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Prepared for practice? Law teaching and assessment in UK medical schools
  1. Michael Preston-Shoot1,
  2. Judy McKimm2
  1. 1Faculty of Health and Social Sciences, University of Bedfordshire, Luton, UK
  2. 2Faculty of Social and Health Sciences, Unitec New Zealand, Auckland, New Zealand
  1. Correspondence to Professor Michael Preston-Shoot, Faculty of Health and Social Sciences, University of Bedfordshire, Park Square, Luton LU1 3JU, UK; michael.preston-shoot{at}


A revised core curriculum for medical ethics and law in UK medical schools has been published. The General Medical Council requires medical graduates to understand law and ethics and behave in accordance with ethical and legal principles. A parallel policy agenda emphasises accountability, the development of professionalism and patient safety. Given the renewed focus on teaching and learning law alongside medical ethics and the development of professional identity, this survey aimed to identify how medical schools are responding to the preparation of medical students for practice in the future. Questions were asked about the location, content and methods of teaching and assessment of law in undergraduate medical education. Examples of course documentation were requested to illustrate the approaches being taken. A 76% response rate was achieved. Most responding schools integrate law teaching with medical ethics, emphasising both the acquisition of knowledge and its application in a clinical context. Teaching, learning and assessment of law in clinical attachments is much less formalised than that in non-clinical education. Coverage of recommended topic areas varies, raising questions about the degree to which students can embed their knowledge and skills in actual practice. More positively, teaching does not rely on single individuals and clear descriptions were offered for problem-based and small group case-based learning. Further research is required to explore whether there are optimum ways of ensuring that legal knowledge, and skills in its use, form part of the development of professionalism among doctors in training.

  • Assessment
  • education/programmes
  • ethics
  • law
  • medical education
  • teaching

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In the UK increasing emphasis has been placed on doctors' preparedness for practice, accountability and professionalism. The need for doctors to practise legally and ethically is seen as one core element of professional responsibility. An initial model curriculum for teaching medical ethics and law1 proposed both content and organisational principles, designed to ensure safe and effective practice that promoted patients' health and welfare. The purpose was to ensure that students acquired knowledge of legal issues relevant to medical practice and an ability to apply it in their decision-making.

An underpinning proposition was that the curriculum should be clinically relevant, covering medical practitioners' legal obligations and exploring the relationship and tensions between law and ethics in order to guide subsequent practice. Core topics to be covered were: informed consent and treatment refusal; the doctor–patient relationship; confidentiality; research; human reproduction; genetics; children; mental disorders and disabilities; life and death; regulation and accountability; resource allocation and human rights. The balance between these topics, and between law and ethics, was left to individual schools' discretion. However, curriculum delivery was perceived to require at least one full-time subject specialist, using large and small group formats and case-based discussion. Sufficient (although undefined) time and resources would be required, with law and ethics teaching fully integrated across the curriculum, including in students' clinical experience, and formally assessed.

The consensus statement has been updated.2 It draws on research findings reported by UK medical schools3 in which three-quarters stated that law and ethics were represented in their curricula. They expressed concerns, however, about their capacity for, and the status, content and assessment of this component of medical education. A foundation in law and ethics is again seen as crucial to professionalism and to safe and respectful medical practice. There is a similar corresponding emphasis on the development of knowledge and understanding of legal responsibilities, critical reflection on ethicolegal issues and application to clinical practice. The content has been expanded and made more specific, reflecting international trends and national legislation. Topics selected also respond to requirements from the General Medical Council, which emphasise the need for professional practitioners to ‘behave according to ethical and legal principles’4 and put patient safety as a primary concern.5 6 An emphasis remains on legal rules surrounding informed consent, confidentiality, children and young people, mental health, beginning and end of life concerns and research. However, the core curriculum now also foregrounds (in) capacity, legal and ethical foundations, professionalism (including the avoidance of discrimination), and patient values and narratives alongside human rights. Resource allocation has been broadened to focus on justice and public health.

Once again, the statement recommends horizontal and vertical integration of law teaching across the undergraduate curriculum, not only with ethics, but also with clinical communication, professionalism and patient safety. It also indicates how students' knowledge and understanding might be expected to develop across the years of the course. The statement advises that teaching should not rely on one specialist; rather, it should be a shared responsibility of all teachers and should be afforded adequate (still undefined) time. Significantly, this statement recognises that more work is required on assessment. It also highlights the impact of the hidden or silent curriculum on the outcomes of formal tuition. In this context the omission of proposals to strengthen the teaching of law in clinical education and in continuing professional development is surprising.

