Ethico-legal considerations of teaching

Rehana Iqbal FRCA MBBS PgDip BSc

Carwyn Rhys Hooper Dip. Phil BSc MBBS MA Matrix reference 1F01, 1F05

Key points For clinicians, there are professional and ethical patients. When more experienced staff are
obligations to teach. Medical education differs available, there is little immediate benefit to the
Medical education differs
from teaching in other professions as it involves a patient of having a trainee undertake a proced-
from teaching in other

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professions as it involves a third individual—the patient. This experiential ure. However, there are a number of ethical
third party, the patient, who learning is associated with certain ethical and arguments which support learning with live
may be exposed to certain legal issues. The content of training is well speci- patients.
risks. This raises certain fied, but the context and the delivery of education-
ethical and legal issues. al content is not. For example, it is recognized
Benefits
There are a number of that anaesthetic trainees learn the technique of
‘new’ challenges to fibreoptic intubation, but how and when this tech- The traditional view that trainee involvement is
delivering teaching and nique should be taught is less clear—see Table 1 of no benefit to the current patient is question-
traditional methods may no for our suggestions in this regard. able. Student and trainee involvement in patient
longer be professionally and Both trainees and established specialists are care may identify certain factors in the history
ethically acceptable. involved in clinical teaching. Traditionally, the or examination which may have been missed
Ethical considerations manner in which teaching was delivered was by other members of the team. It has been sug-
include patient autonomy, based on past role models. Some of these tradi- gested that supervised procedures are preferable
the quantity of information tional methods, such as intimate examinations because teaching may result in a greater atten-
provided, and the roles of under general anaesthesia without explicit consent tion to detail.1 In some cases, quality of care
all parties involved. and practising procedures on the recently deceased, and outcomes are better in teaching hospitals,
The key legal considerations are now recognized as professionally and ethically although this may be attributed to higher case
centre on consent, standard unacceptable. Moreover, the assumption that volume, better access to technology, subspecia-
of care, and supervision. doctors were entitled to train on patients has been list care, and presence of more staff
It is timely to reflect on the replaced with the notion that patients have a right out-of-hours.2 Healthcare is delivered by teams.
ethical and legal to refuse to participate in such training activities. Trainees deliver a significant proportion of
considerations when Current challenges for anaesthetic training patient care and their presence in clinics, and
teaching to ensure that the include a reduction in training time, a greater on the wards, are of benefit to current patients
delivery of teaching is number of techniques to be learnt, greater com- allowing shorter waiting times. Their contribu-
ethically justifiable, legally plexity of procedures, and more high-risk ‘un- tion to inpatient care is especially important in
defensible, and, most the postoperative period when techniques learnt
suitable’ patients. Over the last few decades,
importantly, acceptable to
there has also been a change in the doctor – in theatre may be required in an urgent setting,
patients.
patient relationship with a greater emphasis on out-of-hours, when senior staff are not on site.
patient autonomy, patient rights, and a quality It may also be argued that patients benefit from
control of training by deaneries. The perceived teaching because it gives them the opportunity
Rehana Iqbal FRCA MBBS PgDip BSc
pressure of finding training opportunities may to act altruistically by helping the next gener-
Consultant Anaesthetist and Honorary
Lecturer in Medical Ethics and Law increase the conflict between the duty of care ation of healthcare professionals to learn.
St George’s Healthcare NHS Trust to the patient and the duty to teach. When teaching the actual immediate benefit
67 Selhurst Close to an individual patient is dependent on what is
Wimbledon
For these reasons, it is timely to reflect on the
LondonSW19 6AY ethical and legal considerations encountered proposed, the experience of the trainee, the
UK during teaching to ensure that the delivery of degree of supervision, and patient characteris-
Tel: +44 (0)20 8725 5846 tics. It would be difficult to ethically and
Fax: +44 (0)20 8725 3538
teaching is ethically acceptable, legally defens-
E-mail: [email protected] ible, and, most importantly, acceptable to patients. legally justify treatments which are of no thera-
(for correspondence) peutic benefit and performed purely for educa-
Carwyn Rhys Hooper Dip. Phil BSc tional purposes.
Ethical justifications for
MBBS MA Teaching also benefits future patients and
learning on ‘live’ patients although this benefit does not necessarily
Lecturer in Medical Ethics and Law
St George’s, University of London Established specialists are likely to have con- accrue to the patient who is taking part in train-
London
UK cerns about the justifications for learning on ing, it may do so because many patients require
doi:10.1093/bjaceaccp/mkt018 Advance Access publication 1 March, 2013
203 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 13 Number 6 2013
& The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.
All rights reserved. For Permissions, please email: [email protected]
Ethico-legal considerations of teaching

