent adult give his consent to have another person stick a knife in him. What on earth gives him the right to do so? I don't mean a legal right based on his elaborate skill and knowledge and ultimately on his certification by the appropriate regulatory body. I don't mean a moral right based on the patient's consent or on the likely benefits which will accrue to the patient. To understand the concept of a right in this context is to remind oneself of the extraordinariness of medicine.

Consider the hospital: in no other single building in human society is there such an overwhelming concentration of suffering, despair and death.5 Our normal encounters with suffering and death are piecemeal: an elderly relative gets cancer, a cousin dies in a car crash, our young child has a fever. There is time to deal with it, time to distance oneself from it, time to move on more or less successfully. And yet the hospital staff have to deal with one illness after another in the knowledge that there will always be more to come. Certainly there is cause for joy after a successful treatment; but this cannot dispel the sheer mind-numbing mass of suffering that they are unable to treat.

This is not supposed to be a banal paean to the heroics of the medical profession. My aim, rather, is to remind the reader of that first awe and horror that he felt as an unprejudiced child upon realising what medicine was all about, and before accepting the story that it was a job just like any other. That awe and horror are the natural responses to the socially extraordinary nature of medicine.

Now here's the controversial step in my argument. It is medicine's extraordinary nature that exceeds the poor powers of common or garden ethics. The ethical education that most people receive in childhood equips them well enough for the classroom, the shop, the office, the nightclub, the oil platform, almost everywhere. But the hospital—if one really opens one's eyes to what is going on there—will overwhelm every newcomer, no matter what his age or background. Importantly, it will overwhelm the philosopher too.

I stress that this overwhelming is ethical, and not just psychological. After all, it is tempting to reconceive the experience as one requiring 'mere' psychological fortitude and objectivity, the sort of thing required by bungee jumpers—I put 'mere' in scare quotes because I do not want to imply that it is an easy process to grit one's teeth to the stench and the groans and the gore (just as it is not easy to jump off bridges), but in a way it is easier than having to deal with being ethically overwhelmed. The problem becomes stubbornly ethical when one is suddenly aware that there is no good reason why this child is desperately ill while you are healthy. The problem becomes massively ethical when this child is multiplied over and over in the wards across the country.6 A 'good reason' for an illness, in this context, will obviously not be the causal explanation or diagnosis that some clinicians might consider helpful. But the philosopher is certainly in no better a position to offer reasons.

The ethical, however, should not be seen as comprising only situations of great suffering or great risk of death. Moral philosophers are perversely keen on such extreme situations in their examples, as if the problem can only achieve sufficient clarity in this way. But the ethical mostly comprises the mundane and small-scale, both inside the hospital and out: every expression of gratitude or apology, for example, is ethical. Similarly, the overwhelming nature of the ethical experience in a hospital is revealed not only by the child's reasonless suffering, but also by things like the mundane trade-off between efficiency and kindness. However well-meaning, staff will always be too few. Decisions have to be made at each bedside over how long to stay beyond what is clinically necessary, and over how to extricate oneself politely. These are ethical questions since they have a direct impact on patients who are frightened, vulnerable and lonely. And again, there is no good reason not to spend another five minutes comforting this patient, here and now, whatever the obvious reasons for not spending five minutes more with every patient.

The limits of legislative discussion

So the medical student and the doctor have to learn to cope in order to be effective, and this can be done in familiar, more or less admirable ways, and I do not need to discuss those here. What is more interesting for me are the possible effects of the hospital experience, and of the efforts to cope with it, on the student's ethical understanding of the medical world and of his developing role in that world.

So can the philosopher help? Again, I accept that the philosopher may have a role—although not a privileged role—in teaching some bits of the philosophy of science and mind, as well as critical thinking. But when it comes to ethics I am much less confident. Let me develop what I have called the legislative aspects of ethics, which is what philosophers are good at. A typical medicalethics seminar will turn on 'isms' (such as utilitarianism) or 'issues' (such as euthanasia). The sessions might well be popular and generate enthusiastic discussion. They might lead to extensive research and excellent essays. But assuming I am right about the student's being ethically overwhelmed, can these legislative discussions help the student make sense of his experience? I suggest not. The intellectual activity of arguing for a specific euthanasia policy is radically different from the intellectual perplexity of facing a particular patient asking for your help to die. Even when classroom discussions focus on a particular case, such as that of Diane Pretty,7 the individual is still described in general terms, as part of a search for a consistent approach to types of patient (i.e. the Diane Prettys of the future).