The UK Quality Assurance Agency subject benchmark for medicine7 also requires that graduates can demonstrate knowledge and understanding of, and the ability to, apply the legal rules surrounding practice. It contains comparable lists of topics to be covered. Law as a core component of the undergraduate curriculum has also been stressed by the General Medical Council6 in its recommendations for the education of future doctors. Once again a familiar list of topics is covered, including the ability when appropriate to liaise with other professionals, framed around patient safety as a core principle.

Despite these curriculum statements, however, research evidence suggests that consolidating law teaching in medical education has proved difficult because of a shortage of timetable space, staff disinterest or lack of expertise and financial constraints.8–11 Nor is it clear the degree to which recommended topics are covered and guidance implemented on curriculum integration, time allocation and staff recruitment. A practice survey therefore felt timely. It was conducted in order to ascertain how law is currently taught and assessed in UK undergraduate medical programmes and to compare the findings against the consensus statements and evidence from a systematic literature review.12


The practice survey was carried out in 2009, utilising a detailed questionnaire distributed to all 31 UK medical schools. It aimed to elicit information about where and how law is taught and assessed throughout undergraduate medical programmes and the professional profiles of those involved. Questions were asked about content, who teaches law, the structure and location of law teaching and learning, methods used, clinical placement learning and assessment. Respondents were also asked to review their school's approach and to evaluate students' preparedness for legally informed practice as foundation trainees. Alongside completion of the questionnaire, some schools provided examples of course documentation to illustrate or expand on their responses.

The questionnaire was developed from an earlier version used in a similar practice survey of social work law teaching, learning and assessment,13 modified to reflect the context of undergraduate medical education. A pilot was conducted with contacts responsible for law teaching in some medical schools. The final version was distributed by e-mail to nominated primary contacts in each school identified by the Higher Education Academy Medicine, Dentistry and Veterinary Medicine (MEDEV) Subject Centre. Respondents were informed that information provided would be collated and anonymised when reporting findings. After reminders, responses were received from 25 schools, representing a 76% return.

The questionnaire was designed to identify the challenges in delivering a law curriculum and enabling students to develop a professional identity and professionalism that incorporates an informed understanding of the law. The findings provide a baseline from which to examine the nature, outcomes and pedagogy of law teaching in undergraduate medical education, and to identify further research questions and issues for debate.


Responses received covered both 5 year and 4 year graduate entry programmes. No significant differences were found in law teaching between them. The results are therefore presented in relation to medical progammes overall.


Only two programmes reported teaching law as a separate topic, the remainder integrating it alongside ethics, professionalism or clinical topics. Both these programmes offered law teaching as a student selected component, either in year 1 or year 3, in addition to core law teaching integrated with ethics. The main reason for teaching law as a separate topic was cited as a lack of curricular time for teaching law in the core curriculum. Four other schools reported offering an student selected component in medical ethics and law.

Only 14 of the remaining 23 schools gave details of where teaching law as an integrated topic was included in the curriculum. The number of taught hours varies markedly, with most teaching located early in programmes (see table 1). As clinical placements were described as covering general and community medicine from year 1, with more specialist learning opportunities, such as in mental health or paediatrics, following from year 3 onwards, some law teaching will be quite distant from its practical application.

Table 1

Location and duration of law teaching

The dominant reason cited for integrating the teaching of law within other modules and not as a separate topic was to encourage students to connect the legal rules with all programme areas, including clinical practice, and to promote student engagement with law alongside ethical situations and clinical cases or settings. Many schools incorporated law and ethics teaching as a vertical theme throughout the programme as part of a spiral curriculum. Some used problem-based learning or structured the curriculum around ‘learning weeks’ or ‘cases of the week’, often led by clinicians, when no topics are taught separately. However, it is noteworthy that many schools did not have specific law learning outcomes for clinical placements except for specific legal rules that underpin specialist settings, such as the Mental Health Act 1983 and the Mental Capacity Act 2005 within psychiatry attachments. Many respondents found it difficult to identify specific law-related learning outcomes, given the integration with ethics and clinical cases, while in the relationship between law and ethics the main teaching focus appeared to fall on the latter.


Respondents were asked to confirm which topics were covered in university-based teaching and on clinical attachments (see table 2). The results can be compared with subject benchmark7 and curriculum consensus statements.1 2 It is noteworthy that no single topic is covered by more than three-quarters of responding schools, and that mental health and capacity, consent to treatment, and confidentiality, data protection and negligence are prominent in non-clinical teaching. In clinical attachments, mental health and capacity are again emphasised but here by less than half the responding schools. Some schools identified other taught topic areas including euthanasia and end-of-life decisions and fitness to practice. The selection of topics appeared to be determined partly by clinical relevance but partly by the availability of curriculum space and staff expertise and interest in law, challenges noted in previous research8–11 and the consensus statements.1 2

