1 Morality and philosophy of medicine and education
Autonomy; see also conditional autonomy and principled autonomy The ability to live one’s own life, according to one’s own motives and reason.
Complexity theory This theory concerns the interactivity of elements in open systems, where the magnitude of effects cannot be predicted in a linear fashion from the magnitude of the elements relative to each other.
Conditional autonomy The delineation by an authority of particular areas of activity as ones within which a subordinate may act autonomously.
Consequentialism Ethical theory in which the act that is morally right is determined by the consequences of the act rather than the act itself.
Defensible practice Activity that is carefully negotiated with a patient to take account of scientific knowledge and moral principles.
Defensive practice When fear of litigation encourages (unhelpfully) restricted professional activity.
Developmental resonance The re-emergence of unresolved personal conflicts around autonomy and authority which may then be re-enacted in the relationship between supervisor and supervisee.
Learning contract (see, also, personal development plan, Chapter 8 Glossary) An agreement between learner and teacher to be interested in and extend understanding and abilities relating to health and illness care.
Learning-directed self The aspect of personal identity and motivation which enables new knowledge or skills to be acquired: the primary, shared focus of medical education is engagement with this learning-directed self in order to produce ‘fit-for-purpose’ health and sickness care practitioners.
Participative emergence of form The process by which the various constituents of a complex system (see Complexity Theory) contribute to the maintenance or change of that system. The influence of one part of the system may have effects on the whole which appear disproportionate (greater or lesser) to their actual relative size. The resultant form may or may not be that which was intended.
Principled Autonomy School of moral philosophy developed from Principlism: the key tenets derive from the need to ensure that the application of a principle to one person does not interfere with their simultaneous application to any other.
Principlism School of moral philosophy based on the four principles of beneficence, non-maleficence, respect for autonomy, and justice.
Professional adolescence A stage of professional development through which juniors progress to become fully fledged professionals.
Psychodynamics Study of the relationship between human behaviour and relationships, taking into account conscious and unconscious elements of mental life.
Utilitarianism Philosophical theory in which the morally right action is that which produces the most good.
Virtue ethics Philosophical theory in which virtues (such as honesty or generosity) dictate the morality of actions.
“The point of philosophy is to start with something so simple as not to seem worth stating and to end with something so paradoxical that no one will believe it”
This chapter describes some ethical and philosophical concepts that are key to medicine and medical education. It applies them to issues medical practitioners and educators are currently facing and suggests some core texts in the field. We use the phrase ‘health and sickness care’ because there can be different and even competing demands between the care of health and the care of sickness. In particular, the way ‘health’, ‘sickness’, ‘health care’, and ‘sickness care’ are defined depends on the value attached by the definer to the different experiences of life and the functions performed in living. We start by considering how such definitions are arrived at. Next, we describe a variety of schools of thought about the nature of human development and relationships. Having introduced the principles of ethics primarily from the perspective of health and sickness care, we turn our attention to medical education, analysing and differentiating the rights and responsibilities of learners, teachers, and patients, as both individuals and members of society.
From whatever ethical or social standpoint they are viewed, the goals of both medicine and education are, in principle, ‘good’. The practice of medicine aims to prevent suffering when it is avoidable and alleviate suffering when it is inevitable. Education strives to meet individual learners’ and society’s needs for enhanced knowledge and ability. What amounts to ‘a good’ and how education can achieve it are, however, debatable.
The chance to ‘do good’ and be ‘useful’ is motivating to those who seek to learn and teach medicine. In return for their altruistic motivation, health professionals are given intimate access to people’s lives at times of vulnerability. However, medicine has limitations, so professionals can be faced with the feeling that they cannot be ‘useful’. Worse than that, treatments can cause harm, so practising medicine means balancing the positive and negative effects of treatment. As if that were not difficult enough, one person’s appraisal of an outcome as ‘good’ or ‘bad’ does not necessarily agree with another person’s. Such value judgements are not the only factor at play; what is actually available to treat a patient may be determined by the need to allocate resources equitably. The basis on which such decisions are made cannot be divorced from the value that is placed on the benefits or harms that may accrue. Other value judgements are even more delicate – e.g. is treating someone in order that they can return to work a greater good than treating someone who will never be able to return to work? The ability to examine why treatments may or may not be available and why an outcome is described as ‘good’ or ‘bad’ is a fundamental component of both medical practice and medical education.
The ability to do something is not a sufficient basis for actually doing it and deciding what is useful to do can be complex. If medical practice is defined as prolonging life or improving health, there comes a time for every individual when there is no useful course of action. At such times, the art of medicine is to resist both the temptation to “strive officiously to keep alive” (in the words of the poet Arthur Hugh Clough) and the temptation to abandon the person to death or suffering. In the language of Winnicott (1971), the task of health and sickness care has elements of both ‘doing [to] and being [with]’. Tolerating feeling useless or helpless – coping with one’s patients being ill and not getting better – is an essential contribution of health and sickness care professionals.