However subtle and articulate a knowledge the students may develop of the euthanasia debate, this knowledge will be compartmentalised away from their hospital experience of particular patients, in a similar way that some doctors keep their devout religious faith away from their consultations. So until the student encounters a dying patient, until he really listens to the dying patient, all discussions of euthanasia are little more than shrill posturing stirred up by facile journalistic accounts. Whatever conclusions the student may reach in the debating club will have little effect on what he feels and does during this crucial first encounter, let alone during subsequent encounters. That is why the philosophers' drastic thought experiments, e.g. of whether to shoot one Indian to save nineteen,8 are at best pointless because one has no idea what one would do when actually faced with such an obscene choice; at worst they coarsen and dull our ethical sensitivities by misleading us into thinking there must be a right answer in every situation.

Can the legislative discussion of euthanasia not be of use after the student's first encounter with the dying patient? Again I would say not, because the encounter itself did not take place in the impersonal orientation and theoretical idiom that characterise the legislative efforts, and so a round peg ends up having to be squeezed into a square hole. The more appropriate high-level language by which individuals may discover the meaning of the encounters is literary or theological (both taken in the wider sense), rather than philosophical. The student has to accept the possibility that the most appropriate response to a patient's plight might simply be pity.

The two most important aspects of the encounter are its particularity and its proximity. Particularity means that all the details of the case are in principle available here, and we can go back as often as we need to. 'Going back' here involves not only a search for further relevant information about the patient's unique situation and wishes, but also the opportunity to talk over the situation with the patient, and help him to discover what his wishes are in the first place: it is too easy to hide behind the key legislative concept of autonomy by vouchsafing the patient what he wants (from among viable treatment options) without deeper discussion. Proximity means that the patient is 'in your face' rather than summarised in a textbook or on a PowerPoint slide. There is no avoiding their pain and their anger. Crucially, their proximity means that you will learn something of their point of view. Learning about another's point of view is not a matter of accepting that the patient has another point of view—of course he does; rather it is being struck by the other's point of view, being forced, if necessary, to confront it in a situation where the student is not entirely in control and is slightly vulnerable to surprise.

Philosophical discussions of '-isms' and issues teach the student to talk the talk without any guarantee that he will properly adopt the words. Certainly he will absorb expressions like 'autonomy' and 'best interests' and 'quality of life' without really understanding what they mean; they become shibboleths to ward off ethical criticism. But ethical maturation involves adopting the words: 'quality of life' only means something when it is used in the context of a discussion with a real patient making terrible decisions that will affect his quality of life. Does he want to start the chemo now or does he want to wait a little longer so he can finish a project? The particularity and proximity of such a patient making such a decision is what adds flesh to the words, and brings them to life.

The philosopher's lack of authority

In rejecting the legislative model, I am also rejecting the philosopher's particular claim to expert authority as a teacher of medical ethics. His authority is further undermined by his lack of clinical experience. The obvious response to such a controversial claim is to say that the philosopher is better able to preserve the requisite objectivity by remaining distant from the forum where clinical decisions are made, and is less likely to be distracted by the politics and the technology of the hospital. In addition, surely the principles of ethics are universal: hospital clinicians should be judged by the same standards as the rest of us.

However, imagine the following situation. A hospital wishes to organise a debate on the question of whether a patient can be covertly tested for HIV infection before surgery. Now any invasive surgical procedure carries a risk of needlestick injury and consequent infection from patient to surgeon. Due to the special stigma attached to HIV, however, any testing normally requires the patient's explicit consent.

