AMA Journal of Ethics^®

Medical students undoubtedly experience ethical dilemmas and concerns about appropriate professional behavior during their training [1], and as medical practitioners it seems they will be “encountering ethical uncertainties and even dilemmas in their daily practice with increasing frequency” [2]. However, there is evidence that medical students’ abilities to identify and manage ethical dilemmas decline as they progress through their undergraduate education [3, 4]. The role of medical educators is to adequately prepare future physicians with the knowledge and skills to identify and address such challenges. Giving medical students opportunities to discuss ethical issues they encounter in practice can engage interest and promote relevant learning.

As adviser in medical law and ethics at GKT School of Medical Education, King’s College, London, I wanted a mechanism to engage students in the discussion of clinical ethics dilemmas to ensure that their teaching was translated into practice. I had previously worked as project officer for the UK Clinical Ethics Network, which supports clinical ethics committees in National Health Service (NHS) hospital trusts [5]. I am also a member of three clinical ethics committees in NHS foundation trusts in London, and I thought a student clinical ethics committee would be an appropriate format to enable informed and meaningful discussion of clinical scenarios raising ethical concerns for students. Medical students receive core teaching in ethics and law, and, following discussion of different formats with them, we decided that a meeting that students could attend if they wished and in which they could fully participate would provide a relaxed and informal format for case discussion. I set up the Student Clinical Ethics Committee (SCEC) at King’s in 2010 with a group of medical students. The general secretary of the European Association of Centres of Medical Ethics, Rouven Porz, considered at the time that it was perhaps “the first students’ ethics committee in Europe (in the world?)” (personal communication, 2011). The aim of the SCEC is to provide opportunities for students to consider the ethical and legal issues arising in a real case observed by a health care student in clinical practice and to think through the implications for clinical decision making. There is evidence that students enjoy case-based learning, and this method seems to foster learning in small groups [6]. The SCEC clearly has no remit for providing advice but is rather an educational tool and enables interdisciplinary discussion.

SCEC Meetings

The original group of students who helped set up the SCEC considered what documentation would be necessary and decided to draft terms of reference. The terms of reference set out the objectives and processes of the SCEC, including format and frequency of meetings, who may act as chair, and how cases are referred for discussion. Additionally we drafted a framework for discussion, which is used to ensure that key issues are addressed in the discussion, such as patient capacity and preferences, views of those involved in the decision, and possible options and their outcomes.

Any medical or health care student may refer a suitably anonymized clinical case for discussion with the agreement of the overseeing clinician. The student (referrer) contacts me with an outline of the case (anonymized as much as possible) and identifies the questions he or she would like the SCEC to discuss. This information, with some suggestions for background reading (the referral form), is circulated to those attending the meeting.

Meetings are open to all medical and law students, nurses taking the postgraduate diploma, and master’s degree students in medical ethics and are advertised through the University weekly news bulletins and emails to those who have attended before. They are held every month in the academic year at a regular time and venue and last 75 minutes. Numbers are limited to 20 per meeting; places are allocated on a “first come, first served” basis, with a waiting list.

The meetings start with brief introductions—name, course, and year of study of those attending—and the chair then invites the referrer to sketch out background information for the case to be discussed and the ethical issues to be addressed. The chair then opens the floor for questions to clarify factual issues, such as diagnosis, prognosis, decision making capacity, and other items of clinical or ethical relevance. All who attend are then encouraged to state and discuss their views. A number of students attend every monthly meeting, which has resulted in the development of camaraderie and trust in discussing and reflecting on sensitive and challenging issues.

Certificates of attendance are provided to those who have attended a minimum of two meetings in one academic year. The Institute of Medical Ethics awarded a grant to fund travel costs for medical students from other institutions to attend our meetings, and the SCEC format is now being replicated in other medical schools.

Learning from the SCEC Discussions

The SCEC has discussed a wide range of cases over the years that illustrate the diversity and complexity of ethical issues arising in clinical practice. These include whether an elderly, frail patient who refuses treatment and wishes to die should be given electroconvulsive therapy; the role of a medical student who suspects domestic abuse in the antenatal setting; and whether it is appropriate to insert a percutaneous endoscopic gastrostomy for an elderly man who has already pulled out a nasogastric tube. The SCEC meeting does not aim to “resolve” the case referred, but rather to enable an informed discussion of competing ethical issues, which might include respect for patient autonomy, harms and benefits of different treatment options or refusal of treatment, disclosing information to avert harm to others, and the role of compassion.

For example, a case discussion that focused on a request by a family that the grandmother, who does not speak English, not be informed of her terminal diagnosis prompted students to wonder about the role of cultural norms and about how, as future physicians, they could act with honesty and integrity when there is disagreement about what constitutes a patient’s best interests and how they would approach communication with and care of a family in distress. The journal Clinical Ethics has published a number of case discussions of the SCEC, co-authored by the student who has referred the case [7-10].

Not only do students draw on what they learn about ethics and law in the curriculum but they also develop and refine interpersonal skills, such as the ability to consider other options and differing views, to communicate and actively listen, and to facilitate discussion. Those who attend meetings of the SCEC have valued the depth of the discussion and the learning that follows from it. Feedback from those who have attended meetings is overwhelmingly positive:

“Thanks for organising the sessions throughout the year—it has certainly been an interesting and thoughtful experience.”

“It was a pleasure for me to be able to attend the SCEC meetings and I learnt a lot.”

“All health care students should have to attend one.”

“The meetings enhanced my ability to identify and effectively analyse complex ethical dilemmas.”

Students who attend have also reported feeling well supported and encouraged through the discussion of complex and challenging cases. Some of the students who have attended SCEC meetings go on to membership in NHS trust-based CECs upon graduation from medical school, highlighting that SCEC participation nurtures interest and provides early career training in clinical ethics [11].

Development and Embedding in the Curriculum

Ideally, the SCEC format could be expanded as an educational tool to enable students to engage in ethical discussion in the later years of their medical training by drawing upon knowledge previously covered in the earlier part of the curriculum. Students could refer cases for discussion arising from their own experiences in particular specialities. We are now considering embedding a similar format in the curriculum for the final two years of the medical degree. This raises challenges about how to enable small-group discussion for a large group (King’s has about 450 students per class year) and how to evaluate learning that flows from the discussion.

Setting up and running an SCEC can be time intensive, and administrative assistance is helpful to book rooms, manage numbers attending, and circulate documentation. It is essential to have the support of faculty and committed students in setting up such a form of clinical ethics training. The students who attend meetings have enthusiastically engaged in interesting and wide-ranging discussions, and learning has been disseminated through publication of some of the cases. This form of clinical ethics support provides relevant learning for current students and prepares them for the reality of clinical practice. There is no doubt that a form of clinical ethics support is of value to health care students as they develop their moral compass throughout their training.