Approaches To Ethics In Higher Education
Approaches to Ethics in
Higher Education
Learning and Teaching in Ethics
across the Curriculum
Approaches to Ethics in Higher Education
Learning and Teaching in Ethics across the Curriculum
Prepared for the ETHICS Project by Susan Illingworth. Illustrations by Susan Illingworth.
A partnership of the LTSN subject centres for Philosophical and Religious Studies,
UKCLE, LTSN-01, Psychology, Bioscience and Health Sciences & Practice
© PRS-LTSN, 2004
Published by the Philosophical and Religious Studies Subject Centre,
Learning and Teaching Support Network (PRS-LTSN)
School of theology and Religious Studies
University of Leeds
Leeds LS2 9JT
First Published March 2004
ISBN 0-9544524-2-9
All rights reserved. Except for quotation of short passages for the purposes of
criticism and review, and for use in learning and teaching contexts in UK higher
and further education, no part of this publication may be reproduced, stored in a
retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording or otherwise, without prior permission of the
publisher.
For free distribution to all involved in learning and teaching in Higher Education
in the UK. Available for sale to all others.
Printed in Wales by Cambrian Printers, Aberystwth.
Contents
Foreword ......................................................................... 5
Acknowledgements ....................................................... 5
A. Introduction ................................................................ 6
Who Needs to Learn About Ethics?..............................................6
Approaches ....................................................................................6
B. Approaches to Ethics Teaching............................... 9
1. Pragmatic ....................................................................... 9
a. Introduction ..............................................................................9
b. Professional Codes of Practice...............................................11
c. Research Ethics Committees (RECs) ....................................13
RECs in Higher Education...........................................................15
Primary Sources...........................................................................16
LRECs and MRECs.....................................................................18
Other Government Sources ........................................................19
Subject-Specific Approval............................................................20
Common Themes ........................................................................22
Clinical Ethics – the Power and the Glory................. 24
Ethics in Applied Research and Teaching ................ 27
The Ethics Committee .................................................................27
Ethical codes of conduct..............................................................28
Ethical responsibilities in research ..............................................29
Researcher safety and well-being...............................................30
Data Protection ............................................................................31
Ethics in Teaching........................................................................31
Conclusion..................................................................................31
References..................................................................................32
e. A Case Study ...........................................................................33
2. Embedded.................................................................... 35
a. Introduction...............................................................................35
b. Professionalism and Interprofessionalism..............................36
c. Fitness for Practice ..................................................................39
d. Methods....................................................................................42
The Ethicist’s Tale: Using the Humanities to
Facilitate Learning in Healthcare................................ 54
Introduction...................................................................................54
Humanities in Healthcare Education...........................................54
Using humanities in healthcare teaching and
learning ‘on the ground’ ...............................................................55
e. A Case Study ...........................................................................58
3. Theoretical.................................................................... 65
a. Introduction...............................................................................65
b. Issue-Based Learning..............................................................66
c. Ethics and Philosophy..............................................................68
d. Ethics and Key Skills................................................................71
Care, knowledge and design in professional
practice .......................................................................... 73
Variations within the themes........................................................75
References...................................................................................76
f. A Case Study ............................................................................78
C. Other Considerations.............................................. 81
1. Students’ Initial Expectations....................................... 81
2. Safety............................................................................ 82
3. Mutual Respect ............................................................ 83
a. Cultural and Religious Sensitivity...........................................84
b. Multiple Perspectives..............................................................85
c. Objectivity versus Emotional Engagement.............................86
4. Confidentiality............................................................... 87
Future developments................................................... 90
Appendix A:................................................................... 92
Using Case Studies or Contextualised Scenarios ... 92
Case Studies as Projects ............................................................93
4
Foreword
By David Gosling
Note from Susan Illingworth
The document will be submitted to the external evaluator, David
Gosling, without a foreword.
He has not been approach to supply a personal contribution to the
Guide as I felt it would be difficult for him to give an answer before he
has seen the material he is being asked to introduce.
I intend to send the Guide to him with an invitation to write a
short foreword if he so wishes.
Acknowledgements
With thanks to all workshop participants, Project Officers, Jackie Wilson
for feedback and comments, Karen Taylor Burge for information on
Professional Codes, David Mossley for editorial work in preparing the
text for publication and all the reviewers.
5
A. Introduction
he ETHICS Project was a one year initiative funded by the LTSN1. Its
primary aim was the collective examination of the current provision of
Tapplied/professional ethics teaching within Higher Education (HE) to
identify key concerns and to facilitate the sharing of good practice.
This guide forms part of the Project’s output. It is hoped that it
will provide a useful resource not only for new teachers of ethics looking
for ideas on course development, but also for experienced ethicists for
whom it will provide a ‘snapshot’ of current teaching and learning
priorities.
Who Needs to Learn About Ethics?
Perhaps the best reason for studying ethics is a strong personal interest
in the subject matter but the requirement to teach ethics is a growing
one throughout HE. Many departments whose main academic interests
lie elsewhere are making room within their curricula for an introduction
to the moral issues germane to their primary discipline.
The pressure to teach ethics comes from benchmarking
statements, the requirements of professional associations, and the more
general drive to provide students with key transferable skills. What
these sources have in common is the idea that students need to study
ethics in order to meet the expected demands of their working lives. HE
can only meet this need effectively if it tailors the learning and teaching
environment to the requirements of different student groups so that
students see ethics as:
Relevant to their primary discipline.
A subject that they can tackle with confidence, and with the
expectation of attaining an acceptable level of expertise.
Approaches
The guide summarises three commonly used approaches or ‘ways in’ to
ethics. The pragmatic approach takes as its starting point the framework
of rules and procedures defined by regulatory bodies charged with the
All links are available live at http://www.prs-ltsn.ac.uk/ethics
1 Learning and Teaching Support Network, part of the Higher Education Academy:
http://www.heacademy.ac.uk/
task of raising or maintaining professional standards. In the embedded
approach, students study ethics indirectly, by considering some broader
conception of professional identity which has a significant ethical
dimension. The theoretical approach begins with a study of moral theory,
and considers real-life situations in terms of the application of that
theory. Although teachers may employ methods drawn from more than
one category, the context in which students first encounter ethics
influences their perception of the subject and its relationship to
professional values and behaviour. Each approach is supported by a case
study, illustrating the ways in which case studies can be adapted to
serve a range of methods and objectives. The deployment of case studies
is expanded upon in Appendix A.
This Guide also outlines some issues of general applicability such
as safety and confidentiality.
The closing section considers the future of ethics learning and
teaching in Higher Education, and argues for interdisciplinary
collaboration between ethical theorists and those with expertise in its
subject-specific application.
An online version of this guide, with links to the ETHICS Project’s
Case Study database and other resources can be found at:
http://www.prs-ltsn.leeds.ac.uk/ethics/
7
How do your students see Research Ethics
Committees?
As a fog of obscurity…
… as an obstacle …
... or as the Inquisition
B. Approaches to Ethics Teaching
n ‘approach’ in this context refers to the ‘point or direction from which
one views … a subject of inquiry’2. Teachers of applied or professional
Aethics may use methods drawn from each of the following sections at
some point during a module, but the students’ starting point influences
the way they perceive the subject, both in terms of its relationship to the
rest of their coursework, and its relevance to their working lives. The
ETHICS Project’s review of the current status of ethics in Higher
Education suggested that there are three commonly used ‘ways in’ to the
subject and that this might be a useful way to categorise the different
kinds of learning and teaching offered.
1. Pragmatic
a. Introduction
The pragmatic approach takes as its starting point the framework of
rules and procedures defined by regulatory bodies charged with the task
of raising or maintaining professional standards. The advantage of
introducing students to ethics in this way is that it is easy for them to
see its relevance. As future professionals they have an interest in
avoiding censure. As potential researchers, their research proposals may
need Research Ethics Committee (REC) approval and it will save time
and effort on their part if they can anticipate and accommodate any
ethical concerns that might be raised.
Students introduced to ethics via the pragmatic approach need
not see ethics purely in terms of external constraint. Modules can be
designed to help them acquire some understanding of the principles and
moral arguments that were used in the formulation of the rules, or to
facilitate their internalisation of the values implicit in the rules. In these
cases teaches will often choose to combine the pragmatic approach with
the methods described in the theoretical and embedded approaches.
However, this does not always happen in practice and for some students
in Higher Education, their experience of ethics learning and teaching
will be largely confined to a pragmatic agenda. Helping students acquire
knowledge of professional/research standards and the ability to apply
All links are available live at http://www.prs-ltsn.ac.uk/ethics
2 Oxford English Dictionary (online version) http://dictionary.oed.com/
them is therefore one way in which benchmarked requirements to teach
ethics are currently being interpreted.
The remainder of this chapter offers a brief review of Professional
Codes of Practice to identify the common moral concerns embedded in
them, followed by an outline of the current system of Research Ethics
Committee approval. Both areas are too complex to be covered in detail
in a guide of this nature, and the main aim of these sections is to identify
sources of information for teachers, most of them internet-based. Given
the rapidly evolving nature of the legislation and its associated executive
and administrative structures, the internet is the most effective (and in
many cases the only practicable) way of communicating up-to-date
information. Web page addresses are given for all the sources of
information cited, but when accessing multiple links please view the
online version of this Guide, from which the sources can be accessed via
hyperlinks from the main text.
This section also includes two guest contributions. The first is
from Bryan Vernon, Lecturer in Ethics of Health Care, University of
Newcastle-upon-Tyne, and draws on his experience as a contributor to a
range of Clinical Ethics Advisory Committees. Clinical Ethics
Committees are modelled on the advisory and regulatory model of the
Research Ethics Committee, adapted to the needs of clinical practice.
The functions of the Clinical Ethics Committee can be divided into three
broad areas:
1) Provision of ethics input into Trust Policy and Guidelines
2) Support for health professionals in individual cases
3) Facilitation of ethics education for health professionals and other
Trust staff.
This categorisation was taken from the UK Clinical Ethics
Network website, a new online resource which offers a registration
facility for Clinical Ethics Committees, examples of the range of work
carried out and an issues list, showing the topics that committees have
discussed most frequently.3 Rev. Vernon provides valuable insight into
the qualities needed to be an effective member of such a committee.
The second contribution comes from Diane Beale, Senior Research
Fellow at the University of Nottingham. Her article offers a detailed
description of the management of the ethical implications of applied
research and teaching within Nottingham’s Institute of Work, Health &
Organisations. She argues that students should be encouraged to “think
ethically” rather than simply apply a code or set of standards.
All links are available live at http://www.prs-ltsn.ac.uk/ethics
3 http://www.ethics-network.org.uk/
10
The final part of this section will present a case study defined in
relation to the pragmatic approach.
b. Professional Codes of Practice
Many graduates will work in areas that do not relate directly to their
area of study. Accordingly, most benchmark statements avoid reference
to individual professional codes, but rather require that students:
Understand the need for such codes
Are able to apply them.
In faculties such as those of Law, Medicine or Healthcare the
relevant professional codes can be identified more readily. For example,
the Law Society provides a detailed online guide to the Professional
conduction of solicitors, including advice on discrimination, conflicts of
interest and confidentiality.4
In healthcare, professional codes will often be of immediate
relevance as many students have some experience of clinical practice
before graduating. However, work experience will increasingly take
place within the context of an interdisciplinary team and this has
resulted in some institutions structuring ethics learning and teaching
around an Interprofessional Education (IPE) framework (see section p.*
for a discussion of ethics and IPE). Where classes bring together
students from more than one discipline, there will be more than one
applicable professional code.
The number of Codes of Practice or Conduct applicable within
healthcare alone is vast. For example, within Medicine, the General
Medical Council defines fourteen key principles in the Duties of a Doctor,
with associated guidance on their interpretation and application.5
Individual specialities may then have their own representative bodies
such as The Royal College of Paediatrics and Child Health which defines
a set of duties answering the particular needs of their field6 or the
Association of Anaesthetists of Great Britain and Ireland which provides
a code of conduct for anaesthetists involved in private practice.7 For
Nursing and Midwifery a new Nursing and Midwifery Council Code of
Conduct came into effect in June 2002.8
Paramedical professions have their own codes. For example, the
General Osteopathic Council’s Code of Practice lays down standard
expected of registered osteopaths,9 while the Chartered Society of
All links are available live at http://www.prs-ltsn.ac.uk/ethics
4 http://www.guide-on-line.lawsociety.org.uk/
5 http://www.gmc-uk.org/standards/default.htm
6 http://www.rcpch.ac.uk/about/duties.html
7 http://www.aagbi.org/IPC_codeofpractice.html
8 http://www.nmc.uk.org/nmc/main/publications/codeOfProfessionalConduct.pdf
9 http://www.osteopathy.org.uk/goc/council/code.shtml
11
Physiotherapy specifies rules of conduct intended ‘to reflect the
reasonable behaviour expected of a physiotherapist as a professional’.10
For pharmacists, the UK Medicines Information (UKMI) online service
provides a basic introduction to the function of NHS RECs, the role of
pharmacists on these RECs and the procedure to gaining REC
approval.11
Non-clinical staff are also covered, as in the Code of Conduct for
NHS Managers12 or the College of Health Care Chaplains Code of
Conduct.13
Despite this apparent complexity, an examination of the codes
will reveal a number of recurrent themes, applicable across many
disciplines, both inside and outside healthcare. Their main objective is to
prohibit behaviour likely to bring the profession into disrepute or
undermine public confidence in it, and they do this by stressing a
number of key qualities. Ethics learning and teaching that takes its
starting point from professional codes of practice can therefore be based
around a consideration of these themes. By so doing it will prepare
students to apply the key requirements of most professional codes to
their own behaviour.
The first group of qualities relates to what might loosely be called
‘professionalism’. Professionals are expected to act with integrity, a
complex notion that usually comprises such things as honesty, an
avoidance of plagiarism, avoidance (or at least reporting) of any conflicts
of interest and a willingness to report colleagues suspected of
professional misconduct. The importance of working within the law is
stressed by most codes, and teachers might find it useful to combine
teaching that refers to specific professional codes with coverage of any
associated legal obligations. Service-oriented professions also have a
general requirement that their members should provide a good standard
of care. Both professionalism and the duty of care will also be considered
in the next section of this guide which deals with the embedded
approach to ethics learning and teaching. The difference between the
pragmatic and embedded approaches lies in the fact that the former
concentrates on professionalism as behaviour constrained by an agreed
code of conduct, while the embedded approach interprets this in terms of
the students’ emerging sense of professional identity.
Professions operating through private practice also have defined
duties of financial propriety. Apart from activities such as fraud and
embezzlement, which would be covered by the obligation to act at all
times within the law, codes pay specific attention to advertising, which
All links are available live at http://www.prs-ltsn.ac.uk/ethics
10 http://www.csp.org.uk/thecsp/rulesofconduct/rulesofprofessionalconduct.cfm
11 http://www.ukmi.nhs.uk/Research/Ethics.asp
12 http://www.doh.gov.uk/nhsmanagerscode/code-code.htm
13 http://www.lichfield.anglican.org/healthcarechaplains/code.htm
12
must be accurate (for example, by not making false or inflated claims
about the services one provides). Professions which offer an advisory
service to the public or other professionals may also stipulate that this
advice must be independent and unbiased by any financial rewards that
might be offered to the professional.
More overtly ethical qualities stressed are those of non-
discrimination, the maintenance of confidentiality and the importance of
obtaining informed consent from clients or service-users. These issues
are stressed throughout the whole of Professional Ethics and have
acquired a large and comprehensive literature. However, when
producing materials via the pragmatic approach, information regarding
an appropriate interpretation of these terms can normally be found
within the relevant code of practice or legislation. For example, the GMC
offers advice on seeking patient’s consent,14 as does the British Dietetic
Association.15 Examples within legislation can be found in the Human
Tissue Bill,16 which includes definitions of what is meant by informed
consent, while bodies such as the Scottish Executive provide a review of
the literature relating to mental health legislation which includes
coverage of capacity, competency and consent.17 The ETHICS Project
website also includes downloadable information on consent and
confidentiality.
c. Research Ethics Committees (RECs)
Ethical scrutiny of research proposals is now many layered and evidence
of ethical awareness is an integral part of a well-structured funding
application. For example, the Wellcome Trust requires the following
information and licenses for a funding application.
Signed collaborators’ forms from researchers willing to participate in
or provide materials for the project.
Ethical permission for studies involving patients and the use of
material from human subjects (e.g. blood samples).
Regulatory approval for research involving gene therapy from
applicants’ Local Research Ethics Committee, University’s Genetic
Manipulation Committee, Gene Therapy Advisory Committee and
Medicines Control Agency. 18
All links are available live at http://www.prs-ltsn.ac.uk/ethics
14 http://www.gmc-uk.org/standards/CONSENT.HTM
15 http://www.bda.uk.com/Downloads/informed%20consent.pdf
16 http://www.parliament.the-stationery-office.co.uk/pa/cm200304/cmbills/009/04009.1-6.html#J028
17 http://www.scotland.gov.uk/cru/kd01/purple/review20.htm
18 Medicines and Healthcare Products Regulatory Agency (Medicines Control Agency): http://www.mca.gov.uk/
13
For research using NHS facilities or patients, confirmation that the
applicants are acting within the principles of the Statement of
Partnership on Non-Commercial R&D in the NHS.
Personal and project licences for any animal experiments that
require Home Office approval. 19
Other funding bodies show a clear concern for ethical standards.
The BBSRC (Biotechnology and Biological Sciences Research Council)
expects all grant holders to show that they are aware of the potential
ethical implications of their work and research applications may be
referred to its Advisory Group on BBSRC Response to Issues of Public
Concern, a group which includes not only professionals but lay members
who can provide ‘viewpoints representative of the wider population’20.
PPARC (Particle Physics and Astronomy Research Council) requires
that there must be,
reliable systems and processes in place for the prevention of scientific misconduct e.g.
plagiarism, falsification of data, together with clearly defined arrangements for
investigating and resolving allegations of scientific misconduct. 21
The ESRC, which funds research addressing economic and social
concerns states that it “attaches considerable importance to the
maintenance of high ethical standards in the research it supports”22
while the Medical Research Council publishes a number of downloadable
documents as part of its Ethics Series, defining its concerns on ethical
issues.23
Until recently Research Ethics Committee approval has applied
mainly to postgraduate or professional researchers, but undergraduate
projects are increasingly being treated to the same level of scrutiny as
any other research work. Similarly, while audit projects do not currently
need REC approval, many institutions have separate audit committees
and are concerned that qualitative research is reviewed as rigorously as
clinical research.
