Conclusion and Appendices

Abstract

The world of clinical ethics is brimming with opportunities. It is a young discipline, and its future success lies in part on the active involvement of enthusiastic clinicians. There is much that clinicians can do to promote ethics in their institution or specialty. They could set up a consultation service or an ethics committee in their hospital, pilot an ethics checklist in their unit or conduct ethics-related research, organise a talk or a one-day conference on the ethics of the specialty, submit abstracts on ethical topics in conferences, articles to journals, or chapters to medical textbooks, or just raise ethical issues on ward rounds and team meetings. It is a field for pioneers.

Appendices

Appendix 1: The Dilemma of Authorship

As a graduate student in the humanities I remember being surprised at the tales of bogus authorship recounted by my counterparts in the sciences. One person would do virtually all the work, another would give useful feedback, another would glance at the final version, while yet another would be just someone who worked in the same department—and all would be co-authors of the published manuscript. “It happens all the time,” the scientists would say. I nevertheless ascribed such practices to a pocket of ambitious, amoral scientists in the cut throat environment of a major research institution.¹

With time I discovered that this was not at all unusual in science and indeed in other disciplines. In the months leading up to the UK Research Assessment Exercise, whose outcome determines a department’s academic reputation and share of government funding, I heard of academic ethicists adding the names of struggling colleagues to their publications. Thus I cannot but look on multi-authored publications with suspicion, despite the authorship criteria and other strategies adopted by many academic journals with fine intentions.

Recently a young surgeon approached me with a “tricky situation.” Earlier that day a more senior surgeon had asked to be a co-author of his now completed paper. He had not contributed in any way to the project but needed the publication for career reasons. The other surgeon’s consultant had advised him to piggyback on the junior colleague’s work. The awkwardness arose because the other surgeon now asking to be a co-author had been most helpful in training that young surgeon in the operating theatre. “He’s been so nice to me,” he remarked, “but he hasn’t done a thing related to this paper.” Furthermore, the surgical team worked well together, and the surgeon did not want to sour relations in the firm by turning down the request and upsetting his colleague and the consultant. “And does it really make a difference?” he continued. “I won’t compete with him for jobs, and I’ll still be first author, right?” What advice would you give this troubled surgeon?

It will come as no surprise that I suggested he politely refuse, explaining that the journal requires him to sign a form listing authorship criteria, which in his case would not be met. The junior surgeon could also tell his colleague that, although this particular project is complete, he would be delighted to work with him on another paper. I did not advise him to give a detailed justification for the decision, unless asked for it by the colleague. Invoking words such as honesty, trust, fairness, professionalism, and academic integrity would only highlight the inappropriateness of the initial request, make the colleague feel morally attacked, and sound obnoxiously self righteous.

The eagle eyed among you will have noted that the formulation “the journal requires me to sign a form” could imply that, were it not for that wretched form, the young surgeon would be happy to grant co-authorship. If the phrasing is disingenuous, this cannot be more than a moral peccadillo. If it is morally wrong, it is trivially so. The twin goals of declining a request for undeserved co-authorship and maintaining good relations with a kind colleague take priority and require skilful diplomacy.

But was this advice, however tentative, too demanding? By placing so much moral weight on the requirements of justice and lofty principles, did I evince an insensitivity to the practical realities of the situation and the hierarchical structure of the surgical team? Did I overlook the surgeon’s self regarding duties of preservation? Team harmony and personal relationships are important considerations. Personal disputes at work create an unpleasant environment and may lead, through poor communication or low morale, to poorer care of patients. Without the help of his senior colleague, the young doctor’s clinical skills may not develop as rapidly. And of course these are anxious times for doctors seeking scarce training posts—all the more so for surgeons. Rightly or wrongly, applicants are turned down for lack of peer reviewed publications. To risk irritating a senior colleague who has regular contact with a consultant who writes references is, in the current climate, a dangerous game to play.

Although I feel strongly that this lamentable situation needs to change, I struggle to see workable solutions to the problem. I do not even know whether I gave the surgeon sound advice. Words of William Osler seem pertinent here: “I have tried to indicate some of the ideals which you may reasonably cherish. No matter though they are paradoxical in comparison with the ordinary conditions in which you work, they will have, if encouraged, an ennobling influence.”

As an ethicist I draw comfort from the surgeon’s moral unease at the request. Less reflective colleagues may not have perceived it as an ethical issue at all. It is sad, however, that he should even be confronted with this moral dilemma. To claim authorship in an article to which one has made no contribution is to perpetrate a fraud on the reader. It is incompatible with the ideals of authenticity and honesty espoused by the profession.

Despite the indisputable nature of these ideals, the practical task of changing bogus authorship is a daunting one, requiring a change in mentality across the medical hierarchy, from old school consultants to newly minted doctors.

