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The history of the Institute of Medical Ethics (IME) has been well recorded. Accounts of its origins in the London Medical Group (LMG) were published in an academic paper of 2003,1 in the transcript of a Wellcome Witnesses to Twentieth Century Medicine Seminar in 20072 and in a chapter of the 2009 Cambridge World History of Medical Ethics.3 In 2013, 50 years since the inauguration of its first series of lectures and symposia, the LMG as an organisation no longer exists, but its aspirations and achievements are alive and well, both in the Journal of Medical Ethics and in the IME, now exploring a new phase as a membership organisation. Other papers in this issue will discuss the history and prospects of the Journal and Institute. But the LMG, similar medical groups in all other British medical schools and the Society for the Study of Medical Ethics from which the IME derived also have a significant continuing life in the thinking and practice of many medical and healthcare professionals who participated in their activities, and then in turn on those influenced by their thinking and practice. The LMG, it could be said, is ‘no more’ an organisation ‘Now but a whole climate of opinion’.4
A bottom-up (r)evolution
The first medical students to be involved in the LMG may not have foreseen its influence on their future careers, but many were aware of being part of something new and exciting. One of those with whom the first lecture series was planned was Margaret Lloyd (née Rose and now Emeritus Professor of Primary Care and Medical Education, University College London).
The beginning of the LMG in 1963 was an exciting time for medical students in London. As a mature student entering St Mary's Hospital Medical School (now part of Imperial College) in 1962 I was very aware that there was much more to medicine than was formally taught and examined. The meetings of the LMG filled this gap with a broad range of topics relevant to us as future doctors. Guided and supported by Edward Shotter (now Dean Emeritus of Rochester) we chose the topics and speakers, chaired the meetings and continued discussion with the speakers over dinner. For many of us this had a big impact on our future careers and led to a life-long interest in medical ethics and law. In later years, as an academic general practitioner and teacher of medical students, it was a pleasure to see the LMG flourishing and ethics an important part of the established curriculum.
Another of the early LMG medical students, Roger Higgs (now Emeritus Professor of General Practice, King's College London) expands on the medical and cultural context of that time:
The practice of clinical medicine when the LMG was formed was a reflection of post-war Britain. Much of society was still assumed to be under central command and control. For instance, it was obvious when the first ship of Jamaican immigrants arrived in London in the late 1940s that it was someone's job to find them all a place to live (a bomb-shelter in Clapham Common): likewise a medical school Dean, a Roman Catholic, explained to me how his consultant at a similar time made it his job as houseman to walk the wards with a syringe of morphine to ensure incurable elderly a quiet end in the night. In the 1960s, ration books were still a recent memory for all, so the sexual liberation of the time went hand in hand with the transfer of other personal decision-making to the individual. It then was shocking to be told as a Registrar in 1973 by another young London consultant, subsequently also to become a London medical school Dean, strictly not to burden his patients by telling them what was wrong with them. A career in the ‘purer air’ of general practice was the answer for this young doctor.
The medical curriculum largely reflected this situation. At one London medical school (Westminster, 1967), the ethics curriculum was confined to one lecture, focussing on professional behaviour and called ‘the rule of A's’ that closely followed a Hippocratic tradition: no abortion, no alcoholism, no advertising, no association with unqualified practitioners, no adultery with patients; and, in one of the listener's notes at the time, 'no to Anything that the Professor didn't like’. Most newcomers to the curriculum, such as general practice or elderly health care, were in the wings, or, like psychology or medical sociology, were kept to the side of the stage in all but the most forward-looking schools. Training in communication skills was yet to be created as an entity.
In retrospect one can see that Medical Ethics succeeded in entering effectively the mainstream of the curriculum where other curricular entities failed both because the omission was glaringly and embarrassingly obvious, and precisely because medical ethics was developed as a subject which fitted medical practice as it was reforming itself but was created by young trainee professionals in practice with the support of a few inside the profession but outside the usual teaching framework. It's assault was on the flanks: it was in many ways the key example of a ‘bottom –up’ (r)evolution begun by total outsiders.
It is fascinating to reflect how this development was in parallel to that in academic moral philosophy. British mainstream philosophy of the time had turned itself away from anything that could not be seen and discussed in a positivistic way. Not only was moral philosophy an interest of the misguided few, but the application of such thinking to actual practice, medical or otherwise, was a new idea espoused by the young—such original philosophers as Jonathan Glover or emerging from theologians like Alastair Campbell or Kenneth Boyd. There was thus a gap between academic areas in need like medicine and potential ‘provider’ traditions like philosophy and theology. Some would claim that applied medical ethics has led the way in filling this gap for other areas of practice quite beyond the medical sphere. The continuing problem of research methodologies for applied ethics acceptable to academia for national research assessment exercises demonstrates the unresolved creative dangers at this academic fault-line.
