The silent curriculum

The GMC emphasises that every doctor who comes into contact with medical students should recognise the importance of role models in developing appropriate behaviours towards patients, colleagues and others.1 Campbell et al13 have drawn attention to the power of the hidden or silent curriculum in which extracurricular factors (such as bad role models) can have harmful effects on the ethical development of medical students and junior doctors.14 Rhodes and Cohen15 state, “Without careful and explicit attention to character, students are likely to absorb unacceptable habits and attitudes through the silent curriculum of observing medical misconduct and mistakenly adopting that as the norm” and “as medical educators we have to help our students to understand their professional responsibilities and be people who have the requisite character; and we have to enable them to do the right thing as the well-formed professional would do it”. The view of Campbell et al13 that “Formal ethics training has its part to play in this cultural reformation through its encouragement of critical and independent thinking and its rejection of the false idea that seniority alone is a guarantee of ethical perceptiveness and considered judgement” was implicit in the development of the revised core content set out below.

The Consensus Statement and its review

The Institute of Medical Ethics (IME) was involved in the development of a model core curriculum for teaching medical ethics and law within medical education that led to the 1998 Consensus Statement by teachers of medical ethics and law.9 In 2005, the IME commissioned a survey “to characterise UK medical undergraduate medical ethics curricula and to identify opportunities and threats to teaching and learning”.16 The authors of the report found that, although medical ethics and law were represented in the curricula of the 22 of the then 28 UK medical schools that responded, significant concerns remained about the status, content, delivery and assessment of the teaching of ethics and law in medical schools.

In October 2005, UNESCO adopted the Universal Declaration on Bioethics and Human Rights, which embodies a set of bioethical principles agreed by 191 Member States. They have subsequently articulated the ethical principles in that declaration in a Bioethics Core Curriculum.7

In March 2006 the IME, in conjunction with the British Medical Association and the Higher Education Academy, held a conference on learning, teaching and assessing medical ethics.17 In his keynote address to that conference, Sir Kenneth Calman, President of the IME, suggested that there was a need for “leadership with capacity and capability at all levels of an integrated curriculum; clarity about the purpose and process of learning and teaching in medical ethics; and methods of learning and assessment relevant to the knowledge base in both science and ethics”. The key was “investment in people and for science and the arts and humanities to work together”.17 Delegates generally agreed that the core curriculum proposed in the 1998 Consensus Statement9 had served its purpose well, but was now “ripe for reconsideration”.17 They considered that it was dated with regard to topics and emphasis: there were issues that could now be addressed and were not considered in the original document in sufficient detail; and some subjects in the core list might be more appropriate for postgraduate rather than undergraduate study.

After the 2006 IME conference, the Medical Education sub-group of the IME, subsequently enlarged into the Medical Education Project Steering Group (appendix 1), advocated and subsequently initiated a project to develop and generalise good practice in the teaching, learning and assessment of medical ethics and law across the UK’s by now 32 medical schools.18 Among the priorities identified was the reassessment and updating of the core curriculum for medical ethics and law.

In this paper we describe the process of this reassessment and present a revised core content of learning for medical ethics and law. It is primarily intended for UK medical schools, but may also be relevant elsewhere and for other healthcare professions. The IME has established an assessment group who will consider appropriate assessment strategies for the content of learning and sharing of assessment tools. The IME will also take a role in the dissemination and implementation of the updated content for learning.

A review of both the 1998 Consensus Statement9 and aspects of the UNESCO Bioethics Core Curriculum7 was carried out among the 100 or so participants at the IME conference on the core curriculum and methods of assessment held in January 2009.19 Participants included medical practitioners, those teaching ethics and law in medical schools, other healthcare professionals and medical students. Twenty nine of the 32 UK medical schools were represented. A “nominal group” variation of the Delphi technique20 was used in workshops, where each person was asked to rank on a proforma the themes and topics in the statement and the UNESCO document as “high”, “medium” or “low” priority for inclusion in the revised core content of learning. They were also asked whether they supported a revised set of aims of teaching medical ethics and law and assumptions upon which the core content was based and were invited to add any comments or additional topics. Their rankings were then collated to produce a first set of revised themes and topics for inclusion. Once this had been done, they were asked to reconsider and prioritise topics that had not reached a threshold for inclusion in the first round (all themes had reached the threshold). A second round of collation was then performed to produce a conference-wide view of the topics that were recommended for inclusion in the revised core.