In general, it appears that all students in research oriented
disciplines will benefit from some familiarity with the way RECs operate
and the benchmarking statements reflect this. For example, the subject
skills statement for Psychology requires that the student
All links are available live at http://www.prs-ltsn.ac.uk/ethics
19 http://www.wellcome.ac.uk/en/1/biosfginflic.html
20 http://www.bbsrc.ac.uk/society/research/resp_ethic.html
21 http://home.pparc.ac.uk/rs/rgh/rghData.asp?sb=1.5&si=n
22 Taken from the ESRC’s web pages – http://www.esrc.ac.uk/esrccontent/ResearchFunding/sec22.asp
23 http://www.mrc.ac.uk/index/publications/publications-ethics_and_best_practice.htm
14
[i]s aware of the ethical context of psychology as a discipline and can demonstrate this
in relation to personal study, particularly with regard to the research project. 24
Jane Pearson25 a member of the North West Multi Centre
Research Ethics Committee states that Research Ethics Committees
have three primary functions:
1) To protect research subjects from harm
2) To facilitate good quality research
3) To protect researchers
In addition to the above, they also serve:
To enable researchers to obtain funding from grant bodies
To enable research to be published
When introducing students to ethics through a consideration of
the application procedure for obtaining REC approval for a project, it is
worth stressing that these regulations aim to protect researchers as well
as research subjects. This point is also highlighted by Diane Beale’s
article (see B.1.e) in which safeguards for researcher safety and welfare
is a key concern of the Institute Ethics Committee. It is easy for students
to see research ethics as a hurdle to be got over, rather than as a
supportive framework, so a stress on the benefits to them of REC
scrutiny may be a useful way of encourage a positive and constructive
attitude.
Sources of information on RECs and their relevance to different
kinds of research ethics are numerous, and mainly web-based due to the
rapidly evolving nature of the framework. This guide cannot provide a
comprehensive list of sources (and if it could the list would probably be
obsolete by the time of publication) but the links specified in the next
section will offer a guide for teachers needing material for an
introduction to REC activity.
RECs in Higher Education
The most useful starting point will probably be the web pages of your
own institution. Most colleges of Higher Education with active research
All links are available live at http://www.prs-ltsn.ac.uk/ethics
24 http://www.qaa.ac.uk/crntwork/benchmark/phase2/psychology.pdf
25 Pearson, J. (2003) Presentation on the Role of Research Ethics Committees, offered at ETHICS Project
Workshop, King’s Manor, York
15
programmes will have their own Research Ethics Committee and the
more research intensive units will have several committees operating at
department or centre level. For example:
University College Chester – Centre for Public Health Research:
http://www.chester.ac.uk/cphr/resources.html
University of Cambridge – Human Biology Research Ethics
Committee, Human Biology: http://www.bio.cam.ac.uk/sbs/hbrec/
University of Sheffield – School of Health & Related Research:
http://www.shef.ac.uk/uni/academic/R-Z/scharr/resethics/
Queen’s University Belfast – Psychology:
http://www.psych.qub.ac.uk/ethics/prec.html
For external approval, the following outline indicates the basic
structure at the time of writing.
Primary Sources
Many RECs refer ultimately to legislation on Human Rights. In the UK,
this has its basis in the Human Rights Act 1998, an act designed to give
further effect to rights and freedoms guaranteed under the European
Convention on Human Rights.26
The government department with responsibility for ensuring the
successful implementation of the Human Rights Act (1998) is the
Department of Constitutional Affairs.27
Northern Ireland also has the Northern Ireland Human Rights
Commission.28
For Medical Ethics, a primary source will be the Declaration of
Helsinki, a statement by the World Medical Association designed to
provide guidance to physicians and other participants in medical
research on human subjects (including research on identifiable human
material or identifiable data).29
With regard to animal experimentation, the Home Office provides
information on the use of animals in scientific procedures. Of particular
use to teachers is the section on Frequently Asked Questions which gives
some insight into the ethical issues of public concern.30
Within the National Health Service, the Governance
arrangements for NHS Research Ethics Committees (GAfREC) is the
All links are available live at http://www.prs-ltsn.ac.uk/ethics
26 See http://www.hmso.gov.uk/acts/acts1998/19980042.htm for the Human Rights Act,
http://www.hri.org/docs/ECHR50.html for the European Convention on Human Rights
27 http://www.dca.gov.uk/hract/hramenu.htm
28 http://www.nihrc.org/
29 http://www.wma.net/e/policy/b3.htm
30 See http://www.homeoffice.gov.uk/comrace/animals/ for further information.
16
primary source. It draws on the Department of Health’s Research
Governance Framework for Health and Social Care, in which particular
reference is made to:
the duties and accountability of all NHS organisations that agree to host any research,
whether undertaken by its own employees or by others (GAfREC 1.2)
The primary concern in any research study is identified as:
the dignity, rights, safety and well-being of participants (GAfREC 1.3.)
With regard to the education and training of REC members and
administrators, the regulations state that:
REC members have a need for initial and continuing education and training regarding
research ethics, research methodology and research governance.
Appointing Authorities shall provide, within the annual budget for its REC(s), resources
for such training, guidance on which will be issued by the Department of Health.
(GAfREC 4.10/11)
In addition to the relevant expert members, at least one third of
the membership of the REC should be made up of lay members, where
lay member is defined as a member who is independent of the NHS,
either as employee or in a non-executive role, and whose primary
personal or professional interest is not in a research area (GAfREC 6.5).
At least half of the “lay” members must be persons who are not, and
never have been, either health or social care professionals, and who have
never been involved in carrying out research involving human
participants, their tissue or data (GAfRE 6.7). The BBSRC’s advisory
group (mentioned above) has a similar lay component, while the British
Medical Association’s Medical Ethics Committee includes members
drawn from law and moral philosophy. It is worth bearing this point in
mind when preparing students to submit proposals to committees of this
type, since the information supplied must be accessible, as far as
possible, to people with no subject specific knowledge.31
All links are available live at http://www.prs-ltsn.ac.uk/ethics
31 http://www.doh.gov.uk/research/documents/gafrec.doc
17
LRECs and MRECs
Responsibility for reviewing research proposals to ensure that they meet
GAfREC’s stringent requirements is carried out within the NHS via
Local Research Ethics committees (LRECs) overseen by regional Offices
of Research Ethics Committees (ORECs). LRECs give permission for
research carried out within the boundaries of a single research site,
defined as the geographical area covered by one Health Authority.
Research carried out within the boundaries of five or more
research sites requires Multi-Centre Research Ethics Committee
(MREC) approval. For research undertaken within two, three or four
research sites, researchers can choose whether to make applications to
the LRECs for each site, or a single application to an MREC. 32
This system is coordinated and managed by the Central Office for
Research Ethics Committees or COREC. COREC provides useful
information on its web pages, including downloadable forms.33
COREC also has a training section which provides help in putting
together guides aimed at REC members and Administrators, but which
could also be of use to teachers aiming to familiarise students with the
way RECs function. There are plans to include additional information
such as sample cases, a core syllabus and common issues facing RECs
with the relevant ethical arguments.
Although this network exists principally to serve the needs of
research involving patients, service-users and staff, its Research Ethics
Committees may also provide an opinion on:
ethics of similar research studies not involving the categories listed above, carried out
for example by private sector companies, the Medical Research Council (or other public
sector organisations), charities or universities. 34
Scotland has its own MRECs and LRECs but Research ethics
appraisal is ultimately the responsibility of the Chief Scientist Office of
the Scottish Executive. The online resource “Scotland’s Health on the
Web” or SHOW offers information on ethical standards , including links
to online versions of the Adults with Incapacity (Scotland) Act 2000 and
the Confidentiality and Security Advisory Group for Scotland.35
All links are available live at http://www.prs-ltsn.ac.uk/ethics
32 These details were taken from the COREC website and apply to the end of February 2004. Please check the
web pages for updated information.
33 http://www.corec.org.uk/index.htm
34 http://www.corec.org.uk/whenToApply.htm
35 http://www.show.scot.nhs.uk/cso/index.htm
18
Wales currently has one MREC and a number of LRECs. Details
can be found via the web pages of the Wales Officer for Research and
Development for Health and Social Care.36
An idea of the way LRECs work can be obtained by visiting a few
sample websites:
Cambridge: http://www.addenbrookes.org.uk/serv/resethics/lrec1.html
North Cumbria: http://www.northcumbriahealth.nhs.uk/lrec/
Dyfed Powys: http://www.dyfpws-ha.wales.nhs.uk/ethics/
A complete list of Local Research Ethics Committees can be found
on the COREC website.37
Other Government Sources
The Health and Safety Executive (HSE) has a Research Ethics
Committee responsible for
the ethical conduct of studies which are designed to increase understanding of those
workplace factors that contribute to occupational ill-health or give rise to decrements in
performance which lead to an increased risk of accident. 38
It reviews proposal with reference to the following criteria:
Scientific validity
Justifiability (potential benefits versus risk of harm)
Non-maleficence
Confidentiality and Privacy
Informed Consent
The HSE’s ethics webpage has details of the application procedure
for REC approval, plus discussion papers and links to published
guidelines.39
Many other bodies have their own RECs:
Hospitals
All links are available live at http://www.prs-ltsn.ac.uk/ethics
36 http://www.word.wales.gov.uk/content/ethics/index-e.htm
37 http://www.corec.org.uk/index.htm
38 http://www.hse.gov.uk/research/ethics/index.htm
39 http://www.hse.gov.uk/research/ethics/index.htm
19
The Royal Marsden:
http://www.royalmarsden.org/research/ethics_committee.asp
University Hospital, Birmingham:
http://www.uhb.nhs.uk/about/research/ethics.htm
Glasgow Royal Infirmary:
http://www.ngt.org.uk/research/ethics/griethicscom.htm
Professional Organisations
See the UK Clinical Ethics Network web pages for a list of health-
related professional ethics bodies with ethics committees:
http://www.ethics-network.org.uk/Committee/professional/professional.htm
Examples:
The British Contact Lens Association:
http://www.bcla.org.uk/guidelines.asp
West Midlands Institute of Psychotherapy
http://www.wmip.org/council.html
Private Sector Employers
ADAS (Research based consultancy to rural and land-based
industries): http://www.adas.co.uk/home/policy.html?topid=4#ethics
Other independent organisations:
Dr Foster (an online service which ‘collects and analyses information
on the availability and quality of health services in the UK’).
See http://www.drfoster.co.uk/home/ethics.asp
Subject-Specific Approval
For some types of research, other types of approval may be required.
Embryo and Embryonic Stem Cell Research
The Human Fertilisation and Embryology Act, 199040 specifies that all
human embryo research conducted in the UK must be licensed by the
Human Fertilisation and Embryology Authority (HFEA). This act covers
the creation and storage of embryos in addition to their actual use in
research. Since 1991, when the act was amended to allow the use of
embryos in stem cell research, the HFEA has also been the regulatory
All links are available live at http://www.prs-ltsn.ac.uk/ethics
40 http://www.legislation.hmso.gov.uk/acts/acts1990/Ukpga_19900037_en_1.htm
20
body for embryonic stem cell research in the UK. The HFEA’s web pages
provide information on:
Accepted purposes for research of this type.
Current Research Projects licensed by the HFEA.
Research License application procedure
HFEA licenses are required in addition to the usual REC
approval.41
Xenotransplantation
The United Kingdom Xenotransplantation Interim Regulatory Authority
(UKXIRA)42 was established in 1997 on the recommendation of Advisory
Group on the Ethics of Xenotransplantation, formed under the
Chairmanship of Professor Ian Kennedy in 1995. It provides advice to
the Secretaries of State for Health, Northern Ireland, Scotland and
Wales on the actions needed to regulate xenotransplantation, including
“the acceptability of specific applications to proceed with
xenotransplantation in humans.”
The UKXIRA’s website is a useful source of information on their
background and terms of reference. There are downloadable versions of a
range of publications in addition to a specific guidance on making
proposals to conduct xenotransplantation on human subjects.43
Gene Therapy
Research involving somatic cell gene therapy (i.e. research on any cell
other than sperm or egg cells) must be vetted by the Gene Therapy
Advisory Committee (GTAC)44. At the time of writing (January 2004),
GTAC’s holds that all gene therapy is classified as research, on the
grounds that this procedure has not yet developed to the point where it
can be considered as treatment. GTAC’s terms of reference are:
To consider and advise on the acceptability of proposals for gene
therapy research on human subjects, on ethical grounds, taking
account of the scientific merits of the proposals and the potential
benefits and risks.
All links are available live at http://www.prs-ltsn.ac.uk/ethics
41 http://www.hfea.gov.uk/Research
42 http://www.doh.gov.uk/ukxira
43 http://www.doh.gov.uk/ukxira/
44 http://www.doh.gov.uk/genetics/gtac/
21
To work with other agencies that have responsibilities in this field,
including local research ethics committees, and agencies with
statutory responsibilities – the Medicines Control Agency, the Health
and Safety Executive and the Department of the Environment.
To provide advice to United Kingdom Health Ministers on
developments in gene therapy research and their implications.45
GTAC’s website provides information on research applications,
events and useful links, in addition to a range of downloadable
publications and research.46
Common Themes
As with Professional codes, the same issues and principles recur across
the network of RECs. There is also considerable consensus between
RECs and Professional Codes of Conduct. For example, the ESRC
identifies the following as minimal ethical standards:
Honesty : to research staff and subjects about the purpose, methods
and intended and possible uses of the research, and any risks
involved.
Confidentiality: of information supplied by research subjects and
anonymity of respondents.
Independence and impartiality: of researchers to the subject of the
research.47
For research involving human subject informed consent is also of
key concern.
With regard to the use of animals, the Wellcome Trust states that
it is
committed to the principles of reduction, replacement and refinement. 48
Applying the principle of reduction means reducing the number of
animals used to the minimum. The principle of replacement means that
the researcher will replace live animals with tissues (derived from
humans or animals) wherever possible. The principle of refinement
All links are available live at http://www.prs-ltsn.ac.uk/ethics
45 Taken from GTAC’s website, http://www.doh.gov.uk/genetics/gtac/
46 http://www.doh.gov.uk/genetics/gtac/
47 Taken from the ESRC’s web pages – http://www.esrc.ac.uk/esrccontent/ResearchFunding/sec22.asp
48 http://www.wel come.ac.uk/en/1/biosfginf.html
22
involves amending the design of the experiment to obtain the maximum
amount of information from the minimum number of animals (see the
pragmatic Case Study at the end of this section for a further
consideration of these principles).
Overall, despite the complex multi-layered nature of the REC
network, it is possible to construct modules relevant to students at
undergraduate, post-graduate and CPE level based around key ethical
principles and themes.
23
Clinical Ethics – the Power and the
Glory
Bryan Vernon
University of Newcastle
have been asked to contribute this article as a Lecturer in Health Care Ethics and a
member of a clinical ethics committee. The article demonstrates the ways in which
I an understanding of health care ethics has practical value in the real world of health
service Trusts.
I was in the unusual position to choose my own job title when I was
appointed. I deliberately selected the phrase ‘Health Care Ethics’ as, although the
majority of my work involves teaching medical students, the phrase ‘Medical Ethics’
implies that the ethical dilemmas doctors face are of a different nature from those
faced by other health care professionals. Similarly ‘Nursing Ethics’ implies that
nurses face different dilemmas. I would argue that a nurse who disagrees with an
order from a doctor is in a similar position to a registrar who disagrees with an order
from the consultant. I think it is too simplistic to say that nurses care while doctors
treat, as roles become increasingly blurred. The phrase ‘Health Care Ethics’ also
allows for the ethical dilemmas faced by managers whom other health care
professionals often glibly dismiss as acting from pure pragmatism.
When I chaired the Newcastle Mental Health NHS Trust in 1991 I formed
the first Trust clinical ethics committee in the UK. This was followed by an ethics
committee for one of the long-stay wards as staff grappled with issues raised by
their move into the community. I am a member of an ethics committee of a local
Trust for people with learning difficulties, a committee which meets infrequently, and
of the Newcastle Hospitals Clinical Ethics Advisory Committee which meets about
every six to eight weeks.
The Newcastle Hospitals Clinical Ethics Advisory Committee is chaired by
an old age physician and comprises the Chair of the Trust who is a surgeon, a
philosopher, a nurse philosopher, a social scientist and an ethicist. There are
consultants in palliative care, child health, intensive care and old age psychiatry and
a registrar in public health who chairs one of the LRECs as well as a nurse
consultant in old age and a nursing professor. Members give the impression that
their respect for one another goes beyond mere politeness and do not appear to
have adopted entrenched positions.
The committee exists to assist in developing a defensible resolution of
conflicting claims where there is no consensus about values in the provision of
treatment or care in a Trust setting. Our role is one of clarifying facts, assumptions
and the basis for the conflict and then testing possible solutions.
The definition of ethics that I value and frequently use comes from Al
Jonsen, who wrote, ‘Ethics is… the moral limitation placed on power. Thus the
origins of medical ethics lie in the realization that the power of knowledge and skill
brought to bear on the vulnerability of the sick can be used to exploit and dominate.
The ethics of service nourished in western medicine goes beyond prohibiting the
abuse of power and demands that power be dedicated to the strengthening of the
weak.’49
The use of power merits exploration. As a committee we say that anyone
has the power to refer cases to us. As yet the data is inconclusive as to whether
they do. A common feature of the ethics committees I have been involved with is
that there is an anxiety that there may be a flood of issues if too much energy is
devoted to seeking them out, and no clear idea as to how many issues per year
would be enough. What are the criteria here, and how can they be judged? There is
scope for considerable research here. Are Trust employees concealing ethical
issues that they would like to discuss? Would further education in Ethics uncover
ethical issues that staff had not noticed?
There are issues of power within the committee. While there are people on
the committee who are not employed by the Trust, they are sufficiently involved with
the Health Service to be atypical – but who can represent patients in such a forum?
There are more doctors than nurses, no hospital porters, cleaners or technicians.
We may hope that any hierarchy is challenged by the anarchy of the marketplace of
ideas. Ideas can emerge from many sources, and if they are good ones which
involve sound reasons they deserve to be adopted no matter what their
provenance. It is possible, though, that we are missing some insights because of a
shared set of assumptions that we are too myopic to see.
I would suggest that there are four qualities required of members of Clinical
ethics committees. The first is insight into ourselves and our own motivations. This
will never be absolute, but may be adequate. An awareness of personal and group
conflicts of interest is vital.
Secondly a member requires humility. There may be personal and
professional kudos attached to membership of an ethics committee – the glory of
the title of this piece – but we know that we rely on the insights of others whom we
hold in mutual respect to prevent us from believing that we are God’s gift to the
Trusts we serve. A moment’s reflection suggests that God might in fact have done
better.
