Coming to 'Ethics Education after Medical School' on 5 June in Oxford?
Why not arrive Sunday 4th instead? A day early but a great networking opportunity - delegates and speakers will be around at this time. Some good deals on hotels in Oxford on Sundays - click here.
Do let us know if you plan to arrive on the Sunday so we know to expect you and we can make arrangements!
For event info and to book, click on Events and go to the IME events section.
National Student Debate Final 2017
A huge well done to Queen's University Belfast, who battled it out against University of Warwick to emerge the winners of the National Student Debate Final on Saturday 25 March in Manchester. The motion was: UK medical graduates should either work for the NHS for four years or pay back the cost of their education after graduation.
Congratulations Queen's! ... and well done to Warwick for being worthy opponents.
Thank you to all the teams who entered and reached the final: Queen's University Belfast, University of Exeter, University of Manchester, University of Leeds, University of Warwick, Hull York Medical School, St George's University London & University of Sheffield.
Huge thanks too to our panel of judges: Georgia Testa, Bryan Vernon, Pirashanthie Vivekananda-Schmidt, Andrew Papanikitas, Demian Whiting, Sarah Carter, Anne Slowther & Vivienne Crawford.
Details of next year's National Student Debate Competition will be announced later this year.
Winners! Queen's University Belfast
Runners-up, University of Exeter
Posters by Titilopemi Oladosu, King's College London
Titi is a past recipient of an IME Elective Bursary which enabled her to travel to Nigeria in 2013 for her project entitled: Ethico-Legal Issues and Nigeria's Mental Health Act: Health Workers' Perspectives. This was a qualitative study focusing on health workers' perspectives of the 'lunacy act' in Nigeria, and the ethico-legal issues which arising from implementation (or lack) of the act. Titi's work involved one-to-one interviews with members of the Ministry of Public Health, health practitioners, and NGOs focusing on mental health.
Take a look at her excellent posters below highlighting the project.
Titi orally presented at The World Psychiatry Association International Congress, November 2016 in Cape Town, South Africa.
In poster form, her work has been presented at the Royal College of Psychiatry International Conference 2014 and the Royal College of General Practitioners National Conference 2016.
Elective Report by Laura Shorthouse, 4th Year Medical Student, University of Liverpool
Below is Laura's report following her recent IME elective in Zambia earlier this year ......
A personal reflection of ethical dilemmas encountered, and the cost-benefit analysis to Livingstone Central Hospital in Zambia for hosting my elective in maternal, neonatal and child health.
During my five-week elective I gained hands-on experience in maternal, neonatal and child health at Livingstone Central Hospital, and in three local community districts served by the hospital - Linda, Maramba and Mwandi. Working days contained rich and varied learning opportunities to accomplish my goals and professionally develop, but also, provided powerful ethical dilemmas and lessons in people, life and myself, forever shaping my future medical career and character.
I was introduced to the labour ward on my first day, which was an unforgettable first impression. From the initial ethical 'horror' I felt and not wanting to return to the ward, to the in-depth personal and professional thinking it evoked, to finally overcoming it- it was a life changing experience in growing as a future doctor and person. In a large curtain-less room three women were giving birth in silence and shouted at when they made a noise. The first delivery I witnessed in Africa was stillborn twins.
They were left for over five minutes unwrapped on their mother's lap while the midwives cleaned the floor. They were then disposed, without any opportunity to say goodbye. I wanted to comfort the mother but felt it an inappropriate first impression. Instead, I stood there shocked holding back tears. I found this opening hour to 'obstetrics in Africa' cruel, insensitive, detached and degrading with no patient empowerment. I did not want to go back and play any further part.
As the initial shock of witnessing a different cultural and geographical approach to labour eased, I shamefully realised I was being judgemental. I was impinging my ideology of ethical practice onto others, disregarding their culture and traditions as though the ' west' approach was best. I was determined to overcome this dilemma by returning to the ward and learning more about their culture and ideology. I came to understand that Zambian women have adopted a tough 'carry on' exterior because sadly losing a baby is more of the 'norm' in their culture than mine, as well as them feeing grateful to still be alive post childbirth- to them it is the best way of moving forward. They prefer silence because it is important for them to introduce their baby into a calm environment. Being silent is their personal, empowering and autonomous choice, rather than the oppressive, degrading and paternalistic one I wrongly assumed. Subsequently whilst this was foreign to me, I had chosen to work here and believed it important to respect their wishes and culture moving forward. I therefore felt I was subconsciously empowering my patients and respecting their autonomy thus providing good medical practice; albeit in a very different way to home.
