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How to be a "good" medical student J. Med. Ethicsdoi:10.1136/jme.2003.003848
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science. It is, for example, quite obvious to
science. Theories that do not fit the facts are
me that I am currently sitting at my desk.
of no use and should be discarded. But in
Empirically my senses seem to confirm that I
biology especially, theories can define what
am more or less stationary. I may well believe
counts as a fact and what does not. Sooner or
later a startling new observation is made that
Skene and Parker1 raise a number of concerns
history we believed the earth to be stationary
cannot be accommodated within the existing
about religious doctrine unduly influencing
at the centre of the universe. This assumption
law and public policy through amicus curiae
was confirmed in the Western world by the
contributions to civil litigations or direct
Church itself. Church doctrine confirmed that
categorised. What was written off as noise
lobbying of politicians. Oakley2 picks this up
the earth was the stationary centre of the
is heralded as fact. Thomas Kuhn called this a
in the same issue with an emphasis on the
paradigm shift and his paradigmatic case was
Roman Catholic Church’s interest in prevent-
below. When Galileo challenged this view by
the Copernican revolution.5 One overarching
ing the destruction of embryos for embryonic
promoting the sun centred Copernican sys-
stem cell research. Skene, Parker, and Oakley
another—our understanding of the world is
seem to be concerned mostly with religious
policy. My concern is the negative effect that
Copernicanism was tripartite. Firstly, the
such as the Roman Catholic Church erects its
doctrinal structure on the shaky foundations
some scriptures. Secondly, the Copernican
of a specific theoretical construct. Biology and
research that is itself foundational to the
system contradicted the church sanctioned
developmental biology in particular are com-
science of the day represented by Aristotelian
paratively young sciences that are progressing
incensed that, as he puts it: ‘‘Those who
physics. Thirdly, was the appeal to obvious-
support a total ban on embryonic stem cell
ness or the immediate evidence of the senses.
diverse. By lending its support to a certain
research sometimes talk as if theirs are the
Of the three, only the scriptural objections
theory or position within biology the Church
only views based on moral principle’’.2 What
were fundamentally doctrinal in nature. The
seems to be at issue here though are not the
appeals to science and obviousness were able
balance that exists in science whereby the-
moral principles of the sanctity and dignity of
to be settled by empirical evidence. We now
ories are valued for their explanatory power
know that we are not stationary at the centre
moral principles to biomedical research.
of the universe although this is still far from
compatibility. External interest groups with
political lobbying power may thus hijack the
cally defended the sanctity and dignity of
delicate process of progress in science with
human life to varying degrees at different
dire consequences for future advancement in
times. Human life for much of the past 2000
Church’s influence on science is indirect and
presence of the soul, which was thought at
usually through the medium of public opi-
different times to appear at various different
nion and public policy. As we have seen in
stages during development. Only recently,
the American debate over the status of the
with the advent of modern biology, has the
Roman Catholic Church shifted its position to
Copernicanism thus seems to be very similar
embryonic stem cells this influence may be
claim that the fertilised egg also qualifies as
to that today regarding the status of the early
decisive in the formation of public policy.
the right sort of human life.3 It should be
embryo. The Roman Catholic Church tried to
Indeed President Bush’s decision to effec-
noted that this doctrinal change was funda-
prevent Galileo from collecting empirical
tively ban public funding of embryonic stem
evidence using his telescope and disseminat-
cell research in America is widely believed to
ing his empirical evidence by banning his
have set back progress in the field worldwide
attempted to prevent the gathering of empiri-
embryo is thus based not solely on Church
cal data on the early embryo by promoting a
the embryonic stem cell debate has not been
doctrine but also on a specific interpretation
ban on all experimentation on early embryos.
simply moral or ethical as one might assume
but has openly defended a particular claim
development. It is the Church’s interpretation
become a paradigm for the process of theory
about the biology of the early embryo. Given
of the biology of early human development
change in science. Science is not simply a
the basic lack of empirical evidence regarding
that is foundational to their current stand
collection of results from experiments (or
against experimentation on early embryos.