Thirdly we need a BS detector. The practice of ethics can encourage a
certain preciousness among those who come within its orbit. We are probably all
guilty of this at some point or another, but better at seeing it in others than in
ourselves. A reader of this article may find examples that I have overlooked, and if
so, I apologise.
Finally we require some skill in ethical analysis. It is quite legitimate for
those who are not on the committee to question the authority of those who are. We
are members because we are thought to possess some kind of ethical expertise,
but this is an elusive quality. It is possible to demonstrate an ability to question
assumptions, to weigh evidence and to evaluate arguments. While the process may
be admirable, the outcome, as a decision, may be reached by entirely intuitive
means.
The educational challenge is to develop people with insight who have the
courage to ask difficult questions and who have the clarity of thinking to grasp what
these questions are. We need to develop team players, as most ethical issues are
in fact resolved as a result of good communication within teams, rather than in an
ethics committee.
All links are available live at http://www.prs-ltsn.ac.uk/ethics
49 Jonsen A.R. ‘The end of medical ethics’ Journal of the American Geriatrics Society. 1992:40;393-7
25
26
Ethics in Applied Research and
Teaching
Diane Beale
Institute of Work, Health & Organisations,
University of Nottingham
his paper discusses the management of the ethical implications of applied research
and teaching, particularly in areas concerned with personal and sensitive issues. It
T considers particularly research, teaching and practice in occupational and health
psychology, and related fields. It describes the role of an ethics committee in a
postgraduate institute in applied psychology to illustrate how some of the issues
might be addressed effectively to ensure ethical practice. It takes as a central
premise that researchers and students should be encouraged to “think ethically”
rather than simply apply a code or set of standards.
The Institute of Work, Health and Organisations carries out research in
areas such as work-related stress, violence, bullying & harassment; positive
emotions and behaviour at work; work-family conflict; selection and training
evaluation; knowledge management; health and safety management, and risk
assessment for psychosocial hazards; and management of chronic illness at work.
Many of these areas involve highly sensitive issues for the participants and
research is often carried out in co-operation with employing organisations.
The Institute provides research training for PhD students in all its areas of
research. It also provides a variety of Masters courses in occupational and health
psychology and their areas of overlap, as well as in more general research methods
in psychology. Some courses are accredited to provide the basis for chartership of
the British Psychological Society (BPS). Students come from a diverse range of
cultures and nationalities. Part of the training is to assist students always to think
careful y about the implications of their work.
The Ethics Committee
The Institute Ethics Committee was set up to oversee the application of ethics to the
activities of the Institute. Its responsibilities include:
to establish and follow procedures for evaluating ethical implications of Institute
research projects;
to agree standards based on the British Psychological Society (BPS) Code of
Conduct;
to ensure standards are met in all projects;
27
to act as a point of contact for staff to discuss ethical issues arising from their
research;
to educate students regarding ethics in research;
to ensure safeguards for researcher safety and welfare; and
to require conformity to the University’s Data Protection Policy.
The Ethics Committee requires an Ethics Submission to be completed for all
research projects. This ensures that the implications of all Institute research has
been thought through in terms of ethics as well as theory and methodology. The
submission includes:
a project description;
an Ethics Submission Form comprising:
a checklist of ethical features of the study, and
details of these and measures to address them;
materials, e.g. questionnaires, interview schedules, including
wording of introductions and consent forms.
All submissions have to be approved by two members of academic or
senior research staff who are not directly involved in the project. Any substantial
changes to the research require further approval.
The Ethics Committee comprises core members, who deal with the regular
ethics submissions from research-active staff, and act as a focus for discussion of
ethical problems that emerge from research. It also involves all members of the
Institute academic and research staff, plus PhD students, in a single dedicated
meeting to assess all the MSc students’ submissions for empirical research
projects. As well as sharing out the burden of processing so many submissions, this
exercise provides training for new researchers in identifying problematic ethical
issues. The Committee also has a number of external members who are able to
review procedures.
Ethical codes of conduct
The main ethical code that applies to this type of research in this country is the
British Psychological Society (BPS) Professional Code of Conduct, Ethical
Principles and Guidelines (2000). However, it is also instructive to take account of
codes from other countries, such as the American Psychological Association (APA)
Ethics Code (2002), and those covering allied disciplines, such as the World
Medical Association Declaration of Helsinki (2002), in order to gain a wider
appreciation of the issues.
The BPS Professional Code of Conduct covers issues of competence and
conduct. It requires psychologists to maintain and develop their competence, and to
recognise and work within the limits of that competence. It requires them to behave
professionally, not damaging clients or undermining public confidence. It contains
ethical principles for conducting research with human participants based on respect
and consideration for those participants. These are particularly important in dealing
with sensitive issues and traumatic experiences. Briefly, these principles include:
28
Obtaining valid and informed consent from participants. This involves providing
appropriate information to participants, and ensuring that they are both
competent to give consent and free to give it voluntarily.
Avoiding using deception, unless this is impossible because of the nature of the
phenomenon under investigation.
Providing adequate debriefing to complete participants’ understanding of the
research, particularly where deception has been necessary or negative
emotions might have been generated.
Allowing participants to withdraw from the research either during the procedure
or subsequently, and allowing them to withdraw their consent for their
contribution to be used.
Establishing and maintaining appropriate confidentiality.
Protecting participants from physical/psychological harm in procedures, and
from exacerbating any pre-existing conditions.
Preserving privacy in observational research.
Ensuring that colleagues observe ethical principles.
The APA Ethics Code (2002) advocates five general principles, which are
“aspirational in nature. Their intent is to guide and inspire psychologists toward the
very highest ethical ideals of the profession.” The principles indicate the wide-
ranging responsibilities for psychologists to apply in research and practice. They are
entitled “beneficence and nonmaleficence”, “fidelity and responsibility”, “integrity”,
“justice” and “respect for people’s rights and dignity”.
The World Medical Association Declaration of Helsinki (2002, para. 5) also
provides the concept of putting the welfare of the individual participant before the
good of society. “In medical research on human subjects, considerations related to
the well-being of the human subject should take precedence over the interests of
science and society.” This principle often comes into play in deciding the competing
interests of sponsoring organisations and individual employees in applied research,
as discussed in the next section.
Ethical responsibilities in research
Most codes of ethical conduct concentrate on the responsibilities of researchers
towards the participants, or subjects, of the research. They also deal briefly with
responsibilities to other members of the profession and to society as a whole.
However, for truly ethical research, there are wider and deeper implications that
should be taken into account. Researchers should recognise responsibilities to:
Participants in the research;
Sponsoring and host organisations, if applicable;
Themselves, as individuals;
Their colleagues; and
Their own organisations, including their academic institution, employer and
professional body.
One of the key dilemmas that is ever present when working with
organisations is balancing the requirements of, and responsibility to, the host
organisation with responsibilities towards the employees who participate in the
29
research. In particular, both parties have to be given realistic expectations about
confidentiality. Reports back to the management have to protect the identity of
participants as far as is reasonable without undermining the value of the research,
which the organisation may have paid for in the first place. Participants should be
informed of the safeguards put in place to protect their anonymity or, if anonymity
cannot be guaranteed, they should be made aware that their identity may be
apparent in reports.
Further responsibilities come into play with regard to organisations. There is
an obligation to provide useful feedback to a host organisation whether or not it has
commissioned the research. Further, any recommendations made must take into
account the implications for the organisation, should be realistic and based on
sound evidence, with the limitations of the research properly explained. An
associated responsibility concerns the publication of research, where confidentiality
should apply to host organisations as well as participants. Specific permission
should be obtained from an organisation to identify it in any publication.
Researcher safety and well-being
One aspect of ethical research that has rarely been mentioned in ethics literature is
the welfare of the researchers themselves. In particular, the safety of research
assistants and students in collecting data is rarely considered, except in terms of
specific laboratory safety procedures, or similar. Paterson, Gregory and Thorne
(1999), as a notable exception, have attempted to address aspects of this problem
by designing a protocol for researcher safety in field research. However, a more
complete consideration encompasses not only physical safety but also
psychological well-being and personal reputation.
Physical safety relates to risk from accident, illness or violence. These might
occur in relation to a number of situations in applied research including travel, lone
and night working, and the inherently dangerous working conditions within some
industries. It is incumbent on research supervisors to ensure that there are
adequate personal safety measures included in arrangements for data collection.
These might include, for example, researchers notifying a colleague of their
whereabouts, time of return, a contact number, and what to do if they do not return
at the time expected. Night working might require working in pairs or, at least,
provision of safe transport. Working in a number of industries might involve
exposure to dangerous situations where training in, and adherence to,
organisational safety procedures is vital. It is important that such training, any
necessary supervision and insurance issues are negotiated with the host
organisation at the beginning of a project.
Risks to psychological wel -being might come from such things as exposure
to distressing information. Work-related violence, and health and safety
management are obvious research areas that may require researchers to view
disturbing reports or CCTV footage, or to conduct interviews with victims of
traumatic incidents. It is important that safeguards are in place to ensure that
researchers are not adversely affected by such exposure and have regular
opportunities for debriefing and discussion. Equally, supervisors should ensure that
researchers are not placed in situations where they are vulnerable to harassment or
intimidation, for example a female researcher going into an unknown all-male
environment, or vice versa. Conversely, they should be careful not to put
30
themselves into situations that might compromise their reputation or be open to
misinterpretation as being illegal.
Data Protection
A final area that can be included in the scope of ethical working comprises data
protection issues, largely because of links with confidentiality and consent. Most
organisations now have a code of practice with which researchers should comply.
In line with legal requirements these pertain to:
Obtaining data, i.e. ensuring that only data in which there is a legitimate
research interest is collected, and ensuring that participants have given consent
having had information about use and storage of the data;
Processing and securely storing the data, whether hardcopy or electronic;
Disclosing the information only to individuals and in circumstances agreed by
the participants;
Deleting or archiving information, again in circumstances agreed by the
participants, after a given period or for a given reason.
These guidelines require researchers to have respect for the information
supplied by participants and to be scrupulous in the use that is made of this
information.
Ethics in Teaching
In the teaching of ethics the Institute staff aim to develop an appreciation of ethical
issues in applied psychological research, increase awareness of relevant ethical
codes of conduct, and provide practical experience of preparing a submission to an
ethics committee. Further than that, they aim to encourage students to “think
ethically” rather than simply adhere to a set of rules or guidelines. This involves
thinking through any intended research and considering what effect it might have on
the participants, any organisations involved and others parties. In addition, they aim
to increase awareness of researcher safety and data protection issues.
These aims are achieved both via specific lectures and workshops, and by
incorporating ethical considerations into all teaching. All taught courses include an
early lecture in the basic methods and philosophy module. More detailed
consideration is given in a lecture in the professional and ethical issues module,
including group work examining a range of research scenarios. Specific ethical
issues are included in teaching for particular subject areas, for example for
selection. In addition, Masters students complete an empirical project for which they
have to complete and submit an Ethics Committee submission, following a practical
workshop. For research students there are also Institute Research Days, which
regularly include workshops and discussions on particular ethical issues that have
emerged in the course of Institute research projects.
Conclusion
In conclusion, the Ethics Committee sees its role as keeping all researchers alert to
ethical issues in order to protect against inadvertent risks to participants,
31
researchers and associated organisations. It promotes high ethical standards from
all and teaches good practice to novice researchers. To achieve this effectively, it
attempts to keep abreast of developments in practice, law etc. and to ensure that
new issues are debated and consensus reached.
References
American Psychological Association (APA) Ethics Code (2002). Retrieved
December 6, 2003, from http://www.apa.org/ethics/
British Psychological Society (BPS) Professional Code of Conduct, Ethical
Principles and Guidelines (2000). Leicester: BPS. Retrieved December 6,
2003, from http://www.bps.org.uk/about/rules5.cfm
Paterson, B. L., Gregory, D., & Thorne, S. (1999). A protocol for researcher safety.
Qualitative Health Research, 9(2), 259-269.
World Medical Association Declaration of Helsinki (2002). Retrieved December 6,
2003, from http://www.wma.net/e/policy/b3.htm
32
e. A Case Study
Scenario
Extract from a Research Proposal designed to test the effects of exposure
to fertiliser XYZTM on kidney function.
Experimental Subjects – 100 healthy, six week old rats. Mixed
sex. Approved supplier.
Maintenance: The rats will be housed in individual plastic tanks
with food and water available 24/7 in the University’s purpose built
facility. They will be cared for and monitored round the clock by trained
and experienced staff.
Palliative Care: Previous studies (Smith et al. (1999) suggest that
rats exposed to higher levels of XYZTM may develop minor skin lesions
over the last four or five weeks. Topical analgesia will be administered to
minimise discomfort.
Experimental Procedure: The rats will be divided randomly into 4
groups of 25 and exposed to varying levels of XYZTM administered in
their drinking water.
Group 1 – Control (no exposure to XYZTM)
Group 2 – Exposed to 10 parts per million of XYZTM
Group 3 – Exposed to 100 parts per million of XYZTM
Group 4 – Exposed to 1000 parts per million of XYZTM
At the end of the 3 month exposure period the rats will be
despatched humanely and their kidneys removed for microscopic and
biochemical analysis.
Ethical Issues
This scenario is designed primarily to help the students understand the
principles of reduction, replacement and refinement. This would mean
asking three key questions:
1) Reduction: Could a comparable experimental outcome have been
achieved using fewer rats?
2) Replacement: Could a comparable experimental outcome have been
achieved using a cultured kidney tissue cell line rather than live
animals?
3) Refinement: If the use of live animals is appropriate, does the
experiment maximise the amount of information that could be
obtained from their use. Could the experiment be modified in order to
produce more/better results without increasing the number of
animals or causing them additional distress? Students would be
expected to show an awareness that refinement might sometimes
indicate using more animals, because if the numbers proposed are too
few to generate statistically significant results then those few rats
will have been sacrificed needlessly.
Students might gain additional credit for noting the reference to
previous studies, and asking whether the proposal is merely duplicating
work carried out elsewhere.
An introduction to the principles of reduction, replacement and
refinement can be provided by the extract alone. In these circumstances
students would be asked only to:
recognise the relevance of the principles to the proposal;
indicate which parts of the proposal would give cause for concern;
indicate the questions that would be asked;
suggest the kinds of additional information that might have been
provided by the research applicant to show an awareness of the
principles of reduction, replacement and refinement.
In the absence of more information about the research, they
would not be able to evaluate whether the research met the
requirements of these principles.
However, for more experienced students, the extract could be
expanded to provide a fully defined dummy research proposal, with all
the relevant scientific background, procedures etc. filled in. Students can
then be invited to review the proposal as if they were a REC member,
evaluating whether the research does actually fulfil the relevant ethical
criteria. This would be a more demanding task and would also be time
consuming, but can be a useful format for group work.
34
2. Embedded
a. Introduction
In contrast to the pragmatic and theoretical approaches, it is possible to
teach ethics via the embedded approach without ever mentioning the
words ‘ethical’ or ‘moral’. Students study ethics indirectly, by considering
some area of professional interest which has a significant ethical
dimension but which is not confined to it.
This is not to say that students will not be asked to abstract the
‘ethical’ and subject it to scrutiny, or that there are no advantages to
encouraging some level of overt ethics awareness. As stated in the
introduction to the Approaches section of this guide, the ‘embeddedness’
of the title refers principally to the student’s ‘way in’ to the subject. There
is no reason why they should not explore more ‘pragmatic’ or ‘theoretical’
avenues once inside but it worth noting that this does not always happen
in practice, so that for some students ethics in Higher Education is an
essentially embedded topic.
Ethics learning and teaching can be embedded in terms of its
objectives and/or its mode of delivery.
The remainder of this chapter will consider two forms of
embeddedness with respect to objectives; ethics as a dimension of what it
means to be a Professional and ethics as a component of Fitness for
Practice.
There will also be a consideration of three embedded ways in
which ethics learning and teaching can be delivered, namely through
Reflective Practice, Drama and Narrative. The last of these modes of
delivery will be addressed in more detail by a guest contribution from
Deborah Bowman Senior Lecturer in Medical Ethics and Law at St
George’s Hospital Medical School, University of London, in a paper that,
considers the use of humanities as one imaginative device for facilitating learning in
healthcare ethics and argues that narrative and emotion are powerful tools for engaging
teachers and learners alike.
The final part of this section will present a case study defined in
the narrative format.
35
b. Professionalism and Interprofessionalism
Benchmarking statements and professional codes of conduct indicate
that Professional Ethics are now seen as an integral part of a graduate’s
ability to function effectively in the workplace. As a result, ethics may be
embedded in the rapidly evolving notion of what it means to be a
Professional, an ideal that links ethical behaviour to interpersonal
communication, professional competence and management skills rather
than a facility with moral theory.
For example, the General Medical Council’s Duties of a Doctor50
include the following:
• Treat every patient politely and considerately
• Recognise the limits of your professional competence
• Be honest and trustworthy
• Respect and protect confidential information
• Make sure that your personal beliefs do not prejudice your patients’ care
• Act quickly to protect patients from risk if you have good reason to believe that
you or a colleague may not be fit to practise.
By substituting the appropriate alternative to ‘patient’, any or all
of these duties would be applicable to any profession. Though all have
some ethically significant content, they go beyond moral concerns, and
serve the general aim of maintaining public confidence and professional
reputation.
Most of these duties have already been noted in the preceding
discussion of the Pragmatic approach. This serves to highlight that it is
not learning and teaching content that is at issue here, but the way in
which it is presented. In the pragmatic approach students learn about
honesty, non-discrimination, competence etc. as part of a code of practice
that will be enforced by professional (and in many cases legal) sanctions.
In the embedded approach, they address these themes by developing a
sense of professional identity and a consequent way of working which is
imbued by desirable ethical professional values and behaviours.
One important difference between the pragmatic and embedded
approaches to professionalism is that while the former sees regulation
All links are available live at http://www.prs-ltsn.ac.uk/ethics
50 http://www.gmc-uk.org/standards/default.htm
36
and the raising of standards as (in the first instance, at least) a set of
externally imposed constraints, the embedded approach has a greater
emphasis on personal autonomy. Ethics embedded in the notion of
Professionalism or Fitness to Practice mandates that the individual
takes responsibility for improving their own performance via a self-
directed process of continuing professional development throughout their
working lives. For example, the Duties of a Doctor include keeping their
professional knowledge and skills up to date, 51 while The International
Confederation of Midwives (ICM) states
actively seek personal, intellectual and professional growth throughout their midwifery
career, integrating this growth into their practice. 52
The ICM requirement quoted above emphasises the holistic
notion of the professional which is at issue here. This holism will find its
counterpart in the concept of the service- user discussed in the following
section on Fitness for Practice, and will also be seen to be reflected in the
methods of delivery most often associated with the embedded approach.