The results of the nominal group deliberations (including comments by participants) and the notes taken by rapporteurs during the workshops were collated, and the resulting draft document was put through a series of iterations by the project’s Steering Group to produce a draft revised core content of learning. It was felt that it was now more appropriate for these to be expressed as learning outcomes. The importance of assessment to these was acknowledged, and, as noted above, a further working group has been set up to consider this in greater depth. The Steering Group also established a process, described below, for consultation on the revised core document using the IME website.

Process and results of consultation

The consultation document and a proforma for responses were put on the IME website (www.instituteofmedicalethics.org) and stakeholders (listed in appendix 2) were invited by email to respond as individuals or groups and to involve as many other people as possible in the process. Responses were requested within 6 weeks. Twenty responses came from individuals and 20 from groups (although the size of each group is unknown) from the original 108 invitations. Of these, most were from medical practitioners and those teaching ethics and law in medical schools, but responses were also received from medical students, a nurse and a lay person. Comments were received on behalf of most medical schools, the GMC, the Postgraduate Medical Education Training Board (PMETB), the Royal Colleges of Anaesthetists, Physicians, and Paediatrics and Child Health and the Medical Defence Union.

The responses, including all the additional comments, were collated and considered in detail by the Steering Group, which also considered the learning outcomes proposed in a document, “Information on the principles of medical ethics and legal issues”, itself part of a comprehensive statement on postgraduate medical education by the Academy of Medical Royal Colleges.21 This resulted in the revised core content of learning set out below.

Revised core content

The objectives of the 1998 Consensus Statement9 remain as relevant today as then, in demanding “a balanced, sustained, academically rigorous and clinically relevant presentation of both ethics and law in medicine, and of the relationship and tensions between them. Clinical relevance and the duties and educational needs of students should be stressed. Teaching should reinforce the overall aims of medical education: the creation of good doctors who will enhance and promote the health and medical welfare of the people they serve in ways which fairly and justly respect their dignity, autonomy and rights”.

This new core content of learning is intended to set out a necessary core of knowledge, skills, attitudes and behaviours for doctors of tomorrow. The topics are expressed as learning outcomes for which students should, firstly, be able to demonstrate a critically reflective understanding (which includes, of course, the requisite knowledge). Secondly, there are topics for which students also need to be able to demonstrate appropriate attitudes and practical skills, and that is what is intended by the phrase “Students should be able to demonstrate in practice an understanding of….” Whereas the GMC with their statutory authority are able to use “should” and “must” to differentiate between competencies or outcomes that are respectively expected or required in their guidance on ethical and professionals standards,1 10 11 12 in the proposed core content of learning that now follows we use “should” throughout, not in order to endorse a lesser standard, but rather to reflect our role of recommending rather than in any way trying to enforce it.

Core content of learning for medical ethics and law

Assumptions on which the core content of learning is based

A foundation in medical ethics and law:

• is essential for students to become good doctorsi

• is a necessary part of all clinical encounters and medical and public health interventions

• serves as a framework for understanding duties and responsibilities required for good medical practice

• underscores and explores the key importance in good medical practice of benefitting the health of individuals and populations while minimising harm in ways that respect autonomy and are just

• enables identification of ethical or legal issues in practice

• facilitates reflective and critical thinking on the practical application of the core content

Aims of teaching medical ethics and law

The aims are to enable students to:

• aspire to and be equipped for a lifetime of good practice and learning

• develop an awareness and understanding of ethical, legal and professional responsibilities required of them as students and doctors

• think about and reflect critically on ethical, legal and professional issues

• understand and respect the strengths and weaknesses of views different from their own while maintaining personal integrity

• acknowledge and respond appropriately to clinical and ethical uncertainty

• acquire knowledge to facilitate ethical decision-making and clinical judgement that is morally, legally and professionally justifiable

• respond appropriately to new challenges in medical practice as a result of scientific advances (eg, in genetics) and social changes

• integrate the necessary knowledge, skills, attitudes and behaviours into medical and professional practice

To fulfil these aims, the following content of learning and achievements is necessary.