The way in which medicine is practiced may influence individual and societal attitudes towards health and illness and be influenced in turn by those attitudes. The consequences of this interactivity – for example, the development of policies about how time and finance should be allocated – need to be part of public and professional discourse. Prioritising one treatment over another involves decisions not only about the cost but also about the value of the outcomes to individuals and to the whole community. Individual medical scientists and practitioners all contribute to this discourse alongside patients and experts in other relevant fields such as social policy and ethics. One final consideration in this overview of health and education as social goods is that health interventions can be at the level of whole populations rather than single identifiable individuals. Whilst a net increase in the health of a population must surely benefit individuals, that effect may not be recognisable in any specific person. Practitioners must have a balanced view of the interplay between collective and individual good and help learners to see the collective perspective when they are, as is inevitable, preoccupied with the needs of sick individuals.
Laws tell us which activities are sanctioned and what will happen to people who engage in activities that are not sanctioned. The fact that laws can change in any one jurisdiction and are different in different jurisdictions emphasises that laws are not absolute. What is legal and what is morally correct are not necessarily the same. Ethical analysis plays an important part in the evolution of legal process by systematically and rigorously questioning what is ‘good’.
Medicine exists within the bounds of what is legal in the country in which it is practiced. Learners, educators, and practitioners in any one country must know which activities are sanctioned and which ones are proscribed both in professional practice and lay life. However, the fact that a law exists does not mean that it should be accepted without question; neither should previous interpretations of a law nor the application of those interpretations be left unchallenged. Fear of litigation may encourage unhelpfully restricted professional activity (defensive practice) rather than activity that is carefully negotiated with an individual patient to take account of scientific knowledge and moral principles (defensible practice). An understanding of the principles of ethics is therefore fundamental to the everyday practice of medicine and medical education just as much as it is at the scientific and technological frontiers of practice.
While variation between individuals in what they find morally acceptable in their personal lives is inevitable, professional practice requires agreement on ethical and moral principles. Consensus in such matters is arrived at by ethics committees (usually at national level), which hear academic, lay, ethical, and legal opinion. They disseminate guidance in published documents; advise the bodies that regulate professional practice; and give opinions when new, difficult issues come to public attention. When differences of priority and opinion arise, it is right that there should be moral debate. Intuition and individualism have their place in such debates but rigorous philosophical enquiry is about starting from solid premises to develop arguments which lead to solid conclusions. The ‘perfect argument’ would result from a series of irrefutable premises. But, just as scientific truth is provisional rather than absolute, a particular ethical stance stands only until a more valid argument is put forward. It is the complexity of constructing and comparing well-reasoned arguments and deciding which actions are to be sanctioned or proscribed that makes it necessary to have ethics committees and professional ethicists. Their existence, however, does not obviate the need for informed ethical reflection and analysis in day-to-day practice and a willingness to question the status quo. We must always be open to new ethical questions since we will never know if we have formulated all the questions that could be asked.
Intuition, as the expression of an inherent sense of right and wrong, commonly alerts health care professionals to ethically questionable situations. It leads them to ask why something is morally uncomfortable and to seek an answer by a logical analysis of their own position and that of their colleagues. Arguments have to be examined for the quality of their reasoning. Rhetoric and emotion play little role in the final formulation and exposition of ethical arguments, but this does not mean that ethics is without feeling. Emotions are a fundamental component of the human condition, particularly when caring for people who are at their most vulnerable, so emotions are inseparable from ethics.
In presenting this chapter, we have chosen to give an overview of various schools of thought about moral philosophy and the nature of human development and relationships. One of our goals has been to integrate ethics with developmental and dynamic processes of human relatedness. Another has been to encourage readers to take a discriminating approach to ethics and we provide tools to help them do so.
Principlism (Beauchamp and Childress, 2001) has been a major influence on modern medicine. It has four central ‘pillars’: the principles of
At the start of the chapter, we said that doing good is a major pillar of medicine. Avoiding harm is at least as important. The aphorism “primum non nocere” – “first do no harm” – emphasises the primacy of this principle. The benefits of treatment always interplay with concurrent risks so it is part of the day-to-day work of doctors to understand and balance those risks.
Individual autonomy is ‘an idea that is generally understood to refer to the capacity to be one’s own person, to live one’s life according to reasons and motives that are taken as one’s own… to be directed by considerations, desires, conditions, and characteristics that are not simply imposed externally upon one’ (Stanford Encyclopedia of Philosophy [S.E.P.], 2009; http://plato.stanford.edu/entries/autonomy-moral/). Only in the past half century has medicine begun to leave behind the paternalism of ‘doctor knows best’ in favour of autonomy. Respecting autonomy means accepting a patient’s right to make their own choices, regardless of whether those choices are in accord with the doctor’s preferences and whether the reasoning is acceptable to the doctor.
Gillon (1985) subdivided autonomy into three components:
The principle of justice is that decisions should be made on the relative usefulness of different actions and resources should be distributed equitably (‘to each according to need’ rather than ‘to all equally’). The principle of justice applies to education just as it applies to health care. It demands that mechanisms be in place to distribute resources fairly, whether such resources are reliant on finance, suitably trained practitioners, equipment, or available time.