facts) but perhaps more importantly science
However one of the reasons we may wish to
is the interpretation of those results and the
Roman Catholic Church’s choice of position
experiment on early embryos is that we know
planning of further experiments. For all its
surprisingly little about them. In fact any
chosen solely as a prop for its doctrinal
position that claims to be based on a solid,
philosophers of science tell us, essentially a
position. This prop has then been introduced
theoretical construct. The practical and the-
into the secular debate on the status of the
essentially misleading, as we simply do not
oretical sides of science are of course inti-
have the data available. The reply to this will
mately connected. In fact it is well known
that a researcher’s actions and observations
I believe the Church’s religious fervour for
embryos to make certain claims. For example
are most likely guided to some degree by their
its preferred doctrinal and scientific position
the Roman Catholic Church likes to point out
of the day is fundamentally at odds with the
that the early embryo is obviously the earliest
researchers develop the theories that they use
process and progress of science. Science is an
stage of a human life, and thus attributes to it
to interpret their data. These theories fit the
exploration of the physical world that is
many of the rights associated with actual
results (or facts) that have been previously
people.4 Many would disagree with this on
observed and predict new experiments to be
and, historically at least, major shifts in
done. The role of theory at this stage of the
understanding. Over the last 400 years the
being merely human with being a person. I
process is often underestimated. Theories do
not fall out of results. In fact in biology
accept that science progresses at all and has
embryo is obviously the early stages of a
especially theories are often essential to
preferred to maintain its doctrinal position as
making sense of what is signal (result) and
what is noise (artefact). Theory then is not
obvious to some people but that obviousness
just a bridge to the next fact or experiment
cern here is I think similar to that of Skene
and Parker. The Roman Catholic Church’s
medicine to counteract its effects. His initial
read the leaflet again and again. They may
contributions to public policy are based not
thought was to find something to combat his
only on their moral or ethical principles, but
runny nose, so he chose a product specially
information such as a website and perhaps
indicated for nasal congestion: ‘‘StopSnot’’.
decide to take only half the dose for half the
application of those principles that is backed
After reading the product information leaflet,
amount of time prescribed, or simply decide
by the full force of what is effectively a very
however, Dr Smith felt another kind of chill
powerful lobby group in many countries.
run down his spine. He was struck cold by
In addition to the problem of non-compli-
Like Skene and Parker, I have no answer to
the contraindications, warnings, interactions,
ance, the so called nocebo effect15 needs to be
the problems I have raised. Historically one
precautions, and adverse reactions listed in
considered, whereby the patient’s mindset is
thing is certain, in the future the Roman
the leaflet. If he used this drug, it said, he
often a key element in the appearance of either
Catholic Church’s current position on the
physical or imaginary side effects, as has been
embryo will be judged to have been right or
anxiety, agitation, insomnia, hallucinations,
shown in various studies.16 17 Such an effect
wrong with the wisdom of hindsight. Just as
convulsions, amazement, weariness, arrhyth-
may be caused by information leaflets.
we judge the Church’s persecution of Galileo
mia, dizziness … . Rather than risk all of this,
he thought, why not suffer a few bothersome
snuffles? For his muscular aches, Dr Smith
chose another drug, ‘‘Abatache’’, but the
Practically any city dweller would refuse to
risks described in the accompanying informa-
use transport services, work tools, or recrea-
tional facilities if they were supplied with
included baldness, skin blistering, aseptic
complete, absolute, and extensive informa-
meningitis, pneumonitis, fatal hepatitis, gas-
tion on the hazards using these might entail.
trointestinal perforation, blood in the urine,
Precautions and warnings are usually good
jaundice, kidney disease, peptic ulceration,
Skene L, Parker M. The role of the church in deve-
loping the law. J Med Ethics 2002;28:215–18.
mouth ulceration, visual abnormality … . So
reasonable limits to avoid creating outright
2 Oakley J. Democracy, embryonic stem cell
alarm. Too much information can sometimes
research, and the Roman Catholic church. J Med
pharmacological knowledge, Dr Smith simply
opted to continue blowing his nose and suffer
nificant harms through non-compliance.
3 Pope John Paul II. The Gospel of Life [Evangelium
a few muscular aches. He had no desire to
Vitae]. Vatican city: Vatican Polyglot Press; 1995.
play Russian roulette with his health.
4 Copland P, Gillett G. The Bioethical Structure of a
information supplied by doctors can generate
Human Being. J Appl Philos 2003;20(2):123–33.
5 Kuhn TS. The Copernican Revolution. Cambridge:
corroborated by physical examination. As it
happens all too often, the information was
6 Stolberg 8. Sterncell research is slowed by
The principle of autonomy in medical ethics
not as exhaustive or complete as it might be.
restrictions, Scientists say. The New York Times.
places the patient at the centre of medical
In view of this, we believe that the kind of
decision making about his or her care. It
places particular emphasis on the importance
should be reassessed. The information should
be true, accurate, and easy to understand in
except in rare situations,14 no patient should
as complete a way as possible, but it should
undergo medical treatment or surgical inter-
not generate alarm that can lead to deleter-
The problem of non-compliance with treat-
vention without his or her fully informed
ious consequences in the healthcare sector or
ment and its repercussions on the clinical
authorisation. This is the basis of patient-
evolution of different conditions has been
widely investigated.1–4 Non-compliance has
also been shown to have significant economic
argued that the patient must receive suffi-
implications, not only as a result of product
cient understandable information to make a
drug’s side effects, finally decides not to follow
loss but also indirectly through the complica-
fully informed choice. In practice this means
the doctor’s recommendation. He (or she) will
tion of disease management and its subse-
that someone undergoing a specific treat-
try to relax, perhaps by smoking a cigarette
ment receives information from at least two
laced with nicotine, tar, and a number of other
substances. True enough, doctors recommend
giving up smoking. But who will listen to what
The term ‘‘non-compliance’’ might be taken
a doctor says about smoking when they appear
taken, recommended lifestyle changes, and
to refer both to the failure to follow a drug
to be prescribing drugs truly hazardous to
perhaps a warning of the hazards related to
regimen and to the failure to adopt other
health? After all, a pack of cigarettes only says
non-compliance. At this time, they will also
measures that contribute to improvement in
that cigarette smoking seriously damages your
be provided with information on some of the
health—for example, changes in lifestyle or
health. There is certainly no leaflet listing each
side effects attributed to the drug being
diet. This letter focuses on the former.