Table 1 Possible considerations before teaching fibreoptic intubation Patient obligations

Planning of training event Possible considerations
There is an argument to support the idea that current patients have
1. Define the educational objectives Consider the alternatives to practice on obligations to contribute to medical education. There is a justice ar-
patients for achieving those objectives gument that current patients benefit from the experience and skills
2. Is the standard of patient care
of doctors who gained those skills from learning with previous
proposed acceptable?
patients. This could be construed as a debt to society which ought
† Is the anaesthetic plan proposed † Is intubation required for medical care?
to be paid back. However, not all current patients may have the
clinically indicated? † Is fibreoptic intubation equivalent to or
† Is the anaesthetic plan/technique superior to direct laryngoscopy in opportunity to ‘repay’ such a debt and not all past patients have
appropriate in skilled hands? experienced hands? contributed to teaching. Moreover, the recipients of altruistic acts

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3. Information provision may not have an obligation to reciprocate if they had no obvious
opportunity to refuse to receive the benefit that they receive.
† Should there be explicit consent † Is the use of the flexible fibrescope by
for the use of the flexible the trainer routine? The extent of patient obligations to contribute to medical train-
fibrescope? † Should consent for general anaesthesia ing is open to disagreement. In the context of confidentiality, we
include intubation? Should it also
clearly accept certain situations where the interests of society or an
include the process by which the
endpoint is reached, i.e. equipment identifiable individual override an individual’s interests. However,
used? compulsory participation in training would override patient auton-
omy. This would be detrimental to the doctor– patient relationship
† Should we consent for the † What are the patient risks when this
and also to the objectives of a training programme which should
training? routine technique is carried out by the
trainee. Risks would be related to the include training in attitudes and values and also knowledge and
experience of the trainee and patient skills.
characteristics
† Consider what a reasonable patient
would want to know and what is Ethical considerations
relevant to this patient
† The nature of the training and extent of Patient autonomy and consent
trainee involvement
Respect for autonomy, or the patient’s right to determine what
† Has the trainee met the patient † Importance to patient happens to them, underpins consent. Autonomous decisions
and what was discussed? † Teaching of non-technical attributes
require information, capacity, and voluntariness on the part of the
4. Maximization of benefits and patient. A capacitous patient will voluntarily choose or decline a
minimization of harm † Pre-patient training tools (skills rooms,
simulator, effective teaching skills particular treatment option based on information discussed with
courses) their clinician. Discussion with patients about teaching during the
† Appropriate patient selection
† Adequate supervision
delivery of care facilitates autonomous decisions and demonstrates
† ‘Trained’ teacher respect. Concerns that patients will refuse consent to learner in-
5. Awareness of professional guidelines
volvement in their care are unfounded.3 Ethically questionable
and the law consent for teaching of technical skills may imply to the trainee
that the acquisition of technical skills is of greater importance than
other values necessary for good clinical practice.
Facilitation of patient autonomy when teaching during the de-
future treatment and may receive that treatment from the very pro- livery of care requires that the patient understands and agrees to
fessionals who they helped to train. That said, there is often a the extent of learner involvement. In addition to promoting patient
tension between what is beneficial for the individual patient and autonomy, this approach fosters trust and confidence by reinforcing
what is beneficial to society. that the primary intention of care is to promote patient well-being.
The active participation of the patient in the educational process
enables questions to be answered, anxiety to be allayed, and, in
doing so, dispels concerns that patient deception has occurred.
Future reduction in harm
This may reduce unintentional patient coercion to participate in
Teaching may increase the risks a patient is exposed to. For teaching as it encourages openness and honesty so that the patient
example, dental damage while learning how to intubate a patient. may be more comfortable to discuss what would and would not be
However, if doctors do not learn in supervised conditions as part acceptable to them.
of a training programme, they will learn as established specialists The information provided should be relevant to the patient and
on the job, without the same degree of supervision. This would cover the nature of what is proposed. Broadly speaking, the discus-
expose their current and future patients to greater risks than in a sion should include an explanation of what is to be taught, why it
well-structured training programme. is being taught, and who is being taught.

