We critically evaluate the ways in which competence in medical ethics has been evaluated. We report the initial stage in the development of a relevant, reliable and valid instrument to evaluate core critical thinking skills in medical ethics. This instrument can be used to evaluate the impact of medical ethics education programmes and to assess whether medical students have achieved a satisfactory level of performance of core skills and knowledge in medical ethics, within and across institutions.

There is a long history of medical research that involves intentionally infecting healthy people in order to study diseases and their treatments. Such research—what might be called “human challenge studies”—are an important strand of much current research—for example, in the development of vaccinations. The many international and national guidelines about the proper conduct of medical research do not specifically address human challenge studies. In this paper we review the guidelines on the risk of harm that healthy volunteers may be exposed (...) to in the course of medical research. We examine the ethical arguments that are implicit or explicit in these guidelines. We then ask whether there is reason for limiting such studies on grounds independent of risk of harm. We conclude that the major ethical concern with challenge studies is that of risk of harm and that the fact that a study is a challenge study is not a wrong in itself. (shrink)

OBJECTIVES: To study the resources available and resources needed for ethics teaching to medical students in UK medical schools as required by the new GMC core curriculum. DESIGN: A structured questionnaire was piloted and then circulated to deans of medical schools. SETTING: All UK medical schools. RESULTS: Eighteen out of 28 schools completed the questionnaire, the remainder either indicating that their arrangements were "under review" (4) or not responding (6). Among those responding: 1) library resources, including video and information technology (...) were found to be fairly well developed; 2) many schools had a good supply of handouts and sample cases for teaching; 3) most had a written syllabus, and 4) two-thirds examined in the subject. However, many schools indicated that there was an urgent need for: 1) full-time teachers (most ethics teaching is still by part-time and voluntary staff); funding for books and journals, and 3) additional teaching materials (including further case vignettes, handouts and sample exam questions). CONCLUSIONS: There has been a considerable overall improvement in resources for medical ethics teaching since the time of the last national survey (The Pond Report). However, provision varies widely from medical school to medical school. The particular needs identified were for full-time teachers, library resources and teaching materials. Wider use of existing organisations concerned with medical ethics could help to meet these needs. (shrink)

We describe the teaching programme in ethics, law and communication skills for clinical medical students which is being developed as part of the Oxford Practice Skills Project. These three elements of practice are approached in an integrated teaching programme which aims to address everyday clinical practice. The role of a central value of patient-centred health care in guiding the teaching is described. Although the final aim of the teaching is to improve actual practice, we have found three 'sub-aims' helpful in (...) the development of the programme. These sub-aims are: increasing students' awareness of ethical issues; enhancing their analytical thinking skills, and teaching specific knowledge. (shrink)

The Mental Capacity Act is an impressive piece of legislation that deserves serious ethical attention, but much of the commentary on the Act has focussed on its legal and practical implications rather than the underlying ethical concepts. This paper examines the approach that the Act takes to best interests. The Act does not provide an account of the underlying concept of best interests. Instead it lists factors that must be considered in determining best interests, and the Code of Practice to (...) the Act states that this list is incomplete. This paper argues that this general approach is correct, contrary to some accounts of best interests. The checklist includes items that are unhelpful. Furthermore, neither the Act nor its Code of Practice provides sufficient guidance to carers faced with difficult decisions concerning best interests. This paper suggests ways in which the checklist can be developed and discusses cases that could be used in an updated Code of Practice. (shrink)

There are some ideas that at first seem simple, but which become more complex and profound the more they are explored. Great art, of course, is like that. When I first saw Vermeer's Girl with a Pearl Earring I was excited by its fresh simplicity. I thought, however, it a painting I would soon understand. I was wrong. It becomes increasingly mysterious with increasing familiarity. It has recently inspired a novel.1The distinction between acts and omissions is one of these simple, (...) complex, ideas. When I first studied philosophy I thought I would rapidly be able to decide once and for all whether the distinction is of moral importance or not. I did in fact come to a decision. The problem is that I have kept revising that decision ever since. The issues raised by the arguments over acts and omissions continue to inspire philosophical discussion. They also continue to haunt doctors and relatives at the bedsides of those near the end of their lives.Donna Dickenson, in this issue of the journal,2 reports the results of a survey of opinions from those taking part in an Open University course on death and dying. She believes that for many bioethicists the acts/omissions distinction has been shown to be wrong as a distinction of moral worth. Her survey suggests, however, that for many health professionals this distinction is seen as morally important. She asks whether the bioethical consensus, as she sees it, against the distinction is a result of clear thinking, or whether the views of practitioners result from their taking into account, in a way bioethicists do not, the richness of reality.There is I believe, less consensus amongst bioethicists than Dickenson suggests. In this issue of the journal, Marc Stauch3 argues in favour of the acts/omissions …. (shrink)

Background: Priority setting is necessary in current healthcare services. Discussion of fair process has highlighted the value of developing reasons for allocation decisions on the basis of experience gained from real cases.Aim: To identify the reasons that those with experience of real decision-making concerning resource allocation think relevant in deciding on the priority of a new but expensive drug treatment.Methods: Semistructured interviews with members of committees with responsibility for making resource allocation decisions at a local level in the British National (...) Health Service, analysed using modified grounded theory.Results: 22 interviews were carried out. 14 reasons were identified. Four reasons were almost universally considered most important: cost effectiveness; clinical effectiveness; equality and gross cost. No one reason was considered dominant. Some considerations, such as political directives and fear of litigation, were thought by many participants to distort decision-making. There was a substantial lack of agreement over the relevance of some reasons, such as the absence of alternative treatment for the condition.Conclusions: There is a clear consensus on the importance and role of a limited number of reasons in allocation decisions among participants. A focus on the process of decision-making, however, does not obviate the need for those involved in the process to engage with problematical ethical issues, nor for the importance of further ethical analysis. (shrink)

The “best interests” of the patient are widely seen as a cornerstone of medical practice. They are the explicit legal standard for medical care in the case of patients who lack capacity to consent to treatment.The best interests of the individual patient have, of course, long been compromised for the sake of other potential patients—in infectious disease control for example. The question of the ethics of such compromise became a hot issue, for UK doctors, about fifteen years ago in the (...) context of health care rationing. At that time the fact that there are insufficient resources to provide all patients, in all circumstances, with the best possible treatment became explicit. Faced with this uncomfortable truth, doctors tended to divide into two camps. Some wanted to play no role in decisions about resource allocation. They continued to be guided by the single ethic of each individual patient's best interests. However, “best interests” could be interpreted as “best” given the treatments that were made available by those who determined the allocation of resources. Others took the opposite approach: since choices had to be made as to the best use of available resources, doctors ought to be playing a significant role in making these choices.This polarisation has softened over time. Doctors have become more at ease with the idea that some treatments are not, given the overall resources, cost-effective, even if they are the best available. Clinical guidelines increasingly are influenced by cost-effectiveness. To provide the best health care overall, within the available resources, doctors aim to provide good care for each individual patient, but they do not always provide the best care. (shrink)