As Margaret Lloyd recalls, the medical students who organised the LMG's activities were ‘guided and supported’ by Ted Shotter. This may seem an unlikely choice of profession for the founder of a highly successful medical organisation: as Dr Johnson observed, ‘physicians and lawyers are no friends to religion’ since ‘very few of them have thought about religion, but they have all seen a parson’.5 Indeed, the fact of Shotter being a cleric was said by the professor of medicine at one London medical school to be the main objection to the LMG. Ted Shotter, however, was not quite the kind of parson imagined by Johnson or the professor. In 1963, he was a staff member of the Student Christian Movement (SCM), a liberal, ecumenical and socially engaged organisation which sought not to ‘save’ individuals by extracting them from their everyday lives, but to listen to and address their everyday concerns, and because of its student constituency, especially those of the university and the professions. Although the LMG was from the outset ‘an independent, non-partisan student group’, not affiliated to the SCM, the SCM was a generous midwife.
A new organisation
Recalling the challenges and achievements of the LMG's early years, Shotter writes:
At that time, it was said that ‘ethics could be picked up on a ward-round’; a consultant, declining an invitation to speak, wrote that, if these matters were to be discussed at all, which he doubted, they should be discussed ‘by consultants, with consultants, and in camera’. It was doubted that ethics could be taught and apparently both teachers and taught were unaware that ethics (moral philosophy) and ethics (moral theology) were established subjects, unremarked in university faculties. Consequently, discussion sponsored by the LMG was not described as medical ethics but as ‘issues raised by the practice of medicine which concern other disciplines’.
Topics for discussion were selected by students. This became the role of a student Representative Council and the agenda of a senior multidisciplinary Consultative Council, which advised on the choice of lecturers and discussants, but exercised no veto on the choice of topics identified by students. Initially, prominent academics were invited to give open lectures, followed by discussion from the floor. Subsequently symposia also were introduced, with two or three discussants. Lectures were chaired by a medical student and took place in a medical school lecture theatre at the end of the working day. Symposia were chaired by a consultant from the host hospital, introduced by a student. Typically, they started at 5.45pm and were adjourned promptly at 7pm. Afterwards speakers were entertained to dinner by LMG student ‘reps’ from the host hospital.
In the first year, 1963–64, there were four lectures, with small but sufficient response to encourage the arrangement of eight lectures and symposia in 1964–65 and twenty-one in the following year. Eventually LMG lectures and symposia took place in each teaching hospital in turn every Tuesday and Thursday throughout the academic year with 50 or more topics per annum. These were widely publicised in the then twelve London medical schools by individual posters and an annual lecture list and attracted on average audiences of around 100.
In addition to the programme of lectures and symposia, there was an annual conference, convened by the student president of the LMG. Held in either one of the medical schools or one of the Royal Colleges, it took place on a Friday and Saturday in February and was attended by capacity audiences, mainly medical students but including students and practitioners of other disciplines. There were also series of study seminars, allowing detailed discussion over three or four weekday evenings, a twice-yearly Anglo-French weekend conference, which included participants attending ward rounds in Paris or London hospitals, and from time to time a weekend residential conference in Cumberland Lodge, Windsor Great Park.
A student critique of medical practice
This formidable organisation could not have been created and sustained—from 1963 until 1989—without a method which embodied a vision, described by Lord Rosenheim PRCP as ‘a pincer movement on the profession undertaken by its cadets and senators’, and by Shotter as ‘a student critique of medical practice’. As Roger Higgs suggests, in the 1960s and 1970s, medicine and society were emerging from the aftermath of World War II to encounter a range of new technological and cultural challenges, and alert leaders of the profession, aware of the importance of responding constructively, realised that they needed to pay attention to the concerns of other professions, the public and not least the upcoming generation of tomorrow's doctors. The LMG provided a significant forum for this, where consultants and professors not only lectured but also listened to students in a variety of formal and informal contexts and on topics unimagined in the days of ‘the rule of A's’.