The English language, whilst the official language of Zambia and that of medicine, was predominately limited to wealthy well-educated families, or young children benefiting from international volunteering projects teaching English. Consequently there were several occasions, notably obstetrics and gynaecology, where I needed translators. These were not third party impartial translators like in the UK, but either other doctors, the patient's family or their own children. Where possible I would have preferred doctors, however I did not want to ethically burden my overworked and understaffed host, so relied mostly on the latter two. Taking obstetric and gynaecology histories involve asking many sensitive, intimate and personal questions, which I found not only uncomfortable asking others but took longer. I overcame this discomfort by remembering it was necessary to gather information to treat effectively. In paediatrics, I tried to obtain the history from the child which given their good level of English was more possible and I preferred.
Zambian doctors rarely introduced themselves to the patient, asked how the woman or child was, or sought consent appropriately. No curtains separated the beds and handwritten patient notes were left on makeshift tables often next to the wrong person visible for all to see. Doctors would discuss patients loudly for others to hear and examine them in full view on the ward. Whilst I could not change this practice, I conducted myself in the manner I would back home with some improvisation where necessary. I always introduced myself especially explaining why I was working in the hospital, spoke quietly so only the patient could hear, and asked a colleague to hold a sheet up around the patient's bed when I wanted to examine them privately.
Medical tourism: cost-benefit analysis
I believe my elective benefited the hospital and population it served. Livingstone Central is adjusting to a significant time in its history and facing added pressures that come with a tertiary status. I was an enthusiastic and highly active team player getting involved, and providing teaching opportunities for clinicians to undergo professional development especially on ward rounds. I also impacted my knowledge and experience, which having just completed and passed my medical school finals was of a high standard, and therefore, I believe I facilitated a mutual learning environment. I worked within my competency independently clerking and monitoring patients with minor complaints, so senior clinicians could attend to major complaints and emergencies. I therefore crucially alleviated staffing problems safely without compromising reputations or the work of other staff members.
However, despite only asking the doctors to translate when no-one could speak English I felt guilty for creating extra work for them. Subsequently, if patients could speak some English I preferred to spend longer taking a history than asking the doctors. I would advise medical students to act this way, learn some local/ tribal language where possible, and be acquainted with a place's culture/ customs before arriving.
A complex relationship exists between medical ethics and external influences. Successfully navigating cross-cultural medical ethics requires sensitivity, non-judgemental attitude, and enhanced communication and clinical skills. Through a rich and enjoyable personal elective experience, this study supports the evidence-base 8-10 that electives in developing countries can be beneficial to all.
Word count (997- excluding title, acknowledgement, references)
Thank you to the 'Institute of Medical Ethics' for a Medical Elective Bursary.
The CIA world fact book (2016) 'Zambia' https://www.cia.gov/library/publications/the-world-factbook/geos/za.html. (Accessed 26th August 2016)
World Health Organisation (2012) 'Country cooperation strategy at a glance: Zambia'. http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_zmb_en.pdf (Accessed 26th August 2016)
World Health Organisation (2016) ' Zambia' http://www.who.int/countries/zmb/en/ (Accessed 26th August 2016)
World Health Organisation (2015) 'Zambia: WHO statistical profile' http://www.who.int/gho/countries/zmb.pdf?ua=1 (Accessed 26th August 2016)
Unicef (2016) ' Zambia: HIV and Aids' http://www.unicef.org/zambia/5109_8459.html (Accessed 26th August 2016)
Our Africa (2016) 'Poverty and Healthcare' http://www.our-africa.org/zambia/poverty-healthcare (Accessed 26th August 2016)
Post Zambia ( 2015) 'L/stone hospital starts operating as tertiary medical institution' http://www.postzambia.com/print.php?id=3441 (Accessed 10th November 2015)
Ackerman LK. The ethics of short-term international health electives in developing countries. Ann Behav Sci Med Educ2010;16:40–3
Hanson L, Harms S, Plamondon K. Undergraduate international medical electives: some ethical and pedagogical considerations. J Stud Int Educ 2011;15 (2):171–85.
Banerjee A et al, Medical student electives: potential for global health?Lancet 2011;377 (9765):555.
Report of Intercalated Project by Toni Saad, MA in Bioethics and Medical Law, St Mary's University, Twickenham
I am grateful to the IME for their awarding me the intercalated degree grant for my research project into euthanasia in Belgium. Below is a summary of my dissertation, which, I am pleased to report, received the highest mark ever awarded a dissertation on the MA programme at St Mary's (91%).
