“concentrate on what it is to be a good physician and… what kind of person that physician should be”.
Mirroring Bloom’s learning domains, the corresponding personal characteristics can be categorised as interdependent habits of the head, habits of the hands, and habits of the heart (Dyrbye et al., 2007, citing Lee Shulman). In a medical context, Burns (2003) gives a historical precedent in William Osler, who appealed to philosophia (science and reason in medicine), philotechnia (the art of medicine), and philanthropia (humanity in medicine).
Campbell et al. (2007) place habit at the intermediary level in the pyramid of ethics learning between knowledge (at the base) and action (at the apex). Just as there is international variation in the content of both medical ethics and medical law, so they also stress the importance of not “exporting wholesale a set of values and assumptions about medical conduct from one culture”. In the next chapter the importance of values clarification for student learning in law and ethics will be discussed further, and in the final chapter there is further discussion on the lack of an automatic linkage between ethico-legal cognition, affect, and their behavioural counterpart.
Intentions
The ethico-legal content of our actions is partly constituted by what we consciously set out to do. Although oriented towards an anticipated outcome, intention resides entirely in the antecedent phase of an action. While it may seem slightly paradoxical to view an action as already being shaped by an end before it begins, that is what it means to intend a course of action rather than to embark upon one accidentally. As a result professionals have a dual responsibility to be able to justify both the goal to which a specific practice is oriented, and also the reasons for selecting that course of action as a proper means to the end in question. In certain circumstances, retrospectively accounting for our action may not be enough. Evidence that our intentions at the time were predicated on the interests and benefit of patients may need substantiation by a contemporaneous record. For this reason, detailed and accurate record keeping becomes especially important in clearly written case notes.
The ethical concept corresponding to this responsibility is beneficence. Rather than a general intention to ‘do good’, it is specifically the healthcare of the patient in a given clinical encounter that defines what these best interests are. Further, beneficence is not quite the same as benevolence. As Frankena explains (1973), the principle “asks us actually to do good and not evil, not merely to want or will to do so”. Also, in clinical situations of ‘double effect’, where a single action has two inevitable consequences (benefit and harm), the act may be ethically acceptable in some circumstances (Brazier, 2007), according to which outcome was intended.
The interests and benefit of patients entails another ‘I’, which is ethico-legal imagination as the capacity to envision the goal to which a clinical action is oriented. The theme of engaging this imagination of students is returned to in the next chapter.
The ethico-legal content of our actions is partly constituted by what we consciously set out to do. Although oriented towards an anticipated outcome, intention resides entirely in the antecedent phase of an action.
Guide 53: Ethics and Law in the Medical Curriculum
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