The variety of topics and discussants in, for example, the LMG's 1981–1982 lecture list illustrate some of the concerns arising from these encounters. The year began with a Symposium on Brain Death, subtitled ‘Are the medical criteria acceptable to the public?’: two of the speakers were clinical authorities on the subject, both deans of medical schools and apparently happy to share the platform with the previous year's Reith Lecturer, Ian Kennedy of King's College, the scourge of medical paternalism. This was followed later in the same week and in the two following by symposia on other equally live issues of the time: ‘Survival of the weakest: The morality of inaction in the care of the malformed infant’; ‘Life at all costs: Transplants and scarce resources’; Marijuana: Its medical effects and social implications’; ‘Abandon hope: The consequences of euthanasia legislation’ and ‘In touch: The effects of physical contact on the therapeutic relationship’. The most popular LMG lectures over the years, Shotter observes, were on
topics not found in the formal curriculum, such as ‘The Nature and Management of Terminal Pain’ by Cicely Saunders (an annual lecture which followed the development of palliative care over twenty-five years); ‘Child Abuse’ by Christine Cooper (originally about physical abuse which led to the discovery of the prevalence of sexual abuse of children); and ‘Preparation for Death’ by Anthony Bloom (which always attracted large audiences).
A similar combination of medical, social and highly topical issues was discussed at the annual LMG conferences. Among their titles in the 1960s were ‘The welfare state’ and ‘The prolongation of life’, in the 1970s, ‘The problem of euthanasia’ and ‘Iatrogenic disease’ and in the late 1980s, on the latest challenge to medicine: ‘AIDS, ethics and medicine’ and ‘AIDS, sex, and death’.
An Edinburgh Medical Group was formed in 1967, and later in the same year one in Newcastle. By 1981, there were medical groups in the majority of British medical schools, each employing the same method, with Student Representative and Senior Consultative Councils, an annual lecture list, study seminars and local or regional conferences.
The titles of the lectures or symposia with which these groups began their 1981–1982 session again reflect the current (and in some cases prophetic) concerns of the medical students who suggested them: ‘The private medicine debate’ (Aberdeen); ‘Abortion’ (Birmingham); ‘The care of the dying’ (Bristol); ‘Too busy to care’ (Cambridge); ‘Humanizing childbirth’ (Cardiff); ‘Coronary Care: Home or Hospital?’ (Dundee); ‘Is the doctor the best person to dispense advice? (Edinburgh); ‘What sort of doctor do you want?’ (Liverpool); ‘ECT: an ethical form of treatment?’ (Manchester); ‘Health by the people: Lessons from the Third World’ (Newcastle); ‘Smoking: The Government's dilemma’ (Oxford); ‘Women in medicine’ (Sheffield) and ‘Voluntary euthanasia: Whose death is it anyway?’ (Southampton).
Taking their lead from Edinburgh, which did not wish to be a branch of a London organisation, each group was independent and autonomous, but amicably associated with the LMG through a variety of personal and professional networks, and often by inviting speakers who had proved popular with other medical groups. Dame Cecily Saunders was particularly helpful in this respect to new medical groups seeking to attract an audience, giving the inaugural lecture to Bristol, Aberdeen, Liverpool, Manchester and some other medical groups. The benefits of this, moreover, may have mutual: the interest that these lectures attracted across the country, Dame Cecily believed, had ‘an impact on the fact that palliative medicine became a General Medicine sub-specialty in 1987’.6
Medical ethics and medical education
Unlike palliative medicine, medical ethics has not become a medical subspecialty: but medical and biomedical ethics are now well-established areas of study in a variety of academic disciplines, and a sound understanding of ethical principles and practice is now considered to be an essential outcome of undergraduate medical education. While the medical groups no doubt played a not insignificant role in relation to the former—by stimulating an interest designed to be met by the creation of a variety of postgraduate degrees and diplomas—their main educational contribution was to the development of medical ethics in medical education.
By the early 1970s, the medical groups were already making a substantial extracurricular contribution to medical education. But at that time also, Shotter writes:
As the initial student office-holders of the LMG qualified, the question was posed of including ethics in postgraduate medical education. A postgraduate advisory group was started in 1972, which led to the formation of the Society for the Study of Medical Ethics [SSME], chaired by R B Welbourn, Professor of Surgery at the Royal Postgraduate Medical School. The SSME recruited 250 enquiries through the British Medical Journal and The Lancet, and circulated its members with an occasional folder of original papers and reprints, Documentation in Medical Ethics, until memberships were subsumed to subscriptions to the Journal of Medical Ethics in 1975. In 1984, the Society changed its name to the Institute of Medical Ethics.
The same year, 1984, saw two other significant related developments. One was the first conference held by the General Medical Council to address the teaching of medical ethics in medical schools. In recognition of the substantial contribution of the medical groups and SSME, Shotter was invited to give a paper on the subject. In the course of his paper, he was able to report that the SSME had recently convened a working party ‘to examine alternative possibilities for the teaching of medical ethics’.7 It was in a good position to do this since a variety of curricular innovations, many of them associated with or encouraged by the medical groups and SSME, had been underway, most notably in a research project on medical ethics and education undertaken in Edinburgh University between 1975 and 1980.