The hospital asks a philosopher to argue against the covert testing, and let us say that he presents strong and clear arguments in support of the position. Most philosophers would say that the particular identity of the author of the arguments is irrelevant to the arguments' strength and clarity: if they are good arguments, then they ought to win the debate on their own, as it were; if they are poor arguments they ought to fail. Through persistence and open minds, the ethical truth of the matter (of what, impersonally, ought to be done) will eventually be discovered.

But now consider that the philosopher has never himself been in a situation where he has to face a life-threatening risk of infection through needlestick injury. As such, his ethical opinion on the matter comes too 'cheap': he has never been forced to test it under adversity. Would he really refuse the covert testing as he says ought (impersonally) to be done? He might, but again I suggest that there is no way he can know for sure until he finds himself in that situation. And this ignorance, not of facts, but of himself, undermines any authority which he might claim in virtue of the strength and clarity of the arguments alone, or in virtue of his characteristic philosophical training. There is a very real sense in which he does not know what he is talking about.

I am not going so far as to claim that doctors are entirely immune to ethical criticism from non-doctors.9 Rather, I am saying that philosophers are wrong to conceive of ethical discussion and disagreement as no more than the clash of ideas and reasons. Instead, in certain cases, the opinion's author may well have relevant experiences that allow him to 'stand behind his words'; that add authority to the opinion without adding any expressible discursive detail. And even when a philosopher does not stand by a specific ethical opinion and instead merely facilitates a legislative debate on an ethical issue, his clinical inexperience will undermine his responses to the opinions expressed. For example, the philosopher will be less likely to accept 'expediency' as an explanation for ethically prima facie dubious behaviour if he has not worked in an understaffed hospital and has not experienced that distinctive compassion fatigue that so often follows the ethically overwhelming experience.

Some positive suggestions

What I am advocating is an education in medical ethics focused more on the dramatic aspect. This would recognise that the cultivation of ethical dispositions and sensitivities has not come to an end for adults, and that the ethics sessions should primarily facilitate the student's own exploration of his ethical beliefs, in his own words, as arising from his ongoing encounters in his clinical placements. Now of course the philosopher may be perfectly able to facilitate in this sense, but only by sharply restraining his legislative urges. Ideally the facilitators will have clinical experience, of course, but there may not be enough available, and notoriously, some who do volunteer may have strong didactic impulses. But the best facilitators might well be those with theatrical experience. There is much that could be learned from lecturers in communication skills about how they recruit and train appropriate facilitators.

So I want to finish with a brief outline of the sort of activities I have in mind. I'm not sure any of them are particularly original, but they would assume a new importance within the context of my central argument.

Working with actors

This would be explicitly modelled on, and could be combined with, the teaching of communication skills. A professional actor would play the patient, students would rotate playing the doctor, and the other students would observe and take notes, and then feed back. The ensuing discussion would cover not only communication skills but also ethics. The actor would be provided with a detailed biography, and would be expected to improvise consistently and plausibly as required. The facilitator would be firm in keeping the discussion away from general matters of policy as much as possible: given that the law is thus and so, what should the GP do?10

Confidential 'baggage' forum

This would be a compulsory session, once a semester, where students could bring 'baggage' to unload in confidence among a small group of their peers, in the presence of two clinicians. The clinicians would not be there to teach at all, merely to help the students articulate their concerns and possibly to fill in some relevant details about hospital policy or medical life that the student may not know about.11

The use of film and literature

The problem with case scenarios and vignettes is the lack of detail, and this threatens the particularity and proximity that is so important to deepened ethical understanding. On the other hand, it may not be possible to spend enough time with real patients for any number of obvious reasons. The use of literature and film to present a compelling and detailed portrait of the patient's experience can be an adequate substitute, and can generate much useful discussion.

A central place for theology

On the one hand it is easy to understand the rigid secularisation of the modern medical school and hospital, given the huge success of scientific medicine. On the other hand, by far the most sophisticated accounts of the meaning of suffering and death have been offered by the major world religions. At the very least, medical students should know something of these accounts in order to understand something of their patients' religious beliefs, rather than relying on the hospital chaplain to 'translate' for them. However, I would suggest that students who are themselves already religious believers could be encouraged to develop their theological understanding of medicine alongside the development of their clinical understanding.