Principlism provides a useful framework to analyse clinical, research, and educational practice but the primacy it accords to individual autonomy has been a matter of recent debate. Campbell (1991) highlights how confusions may arise: “[If] ‘autonomy’ is to carry a high value, then what is its polar opposite which is to be equivalently disvalued?… [In] confusing autonomy with independence, the current political mood regards dependency as moral inadequacy. The weak and needy are increasingly being seen as an inconvenient burden which the strong and successful must only grudgingly bear.” ‘Maximal’ autonomy, in which the individual has unlimited freedom to exercise self-rule, is more a theoretical concept than a reality because it is unattainable. Conversely, a more ‘basic’ level of autonomy, consisting of the ability to make reasoned judgements and freedom from explicit oppression (SEP, 2009), is far more inclusive.
Interconnectedness was encapsulated by the poet John Donne’s phrase ‘No man is an island, entire of itself; every man is a piece of the continent, a part of the main’. Simplistic adherence to the principle of autonomy is at odds with interconnectedness. Sennett (1998) argued that a political culture during the latter part of the twentieth century, which set ‘independence’ as a virtuous state for individuals, led to a ‘corrosion of character’. O’Neill (2002a) believed that problems arise when autonomy and individual independence are viewed as synonymous, with the corollary that ‘dependence’ is an affront to autonomy. Sutton (2001), arguing from a psychoanalytic perspective, similarly challenged an absolutist view of individual autonomy; “Instead of a culture which sets dependence and independence as value-loaded polarities, what is required is one which accepts that what can be depended upon may lie within or outside an individual and that this is a dynamic state within and between individuals.” Given that both clinical and educational processes rely on identifying where or within whom resources can be located, interconnectedness is an important perspective in medical practice and education.
O’Neill (2002a) proposed a framework of ‘Principled Autonomy’, whose application to one person does not interfere with its simultaneous application to any other person. She identified three components that, unlike Principlism, reflect the dynamic interrelationship between an individual and the situation they are in:
Graduated autonomy is a developmental perspective, which acknowledges that capacity increases from childhood through to adulthood as a result of maturational processes. Hence, adolescents have ‘conditional autonomy’ (Sutton, 1997, 79); in other words, autonomy of action in areas negotiated with their parents. That process of negotiation (implicitly and explicitly) defines the limits of the responsible adult(s)’ own autonomy. There may be psychosomatic and social dynamics to particular individuals’ experiences of self-determination at different times; for example, the ability to perform at one’s best is influenced by health and sickness. In comparison with their wider peer group, learners participating in professional education programmes such as medicine may have constraints placed upon their activities through the requirements of ‘protoprofessionalism’, a term proposed by Hilton and Slotnick (2005) to describe the undergraduate stage of professional development.
Principled Autonomy strives to balance the rights of individuals against benefits to the widest possible number of people (utilitarian arguments), contextualising ethics to relationships and community interactions. Clinical practice based on Principled Autonomy is the “…provision of sufficient and understandable information and space [to] patients, who [have] the capacity to make a settled choice about medical interventions on themselves, [and] to do so responsibly in a manner considerate to others” and “best fits the optimal patient–doctor relationship in which there is a mutual, unspoken agreement between the parties that recognises the duties and obligations each to the other.” (Stirrat and Gill, 2005) This relationship between what individuals can reasonably expect for themselves and of others needs careful consideration. Since rights and obligations are inextricably entwined, a right cannot be fulfilled unless there is a clear duty on someone to fulfil it. That means that the person(s) on whom an obligation rests must be equipped to fulfil it; an attempt by professionals to present themselves as capable of providing a treatment they are not equipped to provide is dishonest. O’Neill (2002a) eloquently demonstrated the corollary of this in relation to a ‘right to health’: “…since it will never be possible to guarantee health for all, there can be no obligation so to do… there can therefore be no right to health.” Similarly, learners and teachers have the right to expect their medical school to provide resources to support them, but patients and society have to authorise learning and teaching. Fulfilling an obligation, whether in clinical or educational terms, involves both duty and ability: a person’s right is that there should be an aspiration for, and reasonable actions towards, an equitable approach.
The preceding descriptions approached ethics primarily from the perspective of health and sickness care, sometimes showing how principles of clinical ethics apply to medical education. We now take a wholly educational perspective.
The true risks and benefits of learner–patient interactions are unquantifiable because what the learner has learnt from any one encounter will become apparent only at a later date and the learning will not pertain solely to the patient involved. Any direct benefit or harm to the patient may be equally intangible. Learners and teachers must try to anticipate the significance of situations so patients can give truly informed consent. Unfolding processes of involvement should be negotiated in which patients are treated as full partners who understand their right to veto any action at any time.
Education in clinical settings relies on patients’ altruism, optimism, and faith, which depend on the trustworthiness of learners and the medical profession. Baier (1986) describes trust as requiring “good grounds for […] confidence in another’s good will, or at least the absence of good grounds for expecting their ill will or indifference” and entailing “accepted vulnerability to another’s possible but not expected ill will (or lack of good will) toward one.” Patients, however, cannot always understand why they trust or mistrust a learner or doctor. Baier (1986) writes of conscious (proper/reasonable) and unconscious processes of trust. O’Neill (2002) considers that there has been a crisis of trust in the medical profession in the UK as a result of well-publicised breaches such as in Bristol and Liverpool and by Dr Harold Shipman. In Bristol, unfavourable surgical audit data were ignored, which resulted in further deaths. In Alder Hey Children’s Hospital, Liverpool, a pathologist removed and retained organs at postmortem examinations without informing or seeking the consent of parents. Over many years, Harold Shipman systematically killed elderly patients by administering drugs and the death certification system failed to bring his misdeeds to light. O’Neill (2002) further emphasises that the problems that ensue from ‘misplaced mistrust’ can be as great as those that follow from ‘misplaced trust’.