and every one of its possible side effects.
prescribed. Individual patients will tend to
Tobacco kills, but it sometimes looks as if
understand this information in a range of
be the result of a number of different factors9–11
different ways, and it is well recognised that
they will respond with a variety of known
developed in an attempt to control it.12 13 Of
Department of Legal Medicine, College of Medicine
and Odontology, University of Valencia, Valencia,
shown to be effective have only managed to
additional information on side effects from
solve the problem in specific situations over
the information leaflet provided with the
Correspondence to: Dr F Verdu´, Department of Legal
drug itself. These leaflets tend to cite each
Medicine, College of Medicine and Odontology,
techniques to control non-compliance, parti-
University of Valencia E G, Av/ Blasco Iban˜ez, n˚15,
cularly where these are effective, raises
46010-Valencia (Spain); [email protected]
interesting ethical questions about the extent
to which their application constitutes an
information can in some cases be so complete
infringement of the patient’s right to decide
or detailed that even any extremely unusual
on how to manage their own health.8 Here we
syndrome described in relation to the use of
suggest that in some cases one factor that
the drug will inevitably be listed in the leaflet
1 Morris AD, Boyle DI, McMahon AD, et al.
leads to non-compliance is the tendency to
as a possible ‘‘side effect’’.
Adherence to insulin treatment, glycaemic control,
provide extensive and exhaustive information
and ketoacidosis in insulin-dependent diabetes
on side effects in patient information leaflets.
significant effect on the likelihood that a
mellitus. The DARTS/MEMO Collaboration.
patient will take the drug in question and
Diabetes Audit and Research in Tayside Scotland. Lancet 1997;350:1505–10.
may lead to significant ‘‘non-compliance’’.
2 Bruckert E, Simonetta C, Giral P. Compliance with
fluvastatin treatment characterization of the
One morning Dr Smith woke up with a slight
about all the problems that may occur from
noncompliant population within a population of
cold—muscular aches, headache, chills, and
using the prescribed medication, they may
3845 patients with hyperlipidemia. CREOLE
nasal congestion. He decided to take some
start worrying, to say the least. Some people
Study Team. J Clin Epidemiol 1999;52:589–94.
3 Zarate CA Jr, Tohen M, Narendran R, et al. The
clinical procedures. To do so, doctors must
3 Bravo G, Paquet M, Dubois MF. Knowledge of the
adverse effect profile and efficacy of divalproex
obviously also have a good understanding of
legislation governing proxy consent to treatment
these procedures. We recently encountered
and research. J Med Ethics 2003;29:44–50.
pharmacoepidemiology study. J Clin Psychiatry
4 Doyal L. Closing the gap between professional
teaching and practice. BMJ 2001;322:685–6.
4 Maetzel A, Wong A, Strand V, et al. Meta-
standing in a study among junior doctors in
5 Department of Health. Reference Guide to
analysis of treatment termination rates among
England (Schildmann J, Cushing A, Doyal L,
Consent for Examination or Treatment, Available
rheumatoid arthritis patients receiving disease-
Vollmann J. The ethics and law of informed
modifying anti-rheumatic drugs. Rheumatology
consent: knowledge, views and practice of pre
04019079.pdf (accessed 27 July 2004).
registration house officers, submitted for
6 General Medical Council. Seeking patients’
5 Hilleman DE, Phillips JO, Mohiuddin SM, et al. A
consent: the ethical considerations. London:
philosophical and legal knowledge, preregis-
tration house officers (PRHOs) will not be
reductase inhibitors in hypercholesterolemia. ClinTher 1999;21:536–62.
6 Lazarou J, Pomeranz BH, Corey PN. Incidence of
informed consent outlined by O’Neill unless,
adverse drug reactions in hospitalized patients: a
suffice it to say, they know what—practically
meta-analysis of prospective studies. JAMA
In contrast to Bravo et al’s results (in the
7 Johnson JA, Bootman JL. Drug-related morbidity
same issue of the journal), almost all the
and mortality. A cost-of-illness model. Arch Intern
PRHOs who took part in our survey had good
patient organisations to establish databanks
8 Donovan JL. Patient decision making. The missing
on medical complications. Given the refer-
ingredient in compliance research. Int J Technol
Assess Health Care 1995;11:443–55.
