Journal of medical ethics, 1978, 4, 141-145

Teaching medical ethics: University of Edinburgh

Kenneth Boyd, Colin Currie, Ian Thompson, Alison J. Tierney Edinburgh Medical Group Research Projectin Medical Ethics and Education, University of Edinburgh, Edinburgh

The Edinburgh Medical Group Research Project isunique in Britain. Part ofitsfunction is to experimentwith teaching medical ethics both inside and outsideof the Medical School. The papers whichfollow havebeen written by two full-time reseach fellows workingwith the Project and two of the professional advisers,one nursing and one medical. Together they give apicture of the wide scope of exerimental teachingtaking place in Edinburgh and present somepreliminary results from these experiments.

Experimental curriculum-relatedteaching of medical ethicsTraditionally the main formal provision for medicalethics teaching in the Edinburgh Medical School isin six hours of lectures and discussions in theForensic Medicine course, and in a number ofinformal seminars in the Department of Thera-peutics. However, in the past two years this teachinghas been supplemented by a number of attempts tointegrate the teaching of medical ethics intoordinary academic and clinical teaching within thethe Medical School. These innovative experimentshave been associated with the setting up of theEdinburgh Medical Group Research Project inMedical Ethics and Education.

Part of the EMG Research Project's remit was toexplore the feasibility of integrated and multi-disciplinary teaching of medical ethics. Obviouslythe two full-time research fellows and the part-timemedical and nursing advisers had no authority toimplement immediately these proposals. Authorityhad to be sought and co-operation elicited fromHeads of Deparments in the Medical School. Toassist in this task an inter-disciplinary, staff/studentadvisory committee was set up. This committee,under the chairmanship of the Professor of ForensicMedicine, undertook preliminary surveys ofattitudesof staff and students in the Medical School to theteaching of medical ethics; and it became obviousthat there was overwhelming support for thefollowing views:

i) That insufficient time is devoted to the examina-tion of social, moral and legal issues raised by thepractice of medicine;2) That so far as possible medical ethics teachingshould be integrated into ordinary academic andclinical teaching (i.e. that opportunity should be

given for the discussion of the issues as and whenthey arise);3) That didactic teaching of the subject has limitedvalue and that more emphasis should be placed onexperientially-based and participatory leaming;4) That so far as possible opportunities should becreated for multi-disciplinary and inter-professionaldiscussion of the issues and dilemmas in medicalethics.The first major opportunity to attempt some

innovative teaching along these lines came with thesetting up, at the behest of the Medical Faculty, inOctober I976 of a one week course for 5th year MBChB students on Social and Moral Issues in HealthCare. The Edinburgh Medical Group and theMedical Students Council were asked to organisethis special teaching week. A series of lectures,symposia and case-conferences were arranged whichprovided opportunity for the study and discussionof a wide variety of contemporary problems ofmedical ethics and communication in medicine. Thetopics covered ranged from such traditional issuesas abortion and confidentiality, to care of theterminally ill, transplant surgery and more func-tionally orientated topics such as communication inhospital and the structure of the NHS. Speakerswere drawn from teaching and clinical staff ofvarious departments in the Medical School, localhospitals and establishments for the tainig ofnurses, social workers, other health-care pro-fessionals and chaplains. There were fourteensessions in all with the Wednesday afternoon free.The organising secretary of the joint EMG/MSCcommittee was one of the EMG Research Fellows.Although this experimental week has not been

repeated (for fiscal reasons) the Medical Facultysubsequently approached the Edinburgh MedicalGroup with the request that it should include thetopics dealt with during the week in the annualEMG programme of lectures and symposia. Inaddition, the week's general success and popularitywith staff and students resulted in invitations to theEMG Research Staff to participate in and arrangeethics teaching in seven different Medical Depart-ments - in Clinical Surgery, Community Medicine,General Practice, Geriatric Medicine, Obstetricsand Gynaecology, Psychiatry and Therapeutics.The form and extent of participation in these

teaching experiments has naturally varied con-siderably from one department to another, depending

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on the needs and requirements of the subject andthe time available. Different groups of students atdifferent stages of their course have beenencountered: from ist year undergraduates inCommunity Medicine, to 4th year students inClinical Surgery, 5th year students in Obstetricsand Gynaecology, Psychiatry and General Practice,final phase students in Therapeutics and GeriatricMedicine and post-graduate students in Psychiatry.