Appendix 2: The Medical Ethics of the Battlefield

Athena, goddess of war, gave Asclepius two vials of the Medusa’s blood. The blood from Medusa’s left side could raise the dead; the blood from her right side could kill instantly. The descendants of Asclepius—the thousands of medics who today grace the battlefields of the world—rarely use the right sided blood. Battlefield euthanasia, in which death is hastened to avoid prolonged suffering, is a controversial practice; but it is as old as war itself and, whatever laws or rules prohibit it, will doubtless continue until wars cease. In this column, however, I wish to focus on the dilemmas associated with the left sided blood. When should it be used and when forgone? And who should benefit from it?²

The ability to maintain the wounded alive is nothing less than astounding. Medical advances, combined with improved body armour and rapid evacuation, have resulted in lives saved that would have been unsalvageable only 20 years ago. A recent visit to Headley Court, the Defence Medical Rehabilitation Centre, brought home to me the remarkable recoveries of soldiers who, weeks before, were lying on the battlefield on the brink of death. Yet, as in the civilian setting, the power to revive the dying has brought with it a host of ethical difficulties.

In one scenario, a member of the local Afghan security forces has suffered massive injuries from an improvised explosive device. He has lost both his legs and both his forearms. The blast has removed his entire face. Tourniquets are controlling the bleeding from the legs. He is still alive. If he can be saved by use of the coalition forces’ state of the art medical services, what of his future once he is transferred to a local health centre, whose facilities pale in comparison?

One Canadian paramedic working in Kandahar, Afghanistan, in 2007 described the transfer of patients to the local hospital as a “death sentence” (Kondro 2007:134). The hospital had no ventilators, resuscitation equipment, laryngoscope, or monitoring devices. Kevin Patterson, a Canadian doctor also posted to Afghanistan, recalls a mass casualty incident involving a mixture of coalition personnel and Afghans (Patterson 2007). The doctors were told not to intubate any of the Afghans with burns exceeding 50%. Without a burns unit, those patients would be doomed. The coalition patients, on the other hand, could be repatriated to their home countries to obtain high quality burn care. Such divergent treatment is hard to bear and highlights the need to develop local healthcare infrastructure, but what are the immediate alternatives?

Athena’s vials are exhaustible, and resources problems can also plague the military medic. Beds, staff, and stocks are limited. Our patient might singlehandedly drain the hospital’s blood bank, leaving nothing in reserve for future casualties. The third revision of the US Department of Defence’s manual Emergency War Surgery states that “the decision to commit scarce resources cannot be based on the current tactical/medical/logistical situation alone” (US Department of Defence 2004). Such decisions should be made with an eye to the future.

If our Afghan patient is treated and survives to discharge, what kind of life awaits him back in his village, where the realities of survival and attitudes to profound disability may be a far cry from our own? This question cannot be answered without an understanding of the local culture, religion, and outlook. It is morally dangerous to uniformly impose our interpretation of when it is desirable to live or die, dismissing the patient’s views as backward, barbaric, or misguided.

If the decision to treat is made, the patient will need to be evacuated. A medical emergency response team (MERT) helicopter can arrive within minutes to provide advance life support and whisk our patient off to intensive care at a state of the art “role 3” medical facility. Yet, there is another consideration. Every excursion by the MERT carries risk. The helicopter is vulnerable and prone to enemy ground fire, and this additional danger must be factored into the decision.

There is another factor, relevant in this context but seldom encountered in civilian medical ethics: morale. Dwight Eisenhower called morale the “greatest single factor in successful wars” (Charlton 1990:144). Allowing the soldier to die on the battlefield can damage the morale of the troops. It smacks of abandonment. The fact that the patient is Afghan provides an added reason to evacuate him, for not doing so may cause other Afghans to lose faith in the commitment of their fighting partners.

In October 2010 the Defence Medical Services organised a day long meeting to discuss some of the ethical issues facing medical personnel in the field, including scenarios such as the one set out in this column. This was a significant step, a recognition that pre-deployment training should include an appreciation of the ethical challenges that can otherwise startle the unwary medic. When Athena gave Asclepius the vials, she did not provide advice on their use. The Defence Medical Services are working to fill that gap. I cannot remember the last time I left a conference with so many unanswered questions swirling in my mind.

The literature in military medical ethics is growing but still pitifully small. My hope is that experts from relevant fields will devote more attention to one of the most challenging, important, and fascinating areas of medical ethics.

Appendix 3: Ethicist on the Ward Round

Not so long ago in the BMJ I quipped that most professional medical ethicists could not distinguish their “gluteus maximus from their lateral epicondyle” and suggested that such ethicists should undergo a short clinical attachment (Sokol 2006).³

Soon after publication, a nephrologist kindly invited me to observe a ward round at his hospital. It proved to be a puzzling experience, not because the blood gases, creatinine levels, diagnostic tests, and myriad statistics recited by a junior doctor sounded like one of Mallarmé’s incomprehensible poems, but because, as the afternoon progressed, I noticed the patient-as-person fading behind this shroud of science. I felt comfortable with my consultant, my team with their dangling stethoscopes, the all-knowing computer wheeled by the bedside, and the timid patient, dwarfed by our confident crowd. Ethics seemed a million miles away.

This absence of ethics was most puzzling of all. I spend my days thinking, teaching, and writing about medical ethics, but there, in a group of doctors and with the patient before me, the subject seemed alien. “Think,” I urged myself, “what are the ethical issues here?”