Rather than abstracting ethically significant behaviours from their
broader context, the embedded approach leaves them in situ,
encouraging students to acquire professional behaviour patterns which
serve a number of ends simultaneously and, wherever possible,
synergistically. An important part of this involves acquiring the ability to
work with others, so that ethics embedded in the notion of
professionalism, is further embedded in the notion of
interprofessionalism.
Interprofessionalism is of growing importance in contexts such as
scientific research and product development. For example, the
benchmark statement on engineering states that:
Engineers frequently work in multidisciplinary teams and need to understand the
relationship of their work to that of other specialists and to be able to communicate with
them. The essential features of this include communication and interpersonal skills,
accountability, professional ethics and organisational management, all of which are
expected to be refined and developed in the person’s career.53
Here we have ethics embedded in the notion of an
interprofessional worker for whom ethics is not a separate skill or a
All links are available live at http://www.prs-ltsn.ac.uk/ethics
51 http://www.gmc-uk.org/standards/default.htm
52 http://www.internationalmidwives.org/
53 http://www.qaa.ac.uk/crntwork/benchmark/engineering.pdf, p.6.
37
defined way of thinking but merely one aspect of collaborative working
practice.
Health and social care in particular have been subject to
increasing political pressure to deliver integrated services. 54 Malin et al.
noted that Labour government policy requires a much closer
harmonization across the primary health–social care boundary.
With the present government placing great emphasis on collaboration, professionals
skilled at working across organizational boundaries are in high demand. 55
As might be expected, the ability to ‘work with colleagues in the
ways that best serve patients’ interests’56 is a key requirement within
the medical profession.
Even where service provision relies on nominally independent
professionals there is pressure for collaboration to secure public welfare.
For example, the Royal College of Veterinary Surgeons recognises the
links between animal and child abuse and offers advice and support to
members on balancing the conflicting claims of client confidentiality and
the obligation to report cases of suspected child abuse. 57
There are signs that Higher Education is already beginning to
recognise the advantages of incorporating multidisciplinary education
and training provision into their pre-registration programmes. For
example, the Dundee University School of Nursing Mission Statement
includes a commitment to “encourage further development of multi-
professional learning between medical, nursing and midwifery students
and social work.”58 The LTSN subject centre for Health Sciences and
Practice recently commissioned a review to “help teachers engage
effectively in interprofessional education”. 59 The use of interdisciplinary
learning as a means towards the end of greater interprofessional
cooperation is not, in itself, limited to ethical concerns but the Peach
All links are available live at http://www.prs-ltsn.ac.uk/ethics
54 NHS Executive, 1998; Department for Health and Personal Social Services, 1998; Scottish Office Department
of Health, 1999; Welsh Office, 1998)
55 Malin N. A, Wilmot S, & Beswick J. A. (2000) ‘The use of an ethical advisory group in a learning disability
service’, Journal of Learning Disabilities, Vol. 4(2), 105-114, 2000 (10)
56 http://www.gmc-uk.org/standards/default.htm
57 http://www.rcvs.org.uk/vet_surgeons/pdf/advice/animabuse_Mar03.pdf
58 http://www.prs-ltsn.leeds.ac.uk/ethics/event.html
59 LTSN Centre for Health Sciences & Practice (2002) Interprofessional Education: Today, Yesterday and
Tomorrow: A Review, London: LTSN
38
Report60 concluded that the subjects seen to offer most scope for shared
learning were ethics and communications skills. 61
In more general terms, interdisciplinary classes can be used to
facilitate mutual respect and understanding between the professions.62
The more closely teaching and learning opportunities mimic real
working conditions, the more effectively they prepare students to meet
the challenges they will face in their chosen sphere. The ability to arrive
at a morally defensible course of action in concert with co-workers from
other professions is an essential component of this preparation and
interdisciplinary groups can contribute by enabling students to
understand the diversity of moral opinion, and the ways in which
consensus can be reached in a complex and fluid working environment.
c. Fitness for Practice
Courses in Higher Education normally lead to the award of certificates,
diplomas and degrees in recognition of the student’s achievement of a
given level of academic achievement but for subjects such as medicine,
nursing, pharmacy, dentistry, social work and education, graduation will
normally lead directly or indirectly to registration This means graduates
in these disciplines must meet behavioural standards in addition to
academic criteria to ensure their Fitness to Practice.
Fitness for Practice will normally include the duties specified in
the preceding section on Professionalism and Interprofessionalism, but
in service professions these duties are extended to define the general
Duty of Care that these service-providers have towards their service-
users. The GMC’s definition of the Duties of a Doctor emphasise the
importance of showing respect for the patient’s dignity and privacy, and
also reflects the move towards greater client-centredness evidenced
throughout health and social care. The doctor has a duty to:
respect the rights of patients to be fully involved in decisions about
their care;
listen to patients and respect their views;
give patients information in a way they can understand;
make the care of your patient your first concern.
All links are available live at http://www.prs-ltsn.ac.uk/ethics
60 Peach L. (Chair) (1999) Fitness for Practice, Commissioned by The United Kingdom Central Council (UKCC)
for Nursing, Midwifery and Health Visiting,
http://www.nmc-uk.org/cms/content/Publications/Fitness%20for%20practice.pdf
61 Ibid. Para. 5.39.
62 Ibid.
39
The conception of the client on which Fitness for Practice is based
is an increasingly holistic one. For example, midwives are required to:
be able to analyse human occupation from an holistic perspective and the demands
made on individuals in order to engage in occupations63
Similarly, radiographers must:
understand the need to respect, and so far as possible uphold, the rights, dignity and
autonomy of every patient including their role in the diagnostic and therapeutic
process.64
A key objective in promoting client-centredness is to empower
them. For example, within social work, Barnes and Hugman argue that:
The positive effect of social work responses to contemporary social theory can be seen
in the move away from a ‘problem’ focus to a ‘growth/strength’ focus, with intervention
essentially controlled by the ‘client’. 65
Registrant occupational therapists must be aware of the:
evolution of the profession towards the current emphasis on autonomy and
empowerment of individuals, groups and communities66
while midwives support:
empowering women to speak for themselves on issues affecting the health of women
and their families in their culture/society.67
Finally, confidentiality, while present in the broader notion of
professional behaviour, is central to the notion of Fitness to Practice, and
is defined in the context of a relationship of trust between service-
All links are available live at http://www.prs-ltsn.ac.uk/ethics
63 http://www.internationalmidwives.org/
64 http://www.hpc-uk.org/publications/standards_of_proficiency_ra.htm
65 Barnes D.; Hugman R. ‘Portrait of social work’, Journal of Interprofessional Care, Vol. 16, no. 3, pp. 277-288
66 http://www.hpc-uk.org/publications/standards/Standards_of_Proficiency_Occupational_Therapists.pdf
67 http://www.internationalmidwives.org/
40
provider and service-user, in which the provider’s responsibilities are
oriented towards the needs of the service-user. Gastmans gives the
following examples of patient-oriented responsibilities:
• Entering into a confidential relationship with the patient.
• Providing comfort and preserving human dignity in the face of pain and
extreme breakdown.
• Presencing (being with a patient); providing comfort and communication
through touch.
• Guiding patients through developmental and emotional changes.
• Helping patients to cope with the lifestyle consequences of their illness.
• Interpreting the illness by allowing patients themselves to verbalize and
understand.68
Professionalism and Fitness for Practice define ethics in strongly
relational terms, but where the former concentrates on interactions with
other professionals, Fitness for Practice is centred on interactions
between professional and service-user as mediated through an
overarching Duty of Care. Ethical considerations will be a vital part of
this duty of care, but ethics embedded in the notion of Fitness to Practice
is seen as an integral part of a broader behaviour and skills set and
cannot be abstracted without changing its nature.
The theoretical approach considered later in this guide (p*) often
concentrates on what Seedhouse terms specific or ‘dramatic ethics’ such
as end of life issues and the domain of the tragic choice.69 However,
much of Fitness for Practice is concerned with what Seedhouse calls
“persisting ethics”; the underlying ethical issues that underpin daily
working practice. Ashcroft argues that “[m]edical ethical problems …
must be identified as features of an evolving medical Scenario”. 70 These
scenarios will involve a multiplicity of factors, only some of which will be
morally significant and good ethical judgement will often be implicit – a
way of acting rather than an interval of reflection and analysis. The
professional must respond speedily, assessing the situation and “seeing”
All links are available live at http://www.prs-ltsn.ac.uk/ethics
68 Gastmans, C. (1998) ‘Challenges to Nursing Values in a Changing Nursing Environment’, Nursing Ethics, Vol.
5. no. 3, pp. pp. 236-245
69 Seedhouse D. (1998) Ethics: The Heart of Health Care, John Wiley & Sons: Chichester, p.39
70 Ashcroft R.E. (2000) ‘Teaching for Patient-Centred Ethics’, in Medicine, Health Care and Philosophy 3: pp.
287–295
41
how they should proceed without being aware of any deliberative
procedure. Accordingly, their training must help them to reach a point
where their knowledge and understanding is so firmly embedded that
correct decision-making is a rapid and seamless process resulting in
actions that feel like second nature.
The following section will consider some teaching methods
through which this somewhat ambitious learning and teaching objective
might be pursued.
Note: In addition to the professional codes cited above, a detailed review of Fitness for
Practice as it applies to nursing and midwifery can be found in the Peach report.71
d. Methods
A common theme to emerge from discussion at the ETHICS Project
workshops was the importance of demystifying ethics for both teachers
and students. For many, this meant an avoidance of deep theory in
favour of teaching via role-play, practice-based learning, narrative and
other methods designed to help students engage in the moral issues as
real challenges that they can expect to face in their working lives.
In some courses it may be possible to embed ethics learning and
teaching in pre-existing modules, so that from the students’ point of view
it becomes almost invisible. For example, Ashcroft notes that in medical
ethics,
most assessments can be done as elements of assessment in, say, pediatrics, and in
the form of clinical problem-solving exercises (often with actors or real patients).72
There are many embedded teaching methods in use, and the
variety is likely to increase as teachers look for new ways to make ethics
accessible to students from a variety of backgrounds, but for the
purposes of this guide, three methods will be considered in a little more
detail to give some idea of how the approach works in practice. What
they all have in common is that they present ethics embedded within a
complex situation that acts on students at many levels:
rational/emotional, personal/professional, objective/subjective,
conscious/subconscious. Morally significant decisions taken within this
All links are available live at http://www.prs-ltsn.ac.uk/ethics
71 http://www.nmc-uk.org/cms/content/Publications/Fitness%20for%20practice.pdf
Peach L. (Chair) (1999) Fitness for Practice, Commissioned by The United Kingdom Central Council (UKCC) for
Nursing, Midwifery and Health Visiting
72 Ashcroft, R.E. (2000) ‘Teaching for patient-centred ethics’, Medicine, Health Care and Philosophy Vol. 3: pp.
287–295
42
context are similarly embedded, with agents making choices in which
they must weigh up such things as the practical effectiveness of the
courses of action available to them, their competence to pursue those
courses of action, the risks (to the service-user, themselves and others)
and the dynamics of their relationship with the service-user (both social
and emotional) in addition to evaluating it against ethical criteria, often
in circumstances that require that decision to be made in a matter of
moments.
43
i. Reflective Practice
Reflective practice involves students taking a ‘deep’ approach to learning
by reflecting on what they have learned within the context of their whole
life’s experience. They do this in order to:
Better understand their own approach to learning
Consider how they might build and improve upon it.
Fitness for Practice requires
life-long self-directed learning and
Reflective Practice meets these
criteria as it allows practitioners to
develop techniques that can be
readily incorporated into their own
modus operandi.
Within medicine and
healthcare, the concept of reflective
processes in education has become
increasingly valued as a means of
enabling students to analyse their
learning experiences in order to
gain a new understanding and
insight. Reflective practice assists in
the integration of theory with
practice and this helps students to
improve their clinical reasoning skills. In nursing and psychology,
reflective practice is a key activity in continuing professional
development73,74.
Learning outcomes from a successful application of reflective
practice include:
Learning to think critically about the learning process
Learning to think creatively and innovatively about one’s own
performance
Learning to implement those innovations and transform one’s own
practice (and through example, that of others).
The first of these, acquiring a critical approach to the learning
process itself, can be of particular utility in professional ethics where
All links are available live at http://www.prs-ltsn.ac.uk/ethics
73 Peach L. (1999), op. cit. Section 4.23
74 The British Psychological Society, Division of Clinical Psychology: Policy Guidelines on Supervision in the
practice of Clinical Psychology: http://www.bps.org.uk/documents/DCP_SupervisionGuidelines.pdf
44
teachers may feel that they are on as steep a learning curve as their
students. Central to reflective practice is:
the ability to recognise and understand one’s underlying assumptions about the
meaning of teaching and learning in the subject and one’s habitual responses to
teaching situations, and the ability to interrogate the relationships between these. 75
Teachers do not always attain the levels of self-awareness in
relation to their teaching that they recommend to students as learners.
However if students become skilled in reflective practice this helps to
generate a constructive and collaborative learning environment in which
the student is an equal partner in the learning process rather than a
passive or subordinate recipient of the teacher’s expertise. In this
atmosphere, teacher and student may hope to learn from one another,
and to improve their performance as exponents and practitioners of their
subject and as self-learners; a synergy which is of great benefit in a
contested and rapidly evolving subject such as professional ethics.
Teaching and learning resources on the use of reflective practice
can be found on a number of LTSN websites (see the end of this section
for details). Although the subject areas vary, it will be seen that the
process of reflective practice is broadly similar across disciplines and can
be applied directly to the teaching of ethics.
Reflection requires attention to:
Description and Observation
Self-awareness
Diversity of culture – this is important as people are used to different
forms of reflection
Analysis and interpretation
Planning76
There are many ways in which students can reflect on their
performance, varying from reflective essays, presentations, group
discussion, feedback from teachers/facilitators/ mentors and self-
evaluation to more complex outputs such as the preparation of a
learning portfolio.
The advantages of this learning and teaching method for
professional ethics lie in the extent to which it involves the student in
their own education, both during and after Higher Education
All links are available live at http://www.prs-ltsn.ac.uk/ethics
75 http://hca.ltsn.ac.uk/resources/guides/refl_praca.php
76 http://www.lancs.ac.uk/palatine/report-reflective-practice.htm
45
It is a matter for discrimination and judgement how far the
student should be encouraged to give overt and conscious attention to
the moral implications of their behaviour, or whether they should judge
their performance against some broader notion which has ethical values
embedded in it.
Web based sources on the use of Reflective Practice:
UK Centre for Legal Education (LTSN Subject Centre for Law):
http://www.ukcle.ac.uk/resources/reflection/
Palatine (LTSN Subject Centre for the performing arts):
http://www.lancs.ac.uk/palatine/report-reflective-practice.htm
Subject Centre for History:
http://hca.ltsn.ac.uk/resources/guides/refl_praca.php
46
ii. Drama
Live drama can offer an exciting and energising way of presenting
embedded ethical issues. It can be utilised in two ways within the
embedded approach, dependent on whether students observe as an
‘audience’ or alternatively, take an active part in the role-play.
Use of Actors
In this format, the actors are not themselves involved in the learning
process (at least as far as professional ethics are concerned). The use of
real people, present in person, helps to engage students’ attention and
arouse their concern. The actor(s) may speak directly to the audience, as
for example, a patient describing an encounter with a doctor, thus
creating a direct relationship between their character and the students.
If done effectively, this can produce a high level of engagement in the
students, both intellectually and emotionally.
The students need not be confined to an entirely passive role; they
can become participants in the drama by being invited to pose questions
that the actor will then respond to in character (‘respond’ is used here in
the dramatic senses of the word and should not be taken to indicate that
the character will answer the question constructively or even at all). As
this format requires the actor to go beyond the pre-prepared material the
success of actor/student dialogue will depend heavily on the actor being
given adequate preparation before the class, both in terms of the factual
content of their character’s situation and the character itself. In some
cases, a real service-user or client can be asked to present a role of which
47
they have some personal experience. This gives them a stronger basis on
which to improvise answers to unscripted questions, but preparation is
equally important to ensure that they are not distressed by the
experience.
The need for improvisation can be avoided if the actors work
entirely from a script. While this means that students will remain more
passive with respect to the drama, they can still be drawn into a more
active role by asking them to discuss and report on their reactions to
what they have seen. An external perspective can be introduced by
asking the actors to join in the discussion, but this time as themselves,
drawing on their experience of playing the character and contrasting it
with how they themselves might have felt in the same situation.
Another alternative for dramas that depict a professional making
a morally significant choice is for the scene to be written with a number
of alternative outcomes, dependent on the choice made. Students can be
invited to view the drama up to the moment of decision before be asked
to state which option the professional should take, either individually or
following group discussion. The actors then return to play out the
appropriate ending so that students can view and consider the projected
outcome of their choice.
The use of actors can be expensive although there are resources
available that can be accessed (see the end of this section for details).
Another alternative for institutions that have schools of drama or
student theatre groups is to involve students external to the ethics
module in acting roles.
One advantage to performance-based ethics teaching is that it can
be readily adapted to lecture-based formats, where classes must be
offered to large numbers of students at a time, and without the
opportunity to prepare the students via seminar or other forms of small-
group work.
Performances can also be videoed and reused for subsequent
classes. This will be of particular benefit in allowing students to draw on
and evolve their interpretation of the performance in subsequent classes.
Recorded material can also be used as the primary mode of delivery
although this may result in a lesser level of engagement.
Use of Student Role-Play
If the students act the parts from themselves, role-play can become an
integral part of the learning process. There are many scenarios that can
be deployed here – mock trials, professional/service-user interactions,
product-development teams and public debates being but a few. Role-
play can be particularly effective if students are allocated roles that
diverge from their own personality, so an important decision to be made
48
when formulating teaching materials of this type is how roles will be
allocated and whether every student will be required to take a role.
Most of the same options that were discussed in the preceding
section on the use of actors will have some application here too, but with
the additional possibility of having no audience at all for the final
performance (it might be appropriate for the teacher/facilitator to take a
participatory role).
There need be no script for role-play of this type. Rather, students
are provided with information about their character’s situation and
personality on the basis of which they are asked to improvise. This
information can be detailed, or can take the form of an outline that
students must research and fill in for themselves.
