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Moral Behaviour sine qua non of Medical Practice & Medical Education

“Your ability to discipline yourself to set clear goals, and then to work towards them every day, will do more to guarantee your success than any other single factor.” — Brian Tracy

Dr D S Sheriff
Dr D S Sheriff

Edmund D Pellegrino terms deprofessionalisation of medicine as a process whereby the core values of medicine are gradually being undermined by forces both internal and external to the practice of medicine. Yet moral behaviour is the sine qua non of medical practice. However, it is a learned behaviour, not a genetic trait; and as already stated, many students do not begin medical school at the desired level of moral knowledge.

Moral could be defined as values that we attribute to a system of beliefs that help the individual define right versus wrong. These typically get their authority from something outside the individual — a higher being or higher authority (Medical Council of India, Vision of the University or Medical School).


The core beliefs we hold regarding what is right and fair in terms of our actions and our interactions with others. In other ways, values are what an individual believes to be of worth and importance to his profession and life.

The most important core values for any profession including medicine are:

• integrity defines the person who acts,
• service defines what the person does in the context of core values,
• and excellence defines the acts in terms of outcomes.

Integrity comes from the word integer, which means whole. In other words, the real meaning of integrity is wholeness of character. Integrity also demands wholeness of purpose in everything medical professionals do to ensure their actions impact the patients in the right way, and are aligned with Medicine’s core values.

Therefore the moral regulation of behaviour has been necessary for their collective well-being and survival. For the same reasons, ethics, or core values, are just as important today as they were before.

Ethics in the current context can be considered as the decisions, choices, and actions (behaviours) we make that reflect and enact our values. In other words, ethics help to define what personal choice one makes in a particular situation. The difference between ethics and morals can seem somewhat arbitrary to many, but there is a basic, albeit subtle, difference. Morals define personal character, while ethics stress a social system in which those morals are applied. In other words, ethics point to standards or codes of behaviour expected by the group to which the individual belongs. This could be named as medical ethics and professional ethics. So, while a person’s moral code is usually unchanging, the ethics he or she practices can be other-dependent.

Therefore moral regulation of behaviour has been necessary for physician’s well-being for “Moral Behaviour is the sine qua non of Medical Practice and Medical Education.”

In this context it is better to remember the words:

“Watch your thoughts; they become words. Watch your words; they become actions. Watch your actions; they become habits. Watch your habits; they become character. Watch your character; it becomes your destiny.”

Thomas à Kempis, a 14th century German writer and monk wrote, “The highest and most profitable learning is the knowledge of ourselves.” That sets the tone for medical practice and medical education.

It is time to introspect and consider the role of morals, values and ethics in regulating the selection process of medical students, their education, training and service. It is difficult to change the system but it is possible to change the attitudes of our students who in spite of wide variations in their personal characteristics want to learn and become good human beings. This is reinforced and motivated by the value system of the institution where they learn and ethical character of their teachers.

In this context, it is important to acknowledge that marked changes have taken place in the moral education of students at all levels during the past several decades.

1. The values clarification movement based upon the notion that none of us has the ‘Right’ set of values to pass along to other peoples’ children, the role of the teacher is to help students discover their own feelings, their own ideas, their own beliefs, so that the choices and decisions that they make are conscious and deliberate, based upon their own value system.”

2. The cognitive moral development movement championed by Lawrence Kohlberg and based on the premise that children possess certain cognitive structures that come into play in predictable fashion as the individual develops. Not all children develop at the same rate, however, and not all persons attain the same level of moral maturity.

Most of the students who join medicine today are very enthusiastic, having greater intellectual curiosity with additional knowledge of eLearning. What they need is a stimulus given in the first year of their medical education making them realize the importance of medical profession and learn the code of medical ethics acting as the foundation stone for their future medical practice.

The practice of medicine continues to be based upon these virtues — compassion, dedication, honesty, integrity, courage, wisdom, self-sacrifice — these are the virtues we continue to associate with the physician. And not just a good physician, but all physicians. Today’s college graduates educated under a new morality arrive at medical school morally confused at best, and given that limited moral maturation occurs during medical school, we have a profession that, in the opinion of many, may well be in moral disarray. The time-packed curriculum and the pressures to shine in the profession provide little time to dwell upon the ethical aspects of medicine for the students.

In such a state of moral dilemmas and confusion with mechanized high-tech medicare moral sensitivity as well as moral responsibility of physicians need to be sharpened time and again. The human touch and the loving care are still the tenets of a true physician-patient relationship.