In Community Medicine the Research Staff wereasked in the first year to give two introductorylectures on medical ethics. In the second year, at thesuggestion of the Research Staff, two multi-disciplinary case-conferences were held instead. InClinical Surgery two sessions each year weredevoted to the discussion of the management ofterminal cancer patients. These took the form of a' grand round ' with multi-disciplinary participationand a patient being presented on two occasions. Theinvolvement in Obstetrics and Gynaecology andPsychiatry was much more extensive. In the formerthis took the form of six seminars each term. Thesewere of a volufttary nature and held during thelunch-hour so that midwives, social workers anddivinity students could attend. The cases presentedand dilemmas discussed covered a wide range ofmoral issues in reproductive medicine, includingcontraception, sterilisation and abortion, sexualtherapy, artificial insemination, counselling, consentcommunication and the role of institutions andprofessions.

In Psychiatry the research staff together withadditional resource staff including hospital chaplainsand philosophers, were invited to participate inpairs in the clinical tutorials themselves. Each groupof students had two such tutorials each term. Thecases were deliberately chosen to illustrate moraldilemmas in psychiatry, for example dilemnas overrestaining voluntary patients, questions relating tothe treatment of alcholism, compulsory hospitalisa-tion and treatment, suicide and parasuicide. Morerecently the experiment was extended so that theresource staff participated weelly with the samegroup over the whole term. This had the advantagethat the issues could be discussed more naturallywhen they arose.

Participation in the General Practice courseinvolved one of the research fellows sitting in thetutorials for the whole term and then being invitedto contribute a paper at the final tutorial for eachterm. The involvement with final phase students inTherapeutics and Geriatric Medicine took theform of intimate multi-disciplinary case-conferenceswhich encouraged the frank discussion of manyanxiety-producing personal dilemmas. These issuesmainly concerned the communication of prognoses,the change of r6gime in terminal care from atherapeutic to palliative approach, and problems ofintervention with elderly patients, particularly thepatient with psycho-geriatric problems. One of the

research fellows was also asked to participate inspecial seminars on compulsory hospitalisation andtreatment of mental patients in the post-graduateprogramme in Psychiatry.

All these 'experiments' (which will be reportedmore fully in due course) have been undertaken andrepeated on a trial-and-error basis. The enthusiasmof staff and students has encouraged discussion in theMedical School of how these experiments might becontinued in the future. The long-term future of theprogramme is uncertain, but so long as the EMGResearch Project on Medical Ethics and Educationcontinues the research staff will continue toparticipate in and help to arrange and co-ordinatethese new teaching activities.

I E THOMPSONResearch fellow

How do nursing students learn aboutmedical ethics ?An attempt to begin to answer this question wasmade in the course of the work of the EMGCommission on the Study and Teaching of MedicalEthics. The intention was to find out from nurseteachers what provisions they consider they make toencourage nursing students to exane moraldilemmas of contemporary health care; and also todiscover the views of practising nurses on thequestion of how nursing students learn aboutmedical ethics.To this end a small-scale investigation was

carried out. Firstly, nurse teachers on four generalnurse training programmes in Edinburgh (two3-year programmes, one 4k-year degree/nursingprogramme and one college-based 3-year diplomacourse) were invited to complete a questionnaireform and twenty-one returns were made. Secondly,throughout one local large general hospital, copiesof another questionnaire were distributed to trainedand trainee nurses; a total of forty-six completedforms was received (about two thirds of the numberdistributed).

