Medical Ethics has many unsung heros and heroines. Here we celebrate one of these and on telling part of her story hope to place modern medical ethics and bioethics in the UK more centrally within its historical and human contex.
- Medical ethics
- suicide/assisted suicide
- right to refuse treatment
- resource allocation
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Medical ethics today in the academy and public debate is exciting stuff. The range of subjects dissected and disputed is immense. How should we view the ethics of transhumanism? What are the ethical implications of artificial wombs? The very name has become submerged within the broader concept of bioethics, and bioethics is big business with literally hundreds of academic bioethicists in the UK alone. Bioethicists come in several varieties, many are philosophers by background but others are lawyers, sociologists, scientists and of course, some are doctors or other health professionals. Nationally and internationally bioethicists feed into major policy debates. So much is different from the position 25 or 30 years ago when the first centres to study medical ethics began to be established in the UK. It is not just that bioethics has mushroomed or that medical ethics may have morphed into bioethics, but also because as bioethics encompasses so much more than medical ethics it is no longer possible to give a single answer to the question: what is bioethics for? However, in its earlier incarnation—and arguably to this day—there is still one simple answer to the question: what is medical ethics for? It is to help doctors become better doctors. That certainly was the objective of the growing group of people in the 1960s, 1970s and 1980s who were concerned that medical students and practising doctors were too agnostic, ignorant or misinformed when it came to medical ethics. The group included many doctors and in Manchester, the leading light was Dr Mary Lobjoit, then a student health physician, who sadly died suddenly last Christmas Eve. Mary's mission was to educate doctors in ethics and thus help them become better doctors. She did this first through her work in setting up and supporting the Manchester Medical Group (MMG), and later as one of the founders of the Centre for Social Ethics and Policy (CSEP) at the Manchester University.
Mary Lobjoit's death affords an opportunity not just for three of her friends and colleagues to pay tribute to her but also for reflection on aspects of the development of medical ethics in the UK and the chance to consider whether in 2012 we are achieving that aim of helping doctors become better doctors. Of course, this slice of history is partial and every centre for medical ethics will have related stories to tell. This story embodies important aspects of the development of medical ethics in the UK. We begin by looking at the growth of the medical groups.
Mary's work in medical ethics began when she devoted what free time she had to the MMG. MMG was part of a national network of medical ethics groups of which Mary was to become a key member. These were established in the early 1960s by a young Church of England chaplain, Ted Shotter, later to become Dean of Rochester, on whose account.1 Supplementing our own memories, this summary is heavily based. Appointed as a university chaplain to London University he was surprised to discover that medical students were given no formal education in ethics. Keen to avoid being labelled simply as an apologist for Christian ethics to the medical profession, Shotter set up a multidisciplinary group for medical students at the then twelve London University medical schools, the London Medical Group (LMG), which led to similar groups being subsequently created at all British medical schools. All the medical groups were open to nursing students and any others who might be interested. The discussions and subsequently the lectures and symposia and annual conferences organised by these groups addressed subjects chosen by clinical students which concerned doctors and non-medical disciplines and society more generally; the word ‘ethics’ was generally avoided but medical ethics issues were the main ones addressed. In the 1960s, laws concerning abortion and homosexuality were being reformed and attempts were also made to legalise voluntary euthanasia. Such subjects, some fifty a year appeared on the LMG lecture lists. Laws prohibiting active voluntary euthanasia remained unscathed—as they have to this day—partly because of vigorous opposition from the new hospice movement founded by Cicely Saunders, with her and its emphasis on better care of the dying including better control of pain and other symptoms. These topics too were regularly addressed. Heart transplantation was new, bringing with it various associated contentious issues and especially the new fangled concept of brain death and the students added these to their discussions. Psychiatry and the concept of mental illness came under attack so Ivan Illich spoke at an over-subscribed LMG annual conference. And Patrick Steptoe contributed to a packed symposium at St George's Hospital only a week after the birth of Louise Brown. A host of other social issues were addressed including strikes by doctors, infertility, cloning, sexual identity, eugenics, child abuse, legalisation of cannabis, alcoholism, care of older people, the role of the drug industry, marital breakdown. While the subjects to be addressed were all chosen by a representative council of medical students (some of whom went on to become very senior figures including two chief medical officers) the lecturers were chosen on the basis of advice from a consultative council of seniors–mostly senior doctors but also theologians, lawyers, philosophers and social scientists. The principle that medical students should choose the subjects for discussion but that they chose lecturers based on advice from a consultative council of seniors was rigorously maintained. This ‘medical group method’ was characterised by one eminent doctor as ‘a pincer movement on the profession by its cadets and senators’.
Many of these groups were established as a result of prompting by a local health professional (several previously LMG officers) who usually became the co-ordinator of the group, providing organisational advice and assistance, liaison and continuity as the medical student officers came and went. Mary Lobjoit was the long-term coordinator of the MMG, providing her services on an entirely ‘pro bono’ basis for many years. Some of the first medical group coordinators were university chaplains, but keen to avoid identification of such discussion groups with any particular religion or indeed any other specific life stance, religious atheistic political or cultural, Ted Shotter went out of his way to recruit a variety of associates. One of the present authors (RG) doubted, when he first met Ted Shotter that as a Jewish atheist he would be of any use or interest to his ‘outfit’. On the contrary, Ted told him, ‘You would be a Godsend’.