ences (for example, an article by Paans, a
9 Col N, Fanale JE, Kronholm P. The role of
positive result of the change in the curricu-
journalist, entitled ‘‘Medical errors to be kept
medication noncompliance and adverse drug
lum at their particular medical school, which
secret’’) and the lack of argumentation, there
reactions in hospitalizations of the elderly. Arch
includes extensive sessions about informed
is substantial danger of misinterpretation of
communication skills. However, despite their
frustrate the process of increased transpar-
ency. We would therefore like to respond to
this by giving background information and
11 Billups SJ, Malone DC, Carter BL. The relationship
study still experienced problems about their
between drug therapy noncompliance and patient
role in the consent process. The problems
reasons for some of the choices that were
characteristics, health-related quality of life, and
pertained to pressure of time and lack of
made with respect to the registry of compli-
support by senior doctors, as well as pressure
12 Bond WS, Hussar DA. Detection methods and
strategies for improving medication compliance.
that they should not. This gap between the
which are often confused. From Gebhardt’s
reference to the journalist’s article which
13 Arnet I, Schoenenberger RA, Spiegel R, et al.
taught to medical students and the clinical
discusses the same registry of adverse out-
Conviction as a basis for compliance andstrategies for improving compliance. Schweiz
realities they face, and into which they are
comes, but with the title referring to errors,
both Gebhardt and the journalist think errors
14 Roscam Abbing H. Human rights and medicine: a
If informed consent is to fulfil the purpose
and adverse outcomes are the same thing.
Council of Europe convention. Eur J Health Law
of respecting the autonomy and dignity of
However, an error refers to the process in
patients, sufficient resources are required to
15 Barsky AJ, Saintfort R, Rogers MP, et al. Non-
train young doctors to do the job properly,
standard performance, regardless of the out-
specific medication side effects and the nocebo
especially as regards their understanding of
come. It has been explained by others that
phenomenon. JAMA, 2002;6;287, 622–7.
16 Khosla PP, Bajaj VK, Sharma G, et al.
Background noise in healthy volunteers—a
subjectivity.2 An adverse outcome refers to
consideration in adverse drug reaction studies.
municators. One thing is clear: if they cannot
the outcome which is unwanted but does not
Indian J Physiol Pharmacol 1992;36:259–62.
17 Flaten MA, Simonsen T, Olsen H. Drug-related
guidance issued by both the General Medical
made. This is why the term ‘‘adverse out-
Council and the Department of Health, they
comes’’ is used rather than the term ‘‘com-
responses that modify the drug response.
should not be doing it at all.5 6 Trusts and
plications’’, since the latter term is often
colleges should ensure that all supervisory
18 Myers MG, Cairns JA, Singer J. The consent form
staff are aware of their responsibilities in this
registration of medical complications that
as a possible cause of side effects. Clin PharmacolTher 1987;42:250–3.
Gebhardt refers to is a registration of surgical
adverse outcomes guided by an unambiguousdefinition of the term ‘‘adverse outcome’’, of
Institute for History of Medicine and Medical Ethics
and Department of Medicine III, Friedrich-Alexander-
which only a small percentage is related to
errors.3 Furthermore, some errors will bemissed in this registration—that is, errors
which have not led to adverse outcomes.
We read with interest the papers on informed
Department of Human Science and Medical Ethics,
Secondly, with respect to confidentiality,
consent published in a recent issue of the
Queen Mary’s School Of Medicine and Dentistry,
this is relevant in particular for the initial
Journal of Medical Ethics.1 Whatever their
years of such a registry during which it is
thoroughly tested and accuracy of the regis-
tioned some aspects of the duty to respect
tration may vary widely between participants.
Institute for History of Medicine and Medical Ethics,
Friedrich-Alexander-University Erlangen-Nuremberg,
Nothing is gained by false positive signals
informed consent for therapeutic interven-
with respect to the high incidence of adverse
outcomes in some hospitals, except perhaps
competent adult patients are entitled to a
Correspondence to: J Schildmann, Institute for History
by flashing headlines in newspapers. In this
core of basic information about their treat-
of Medicine and Medical Ethics and Department of
respect one may compare the development of
ment options. There was also consensus that
Medicine III, Friedrich-Alexander-University,
such a national registry to the development of
training in the process of obtaining consent is
Erlangen-Nuremberg, Germany; jan.schildmann@
important. In our experience, two dimensions
about confidentiality and thorough testing
of such training are of particular interest. On
until proved safe. Moreover, a pharmaceuti-
the one hand, students require good theore-
tical understanding of the ethical and legal
markets a new drug without proper research.
It is intended that after this initial period,
1 Symposium on consent and confidentiality. J Med
national adverse outcome data will become
other hand, they need practical training in
the relevant communication skills and how
2 O’Neill O. Some limits of informed consent. J Med
to apply them to obtain consent for specific
some means empirical findings could influ-
aware that these data need to be interpreted
ence our ranking of the normative principles.
