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Kant, curves and medical learning practice: a reply to Le Morvan and Stock
  1. J Ives
  1. Correspondence to:
 J Ives
 Department of Primary Care and General Practice, Centre for Biomedical Ethics, University of Birmingham, Edgbaston, Birmingham,B38 9AJ, UK;ivesjz{at}


In a recent paper published in the Journal of Medical Ethics, Le Morvan and Stock claim that the kantian ideal of treating people always as ends in themselves and never merely as a means is in direct and insurmountable conflict with the current medical practice of allowing practitioners at the bottom of their “learning curve” to “practise their skills” on patients. In this response, I take up the challenge they issue is and try to reconcile this conflict. The kantian ideal offered in the paper is an incomplete characterisation of Kant’s moral philosophy, and the formula of humanity is considered in isolation without taking into account other salient kantian principles. I also suggest that their argument based on “necessary for the patient” assumes too narrow a reading of “necessary”. This reply is intended as an extension to, rather than a criticism of, their work.

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  • i See Brecher’s, why the Kantian ideal survives medical learning curves,1a and why it matters for a discussion of this issue.

  • ii A reviewer of this paper suggested that in the light of this, we can resolve the conflict entirely if we can properly think that the clinician who is learning is not treating the patient merely as a means, but also as an end, as the motive to help the patient is also present. I think this point has merit, but Le Morvan and Stock1 have given good reasons for thinking that although this dual motive may be plausible for the learner, it is not plausible for the supervising clinician (see later). The aim of the argument that follows is to establish that even if the clinician is using the patient solely as a means, it does not necessarily conflict with the kantian ideal.

  • iii John Harris6 has recently offered a related argument, claiming that there is an obligation to participate in research. One of his arguments claims that it is unfair to expect a free ride and if a person wishes to benefit from medical advances, then that person should be prepared to participate in the research that makes those advances possible. He also suggests that it is fair and justified to assume that people are moral agents with an interest in being moral. Harris appeals to notions of “fairness” rather than “rationality”, but the end result is the same.

  • iv For a good discussion of this doctrine see Stern’s10 excellent paper.

  • v I should note that “expect” here may have two meanings. If I expect to be treated by a top clinician, I might mean either that (a) I actually think I will be treated by a top clinician or (b) I think I should be treated by a top clinician. Clearly, the patient would have to believe something like (a) in order for the objection to work. However, it seems far more likely that patients believe something more like (b).

  • vi Incidents an the exposure of incompetent surgeons may call into question the profession’s ability to meet this expectation. Oakley12 argues that given that the risks in surgery vary according to the surgeon performing the procedure, part of the consent procedure for surgery should include making the patient aware of the individual record of the surgeon. I think that Oakley’s point is a fair one, but it does not affect my argument here. Provided that the clinicians are competent, there is no conflict with the kantian ideal. If they are not competent or sufficiently qualified to carry out a procedure then the kantian ideal might have been violated. I say “might” because it is not clear that any kind of deception has occurred.

  • Competing interests: None.

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    BMJ Publishing Group Ltd and Institute of Medical Ethics

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