Information Medical

The main function of the BMA (established 1832) is to protect the interests of its members; it is the trade union for doctors in the UK. It is involved in the negotiations on behalf of doctors at national level as well as representing members at a local level in employment-related disputes (English et al. 2004). Membership of the BMA is optional. A doctor who is a ‘paid-up’ BMA member has to raise a problem locally for industrial relations officers to become involved in a local dispute over work conditions (otherwise there would be no point in paying to be a member of a trade union). As well as representing members’ interests, it also passes comment on behalf of the profession on matters related to health such as banning tobacco advertising, and on global issues such as the role of doctors in executions and torture. The BMA also has a research unit and an ethics department, which provides guidance on contentious issues (see below). BMA members can seek personal advic...

The chief role of the Royal Medical Colleges is to set educational, professional and clinical standards for their specialty. Trainees in a given specialty must now generally pass a membership examination from the relevant college before obtaining a certificate of completion of specialist training. Some newer specialties have their standards set by a faculty of a Royal Medical College. For example, forensic medical examiners have their standards set by the Faculty of Forensic Medical Examiners at the Royal College of Physicians. Now that doctors will have to supply evidence of fitness to practise after specialization (a process called revalidation), the Royal Colleges will set specialty-specific standards on behalf of the GMC. The colleges also pass comment on issues relating to their specialty and the health service. The colleges support research (e.g. with financial grants and opportunities to showcase research at conferences and in college journals) and will have a ...

The GMC also sets out duties for medical students. Medical students have legal restrictions on the clinical work they can do, but must be aware that they are often doing things that a qualified doctor might do (such as ‘taking a history’) and that their activities will affect patients. Patients may see students as knowledgeable, and may consider them to have the same responsibilities and duties as a doctor. Students must be aware that their behaviour outside the clinical environment, including in their personal lives, may have an impact on their fitness to practise (professional boundaries are discussed later in this chapter). Therefore: • students have a duty to make sure that patients know that they are students and not doctors. For example: should medical undergraduates introduce themselves as medical students or as student doctors? The title ‘Student doctor’ could mislead a patient that the person seeing them is medically qualified • students have a duty to beha...

The role of the GMC (established 1868) is broadly: • to set professional standards of practice • to ensure that those allowed to practise medicine (registered medical practitioners) are fit to do so, in terms of knowledge, skills and their behaviour • to maintain a register of doctors who are licensed to practise medicine in the UK. It is illegal to practise medicine without a licence in the UK • to supervise standards of undergraduate and postgraduate education – the GMC sets out a syllabus for medical schools to follow, and since 2008, now also works with the Royal Colleges to ensure appropriate standards for specialist training and continuing medical education. (The GMC has taken over this role from the Postgraduate Medical Education and Training Board.) This latter role includes supervising revalidation (see below), supervision of doctors’ fitness to practise after qualification as a general practitioner (GP) or specialist • to enforce professional discipline –...

Oaths and declarations are a way in which professions promise to the public that they will uphold a publically accepted set of values, enabling that profession to be trusted and have a certain status within society. They also represent a way in which a profession can remind its members of those core values. The Hippocratic Oath ( 425 BC) has historically been seen as part of the Western medical tradition. It encourages a number of concepts that are still relevant today: the teaching of medicine; the consideration of the patient’s best interests; confidentiality and the abstinence from ‘whatever is deleterious and mischievous’. However, it does not mention concepts such as autonomy or justice, and forbids performing surgery. The original Hippocratic Oath is now rarely taken in UK medical schools, though some have written modern versions. The Declaration of Geneva (1948, amended 1968 and most recently revised in 2006) is a modern-day Hippocratic Oath, requiring doctor...

Doctors may sometimes fall foul of the criminal law (this is discussed in relevant sections over the next four chapters) but the majority of cases against doctors are heard in the civil courts. Civil law cases involving doctors are usually actions in medical negligence. There are some basic components of a medical negligence action. A duty of care: it must be shown that the defendant (that is the person or authority accused of negligence) owed the claimant (that is the injured party or the person accusing the defendant of negligence) a duty of care: • The duty of care of a GP crystallizes when the patient registers with that GP and then consults with the GP on the occasion in question. • The duty of care of a hospital doctor crystallizes when the patient is formally accepted into hospital. English law does not oblige doctors to give emergency treatment outside of the above situations except when: • a patient presents to an A&E department • when a GP is requested ...

