Jonsen et al. (2006) propose a four topic method based on the determination of the following variables:
• • • •
the medical indications in the case that are of ethical relevance; patient preferences;
the impact on the patient’s quality of life; and wider contextual features.
Schwartz et al. (2002) offer an ethical decision-making tool involving clarification guided by an ordered sequence of reflection which is focused on:
• • • • • •
getting the story straight; your initial reaction;
identify the ethical problem(s); duties and outcomes;
alternative courses of action; principles;
• legal and professional requirements; • reflection on the answers so far; • decision;
• justify your decision;
• anticipate criticisms and costs; and • implement and document.
This tool in turn shares morphological features of the step-by-step process set out by Myser et al. (1995a). Seedhouse (1998) develops a structure that provides a set of prompts covering the range of factors to build into ethical deliberation, which places at its centre the (more abstract) drivers of responsible action in the social world and, peripheral to this, zones of (progressively empirical) drivers when deciding on the responsible action that would be entailed by the ethical justification governing each zone.
Ethico-legal awareness and analysis will also require core learning in medical law. Box 14 offers a selection of key areas, though there will be differences according to the jurisdiction. Preston-Shoot & McKimm (2010) summarise the range of content areas in legal education across medical schools of the United Kingdom. Within European law, Parker & Dickenson (2001) identify three distinct voices relating to medical practice: the ‘deontological’ traditions broadly associated with southern Europe that are modelled more on the responsibilities of patients than on rights; the liberal traditions of western Europe that tend to privilege the choice of patients in responding to medical opinion; and the social welfare traditions of Nordic countries that promote comprehensive rights of healthcare provision.
To consider consent as an example, internationally there are differences across jurisdictions in the way this notion is conceptualised. In English law, strictly speaking there is no right to fully informed consent (Parker and Dickenson 2001), since the requirement to have a patient’s authorisation for treatment is based on the need for doctors to have a defence in law against possible allegation of battery, whereas in American law the basis for consent is enablement of autonomous decision-making by the patient.
Guide 53: Ethics and Law in the Medical Curriculum
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