The working party, which included a moral philosopher (Jonathan Glover), a moral theologian (Keith Ward) and a law professor (Gerald Dworkin) as well as medical and nursing members, was chaired by Sir Desmond Pond, past President of the Royal College of Psychiatry and until 1985 Chief Scientist at the Department of Health and Social Security. Sadly, Sir Desmond died shortly before the group's report was published, but not before his skill, courtesy and good humour had achieved consensus on a final draft among the diverse opinions as well as disciplines represented in the working party. The preface to the report, written by another member of the group (also a former Chief Scientist), Sir Douglas Black, concluded: ‘It is the hope and expectation of all his colleagues on the Working Party that this Report will become widely known and much referred to as “The Pond Report”’8—a hope and expectation subsequently well vindicated.
The Pond Report made 12 main recommendations, among which the following in particular again have been well vindicated as medical ethics has become established in undergraduate medical curricula:
Medical ethics teaching should recur at regular intervals throughout medical training, and time should be set aside within existing teaching for ethical reflection relevant to each stage of the student's experience.
Clinical teaching of ethics should normally begin from clinical examples. Such teaching should be exploratory and analytical rather than hortatory. Adequate provision should be made for small group discussion. Discussion should be supported by critical reading of relevant papers on medical ethics.
Interested medical teachers should be encouraged and assisted to undertake further study of medical ethics in the context of courses already available.
Care should be taken to avoid leaving ethics teaching in the hands of a teacher whose tendency is to promote a single political, religious or philosophical viewpoint.
Examination questions or essays (and where appropriate, project work) on ethical issues should be included in the assessment leading to a medical qualification.9
Research in medical ethics
The Pond Report was the product not only of the deliberations of the working party, but also of background research and interpretative editing undertaken by a small research team (Kenneth Boyd, Brendan Callaghan SJ, Raanan Gillon, Mary Lobjoit and Richard Nicholson). A similar method had been employed earlier by the 1975–1980 Edinburgh University research project on medical ethics and education, resulting in substantial reports on resource allocation and on death and dying (edited, respectively, by Kenneth Boyd and Ian Thompson)10 and by a SSME working party on the ethics of research with children published in 1986 and edited by Richard Nicholson.11 In 1986 also, the report was published of a further (now IME) working party on abortion and the treatment of infertility (edited by Kenneth Boyd, Brendan Callaghan SJ and Edward Shotter).12 Three further IME working parties followed. The report of one, on the ethics of using animals in medical research, was published in 1991 as Lives in the Balance (edited by Jane Smith and Kenneth Boyd).13 Two others, on the ethics of assisted dying and on the ethical implications of AIDS, prepared a series of discussion papers (edited by Kenneth Boyd) which were published in leading medical journals, including the British Medical Journal and The Lancet between 1990 and 1995.14
These various working parties had been funded by research grants from the Leverhulme Trust, the Nuffield Foundation, the All Saints Educational Trust, The King Edward VII Hospital Fund for London and others. By the mid-1990s, however, the infrastructure to seek funding and provide resources for further IME research projects was no longer available. In 1989, as medical schools began to make greater provision for medical ethics teaching within the undergraduate curriculum, the LMG's extracurricular programme of lectures and symposia was no longer financially sustainable, and while medical groups for some time continued to operate independently outside of London and in some of the London medical schools, the formal LMG programme was wound up as a going concern.
Although the IME research programme came to an end in the early 1990s, its example, interests and methods were very effectively carried forward by others. This included groundbreaking research on ethical aspects of neonatal intensive care15 conducted by Hazel McHaffie of Edinburgh University and an honorary IME fellow. On a larger scale, since 1991, the Nuffield Bioethics Council (funded by the Nuffield Foundation, the Wellcome Trust and the Medical Research Council) has conducted a series of highly significant enquiries into bioethical issues employing basically similar methods to those of the IME research; the Council's inaugural chairman, the distinguished civil servant and academic Sir Patrick Nairne, had previously chaired the final IME working party on the ethical implications of AIDS. An earlier working party on the ethics of using animals in research, chaired by the IME's Vice-President Professor Gordon Dunstan, moreover, provided personnel, a very able secretary-researcher and an eponymous chair for the Boyd Group which through the 1990s and the 2000s has brought together many different and often conflicting interests and perspectives in the debate on biomedical research with animals.