Learner–patient interactions rely, at least to some extent, on an extension of trust to learners in their role as (future) members of the medical profession. Patients must be confident about the value of learners being involved, the reasonableness of the proposed activity (particularly if a learner has not carried it out before), and that learners and teachers are competent judges of its reasonableness. The same professional standards apply to learners as to fully trained doctors; as emphasised by the UK General Medical Council (GMC, 2006), teachers and learners must enact their roles only if they are fit to “be honest and open and act with integrity – act without delay if you have good reason to believe that you or a colleague may be putting patients at risk.” Of specific importance to both learner and patient is that the teacher can judge what can reasonably be expected of a learner.
A learning contract – a shared agreement to be interested in and extend understanding and abilities relating to health and sickness care – is what brings learner and teacher together, whether in the immediacy of caring for a patient or remote from it. All parties have to be able to put themselves in the service of learning, whilst simultaneously ensuring that whatever action is taken is in the best interests of the patient. Teachers play the important role of providing guidance and setting tasks that are within learners’ ‘zones of proximal development’ (Vygotsky, 1978). By challenging learners, teachers help them expand their knowledge (including awareness of what they have yet to learn) and acquire new abilities. By doing so in a controlled and thoughtful manner, teachers limit the extent to which learners experience failure (Lave and Wenger, 1991). Learning requires humility but is undermined by humiliation, which demotivates learners, undermines relationships between learners and teachers, and can undermine doctor–patient relationships too. Attempting but not succeeding is not necessarily the same as failing. It may be only through trying to perform a skill that it becomes clear what elements of the skill learners have acquired and what elements they still need to acquire.
There are three key issues for clinical education: the safety of patients, the maintenance of a developmental trajectory towards enhanced professional capability, and judging whether the achieved standard is sufficient for continued progress. For that positive process to occur, there needs to be a particular form of trust between learners and teachers. Phillips and Taylor (2009) argue that kindness is derived from ‘kin-ness’ – similarities in experiences and/or aspirations – and calls for an ‘ability to bear the vulnerability of others, and therefore of oneself’. Applying that concept to the learner–teacher relationship, the two parties need to show kindness in rather different ways, not least because of the different parts they play in safeguarding the welfare of patients. Learners and teachers will do that best if they feel confident in the support of their institution and society in general.
The particular relationship between learners and teachers can usefully be thought of in terms of what each is putting in the hands of the other, their engagement with developmental processes, and the unconscious dynamics that result. Chronological definitions of ‘adolescence’ vary, some authors suggesting that it continues into the early twenties, which includes most undergraduate entrants to medical education and even early postgraduate learners. In putting oneself forward for vocational education, there is an understanding that one is not ‘equipped to act’ in certain ways but an expectation that one will become so and that carrying out such actions will rely on appropriate authorisation by patients and a proper authority. Since adolescence is a stage of ‘conditional autonomy’ (see page 7), adolescents and adults have to “negotiate which of them can ‘speak’ with sufficient authority about a particular issue and therefore assume responsibility for what will or will not be done” (Sutton, 1997). Teachers and teaching institutions need to respect the developmental stages of their learners. Sutton (1997) further suggested that postgraduate training can be conceived of as a form of “professional adolescence” in which conditional autonomy applies to learners’ professional responsibilities despite them having become fully autonomous in other aspects of their lives. Professional adolescence may be complicated by developmental resonance in which there is “re-emergence of unresolved conflicts around autonomy and authority, which may then be re-enacted in the relationship between supervisor and supervisee,” something that must be taken into account in managing relationships.
Safe and productive learner–patient interactions rely on teachers’ guidance, learners’ ability to recognise their own limits, and patients’ trust that proper professional standards are being upheld. Even patients who do not understand statements such as ‘I’m a third year medical learner’ may at least appreciate that a professional apprentice will be carrying out tasks appropriate to their level of training. Patients’ expectations of learners may, however, be unrealistic so the grounds for learners’ participation need to be made clear; for example, whether they can carry out a procedure as a substitute for a doctor or only under a doctor’s direct supervision. Committed teachers and patients can see that learners are an investment for the future, and may also benefit from a naive, ‘fresh’ perspective, for example, when a learner’s need for clarification and correction exposes lay misunderstandings.
Principled Autonomy implies that there must be some basic mutuality of purpose if being involved with others is to be considered morally justifiable. If there is no mutuality, the relationship becomes an exploitative one. Learners in clinical environments may contribute much or little directly to patient care, but any educational situation involves an element of looking into the future because learners represent – as the GMC put it – “Tomorrow’s Doctors” (http://www.gmc-uk.org/education/undergraduate/tomorrows_doctors_2003.asp). Learners who see patients without being able to help may be experienced as an intrusion, perhaps even as voyeurs. Being present, however, and actively observing without acting upon a patient, is both a key clinical skill and an expression of empathy, or ‘kindness’ (Philips and Taylor, 2009). Learners must experience authentic clinical encounters in order to be equipped for their later role; even a dying patient may sincerely wish to contribute to the future by allowing a learner to be present.
