At the end of a stimulating day of discussion on education, bioethics and medical humanities at the Cumberland Colloquium, we were delighted to welcome the eminent lawyer Sir Ian Kennedy to deliver the evening lecture, entitled “Health: Doing What’s Right”. As a leading authority on medical ethics and chair of a number of commissions and inquiries, he brought a wealth of experience and critical reflection to an audience of health professionals, bioethics and medical humanities students.
Sir Ian’s starting premise was that moral problems arise all the time in everyday medical practice, and are not confined to the types of moral dilemma that often form the basis of ethics education for health professionals (of which situations involving Jehovah’s witnesses form a disproportionately large subset). Day to day problems are a world away from the abstractions and principles of moral philosophy, but the moral quality of these problems is rarely recognised and understood. The simple and ostensibly culturally acceptable act of one’s name being announced in a GP surgery waiting room raises a little acknowledged moral question about confidentiality, for example. Furthermore, the role of moral reasoning and opinion in public discussions of highly charged ethical issues is often obscured beneath claims about medical and scientific fact: Kennedy highlighted the recently stated opinion of the new Secretary of State for Health, Jeremy Hunt, that on his interpretation of the evidence, abortion should be limited to 12 weeks after conception, on account of when he deems life to start. Encouraging the audience into a lively response, Kennedy pointed out that such statements rest on a moral judgement about our duties towards an embryonic entity that has nothing to do with medical evidence or the answer to a scientific question, but again it is not clear that the moral judgement at the heart of this debate is being exposed and questioned in the way that it should.
Responding to healthcare scandals and failures in practice also brings with it often implicit ethical questions, which, once recognised, may point to deeper underlying problems in the organisational culture of medical practice that need to be addressed. Kennedy described an inquiry into an outbreak of C. diff. in an elderly patient ward that had resulted in several deaths. The investigation eventually discovered that the same mop was being used to clean the kitchen area and the lavatories. It transpired this had occurred because one mop had been broken/gone missing, and the cleaner’s contract stipulated that losses or breakages had to be paid for out of the cleaner’s wages. Unsurprisingly, because of this sanction the loss wasn’t reported and the cleaning staff resorted to using the single remaining mop in both places, resulting in the spread of a virulent infection. Ultimately, a decision made in an HR department led to the deaths of patients. Kennedy argued that in healthcare, decisions are made in a complex organisational context that, morally, cannot be ignored: the care and health of patients is at stake.
Returning to the question of ‘doing what’s right’, Kennedy cited a shocking instance of a failure in basic nursing care that resulted in an elderly patient being treated in a horrendously undignified and distressing manner. Rather than blame the nurse concerned, or lament the standards of nursing care, he suggested that in order to understand how such a situation could arise, we must look to the context in which it occurred: not only the time and resource pressure the nurse was under, but also the management culture and failures of leadership that could lead to individual health professionals losing their moral compass to such an extent. All too often the ‘service’ aspect of healthcare in the NHS is de-prioritised when management is required to cut costs and increase patient intake. What is needed is a culture of care, resilience and courage to maintain one’s moral compass and ability to challenge the culture when wrongdoing occurs. This is an admirable aim, and one with which few would disagree. Kennedy was optimistic that the tribal, hierarchical culture of medical practice was beginning to change, enabling better leadership and collaboration between different professionals and indeed with patients. Ethics is, then, part of everyday healthcare, but not as a procedure, routine, or additional tick box exercise. It is and ought to be embedded into the mindsets of those who seek to provide a service and be willing to listen.
I found much to be optimistic about in Sir Ian’s talk. Calling for effective leadership, courage and resilience, and the instilling of a firm moral compass are all admirable aspirations and ideals, which heighten one’s awareness of the need for thorough and self-reflective education in ethics for all involved in healthcare. But I was left slightly unsure about quite how strong leadership could be developed, particularly at a time of such tumult in the NHS, and particularly given the pressures faced by young health professionals entering a world of high demands on their time and scarce resources. There are shining examples of good practice throughout medicine, and courageous whistleblowers who stand up when they see wrongdoing. However, as one commentator illustrated, they are often vilified and demoted or fired in the process. Perhaps recognising that ethics permeates everything a health professional does, and is not merely of concern in unusual or extreme cases, is a first step towards engendering the strength of moral conviction that is needed in every part of the health service.
To this end, many of the talks throughout the day demonstrated some fascinating and innovative approaches to ethics education. We will shortly be writing up a report on the day itself, which I shall post in due course.