As the initial cohorts of medical students running the LMG turned into doctors they wished to continue to develop their interests in medical ethics and the broad range of related issues which the LMG had considered and so with Shotter's help they founded a postgraduate group, the Society for the Study of Medical Ethics, subsequently transformed into the Institute of Medical Ethics; they also collected and circulated copies of relevant documents called ‘Documentation in medical ethics’, subsequently to be replaced, in 1975, by a new Journal, the Journal of Medical Ethics.
Recurrent efforts were made to persuade medical schools to include medical ethics as part of the medical curriculum, including an influential Institute of Medical Ethics report chaired by Sir Desmond Pond.2 Courses were gradually introduced, though not universally until after the General Medical Council stated in 1993 in ‘Tomorrow's Doctors’ that an understanding of medical law and ethics should be a required part of the medical curriculum.3 When medical schools started appointing lecturers in medical ethics, Ted Shotter moved on to become Dean of Rochester Cathedral, and most of the medical groups faded out although a few continue to this day; but their clinically embedded contribution to the development of medical ethics education in the UK deserves more recognition than—largely submerged by the more visible expansion of academic medical ethics and bioethics—they tend to get.
Mary Lobjoit's leading role in the MMG was her first major contribution to the re-founding of medical ethics in Manchester. Re-founding, because the original foundation of medical ethics (actually, if not properly, so-called) was the work of another Manchester figure, the physician and health-reformer Thomas Percival, who probably coined the phrase in his book entitled Medical Ethics published in 1803 but previously circulated privately from around 1794. Three other Mancunian academics joined Mary Lobjoit in a more broadly ‘bioethics’ venture, together founding Manchester's CSEP in 1986. They were Anthony Dyson, then Professor of Social and Pastoral Theology in The University of Manchester and two of the co-authors of this paper, Margot Brazier and John Harris. John first met Tony Dyson on a train to Scotland where (unbeknown to one another) they were billed to speak on opposite sides of a debate on medical ethics. Chance placing them in the same carriage they struck up a conversation, and were amazed, both by their shared interests and by the fact that, while both were Manchester academics, they had never heard of let alone encountered one another, yet each valued the friendship and inspiration of Mary Lobjoit. Then and there, they decided to create a Centre for medical and applied ethics broadly conceived and immediately teamed up with Mary Lobjoit and Margot Brazier. Margot and John already knew each other, again by a chance connection. Margot had been invited by a distinguished law colleague to a seminar at which John was speaking and thought Margot might be interested because ‘it is about some rather disgusting medical sort of a thing—just up your street!’. Thus, the gang of four were complete and Manchester's CSEP was launched. All four founders had been waiting for the right collaborators and the right mixture of disciplines and expertise, each believing that medical ethics had to have a reasonably broad balance of disciplines, in this case medicine, theology and theological ethics, medical law and philosophy. CSEP's interdisciplinary base has now broadened considerably embracing additionally social science, global governance, biology, politics and neurology. Only John and Margot now remain at the University from the original group. Tony Dyson tragically died in 1998.4 Mary survived to see the Centre she co-founded in 1986—one of the first in the UK having been founded virtually at the same time as Ian Kennedy's group at King's College London—establish itself as one of the leading such centres in Europe while retaining her and its original mission to help make the world a better place and to establish ethics at the heart of medical practice and increasingly of science. The education of health professionals remains central to CSEP. The Masters' programmes in Health Care Ethics and Law that Mary helped shape have in turn helped shape the Centre with many of their graduates holding senior posts in the National Health Service and others returning as colleagues. The practical emphasis of the course, with a case based core course unit, remains crucial.
Academic bioethics in the UK owes much to its unsung heroes. Little attention is now paid in the literature to figures such as Mary Lobjoit and generations of enthusiasts who saw and insisted upon the need to put the ethics firmly first into medical ethics and more recently into the ethics of the biosciences (bioethics) and science more generally (science ethics). At least in part because of their efforts, mainstream medicine, led by the General Medical Council itself, has focused in a major way on the study and implementation of ethically appropriate medical practice. Yet we have some fears for the future. Within a reformed and cash strapped National Health Service, in England at least, new ethical dilemmas may confront health professionals. With money short, funding to study bioethics and law in depth in Masters' courses will be hard to come by. Universities now focusing on the need to attract undergraduates paying £9000 a year and the demands of research performance evaluation may attach less value to the taught postgraduate courses that have educated so many health professionals in ethics. In paying this tribute we hope to praise our departed colleagues and to recall some often forgotten elements of the history of our field and indeed of this journal. We also hope to stress that in teaching medical and bioethics, following the example of Mary Lobjoit and Ted Shotter we provide a service to the community as a whole and not just an indulgence for our own academic passions.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.