In the immediate situation, patients who see learners may not gain anything directly, so it is hard to regard mutual benefit as a reason for them to agree to such interactions. But, do present patients have a responsibility to future patients they will never meet, such that they should be expected to allow learners to examine them? Or, should they be allowed to reject any responsibility towards future patients? An approach grounded firmly in ‘Individual Autonomy’ would answer ‘No’ to the first question and regard the second question as irrelevant because patients do not need to be granted permission to refuse. ‘Principled Autonomy’ would argue that the answer should take into account the communities of which patients are part; since current treatments were made possible by the educational experiences of prior doctors, the continued availability of care relies on mutuality and reciprocity. Further, patients may also have a right to the opportunity to participate in building the bank of experience that helps doctors achieve competence. The application of the principle of equal opportunity relating to research involving human participants in the Declaration of Helsinki (1964) to education warrants further attention.
In health and sickness care systems that require citizens to contribute financially through tax or insurance, there is a clear expectation that the fruits of paid work, made possible by sufficient health, will be used to ensure that care exists and will continue to exist. Should that expectation extend to contributing to medical education? It might be argued that medical learners have a ‘right’ to learn. They have entered into a contract to learn to be doctors and clinical learning requires access to patients. That argument could be seen to place an obligation on patients to serve as a resource for learning. There is acceptance, however, that ill people may be unable to fulfil their usual duties and that special allowance should be made to minimise hardship; this is manifest, for example in paid sickness leave. Illness may limit patients’ autonomy across a wide range of their usual activities, from total incapacity because of pain, mechanical, or physiological impairment, through to constraints arising from fear. Impairment resulting from illness (or even fear of illness) places people in a different position in the relationships upon which they depend and it can be argued their rights and obligations change accordingly. The extent of patients’ obligations to the health and sickness care system is clearly contingent upon their state of health. Learners’ needs for learning opportunities cannot take absolute priority over sick people’s needs and rights.
The preceding argument might suggest that interacting with learners is perceived negatively or as a burden by patients. That is often not the case. Once the purpose of learner interaction – the promotion of learning and the possibility of helping future patients (including themselves next time) – has been explained, many patients feel they can turn their illness into something positive. Contributing to learners’ learning counteracts emotional strains which result from dependence, so becoming educators, or at least active participants in educational processes, can be beneficial. ‘Expert Patients’, who give personal accounts of their chronic diseases and/or teach physical examination, contribute by building bridges between text books and the reality of living with disease. They mix personal with generalisable experience, though they may repeat lay misunderstandings as well as understandings of diseases. One way or another, patients are the ultimate truly authentic teaching resource – and giving them the opportunity to teach places their experiences in a pivotal position to be of value and valued. A respectful system recognises the mutual benefits of learner–patient interaction, encourages patients to be involved, supports them in being so, and avoids actions that are coercive or even subtly change the contribution from a voluntary one to a perceived obligation.
Professionals do not simply exchange goods or services for remuneration, nor are they simply purveyors/distributors of goods produced by others. The exchange is one in which judgement must be exercised as to whether what is proposed is reasonable. Professionals must give their own informed consent to the process alongside patients and be prepared for potential disagreement about proposed courses of action. Stirrat and Gill (2005) summarise this as “the doctor fulfilling his or her duty to the patient by exercising his or her own autonomy and, as such, [this] may be entirely justified. Indeed, there will be some occasions in which acquiescence to a requested intervention against one’s clinical or ethical judgement will be abrogation of one’s duty as a doctor.” Similarly patients cannot be viewed simply as recipients of goods from a third party (e.g. The UK National Health Service [NHS]). Neither can professionals be viewed simply as agents of a third party, acting without exercising professional judgement.
Arguments derived from Principled Autonomy, in line with Baier’s formulation, highlight the central importance of the dynamics of trust, placing a reasonable expectation of mutual trustworthiness as a central pillar. This must also be understood in terms of human development, the dyad of patient/professional, and the wider community in which the members of that dyad live and practice.
Evolution provides a useful analogy for developmental processes. Different constituents in an evolutionary system impact on each other, sometimes changing each other’s form or function; there is a dynamic of compatibility and incompatibility, complementarity and non-complementarity. Changes may be irreversible. They may alter the integrity of one or more components. They may even bring about the destruction of other components. Although Darwin’s model is often presented as ‘the survival of the fittest’, the issue is actually one of the survival of the fit between the needs, demands, and effects of biological systems in relationship to each other and their environment. The perpetuation of a particular system does not indicate anything about optimal functioning or desirability; only that equilibrium has been obtained. No intent to bring about the outcome is present, but the result can be ascribed value in terms of its potentially beneficial or detrimental influences.
When considering human actions, the possibility that they may have adverse effects on individuals or groups needs due consideration. Examining outcomes and reflecting on whether it is justifiable to continue the actions that lead to them is an essential component of practice. Evidence-Based Medicine supports such a process of examination by making available robust evidence about outcomes to support decision making. ‘Values-Based Medicine’ (Fulford, 2004) goes one stage further by evaluating the desirability (as opposed to likelihood) of different outcomes from different people’s points of view.