My reverie would soon be interrupted: “Urine output… raised creatinine levels… metabolic acidosis… abdominal x ray.” Even in cases that I knew had obvious ethical dimensions, such as those involving futility and end-of-life decisions, I felt powerless to use ethical reasoning since I could not perceive the ethical issues with any clarity. It reminded me of a time when, intent on discovering a card magician’s method for a trick, I got so engrossed in his patter, in Sam Spade and the evil kings (a dramatic reference to the ace of spades and the four kings), that I forgot to observe the subtle movements of the conjurer’s hands and body. Magicians, like doctors, are well aware that language can disguise reality, distracting the mind from the disappointing truth ahead, be it a palmed card or a grim prognosis.

My proximity to the patient, instead of highlighting the ethical components, obscured them. The incantation of scientific jargon, the outward confidence of the consultant and his team, the austere clinical environment, and the meekness of the patient all combined to give an air of certainty to the ritual. Ethics, this antithesis of science, had no place in this assured display. I could now see why some doctors and medical students found it so hard to appreciate the relevance of ethics to clinical practice. “Ethics and medicine are inseparable,” we tell our students, but up close the link is not so obvious. It may be easy enough to identify ethical issues in the classroom, but at a crowded bedside the task takes on added complexity and requires practice.

More recently, I attempted to fill the gaping holes in my medical knowledge by spending five weeks in a southern Indian hospital, observing the work of a rural surgeon. Again, I initially struggled to perceive the ethical elements. I was enthralled by the medicine, the ritual of surgery, the mesh, the corkscrew, and other instruments, the different kinds of suture material, the mattress and subcuticular stitches, the smells and sounds and techniques. But as the days went by, as I saw more surgeries, it became easier. I learnt to zoom out of the medical and focus on the social and ethical dimensions. These more uncertain, fuzzy elements of the healing endeavour began to emerge from the mass of clinical information.

As my ethical gaze slowly sharpened, I reflected on the surgeon’s kind hearted paternalism and the submissiveness of patients; the considerable influence of relatives in decision making; the prevalence of disclosures that were “economical with the truth”; the limited importance of confidentiality in this communal setting; the perfunctory nature of obtaining consent; the ethical implications of treating illiterate and medically unsophisticated patients; the financial and emotional costs of surgery to poor families; the responsibilities of sleep deprived surgeons and anaesthetists towards their patients, their colleagues, and themselves; the difference a few words of comfort can make in times of pre-operative fear; the role of humour and camaraderie in the theatre; the wisdom of using mobile phones when operating; the extreme difficulty of speaking your mind when offence may result; the proper relationship between culture and ethical norms; and many other issues that were initially as invisible to me as the card magician’s sleights. I was not merely thinking about clinical ethics, but actually “doing ethics,” in real time with flesh-and-blood patients.

The first step to moral action is moral perception, since an ethical problem can seldom be resolved if not first spotted. For teachers of medical ethics, developing this skill in students should be a priority and the most critical place to do so is at the bedside. Suturing an orange in a lab and suturing a uterus in a casesarean section are quite different activities. The same holds true with studying ethics in the lecture hall and “doing ethics” on the wards. The aseptic first is a poor approximation of the messy second.

Appendix 4: The Slipperiness of Futility

He was shot in the back. The surgeons could not save him. He lay in bed, unconscious, his life ebbing away as blood trickled down tubes to large jars at the base of his bed. As cardiopulmonary resuscitation would have been futile, we wrote a “Do not attempt resuscitation” order. The case reminded me of the etymology of the word “futile.” “Futilis” in Latin means “leaky.” The patient was leaking blood from various wounds, and nothing could stop it.⁴

At a recent examiners’ meeting, a professor of surgery admitted that he would have got the ethics question wrong. The question concerned the definition of futility. “So how would you define futility?” I asked. He paused and, like Humpty Dumpty in Through the Looking Glass, answered: “Something is futile if I say it is.” This remark highlights the semantic slipperiness and subjectivity of the term “futile.” Yet, in the clinical frontline, futility, coated with a veneer of objectivity, is often used as a moral trump card, a dismissive pronouncement to end all discussion: “I’m sorry. We’re stopping aggressive care. It’s futile.”

Psychiatrists must sigh in frustration when asked whether a patient has capacity. The capacity to decide what? Similarly futility is not free floating but linked to a specific goal. Prescribing antibiotics for a viral illness is physiologically futile, but if your goal is to leave the surgery in time for the first aria in Don Giovanni then it is not (although this would still be a breach of your duty of care). Futility, then, is goal specific, and when you next hear colleagues say that such and such is futile you can surprise them and ask, “Futile with respect to what?”

