2. GB Shaw..a profession is a group of people who band together to hide their own shortcomings.. Preface to The Doctor’s Dilemma

3. Illness as metaphor Illness is the night-side of life, a more onerous citizenship…everyone holds dual citizenship Impossible to take up residence unprejudiced by the lurid metaphors with which it has been landscaped

4. Upstream ethics Towards an ethics of care, communication and competence Emphasis on personhood in old age and dementia

5. Competence Care Communication Reflective practice Ethics Societal Contract Law

6. Code of practice Philosophy Habit Aesthetic

7. Why? Special position of trust Not like repairing a car Can do lasting harm Huge fiscal implications of practice

8. What underpins? Judaeo-Christian Prejudices Human failings

9. Major ethical issues Inadequate resource Inadequate dignity and communication

10. Barriers I Non-prioritization by profession Media obsession with end-of-life/ hard issues Strangers at the bedside Lawyers Some non-clinician ethicists

11. Vulnerable groups Tuskegee Prescribing habits for poorer patients

12. The Ballad of Reading Gaol And every human heart that breaks, In prison-cell or yard, Is as that broken box that gave Its treasure to the Lord, And filled the unclean leper’s house With the scent of costliest nard.

13. Cloverhill Remand Prison 456 beds Wheatfield Prison Design capacity320 Bed capacity368

14. Prisoners and health Worse than general population Older prisoners even worse Collins, 2006 Novick, 1997

15. Trebling of older prisoners in UK 1990- 2000

16. Doctors, medical students and prisoners Personhood, prisoners as patients

17. Role model

18. Role model 2

19. A student in prison

20. Students in UK 47% placed in a situation where they had to act unethically 61% observed a teacher acting unethically 3 main types –Conflict between medical education and clinical care –Responsibility exceeding student’s capabilities –Involvement in care perceived to be substandard Hicks, BMJ, 2001

21. Intimate examinations A survey of students in one medical school found that intimate examinations had been done by second and third year students in situations that they found disconcerting It also found that a quarter of examinations in anaesthetised or sedated patients seem not to have adequate consent from patients Coldicott, BMJ, 2003

22. What students see.. Communicative violations –(to or about patients or other health care professionals) Role resistance –(individuals chafing against constraints or expectations of their perceived roles) Objectification of patients –(ignoring patients or treating patients as vehicles for learning) Accountability –(to colleagues or patients, including avoiding patients, failing to disclose information, or failing to treat appropriately) Physical harm –(to patients or others) Crossfire –(being put in the middle of a struggle between superiors) Ginsburg, Academic Medicine, 2002

23. How they incorporate it… Sense of witnessing (n = 34) Knowing about (n = 4) As opposed to self-reported (n = 10)

24. Clinical clerkships USA 58% reported having done something they believed was unethical 52% reported having misled a patient 80% reported at least one of these two behaviors 98% had heard physicians refer derogatorily to patients

25. 61% had witnessed what they believed to be unethical behavior by other medical team members Of these students, 54% felt like accomplices Feudtner, Acad Med, 1994

26. More likely to experience erosion of own ethical principles or act improperly –Evaluation fear –Fear of not fitting in

27. Since, for the most part, students believe that they behave ethically, they are less likely to see the need for medical ethics education. So, unlike philosophy programme education, the first hurdle for professional schools ethics education is the establishment of its importance and its relevance R Rhodes, 2002

28. ….(medical students) showed a levelling process of their moral reasoning. This finding prompts us to ask whether a hidden curriculum exists in the structure of medical education that inhibits rather than facilitates the development of moral reasoning. Patenaude, CMAJ, 2003

29. No easy rule-based solutions... “Well, actually, they are written in stone”

30. No easy algorithms...

31. MedLine Ethics

32. Talleyrand Loyalty is a matter of timing Ethical probity a matter of timing?

33. The one that got away

34. Prisoners in A/E 20/20 assessed chained to prison officers Including 65 year-old, 5’ 2”, acutely dyspnoeic after MI

35. Upstream ethics If we don’t get the every day discourse right…. Small abuses lead to larger abuses

36. Prisoners in A/E Risk assessment Liaison between hospital and prison Secure facilities Urgency prioritization

37. Capital Punishment Disallowed actions include: Starting intravenous lines for lethal injection drug Determining death during execution Administering the lethal drug Supervising personnel who give the lethal drug

38. Capital Punishment Disallowed actions include: Ordering lethal drugs for the prison pharmacy Maintaining or inspecting lethal injection devices Monitoring vital signs during execution Selecting injection sites for lethal drugs

39. Physician Attitudes about Capital Punishment 80% indicated that at least 1 of the disallowed actions was acceptable 53% indicated that 5 or more were acceptable 34% approved all 8 disallowed actions

40. AMNCH Survey 76 consultants and 139 NCHDs 184 responded: 60% of the consultants and 100% of the JHDs

41. 98% had treated prisoner patients at some stage in their career and 90% had done so in the last 2 years. 60% felt uncomfortable whilst examining patients who were prisoners 181 (98%) were unaware of any guidelines in place for the treatment of prisoner patients in general hospitals

42. Breaches of confidentiality 7% always 88% sometimes 3% never

43. Asking prison officer to leave 4% always 65% sometimes 31% never

44. Inquiring as to risk 14% always 57% sometimes 29% never

45. Examining patient while restrained 16% always 67% sometimes 17% never

46. Balanced score-card Self-evaluation and awareness accepted in medical profession Need to develop structures and guidelines appropriate to professional practice with prisoners

47. I never saw a man who looked With such a wistful eye Upon that little tent of blue Which prisoners call the sky The Ballad of Reading Gaol

48. Reason..must approach nature [science] in order to be taught by it: but not in the character of a pupil who agrees to everything the master likes, but as an appointed judge who compels the witnesses to answer the questions he himself proposes Kant, A Critique of Pure Reason

49. Scientism..science’s belief in itself: that is, the conviction that we can no longer understand science as one form of form of knowledge, but rather must identify knowledge with science Habermas, Knowledge and Human Inquiry

50. Profession Develop articulacy Make case for adequate resource Deal with prejudice Self-critical Strive for evidence base Avoid artificial dichotolies

51. Priorities Develop ethics of –Communication –Competency Research Shake complacency Joint working of clinicians/philosophy