In such a situation, can we teach ethics without virtue though it is not equally impossible to practice medicine without a code of ethics based upon virtue?

There are shifts in moral and ethical consequences followed by growing absence of a shared understanding of the moral values essential for the students and practice of medicine. This is very true of universities and medical schools in the developing stage. Apart from buildings, facilities the real investment is student community that adorn these campuses. The students selected come from different background of family values, religious beliefs, ethnic variations and cultural confusion. In such a situation how do we amalgamate the student community into one united moral force that is going to serve and shape the concept of a true physician holding the torch that illuminates the motto “their lives (patients’) in your hands (physicians)”?

This concept of responsibility needs to be inculcated from the day they join the medical institution. They need to be informed what a physician’s role in society is. How he or she is considered a role model for others to follow. Apart from that a medical student must be made to realize medical education is a serious business. Therefore, the question what is medical education needs to be explained.

The aims of medical education must be to
• impart true knowledge to the student,
• make him attain basic clinical skills, and
• develop a character of honesty and trustworthiness.

How do we give true knowledge to the students?

With the fast development of eLearning and Internet access education in general and medical education in particular has gained more with content and less with moral responsibility. Education without such responsibility may make one intelligent but not responsible. That responsibility comes only when a student imbibes the three most essential qualities which are important: discipline, dedication and devotion. These virtues cannot be forced upon as they are considered as learned behaviour. The learned behaviour needs a crucible where it is available for them to develop. That crucible is the medical institution whereby its institutional motto and prescribed core of values (do’s and don’ts) moulds the student into a responsible, respectable and responsive learner.

For example, a medical student must know how to respect human life for he or she has to deal with it. “Reverence for life”, the concept of Albert Schweitzer, and the religious doctrine that all knowledge comes from above should be made to be understood with conviction and love.

When a medical student deals with a human body in an anatomy dissection hall, the student must learn to respect it. In certain institutions, before they teach anatomy dissection, they start with a prayer to show how important it is to respect the human whose body is given to them for their learning. The practicality of doing a dissection tells you how careful you need to be to understand that beneath a surgeon’s knife there lurks a life.

Apart from that there is a need for medical professionalism among physicians. Physician unionization, waning ability to self-regulate, medical errors, bioterrorism, compromised access and healthcare delivery, conflicts of interest precipitated by managed care and for-profit medicine, and the pharmaceutical industry’s role in patient care and medical education reflect the range of issues that challenge the medical profession globally. At this crossroads, the medical profession urgently needs a united front to influence and inform the culture and context of both clinical practice and medical training.

In the UK, in recent years, there has been a gradual erosion of the public’s trust in the medical profession. An increasingly informed community is asking for accountability, transparency and sound professional standards. Such increased awareness has partly come about as a result of certain well-publicized acts of medical negligence and criminal behaviour. The Harold Shipman incident is a prime example, but others such as the organ retention scandals at Bristol and Alder Hey (Liverpool) collectively served to undermine the high regard for doctors held by the public. In the aftermath of such events there has been a spate of enquiries and reports analysing the working practice of the British medical establishment with special emphasis on medical regulation and the effectiveness of the GMC (General Medical Council). In the 5th report of the Shipman enquiry, Dame Janet Smith was critical of the culture and functions of the GMC, concluding that it was more likely to protect the interests of the doctor than of the patient. There is a dire need for medical professionalism. What does medical professionalism mean? Medical professionalism signifies a set of values, behaviours and relationships that underpins the trust the public has in doctors.

It can be thought of as embodying a code of practice and conduct that will ensure a strong bond of trust between doctor and patient, and which will help bring the public and medical profession closer together.

Within the fabric of medical professionalism the public has certain expectations of doctors, which may be summarized as:

1. The doctor should be dedicated to serving the interests of the patient (the principle of primacy of patient welfare);
2. Patients wish to make up their own minds about their options for the management of their illness. To effectively enable this patients expect their doctors to be honest with them and empower them to make informed decisions about their treatment (the principle of patients’ autonomy);
3. The medical profession must promote justice in the healthcare system, including the fair distribution of healthcare resources (the principle of social justice);
4.Good communication is essential in the medical consultation;
5. Patronising or arrogant behaviour is unacceptable;
6. The profession should show its determination to confront poor practice and end the secrecy that surrounds it; and
7. Doctors should be prepared to accept more accountability – individually and collectively.