When teaching this subject to medical students I shuffle a pack of playing cards, select a card at random, and ask whether it is futile for them to guess the identity of the card. Some say yes, others say no, and once in a blue moon a statistically minded student will ask if the two jokers are included in the pack. Never is there unanimous agreement. The point of the exercise is to illustrate the variability of our quantitative assessment of futility. Some scholars have suggested that an intervention is futile if it has not worked in the last 100 cases (Fins 2006, Schneiderman et al. 1990). Under that definition, guessing the card would not be quantitatively futile. Even if we accept this somewhat arbitrary “last 100 times” rule, in practice the problem is that it is rarely possible to know whether an intervention has worked the last 100 times, especially as no two cases are identical.

The students who believe in the futility of naming the card still venture a guess if tempted by a £50 cash prize. The perceived futility of the exercise does not translate into a refusal to try. The reason is that there is no cost associated with the guess. The benefit is potentially significant and the cost minimal. As Kite and Wilkinson point out, sometimes the reason why clinicians withhold or withdraw an intervention is not because it probably won’t fulfil its purpose but because it will cause harm or deprive others of benefit. An intervention can be simultaneously futile, harmful, and wasteful (Kite and Wilkinson 2002).

One of the saddest cases I have seen involved a woman so viciously mauled by dogs that she was left in a vegetative state. When considering her resuscitation status, one of the doctors stated that, on the grounds of futility, she should not be resuscitated. When probed further, it emerged that the doctor believed that the patient’s quality of life was so awful that cardiopulmonary resuscitation was not medically indicated. This is another type of futility: qualitative futility (Jonsen et al. 2006:29). It is based on a subjective evaluation of whether the goal of the intervention is worthwhile.

Although ethically aware clinicians need not be familiar with the vast literature on the concept of futility, they might wish to remember the following four points (Burns and Truog 2007, David 2008, Grossman and Angelos 2009):

• Futility is goal specific.

• Physiological futility is when the proposed intervention cannot physiologically achieve the desired effect. It is the most objective type of futility judgment.

• Quantitative futility is when the proposed intervention is highly unlikely to achieve the desired effect.

• Qualitative futility is when the proposed intervention, if successful, will probably produce such a poor outcome that it is deemed best not to attempt it.

When using the term, clinicians may be referring to several types of futility—for example, that an intervention is highly unlikely to achieve the goal (quantitative futility) and also that the goal itself is undesirable (qualitative futility). As futility is so rhetorically powerful and semantically fuzzy, doctors may find it helpful to distinguish between physiological, quantitative, and qualitative futility. This classification reveals that a call of futility, far from being objective, can be coloured by the values of the person making the call. Like “best interests,” “futility” exudes a confident air of objectivity while concealing value judgments (Gillon 1997, Sokol 2008).

I conclude on a practical note. Clinicians should be wary of using the word “futile” in front of patients and relatives. As Jonsen, Siegler, and Winslade propose, it may be better to think in terms of proportionality or “the imbalance of expected benefits over burdens imposed by continued interventions” (Jonsen et al. 2006:33). Furthermore, “futile” suggests that nothing can be done. Recall the ancient medical wisdom: “To cure, sometimes. To relieve, often. To comfort, always” (Russell 2000). There is always something to be done.

Appendix 5: Heroic Treatment: Reflections on Harm

There is an amusing scene in the television series Scrubs in which J.D., a cheerful hospital doctor, gathers his interns in a huddle at the start of a day’s work. “Hippocratic Oath on three,” he orders, “one, two, three….” In unison, hands atop hands, they exclaim, “first do no harm!”⁵

This expression, or its Latin equivalent primum non nocere, is found neither in the famous oath nor in the Hippocratic corpus. The phrase, coined by Thomas Inman, dates from 1860, around the time of this lithograph (Inman 1860). The lithograph, depicting some unfortunate and clearly petrified patient, takes us back to a time when doctors, however benevolent in intent, often caused more harm than good (Wootton 2006). James Simpson, an esteemed professor of surgery at Edinburgh in the mid-19th century, believed surgical patients in hospitals were “exposed to more chances of death than was the English soldier on the field of Waterloo (Porter 1997:369).”

In 1850, a French physician, J. Dupuy, defended his doctoral thesis on limb amputation. He counted all amputations performed in a four-year period in his Bordeaux hospital and noted 94 amputations, 47 deaths, and a mortality rate of 50% (Dupuy 1850).

Although buzzing with the advent of modern anesthesia (1846), which along with numbing pain allowed more time to operate, these were still the dark days before Lister and his antiseptic technique (Lister had a mortality rate of 45% for major amputations in Glasgow during 1864–1865; it dropped to 15% during 1867–1869 following the introduction of his antiseptic routine) (Kirkup 2007).

With such high risks, primum non nocere was sage advice. The phrase, however, needs to be refined. Each time we attempt to benefit someone, in medicine or everyday life, we also risk harming them. We cook a sumptuous meal for friends, only to give them gastroenteritis, or utter a comforting comment to a depressed friend only to redouble their anxiety. Thus, any clinician who interprets primum non nocere literally ought to leave medicine, as benefiting patients often requires the infliction, or at least the risk, of harm. The surgeon cuts open the abdomen (harm) to remove the inflamed appendix (benefit). Ethicists thus talk of the obligation to avoid causing net harm. One translation might be primum non in ultimum nocere (“first, cause no ultimate harm”), but ultimum also implies “lasting harm,” which is not accurate as some procedures are beneficial overall despite causing permanent damage. Hence, a neurosurgeon may excise a glioma, saving the patient’s life, but at the cost of slight and permanently reduced motor function.