Performances may be videotaped to facilitate discussion, feedback
and evaluation (be it self-evaluation, peer evaluation, or evaluation by
teacher/facilitator/external evaluator) but it should be born in mind that
this can make the experience more stressful for some students. If there is
an intention to use the recording as a future learning and teaching
resource, consent should be sought from the students involved in the
performance.
In addition to opportunities for role-play, the use of drama can be
extended by inviting students to contribute to the writing of the script.
This offers students who are uncomfortable with the idea of ‘performing’
to make a contribution, in addition to broadening the potential of the
format as a learning and teaching device.
Outcomes
Whether the mode of delivery uses actors or student role-play, drama
can be used to enrich students’ perceptions of morally significant
situations by helping them to:
Think from multiple perspectives with regard to culture, gender,
religion etc.
Understand the service-user’s point of view
Empathise with others, even those with characters divergent from
their own
Promote a holistic view of professionals and service-users
Comprehend what it feels like to make decisions under pressure and
in sub-optimal conditions
Resources
Psci-com — a guide to Internet resources on public engagement with
science and technology, including Drama and Science.
49
http://www.psci-
com.ac.uk/browse/detail/205b8c9a6b18d476abc94908e0280ea5.html
Drama as a Teaching Tool in Bioethics:
http://bio.ltsn.ac.uk/events/reports/stirling2003ethic.htm#drama
The YMCA’s Y Touring theatre group.
http://www.ytouring.org.uk/science/
50
iii. Narrative
Discussion of morally sensitive issues can become over-heated if they are
handled incorrectly. This is of particular concern when students are
asked to draw on their own experience to provide cases or scenarios for
consideration for they will then have a personal stake in the subject
matter. In general, a moderate distance from the issues is conducive to a
balanced and constructive debate. One advantage of using narrative
(drawn from books, films television etc.) over stories drawn from
personal experience is that it allows a degree of emotional or empathic
response without the close identification that one gets when people
describe their own actions, or actions that have impacted on them
personally.
There is some overlap between the drama and role-play discussed
in the preceding section and the use of narrative, but narrative drawn
from films, plays and television dramas/documentaries is fixed and
therefore not susceptible to direct student interaction. However, it can be
equally productive as a stimulus to debate and discussion, both verbal
and written, of the issues raised. Further, narrative is not limited to
dramatic forms but extends to include the use of other written texts
(both fictional and biographical and poetic, plus visual art (both painting
and photographic).
51
In many cases, the student may have prior experience of the
narrative resource, and it can be instructive for them to contrast their
previous reaction to the more reflective response prompted by a
narrative-based ethics learning and teaching module. Narratives that
are already in the public domain can be discussed without concern over
the infringement of confidentiality or informed consent requirements.
Since many texts are normally read for pleasure, pre-seminar reading is
more likely to have been done, and done thoroughly.
Written texts such as novels or biographies, with their intense
and detailed depiction of a person’s inner life, can offer an excellent way
of conveying the nebulous nature of real-life ethical decision-making; a
realisation that learners in Higher Education have normally reached
with respect to their private lives but which does not always get
translated into the professional domain. In the past, professional ethics
learning and teaching has sometime reinforced this division but over
recent years there have been moves to a more holistic interpretation. For
example within medicine, instead of a conception of the patient as ‘the
appendectomy in bed three’, one now begins to find an appreciation of
the fact that:
[I]n the context of a patient’s life … sets of consequences and options are usually fuzzy
and open. The role of narrative ethics as a supplement to virtue ethics (and the ethics of
care popular in nursing circles) is to handle decision-making in the context of a patient’s
life-story; something which is rarely, if ever, linear.77
The link between the concept of a service-user’s life story – their
tendency to perceive their own real experiences as a narrative – and the
use of written or dramatic texts is a key concept in the use of narrative
as a learning and teaching method.
Modules designed with these objectives in mind aim to develop
empathy by encouraging the use of ‘thick’ descriptions in which the
students’ own emotional reactions to the case and the client’s character
or family circumstances are all admitted as relevant factors in moral
deliberation.78
Visual texts such as drama or iconic images can be an excellent
resource for sensitising students to the importance of non-verbal
communication when considering ethical issues. For example,
radiographers are required to be,
All links are available live at http://www.prs-ltsn.ac.uk/ethics
77 Ashcroft, R.E. (2000) op. cit.
78 Carson A.M. (2001) “That’s another story: narrative methods and ethical practice”, Journal of Medical Ethics,
vol. 27, no. 3, pp. 198-202(5)
52
aware of the characteristics and consequences of non-verbal communication and how
this can be affected by culture, age, ethnicity, gender, religious beliefs and socio-
economic status.79
An appreciation of these issues can be developed either by viewing
visual images (both static and moving) or by reading a text with
reference to the way the author indicates a character’s feelings or
characteristics through descriptions of their behaviour or body language.
Students need not be restricted to the discussion of existing
sources, but can be encouraged to explore issues creatively, by producing
their own narratives in the form of short stories or poems, or by selecting
images that have particular relevance to themselves.
Narrative texts and resources can be used in many ways, but in
general terms there are a number of learning outcomes that they can be
expected to serve:
Allow students to consider ethical issues as one aspect or dimension
of a complex situation in which action depends not only on the
outcome of a moral decision but on other significant factors.
Encourage the use of ‘thick’ descriptions that draw on personal
characteristics, social relations and emotional states in addition to
ethical concepts and principles.
Encourage an appreciation of multiple-perspectives on contested
issues.
Develop empathy.
Promote a balance between personal engagement with the issues and
objective evaluation.
Allow the use of imagination in concert with reason in the
formulation of ethically significant courses of action.
Facilitate the application of a variety of learning styles to ethics
learning and teaching.
Promote a service-user-centred approach.
Promote a holistic view of persons (professional, service-user and
others).
All links are available live at http://www.prs-ltsn.ac.uk/ethics
79 http://www.hpc-uk.org/publications/standards_of_proficiency_ra.htm
53
The Ethicist’s Tale:
Using the Humanities to Facilitate
Learning in Healthcare
Deborah Bowman
St George’s Hospital Medical School
Introduction
erhaps one of the greatest challenges for all teachers and learners is to remain
imaginative about education: for teachers to avoid the safety of using only well-tried
P teaching methods and for students to avoid the temptation to become passive
recipients of information. Although this is an educational challenge for all those
involved in teaching and learning, the challenge can be particularly acute for those
training healthcare professionals where there is frequently an already crammed
curriculum and a great deal of ‘information’ to be both delivered and learned
(though, of course, the two things do not always seamlessly merge). This paper
considers the use of humanities as one imaginative device for facilitating learning in
healthcare ethics and argues that narrative and emotion are powerful tools for
engaging teachers and learners alike.
Humanities in Healthcare Education
The place of humanities in healthcare education has a relatively recent history.
Even in the United States (which is frequently seen as the place in which the
‘medical humanities’ movement began), the subject only really began to take its
place in faculties and on curricula in the 1970s. In the United Kingdom, there has
been increasing interest in the use of humanities in healthcare education in the last
decade. Much of this work has been led by Dr Deborah Kirklin and her colleagues
at the UCH and the Royal Free Medical School and Dr Jane McNaughton who is
the Director of the Centre for Arts and Humanities in Health and Medicine at the
University of Durham.
Ethics and Humanities
Is there a natural link between healthcare ethics and humanities? Perhaps it is
worth considering first of all the ways in which the subject of ‘healthcare ethics’ is
constructed and understood. Is the subject of ‘healthcare ethics’:
A branch of moral philosophy?
A close relation of medical law?
An historical and social perspective on professional rules and regulations?
A sub-set of a broader subject that might be called ‘medical humanities’ or the
human and behavioural aspects of healthcare
None or all of the above?
It may be that whatever one believes one is teaching when delivering
seminars, courses and lectures in ‘healthcare ethics’, the importance of emotion
and the power of the narrative is greatly under-developed in, but a nonetheless
essential aspect of, the business of moral reasoning.
Indeed if one accepts, that the aims of healthcare education are to produce
practitioners who are reflective, empathetic and humane, professional, patient-
centred, honourable and responsible, drawing on emotion and offering contrasting
human perspectives on moral dilemmas in healthcare may be an essential part of
ethics teaching and learning. Medical humanities offers an innovative approach by
which to engage students AND staff in reflection on values and development of
virtue in education. In particular, humanities can:-
Accentuate the power of the narrative in healthcare ethics (thereby reminding all
that healthcare is a human science and engaging learners)
Offer multiple perspectives on a dilemma or problem
Capture the ‘silent’ or overlooked perspectives in ethics
Make emotion and psychological responses an explicit and integral part of what
constitutes a practitioner’s ‘duty of care’
Using humanities in healthcare teaching and learning ‘on the
ground’
At St George’s Hospital Medical School, we have experimented with the use of
humanities in teaching and learning. Some of the activities tried include:
Students selecting and bringing their own fictional and non-fictional accounts of
mental illness to ethics seminars in mental health
Special Study Modules in music and medicine, art and healthcare and literature
and medicine
Core clinical teaching in psychiatry includes representations of mental illness
and psychiatrists in film
Including fictional and autobiographical reading on the standard reference list
for most Problem Based Learning tutorials e.g. Gearin Tosh for a tutorial
concerning multiple myeloma, Ruth Picardie and John Diamond for tutorials
concerning cancer and Lauren Slater for a tutorial concerning epilepsy.
Students are encouraged to make their own recommendations for inclusion on
reference lists.
Excerpts from Jed Mercurio’s ‘Bodies’ provide trigger materials for seminars on
‘duties of care’, ‘whistleblowing’ and ‘self-care’
Atul Gawande’s ‘Complications’ provides trigger material for a seminar on
uncertainty
Staff/student trip to see ‘Blue Orange’ as part of psychiatric ethics module
Staff/student trip to see ‘The Talking Cure’ at National Theatre
55
Anatomy/ethics trip to ‘Bodyworlds’ exhibition followed up by discussion of
dignity in death and consent for post-mortems
To date, using humanities has proved advantageous in three principal
ways. First, students appear to value innovation and variety in teaching. Enhanced
engagement and enthusiasm is perhaps the greatest incentive of all to continue
developing the place of humanities in applied ethics teaching. The benefits are not
simply limited to enhanced student engagement however. Secondly, teachers and
academics enjoy considerable personal and professional development by
expanding their knowledge and skills base and perhaps revisiting familiar ideas
from a new perspective or in an original context. Refreshed teachers are generally
better and happier teachers! Finally, the use of humanities revives the importance of
the narrative in healthcare ethics and reminds us all, that just as medicine is a
human science, so healthcare ethics is concerned with the application of philosophy
to human dilemmas and experiences. In the words of Hudson-Jones (1999)
narrative in ethics requires readers to consider whether the patient is ultimately the
author of his own text.
Humanities and Healthcare Resources
Perhaps the most important resources for anyone interested in using humanities in
teaching applied ethics are other people: staff and students who read, attend the
theatre, listen to and play music, visit art exhibitions, paint and draw are all potent
sources of inspiration. Beyond the many resources that surround each of us in the
form of colleagues and students, there are some other useful resources. The
Journal of Medical Ethics has a discrete medical humanities supplement called the
Journal of Medical Humanities. Other teaching and learning journals such as
‘Medical Education’ have features on the use of humanities. On the internet, the
huge and impressive resource80 from New York University is unsurpassed although
largely limited to literature. Finally, there is a UK project based on the New York
University resource.81
Humanities and Healthcare Ethics: The Future
Presently, humanities in the education of healthcare professionals is at a relatively
nascent stage of development. The challenges that face those enthusiastic about
the inclusion of the humanities in teaching and learning include developing
scholarship, evaluating outcomes and training staff and students to feel confident
about facilitating some of the emotional responses that can occur when powerful
and touching materials are used in teaching and learning
If there is a mass of interested academics in UK who are keen to develop
their skills and interest in this area, perhaps it is time that we begin work on a nation
wide exchange of ideas, experiences and resources. Such a network should extend
beyond the exchanging of cards in a flurry of enthusiasm at a conference. So to
All links are available live at http://www.prs-ltsn.ac.uk/ethics
80 http://endeavour.med.nyu.edu/lit-med/
81 http://www.mhrd.ucl.ac.uk/
56
those with whom I exchanged cards at the LTSN workshop, please send me an e-
mail!
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e. A Case Study
Students would be asked to read the following story.
In the Name of the Mother, the Son and the Holy Ghost
It was only twenty two days since the baby’s premature birth but
already the sights, sounds and smells of the Special Care Baby Unit had
become as the familiar to Janice as those of her own kitchen. For the
first week, when her daughter Lisa had been too ill to leave her bed,
Janice had had the clear plastic box and its fragile contents to herself, so
that by now baby Reading seemed more like her son and her grandson.
She had even named him in the privacy of her own head – calling him
Paul after her much missed elder brother.
The second week had seen the first of Lisa’s visits and had been a
precious time of mutual support but with Week Three had come a
sudden twist of discord. The medical staff had begun, through carefully
phrased hints and indications, to prepare them for the likelihood that
baby Reading would not see the end of his first month and after an
initial half-hour of shared anguish the whispered arguments between
mother and daughter had started. Janice wanted to baptise her
grandson but Lisa was adamant that this would not be done.
Janice found Lisa’s attitude difficult to understand; her own
Catholic faith was a source of comfort at times like this, offering an
assurance of the ultimate purpose of seemingly random events, and the
promise of reunion in the face of imminent loss. Lisa’s religious
observance had been patchy since her teens but Janice blamed this on
her son-in-law – a nice enough lad but as far as religion was concerned
he said he was C. of E. and everyone knew what that meant. Lisa had
still been keen enough to have a nuptial mass for her wedding day and
in the complication-free first trimester of her pregnancy, had raised no
objections to Janice’s talk of the big ‘Do’ for the christening of the first
grandchild. They had even picked out a gown for the baby – all lace and
elaborate stitching – but Lisa had refused to allow Janice to buy it before
the birth, saying that she didn’t want to tempt fate.
Now everything had changed. Sometimes Lisa said that God
wouldn’t be so cruel as to condemn an innocent baby to Limbo. At other
times, she said that if there was a God, why would he be so wicked as to
let her baby die? At all times she was clear that there would be no
anointing, no water, no ‘renouncing of the Devil’. It would be like
accepting that the baby had no chance at all and he did have a chance.
He was getting stronger every day. The doctors didn’t say that he
couldn’t live – only that it was touch and go. Lisa would never give up
hope, no matter what her mother might say.
These were thoughts that thronged inside Janice’s head as she sat
beside the incubator and watched the tiny lungs battle against failing
strength. Lisa was asleep on the sideward so Janice had Paul to herself
for a while. She wasn’t sure for how long – maybe thirty minutes –
maybe an hour if she was lucky – then Lisa would be back to join the
vigil and maintain a guard. Suddenly was it clear to Janice what she
must do. The resolution presented itself, whole and fully formed, from
the apparent chaos of her subconscious mind.
She picked up the plastic cup of water that one of the nurses had
brought her earlier. Its contents were at room temperature, which
meant 28°C in the overheated atmosphere of the baby unit. The only
snag was that she needed to raise the lid of the incubator and was afraid
of setting off the alarm.
At the other side of the room was a nurse – a tall well-spoken girl
in her late twenties, and the one with whom Lisa had established the
greatest rapport.
‘Nurse!’ Janice called softly, ‘Nurse Emma.’
Emma sighed to herself and mentally postponed her cup of tea yet
again. ‘Yes Mrs Phillips?’ she responded, padding across in sensible
shoes. ‘How are you doing?’
‘Coping,’ Janice smiled and Emma saw exhaustion etched into
every feature. ‘for now at least.’ Janice hesitated, her hands squeezing
the plastic cup so tightly that its contents rose up and threatened to
overspill. ‘I wanted to ask your favour.’
‘Of course,’ the nurse replied cautiously, ‘if I can.’
‘I want you to raise the lid on the incubator.’
Emma said nothing but her face was eloquent with doubt and
concern.
‘I want to baptised him,’ Janice nodded towards the sleeping child.
‘Before it’s too late.’
For a moment Emma maintained her silence, then she took a
deep breath and began slowly,
‘But Mrs Phillips …’
‘There’s no danger,’ Janice interrupted, one eye on the door where
her daughter might appear at any moment. ‘All I need to do is pour a
little water over his forehead – a just drop – only the tiniest drop – and
say a few words.’
‘But Mrs Phillips – Janice …’ Emma reached out to put a
placatory hand on Janice’s arm.
‘It won’t take long,’ said Janice. ‘No more than fifteen seconds.’
Her voice was rising now, sensing opposition. ‘The incubator is open for
much longer than that when you’re washing him.’
‘I know, but – .’
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‘I don’t need a priest or anything. My religion allows anyone to do
it in extremis.’
‘I know – .’
‘Then you must understand what it means to me – to him – to be
baptised before he dies,’ Janice urged. ‘All I have to do you is say “I
baptise thee Paul” – that’s the name I’ve given him – Paul after my
brother – “I baptise thee Paul in the name of the Father, Son, and Holy
Ghost.” Then a little water poured over his head and it’s done. What
harm can it do?’
‘That’s not the point,’ Emma said firmly. Her grip on Janice’s arm
changed from comfort to one of gentle control. ‘Why don’t you come
through to the Relatives’ Room? We can talk better there. Or I could call
a priest to counsel you.’
‘It isn’t me that needs the priest’ Janice wailed, tears of
frustration welling into her eyes. ‘And there isn’t time to talk about it.
Lisa could be here at any minute.’
‘Yes and that is the point.’ Emma stood back and folded her arms
across her chest, her gaze shifting to her patient. ‘I’m sorry Janice – I do
understand that this is very difficult for you but you know very well that
Mrs Reading doesn’t want her baby baptised just yet, and she is his
mother. It’s her decision, not yours.’
‘She doesn’t mean it.’ Janice took a deep breath to suppress the
sobs that were constricting her throat and making it difficult to speak.
‘She’s angry and in pain right now, but when all this is over and the baby
is dead she’ll wish she’d done the right thing.’
‘What about now?’ Emma asked quietly. ‘Shouldn’t you consider
what Lisa needs right now?’
‘She needs her baby to live but you can’t give her that and neither
can I.’
‘There’s always hope, Mrs Phillips. And if the worst happens –
well the human mind has great powers of recuperation, but your
daughter will need all your support. If you make her feel guilty – .’
‘Do you really think I would?’ Janice cried. ‘I’d never say a word –
not when it was too late – but I wouldn’t need to. Once a Catholic,
always a Catholic. Her beliefs are still there, whatever she might say
and in the long run it will kill her to know that she kept her son out of
heaven.’
‘Mrs Phillips! Please!’ Emma was bitterly regretting having
started this conversation and knew that she was way out of her depth.