In such a social stressful atmosphere the development of medical professionalism among physicians is crucial and could pave way to dispel and develop a trustworthy image of the profession among the community. We need to have a system of positive feedback to assess the outcome of such endeavours undertaken by an authority like the Medical Council of India (MCI). The feedback system needs to be a wholesome and must come from all involved in the medical profession, public and the patients.

Every decision, and every action, has implications not only out there in the world but also in our innermost beings. It’s like throwing a stone into a pond. It never just sinks, but also creates ripples. In the same way, anything you do, however small, creates ripples in your character. It makes it a little more likely that you’ll act in the same way again. Patterns are formed, however subtly. Habits of mind and of conduct begin to take root. And you change, however slightly, from what you previously were. In everything we do, however large or small, we should always be asking ourselves: “In doing this, am I becoming the kind of person I want to be?” One of the greatest dangers in life is the ever-present threat of self-deception. We often believe we can do something, “just this one time,” without it having any implications for who we are. But there are no exceptions to this process. We can never take a holiday away from moral significance. Everything we do forms us, moulds us, shapes us into the people we are becoming.

Excellence in everything we do focuses on the moral outcome and quality of performance. One must understand the immediate and the long-term consequences of an act, the direct and indirect consequences, and the intended and the unintended consequences. The moral outcome is simply what happens to persons because of the moral agent’s act. So, the important question is, “What results ought to be attained and what results ought to be avoided?” Additionally, the pursuit of excellence requires that “we develop a sustained passion for continuous improvement and innovation that will propel the field of medicine into a long-term, upward spiral of accomplishment and performance.” Therefore, self-awareness of one’s ethical behaviour and actions is insufficient in and of itself. Physicians must also gain an understanding of the expectations of others in terms of which results are needed and which ones ought to be avoided. Therefore a feedback system like 360-degree feedback provides an excellent means of obtaining this information in the pursuit of continuous improvement and excellence.

According to Charles R Myers, all morality concerns persons doing things that affect others. He states: The three dimensions of any ethical issue are thus: (1) the someone who does something [Agent], (2) the something that person does [Act], and (3) the outcome of that act for someone. In particular cases, the lines dividing these dimensions will be blurred because the three dimensions are inextricably linked together. A person performs acts, but those acts in turn help define who the person is. Acts produce outcomes, but acts are in part defined by their outcomes. And outcomes affect persons, but it is those persons who say what the outcomes mean for themselves and others. Still, one can discern these three dimensions — agent, act, and outcome — in every ethical issue. They are the logic or grammar of moral reasoning — the subject, verb, and object.

Since outcomes of peoples’ actions affect others, it makes sense that individuals affected by the actions are usually in the best position to help define “who the person really is” by providing feedback regarding the ethical implications of his or her actions in the context of Medicine’s values. For this reason, the Medical Council needs to expand its performance feedback programme to encompass 360-degree feedback. This change would permit physician to benefit from receiving meaningful feedback from individuals most impacted by a physician’s actions who are in the best position to provide it — such as subordinates, peers, patients, pharmaceutical and medical suppliers.

Such a system, if well developed, will improve the standards of our medical education and profession. With so much attention these days on medical professionalism and medical regulation, it is no wonder that doctors are feeling increasingly under siege. However, it must be stressed that the majority of practising doctors (in India and worldwide) consistently uphold excellent standards of healthcare. The purpose of renewed interest in medical professionalism is to ensure that the highest possible standards of healthcare are maintained across the field, and that a strong trust is preserved between doctors and the public.

Therefore, the seeds of value system need to be sown in the formative years of medical student in a medical school. Their intellectual hunger must be quenched with standard knowledge. The road to learning and medical knowledge is hard and long. It cannot be compromised with easier shortcuts.

Therefore, the initial grooming is the most vital part of an education which is going to qualify a medical student to handle human life.

The well-being of a patient depends upon his/her autonomy. The autonomous patient needs to ask questions, make choices, get a second opinion and finally select a trustworthy physician. The character of a physician includes the element of trust, honesty and moral sensitivity. The moral attributes honesty and trust play a very vital role in the process of healing and physician-patient relationship. Therefore, apart from the academic excellence of a student, the personality of the physician-student plays a vital role particularly in a mechanized world of medicine.

Dr D S Sheriff
Faculty of Medicine
Benghazi University
Benghazi, Libya

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