More precise, though less pretty, would be primum non plus nocere quam succurrere (“above all, do not harm more than succor”). I somehow doubt J.D. and his interns would bellow such a phrase. The lithograph’s caption [the lithograph (not reproduced here) shows a traumatised patient strapped to a chair with no arms and legs, and reads “This is what I looked like after what doctors call heroic treatment”] suggests that clinicians at the time were inclined to overtreat patients. Doubtless this was true of some, yet Dupuy’s thesis reveals a clear appreciation of the seriousness of amputations, and of the need to balance the risks and benefits. He observes, “it is indeed a quite sudden transition which, in a matter of hours, deprives a man of an entire limb (Dupuy 1850).”

The issue of overtreatment is also pertinent in the early 21st century. I remember a meeting in a major Canadian hospital, in which a senior clinician read an interminable list of procedures performed on a recently deceased cancer patient. When he finally got to the end, he shook his head and said, “It’s not easy to die in this hospital.” With ever-improving technologies and the corresponding ability to keep people alive, however dreadful their injuries and grim their quality of life, the question, “when should we stop aggressive care?” will be increasingly posed.

When patients have capacity, a reliable way to ensure that a treatment’s benefits outweigh the harms is to ask them directly, giving them accurate information about the alternatives, since what we value and how we balance different values vary amongst individuals. However, this approach cannot be applied when the patient is not autonomous. Advance directives, which allow us to know the autonomous wishes of now incompetent patients, and appointed proxy decision-makers, will become even more important as new tools and knowledge keep death at bay for longer and in more situations.

At all times, we should be guided by what is best for the patient. While this may sound trite, the observation about the difficulty of dying in a state of the art hospital suggests that on occasion we treat aggressively because we can rather than because we should. This lithograph captures the horror of surgery at a time when mortality rates were sky high. It also coincides with a momentous development in medical thought: the realization in the community that medicine helped little and often caused more harm than good.

In my medical school, we sometimes ask prospective medical students at interview what they believe is the greatest advance in medicine in the last 150 years. This aforementioned realization, though an ideological rather than a technological or pharmacological breakthrough, would give antibiotics, vaccination, or imaging a run for its money. Although printed over a century and a half ago, the lithograph also prompts us to reflect on, and question, our current practices. Are we really doing more good than harm, and, if harm is inevitable, how can we benefit our patients with minimum harm? These are questions that, unlike the coats and cravats of the surgeons, will remain in fashion.

Appendix 6: The Moment of Truth

Edmund Pellegrino, a professor of medicine and a giant of medical ethics, once remarked that, for the clinician, the “moment of truth may come at three in the morning, when no one is watching.” This prompted me to ponder on “the moment of truth.” What is it? And can we prepare for it?⁶

The moment of truth is a bullfighting term. The “hora de verdad” refers to the moment when the matador entices the bull with the “muleta” (the red cape draped over a stick) and, with the precision of the anaesthetist hitting the epidural space in an obese patient, plunges the sword into the bull’s neck for the kill. If he thrusts the sword at a slight angle he will sever the aorta and the bull will die in seconds. If the matador misses, his body is exposed to the sharp horns of the frenzied animal.

We encounter a moment of truth when we are put to the test, and how we respond becomes a measure of our worth. Sometimes, as in an acute emergency, the moment of truth is clear: the patient is hypoxic, oropharyngeal visibility is poor from the blood and swelling of trauma, and the tube must go in immediately. At other times, especially with patients with more chronic illness, the moment of truth is identified only retrospectively. A doctor may realise too late that he or she omitted something that could have prevented a poor outcome, such as the radiologist who realises that he or she missed a lesion on the x-ray picture.

The moment of truth can involve physical actions, as in the difficult intubation; decisions, as with the surgeon contemplating whether to operate; or attitudes to events or circumstances. William Osler wrote of being “ready for the day of sorrow and grief with the courage befitting a man.” For Osler, that moment came years later with news of the death of his only son from shrapnel wounds in the first world war (Starling 2003).

The “truth” in the phrase “the moment of truth” can refer to true skill, true merit, or true strength of character. This helps us answer the question of how we can prepare for moments of truth. We can prepare by honing our technical competencies. The cardiothoracic surgeon Fyodor Uglov, famous for his technique, sutured 400 rubber gloves before performing portacaval anastomoses on patients (Lichterman 2008). Alone, at three in the morning, the well prepared trainee can insert that all important central line in the patient with a sudden onset of severe sepsis. It is this fear of encountering the moment of truth that, at least in part, explains why some junior doctors look on the night shift with dread.

We can work on developing our character, putting ourselves in situations in which we can learn to exercise virtues such as courage, kindness, and wisdom. This may require us to seek new experiences and step outside our comfort zone.