Foundations of medical ethics and law

Students should be able to demonstrate an appropriate and developing understanding of:

• methods of ethical reasoning that inform decisions in medical practice

• the legal and professional frameworks within which medicine is practised in the UK

• the importance, scope and implications of the doctor’s duty of care

• the implications of the practice of medicine in a diverse, multicultural society

• the influence of values, assumptions, attitudes and emotions on their decision-making and practice

Students should be able to:

• consider, apply and reflect critically on the ethical and legal bases for clinical decisions

• identify values of different stakeholders involved in, or affected by, decision-making, including the student’s own values

Professionalism: “good medical practice”

Students should be able to demonstrate in practice:

• an understanding of and respect for the role, responsibilities and requirements of the GMC and its primary concern to promote the health and safety of patients

• an understanding of:

• • the importance of trust, integrity, honesty and good communication in all professional relationships

  • the need to accept personal responsibility and be aware of limitations of their practical skills or knowledge and to know how and where to seek appropriate help (including when abroad on electives)

  • the need to maintain professional boundaries with patients

  • issues raised by the religious beliefs of patients, students and other healthcare professionals and the role and limits of conscientious objection

  • the need to recognise and avoid all forms of unfair discrimination in relation to patients, colleagues and other healthcare professionals

  • areas of potential conflict of interest, eg, the pharmaceutical and medical equipment industries

Students should be able to:

• respond appropriately to clinical errors

• follow procedures for reporting adverse incidents

• adhere to legal and ethical responsibilities that protect patients

Patients: their values, narratives, rights and responsibilities

Students should be able to demonstrate a critically reflective understanding of:

• the differences between moral, legal and human rights and how these impact on professional practice

• the importance of the patient’s dignity, narrative and perspective in the clinical encounter

• the rights and responsibilities of patients and possible justifications for limiting their rights

• ethical and legal aspects of the relationship between the interests of patients and their relatives/carers and, where relevant, how best to involve and respect the latter’s views

Informed decision-making and valid consent/refusal

Students should be able to demonstrate in practice an understanding of legal and ethical aspects of:

• informed consent, voluntariness and disclosure of diagnosis

• patient refusal of treatment

• the significance and limits of respect for patient autonomy

• recognition of the legal and ethical boundaries of the clinical discretion to withhold information

Capacity and incapacity

Students should be able to demonstrate in practice:

• an understanding of ethical and legal aspects of treatment for patients who lack capacity for a particular decision or who have capacity but are otherwise vulnerable

• knowledge of the legal criteria for establishing that a person lacks capacity

• an understanding of the ethical challenges and legal requirements of determining and acting in the best interests of patients who lack capacity

• an understanding of ethical and legal tensions between the interests of the patient, family and the community

Confidentiality

Students should be able to demonstrate in practice an understanding of:

• the concept of confidentiality and its legal, professional and ethical bases

• when it is legally, professionally and ethically justifiable or mandatory to breach confidentiality

• how to share confidential information within clinical teams appropriately

• legal and ethical aspects of the use, transmission and storage of electronic data

• good practice in sharing information with relatives and carers and recognition of potential ethical and legal tensions

Justice and public health

Students should be able to demonstrate a critically reflective understanding of:

• legal and ethical issues involved in balancing individual and community interests in accessing healthcare resources

• local, national and international prioritisation in relation to clinical decisions

• principles and criteria for just distribution of finite healthcare resources

• the role of the doctor as patient advocate

• the ethical and legal considerations with respect to patient responsibility for health

• the responsible use of resources in referral, investigations and prescribing

Children and young people

Students should be able to demonstrate in practice an understanding of:

• the duty to respect the rights and interests of children and young people

• the legal and ethical aspects of the capacity of young people to consent to and refuse treatment

• the respective roles of parents/guardians, healthcare professionals and the courts in decisions about the treatment of children

• the ethical and legal issues in child protection

• the application of the duty of confidentiality to young people

Mental health

Students should be able to demonstrate in practice an understanding of:

• ethical, legal and professional implications of the care of patients with mental illness

• the implications of mental capacity legislation for clinical practice

• mental health legislation relating to compulsory detention and treatment

• the ethical and legal issues of restraint

Beginning of life

Students should be able to demonstrate in practice an understanding of:

• ethical and legal issues surrounding the status of the embryo and fetus, and areas of contention and debate including possible maternal–fetal conflict

