Creating an ethics community

Medical students and junior doctors commonly perceive unethical behaviour but feel unable to speak up or feel that speaking up will be ineffective.6 ,7 Healthcare organisations need to nurture a culture that supports health professionals raising concerns. When healthcare professionals are in a system that ignores patient distress or allows financial pressures to take priority over human dignity, individuals find themselves doing things that do not reflect the kind of person they want to be. Their moral identity is eroded and ethical practice becomes difficult to sustain. However, to take a stand is difficult and takes courage.8 We should therefore be humbled by the story of Julie Bailey, whose mother died at Mid Staffordshire. Julie Bailey founded and led the campaign group Cure the NHS which was, in turn, instrumental in bringing the failures at Mid-Staffordshire to light.9

Julie Bailey's story demonstrates the importance of creating a community and how such a community can provide the collective determination and strength to make a difference. Medical ethics similarly needs a large and vibrant clinical-academic community which will promote ethical dialogue and give individuals the skills and confidence to speak up and bring about change in clinical practice.10 A thriving community will provide the critical mass to enable the language of ethics to flourish and to move out of the classroom into everyday clinical discourse.

There is already a strong academic community in medical ethics. However, few clinicians see themselves as potential members of this community. Most clinicians will have little knowledge of the wealth of excellent ethics research. In the absence of a strong academic-clinical community, clinicians may feel that such research is inaccessible or of little relevance to everyday practice (eg, high profile discussions about human cloning, genetic enhancement or physician-assisted suicide). An ethics community that brings together clinicians and academics can help inform the direction of ethics research and help translate research into discourse relevant to everyday clinical practice. For example, there has been substantial work around the ethics of clinical trials in low income countries.11 ,12 At first sight this may seem of little relevance to a busy GP in an inner city practice in the UK. However, the ethical analyses around global justice, ethical duties to assist and the fiduciary relationship between doctor and patient all have a bearing on how that GP should approach the familiar ethical dilemma of the care owed to patients from resource-poor countries who are not entitled to NHS treatment.

Moral resources and moral imagination

In his moral history of the 20th century,13 Glover describes the human tendencies of sympathy for human suffering, respect for others and sense of moral identity as our moral resources that help restrain us from unethical actions. Good medical ethics should equip us to reflect on and harness our moral resources to support ethical actions when faced with difficult situations.

Glover's book reflects on atrocities from conflicts in the 20th century and considers the factors that contribute to the failure of our moral resources to constrain barbaric behaviour.13 The recent scandals in NHS healthcare cannot and should not be likened to the wartime atrocities that scarred our recent history. However, the moral resources shared by the vast majority of healthcare professionals and managers failed to prevent individuals and healthcare institutions from mistreating those under their care. Robust philosophical reasoning is essential in deciding how we should act, but good medical ethics should also invest intellectual effort into understanding why, as in Mid Staffordshire NHS Trust and elsewhere, our moral resources sometimes fail to constrain unethical behaviour.

Medical ethics has been criticised for reaching conclusions that fail to square with clinical experience.14 This mismatch is also likely to contribute to the gap between ethical thinking and what we do in practice. Our ability to reason is a valuable human characteristic, but so too are our emotional responses which underpin our innate sympathy for the suffering of others and tendency to show respect for other people. Our emotional responses, combined with reasoned reflection, form what Glover describes as our moral imagination.13 The quality of ethical reasoning will be constrained by the limits of our moral imagination. Limitations in our moral imagination may explain why sometimes apparently sound ethical reasoning provides unsatisfactory conclusions for clinical practice. Conversely, a rich moral imagination carries a deep visceral component which may be critical to ethics becoming part of who we are rather than just something we do.

Good medical ethics should therefore develop our moral imagination as well as our moral reasoning. There is growing evidence demonstrating the value of medical humanities in the development of moral identity and moral imagination.15 ,16 As part of his work exploring the ethical value of the human body,17 Campbell reflected on the parental narratives from the Bristol Royal Infirmary Inquiry.18 These narratives convey the profound emotions experienced by parents on discovering that their children's internal organs had been removed and retained at post mortem without their consent.19 As such, the narratives provide rich food for the moral imagination, particularly for doctors working within a culture dominated by a dualistic approach to the human body.

Tick-box ethics

A language thrives when it serves a function. If ethical reasoning does not help health professionals to work out what to do in real-life situations, it will remain a classroom language. The tendency to reduce ethical reasoning to a checklist of a priori statements risks it becoming like a cheap phrasebook: looking good on the shelf but of little practical help.

Principlism—and, in particular, a simplistic version in which it is reduced to a flowchart approach denuded of nuanced reasoning—seems to have become dominant in medical ethics, at least among health professionals. Furthermore, within the four principles approach, autonomy is often assumed to have overarching value. Dawson has criticised the lazy use of autonomy as a substitute for real ethical thinking.20 Ethics should be a reflective process which adapts to new challenges and the nuances of individual circumstances. However, the temptation is for flowcharts to become a quick fix ethical shortcut. Used in this way, flowchart priniciplism can yield unsatisfactory conclusions.

For example, should a doctor simply accept the informed but poor choice of a patient on the grounds of respecting autonomy? Or is there an ethical obligation to persuade him otherwise and, if so, where does this obligation arise from? A more nuanced use of the four principles yields a more sophisticated response, but does not acknowledge morally important factors such as the virtues of a good doctor or the special nature of the doctor–patient relationship, which are likely to underpin the actions of the doctor in reality.

The current culture of medical education, with its focus on competency-based outcomes, assessment-driven learning and students as free market consumers, presents a challenge to those teaching medical ethics.21 Similarly, healthcare has become dominated by a culture of measurable targets and outcomes. Ethical practice is interpreted as adherence to flowcharts and completion of tick-boxes. The language of ethics becomes subsumed into the management speak of quality improvement targets and key performance indicators; the ethical basis and, more importantly, the ethical reasoning for these targets and indicators are forgotten.