A turning point in my development as a medical ethicist was on hearing a song, “Moi mes souliers,” by the Canadian singer Félix Leclerc. It was about a man’s travels and adventures, from school to war, through fields of mud, through countless villages and streams. The final stanza, loosely translated, goes: “Heaven, my friends, is not the place for polished shoes. So if you seek forgiveness, hurry and get your shoes dirty.” As I could see my own reflection in my shoes, I travelled to various hospitals around the world to get them dirty.

Alone, at three in the morning, the trainee with dirty shoes can then decide to reassure a frightened patient when it would be easy to pretend not to notice. Yet, even with the cultivation of skill and virtue, it is impossible to prepare fully for some moments of truth, those monumental ones defined by their life changing nature. Osler never recovered from his son’s death and was prone, in private, to bouts of weeping.

Moments of truth reveal something fundamental about ourselves, and as such they represent an opportunity for self improvement. They are perhaps unique to humans. The charging bull cannot conceive of a moment of truth. Only the matador can experience it, thinking to himself, as he sees the saliva flying from the charging animal’s mouth, “This is it.” For Pellegrino and many medical ethicists who call themselves “virtue theorists,” the focus of medical ethics should not be on what is the right or wrong action but on developing the character of the clinician, fostering the virtues that will help him or her cope with the “this is it” moments in the practice of medicine.

Respected clinicians on the wards and in the GP’s surgery have a much greater influence in the development of virtue in students than my colleagues and I do in the classroom. It is difficult to teach courage or integrity in a packed lecture theatre. Virtues in medicine are learnt most effectively by watching and learning from clinicians who act virtuously. Osler believed that medicine should be taught on the wards (Osler 1906); so should the bulk of medical ethics, for ethical decisions in clinical medicine are made under conditions that cannot be recreated in a classroom. Repeated, realistic exposure is the key to good ethical training. After all, it is in the arena—with the cheering crowd, blustering heat, dazzling sun, swirling sand, and raging bull—that matadors learn the essence of their art.

Appendix 7: ‘Make the Care of Your Patient Your First Concern’

The first rule of Good Medical Practice, issued by the General Medical Council, is: “Make the care of your patient your first concern” (General Medical Council 2006). With its strong Hippocratic flavour, the statement captures a fundamental truth about the practice of medicine, pointing to the sacred and timeless nature of the encounter between the healer and the sick person.⁷

Yet, however noble in spirit, the rule should be no more than a rule of thumb. Although “patient” is in the singular, few doctors have only one patient. Doctors must therefore choose how to allocate their “concern” among their many patients. It is neither possible nor desirable to treat each patient as a first concern, as some patients, usually the sickest, merit more concern than others. The principle of justice requires the doctor to determine which patient deserves the greatest attention.

In a field hospital in a conflict zone, four polytrauma patients are admitted after an explosion. One has multiple traumatic limb amputations. The others have less severe injuries but require blood transfusions. Treatment of the first victim will activate the massive transfusion protocol. Should the hospital’s entire stock of blood and plasma be used on that one patient? In such a situation triage priority shifts from “treat those in greatest medical need” to “save the most number of lives.” The care of your multiple amputee is, regrettably, no longer your first concern. The rule is modified as follows: “Make the care of your patient your first concern, bearing in mind your other patients and their particular needs.”

At times the interests of the public outweigh the obligation owed to an individual patient. A doctor is under an obligation to inform the authorities of a patient with yellow fever, however much the patient may protest. The first concern is not so much the patient but protecting the population from infection. So the revised rule is now: “Make the care of your patient your first concern, bearing in mind your other patients and their particular needs, as well as any protective obligations to the broader community.”

I have recently argued in this column that doctors’ duty of care is not an absolute obligation, to be discharged however perilous the situation (Sokol 2009). In extreme circumstances—such as epidemics, where treating patients involves a high risk of infection and modest benefits to patients—doctors’ obligations to their children, parents, siblings, and loved ones may take priority over the care of patients. The doctors who left their dying patients in the early outbreaks of Ebola haemorrhagic fever in Sudan and the Democratic Republic of Congo did not necessarily act unethically. The doctors and nurses who remained, many of whom lost their lives to the virus, acted beyond the call of duty. The rule now looks as follows: “Make the care of your patient your first concern, bearing in mind your other patients and their particular needs, as well as any protective obligations to the broader community and obligations you may have towards others for whom you are responsible.”

Even in ordinary times, making the care of your patient your first concern seems too demanding. Your life, personal and professional, would be dominated by this overriding concern; your working day would be interminably long, your holidays pitifully short. Your relations with friends, family, and others would suffer. You would not conduct research, publish articles, attend conferences, conduct activities that would further your career, or develop your skills to help future patients, for the rule ignores your personal ambitions and talks only of the present patient.

