Niall Dickson
Chief Executive and Registrar
General Medical Council
This programme has been developed by the
GMC in partnership with an advisory group
Tonight’s event has been sponsored by
Medical professionalism
Medical professionalism signifies a set
of values, behaviours, and relationships
that underpins the trust the public has in
doctors.
© 2005 Royal College of Physicians of London
The doctor’s dilemma
Photograph of scene designed for George Bernard
Shaw's Doctor's Dilemma, 1927
George Bernard Shaw
Dr Michael Devlin
Head of Professional Standards and Liaison
MDU
The doctor’s
dilemma
#gooddoctors
Who are we?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Patient or carer/relative
Consultant
GP
Doctor in training
SAS/other doctor
Medical student
Medical educator/trainer
Employer (including Responsible Officer)
Other health professional
Other
2%
35%
14%
7%
14%
7%
5%
2%
4%
11%
In the future all doctors will be required to
publish their team and individual results in some
form or another. Do you…?
1. Agree, this is a welcome
development
22%
2. Agree, but we need to be wary of
perverse consequences
52%
3. Disagree, we have already taken some
measurements of this kind too far
4. Not sure
20%
7%
Doctors today are less compassionate
than 20 years ago. Do you…?
1.
2.
3.
Agree – it’s the product of too little
time, increasing patient demand and
expectations
11%
Agree – it’s the product of pressure on
organisational performance and
management demands
26%
Agree – the way we train doctors
removes much of the idealism and
compassion that attracted them to
medicine in the first place
4.
Disagree – whatever the pressures,
compassion still motivates the vast
majority of doctors
5.
Not sure
13%
44%
5%
Don Berwick said the NHS should continually and forever
be reducing patient harm by embracing wholeheartedly
an ethic of learning. How far is the health system
achieving that?
1. Huge progress has been made, though
obviously more to do
16%
2. Some progress has been made, a great deal
more to do
47%
3. No more than rhetoric, system does not yet
realise the extent of change required
4. I don’t agree that’s the way to go about it
5. Not sure
30%
2%
5%
Medicine is a tough career; we need doctors
trained to be resilient and better capable to deal
with adversity. Do you…?
1.
2.
Agree – current selection and undergraduate
programmes do not produce students who
are adequately prepared for a challenging
career
13%
Agree – but most of the problems lie in the
organisations in which or with which doctors
have to work
3.
Disagree – doctors are already resilient – the
focus should instead be on providing proper
levels of support for hard pressed
practitioners
4.
Disagree – resilience comes largely from
experience
5.
Not sure
27%
50%
10%
0%
Professor
Deborah Bowman
Professor of Bioethics, Clinical Ethics and Medical Law
Institute of Medical and Biomedical Education, St George’s,
University of London
Once upon a time . . . .
To be, or not to be, that is the question:
Whether 'tis Nobler in the mind to suffer
The Slings and Arrows of outrageous Fortune,
Or to take Arms against a Sea of troubles,
And by opposing end them: to die, to sleep
No more; and by a sleep, to say we end
The heart-ache, and the thousand Natural shocks
That Flesh is heir to? 'Tis a consummation
Devoutly to be wished. To die to sleep,
To sleep, perchance to Dream; Ay, there's the rub,
For in that sleep of death, what dreams may come,
When we have shuffled off this mortal coil,
Must give us pause. There's the respect
That makes Calamity of so long life
(Hamlet, Act 3, Scene 1 . . . Usually . . . .)
• Dr. Rosencrantz is called to see Gertrude. Gertrude is 89 years
old and lives in a nursing home. Gertrude has metastatic lung
disease for which she has, until recently, been treated with a
life-extending drug funded by the NHS cancer fund. Gertrude
was admitted to St. Elsinore, via A&E, in a confused state with
a raised temperature and shortness of breath. Dr. Rosencrantz
immediately notices that a tourniquet has been left on
Gertrude’s arm.
• Gertrude’s husband, Claude, is with her and says that
Gertrude ‘has had enough’. Her son, Hal, arrives and asks Dr.
Rosencrantz to update him on his mother’s health. He tells Dr.
Rosencrantz that his mother ‘would want everything possible to
be done’, adding that Claude is Gertrude’s second husband
and that his knowledge of his mother is more reliable.
• Dr. Rosencrantz calls his consultant, Dr. Guildenstern who is
with a collapsed patient. He expresses his frustration at being
disturbed and tells Dr. Rosencrantz that he ‘really should be
able to handle these sort of situations by now’.
