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Medical ethics: a case based approach
  1. R Ashcroft

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    L Schwartz, P E Preece, and R A Hendry. W B Saunders, 2002, £15.99 (pbk), pp 228. ISBN 0 702 02543 7

    Teaching medical ethics and law to medical students has been a requirement for all medical schools in the United Kingdom since the General Medical Council’s Tomorrow’s Doctors guidance on medical curricular reform of 1992. All United Kingdom medical schools now have at least some medical ethics and law in their curricula and most have a person appointed primarily to be responsible for this teaching. Since the publication in the Journal of Medical Ethics in 1998, volume 24, pages188–192, of a consensus statement on a core curriculum in medical ethics and law for medical students, most medical schools have gradually come to conform to this as the benchmark for the content of such teaching. There remains, however, a great diversity in the approaches taken to ensuring that learning this content takes place. A wide range of strategies have been adopted to such matters as: preference for “theme” or “problem based” or “system based” teaching; types of assessment; relationships with communication skills or medical humanities; responsibility for curriculum design and delivery resting with a specialist in medical ethics or with medical educationalists, communications skills specialists, or senior clinicians; classroom based or ward based or general practice based teaching, and so on. In parallel with this diversity in approaches to teaching and learning, there is a great diversity of different learning resources available, from traditional textbooks, to case books, anthologies of classic literature, problem based learning cases, web resources, and distance learning materials. To find one’s way through all this variety is quite difficult as there is no formal network of teachers of medical ethics in the United Kingdom, nor is there much investment in research into the effectiveness of different methods of teaching medical ethics, although some (such as Schwartz herself) have pioneered work in this area.

    This variety is probably a good thing at this stage in the development of medical ethics education. Yet for a long time there has been a need for a textbook that provides not only broad coverage of the issues, but also is educationally sophisticated enough to be a useful resource for students and teachers, while being intellectually sophisticated enough to bridge the gaps between clinical relevance, philosophical rigour, and legal and regulatory accuracy.

    Schwartz and colleagues make a very good stab at filling this need. The book starts from a consideration of the ethical content of clinical practice and of the doctor/patient relationship, rather than being a dry string of topics. It is written in an engaging style, is easy to read, and makes excellent use of clinically realistic case studies, both classical and new. A very nice feature of the book is the use made of contemporary art. It has long been a worry of mine that medical ethics is hard to illustrate; I find this book’s approach stimulating and encouraging. The book is mainly a narrative account of the main issues in medical ethics, interspersed with case studies and stimulus exercises for the reader to complete.

    I do, however, have some reservations. Perhaps because of the starting point of the book in the doctor/patient relationship, rather than the more legal or thematic orientation one usually finds, such issues as confidentiality and consent are rather buried away in the text, and many issues in the core curriculum are not covered in any depth—for example, the ethical issues in care of children or in psychiatry. The early chapter on different philosophical approaches in ethics is arguably weaker than it could be, in part because the authors (rightly) see these approaches as different tools in one’s analytical tool box, but present them so briefly with a list of pros and cons for each approach that the student may not really grasp why they are either important, useful, or controversial. I also wonder how well students will take to the use of the learning exercises in the text; I have had bad experiences with this sort of approach to learning in the past. That said, the book is written by a team who have had considerable success in using just this approach.

    On balance, I would argue that this is a book that will be useful to any teacher of medical ethics in planning curricula and learning activities, and many will find it a useful textbook for their particular purposes. It deserves to do well. Yet it is not the discipline defining work for which many of us have hoped. What it does do, perhaps better than any other books I have seen recently, is concentrate attention on the day to day ethics of clinical medicine, and on the moral and humane significance of medicine as a caring profession.

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