Individual development can be considered as a person’s ‘evolution of form’ under various internal and external influences. Future possibilities are defined by how those internal and external influences interact. Winnicott’s (1965) book “The Maturational Processes and the Facilitating Environment” captures this evolution in terms of its developmental desirability (‘maturity’) and the contributions of both individuals themselves and the relational and physical environments in which their time is spent (the ‘good-enough’, facilitating environment). The title underlines the fact that human development arises from interaction between possibilities present in the human givens of genetic endowment and possibilities arising from physical and relational environments. The co-existence of genetic and environmental possibilities in particular forms at particular times means that the likelihood of any form continuing or being feasible again in the future can increase or decrease through the same operations. There is not an infinite number of possibilities but patterns arise, indicating that different outcomes or ranges of outcomes are more or less probable or improbable. Translated into our expectations of people admitted to undergraduate or postgraduate medical education, there is an acceptably high likelihood that they will be suitable for progression. This progression, which must be within an acceptable range of diversity, occurs through a dynamic interaction between developmental processes and environmental influences.
Complexity Theory uses the term self-organisation to describe the emergence of systems that are identified by their structures and functions but not by any intent that they should come into being or remain in being (see, e.g. Sweeney and Griffiths, 2002). In considering organisation and management, Shaw and colleagues propose the term ‘participative self-organisation’ to capture the fundamental influences of interactivity, whereby there occurs ‘an inescapably self-organising process of participating in the spontaneous emergence of continuity and change’ (Shaw, 2002). Philosophical and psychodynamic considerations, however, mean that even the inclusion of the word ‘self’ introduces further complexity. To what extent are we considering this process of change as fundamentally the experience and expression of self as agent? To what extent can the experience of self as agent be equated with the fact of oneself as having been ‘an/the agent’ of what occurs?
There is no doubt that self and others participate in medical education, so we need to consider the different contributions that are necessary and sufficient for individual evolutionary journeys of practitioners as they are influenced by and influence the system within which they are learning. All parties come under the influence of each other simultaneously and bear responsibility to consider the impact they may have on the primary task. Changes in pre-university education may alter medical schools’ expectations of learners at entry; financial currents may influence the ability to study; or changes in employment law may alter the educational opportunities available for learners. Such processes call for an ability to consider intended and unintended outcomes, the part different factors have played in those outcomes, and whether the form that emerges truly serves the desired purpose of providing good practitioners. We suggest the term ‘participative emergence of form’ to capture this process in which even subtle changes in one part of the system may have disproportionate effects on the whole, whether intended or not.
In considering medical education, professionalism, and different expressions of personhood, ideas of ‘self’ related to living the good life (in philosophical rather than hedonistic terms) present further questions. ‘Self-directed learning’ (SDL) has been a powerful theme in medical education during the last two decades. In the context of this chapter, what does it mean in terms of self-ness? Does it mean ‘self to the exclusion of others’ or ‘self in relation to others’? Could it suggest selfish, the idea of self in the service of others, or are both possible simultaneously?
My (AS) experience is that the term ‘SDL’ has strengths and weaknesses. The emphasis on ‘self’ promotes personal responsibility to learn (including learning how to learn) but may unintentionally deny the importance of learning relationships. It can leave some learners feeling alone and teachers feeling disqualified from teaching. Winnicott (1971) emphasises that, since autonomous individuals are never truly independent of their environments, ‘Independence does not become absolute’, although mature individuals ‘may feel free and independent, at least so far as is necessary for happiness and a sense of personal identity’.
The formulation of education as a participative emergence of form is consistent with the tenets of Principled Autonomy. It places autonomy in the arena of individual development, interpersonal relationships, and organisational structures rather than individual ‘self-ness’, which the term is often taken to mean. It also allows links with psychological theories of personal, relational, moral, and social development related to learning. Eriksen (1950), for example, described themes in personal and social development across the life-span, using a vocabulary shared with moral philosophy – for example, ‘trust versus mistrust’ and ‘autonomy versus shame and doubt’.
Does self, however, exist as an entity that an individual experiences without it having externally recognisable features or must it be manifest in a form identifiable, by self and other, in actions? This issue of the experience and expression of self as acting and being acted upon leads psychological and educational theories, along with moral philosophy, to a shared interest in the concept of the ‘self as agent’. This self as agent also needs to be integrated with an ability to appraise situations, recognising their similarities and differences, in order that further potentially beneficial actions can increase and detrimental ones decrease. It needs to take account of how relating with others may sequentially influence the perception of events and actions. An example would be where the wish to please someone influences activity in a way that overrides one’s ‘better’ judgement. The ability to have ‘a mind of one’s own’, know that one can be ‘in two minds’, and appreciate that one’s autonomy of action may be limited is crucial in assimilating new experiences and being able to reflect on motivations and actions.
The picture presented is one of abilities changing and different facets of self emerging and being expressed in the course of development. We suggest that it is useful to think of a ‘learning-directed self’ in conjunction with other aspects of self. This ‘learning-directed self’, which motivates people to learn, may have various roots: pleasure derived from novelty and learning; altruistic desires to make a difference; pleasure in participating and learning alongside others; and the wish, eventually, to earn a living. It may also have a variety of routes for expression: intellectual; artistic; physical; and philanthropic. The primary, shared focus of education is engagement with this learning-directed self in order to produce ‘fit-for-purpose’ health and sickness care practitioners. The framework should also provide practitioners with the experience of a good life in philosophical terms, or in Winnicott’s terminology, a good-enough experience of life.