Funding the LMG
When in November 1989, Ted Shotter resigned as Director of the IME on his appointment as Dean of Rochester there was much to celebrate in the record of the LMG's achievements. No account of the LMG can be complete without notice of how effectively it was funded over the 26 years of its existence and of the remarkable inheritance it has left to the IME today. This account is best expressed in Shotter's own words:
Initially the LMG relied financially on Shotter's small [SCM] expense account: in its first year the LMG spent £60 (mainly printing and postage) on a budget of £40; the following year it cost £100, when the allowance was £60; but in 1966–67 on a budget of £100, its costs totalled £1179. At this point, it was decided that the LMG should stand alone. A Governing Body was formed which Lord Amulree (sometime Consultant Geriatrician at University College Hospital) agreed to chair, on condition that it did not involve fund-raising: in fact it involved little else.
In 1967, in the hiatus following the withdrawal of SCM support, a lawyer, David Lister, despite, as he put it, ‘my own retiring nature … launched a personal appeal for funds from all manner of people I knew to have been associated with Edward—his personal friends and relatives, school friends and schoolmasters, university dons, diocesan bishops, a secret service agent, people living as far away as the United States and Thailand… The response was remarkable… £700 was exactly the sum needed to save the London Medical Group from financial collapse’. Lister made this appeal, he later wrote, because ‘it then appeared to me that this subject of medical ethics was one of the crucial topics of humanitarian debate –and anguish—not only for the present, but many years to come. Here was an area of discussion which transcended the boundaries of medical science and was of concern to all humanity; to philosophers and lawyers, to sociologists and theologians, to the religious of all creeds and to agnostics and atheists alike… Above all, I saw in this embryonic movement the realisation of that care and concern for individuals and ‘cases’ as living people which must be fostered in all professions and callings if civilization is to continue to have any living meaning…The need for competent bodies like the London Medical Group to give student doctors a realistic introduction to the heart-rending problems and decisions they will face in practice is no longer desirable: it is axiomatic.’16
An equally significant intervention was made in 1972, related to that year's LMG annual conference, on ‘The Problem of Euthanasia’. The opening paper, ‘Clarifying the Issues’, was given by G R Dunstan, Professor of Moral and Social Theology at King's College London, who brought careful moral argument to bear on the relevant clinical, professional and empirical issues, drawing clear and helpful distinctions between what was and was not ethically appropriate in end of life care. A little time after the conference however, Shotter recalls:
A report in The Times, headlined ‘Bavarian doctor admits to 30 or 40 cases of euthanasia’ appeared to describe good control of pain, which may well have shortened life. On the basis of the conference, a letter signed by Lord Amulree and Professor Welbourn was published in the paper under the heading ‘Control of pain is not euthanasia’. This produced a response from Ernest and Cyril Kleinwort, the merchant bankers, who made a grant of £45 000 over three years to launch the Journal of Medical Ethics, but also to underwrite the LMG. It was Ernest Kleinwort's intention that any profit from the journal should be applied to the LMG, eventually benefitting the IME. This totally unexpected financial support transformed the LMG and was described by Professor Welbourn as ‘serendipity’.
A direct consequence of the Kleinwort involvement was the need to set up a Finance and General Purposes committee, of which Ernest Kleinwort became first chairman. He was followed briefly by his brother, Sir Cyril, until another Kleinwort banker, Lord Limerick took on the task. Patrick Limerick was to serve in this role for some ten years, accessing funds at critical moments and ensuring the survival of the nascent institute and its journal.
Over the years, grants and donations were received from a large number of charitable trusts and foundations. From 1967, the list of annual donations was headed by Her Majesty the Queen. The Edinburgh Medical Group also had a royal patron in the Duke of Edinburgh, Chancellor of Edinburgh University, who in 1971 chaired an Edinburgh Medical Group conference on Health and the Environment.
Throughout its existence, the LMG was financed by ‘soft’ money. The LMG's income eventually included small grants arranged through the good offices of the Conference of Metropolitan Deans, from some, but not all, of the London medical schools or hospital special trustees. As the exercise developed, fund raising became a major preoccupation: by 1988–89, £250 000 per annum was required. With the appointment by the medical schools of the first lecturers in medical ethics, funding of a voluntary body became increasingly problematic and the decision was taken to wind up the LMG, while it was still flourishing. In the process, a half share of its only asset, the Journal of Medical Ethics [JME] was sold to the British Medical Journal. After a period of financial consolidation following the winding up of the LMG, the IME's ongoing income from its remaining half-share in the JME has been increasingly sufficient to underwrite the IME's now flourishing educational activities.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.