In describing how they consider their studentslearn about medical ethics, and learn to cope withmoral dilemmas in practice, the teachers identified awide variety of influences. These ranged fromdiscussion with peers and teachers to the massmedia ... and from reading to the example ofnursesin wards. The provisions made by the teachersthemselves varied amongst the four tainingprogrammes. One relies mainly on discussion groupswhile another also involves sessions with the hospital

aplain, reading and reference to the ICN Code ofEthics; the third programme uses role play, filmsand TV entensively and the fourth stresses theimportance of leaning opportunities at variousstages of taining and in relation to all nursingtopics taught. The diploma and degree programmes

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Teaching medical ethics: University of Edinburgh 143

encourage teachers to undertake clinical supervisionof students in addition to theoretical teaching andthese groups of teachers see this as an importantopportunity to discuss moral dilemmas as they are

encountered by students in clinical settings.In their questionnaire the practising nurses were

asked to identify what dilemmas they felt arose intheir work. Many different moral dilemmas were

specified but, interestingly, three particular issuesseem to predominate, irrespective of clinicalspecialty. These are:

i) Issues arising in the care of terminally illpatients (in particular, about the use of sedation).2) Whether or not to resuscitate particular kindsof patients following cardiac arrest.3) Whether or not patients and/or relatives shouldbe told the truth about diagnosis (in particular, a

diagnosis of cancer and in cases where the doctorwishes to withhold the truth).

Asked about provisions available to help studentnurses learn about medical ethics, the practisingnurses identified provisions in the ward and tutorialgroups, individual personal support as necessary,and Kardex report discussions. A few student nurses

said the provisions made are inadequate and claimedthat ward sisters tend to avoid discussion of morallycontroversial issues. Provisions made in the class-room were considered by the student nurses to behelpful, whereas the trained nurses seemed unsure

or unappreciative of this contribution. Interestingly,both the student nurses and the trained nurses

identified 'experience' and 'example of senior nurses'as the two most important factors contributing to

nursing students' learning about medical ethics.It was felt by the nurse teachers and practising

nurses that improved learning opportunities were

needed to bring about a more informed and respons-ible approach to moral decision-making in nursing.Argument was made for more interprofessionaldebate, better communication between nurses anddoctors, and greater emphasis on ethics in thenursing curriculum.

So, even although provisions are made for nursingstudents to learn about medical ethics, it appearsthat more planned learning opportunities are neededand wanted. Nurses have always participated in theEdinburgh Medical Group's ordinaryextracurricularactivities, including lectures, symposia, study daysand residential conferences. More recently some

innovative and experimental teaching of medicalethics for nurses has been possible through theEMG Research Project. Examples of this are thecourses of four half-day 'workshops' on moral issuesin health care held in Queen Margaret College in1977 and I978 at the invitation of the lecturer incharge of the course which prepares registerednurses to become clinical teachers. Between thirtyand forty students were involved in each course,including trainee clinical teachers, district nurses,

health visitors and social work students. Eachworkshop involved a case presentation and small-group discussion with some theoretical input by oneof the 'resource personnel' taking part (two chaplainsand two philosophers). In general the reaction to thecourse was overwhelmingly favourable and it ishoped that it may be repeated, perhaps involvingother health care professionals as well. In addition,planning is under way to involve the EMG ResearchFellows in medical ethics teaching in the University'sDepartment of Nursing Studies. These 'experi-ments' in their own right make a useful contributionto the teaching of medical ethics in nursing educa-tion. In addition, they may help to demonstrate thatincluding multi-disciplinary discussion of moralissues in health care within the nursing curriculummay be a realistic proposition rather than just anidealistic dream.

ALISON J TIERNEYNursing adviser

Teaching and learning of medical ethicsin Edinburgh: traditional aspectsIn Edinburgh, the Department of Forensic Medicinehas the responsibility of teaching the small body oflaw and etiquette which is regarded as indispensableto the practice of medicine. That is the most explicitand perhaps the only manifestation in the formalcurriculum of the teaching of medical ethics.

In its fullest extent, the teaching and learning ofmedical ethics is more complex and more diffuse.From the point of view of the teacher, it would seemthat medical education is inseparable from medicalethical education (Scratch any teacher of medicineand you will find a teacher of medical ethics) andfrom the point of view of the student the acquisitionof attitudes cannot be separated from the acquisi-tion of knowledge and skills.