The “bare” rule, strictly interpreted, would also pose problems for trainees learning to perform procedures. If a junior doctor is anxious about inserting a central line or carrying out a cholecystectomy, the rule suggests that he or she must ask a senior colleague to do it, as this is probably best for that particular patient. A trainee is more likely than an experienced colleague to make a mistake or cause discomfort, even if supervised. Yet this logic is not conducive to learning and development. Although the present patient will benefit, future patients will suffer. Thus the updated rule is: “In your professional capacity as a doctor, make the care of your patient your first concern, bearing in mind your other patients, including at times future patients, and their particular needs as well as any protective obligations to the broader community, your own obligations to develop your skills and knowledge as a clinician, and obligations you may have towards others for whom you are responsible.”

Finally the rule can be misused. I have heard doctors invoke the rule to justify their exaggerations to radiologists to expedite their patient’s scans. Doctors in the United States have been known to deceive insurance companies to obtain treatments for their patients (Wynia et al. 2000). If the care of your patient is your first concern, this may lead you to flout other rules, including legal ones. So the final version of the rule is: “In your professional capacity as a doctor, make the care of your patient your first concern, acting within morally and legally acceptable limits and bearing in mind your other patients, including at times future patients and their particular needs as well as any protective obligations to the broader community, your own obligations to develop your skills and knowledge as a clinician, and obligations you may have towards others for whom you are responsible.”

The first rule of the GMC is a profoundly important statement, but its brevity necessarily obscures the complexity of modern medical practice. Ironically, too literal a reading of the rule could lead to unethical conduct. It should be seen as a starting point, not a commandment.

Appendix 8: Informed Consent is More Than a Patient’s Signature

The phone call came at an inopportune moment: the Friday lunchtime curry at the local Sri Lankan restaurant, usually an oasis of delectable peace away from the hustle and bustle of the medical school. “I’ve had a dreadful consent experience” were the opening words, “dreadful.” The caller was a friend needing surgery to remove a submandibular gland.⁸

And so, as my curry lost its warmth, he proceeded to tell me about the strong pressure to tick the boxes on the consent form (“Oh, just tick them all—he’s a very good surgeon,” said the senior house officer (SHO)); about the SHO’s evident ignorance of the procedure; about his distinct sense of being a nuisance (“It’s half past six, and we usually go home at five o’clock,” the SHO observed); and about his general unease at the whole experience. He ended his account by saying that he had, under stress, signed the consent form but that on reflection he had not truly given consent. After our discussion he cancelled the operation and opted to go private.

Ten years ago the lawyer Michael Jones published an article entitled, “Informed consent and other fairy stories” (Jones 1999). Since then informed consent has come under many attacks, for its conceptual fuzziness to its impracticability in real world medicine (Manson and O’Neill 2007). There are undoubtedly many barriers to obtaining valid consent. Some are real and deeply problematic, others are imaginary. In rural India doctors told me that it was pointless to explain interventions to patients as they were too medically unsophisticated to understand. As a lecturer whose job it is to explain philosophical concepts to students whom unkind colleagues might call philosophically unsophisticated, I was not convinced. Is it not part of a doctor’s job to communicate medical information in a manner that is comprehensible to the patient?

Assessing a patient’s competence to consent can also be a problem, notably in areas such as geriatrics, paediatrics, psychiatry, and neurology. At times it is not clear whether patients can understand relevant information, retain it long enough to make a decision, weigh up the pros and cons, and communicate their decision. In some parts of the country, such as east London, where many patients do not speak English, obtaining high quality consent is an ideal whose attainment is a constant struggle, all the more so if the patient speaks an uncommon language.

And what of the patient whose culture dictates that decisions be taken by the family rather than the patient? How can we reconcile this focus on the family with our atomistic notion of informed consent and respect for individual autonomy? I remember meeting an interpreter who had been asked by relatives to misinterpret the clinician so as to protect their loved one from a grim truth that would never be revealed in their home country.

Another barrier to valid consent is the skewed presentation of information. It is quite easy, through verbal and psychological manipulation, to persuade a patient to agree to an intervention (Sokol 2008). This can be deliberate or unintentional. Because of our belief in a procedure’s value, or out of a concern not to worry the patient unduly, we can paint a rosy picture of the situation. At times, when a senior clinician delegates the task of obtaining consent to a junior member of the team, the junior may feel some pressure to secure the patient’s consent, fearing fireworks from the consultant if consent isn’t given (“What do you mean the patient refused?”).

Some patients are not as autonomous as you or me, one argument goes, so how can they truly give consent? Patients may be sick, frightened, embarrassed, or intimidated by the doctor. They may come from a culture where it is considered rude to question a doctor. They may wish to be a “good” patient—in other words, one who does not make a fuss. Even my friend with the missing submandibular gland, an unusually stubborn fellow, did not want to irritate the medical team. These emotional states are not conducive to autonomous choice; but is it not possible, by giving patients enough time, by creating a safe environment, by supporting patients and encouraging them to ask questions, to enhance a diminished autonomy sufficiently to get valid consent?

Time is the second highest barrier. Obtaining high quality consent usually takes more time than obtaining mediocre consent. I do not have a solution to the time problem, but it is worth noting how easy it is to use “lack of time” as a trump card against a tedious or unpleasant task. “Hurry is the devil,” wrote William Osler, and in my biased view rushing consent should be avoided in the same way that a medical procedure should not be rushed. Both are bad medicine.