An agnostic herself, she was generally tolerant of religious belief in
others, but she found Janice’s acceptance of a God who would condemn a
baby on such trivial grounds repugnant. ‘I really think that we should
go through to the Relatives Room. I’ll make some tea and ask the priest
60
come round as soon as possible. I’m sure there must be some other way
to set your mind rest – .’
‘There’s no other way,’ said Janice miserably. She thought for a
moment then tried a different tack. ‘What about the father?’ she
suggested. ‘My son-in-law said he didn’t mind the child going to a
Catholic school – .’
‘All this is for Mr and Mrs Reading to decide,’ Emma insisted,
taking Janice by the shoulder and steering her firmly towards the door.
‘Now come and sit yourself down. Perhaps your daughter will agree to
speak to the priest with you – it might help her if you are correct about
her true feelings. But I hope you understand that we can’t override
Lisa’s wishes in this. It wouldn’t be right.’
Janice paused and made her final appeal.
‘She needn’t know,’ she whispered. ‘Let me baptise the baby now,
without telling her. And I’ll never tell her – not unless she regrets
refusing to do it herself. Just think about Lisa and how she’ll feel when
she does change her mind and it’s too late. Think how it will prey on her
conscience. Help me now so I can help her then – I’ll be able to tell her
not to worry – that the baby was baptised – that he is happy in heaven.
And if she never changes her mind I won’t say a word – not to my dying
day.’ Emma hesitated. It made a sense of a kind and she found it
difficult to account for her own reluctance, but the bottom line was that
the parents said “No” and that was all there was to it.
‘You could always lie,’ she said at last.
‘What?’
‘If your daughter regrets not baptising the baby, you could tell her
that you had done it.’
‘But it wouldn’t be true.’
‘Would that matter if it gave Lisa piece of mind?’
Janice shook her head and admitted defeat.
‘You just don’t understand – you’re not a Catholic.’
‘No, Mrs Phillips I’m a nurse. I’m really sorry but I have to put
the baby and his parents first.’
And with that she led Janice over to an armchair then went to put
the kettle on.
Ethical Issues
There are a number of issues that have a moral dimension in the above
story, but a key difference between the embedded approach and the
pragmatic and theoretical ones here is that there need be no overt
reference to ethics or morality in either the story itself or the students’
consideration of the story.
61
It may also be noted that although the nurse is asked to make a
morally sensitive decision, it does not relate to an aspect of medical
ethics as there is no clinical decision to be made about the best interests
of the patient. It does, however, highlight the difficulty of interpreting
the Duty of Care as defined in the notion of Fitness for Practice.
For example, to whom is the duty of care owed?
To the baby and his mother the duty is owed in respect of their
position as patients within the hospital. Lisa might claim an additional
claim as the parent of a minor but what about Janice? Does she have a
claim at all, and if so, is it a direct claim that the staff should consider
her welfare or does she have only an indirect claim based on her
contribution to the welfare of the baby and his mother? Can one
formulate a general position with respect to grandparents of premature
babies or can one only answer the question by reference to the individual
circumstances of this case such as Janice’s three-week presence on the
ward, her character, and her relationship with her daughter.
These are complicated and deeply interrelated questions, and
exploration via narrative formats will sometimes be the best way for
students to tackle them.
Facilitators can invite students to consider whether the nurse’s
behaviour is defensible by reference to overtly ethical concepts and
principles, but this is not essential. More important is that they explore
their own reactions to the story. There are a number of prompts or
questions that might be posed to help them do this:
With whom do they identify most in this story?
Do their sympathies change as the narrative unfolds?
What kind of people are Janice, Emma and Lisa?
If Lisa’s unnamed husband had been involved would he have had a
different perspective on the situation?
Would they have acted as Emma did?
If not, in what way were their actions have differed?
If the narrative is presented within a group discussion format it is
also worth students asking themselves: Does their reading of the story
change as a result of group discussion?
An enquiry along these lines will bring out much that is ethically
relevant in the students’ attitudes, and the teacher may choose to bring
these aspects to their attention for overt consideration. Indications that
students are not applying their ethical values or principles consistently
or that they have difficulty in stating the moral issues embedded within
the story would identify areas where there is potential for the student to
learn and enrich their capacity to behave ethically.
62
Alternatively, if the embedded format is used to serve embedded
learning objectives, the narrative would be used to explore and enrich
the students conception of what it means to be ‘Fit to Practice’. The
ethical dimension would be examined in concert with other factors
through their consideration of a story in which ethical principles and
concepts are embedded, but would not be treated to separate and overt
consideration. Indications that a student’s conception of Fitness to
Practice is incompatible with the requirements of registration as
assessed at their institution, will identify areas where there is potential
for the student to learn and develop their views.
63
Theoretical Approaches to Ethics
I want to know what it is like for a bat to be a bat …
Thomas Nagel, Mortal Questions
What is it like to be a rat?
The trouble is not … that human concepts cannot be extended to
other species. It is that such extensions must be done sensitively.
Apparently similar patterns can play very different parts in the lives
of different species.
Mary Midgley, Beast & Man
I do not wish [women] to have power over men; but over
themselves.
Mary Wollstonecraft, A Vindication of the Rights of Woman
Whose Right is it anyway?
Every community has a right to demand of all its agents, an
account of their conduct.
Tom Paine, The Rights of Man
So the good has been well explained as being that at which all things aim.
Aristotle, Nicomachean Ethics
The Virtues of the Professional
For Aristotle, each of the virtues is an organized way of cherishing a particular
end that has intrinsic value.
Martha Nussbaum, Virtue Ethics: a misleading category?
3. Theoretical
a. Introduction
Ethics in its broadest sense is perhaps more properly regarded as
supradisciplinary than interdisciplinary, for it is concerned with human
actions and agency and as such, has relevance to all areas of human
endeavour. Within learning and teaching, there is an assumption that
learning itself is a moral endeavour but ethics is often marginal as an
overt discipline. Implied values are not made clear and are often
unsupported by coherent and consistent arguments. Learning and
teaching which takes as its primary objective the overt statement of
these implied values facilitates scrutiny and provides a sound basis for
debate regarding the role of moral values in education as a whole, and in
the evolution of ethics education across the curriculum.
Taking a theoretical approach to ethics learning and teaching
means starting with a study of ethical theory; the concepts, principles,
and arguments that underpin the Codes of Practice considered in the
pragmatic approach and the notions of the Professional behaviour and
Fitness to Practice considered in the embedded approach.
It can be argued that a deep understanding of ethics as applied to
any discipline requires some attention to theory, but the experience of
teachers working outside disciplines such as philosophy and religious
studies suggests that the theoretical approach is the one which students
are least likely to relate to the rest of their studies and their future
working lives. Where ethics is taught on an elective basis this might not
be a problem provided there are enough students with an aptitude for
conceptual analysis and the consideration of normative issues to make
the module viable. However professional ethics will often be mandatory,
either as a separate module or as a component in a broader syllabus, so
the difficulties many students find in the theoretical approach must be
taken seriously.
It is not possible within a guide of this type to offer a
comprehensive review of theoretical approaches to learning and teaching
in ethics. The theoretical approach has a tradition dating back over two
thousand years and is a core component of the curriculum for any
department of philosophy or theology. In addition, most taught post-
graduate courses in professional ethics will make significant use of moral
theory. This section will therefore be confined to three areas that may be
of interest to teachers of ethics across the curriculum.
Firstly, it will consider the role of theory in issues-based ethics
teaching. Secondly, it will outline the key differences between the
theoretical approach and the pragmatic/embedded approaches in respect
of learning and teaching objectives. Thirdly it will consider the key skills
that may be enhanced by adopting a theoretical approach.
While students from disciplines outside philosophy and religious
studies may study ethics without making any use of the theoretical
approach, it is arguable that those with a responsibility for teaching this
subject need some acquaintance with the more abstract conceptual forms
of analysis on which it depends since it is principally through this
medium that discussion about how ethics can and should be taught
across the curriculum is carried out. A guest contribution from Rev. Dr
John Strain, Director of Federal University of Surrey Centre for Applied
and Professional Ethics provides an example of this type of discourse
when he asks ‘What is distinctive about ethics in particular disciplinary
practices and what is transferable across disciplines?’.
The final part of this section provides an example of a case study
as it might be used within the theoretical approach.
b. Issue-Based Learning
The more influential science becomes, the more ethical issues become associated with
scientific practice directly, and scientists are increasingly required to participate in the
value questions born from new knowledge and new technologies.82
The pragmatic approach has been considered in the context of
disciplines with a strong research component, while Fitness for Practice
and Professionalism is of particular importance to graduates from
subject areas feeding the service professions. However many subjects
will have some area of enquiry or application that arouses public concern
and many benchmarking statements reflect this by requiring that
graduates have some understanding of ethical issues of significance to
their subject area and the ability to contribute to debate on these issues.
For example, the benchmark statement for Bioscience states that:
Whatever the subject discipline, students should expect to be confronted by some of the
scientific, moral and ethical questions raised by their study discipline, to consider
viewpoints other than their own, and to engage in critical assessment and intellectual
argument. 83
All links are available live at http://www.prs-ltsn.ac.uk/ethics
82 Clarkeburn H.; Downie J.R.; Matthew B. (2002) ‘Impact of an Ethics Programme in a Life Sciences Curriculum’,
Teaching in Higher Education, Vol. 7, no. 1, pp. 65-79
83 http://www.qaa.ac.uk/crntwork/benchmark/phase2/biosciences.pdf
66
For Veterinary Medicine:
graduates must … be able to construct reasoned arguments to support their actions
and positions on the ethical and social impact of veterinary science and the allied
biosciences. 84
For Occupational Therapy:
The graduate occupational therapist must … treat individuals with respect and draw on
ethical principles in the process of reasoning.85
For Pharmacists, the graduate
must be able to recognise ethical dilemmas in healthcare and science and understand
ways in which these might be managed by healthcare professionals, whilst taking
account of relevant law.86
In order to fulfil this requirement, students must be able to give
overt consideration to moral questions. This means being able to:
Recognise ethically sensitive issues.
Identify and describe their ethical dimension.
Distinguish ethical issues from associated non-moral factors such as
matters of fact or of law.
Formulate the relevant moral arguments, both for and against.
Offer a balanced appraisal of the relative merits of these arguments
Present their views in terms appropriate to public debate.
This approach contrasts strongly with the embedded one, in that
it seeks to abstract and isolate moral issues, as far as possible; to provide
a ‘thin’ description that eschews personal context, emotional content and
the specifics of an individual situation.
The main difference between a consideration of these issues
within departments of philosophy or religious studies and that found in
other faculties such as science relates to the primary domain of
expertise. For example, on a controversial area such as
xenotransplantation, a bioscience student can be expected to have a good
grasp of the science, but will lack the depth of moral theory that might
All links are available live at http://www.prs-ltsn.ac.uk/ethics
84 http://www.qaa.ac.uk/crntwork/benchmark/phase2/vet_sci.pdf, p.7
85 http://www.qaa.ac.uk/crntwork/benchmark/nhsbenchmark/ot.pdf, p.15
86 http://www.rpsgb.org.uk/pdfs/compfutphwfph1s6.pdf
67
be expected of a philosophy student, while for the philosophy student the
converse is true.
Issues-based learning and teaching in ethics will therefore require
careful identification of the students’ expected strengths and weaknesses
in approaching the topic, to determine which aspects of the issue can be
apportioned to the students for their own research, and which areas will
require more input and guidance from the teachers.
c. Ethics and Philosophy
The theoretical tradition of applied/professional ethics teaching has the
longest history within Higher Education as it is the approach taken
within departments of philosophy, theology and religious studies for
whom ethics has been a core subject from the outset. Departments of
Law also take a theoretical approach designed to give students an
understanding of the moral arguments and principles that were
instrumental in the formulation of legislation, and which have an
ongoing role in its interpretation.
Students within these departments approach applied ethics by
first considering the relevant concepts, principles and arguments of
moral theory to provide a framework within which particular cases can
be located and analysed. This strong theoretical foundation is itself
grounded in core modules that provide a broader conceptual and
methodological framework from a consideration of subjects such as logic
and theory of knowledge, and the acquisition of broadly based analytical
and reasoning skills.
Only when students have attained a sound grasp of moral theory
will they be asked to apply it to real-life or life-like situations. The
function of applied ethics within this context is not to prepare students
to cope with those situations in real life, but rather a means of deepening
of their understanding of moral theory through a consideration of its
application to human action in specific situations.
Though much of the language used in this environment would not
be familiar to those based in other departments, the key processes of
conceptual analysis, reasoning and argument would not be regarded as a
barrier to discourse with people from other disciplines, but as a way of
breaking down such barriers. Learning and teaching objectives would,
accordingly, focus on developing those abilities deemed essential to
anyone wishing to address ethical issues in a rational, transparent and
consistent way and would normally include one or more of the following:
Development of critical reasoning faculties.
68
Application of moral theories such as Rights, Virtue Ethics,
Consequentialism or Kantian deontology to real-life situations.
Identification and analysis of morally challenging situations.
Acquisition of a facility with the language of moral discourse.
Awareness of multiple perspectives on contested issues.
Development of coherent principles of thought and action.
Capacity for verbal and written presentation.
Modules based on this tradition do not seek to persuade students
of the merits of a particular set of moral beliefs, or motivate them to
attain predefined standards of behaviour. In this respect they form a
marked contrast with modules in which the student’s knowledge of
ethics is a means to the end of shaping their actions as future
professionals. Even where courses are not overtly prescriptive, there can
be an implicit intention to go beyond the delivery of a body of knowledge;
to enter the realm of character development and the promotion of
professional virtues.
Rest defined a four component model for moral behaviour:
1) Moral sensitivity
2) Moral judgement
3) Moral motivation
4) Moral character. 87
The enhancement of moral judgement is common to all three
approaches although it may not be referred to explicitly in the pragmatic
and embedded forms.
So too is moral sensitivity,
a practical skill that enables one to recognize when an act, situation or certain aspects
of a situation have moral implications. 88
Where the approaches differ is in the attention paid to moral
motivation and character. Moral motivation involves prioritising the
moral over other significant concerns, while moral character means
being able to construct and implement actions that service the morally
desirable choice. Both these elements of moral behaviour are frequently
addressed within pragmatic and embedded learning and teaching, and
All links are available live at http://www.prs-ltsn.ac.uk/ethics
87 Rest, J. R. (1983). Morality. In Mussen, P. H. (ser. ed.), Flavell, J., and Markman, E. (vol. eds.), Handbook of
Child Psychology: Cognitive Development, Vol. 3, Wiley, New York, pp. 556-629
88 Jaeger S.M. (2001) ‘Teaching health care ethics: the importance of moral sensitivity for moral reasoning’,
Nursing Philosophy, vol. 2, no. 2, pp. 131-142
69
modules from this domain will normally serve one or more of the
following outcomes:
Apply research guidelines or a professional code.
Promote good professional conduct.
Engage in reflective practice.
Explore background moral beliefs.
Develop empathy.
Help students perceive a particular choice or course of action as
the correct one, where that correct course of action is determined by
reference to such things as:
Government Legislation and Guidelines.
Professional code(s) of conduct.
Research Guidelines.
Canonical Text(s).
Insofar as these learning outcomes refer to morally desirable
behaviour they would be considered inappropriate to the philosophical
approach. McNulty states that:
[p]hilosophers are ill-suited to the role of moral guidance. Instead they should set out to
instil in students the necessity of being able to formulate rational bases for moral
views.89
Similarly, within philosophical medical ethics Gillon rules out the
quoting or drawing up of professional codes of conduct, accounts of the
legal constraints on doctors’ behaviour and the expression of religious
rules or sentiments.90 Instead, there is an emphasis on analysis and a
critical examination of “concepts, assumptions, beliefs, attitudes,
emotions, reasons, and arguments”. 91
It is therefore important for teachers combining material from
more than one approach to be clear about their learning and teaching
objectives in different parts of the course, not only as a means of
ensuring that these objectives are met but as a way of anticipating
potential conflict between them. For example, a pragmatic approach, in
which students accept the mandates of a professional code of practice as
All links are available live at http://www.prs-ltsn.ac.uk/ethics
89 McNulty M. (2002) Teaching Applied Ethics Effectively, Teaching Philosophy, Volume 21, Number 4, pp. 361-
372
90 Gillon R. (1999) Philosophical Medical Ethics, John Wiley & Sons: Chichester. p.1.
91 Ibid. p.2.
70
‘given’ might militate against learning and teaching format based on the
‘theoretical’ objectives of critical evaluation of assumptions and
arguments. These potential conflicts between the approaches are
symptomatic of tensions within ethics teaching across the curriculum as
a whole.
d. Ethics and Key Skills
Learning and teaching via the theoretical approach enhances teaches a
number of transferable skills.
Analytical Skills: Philosophical enquiry develops an aptitude for clear
and logical thought. Students learn to think critically and break
down complex problems.
Flexibility and Independence of Mind: Philosophers must be able to
consider issues from multiple perspectives. A willingness to challenge
orthodoxies is encouraged, as is the value of setting aside one’s own
personal convictions to pursue an argument wherever it might lead.
Decision Making: Philosophers search for coherent principles of
thought and action and learn to determine what kinds of evidence
are needed to support their views and choices.
Communication skills: Philosophy students must learn to express
their views verbally and in writing. There is an emphasis on group
discussion and the articulation of arguments in direct response to
verbal questions and critiques.
In so far as an applied/professional ethics module takes a broadly
theoretical approach to its subject matter, it can be expected to enhance
the students’ facility with the key skills listed above. For students whose
primary area of study lies outside philosophy, theology etc. at least some
of these skills will not be developed to the same degree by the rest of
their coursework.
The study of ethics also introduces the consideration of values and
this is potentially of even greater importance to the graduate’s
performance in a work environment because a professional needs to do
more than decide what their options are and how those options can be
put into practice; they must also decide what ought to be done. A
professional who has learned to recognise, define and justify value
judgements will therefore be a more effective decision-maker than one
who lacks these skills. Ethics training can be of particular benefit to
students from science and technology where the emphasis on
implementation and problem solving means that students would
71
otherwise have very little opportunity to consider embedded concepts
and values.
72
Care, knowledge and design in
professional practice92
John Strain
Director, Federal University of Surrey Centre for Applied and
Professional Ethics
roadly my thesis is that three particular concepts: care, knowledge and design figure
necessarily as common features in the ethics of all professional practices. But the
B precise way in which these concepts relate together provide for the variety and
difference between different professional practices.