THE PATH OF LEAST RESISTANCE? HISTORICAL, POLITICAL AND PHILOSOPHICAL CONTEXT OF THE BELGIAN EUTHANASIA EXPERIENCE
Following the Netherlands by a few months, Belgium is the second nation worldwide to decriminalise voluntary euthanasia. It did so in 2002 with the passing of the Act on Euthanasia, though euthanasia was relatively widely practiced in Belgium beforehand. Moreover, the Act did not put an end to illegal practices in regard to euthanasia: much euthanasia remains unreported, and non-voluntary euthanasia and physician-assisted suicide, both of which are illegal, continue to occur. Chapter One of this dissertation considers the state of affairs concerning euthanasia prior to and after the 2002 Act, and traces its development and influences. It shows that the process which preceded the decriminalisation of euthanasia was expedited by political motive, and that the Act itself suffers from conceptual flaws. Chapter Two places this Belgian euthanasia experience in its historical-philosophical and political context. It begins by outlining one influential ethical tradition, Aristotelian-Thomism, and describing how departure from it has radically changed the nature of moral philosophy, and, consequently, the fabric of moral debate. Furthermore, it argues that in the social context of political liberalism, the Belgian euthanasia experience and similar phenomena are somewhat inevitable developments. Analysis of the changing nature of moral debate confirms that, though it is very difficult to achieve moral consensus today, trends in moral philosophical thought nevertheless run in definite directions. It is concluded, therefore, that the Belgian euthanasia experience is a single symptom of broad and powerful changes in moral and political philosophy.
Chapter One: The Belgian Euthanasia Experience: Historical and Political Review of a Law unto Itself
In this first chapter I considered the historical and political development of the Belgian law on euthanasia, beginning with the practice of euthanasia before the 2002 law was passed. I examined this law in detail, and traced its evolution, and compared euthanasia practiced before and after its passing into law. Here is a quote from my conclusion of chapter one: "The 2002 Act on Euthanasia was a rushed and deficient piece of legislation which served to justify a pre-existent practice. In a sense, it was a mere formality, though one strongly influenced by the political climate, rather than interested parties. The Act suffers from conceptual and practical shortcomings and remains significantly under-enforced—only half of all cases of euthanasia are reported. The later amendments it has undergone, particularly that of 2014 concerning the repeal of an age restriction on access to euthanasia, reflect the existence of a strong political will to liberalise euthanasia. And, as in 2002, calls to amend the law did not come from interested parties. At present, euthanasia in Belgium remains a concern because physicians do not abide by the law in terms of reporting euthanasia, continue to practise physician-assisted suicide and, most worryingly, non-voluntary euthanasia."
Chapter Two: The Moral and Political Context of the Metamorphosis of Bioethics
The second chapter takes a broader look at the phenomenon of the Belgian euthanasia experience (BEE), and sets it in its philosophical context. I consider one significant ethical tradition (that embodied by Aristotle, Thomas Aquinas and John Finnis) and describe how departure from it leads almost inevitably to the multiplication of phenomena like the BEE. I consider thin theories of good in the light of this, and explain them in the context of a concurrent evolution in political theory. These changes are then considered in terms of how they bear on contemporary bioethical discourse and debate.
Here is the conclusion to which I come: "the BEE is not an isolated or even a surprising phenomenon. It is the product of an anaemic moral philosophy which has abandoned a substantive notion of human goods. Into the resulting vacuum has entered a conceptually-thin formally rational debate, coupled with shifts in political ideology which seek to place morality in the hands of individuals rather than the State. Ethical discourse is changed unrecognisably as a result...The fact that euthanasia was relatively widely practised before it became legal, and before any significant public debate occurred on the subject, is evidence of the psychological influence of this moral evolution. It is only a society with a very narrowly redefined axiology which can tolerate such widespread transgression of the basic good of life. And it is only a formally rational terrain of debate which can allow such actions to be rationalised in law in order to maximise individual autonomy. That euthanasia continues to go unreported in Belgium, and that there was such a strong political will for its passing into law, is additional evidence of Belgian society's desire for something which was once unthinkable. And the decision to extend the scope of euthanasia to include children is due to the projection of paper-thin axiological values onto the youngest and most vulnerable members of society..."