• concepts of personhood

• ethical, legal and professional aspects of contraception, artificial reproductive technologies, termination of pregnancy and neonatal care

• ethical issues associated with preimplantation/prenatal testing and embryo selection, genetic testing and screening after birth

Towards the end of life

Students should be able to demonstrate in practice an understanding of ethical and legal issues at the end of life including:

• dignity, patient choice, limits on respect for patient autonomy

• “ageism”, “futility”, sanctity and quality of life

• withholding and withdrawing treatment, eg, clinically assisted hydration and nutrition, “Do not attempt resuscitation” (DNAR) orders, and other advanced decisions about treatment

• the need to respond sensitively to patients at the end of life and to their families/carers

• respect for diverse cultural practices at the end of life

• the requirements for death certification and completion of relevant certificates and legal documents

• students should be able to demonstrate an understanding of the law and ethics as they apply to euthanasia and assisted suicide

Medical research and audit

Students should be able to demonstrate in practice an understanding of:

• the purposes and differences between research and audit

• ethical, professional and legal considerations involved in medical research and audit

• the importance of trust and integrity in research and audit

• ethical and legal issues in conducting and reporting clinical trials

• additional ethical and legal limitations on (boundaries of) research with children and other vulnerable individuals

• the situations when research ethics committee approval may be required and how to seek it

• ethics of research in developing countries

• potential conflicts of interests in relationships with the pharmaceutical and medical equipment industries

Generic competencies

We suggest that students should be able to demonstrate the following knowledge, skills and aptitudes as the course progresses. Given that the length and organisation of the course varies among medical schools, the following suggestions are intended only to be indicative and should be interpreted flexibly and with common sense.

Years 1 and 2

• Recognition and understanding of core ethical and legal topics

• Application of common ethical arguments using constructed case scenarios

• The ability to understand and discuss differing viewpoints

• Awareness of the requirements of GMC on student fitness to practice12

Years 3 and 4

• Familiarisation with the GMC’s professional codes of conduct10 11

• Recognition of ethical and legal issues and ability to apply common ethical arguments to actual clinical encounters in different specialties and public health interventions

• Recognition of and conformity to professional and legal obligations in practice

• The ability to reflect on ethical practice of self, peers and teachers

Years 5 (and 6 where applicable)

The ability to:

• integrate ethical analysis of actual clinical encounters with clinical knowledge and skills and legal obligations

• elaborate on common ethical arguments

• propose action/decision based on this synthesis

• display professional attitudes and behaviours consistent with Good medical practice10

• Be aware of own values

In the foundation years and their subsequent careers, doctors should be able to demonstrate increasing competence in how to identify, acknowledge and deal with ethical, legal and professional issues on which good medical practice is based. Teaching and learning should be attuned to the learners’ needs appropriate to both their particular stage of training and relevant specialty-specific ethical issues.

Conclusions

We have sought and listened to the views of doctors, ethicists and lawyers involved in teaching medical ethics and law, as well as students, lay people and the GMC and other bodies with responsibilities for, or interests in, medical education. The GMC and British Medical Association have confirmed that this curriculum is consistent with their guidance on undergraduate education. Those who have “signed up” to this revised core content of learning are listed in appendix 3 (available online).

The following points have been reinforced by this process:

• Not only should the teaching and learning of medical ethics and law be integrated vertically and horizontally throughout the undergraduate curriculum as a whole (beginning early and being reinforced throughout the course), but it also needs to be specifically integrated with other complementary subjects such as clinical communication22 and, perhaps, the World Health Organization recommendations on patient safety23 currently being piloted in 10 medical schools worldwide.24 It is a shared obligation of all teachers throughout the course and is not the sole responsibility of designated teachers of medical ethics and law.

• The GMC requires that educational facilities and infrastructure be appropriate to deliver the curriculum.1 Thus it is the responsibility of each medical school to provide adequate teaching time and resources to achieve the aims of the indicative content of learning for medical ethics, law and professionalism. We therefore reiterate that the adequate provision and coordination of teaching and learning of ethics and law requires at least one full-time-equivalent senior academic in ethics and law with relevant professional and academic expertise.9

• Teaching the teachers is an integral part of the teaching and learning of medical ethics and law.16 17