Visits to a hospice

It might seem that a hospice is insufficiently different from a hospital, in terms of what a student could learn from a special visit. However, the hospital patient might not know or accept his fate, he might die too quickly, and all the ongoing treatment will be distracting. In a hospice, the residents are more likely to have prepared themselves for death, and to be ready to discuss it.

Assessment

This has always been a problem. Multiple-choice and short-answer questions in ethics are utterly pointless, however efficiently they might test other subjects. At most, some ethical aspects of the law can be indirectly tested in this format. Essays are very inefficient for the huge medical cohorts; at best they encourage legislative thinking, at worst little more than regurgitation. Assessing ethics by practical demonstration (eg as an Objective Structured Clinical Examination (OSCE) station) might be feasible, but there are obvious problems with objectivity and consistency, and with the inability to prevent a 'check-list' approach.12 I would suggest that the student's ethical conduct and character should be assessed more rigorously by the Fitness-to-Practice Board using the standard reports from tutors through the years. It might be possible to add explicit ethical categories to the report forms such as 'ethical sensitivity' and 'ethical maturity'.

Admissions

Applicants are normally selected for medical school on the basis of their academic ability and scientific knowledge, and this is clearly important. However, this should be supplemented by:

  1. an explicit prerequisite of at least a year working or volunteering in a health care facility, or at least in a charity that helps vulnerable people. The director of such a facility or charity would then be asked to provide a reference, which would include details of the applicant's character.
  2. In addition, there should be a minimum age of 23, although the applicant need not already be a graduate. It is enough that he has already seen a little more of the world, and has a character that has settled a little more, than the 18-yearolds who make up the bulk of British first-year medical students.

Endnotes

  1. Most of what I have to say about medicine, medical schools, medical students and medical ethics will probably apply to the other people-oriented professional schools, such as nursing, physiotherapy, and social work. My own experience has been entirely in a medical school, and so I shall draw from that in what follows.
  2. As the lecturer in ethics in a UK medical school, I am therefore effectively arguing myself out of a job.
  3. There is also a place for philosophers (perhaps together with economists) when discussing the recurrent problem of scarce resource allocation. Insofar as this is a managerial problem for the health services, then it is a good matter for philosophical discussion. But insofar as it involves decisions made by individual healthcare staff, e.g. triage nurses and ICU consultants, then I would suggest that the philosopher is less able to discuss it, for the reasons that will follow.
  4. An excellent discussion of this kind of ethical persuasion is to be found in Cora Diamond 'Anything but Argument?' in her The Realistic Spirit, MIT press 1995. See also Martha Nussbaum, Love's Knowledge, OUP 1990.
  5. A prison contains plenty of suffering, but it is a different kind of suffering in virtue of its putative link with guilt and desert. The overwhelming concentration of suffering in the hospital is similar, however, to that of the battlefield and the slum. And much of what I have to say can equally be said of those contexts. However, I am assuming a reader of Western middle-class background, with little experience of battlefields and slums.
  6. Again, the same sort of sudden awareness of the striking contingency of the other's death on the battlefield, or the other's extreme poverty, is not the sort of thing that can be subdued by reasons.
  7. Diane Pretty suffered from motor neurone disease, and she reached a stage where she was physically unable to commit suicide except by refusing to eat and drink. In 2002 she formally requested that her husband be granted immunity from prosecution for murder if he helped her to commit suicide. All levels of the judiciary, culminating in the European Court of Justice, rejected her request.
  8. This example is from Bernard Williams 'Part II: Against' in: JJC Smart and B Williams, Utilitarianism: For and Against, OUP 1973.
  9. There are similar debates about ethical criticism of soldiers by civilians.
  10. One well-known textbook to advocate the combination of ethics and communication skills in such a way is Hope, Fulford, Yates, The Oxford Practice Skills Course, OUP 1996.
  11. This idea was originally suggested by Deborah Bowman of the St. George's Hospital medical school.
  12. See: http://wings.buffalo.edu/faculty/research/bioethics/osce.html

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