There is, therefore, an interlinking of necessary and sufficient components for this participative emergence of form at each stage of medical training from application to medical school through to retirement. In order to withstand ethical scrutiny, frameworks for education must provide for learning about what is necessary and sufficient for full and reasonable use to be made of these people as they live their lives trusting that expectations of them will be reasonable.
In terms of the psychodynamics of trust, a model of a necessary and sufficient sense of common purpose is pivotal. Misplaced trust can distort interactions through lack of scrutiny and accountability; misplaced mistrust can disrupt through fear of scrutiny and blame leading to unhelpful, defensive practice. Although patient safety cannot be left to the vagaries of learning by ‘trial and error’, the process of clinical practice and learning is inevitably one of ‘trial and improvement’. Establishing and maintaining an environment for medical education in conjunction with good medical practice relies on a culture that places a high regard on both trustworthiness and a ‘kindness’ which protects the most vulnerable.
It is plainly necessary to identify those who should or should not be admitted to medical school, awarded a degree, and allowed to practice. Active participation by learners and staff in selection, whether as selected or selector, is a moral imperative – certainly for the good of patients and perhaps also for the good of individuals who might otherwise be training or practicing when not fit. There are good arguments for involving patients and other members of the public in selection, not least to promote a sense of responsibility among members of the public to participate in medical education.
Clearly, the aim of selection is to choose people who have a high probability of being ‘a good’ to society. Careers in medicine cover a wide range of work practices including direct clinical practice with patients, direct input to patient care without direct patient contact, education and training, research, and the planning and management of health and sickness care. All of these represent useful societal functions, which have particular developmental pathways, draw upon different qualities or abilities, and are hindered by different inabilities or disabilities. Articulating what such qualities are and identifying indicators of their potential development are areas of continuing exploration.
In order to make good use of the doctors they consult, patients must trust the quality of their practice, which is an admixture of the art and science of medicine; but how do they know if that trust is deserved? Being trustworthy is not the same as putting patients at their ease or agreeing to their requests. Circumstances may not allow the continuity of care which makes for a well-informed decision about this practitioner; yet the practice of medicine relies on trust developing in an often short timescale. Clinical situations are riddled with uncertainty, which has to be managed honestly, consciously, or unconsciously (see Jackson, 2001). Preparation for practice therefore requires education for uncertainty coupled with a need for decisive action (which may include ‘watchful waiting’ or deciding no action is required).
If articulating why we believe a doctor is trustworthy is not straightforward, identifying learners who have the potential to be trustworthy doctors is no less complex, yet an effort must be made. Sulmasy (2000) highlights an inherent dilemma of attempting to measure trust “…truly virtuous physicians are those who can be trusted to do what is right and good for patients even when no one is measuring.” The way developmental and relational processes interweave makes it particularly challenging to articulate what makes somebody morally suitable for the practice of medicine. McMillan et al (2009) summarise the challenge posed by applicants who have a criminal conviction for which they have served their sentence. There is no uniform practice in UK medical schools; decisions range from the ‘hard-nosed’ (absolute rejection) to the ‘contrition view’ (consideration of a learner’s application being based on whether they are felt able to let sound moral judgement govern their future behaviour). Will the more ‘hard-nosed’ approach ensure safer practitioners and maintain patients’ confidence in the medical profession? Or can it exclude potentially useful doctors on a ‘morally healthy’ developmental trajectory, which has included antisocial activity? Decision-making must take into account whether aberrant behaviour is particularly relevant to future medical practice (see Colliver et al, 2007). Ziliak and McCloskey (2008) highlight the importance of differentiating between whether or not a finding of statistical significance is of real significance to the desired aims. Aberration in one aspect may or may not be a powerful influence on the desired outcome; they call this the difference between ‘precision’ and ‘oomph’.
Selection for medical education must, in summary, have inclusion and exclusion criteria that command the confidence of patients, practitioners, and commissioners of services. A comparable confidence is needed for processes governing progress during undergraduate education, postgraduate education, and continuing professional development. This remains an area of extreme complexity given that individuals’ life experiences (e.g. health and social adversity) affect their abilities in unpredictable ways, which only time can tell.
A recurrent theme of this chapter is that the range of attributes needed to provide the workforce with appropriate medical practitioners is wide. Academic/intellectual ability, relational attributes, physical attributes such as manual dexterity, developmental potential, and trustworthiness are notoriously difficult to specify, particularly when they come to be synthesised to produce good-enough practitioners. Mechanisms to decide whom to offer places for training are required but there is a real dearth of evidence about reliability, validity, specificity, and sensitivity. Interviews, for example, are frequently used. But could they lead to bias because the conscious or unconscious manifestations of ‘kin-ship’ propagate a well-established, if not necessarily optimal, system? If there is no reasoned way of differentiating between applicants, is random allocation of people meeting a necessary minimum academic threshold a more just system? This was used in Holland but had to be modified because very able learners were not being selected (De Gruiter, N.M. (2006) cited in Stasz and van Stalk (2007)).