Perceiving and Responding to
the Doctor’s Dilemma(s)
•
•
•
•
•
•
•
•
•
•
Dr. Rosencrantz’s well-being, status in the hierarchy and competence
Gertrude’s age, health & quality of life (and assumptions about the same)
Capacity
Consent, including proxy or substituted decision-making (LPA/AD) &
DNAR status
Confidentiality and information sharing
Choice and decision-making in the context of uncertainty and temporal
limitations
Resource allocation and funding (nationally and locally)
Clinical error, disclosure and duty of candour
Dr. Gildenstern’s responsibilities and priorities in a resource-limited
system
Shared responsibilities and duties of care amongst different
organisations
“Many—professionals, students and ‘the public’ alike –come to
medical ethics not only to understand the moral dimensions of medicine, but in
the belief that it will speak to their experience of illness and its treatment. For
some, it is so, but for many it is not.
Take, for example, the subject of ‘consent’. It is likely to feature in
every curriculum. Most assessments will include consent. A search reveals
hundreds of papers written about consent.
I too have written and spoken about consent many times. And yet,
students, clinicians, patients and carers describe ethical problems that
continue irrespective of the depth of their knowledge or facility to debate
consent. Students recount difficulties introducing themselves to patients
because of a senior's discouragement. Carers describe how inadequately a
relative has been involved in care planning. Clinicians relay the mismatch
between working conditions and the possibility of facilitating meaningful
choice.
None of this is remedied by ‘more medical ethics’, at least in its
conventional form.”
(Bowman, D. J. Med. Ethics 2015; 41: 60-63)
Influences on Ethical
Enactment
•
•
•
•
•
•
•
•
•
•
Moral awareness and ethical sensitivity.
Ethical competence and confidence.
Emotion and character.
Personal beliefs, values, assumptions and
preferences.
Rationality and structured analysis.
Moral courage and conscientiousness.
Context and pragmatism.
Experience, discretion and judgement.
Tolerance of divergence and inclusivity of approach.
Guidance and capacity for interpretation & reflection.
Imagination
and
Evidence
Leadership and
influence
Complexity and
contradiction
Ethics as Practice cf: as
problems
Systems and
individuals
People cf:
professionals
Absence and
presence
Likeness and ‘this-ness’
Form
and
content
Meaning
cf: claims
Emotion and
reason
Relational and care cf:
issue and consultation
Nuance cf:
position
The doctor’s
dilemma
#gooddoctors
If I were to raise a serious concern in my
institution I would be…
1. Reasonably confident that I would
be supported by clinical and other
leaders
36%
2. Unsure as to whether I would be
supported by clinical and other
leaders
44%
3. Not at all confident that I would be
supported by clinical and other
leaders
4. Not sure
19%
2%
If I were struggling to cope as a result of pressures on the
service, I am confident that I could ask for and receive help
without being penalised in any way.
1. Strongly agree
5%
2. Agree
3. Neither agree nor disagree
34%
16%
4. Disagree
5. Strongly disagree
30%
14%
A supportive working environment is:
1. How I would describe my current place
of work
2. A pipe dream because of the current
pressures we face
3. Talked about often but rarely achieved
4. Achievable but only when made a
priority by medical leaders and
employers
13%
9%
25%
54%
Doctors are expected to use their professional judgement to
decide the right course of action and what is in their
patients’ best interests. How often are you uncertain you
made the right decision?
1. Rarely – I am generally confident I have
made the best decision with the
information available
14%
2. Occasionally – there have been cases
where I have wondered if I should have
made a different decision
3. Often – I frequently question whether I
should have done something differently
57%
29%
Confidentiality is fundamental to the trust between doctors
and patients. However there is a duty on doctors to
disclose information about their patients in the public’s best
interest. For example to the police or DVLA. Do you…?
1. Agree – confidentiality is important,
however it should not prevent the sharing
of information which is in the public’s best
interest.
2. Disagree – confidentiality needs to be
maintained at all times. If it isn’t then trust
between patients and their doctors would
be removed which may result in vital
information not being disclosed e.g. HIV
3. Not sure
95%
5%
0%
The doctor’s
dilemma
#gooddoctors
Table discussions
We would like each table to cover one or two of the following topics:




The limits of ethics and things that can stop people from being open
Confidentiality and mandatory reporting
Consent
Safeguarding
Dinner
Panel discussion
 Professor Deborah Bowman
Professor of Bioethics, Clinical Ethics and Medical Law, Institute of Medical and Biomedical
Education, St George’s, University of London
 Dr Michael Devlin
Head of Professional Standards and Liaison, MDU
 Julia Jackson
Patient Representative and Pastoral Leader, Joseph Chamberlain Sixth Form College
 Dr Vinnie Nambisan
Consultant in Palliative Medicine, North Middlesex University Hospitals NHS Trust
 Dr Mark Porter
Chairman, British Medical Association
 Professor Kate Thomas
Vice Dean and Programme Director, University of Birmingham Medical School
Thank you
#gooddoctors