Earlier in the article, they make an even
interested in the experience of doctors or
stronger claim about the influence of empiri-
hospitals to treat certain diseases or to
perform certain operations, since the ques-
principles. They suggest that, if it were
hospital? This simple question is not easy to
tion they want answered is ‘‘What is the best
demonstrated empirically that some patients
answer for individual patients who need a
place to go to for this type of problem?’’. That
prefer to delegate medical decisions to health
good diagnosis and the best treatment. The
this doctor or hospital probably has a high
care professionals, a serious challenge would
adverse outcome record is not relevant, since
be levied against the normative assumptions
this may well be explained by the complex
underlying the principle of respect for auton-
organisations have published several con-
patients who are referred to more experi-
omy, at least under the mandatory autonomy
sumer guides for specific diseases to help
enced doctors. As argued in a previous paper,3
view, which holds that patients not only have
patients find their way in the labyrinth of the
it is essential that there is an increased
a right but also an obligation to act autono-
mutual trust between the medical profession
mously (p 103).1 In the light of many recent
many difficulties in getting access to relevant
and patients’ organisations that supports a
empirical studies challenging the centrality of
information from doctors’ organisations and
combined effort to improve the quality and
patient autonomy and shared decision mak-
availability of patient information. Such
ing in bioethical theory, I think it is instruc-
wants to cooperate with these organisations
initiatives will benefit both patients and
tive to evaluate the means by which empirical
doctors and are too important to be frustrated
findings, like those offered in Joffe et al,
by references to ‘‘powers that must be kept
available. A joint project for a databank on
ethical principles. In particular, I would be
best practices started in September 2003.
interested in how these authors propose that
Patients are not interested in black lists of
Association of Surgeons in the Netherlands,
their data led them to the normative conclu-
In the last paragraph of their article, Joffe
make a well informed choice for a doctor or
et al write: ‘‘we do not recommend that
Department of Medical Decision Making, Leiden
on objective measures such as the risk of
University Medical Centre, Leiden, the Netherlands
determine ethical frameworks. We do, how-
infection in a hospital, the specific skills of a
ever, believe that data such as those pre-
doctor, how many patients with this specific
Correspondence to: Dr P J Marang-van de Mheen,
disease a doctor treats a year, etc. Patients
Association of Surgeons in the Netherlands; p.j.
sented here can contribute to the search for
would also like to receive subjective infor-
reflective equilibrium in bioethics’’(p 107). The term ‘‘reflective equilibrium’’, as the
mation on a specific hospital or doctor: How
is the communication between a doctor and
Rawls. At least in its first instance, it refers
to a way of constructing a moral theory by
balancing one’s considered moral judgements
needed?, etc. This experience based infor-
1 Gebhardt DOE. Patient organisations should also
establish databanks on medical complications.
against one’s moral principles, until one’s
judgements and principles form a consistent
2 Hayward RA, Hofer TP. Estimating hospital deaths
set—that is, a moral theory (p 288).2 Joffe et
due to medical errors: preventability is in the eye of
al’s idea seems to be that by surveying
with organisations of healthcare providers
the reviewer. JAMA 2001;286:415–20.
patients’ perspectives they will be able to
3 Kievit J. Regarding covering-up: a database for
capture one side of this equilibrium, consid-
registration of adverse outcomes [in Dutch]. Med
ered moral judgements, or moral principles
(they do not specify which), and in so doing
translate the data into consumer information
4 Marshall MN, Shekelle PG, Leatherman S, et al.
that meets the needs of the patients, based
The public release of performance data. What do
contribute to the desired end: a consistent
we expect to gain? A review of the evidence.
ethical framework to govern medical encoun-
on research and experiences of patients.
important information accessible for doctors
patient community. Whatever the merits of
this goal, however, Joffe et al fail to capture
either the considered moral judgements or
the moral principles of those they survey andso fail to contribute to the moral theory they
In the Journal of Medical Ethics, Joffe et al
Finally, what does the patient want? (see
recently published an article titled ‘‘What do
box 1). International research has shown that
patients value in their hospital care? An
patients do not use public information on
empirical perspective on autonomy centred
moral capacities, which he considers analo-
bioethics’’.1 This empirical study evaluates
gous to our linguistic capacities, are ‘‘most
whether patients’ willingness to recommend
likely to be displayed without distortion’’—
because, among other reasons, they do not
their hospital to others is more strongly
for example, those offered without hesita-
understand and do not trust these data.4 This
associated with their belief that they were
tion, given without strong emotions like fear,
also applies to adverse outcomes data. For
treated with respect and dignity than with
interpreting the incidence of hospital specific
their belief that they had an adequate say in
interests (p 47).3 The distinction between
adverse outcomes it is important to know the
their treatment.* Joffe et al go on to suggest
considered judgements and judgements gen-
context—for example, since older, sicker, and
that confirmation of these empirical hypoth-
more complex patients have higher probabil-
moral theory for a particular community—
ities of adverse outcomes.3 It is therefore vital
elevating the principle of respect for persons
to establish a reliable registry which can be
to the level that the principle of respect for
autonomy currently enjoys in our model of
reflect the respondents’ real moral sensibil-
professionals and the public. For this reason,
the ideal patient–physician relationship (p
ities, and not those stemming from super-
104).1 In other words, they suggest that by
ficial prejudices or their mood on the day
* Joffe et al also evaluate whether patients’
important questions, however, for research-
(NPCF) are collaborating with respect to the
reports that they had confidence and trust in
ers, who, like Joffe et al, are using the concept
national surgical adverse outcome registry, in
their health care providers significantly pre-
of reflective equilibrium: (1) precisely how
particular, to produce information that is
considered do considered judgements have to
relevant for patients about treatment and
hospital to others. For simplicity’s sake, I
be if they are to count; and, more practically,
hospital choices. Supported by the interna-
address only Joffe et al’s treatment of the
(2) how can a researcher know whether he or
tional literature, the NPCF holds the view
respect for persons and the respect for auton-
she is collecting them—that is, what survey
that patients are not primarily interested in
method, if any, is appropriate for the task?