Medical education may be seen as a process ofpassing on a body of factual knowledge, a reper-toire of clinical skills and a gradually accumulatingapparatus of professional habits, manners andattitudes. The graduate of the medical school isdistinguished from the first year entrant not simplybecause he knows more and can do more, butbecause he has acquired, if not a high gloss finish, atleast a serviceable undercoat of professionalisation.These three components of medical education,

knowledge, skills and attitudes, are not uniformlyaccessible to study. The transmission of factualknowledge is easiest to consider. One can beginignorant and end informed. A teacher may help orsimply encourage. There is a science, or at least amethodology, of educational assessment whichpermits achievement to be measured with reasonablenumeracy and peace of mind.The teaching, learning and assessment of skills is

less crisply sorted out, but a variety of honest

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attempts are made in the name of Finals, in whichhumanity combines with breezy simplification and aconfidence on the part of the eminers that theyknow a good student when they see one, to producean agreed yardstick of clinical competence.The third factor, the vague but indispensable

concomitant of skill and knowledge, is moremysterious both in its being and its transmission.The body of values and attitudes, explicit andimplicit and including much of what is widelyregarded as medical ethics, is much less susceptibleto educational analysis. Professionalisation is aprolonged and subtle indoctrination with the valuesand habits, the inward and outward hallmarks of aclosed group, and for most medical students it is theprincipal vehicle of ethical learning.A rigorous study of how medical ethics is learned

would prove unrewarding for the educationalist orsocial scientist. There is not much that can bemeasured or counted. Investigations must founderon problems of definition of training objectives,description of relevant interactions and the measure-ment of attainment. The field is therefore open forassertion and speculation, fuelled by presuppositionand supplemented, where necessary, by individualobservation inevitably restricted by person andcircumstance.Two limited local surveys have been carried out

on the teaching and learning of medical ethics inEdinburgh. They are presented not so much toelucidate the matter as to demonstrate the difficultyof its being investigated. The two studies are in asense complementary, the first being of teachers,represented by their heads of departments, thesecond being of pre-registration housemen, the vastmajority ofwhom were local graduates and thereforethe products of education provided by the former.

Thirty-one of thirty-nine heads of departmentsanswered a preliminary questionnaire. Two thirds ofthe respondents stated that there was no formalprovision for the teaching ofmedical ethics, but thatinformal discussion of moral dilemmas took placewith undergraduates on a case-related basis asopportunities arose in the course of practicalteaching. A similar proportion considered thatstudents acquired education in moral attitudesthrough education in their subject within theirdepartments. Content of ethical education wasdetermined by specialist interest, and the majorityfavoured as method the informal, case-relatedapproach alluded to above.

Forty-five of seventy-seven housemen surveyedresponded. They were asked in what areas ofpractice they experienced social, ethical or communi-cation difficulties and how well they had been pre-pared to deal with them. Problems concerningdeath, dying, and bereavement figured prominently.Preparation for dealing with them was felt to beinadequate. Views on how this might be remediedwere invited. On the whole self-teaching and

experience ranked highest, and many respondentsfelt that nothing in their undergraduate educationassisted them with problems encountered in the firstyear of practice. There was general scepticism aboutformal thing.

Teachers evidently feel that they are passing onattitudes and values. Students, it appears, feel thatthey pick them up for themselves. Perhaps both areright. The Edinburgh curriculum is characterisedby long exposure of students in small groups toindividual teaching clinicians, both senior and junior.The process of professionalisation is thereforediffuse in time and space, and is in any case by itsnature so integral to the teaching and learning ofmedicine as to proceed perhaps without the explicitawareness of teachers and learners. Few generalisa-tions are possible and, for the reasons stated, littleanalytical work has been done. Perhaps an anthro-pological understanding is most appropriate, withthe tribe as the model rather than classroom.

COLIN CURRIEMedical adviser

Extra-curricular study of medical ethicsThe general aim of the EMG Research Project is todevelop the study of medical ethics in Edinburghand, in association with other Medical Groups andprofessional organisations, in other British centres ofmedical and nursing education. Within this generalaim, the project has two major objectives: to exploremedical ethics teaching in the medical school context(discussed in the previous section); and to studyselected medical ethics topics in appropriate depth.The latter is being done in multi-professionalworking groups, by sustained informal interdis-ciplinary discussion between practitioners, teachers,students and laymen with experience of the relevanttopic. Two of these groups, on death and bereave-ment and on resource allocation, have completedtheir work, and it is hoped that their reports will bepublished in due course. In the meantime workinggroups on mental health, reproductive medicineand medical research are also in progress.The multi-disciplinary working groups themselves

are quite small, each having about twenty members.In order to give them a wider sounding board, andalso to integrate their work with the project's otheractivities, a number of extra-curricular conferencesand seminers were organised. In connection withthe first working group, two residential studentconferences, on 'Death and Professional Ethos' andon 'Professions and Professional Education', werefollowed by a series of weekly case-conferencediscussions on doctor-nurse-patient attitudes, and ahalf-day conference on 'Convergent and DivergentElements in the Ethics of Nursing and Medicine'.These were held during the autumn and springterms of the first year of the project (I975-1976).