So what is the most redoubtable obstacle to valid consent? It is the still prevalent attitude that obtaining consent is a necessary chore, a medicolegal hurdle to jump over. Too often “consenting” a patient is reduced to the mechanistic imparting of information from clinician to patient or, worse still, the mere signing of a consent form, rather than the two way, meaningful conversation between clinician and patient it should be. If we can change this mindset and view obtaining consent as an ethical duty first and foremost, one that is central to respecting the autonomy and dignity of patients, then we will have taken a major step towards first class consent and uninterrupted lunches.

Appendix 9: What to Tell Junior Doctors About Ethics

Tomorrow I must give a talk to junior doctors. The title was imposed on me: “Essential ethics and law for the junior doctor.” This may be the only hour they have on the subject in the entire year. What should be included in that hour?⁹

Consent is an obvious, unexciting choice. It is still the case that some junior doctors are asked to obtain consent for unfamiliar procedures; and, although some politely decline to do so, others do not want to make a fuss and acquiesce. And what of the patient who simply says, “I don’t want to know—just do what’s best, doctor”? Heaven also knows that some surgical patients are “consented” on the morning of the operation and have little idea of what awaits them. On the trolley heading for the operating theatre, one patient at a colleague’s hospital told the porter that she was relieved at finally having the operation as she was looking forward to starting a family. She was about to undergo a hysterectomy. The porter called the medical team, and the operation was postponed.

(If I have learnt one thing as a superannuated student and lecturer, it is that an ethics presentation without stories is like an operation without anaesthetic.)

Another “essential” issue is confidentiality. I shall not bore the junior doctors with old sayings about soundproof curtains and indiscreet discussions in the cafeteria. Instead I will focus on trickier scenarios, such as when to share confidential medical details with a patient’s “partner” or when to breach confidentiality. The story this time will be of the patient who dies from a ruptured cerebral aneurysm during overzealous intercourse with his mistress. The distraught wife asks the medical team what happened. Discuss.

End-of-life decisions are another possibility, and there is much to be said about “do not attempt resuscitation” (DNAR) orders (BMJ 2009;338:b1723), quality of life, and the chameleon concept of “futility” (see Appendix 4), but junior doctors are unlikely to make such decisions in the near future. Still, they may be unsure about the exact implications for patient management of a DNAR order. Should they, for instance, start intravenous antibiotics on a DNAR patient? To close this section, a well placed anecdote concerning a grossly overtreated patient with cancer and the consultant’s immortal words on reviewing the long list of procedures she had endured (“Jeez, it’s hard to die in this hospital!”) may stir them from their slumber and trigger a conversation on goals of care and the purpose of medicine.

This could lead to a discussion on the meaning of best interests. When we say that something is in the best interests of the patient, what do we mean? Examples from less conventional areas of medicine can provide a broader view of the concept. Sports doctors sometimes face a tension between clinical best interests and overall best interests, as when the patient, a professional boxer with a broken rib, wants to finish the round in the most important boxing match of his career. A prison doctor may also face a dilemma when she knows that a patient requesting diazepam is being coerced by some rough types to ask for the drug. The patient will not be treated kindly by the requestors if he fails to get some.

One option would be to talk more broadly about organisational ethics and problems with locums, rotas, continuity of care, targets, and patient safety. If I opened up the discussion, I could expect a torrent of stories about certain incompetent locums and, in the words of one of Eddie Murphy’s film characters, locums who “don’t speak English good” (It may be politically incorrect to say so, but safe and effective communication within the medical team and between patient and clinician is difficult without linguistic proficiency.) There might also be stories about government targets so slavishly followed that care of patients is undermined, and other dubious practices. NHS trusts, as public bodies, also have duties of care; and they can be sued for failing to provide adequate supervision or competent staff. This might be a good place to outline some law on clinical negligence, briefly looking at the standard of care and the controversial Bolam test, breach of duty, and causation. I will tell them that, after the 1988 case of Wilsher Vs Essex Area Health Authority, inexperience is not an excuse for negligent care and that calling your senior when unsure is legally, as well as medically, a very wise move.

Whistleblowing remains a problem, despite the Public Interest Disclosure Act 1998 and whistleblowing procedures adopted by NHS trusts. The story of junior doctors reporting their concerns about an underperforming colleague to a senior doctor only to see their concerns ignored, sometimes repeatedly and disdainfully, is a familiar one. The irony is that “the incompetent colleague” is a common question in membership examinations and job interviews, and candidates doubtlessly all give the right answer (“The care of my patient is my first concern”). The gap between the ideal world of General Medical Council guidelines and the clinical front line is a topic in itself.

Days could be spent on each of these issues, and I have ignored countless others, but the purpose of the session is not to provide the junior doctors with a solution to their problems (although I intend to give some answers at least) but to whet their ethical curiosity and provide them with a deeper appreciation of the pervasiveness of medical ethics. Most importantly, I would like them to leave the session with a spring in their step. What other profession can boast such a fascinating range of challenges and opportunities? That, perhaps, should be the essential message.