Noddings (2003) proposes an ethic of caring in which relationships between
people, not individual people themselves, have an ontological primacy. Noddings
wrote as an educationalist rather than as a healthcare professional but the ethics of
care has been taken up with some enthusiasm within nursing by, amongst others,
Benner and Wrubel (1989), and Johnstone (1994). Tschudin (2003:1) suggests that
“caring is not unique to nursing, but it is unique within nursing.” Part of what I want
to suggest in this paper is that the mode in which care for people is expressed is
unique to each professional practice. All professions are concerned with offering
some service intended to benefit a client. In less utilitarian terms, we might say that
some activity is conducted which the client has good reason to value. For
professions are neither about harming people nor acting indifferently towards the
interests of clients. To that extent there is some relationship of care between
professional and client, a relationship which might be guarded, or not, through
various legal embodiments such as duties of care in common law or by contractual
obligations of care.
But there is clearly more to being a professional than caring for another in a
relationship. What distinguishes a professional relationship from a marriage
relationship or a close friendship is that the relationship is bounded by a particular
domain of practice and by a body of well founded knowledge associated with that
practice. A nurse, doctor, architect or school teacher has something to profess in
the relationship with a client and the appropriateness of how a professional acts is in
part determined by the well founded-ness of this knowledge. I use the term ‘well
founded’ here to resist any particular purchase into ‘scientific’ or ‘positivistic’ notions
of knowledge. But at the same time nurses, doctors and architects must “know what
they are talking about” in a manner beyond that demanded of armchair theorists
and people on the Clapham omnibus.
All links are available live at http://www.prs-ltsn.ac.uk/ethics
92 This is a revised version of a short paper delivered at the LTSN conference to
help stimulate discussion. It presents what might be called a weak thesis for
discussion about what is common and what is distinctive about ethics in different
professional practices.
73
The relationship between a professional’s knowledge and the expression of
care is often far from straightforward. Frequently, a doctor or nurse will take actions
when there is very little knowledge of, or evidence for, the efficacy of the action in
the particular circumstance. So care is not expressed simply by the exercise of
knowledge. But experience and recognition of the relative risks of acting or taking
no action are all deemed to count in the exercise of professional judgement. And
they are what frequently distinguish professional action from the actions of caring
people in the community.
The approach to knowledge taken by professionals is not quite the same as
the approach taken by scientists or scholars. Scientists or scholars may be content
that knowledge adds to (or perhaps replaces) existing theory or adds to the ways in
which it is possible for people to comprehend phenomena. But for the professional,
there is a more fundamental question: how can this knowledge help this client in this
circumstance? There is some artefact, some process that needs to be designed for
a client that is somehow ‘fit for purpose’ in relation to the client. This suggests a
third key concept in what defines the professional: her or his concern to design
something, an event, an artefact or a process which benefits the client and
addresses the circumstance in which the client finds her or himself.
As well as identifying care, knowledge and design as key components of
professional practice, there can also be identified a number of relationships
between caring, knowledge and design which are common to all professionals. If
whatever it is that the professional designs for the client is to address the client’s
circumstances, then some process of communication is necessary. Communication
has a bearing on care and on knowledge. If the client is to place adequate trust in
the professional to expose sufficient of his or her own vulnerable self for this
communication to take place, then a sufficient relationship of care is required. The
outcome of this communication for the professional needs to provide some basis for
selecting, choosing or deciding upon whatever is to be designed for the client,
based on well-founded knowledge. Thus communication, two-way communication
is a link between care and both knowledge and design.
Another relationship between caring and knowledge concerns the process
or journey of learning that takes place within the client. A patient’s relationship with a
nurse is in part a relationship of learning in which the client comes to understand the
characteristics of, constraints upon, and opportunities for their own journeys of
health, facilitated by the nurse or perhaps a doctor. A client’s relationship with a
solicitor is in part a learning journey for the client about the characteristics of the
client’s circumstances in regards to law, the constraints upon these circumstances
and opportunities for the future.
The professional is thus an agent of other people’s learning. What links the
professor with the professional is that knowledge is professed in a way that others
learn from it, either in the formal sense of the classroom, in the case of teacher, or
through the process of understanding how one’s needs and aspirations might be
met by an artefact or process, the wisdom of adopting the artefact or process being
grounded in knowledge. Both the architect and computing engineer begin with
some notion of someone else’s needs or aspirations. The owners of these needs
and aspirations, the clients or patients go through some process of learning about
how their aspirations can be realised. I am at pains here to be clear about how
different these relationships with knowledge can be. For a teacher of science, an
important aspect of how knowledge figures in his professional life is a respect due
to the sheer facticity of things, things which are the case regardless of our feelings
74
about, or our perception of them. But for a teacher of poetry an epistemology which
stresses and helps articulate a child’s response to a poem rather than a set of facts
about the poem, may be particularly important.
These three concepts: caring for people, designing something for people
and enlightening people through an interaction with knowledge are not altogether
independent. The design of a building, process or product in seeking to realise the
client’s aspirations will often need to respect the laws of physics, mathematics or
chemistry. An intrinsic component of caring for people will need to be sensitive to
the learning journeys that patients or clients make when they articulate their needs.
Variations within the themes
The three themes of care, design and knowledge provide a canvas upon which
many variations are possible for different professions. For some professions,
particularly in healthcare, to care for persons means to hold them in an
“unconditional positive regard”, to use Carl Rogers words (1961). It reflects a
commitment to the primacy of the perspective of those being cared in a relationship
in which the well-being of the person cared for is paramount. This is not an
understanding of ‘caring’ which would come naturally to a consulting engineer or a
computing engineer. But the codes of conduct of both these professions are quite
incompatible with any idea that the client is not cared for or cared about. Amongst
the seventeen rules in the Code of Conduct for Members of the British Computer
Society, the first rule specifies the due care and diligence in accordance with the
relevant authority’s requirements, and the interests of system users that are to be
safeguarded in the design of a computing system. Now, within the healthcare
profession, and nursing in particular, caring for people has emerged as a defining
component of professional identity. But as Hewitt (2002:434) remarks, drawing too
close a link between ethics and caring risks conveying the suggestion that nurses
are the only ethically oriented group in contact with patients. Doctors, healthcare
professionals outside nursing as much as engineers and teachers all articulate
some concept of care for people in their expressions of professional identity.
A clearer understanding of how care, design and knowledge for the
professional might be gained by considering some examples of the different ways in
which professionals care for clients. A nurse might see caring for a patient as
demanding an almost exclusive focus and empathy on a patient’s expression of
pain. But caring for a patient entails a commitment to finding a remedy, a therapy, a
way forward, all of which entail design and all of which must be well founded in
knowledge. Where as all three, care, design and knowledge are important there is
something natural about regarding a nurse as someone who focuses primarily on
care, secondarily on design, and lastly on knowledge. But even here there may be
differences across different categories of nursing and across contexts. Someone
working with those approaching the end of their lives in a palliative care context
might have little difficulty with the order of priorities of care, design and knowledge,
whereas a nursing sister working in an operating theatre might in practice be far
more concerned with following the procedures of a particular therapeutic design.
But in both cases, the nurses might be seen as practitioners rather than the
gatherers and guardians of well founded knowledge of bodily function and
possibility. And medical doctors might be seen as focusing on knowledge, its
75
medical validity and its applicability for the design of processes, but not to the extent
that they could be accused of ‘not caring for patients’.
It would hardly be considered ethical for a science teacher not to care about
the pupils. But it might not be deemed unprofessional if limits were set to this care,
limits set in terms of the safety and security of the child in the learning context and
the teacher were then to invest energy in capturing the child’s attention and
cognition with the sheer wonder of knowledge, of physics or of chemistry. To do
this, the teacher’s primary activity might be the design of pedagogic steps in the
curriculum, steps and devices that engender that sense of ‘wow’ in the child’s mind
that the world could be as fascinating as this. The teacher’s care for the child is put
into practice through designing and implementing a curriculum rather than through
caring in the sense that a hospice nurse or psychotherapist might understand caring
for a person. And the teacher, like the nurse, may be less directly concerned with
knowledge.
An architect provides another example of how care, design and knowledge
form components of professional practice. A commission begins with a client’s brief,
followed by a design to meet the requirements of the brief. But the architect is rarely
chosen simply on his capability to meet the brief, but to bring a ‘wow’ factor to the
design, a wow that stuns the client because the client had no idea a design that met
the brief could look or feel quite like that. So the architect does not fail to care for his
client’s brief but is eager to put energy into aesthetics and design. The architect
might also want to draw the client gently along the design journey so that the wow
at the end is not a painful
These examples are intended to illustrate the different ways in which three
key concepts of professional ethics, care, design and knowledge figure together in
different ways in different professional practices.
Well, what’s the significance of the claim that professional ethics differ
across different professions according to the way that care, knowledge and design
figure in different ways together? What’s the impact on teaching and learning in
ethics ? One important way of thinking about professional ethics is rooted in the
Aristotelian tradition of virtue rather than the more recent, post Kantian tradition of
principles. Virtue theory focuses on the acquisition and development of dispositions
in the practitioner, dispositions that enable the practitioner to act with an appropriate
emotional response, and which reflect the practitioner’s acting with practical wisdom
or phronesis in any circumstance. Virtuous action is action which can be
characterized as lying between two vicious extremes. So acting with appropriate
generosity, for example, lies between the vicious extremes of both profligacy and
meanness. But how are these vicious extremes defined. They may, and indeed
Aristotle suggests they will, vary in different practices. One possibility is that the
meanings of care, knowledge and design help articulate these vicious extremes. A
‘bookish’ nurse may an unacceptable extreme for a nurse o, in a way in which it
would not be a vicious extreme for a engineering novice or schoolteacher. In short,
we may need to go beyond care in understanding the demands of virtue in different
professions.
References
76
Noddings, N (1984) Caring, a Feminine Approach to Ethics and Moral
Education, 2003
Hewitt, J (2002) ‘A critical review of the arguments debating the role of the
nurse advocate’ Journal of Advanced Nursing, 37 (5) 439-445
Tschudin (2003) Ethics in Nursing, the Caring Relationship, London,
Butterworth, 1986, third edition 2003
Benner P & Wrubel J. (1989) The Primacy of Caring Addison Wesley,
Menlo Park
Johnstone, M-J (1994) Bioethics; a Nursing Perspective, 2nd edition,
Saunders, Marrickville, NSW
77
f. A Case Study
Scenario
Consider the following two cases:
Case One:
Ms X is 26 weeks pregnant. She has developed a medical condition, Z. If
left untreated, Z poses a 75% risk of serious permanent damage to Ms
X’s health.
Ms X can be cured by a single oral administration of medication
Med.1, but only if it is administered immediately, before the condition
has a chance to progress. A side-effect of this treatment will be the death
of the foetus and a miscarriage.
The foetus is currently healthy and is unlikely to be affected by
condition Z, so if Ms X decides to reject treatment the prognosis for her
pregnancy is that it will result in a healthy, full-term baby.
Case Two:
Ms A is 26 weeks pregnant. She has developed a medical condition, B,
which means that if she continues with the pregnancy there is a 75%
risk of serious permanent damage to Ms A’s health.
The safest method of securing a termination for Ms A is a single
oral administration of Med.2, which will cause the death of the foetus
and induce a miscarriage.
The foetus is currently healthy and is unlikely to be affected by
condition B, so if Ms A decides to reject treatment the prognosis for her
pregnancy is that it will result in a healthy, full-term baby.
Ethical Issues
This scenario is designed to illustrate the Rule of Double Effect (RDE).
The RDE applies in cases where an action has two outcomes, one
good and one bad. It would be located within the context of a
consideration of whether actions should be evaluated purely on their
consequences, or whether the agent’s intensions have moral significance
and should be taken into account.
Where an agent performs an action that has good and bad
consequences, does it matter whether the agent directly intends the bad
consequence, or whether they merely foresee it? Some moral positions
argue that it does, and apply the RDE to determine whether action is
permissible.
78
The scenario above compares cases in which the actions and their
consequences are similar; in each case treatment is administered that
will cure of a serious medical condition in a female patient, but which
will also result in the death of a 26 week foetus that would otherwise be
expected to develop into a healthy full-term baby. The cases differ with
regard to the intentionality of the agent in respect of the bad effect.
Beauchamp and Childress93 identify four necessary (and, taken
together, sufficient) conditions for an act with a double effect to be
permissible according to the RDE:
1. The act must be good, or at least morally neutral (independent of its
consequences).
2. The agent must intend only the good effect.
3. The bad effect must not be a means to the good effect.
4. The good effect must outweigh the bad effect.
The scenario is designed to isolate point 3 by presenting cases
that are similar in all but that respect.
In Case One there is no intension to cause the death of the foetus
although it is a foreseeable consequence of treatment. If Ms X were not
pregnant, or if the treatment had no effect on the foetus, there would
still be a clinical reason to administer Med. 1 assuming that all the other
conditions remained the same.
In Case Two, the agent intends only the good effect of curing Ms A
(for they would not terminate the pregnancy if Ms A did not have the
harmful medical condition) but this is achieved as a direct consequence
of the bad effect. The bad effect is a means to the good effect. If Ms A
were not pregnant, or if treatment had no effect on the foetus, there
would be no clinical reason to administer Med. 2 assuming that all the
other conditions remained the same.
Case One would therefore meet the conditions for permissible
action subject to the RDE. Case Two would fail condition 3.
Discussion
In this Case Study, the scenario is used to illustrate a single condition in
a specified principle. Students would be asked to accept, for the purposes
of the illustration, that the good effect of curing a medical condition
which carries a high risk of serious, permanent damage to the patient’s
health outweighs the bad effect of causing the death of a 26 week foetus.
In practice, this view would be challenged by those who regard
All links are available live at http://www.prs-ltsn.ac.uk/ethics
93 Beauchamp, T.L. & Childress, J.F. (1994) Principles of Biomedical Ethics,
Oxford:Oxford University Press, pp. 207
79
the foetus as having the same value and rights as the mother (which
would mean that both cases failed condition 4). Conversely, it might be
argued that the death of the foetus was not a sufficiently bad
consequence to be considered significant in evaluating the moral
consequences of treatment. Others might reject the RDE and require
that the cases should be evaluated purely in terms of their consequences.
However, students are not being asked to reach a final conclusion
on the moral justifiability of treatment, nor to decide what they
themselves would do, but to explore how the application of the RDE
might influence the outcome of the decision-making process. Using Case
Studies via the theoretical approach will sometimes mean asking
students to accept, for the purposes of argument or illustration, a moral
position that they do not in fact hold, in order to understand the
reasoning processes of people who have differing views from their own.
In this case, they are asked to understand why those who regard
intentions as being morally significant might make a distinction between
Cases One and Two, allowing treatment to be morally justified in the
first case but not the second.
80
C. Other Considerations
1. Students’ Initial Expectations
thics is an essentially contested subject, and is capable of arousing
powerful responses. Some students will have little or no experience of
Ethinking about moral issues, or of debating them with others. This can
give rise to a number of potential problems that should be anticipated by
those responsible for devising course material aimed at students who are
tackling ethics within Higher Education for the first time.
Students might need help in order to realise that they already have
opinions on moral issues.
Students will sometimes find that the differences between an
effective ethics learning framework and their accustomed discourse
environment require some adjustment. If, for example, a seminar
group is more culturally and socially diverse, or reflects a wider range
of religious perspectives than they are used to, it will be necessary to
establish rules or guidelines on appropriate and inappropriate modes
of argument and self-expression.
Modules may serve a wide student body with members representing
several faculties, resulting in groups who are comparative strangers
to one another with no pre-established grounds of mutual trust or
confidence. Alternatively students could be drawn from a single
course and know one another quite well, but need not be on friendly
terms as a result of this. Either circumstance can make it difficult to
generate open and honest discussion on what they might hitherto
have regarded as their own personal opinions. The relationship
between personal and professional morality, or between personal
morality and philosophical ethics may therefore require some
explanation.
Students often approach ethics with an initial expectation that there
will be a correct answer to each question posed. It is important to
help them come to terms with the fact that there will not always be
correct answer but instead, one requiring personal judgement.
Preparing students in advance so that they know what to expect
from the course and of themselves is advisable. Part of this preparation
should focus on the formal structure and conventions of the learning and
teaching environment. The preparation needed will depend to a large
extent on the nature and content of the course but three key areas that
should be considered are safety, mutual respect, and confidentiality.
81
2. Safety
It is important for the teacher to have what Bielby calls ‘emotional
intelligence’, i.e. the ability to recognise the way in which contentions
moral issues can affect people, especially when they impinge on some
aspect of personal experience94. As private individuals we can refuse to
participate in a debate if it distresses us, either by remaining silent or by
walking away but when beliefs and values are considered within the
context of an ethics seminar, students might regard themselves as being
obliged to remain. This sense of obligation can arise from a fear of
‘causing a scene’ or losing face by reacting differently from the peer-
group, or from a concern that failure to complete the class will result in a
lower mark for their coursework. A similar concern can arise in the
context of written work that requires students to draw on their own
experience.
It is therefore worth considering whether students can be given
the right to opt out from topics that they find distressing. Opt-out may be
made available for any topic on the course, with the actual omissions
being determined in the first instance by the student, subject to approval
by those responsible for ensuring that the course learning and teaching
objectives are met. Alternatively, where it is possible to predict in
advance which areas are of particular sensitivity, opt out can be limited
to those areas.
‘Opt-out’ can mean that students simply leave out that portion of
the course, or that they are guided in the selection of an alternative topic
that will meet the course learning and teaching objectives.
Where opting out is considered an acceptable option for students,
it will only be effective if students are made aware of this right, and
given a mechanism through which they can feel comfortable about
exercising it.
In some cases withdrawal might not be considered acceptable.
This is not to say that a student will be ‘forced’ to comply, but rather that
a student who opts out will, ceteris paribus, be deemed to have
performed less effectively than one who remains. There are a number of
reasons why it might be difficult to allow a student to opt out. Students
could be required to participate because:
The ability to retain a level of detachment or objectivity when
discussing moral questions is a stated learning objective.
All links are available live at http://www.prs-ltsn.ac.uk/ethics
94 Bielby, P. (2003) ‘Courting Controversies: using insights from a legal philosophy course to develop practical
recommendations for realising pedagogical objectives in teaching morally contentious issues’, Teaching in Higher
Education, Vol. 8, No. 3, 2003, pp. 369–381
82
There is concern that a right to withdraw could be abused by
students who are unwilling to complete all portions of the course for
other reasons such as a heavy workload.
Frequent exercise of a right to opt out could result in the student
failing to reach the benchmarked requirement for ethics.
The issue is one that students will have to face when they come to
practice their chosen profession. This would be of particular
importance in vocational courses where the student’s probable future
working environment is known.