Although it is difficult to give a positive
better predictor of patient satisfaction than
limitations that its size produces: does this
answer to these questions (and I will not
him or her acting with respect for autonomy,
survey really address what we mean by the
attempt to do so here), some survey methods,
Joffe et al conclude that the principle of
such as the mailed questionnaires that Joffe
respect for persons should be assigned as
et al used, seem particularly inadequate.
much importance, ethically speaking, as the
Rawls suggests that certain external condi-
principle of respect for autonomy. As should
there is a gap between the empirical hypoth-
be clear, this conclusion does not follow from
eses the study confirms and the normative
judgements: ‘‘the person making the [con-
Rawls’s conception of how one constructs a
conclusions its authors would like to draw
sidered moral] judgment is presumed … to
moral theory. In a Rawlsian view,`3 6 a moral
from it. In their article Joffe et al hoped to
have the ability, the opportunity and the
bridge this gap by invoking Rawls’s notion of
desire to reach a correct decision (or at least,
patients hold, not whether those principles
the reflective equilibrium. As I have explored,
not the desire not to)’’ (p 48).3 Very likely,
are associated with patient satisfaction. Joffe
however, the study does not contribute to
however, many of Joffe et al’s respondents
et al seem to be operating with an underlying
either side of the reflective equilibrium they
lacked the necessary ability, opportunity, or
utilitarian assumption to the effect that what
imply, and, thus, they fail to demonstrate
desire to reflect on their moral judgements
we ought to do ethically speaking is whatever
how their findings challenge the centrality of
when responding to the questionnaire they
will lead to the greatest patient satisfaction.
received in the mail. Furthermore, even if a
Although there may be reasons for accepting
this utilitarian assumption (which Joffe et al
Joffe et al’s failures are instructive, how-
considered judgements, there is no way to
do not provide), certainly there are others for
ever, insofar as they suggest how we could
distinguish these from those made by respon-
rejecting it. For instance, although patient
better bridge the gap between research and
dents who lacked the requisite ability or
satisfaction may give a hospital a very good
theory. The use of the reflective equilibrium
desire. Although the size of Joffe et al’s study
reason to change a policy, we probably do not
in empirical research has promise, provided
is of value for its ability more accurately to
want to say this reason is a good ethical
researchers are clear about: (1) how to define
reflect a population’s response to its survey
reason. It is just good business sense. This is
considered moral judgements and/or princi-
questions, because of the practical limitations
ples; (2) how their methods capture these
that come with its size, the study falls short
principles that Joffe et al evaluate. Respect
judgements and/or principles reliably; (3)
of capturing patients’ considered moral jud-
traditionally viewed deontologically—that is,
judgements strengthens rather than weakens
it terms of duties or rights, which are valued
bioethical theory; and (4) how their instru-
equilibrium, as Joffe et al’s, faces a second
for their own sake rather than the conse-
challenge: why do we want people’s consid-
quences (such as patient satisfaction) that
principles they mean to assess. In addition,
empirical research can contribute to bioethics
theories of ethics in the first place? In his
considerations take us far from patients’
by questioning the assumptions implicit or
influential critique of reflective equilibrium,
actual moral views, the very things Joffe et
explicit in our normative views. Joffe et al try
al, by invoking Rawls’s reflective equilibrium,
introduction to their article (p 103)1 that
Lastly, there is a question of their instru-
patients’ desire to delegate decision making
ment’s validity. As I have been arguing, Joffe
challenges the mandatory autonomy view.
et al claim to assess whether patients are
However, if empirical findings are to defeat aparticular normative principle, the assump-
treated according to the principles of respectfor autonomy and respect for persons. Yet,
tion that those findings challenge must be
their single item assessing respect for auton-
omy—the question, ‘‘do you feel you had
principle. For instance, without showing that
your say?’’—does not do the principle justice.