Table 2

Content and location of law teaching

Teaching and learning

Among responding schools, 88% of law teaching is the responsibility of more than one person, as recommended,2 with most programmes having between two and four curriculum law leads. This responsibility is usually combined with teaching ethics. These teachers tend to be medical ethicists, philosophers or lawyers. Curriculum leads may be supported by academic lawyers or doctors, NHS managers or clinicians, especially when programmes use problem-based, small group teaching, or case-based scenarios, and for law teaching in clinical attachments (see table 3). Clinicians are viewed as invaluable for putting the law into a clinical context. They play a variety of roles. Some are specialists in law or ethics, but the majority provide input on law relating to their clinical speciality, most commonly paediatrics, mental health, obstetrics and gynaecology, palliative care and general practice. Not all these contributors will have formal ethicolegal training or qualifications, which raises questions about professional development to teach law effectively.

Table 3

Professional backgrounds of teaching teams

There is limited outcome focused research on what combination of teachers best facilitates medical law learning.12 As with social work law13 no common pattern emerges. A multiprofessional teaching team demonstrates to students an openness to interdisciplinarity, offers breadth of experience and knowledge, and potentially can illuminate legal discourses and processes. The challenge is to ensure that teaching is relevant to professional practice and to secure time for preparation so that the team can blend their different orientations and approaches to the subject.

Examples were given of contributions from patients and carers, but their involvement appears underdeveloped, as is true elsewhere in professional education (such as social work).13

A wide range of teaching and learning methods is used (see table 4), the choice of which related closely to overall curriculum structure and approach, such as problem-based learning with an emphasis on medical professionalism, or a spiral integrated curriculum wherein students return to blocks at different levels and with additional new material. Most schools used a combination of methods but with a developing programmatic emphasis on application to clinical situations in order to embed learning. Clinical contextualisation is overwhelmingly seen as central. Case scenarios, tutor-led seminars, clinical placement teaching and lectures are the most common methods used. E-learning and simulation exercises are little used. Three respondents noted that small group learning is probably one of the most effective ways of teaching and learning law, but that their approach was constrained by curriculum space, resources and budgets.

Table 4

Teaching and learning methods

A range of materials and sources of law is used to foster and embed law learning (see table 5). The most common sources of law cited were codes of practice (64%), guidance (60%) and case law (56%). However, given that the law evolves rapidly in response to social concerns, and comprises a body that begins with statute and is developed through regulations, guidance and case law, the coverage of sources and materials may be insufficient to enable students to appreciate the full extent and complexity of the legal rules. For example, evidence14 suggests that students benefit from reading case law because it illuminates legal and ethical practice issues such as those surrounding assisted suicide, consent to treatment and vulnerable adults who self-neglect. However, this source of learning appears underutilised.

Table 5

Materials used in law teaching

Clinical placements

Schools reported law teaching and learning as occurring across the range of clinical attachments, predominantly in later years of the programme. Seventy-six per cent of schools, however, did not have specific learning objectives for clinical placement teaching of law. Only 16% of schools included law overtly in clinical placement learning agreements. Eighty per cent did not provide any guidance or continuing professional development to clinical teachers to support their teaching of law. Programme respondents were increasingly aware that this curriculum component had not been formally planned, coordinated or adequately monitored. If the practice curriculum for law learning in medical education is underdeveloped, there are parallels elsewhere in professional education.13


Choice of assessment methods was linked to overall course structure and approach, with 92% of schools reporting that assessment of law was integrated with assessment of other topics, such as ethics, and with a strong applied practical focus in addition to testing accurate knowledge. Ninety-two per cent of schools assess law using written assessments. A range of coursework and written summative assessments was used, including presentations (20%), case studies (24%), multiple choice (44%) or short answer papers (36%) and essays (28%). Forty-four per cent of programmes tested practical application using objective structured clinical examination, with smaller numbers employing work-based clinical assessment, objective structured long examination records or a moot court. Seventy-two per cent of respondents cited that the purpose of assessment was to assess students' application of ethical principles to professional medical practice, with 68% looking for students to apply the law to professional medical practice. Specific aspects of law that were assessed included human rights (48%), content of legal frameworks (32%) and sources of law (28%). Only 20% noted that they required students to demonstrate a critical analysis of legal frameworks, an area that the revised core curriculum2 emphasises.

Eighty-four per cent of responding schools did not assess law formally on clinical placements, raising questions about how to ensure that student knowledge has been embedded in practice. Reasons cited were that it was not practical, that students had enough assessments already and that assessment of law has never been part of the clinical curriculum.