Where a right of withdrawal cannot be offered there will often be
other support mechanisms that students can be made aware of should
they need help or advice in dealing with issues raised. For example,
students could be given a handout at the start of the course with contact
details for:
University Students’ Counselling Services
University Chaplaincy
Professional Bodies offering counselling services (these will be of
relevance mainly to CPD courses or vocational undergraduate
courses in which participants have the option of taking out student
membership of a professional association. For example, The Royal
College of Nursing offers its members professional and confidential
counselling by appointment, either by phone or face-to-face at various
RCN offices throughout the UK95
Internet Services such as Ahead 4 Health, an online counselling
service based at the University of Leeds.96 This website also has a
useful list of national links.
3. Mutual Respect
The rules of debate for an ethics seminar are normally more constrained
than they would be for an informal discussion between friends and
family. Assumptions will be challenged and arguments scrutinised for
coherence and consistency. Some students will find it difficult to accept
criticism in areas that affect personal value systems, or which threaten
their sense of self-identity. A general atmosphere of mutual respect and
tolerance is a desirable aim but is more readily stated than achieved. It
is important that the rules of discussion are explained clearly, and that
the teacher/facilitator is sufficiently experienced to recognise when
student behaviour falls outside that framework, and respond to it
All links are available live at http://www.prs-ltsn.ac.uk/ethics
95 http://www.rcn.org.uk/whyjoin/personalsupport.php
96 http://www.leeds.ac.uk/ahead4health
83
appropriately. In defining the rules or framework for discussion,
attention should be paid to the following:
a. Cultural and Religious Sensitivity
The student body will often be multicultural and multi-faith so
consideration should be given to the background ethos of the discussion
environment. This is of particular importance if participants are to be
asked to set aside cultural and religious appeals when justifying beliefs
and courses of action.
A secular rationalist framework for ethics discourse can be as
beneficial to a person of deep religious faith as for the secular humanist
in so far as it allows them both to investigate how far a moral position
can be supported without appeals to tradition, canonical texts or belief in
God. However, it can produce tensions within the discussion group when
there are some participants for whom the secular, rationalist framework
is the norm, and others for whom it represents a significant departure
from their accustomed way of tacking moral questions.
The difficulties attendant on recognising and respecting cultural
or religious perspectives may be more acute within Professional than
Applied Ethics discussion groups. Applied Ethics students need only
adopt a secular framework as a temporary learning methodology. The
spiritual, religious and cultural perspectives left outside the classroom
door at the start of the seminar can be collected and reapplied at its close
(unless, of course, the student’s own learning experience has resulted in
a change of belief). For students of Professional Ethics, in so far as the
seminar’s learning objectives focus on shaping professional behaviour,
the framework adopted as a learning method will act as a modus
operandum for real-life ethical decision-making. This can often mean
that the secular perspective imposed within the class is put forward as a
component of their professional moral identity. A clear and transparent
statement of the approach chosen and the reasons for imposing it (for
example, by reference to legal obligations and Professional Codes) will
facilitate constructive debate.
Bielby notes that if a student expresses a moral view but then
refuses to submit that view to further scrutiny, the teacher will be faced
with competing pedagogical objectives:
They can show respect to the student, by respecting their wish not
to discuss the matter further, but at the risk of leaving others student’s
feeling frustrated that they have not been allowed to explore the matter
further They can give priority to the values of critical enquiry by
facilitating a debate on the issue but at the risk of creating an
84
‘oppressive’ environment for the student thus compelled to hear criticism
of a deeply held belief. 97
Guidance on awareness of Religious Perspectives can be found in
the Faith Guides to be published by the subject centre for Philosophy,
Theology and Religious Studies in 2004.
b. Multiple Perspectives
Multiple perspectives can arise from differences of culture, religion,
social class, gender or academic discipline. This diversity can be
advantageous in group discussion-based teaching formats by exposing
students to a range of views but when several students within the group
share a perspective the discussion can break down into a contest
between rival ‘factions’ and can also lead to the isolation of students
whose perspective is not shared by any other group member. A clear
framework can be helpful here by ensuring that:
Every member of the group has an opportunity to speak.
Views can be expressed without interruption.
Criticisms are aimed at arguments and not individuals.
There are mechanisms for defusing heated situations.
Participants are encouraged to apply constructive criticism to their
own beliefs
Participants are encouraged to look for common ground between
opposing views
Teaching materials are selected for their accessibility to a range of
viewpoints.
For similar reasons, drawing students from different disciplines
can greatly improve the effectiveness of ethics seminar/discussion groups
by exposing students to different personal and professional perspectives
and to divergent points of view98. These differences of perspective can
have a direct impact on the student’s learning experience but the
relative sizes of different professional subgroups can be critical, as can
the skills of the teacher/facilitator. The internal dynamics of such groups
are likely to affect the students’ learning experience. For example,
interdisciplinary healthcare ethics seminars will differ from single-
discipline format in a number of ways:
All links are available live at http://www.prs-ltsn.ac.uk/ethics
97 Bielby, P. (2003) ‘Courting Controversies: using insights from a legal philosophy course to develop practical
recommendations for realising pedagogical objectives in teaching morally contentious issues’, Teaching in Higher
Education, Vol. 8, No. 3, 2003, pp. 369–381
98 Tugcu P, Hung R.J, Pan H.L, Nolan P.W, Smith J. (1995) “Ethical awareness among first year medical, dental
and nursing students”, International Journal of Nursing Studies, vol. 32, no. 5, pp. 506-517(12)
85
Profession-relative variations in embedded or implicit value-sets are
more likely to be recognised and addressed in interdisciplinary
groups. In a study of in-hospital ethics seminars carried out by
Alderson et al, “[a]haematologist noted the frequently discussed
contrast between geneticists offering choice and other clinicians
recommending best treatment: ‘The neonatal team have to think
about best care, whereas in genetics the ethical goal is more informed
choice, when you don’t impose your view.’”
Professional relationships operate within a hierarchy of power and
authority that sometimes makes it difficult for junior or subordinate
members of staff to express moral concerns99. Interdisciplinary groups
can be used to explore the extent to which different professions have
differing attitudes to authority and its relevance to moral
responsibility.
Professions often show differing gender profiles100. Interdisciplinary
groups can help to avoid gender imbalances in discussion groups,
thus facilitating a broader perspective on gender-sensitive issues.
Nursing and paramedical staff often spend more time with their
patients than doctors, and converse with them in a way that goes beyond
the medical details of their case. The extent to which the professional
develops a ‘relationship’ with a patient can influence their views on
issues such as the patient’s ability to offer informed consent and their
quality of life. Interdisciplinary groups encourage an understanding of
these different perspectives, and can be used to develop ways of reaching
inter-professional consensus.
c. Objectivity versus Emotional Engagement
It can be dangerous to allow students to personalise the issues under
discussion as this may arouse feelings of guilt and a need for self-
justification. It is not inappropriate for students to be given some
mechanism for addressing such issues and the ethics modules might be a
good place to publicise the existence of that mechanism but this does not
mean that the seminar is in itself a suitable forum for students to
address morally problematic aspects of their own experience. Where
there is a demand for this kind of support a properly constructed self-
help group or access to external support services (see the section on
Safety above) should be considered as an alternative.
All links are available live at http://www.prs-ltsn.ac.uk/ethics
99 Alderson P, Farsides B, Williams C. (2002) “Examining ethics in practice: health service professionals’
evaluations of in hospital ethics seminars”, Nursing Ethics vol. 9 no. 5 pp. 508-521(14)
100 For example, women currently comprise 36% of the veterinary profession (RCVS News, November 2002) but
80% of UCAS 2003 applications from students wishing to study veterinary medicine were from women 2003
(RCVS News, March 2003).
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Students will normally be required to maintain a degree of
emotional distance to the issues under consideration. The level of
detachment required should be determined by the teacher with reference
to their stated learning objectives and the teaching materials to be
employed, and should be reflected in the discussion framework.
A highly theoretical approach will militate against personal
involvement but can lead to too much distance from the issues and a
failure to engage in moral dilemmas as real challenges. It is most suited
to modules in which the learning objectives emphasise conceptual
analysis and reasoned argument.
Practice-based learning allows students to relate the ethical
issues under discussion to their own personal experience. It is subject to
the danger of excessive personal engagement mentioned above but can
be suited to more experienced students, or those for whom the ability to
maintain a degree of objectivity or distance on ethical issues is a key
learning objective. It can also be appropriate in courses that aim to
develop or enhance empathy.
Narrative based learning can also be a good way of helping
students maintain a balanced approach (see p. * for a more detailed
discussion of teaching ethics through narrative).
4. Confidentiality
When using Contextualised Scenarios or Case Studies drawn from real
life there are three main groups whose confidentiality must be
maintained:
1) The seminar participants.
2) Professionals involved in the cases under discussion
3) Service-users or other members of the public involved in the cases
under discussion.
When using pre-prepared case studies or contextualised scenarios
it should be possible to define them so as to protect groups 2 and 3 (if it is
not, then the case should not be used) but confidentiality will be more
difficult to maintain when students are invited to supply material drawn
from their own experience particularly if this is done in a spontaneous or
ad hoc way rather than as the result of pre-seminar preparation.
Changing the names of any real people mentioned in a case study
will be necessary unless the full details of the case are a matter of public
record. This makes issues that have been brought before the Courts a
good source of teaching material. For cases drawn from other sources
confidentiality should be maintained. The General Medical Council’s
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Ethical Guidance on confidentiality in materials used for education and
training states that while:
‘[d]isclosure of information about patients for purposes such as … use in education or
training … is unlikely to have personal consequences for the patient … you should still
obtain patients’ express consent to the use of identifiable data or arrange for members
of the health care team to anonymise records’. 101
Changing the names will not always be sufficient to prevent
identification of the real people involved. For example, if the case is
drawn from a workplace of which students have some prior knowledge,
they might be able to identify members of staff from details of their
position in the workplace, their personal characteristics and
idiosyncrasies or their values and beliefs. Similarly, the students might
have come to hear of the case through work placements and be able to
identify the service-user or staff involved from other aspects of the case
(this is more likely for cases selected for discussion because of their
distinctive or controversial nature).
Maintaining confidentiality for those involved in real cases will
therefore require some knowledge of the background of the participants
in the seminar, to determine the depth of ‘disguise’ that must be applied.
When cases are offered spontaneously, this level of preparation will not
be possible and confidentiality will require the seminar participants to
work to general rules and safeguards designed to protect confidentiality.
Healthcare students will often be used to working within this
framework. For example, student nurses will normally be issued with a
handbook applicable to the whole of their training in which the rules
governing confidentiality are specified clearly. Students coming to an
ethics seminar with some experience of work placements may be used to
participating in case study meetings where confidentiality rules apply,
and will simply need to be reminded that ethics seminars are not exempt
from normal good practice in this respect.
However, when students (and teachers/facilitators) are not
accustomed to professional/service-user relationships a more detailed
statement and explanation of the rules might be needed. There is also a
wider question concerning examples offered by students from their own
personal (as opposed to professional) lives. This might include the
experiences of friends or family members who would not normally be
accorded the confidentiality rights of the professional/service-user
relationship, but should be afforded the same protection as other
subjects within the context of a learning and teaching environment.
All links are available live at http://www.prs-ltsn.ac.uk/ethics
101 ‘Confidentiality: Protecting and Providing Information’, http://www.gmc-uk.org/standards/default.htm
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The confidentiality of seminar participants can be protected by
the adoption of the Chatham House Rule which reads as follows:
When a meeting, or part thereof, is held under the Chatham House Rule, participants are
free to use the information received, but neither the identity nor the affiliation of the
speaker(s), nor that of any other participant, may be revealed.102
However, it should be borne in mind that some students might
express an unwillingness to observe Chatham House Rules, perhaps
because they would feel obliged to act on any information re illegal acts
that might be revealed in the course of a class. Teachers need to be
prepared to respond appropriately, to maximise contributions in a way
that does not threaten confidentiality.
All links are available live at http://www.prs-ltsn.ac.uk/ethics
102 http://www.riia.org/index.php?id=14
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Future developments
Society is empowered by ever-improving access to more and more information, and is
demanding greater transparency and accountability. 103
hen our graduates leave university they will increasingly be asked to
discuss moral issues competently and constructively with a diverse
Wrange of people. In some cases they will be asked to address the
concerns of members of the public. One of the primary motives behind
the drive towards a greater ethical awareness among graduates is an
appreciation of the consequences for any profession of a loss of public
confidence. It will therefore be increasingly important for teachers of
ethics to produce learning and teaching outcomes on three levels:
Subject-specific: students will need to understand:
The moral issues that arise most frequently within their own
subject area.
The perspectives of students and professionals within this
subject area.
The perspectives of key stakeholders/service users in the
professions served by that subject area.
Interprofessional: students will need to understand the perspectives
of people from professionally related subject areas on issues of shared
moral significance.
Public: students will need to understand the perspectives of private
individuals and relevant social groups on moral issues arising within
their subject area.
The third level is potentially the most complex and challenging of
all and is likely to become of even greater importance as internet access
grows. From official sources such as the Home Office’s pages on the use
of Animals in Scientific Procedures104 through the Research Councils105
and bodies such as the Nuffield Council on Bioethics106 to national and
international campaigning organisations such as Greenpeace107 and the
All links are available live at http://www.prs-ltsn.ac.uk/ethics
103 The British Council (2000) Science and Society: Towards a Democratic Science,
http:/ www.britcoun.org/science1/intro.htm
104 http://www.homeoffice.gov.uk/comrace/animals/reference.html#
105 See The Welcome Trust’s Biomedical Ethics Programme at http://www.wellcome.ac.uk/en/1/pinbio.html
and the MRC’s Centre for Best Practice for Animals in Research at http://www.mrc.ac.uk/index/public-
interest/public-ethics_and_best_practice/public-use_of_animals_in_research/public-cbpar.htm
106 http://www.nuffieldbioethics.org/home/
107 http://www.greenpeace.org.uk
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Worldwide Fund for Nature,108 people can inform themselves on
ethically sensitive matters and involve themselves in public debate more
readily than ever before. Any graduate entering a profession which has
attracted interest or concern must therefore be prepared to discuss
ethical issues on a peer-to-peer basis with those who do not share their
professional perspective.
While many academic disciplines must respond to societal
changes and be sensitive to public opinion, few can rival professional
ethics for the dynamism and immediacy of its relationship with external
factors. This often makes it a rewarding area in which to work but it can
also mean operating within a learning and teaching environment that is
in such a constant state of flux that everyone has to run merely to stand
still.
More opportunities should be sought to reflect on the way in
which profession ethics is evolving. An open and constructive debate
between those concerned with this challenging but vital subject would
help to ensure that that public confidence grows hand-in-hand with
professional morale. Teachers of moral theory have much to offer in that
enterprise, but their expertise will be of greater benefit when it is
applied in concert with contributions from those whose subject specific
knowledge includes a profound understanding of the contexts in which
professionals must bring theory to life.
All links are available live at http://www.prs-ltsn.ac.uk/ethics
108 http://www.wwf.org.uk/core/index.asp
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Appendix A:
Using Case Studies or
Contextualised Scenarios
A stated output for the ETHICS Project was an online case study (or
contextualised scenario) resource for teachers. The reason for selecting
case studies was that it is a teaching resource used across the
disciplines. Contextualised Scenarios or Case Studies are working
examples of applied ethical problems used in teaching to highlight
relevant ethical principles which are:
Defined in relation to stated learning and teaching objectives.
Of proven effectiveness in meeting those learning and teaching
objectives.
Drawn from a wide range of disciplines but presented so as to
facilitate translation into other subject areas.
As the case studies presented in this guide have indicated, what
counts as a case study, how it is presented and the learning and teaching
objectives it serves will vary considerably.
This reference will be completed when the address of the database
has been determined.
For more case study teaching resources see the ETHICS Project’s
website at http://www.prs-ltsn.ac.uk
In the example provided in the pragmatic approach, the case
study is presented as an extract from a research proposal. It could be
used as it is, to highlight an area of particular concern to Research
Ethics Committees (namely the use of animals as experimental
subjects), or it could be expanded into a complete research proposal
outline, with appropriate scientific detail, so that students can begin the
more complex process of evaluating the scientific merits of the research
and weighing them against the costs in terms of animal
experimentation.
That same outline could also be expanded with the detail
necessary for students to role-play an application, with some acting as
scientists, some as REC members and others as animal rights
campaigners.
Alternatively, it could be presented in a context that highlighted
the reasoning behind the principles of reduction, replacement and
refinement and used as a learning and teaching resource for the
theoretical approach.
The scenarios employed in the other two case studies could be
similarly represented to serve the needs of different approaches.
Provided the teacher is clear about their objectives, and the way
the case study operates to serve those objectives, material can be tailored
to meet the needs of the subject area, the expected level of experience (of
both student and the teacher), and practical constraints such as group
size and number of teaching hours.
Case Studies as Projects
Case studies can be offered to students as projects, to be tackled either
individually or by groups of students. This can be of great benefit,
especially if students have an opportunity to devote a number of weeks
to the project. However, care must be taken to ensure that the group
composition, in terms of both background and level, is appropriate to the
demands of the case study selected.
(Ref to PRS mini-project here if the report is submitted in time for
inclusion)
Teaching via case study project can be used to develop a number
of key skills:
Time Management
Presentation and Practical skills
Research
For Group work on Case Studies it also helps with:
Defining different roles
Group dynamics
Handling of uneven workloads
Resolution of conflict
Case studies can also be used to give students an insight into the
roles they can have when they leave university, by exposing them to
visiting experts who also function as role-models. These visiting experts
can be invited to set up case studies or problems that student groups
must solve by working together, and to evaluate the end result. The
visitors may need training in order to perform their role effectively,
especially if they are not actively involved in teaching outside their role
as visitor. This training should cover:
Conceiving an appropriate case study – concentration on current
issues.
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How to write up the case study for presentation to the students
Assessment and Providing Feedback to students
This process may help to develop links between the department
and potential employers. Visitors get a chance to see how the
department works, form a relationship with the staff and assess the
quality of teaching the department provides. Individual students who
show promise in their execution of the case study might be targeted as
future employees.
Group assessment of case study projects can be done by a variety
of means:
Student questionnaires
Peer-tutor focus groups
Lecturer’s perceptions
Student Marks and Attendance records109
All links are available live at http://www.prs-ltsn.ac.uk/ethics
109 Further information can be found on www.cases.bham.ac.uk/group. This material has been developed for
metallurgy and materials but much of it can be adapted to the needs of applied ethics learning and teaching
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