Ethics: Musings on the moral life

I GET INTO the back seat of a taxi at Boston’s Logan Airport, hoping to catch a snooze during the drive. But the taxi driver wants to chat. In a soft Egyptian burr, he asks, “In town on business?” “Kind of,” I reply, in an attempt to close down the conversation. Not taking my hint, he asks what I do for a living. I reply, “I teach medical ethics to student doctors.”

Curious to observe his reaction, I watch his face in the taxi rear-view mirror. His eyebrow rises slightly and his reflection glances at me. A pause… and then, the inevitable, “What is this … medical ethics?” I eye the driver, trying to gauge my audience. Boston is a funny old town. I once struck up a conversation with a shoe sales assistant, who turned out to be a Russian obstetrician earning some cash while studying for the US medical licensing exams. And a previous taxi driver had told me about his degree in economics from a Moroccan University.

“What is this … medical ethics?” A difficult question to answer. The scope of medical ethics is broad, and there is no short explanation that does an adequate job of describing this discipline. I decide to keep my answer inadequate but simple. “Well”, I reply, “learning about medical ethics helps doctors to know the right thing to do in a complicated situation.”

He thinks about it, then says, “I think everybody always want to do the bad thing, the wrong thing – to lie, cheat, or steal – for their own gain. This is why we need so many rules and laws and religion – to keep us away from doing the bad thing and make us do the right thing.” And then, he adds, “Doctors are no different in this.” Nothing in the expression on his face tells me he is joking.

This is the age-old debate: where does one’s moral compass come from? Does human nature really default to doing the immoral rather than the moral act? Is this why we need rules to keep us on the straight and narrow – to prevent us from slipping to ‘the dark side’?

These issues are very relevant to medical education. For years, scholars have debated how moral and professional values can and should be shaped, or even ‘instilled’, during medical training. Students start medical school with their own mix of moral and personal values, already ingrained from their unique familial, cultural and religious upbringing. Medical training then imparts knowledge about the virtues and values expected of doctors by society, as laid out in professional codes of conduct. These are essentially the ‘rules’ that try to define what being a ‘good’ doctor entails, designed to keep us on the straight and narrow. Just as Aristotle’s apprentices learned moral values through continual exposure to, and the habitual practice of, these values, medical students absorb the profession’s culture and behaviours through exposure to medical practice.

And yes, it does appear that such rules are necessary. The spectre of doctor-murderer Harold Shipman warns us that doctors are not immune from immoral acts. Studies have shown convincingly that clinicians do exhibit unprofessional behaviour – rudeness, arrogance, dishonesty, self-interest, and disrespect towards both patients and colleagues – and, worse, that this is absorbed and copied by medical learners as part of the professional culture. And there have been recent international initiatives, such as the Medical Professionalism Project, in response to increasing concerns over self-interest and commercialism in medicine.

But are these examples related purely to flaws in the fundamental morality of doctors? The Chinese philosopher Mencius, in around 370 BC, argued that human beings were naturally compassionate, with an innate sense of right and wrong, and: “When they do evil, it is because adverse conditions have corrupted their nature”. It is true that, in modern day medical practice, ‘adverse conditions’ exist; physician illness, isolation, depression, addiction and stress – as well as organisational pressures that intensify these factors – all potentially influence the behaviour of physicians. This can have serious consequences for patient safety and the quality of patient care.

Doctors are, quite rightly, held to the highest standards of morality by society. But it seems that the teaching of these ideal values must go hand in hand with the teaching of practical coping mechanisms for Mencius’ ‘adverse conditions’. Students need to develop insight and self-awareness, recognise that doctors are not infallible, and understand how to access sources of help and support. Fail-safe mechanisms for when the gasket is about to blow.

I ask the taxi-driver, “Do you really think that doctors are driven by self-interest more than by doing the right thing?” His face breaks into a grin, “No”, he says, “but I made you think, yes?” And he switches on his radio, stifling any further talk with some loud and extremely dramatic Arabic music.

• Dr Helen M Manson is a lecturer in medical ethics at Dundee University Medical School