Respondent evaluations

Nineteen schools responded to a question about how prepared they believed students were in relation to law for their next stage of training. Twenty-six per cent stated that students were well prepared and 47% adequately prepared. Sixteen per cent thought that students were insufficiently prepared while 11% said that their teaching would shortly change. A majority (56%) of respondents were very or reasonably satisfied with their current approach to teaching, learning and assessment of law in medical education. This appeared, however, to be primarily based on student, teacher and external examiner feedback and personal reflection. Eighty-four per cent of schools have not undertaken any systematic outcome study of law learning. The principal reasons for dissatisfaction related to a lack of curriculum time and the absence of specific law-related learning outcomes.


The practice survey found a high level of concern, development and engagement from respondents in ensuring that students learn about the law in relation to future medical practice. There has been a responsive approach to new legislation and case law, especially surrounding mental health and mental capacity, and there is clearly much sharing of practice between schools and individual teachers. However, although law curricula draw from literature, medical education guidance and landmark cases, there is little reporting of sharing of practice from other professions in the most relevant ways to teach and assess law. Neither do respondents report drawing heavily from research. Given the significant gaps in the evidence base,12 this is unsurprising.

The survey confirmed that law teaching, learning and assessment in medical education is largely linked with ethics and applied to clinical contexts. However, the conflation of law and ethics can lead to a tendency for medical students to consider the two as synonymous rather than thinking critically about the law and its structures and frameworks. Subject benchmarks7 and the literature12 also largely portray a harmonious coupling of law and ethics. Yet, what is lawful may not be perceived as ethical; what professionals regard as ethical may be unlawful. This complexity is somewhat undertheorised,12 but students must be assisted to engage with critiques of both legal and ethical frameworks if they are to navigate the dilemmas that working with patients, families and communities will present.

Much of the formal law learning is located in the early years, with the typical model being a subsequent devolving of law teaching to clinicians in various specialities. Strong endorsements for this integrated approach were provided, namely the need for students to embed law learning in a clinical context and that understanding of medical law is best acquired alongside medical ethics so that issues can be debated from different viewpoints. However, these assumptions have not been tested empirically and the research literature11 12 questions whether the timing, content and approach to law teaching is sufficient to ensure student retention of knowledge and development of skilled application, particularly as students move into more independent practice.15–17 Indeed, the formal and systematic teaching and assessment of law is much less evident in the more clinically oriented stages of the programmes, in which clinical tutors may not have relevant up-to-date knowledge or access to continuing professional development,12 15 16 18 and by which time student learning from earlier curriculum inputs may have decayed.13 15–17

Many respondents appeared dissatisfied with how law is taught and assessed, unconvinced that medical students are as prepared as they might be for legally literate practice. Some raised concerns about the adequacy of resources, especially given the need for interactive, small group teaching to stimulate discussion and learning about more challenging and complex situations in which ‘answers’ may be unclear.

New curriculum guidance2 6 emphasises the development of professionalism, the ability to reflect and reason critically from an informed knowledge and practice base, and the ability to safeguard and promote patients' health. While how to define, teach and assess professionalism may be contested, the guidance connects it with students' capacity to understand and apply law knowledge, alongside professional ethics, to medical practice19 (see figure 1). Developing that capacity is not without problems. Parts of the law curriculum remain underdeveloped in medical education, with an impact on students' capacity to apply legal knowledge in medical practice. Equally, the medical law research literature12 does not clarify how the teaching of law and ethics is connected to other parts of the curriculum in order to facilitate the formation of professional identity. The inclusion of law as a discrete topic within professional identity formation has been largely ignored in the literature, where law is often conflated with ethics. In parallel, law may be taught with varying degrees of emphasis on technical knowledge, ethics and patients' rights,13 in which a curriculum should assist students to work through complex interrelationships, including mechanisms through which students can develop a rounded professional identity.

Figure 1

A model of professional identity formation.

The practice survey indicates that, although medical schools are clearly addressing the need for students to learn legal and ethical principles, their focus has been on enabling the acquisition of factual legal knowledge (although this varies between schools) and ensuring law is applied to clinical scenarios. The development of criticality is less evident, as is how this teaching and assessment incorporates and secures the engagement with law in practice as part of the development of professional identity and the demonstration of professional behaviours. This is an area for further exploration, given recognition of a hidden curriculum2 and current policy emphasis on patient safety, risk and error reduction2 5 and professionalism.6 Similarly, further research is required into whether a particular curriculum approach, or combination of teaching, learning and assessment activities, is effective in enabling students to embed and then skilfully apply their legal knowledge in a way that positively impacts on the experiences of patients and carers. Finally, as continuing professional development in law has not been developed and offered in a structured way,16 exploration is required of the most effective ways of ensuring that medical graduates retain up-to-date medicolegal knowledge and skills.



  • Funding The study was funded by two higher education academy subject centres: MEDEV (Medicine, Dentistry and Veterinary Medicine) and UKCLE (UK Centre for Legal Education).

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the University of Bedfordshire Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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