Autonomy literally means ‘self-rule’. In essence, it refers to an ability: (1) to reason and think about one’s own choices; (2) to decide how to act and (3) to act on that decision, all without hindrance from other people. Autonomy is more than simply being free to do what one wants to do. It implies that rational thought is involved in a decision. While many animals are free to do what they want, they are not autonomous because they do not critically evaluate the benefits and risks to themselves, or others, involved in their decisions. In respecting a person’s autonomy, we recognize that they are entitled to make decisions that affect their own lives. Justification for this principle is most obviously found in Kantian theory: the idea that people should be treated not simply as means, but as ends in themselves. However, support for autonomy can also be found in those versions of rule-utilitarianism which hold that the best outcomes arisewhen autonomy is respected. O...

In the late 1970s, two Americans, Tom Beauchamp and James Childress, introduced the idea of the ‘four principles’ or ‘principlism’. Historically, principlism represents the most widely taught ethical framework in UK medical schools and probably the most widely used ethical framework by clinicians in English-speaking countries. The four principles are: • autonomy: the principle of respecting the decisions made by those capable of making decisions. Autonomy also includes respecting (as far as is possible) the autonomy of people whose ability to make decisions is limited, e.g. by senility or illness • beneficence: the principle of doing good or providing benefit • non-maleficence: the principle that a person should avoid doing harm, or minimize harm as much as possible if it is unavoidable • justice: the principle of ensuring fairness and equity in the distribution of risks and benefits. This includes the idea of treating equals equally and recognizing relevant inequ...

Consideration for individual values, particularly those of the patient, can be difficult within the context of modern health care, where complex and conflicting values are often in play. This is particularly so when a patient’s values seem to be at odds with evidence-based practice or widely shared ethical principles, or when a health professional’s personal values may affect the care provided. Values-based practice, a framework developed originally in the domain of mental health, maintains that values are pervasive and powerful influences in healthcare decisions and research, and that their impact is often underestimated. It suggests that our current approaches lead us to ignore some important manifestations of values at both the general level, as relevant in legal, policy and research contexts, as well as at the individual level, as relevant in clinical practice. All students and trainees are continually exposed to areas of ethical difficulty thr...

Deontology covers those theories that emphasize moral duties and rules, rather than consequences (from the Greek deon, meaning ‘duty’). Perhaps the best known deontological principles are those set down in the Ten Commandments. Deontology is associated with Immanuel Kant (1724–1804). He believed that morality was not dependent on how much happiness resulted from particular actions. Rather, he thought morality was something humans imposed upon themselves because they are rational beings. Although Christian, Kant did not believe that God was necessary for moral law. Kant argued that we can find out which moral rules to obey by using our powers of reason. He said that by seeing whether our desires can be applied universally, we can tell whether or not they follow rational moral principles. This ‘universalizability’ test is called the ‘categorical imperative’. It states: Act only on that maxim through which you can at the same time will that it should become a universa...

Ethical theories attempt to provide an over-arching theoretical framework for addressing the problem of how human beings should behave with one another in the world. There are three key theories which have historically dominated medical ethics teaching: Utilitarianism, Deontology and Virtue Ethics. More recent frameworks attempt to reconcile different theories and values. The widely taught four principles of biomedical ethics attributed to Beauchamp and Childress is one such attempt. ‘Values-Based Practice’ or ‘Values in Medicine’ has recently gained prominence in psychiatry and general practice, and is taught on some undergraduate medical degrees (these theories are considered below).

The core curriculum in medical ethics and law was updated in 2010 (Stirrat et al 2010) and sets out a core content of learning for medical ethics and law in the UK. It has been endorsed by the General Medical Council (GMC), which means it will form a basis for the standards expected from medical schools and hence of medical students. In Years 1 and 2 medical students are expected to: • recognize and understand core ethical and legal topics • apply common ethical arguments using constructed case scenarios • be able to understand and discuss differing viewpoints • be aware of the requirements of GMC on student fitness to practice. In Years 3 and 4 medical students are expected to: • be familiar with the GMC’s professional codes of conduct • recognize ethical and legal issues and be able to apply common ethical arguments to actual clinical encounters in different specialties and public health interventions • recognize and conform with professional and legal obligat...

‘Ethics’ or ‘moral philosophy’ is the study of morals in human conduct. Like all branches of philosophy, it deals with the critical evaluation of assumptions and arguments. Within the field of philosophy, ‘Medical ethics’ is the study of morals in the medical arena (Fig. 1.1). In practice this means that medical ethics plays a role wherever the question, ‘What ought to be done?’ is raised in the medical context. Campbell and Higgs (1982) describe three concepts of ‘ethics’ held by doctors: 1. Professional etiquette: the accepted conventions of a social role 2. Synonymous with ‘morals or morality’ 3. Moral philosophy: the critical study of morality. In the past, many medical schools did not formally teach ethics. It was thought that the student would be able to learn what was considered right and wrong by observation of senior doctors, and by doing as they did. The explicit teaching of ethics aims to help to foster an ability to make rational, moral decisions – rather...