London Medical Group was founded in 1963. It was student-led, spawned Medical Groups in almost every UK medical school and met a need for non-partisan debate and dialogue in medical ethics. It became a victim of its own success as the Institute of Medical Ethics published the Pond Report in 1987, which recommended that medical ethics be incorporated into the undergraduate curriculum. Medical schools began to teach medical ethics and the General Medical Council demanded this in 1993's Tomorrow's Doctors. The Institute of Medical Ethics had grown out of the LMG. After running a number of successful conferences for medical ethics teachers, the Institute of Medical Ethics is recapturing the natural innovative tendencies of students and junior doctors that the LMG and related Medical Groups had fostered. It is now launching itself as a membership organisation: the recommendations of the Francis report and responses to it have emphasised the need to support individuals with the ability, freedom and confidence to question the status quo from a reasoned ethical basis. The Institute of Medical Ethics aims to develop a robust medical ethics community ready to face the challenges of 21st Century healthcare.
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Medical ethics in the UK owes much to the London Medical Group (LMG). Reflecting on the legacy of the LMG and the current challenges in healthcare, there is arguably a need for a renaissance of the vision that underpinned the LMG. As the 50th anniversary of the LMG is celebrated, the Institute of Medical Ethics (IME) will be launching itself as a membership organisation, inspired by and building on the achievements and ethos of the LMG.
Today, medical students and the general public take it for granted that medical ethics is a core component of the undergraduate medical curriculum. However, in 1963, when the LMG began, many considered medical ethics to refer simply to codes of professional etiquette, and there was a widely held view that wider-reaching moral concerns could not and should not be formally taught in medical schools.
Within a decade of its inception, student-led medical groups following the LMG model had been set up in almost every medical school in the UK. In the 1970s the annual LMG conference would regularly attract several hundred delegates with significant numbers from non-medical disciplines. The success of the medical groups in the 1970s can be seen as an indicator and a catalyst for the growing interest in non-partisan debate and dialogue in medical ethics. Although not the sole factor, the communities formed by the medical groups contributed towards a climate in medical education that was receptive to bringing medical ethics into the mainstream medical school curriculum.
The LMG harnessed the interest, energy and intellect of medical students and junior doctors. Students were given the freedom to reflect on medical practice and identify important topics not covered by the medical syllabus of the time. Seminars and conferences provided an interdisciplinary forum for the discussion of issues such as palliative care, child abuse and iatrogenic disease, long before they had found their way on to the medical curriculum. Although not always the specific focus, medical ethics was often central to many of the issues discussed.
Of course, the IME owes its existence to the LMG and sister medical groups. In 1972, recently qualified former LMG students saw a need for medical ethics dialogue in postgraduate training and set up the Society for the Study of Medical Ethics (SSME). The SSME launched the Journal of Medical Ethics in 1975 (discussed in a related article in this issue) and in 1984 it became the IME.
In 1980, Ian Kennedy delivered the Reith Lectures, ‘Unmasking medicine’, a lecture series that was very well received by the public in general but seen by many in the healthcare profession as highly critical of doctors.1 In his fourth lecture ‘If I were you Mrs B’ he argued for the need to recognise the normative discourse of medicine and to educate doctors in how to engage with that discourse.
Prior to the Reith Lectures, Ian Kennedy had already had a long association with the LMG and described himself as a ‘critical friend’. He was highly supportive of the group's activities but, at the same time, recognised that this student-led movement alone could not bring about the much needed changes in healthcare culture. He argued that all senior clinicians, not only the few who were involved with the medical groups, also needed to engage with ethical debate and that medical ethics had to become part of mainstream medical education and not simply ‘preach to the converted’.
The LMG was a victim of its own success. In 1987, the IME published the Pond Report, which recommended that medical ethics teaching should be incorporated into the undergraduate curriculum.2 In London, medical schools whose grants had previously supported the LMG were now appointing lecturers in medical ethics, taking away a major funding source for the LMG.
Interestingly, during the debates about teaching medical ethics in the 1980s, the IME (and its forerunner, the SSME) had raised concerns about the professionalisation of medical ethics. It was argued that medical ethics was multidisciplinary and should not be the sole preserve of medical schools and that the appointment of medical ethics teachers might in fact stifle interdisciplinary ethical dialogue. To some extent, these concerns were borne out. Aware that its funding was unsustainable, the LMG was wound up in 1989 although still very active. Elsewhere in the UK, as medical ethics was brought into medical schools, the interest in ethics dialogue outside of the establishment appeared to diminish.3
In 1993, the recommendations of the Pond Report2 were accepted by the General Medical Council (GMC) in its review of medical education, ‘Tomorrow's Doctors’.4 Since then, the IME has continued to promote and support medical ethics teaching and teachers. In 1998, it was heavily involved in publishing of a consensus statement5 on the core content of learning for medical ethics and law, in consultation with UK medical schools, academics and professional bodies. In 2008, the core content of learning was revisited through IME-funded stakeholder conferences and an education working group to produce an updated consensus statement in 2010.6
Twenty years on from the GMC review, medical ethics is a compulsory part of the undergraduate medical curriculum, providing medical students and junior doctors with the core skills for ethical discussion and analysis. It forms one of the competency domains in the Foundation Years curriculum and is becoming an increasingly common feature in speciality exit examinations.