patients’ desire for autonomy is necessary forour holding the mandatory autonomy view,
The principle of autonomy not only requires
the studies that Joffe et al cite, even if valid,
that the health care provider asks the patient
can be interpreted variously as devaluing the
for his or her opinion, but also that the
provider acts on the patient’s opinion. Their
ing that we better educate patients on the
instruments are similarly inadequate for the
value of autonomy. This normative question
principle of respect for persons, which, they
If moral judgements are liable to reflect
suggest, includes ‘‘autonomy, fidelity, vera-
superficial prejudices, one could argue, con-
Empirical researchers have the potential to
city, avoiding killing, and justice’’, as well as
sidered moral judgements are liable to reflect
contribute substantially to bioethics, but their
‘‘respect for the body, respect for family,
deep seated ones. Surely this prejudice is
respect for community, respect for culture,
something ethicists would like to overcome,
empirical rigor that comes from truly inter-
respect for the moral value (dignity of the
not codify. While I do no think this challenge
individual), and respect for the personal
is insurmountable,À5 it does demand that
informed by a careful reflection on the proper
narrative’’(p 104).1 How are we to know
researchers justify the inclusion of considered
relationship between descriptive and norma-
whether patients had all or any of these in
judgements in ethical theory before using the
tive ethics.7 Joffe et al take us part of the way
mind when they answered the question: ‘‘Did
method of reflective equilibrium. Joffe et al
down that path. An exciting research itiner-
you feel like you were treated with respect
and dignity while you were in the hospital?’’
Joffe et al’s study is susceptible to a second
Joffe et al acknowledge that these ethical
line of critique. Even if the study’s use of
concepts are a bit unwieldy for a survey of
mailed surveys is appropriate, it fails to
manageable length. However, these practical
capture either patients’ considered judge-
considerations should be used not only to
ments or principles, because, put simply, it
excuse the study but also to question its
does not ask for considered judgements or
ability to clarify the ethical concepts it claims
principles. Instead, it asks patients whether
providers respected their person or respected
regardless of the survey’s scale and the
their autonomy, and then tests patients’
responses to these questions against whether
` I say ‘‘a Rawlsian view’’ rather that ‘‘Rawls’s
they report being satisfied with their care. If a
view’’ because, in his theory of Justice, Rawls
provider’s acting with respect for persons is a
advocates balancing a single person’s consid-
1 Joffe S, Manocchia M, Weeks JC, et al. What do
ered moral judgements (for example, Rawls’s or
patients value in their hospital care? An empirical
À See, for instance, Delden and Theil,5 in which
his reader’s) with a single person’s moral
perspective on autonomy centred bioethics. J Med
the authors argue convincingly that a reflective
principles (p 50).3 Although he later gestures
equilibrium-like method may be valuable for
towards reflective equilibrium as an exercise
2 Rawls J. The independence of moral theory. In:
capturing the norms of health care providers
that involves the considered moral judgements
Freeman S, eds. Collected papers/John Rawls.
and that knowledge of these norms may guide
of others (p 8),6 it is probably safer to say
3 Rawls J. A theory of justice. Cambridge, MA:
sphere of intimate examinations. It concerns
consent be obtained. Neither the diminished
the moral obligations of medical students
responsibility of the medical student, nor his
4 Haslett DW. What is wrong with reflective
faced with ethically dubious situations. In
status as an apprentice, removes the need for
short, what should a ‘‘good’’ medical student
Indeed, far from absolving him from moral
Delden JJM, Thiel GJMW. Reflective equilibriumas a normative-empirical model in bioethics. In:
In an article on the scope of medical ethics,
inquiry, these factors should encourage a
Professor Raanan Gillon recounts two experi-
process of ethical questioning. This exercise
equilibrium: essays in honour of Robert Heeger.
ences from his days as a medical student.3
The first describes his teacher’s refusal to
flourishing as a morally responsible future
grant an abortion to a 14 year old girl on the
doctor. To paraphrase Nick Hornby: ‘‘it’s not
6 Rawls J. Political liberalism. New York: Columbia
grounds that she was ‘‘a slut’’; the second his
enough to just be a medical student’’.
own refusal to examine a scrotal lump on a
7 Sulmasy DP, Sugarman J. The many methods of
medical ethics (or, thirteen ways of looking at ablackbird). In: Sugarman J, Sulmasy DP, eds.
examined by five other students. Gillon’s
The author thanks Raanan Gillon, George Freeman,
Methods in medical ethics. Washington, DC:
objections were very much the exception.
Richard Ashcroft, and Anna Smajdor for their
Georgetown University Press, 2001:3–18.