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Teaching medical ethics: University of Edinburgh I45

During the summer term and the following autumn,a series of evening seminars on 'Health, Poverty andScarce Resources', and a residential conference on'The Ethics of Resource Allocation' discussed thetheme of the second working group. In the springterm of the second year (I976-i977) a large two-dayconference was organised in association with theSociety for the Study of Medical Ethics: this con-ference, on 'Human Birth', was designed to open uplocal discussion of the issues to be studied by thefourth working group. In the autumn term of thethird year (I977-78) two further residential con-ferences were held. One, on 'Moral Dilemmas inPsychiatry', along with a series of lunch-timeseminars on 'The Meaning ofMadness' was plannedas a pilot for the third working group. The other, on'Learning to Communicate', which was preceded bya series of evening case conferences on 'Communica-tion in Health Care', was concerned with issues ofcommon interest to all of the working groups.

Overall, these events involved a considerablenumber of students from all of the relevant dis-ciplines, ranging from over a hundred at the largestnon-residential conference to an average of thirty atresidential events and of twelve at small groupdiscussions. The number of teachers and practi-tioners involved as lecturers and leaders was alsolarge, many different specialities and disciplinesbeing represented. From the working groups' pointof view these events were particularly helpful: theproceedings were reported to them and many of thequestions raised by the students were later examinedby the working groups in greater detail. From thestudents' point of view, elicited by requests forwritten comments, these events were considered,with few exceptions, to be helpful learning ex-periences. The most helpful, in the students' view,were the residential conferences, which are able toachieve a great deal in a short time: case-conferencediscussions of moral and inter-professional questionswere also judged helpful, particularly those in whichrole-play was used.The Research Project responsible for the activities

described in this and previous sections was fundedby the Leverhulme Trust and the Nuffield Pro-vincial Hospitals Trust: and it is based in theUniversity of Edinburgh, the Deans of the Facultiesof Medicine and Divinity and the Director of theNursing Studies Research Unit acting as Grant

Holders. The initiative for the project howevercame from the Edinburgh Medical Group, whichalong with the University is responsible for itsconduct through the Project Steering Committee onwhich the student officers of EMG serve. Studentinitiative and involvement thus play an importantpart in the project, and without the existence ofEMG's continuing student constitutency, it isdifficult to see how a programme of the kinddescribed here could have been set up so easily andcarried out so successfully. All the activities des-cribed, it should be added, were arranged in additionto the annual series of lectures, symposia, anddiscussions arranged by the EMG students andsenior advisers.At this stage in the project any conclusions must

be provisional. But support and enthusiasm forthese curriculum-related and extra-curricularactivities suggests that they met a widely felt needfor study and discussion of medical ethics topics inthe medical school context. A similar conclusion alsoseems to be emerging from the project's involvementwith nursing education. For theoretical and practicalreasons alike, such study should be multi-disci-plinary and dialectical (i.e. allowing for the exchangeand discussion of different points of view) and itscontent should be related to concrete cases andclinical experience. In practice this suggests amultiple strategy approach to medical ethics teachingand learning, including both curriculum-related andextra-curricular activities, with some room forconsideration of ethical, legal and other theories as aframework for the substantial debate about casesand examples. The conclusion forced on the EMGresearch staff by their experience during the pastthree years is that such a multiple strategy approachwill probably be needed in the foreseeable future,just as it has proved necessary during the period ofthe teaching experiments.

K. M. BOYDResearch fellow

AcknowledgementsThe Edinburgh Medical Group Research Project inMedical Ethics and Education gratefully acknow-ledges financial assistance from both the LeverhulmeTrust Fund and the Nuffield Provincial HospitalFund.

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