A policy of Widening Participation [W.P.] in higher education has been adopted in England “…to promote and provide the opportunity of successful participation in higher education to everyone who can benefit from it. This is [viewed as] vital for social justice and economic competitiveness… [and is]… closely connected with broader issues of equity and social inclusion” (Higher Education Funding Council for England, 2009). Hilton and Lewis (2004) assert that “The need for widening participation in medicine is essential.” There is a pragmatic argument in this for medical schools: there is an established government policy, so substantial institutional funding relies on compliance. However, the same authors also assert, “The underrepresented sectors of society that widening participation aims to include are also those same sectors with high health and social care needs. If the NHS is to understand and serve the community the make up of its workforce should reflect that community.” Assertions of the value of social change like this contain an implicit view of how systems, relationships, and individuals can best operate in relation to policy aims. However, thinking, as a prerequisite for understanding, does not reside in a ‘system’ although the individuals involved may share ways of thinking and understanding. So, can a health service understand and can people feel understood by a health service? The answer to the former must be ‘No’ although the answer to the latter may be ‘Yes’.
Furthermore, does equating ‘similarity’ with ‘understanding better and serving better’ withstand scrutiny? From a psychological point of view ‘being-like/not-being-like’ are not reasonable grounds to determine whether someone is capable of ‘being of good service to/not-being-of-good-service-to’. Particular forms of prior experience may make a person better able to appreciate how others are affected by similar experiences and act as their advocates, though the judgment of similarity may obscure what is different in the other person’s experience. It may lead to collusive over-generalisation, obscuring rather than enlightening, or a failure to recognise the individuality of the other. Is such political rhetoric any more defensible than a child’s retort when insulted “It takes one to know one?”
The Dutch lottery system and WP initiative pose further questions relating to the place of medical education in meeting societal goals. Does the value gained fit sufficiently with those other qualities necessary for and the resources (personal, institutional, financial) available to produce the necessary range of doctors? Should medical schools be established to meet only the needs of a particular form of health service in a particular country at a particular time or is there a responsibility to the wider world, current and future? There needs to be further exploration of medicine’s ability to bring about social change in an international context to identify medical education’s core tasks and the impact of linking these with other societal aims.
One theme of this chapter is that there has to be an on-going process of selection that determines progression through medical education and continued licensure once fully trained. Clinical work forces practitioners to examine their interactions, opinions, recommendations, and actions constantly. Thus practice, or more specifically, truly reflective practice, is an iterative, formative assessment. In common usage, however, the term assessment refers to mandatory punctuations which determine progress within training or confirm fitness to remain in specialist practice. It is vital that those assessments test what they set out to test, or at least act as suitable surrogates for the desired outcomes. From an ethical standpoint, the principles described in the first part of this chapter apply to assessment. Principled Autonomy, which underpins the learning contract between all parties in the service of medical education, provides a framework to define and enact rights and obligations.
Assessment influences learning, particularly in strategic learners, people adept at shaping their learning to assessment (well represented among medical learners). The contribution of assessment to shaping learning outcomes is not always positive. Newble and Jaeger (1983) described how an alteration in assessment could produce the opposite of an intended effect on learning through “distortion… [where] there is a mismatch between the Faculty’s real objectives and the objectives expressed in the assessment scheme.” I (AS) have experienced comparable concerns in undergraduate communication skills and post-graduate psychiatry examinations. The time-limited nature of formal tests and high stakes create a difficulty for candidates because preparing for assessments may have an undue effect on how they behave in everyday practice. Punctuating progress in that manner could unintentionally perpetuate inappropriate practice. Socrates’ aphorism “The unexamined life is not worth living” may not win much favour with those in the process of being examined but an unexamined professional is certainly not worth entrusting one’s life to! Assessments must not only stand practical and scientific scrutiny but also be based on enquiry about their own validity and humanity.
Medical education is a complex interweaving of the sciences and arts of education and medicine. At its heart is the welfare of human beings. Those practicing and training for practice must be concerned with alleviating suffering, assisting adaptation to illness and disability, extending life, and contributing to a better death. Ultimately, there is no area of practice that can be regarded as value-free, so the ability to examine the values influencing action is an essential part of professional practice. If action is to be well reasoned and reasonable, the study of ethics is an essential, foundation component of medical education.
We have introduced some key areas of medical ethics and directed readers particularly towards the contribution we believe ‘Principled Autonomy’ can make because we believe it strikes a balance between the reasonable and unreasonable aspirations or expectations individuals may have of themselves and others. It also readily links to developmental and relational influences on learning and practice. Implicit in the presentation have been references to other schools of moral philosophy, for example, Consequentialism and Virtue Ethics; we encourage a deeper investigation into them. The goal is to be able to maintain personal integrity, remain sane whilst being in at least two minds (one’s own doubts, in addition to one’s own mind and that of a patient), and still achieve productive activity with others.
The educational process itself should help learners examine the moral basis of medical practice; it has to be a living model conducted on a morally sound basis. Implicit in our exposition is the need for research into the impact on patients, learners, teachers, and the wider community of the educational methods in common use. Further to this is the place of kindness in establishing and maintaining practitioners’ usefulness and ability to respect and be worthy of trust.
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