However, the anticipated benefits for healthcare practice have been slower to materialise. Ethical issues are rarely discussed in everyday clinical practice, and the competency domains are easily relegated to a tick box exercise. Whilst there have been many successes in healthcare, public scrutiny and criticism seem greater than ever in the face of recent healthcare scandals.
The Mid Staffordshire Inquiry7 exposed shocking failures in healthcare watched over by health professionals with signed off competencies in medical ethics and law. These concerns eventually came to light because of the concerted efforts of families of patients of the Mid Staffordshire NHS Trust rather than concerns raised within the organisation itself. The recently published Keogh Report8 has shown that failings in healthcare were not limited to Mid Staffordshire, and the Francis Report identified a need for a transformation in culture and leadership across the whole NHS.
All this has happened at a time when the quality of care is subject to more inspection and regulation than ever before and doctors have unprecedented access to guidance on ethical practice. In response to the Francis Report, the King's Fund has produced a paper addressing leadership at all levels of the NHS. In this it draws a distinction between regulated trust and real trust, arguing that regulated trust is ‘secured through intrusive inspection and box ticking … [and] risks substituting technical rules for moral principles’.9 In contrast, real trust depends on individuals being able to decide and take the right course of action.
This echoes the distinction made in the 1987 Pond Report between two different ideas about the teaching of medical ethics. The first was teaching people what they ought to do, and the second was teaching the analysis of why they ought (or ought not) do certain things. It is the latter approach—the why rather than the what—that has always been the focus of the LMG and the IME.
Ethical practice requires that individuals have the ability, freedom and confidence to question the status quo and accepted norms. One of the problems identified at Mid Staffordshire was that doctors looked the other way and that health professionals and managers accepted poor practice as the inevitable norm. Seen from another perspective, staff stopped questioning what constituted acceptable patient care. Medical ethics teaching can provide the core skills to question and reason. However, the confidence to question and explore these questions comes with practice. Central to the LMG ethos was the focus on creating communities that nurtured open interdisciplinary non-partisan ethical dialogue. The IME retains this ethos with its core object ‘to advance for the benefit of the public the education of medical practitioners and medical students in the UK in the impartial understanding and practice of medical ethics and law and in the integration of these disciplines into clinical practice’.10
In his report, Bruce Keogh says of junior doctors that ‘They are capable of providing valuable insights, but too many are not being valued or listened to’.8 ‘Their constant interaction with patients and their natural innovative tendencies means they are likely to be the best champions for patients…’.8 The LMG model was remarkable in that, in spite of the strongly hierarchical nature of medicine, it trusted students rather than senior doctors to identify and articulate the important questions raised by medical practice. A review of the topics covered by medical groups across the country clearly shows that this trust and confidence in the insight of students was well placed.2 The ‘natural innovative tendencies’ of junior doctors were seen in the founding of the IME by recently graduated doctors and the subsequent launch of the Journal of Medical Ethics. The King's Fund has argued that modern leadership needs to be ‘shared, distributed and adaptive’. Ahead of its time, the LMG model arguably nurtured the modern leadership style that we aspire to today. The achievements of the LMG form part of 20th century medical history and remain relevant today as the NHS is challenged with cultural transformation.
Once medical ethics was incorporated into the curriculum, leadership moved to the educators, and the IME has organised a series of successful conferences for those who teach medical ethics and law. There has recently been greater emphasis on encouraging student attendance; their enthusiasm is enabling the IME to rediscover the LMG ethos and to put students and junior doctors at the centre.
The core aim of the IME since its inception has been to raise ethical standards in clinical practice, not by prescribing those standards, but by promoting dialogue, teaching and research in medical ethics. A key motivator for the IME becoming a membership organisation is the recognition that a large and thriving community is needed for ethical dialogue to flourish and bring about change in clinical practice. This community needs to be engaged with, but independent of, healthcare and academic institutions and policy makers.
By becoming a membership organisation, the IME hopes to create and support a network of clinicians, students and academics who share its core values and in so doing engage with a much wider audience. The IME's vision is for a locally led organisation in which regional communities determine their priorities for medical ethics, supported centrally through grants, bursaries, representation and advocacy. With an ever changing healthcare landscape, a membership will ensure that the IME's agenda continues to remain relevant and effective. With a focus on students and junior doctors, the IME can harness their ‘natural innovative tendencies’ to build a robust medical ethics community to face the challenges of 21st century healthcare.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.