Conference Report: Centre for Ethics in Medicine, University of Bristol
Below is a post-conference report by two recent Institutional Grant recipients, Rachel Gallagher & Charlotte Mills, University of Bristol, following their Bioethics Conference on 13 April 2016.
Well worth a read as it focusses on a very interesting topic which is not often discussed.
Centre for Ethics in Medicine, School of Social and Community Medicine
University of Bristol
Bioethics conference 2016: Gender, Relationships and Equality
Report for the Institute of Medical Ethics
The conference 'Gender, Relationships and Equality' was an exploration of how medical and social notions of gender affect our relationships. The topic covered a broad range of areas: intersex, fatherhood, prenatal testing, surrogacy and the future of medicine. The audience was mostly students, including bioethics students from the University of Bristol and University of Birmingham, and nursing students from the University of West England.
Dr Sorcha Ui Chonnachtaigh (Keele) presented the first talk on 'the parent-child relationship and decision-making regarding surgeries on intersex children.' This taught us to modernise our conception of gender, as we learnt that it is not a binary notion. This increased our awareness of related issues, and gave us insight into how to address such situations that may arise in our future careers with sensitivity.
Next, Dr Jonathan Ives (Bristol) gave a presentation on 'fathers and reproduction: rights, interests and relevance.' He discussed the different approaches taken by different European countries with regards to abortion and reproductive technologies, and highlighted some key issues about potential inequalities. This encouraged us to analyse the current healthcare approach to pregnancy with more consideration of the father.
Dr Sandi Dheensa (Southampton) continued with the theme of the role of the father, speaking on 'men's involvement in prenatal genetic/genomic testing.' This highlighted conflicts between a need to include fathers in prenatal healthcare, and protection of mothers in instances with potential domestic abuse. Interestingly, 30% of domestic violence starts during pregnancy.
Our final speaker was Dr Katherine Wade (King's College London) who discussed 'improving the surrogacy framework in the UK: a children's rights perspective.' This was especially interesting as it provided an alternative perspective on a topic that the majority of the audience had been studying throughout this year. Dr Wade highlighted how the current law on surrogacy is ineffective as it conflicts with the best interests of the potential children that are brought about in this way.
To finish we were joined by Professor Lois Bibbings (Bristol), for a panel discussion on why bioethics should be concerned about gender, chaired by Dr Zuzana Deans (University of Bristol). Discussion focused on feminist approaches to bioethics, and how these could shed light on issues around gender that may arise in our future careers as doctors and nurses. There was active participation from the audience, including group discussion, which raised some key issues about gendered pay structures and (in)equality of opportunities.
Overall, the discussions throughout the day displayed diverse opinions and disciplinary perspectives on a variety of issues regarding 'Gender, Relationships, and Equality.' The conference was thoroughly enjoyable, and beneficial to all. We would like to express our gratitude to the Institute of Medical Ethics for making this valuable learning opportunity possible.
Rachel Gallagher and Charlotte Mills
Student Representatives, Bristol BSc Bioethics programme
The Messiness of Medicine by Daniel Sokol
Written with medical ethics educators in mind, this BMJ blog piece by Daniel Sokol, Barrister & Medical Ethicist, can be found in our Resource centre.
IME Education Conference 11 March 2016 Speaker Presentations
Presentation slides by Dr David Molyneux & Prof Susan Bewley are available in our Resource Centre. Please do not use or copy without author attribution.
100 Cases in Clinical Ethics and Law, Second Edition
Carolyn Johnston, Penelope Bradbury
Available from 14 January 2016: Paperback £22.99 eBook £16.09 eBook Rental £10.00
A 30-year-old Polish lady is admitted in labour. This is her first pregnancy and she is full term. She is in a lot of pain, her liquor is stained with meconium and the trace of her baby's heart is classified as pathological. Her grasp of English is limited. You have been asked to obtain her consent for a caesarean section…
100 Cases in Clinical Ethics and Law explores legal and ethical dilemmas through 100 clinical scenarios typical of those encountered by medical students and junior doctors in the emergency or outpatient department, on the ward or in a community setting. Covering issues such as consent, capacity, withdrawal of treatment, confidentiality and whistle-blowing, each scenario has a practical problem-solving element, encouraging readers to explore their own beliefs and values including those that arise as a result of differing cultural and religious backgrounds. Answer pages highlight key points in each case, providing advice on how to deal with the emotive issues that occur when practising medicine and guidance on appropriate behaviour.
Covers all the topics of the IME core content of learning (2010)
Contains input from consultants, lawyers, religious leaders and healthcare professionals