When these events took place in the 1960s,
medical students were simply expected tofollow their teachers’ orders and to absorb
their evident wisdom without question. Since
Medical Ethics Unit, Department of Primary Health
Care & General Practice, Imperial College School of
then, medical ethics has developed from an ill
The public revelation in 2003 that medical
discipline in its own right, with specific
journals and associations, and a place in the
1 Coldicott Y, Pope C, Roberts C. The ethics of
journals. Using this case as a springboard
students at Bristol, however, the growing
intimate examinations—teaching tomorrow’s
for discussion, I will argue that medical
emergence of medical ethics has not dispelled
schools should encourage students to raise
2 Nesheim B-I. Commentary: Respecting the
the awkward climate of unquestioned rever-
their ethical concerns and call for a change of
patient’s integrity is the key. BMJ 2003;326:100.
ence towards teachers. Many of the students
policy making it easier for students to do so. I
3 Gillon R. What is medical ethics’ business?
felt uneasy about the examinations, but were
will also address the question of medical
Advances in Bioethics 1998;4:31–50.
too intimidated to voice their concerns: ‘‘You
4 Hornby N. How to be good. London: Penguin,
students’ moral obligations towards their
couldn’t refuse comfortably. It would be very
patients, and conclude that medical students
awkward, and you’d be made to feel inade-
ought to express their discontent when faced
quate and stupid’’, commented a fourth year
with unethical practices or attitudes.
student who participated in the study. It
In early January 2003, a study appeared in
the British Medical Journal revealing that
strive to foster a climate more conducive to
open discussion on ethical issues between
examinations on anaesthetised patients were
students and teachers. Students should not
have to perform heroic acts of courage to
The JME editorial office has now moved to
patient consent.1 Although the study did not
raise ethical concerns. In light of medical
generate the firestorm of controversy many
ethics’ place in the curriculum, the situation
expected, it engendered much discussion on
ethical issues surrounding informed consent
+44 (0) 207 383 6439. Fax: +44 (0) 207 383
and patient autonomy, as well as stressing
patient’s autonomy one day, but witness an
6668. The point of contact is Nayanah Siva,
obvious violation of this principle by their
teachers the next. For the subject to be of any
however, the case of intimate examinations
use, students must not only be allowed, but
is, to my mind, relatively uninteresting. If we
positively encouraged to put into practice their
agree that it is wrong for doctors to perform a
The IME wishes to award 10 bursaries of up
vaginal examination on a conscious person
‘‘inadequate and stupid’’. If a student’s
without their consent, then it follows that it
Electives, or exceptionally Special Study
will still be wrong if that same person is
discussion with the teacher, there should be
Modules, on issues in medical ethics.
Medical students, jointly with their super-
chaotic if a person suddenly lost his rights
through a committee specifically set up for
visor, are invited to apply by 28th February
that purpose, or through the school’s medical
2005. Application is to be done via email,
explaining the project’s relevance to medical
examination and so cannot be harmed is, at
matter thoroughly. Medical ethics is, after
requested. An outline study protocol and pro-
revealed tomorrow that sociology students
It is nonetheless all too easy to blame the
ject budget should in included or attached.
had placed hidden cameras in the cubicles of
medical establishment and individual tea-
public toilets to study urination habits. Most
chers for the unethical behaviour of students,
people would be understandably outraged by
as if the appellation ‘‘medical student’’
this violation of privacy, even though the
shielded individuals from moral fault. In
Successful applicants will be informed by
victims were not harmed by it at the time.
Nick Hornby’s novel ‘‘How to be good’’, the
This is based on the belief that a person’s
rights can be violated without that person’s
mechanically repeating ‘‘I must be good. I’m
As for the conflict between the educational
a doctor’’.4 It is only later that she acknowl-
need of students and the respect for patient
edges that her justification is too facile: ‘‘it’s
autonomy, it would only arise if an over-
not enough to just be a doctor, you have to be
whelming number of patients refused to be
a good doctor’’. Students, however wide eyed
examined. This is an unlikely scenario. In a
or intimidated, are still capable of indepen-
commentary on Dr Coldicott’s study, Britt-
dent thought. Their personal values should
An error has been pointed out in the affillia-
Ingjerd Nesheim, a professor of obstetrics and
not vanish as they put on the white coat, just
tion for R Andorno, author of The right not to
gynaecology in Norway, affirms that obtain-
as a patient’s rights should not evaporate
ing patient consent to student examinations
when under anaesthetic. Although the reluc-
2004:30;435–439). The correct affiliation is
is not difficult, as long as the patient feels
tance of many Bristol students to perform the
Interdepartmental Center for Ethics in the
comfortable with the arrangements.2 Yet for
examinations is comforting, it seems that
Sciences and Humanities (IZEW), University
none acted on their qualms by declining to
question which extends beyond the recondite
perform the procedure or asking that proper
NACIONES Convención sobre los Derechos del Niño COMITÉ DE LOS DERECHOS DEL NIÑO 50º período de sesiones EXAMEN DE LOS INFORMES PRESENTADOS POR LOS ESTADOS PARTES EN VIRTUD DEL ARTÍCULO 44 DE LA CONVENCIÓN Observaciones finales El Comité examinó el segundo informe periódico del Chad (CRC/C/TCD/2) en sus sesiones 1374ª y 1375ª (CRC/C/SR.1374 y 1375), celebrad