204 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 13 Number 6 2013
 Ethico-legal considerations of teaching

The nature of what is proposed would include a description of particularly important if a complication occurred. For example, if
what is to occur and why. In the context of medical care, the dental damage occurred after intubation by a trainee, the patient
amount of information which ought to be given raises certain ques- may feel deceived and be less understanding if they had not met
tions. First, it is difficult to quantify the risk to a patient of having the individual who had undertaken the intubation.
a trainee undertake specific aspects of the delivery of their care— In summary, the information shared should be context-specific,
although this could be partially rectified by allowing the trainer to aiming to enable that particular patient to determine how their care
have access to the trainee’s logbook before seeking consent. is to be provided by exploring their preferences, concerns, and
Secondly, delivery of care consists of a number of components. In clarifying the role of the trainee in their care. Risks and benefits
the example of intubation for general anaesthesia, the components should be discussed and reassurance given that the primary aim of
of the procedure could include the type of laryngoscope blade care is to benefit the patient, not to promote medical education. In

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used, the use of the bougie, indirect laryngoscopes, or flexible particular, patients ought to be informed that seniors would inter-
fibrescope. For some, it is common practice to consent specifically vene quickly if the trainee was having difficulty or needed
for the use of the flexible fibrescope but for others who use it rou- assistance.
tinely in their practice, this may not be the case. Thirdly, should
information provided involve a discussion of the endpoint/aim of
Duties, responsibilities, and needs
the procedure and/or the process of achieving the endpoint? For
example, when general anaesthesia is discussed, the drugs used to Teaching in medicine involves three parties: the teacher, the
achieve this are usually not mentioned and similarly when institut- learner, and the patient. This tripartite relationship deserves consid-
ing regional anaesthesia, the anatomical approach and choice of eration, particularly when the teaching of clinical skills and atti-
needle are usually not discussed. tudes exposes the patient and learner to the risk of harm. The
This difficulty in defining what constitutes a procedure and relationship between the three parties is not a hierarchical one. It is
what components of a procedure warrant separate discussion is an interrelated relationship of mutual dependence. Recognizing the
reflected legally and professionally. In the case of Davis v duties, responsibilities, and needs of all parties is essential.
Barking, Havering and Brentwood HA, the courts found no distinc- The teacher has a duty of care to the patient which includes
tion between omitting to discuss the insertion of a tracheal tube or good quality care, minimization of harm, accountability, and, im-
insertion of a caudal while under general anaesthesia.4 This is an portantly, the respect of autonomy and confidentiality. This takes
unlikely defence now. It has been recommended that specific dis- priority over the duties that the teacher has to the learner,
cussion should occur if the aim of the procedure is changed or the namely the transferral of knowledge, skills, and attitudes for
components are changed to the extent of altering the risks.5 future independent practice. Closely related to this is the respon-
Information about the trainee is equally if not more important sibility that the teacher owes to future patients and society. This
to the patient. One would expect that the experience of the responsibility is reflected in the duty to ensure that there are
trainee would influence the patient’s decision to participate with clearly defined, assessable competencies which must be achieved
patients refusing if the trainee is at the beginning of the learning by the learner and that training programmes and trainers meet
curve. However, this is not necessarily the case. Patients may feel strict levels of quality control. Finally, there is the need for ad-
that very inexperienced trainees will receive closer supervision equate resources (time, equipment, staffing, etc.) and suitable
than more experienced trainees and it has been suggested that willing patients.
patients may be more likely to agree if they have met the The learner has a similar duty and responsibility for patient
learners.4 care—although this has the potential to be forgotten when direct
The active role of the trainee in information provision to the supervision occurs. This duty must take precedence over the edu-
patient is essential for a number of reasons. Professional guidelines cational event. In addition to this, the learner has a need to obtain
have emphasized the importance of teaching non-technical attri- certain competencies and to be adequately supervised. The learner
butes: ‘Consultants are responsible for teaching trainees not only also has a responsibility to engage in the educational process and
the science and practice of anaesthesia but also all the other attri- to fulfil the preparatory requirements to be involved in what is pro-
butes that make a good anaesthetist’.6 posed to be taught. For example, in the context of practical proce-
Meeting with the patient reinforces the treatment of patients dures, where possible, the learner should have acquired the
with dignity and the recognition that it is a privilege, not a right, knowledge and manual dexterity in classroom, skills room, and
to develop clinical skills ‘on’ patients. It allows the opportunity for simulation before gaining experience with patients.
the trainee and the patient to develop a rapport. For the patient, it Despite the educational process, the patient will invariably
reinforces the role of the trainee as a clinician who has a shared re- want to experience an acceptable standard of care. The duty of
sponsibility for their medical care. Also patients’ may be more patients in the context of medical education is less clear and
willing to contribute to the learning of an identifiable individual. debated in the literature. Although there are strong arguments that
One can assume that this would result in more satisfactory patients have a responsibility within a society to be involved in
trainer– patient and trainee –patient relationships which are training, this is not accepted as an obligation.

