How should students learn? Some continuing difficulties with consent

The availability of skilled doctors is both a necessary and an incontrovertible public good. How they should develop their skills, however, and what doctors and patients can reasonably expect in a teaching context, may raise ethical concerns. At some point, medical teaching must leave the classroom. Patients understandably expect doctors to be expert in any procedure they undertake, yet every doctor must have a “first time”. This conflict between the need to learn and the desire for the best available treatment is not easily resolved. Without appropriate supervised practice, doctors are likely to be clumsy or inexpert when carrying out procedures that should be routine, and harms would inevitably result. In contrast, what constitutes a legitimate intrusion when a person is ill and vulnerable? Perhaps all members of society have a duty to participate in the teaching of doctors as all individuals are likely to need their skills in the future? Medical procedures need both technical expertise and communication skills. So, much can be done with mannequins and, with appropriate permission, cadavers, but at some point the transition to live patients is needed.

Sometimes teaching medical techniques causes conflict between the need for students to learn and the need to protect patient autonomy. The utilitarian justifications that once governed teaching practice, holding that the net social benefit outweighed any harm to individual patients, are beginning to give way to a more rights based or deontological approach that sees individual autonomy as an almost inviolable good. Practice in the past may have failed to recognise or to heed the significance of patient choice and the importance of recognising, in Kant’s phrase, that patients are “ends in themselves”. It follows of course that patients are not being exploited as a “means” if they voluntarily consent. In turn however, this raises the issue …