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 Ethico-legal considerations of teaching

Summary 3. Santen SA, Hemphill RR, Spanier CM, Fletcher ND. ‘Sorry it’s my first
time!’ Will patients consent to medical students learning procedures?
There is an ethical and professional obligation to teach, develop, and Med Educ 2005; 39: 365–9
maintain skills. There are a number of ‘new’ challenges to delivering 4. Davis v Barking, Havering and Brentwood Health Authority. Med Law
teaching and traditional methods may no longer be professionally Rep 1993; 4: 85
and ethically acceptable. Much attention has been given to the 5. Maclean AR. Consent, sectionalisation and the concept of a medical pro-
cedure. J Med Ethics 2002; 28: 249– 54
content of medical education with less attention to the context.
6. AAGBI. Consultant trainee relationships. A guide for consultants.
There has been a significant change over the last few decades in AAGBI, 2001
terms of the ethical acceptability and professional guidelines govern-
7. Department of Health. Reference Guide to Consent for Examination or
ing training and also in terms of the behaviours and values expected Treatment, 2nd Edn. London: 2009

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of trainees and their clinical and educational supervisors. The appro- 8. Association of Anaesthetists of Great Britain and Ireland. Consent for
priateness and process of training delivery in anaesthesia should be Anaesthesia, Revised Edition. London: 2006
case-specific, ethico-legally justifiable, and should pay particular 9. General Medical Council. Seeking patients’ consent: the ethical issues.
heed to the values of patient autonomy and the role of consent. London: GMC, 1998
10. Bolam v Friern Hospital Management Committee. WLR 1957; I: 582
Declaration of interest 11. Bolitho v City and Hackney Health Authority. Med LR 1993; 4: 381
None declared. 12. Nettleship v Weston. All ER 1971; 3: 581
13. Wilsher v Essex Area HA. AC 1988: 1074
References 14. General Medical Council. Good Medical Practice: Teaching and Training,
1. Yentis SM. The use of patients for learning and maintaining practical Appraising and Assessing. London: GMC, 2006
skills. J Roy Soc Med 2005; 98: 299–302
2. Allison JJ, Kiefe CI, Weissman NW et al. Relationship of hospital teaching
status with quality of care and mortality for medicare patients with acute Please see multiple choice questions 13 –16.
MI. J Am Med Assoc 2000; 284: 1256– 62

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