Ethics and the Good Doctor: Character in the Professional Domain

Full text

i
Ethics and the Good Doctor
Ethics and the Good Doctor brings together existing literature and an
analysis of empirical research conducted by the Jubilee Centre for
Character and Virtues to examine the ethical nature of medical practice
and explore medicine as a virtuous profession.
The book is based on the idea that medical practice is an inher-
ently moral profession, in which notions of trust, care and meaningful
relationships form the foundations of being a good doctor. By taking
into account the ethical dimensions of medical practice that have come
under greater scrutiny and pressure over recent years, this book explores
how personal and professional character is understood, enacted, and
experienced by medical practitioners at various stages of their career.
Ethics and the Good Doctor situates and presents the empirical data
in a way that is accessible to practicing doctors, medical students, and
medical educators. Clear implications for policy, practice, and research
are offered, ensuring this book will be of great interest to a range of
stakeholders involved in medical practice, including those working in
medical policy.
Sabena Jameel is a General Practitioner (family medicine) and is also
Quality Lead and Medical Professionalism Lead for the University of
Birmingham Medical School, UK.
Andrew Peterson is Professor of Character and Citizenship Education
and Deputy Director of the Jubilee Centre for Character and Virtues at
the University of Birmingham, UK.
James Arthur is Professor of Education and Civic Engagement
and Director of the Jubilee Centre for Character and Virtues at the
University of Birmingham, UK.

ii
Character and Virtue Within the Professions
Series Editors
James Arthur, Professor of Education and Civic Engagement and
Director of the Jubilee Centre for Character and Virtues at the University
of Birmingham, UK.
Andrew Peterson, Professor of Character and Citizenship Education and
Deputy Director of the Jubilee Centre for Character and Virtues at the
University of Birmingham, UK.
The principal objective of the series is to highlight the interplay
between practitioners’ personal character and the ethical dimensions
of their professional domain. Each book will explore the specic eth-
ical dimensions of the given profession at hand, including the interplay
between professionals’ individual character virtues and their working
environments. In a time when cultures of managerialism, auditing, per-
formance metrics and commercial success are seemingly increasing,
this series attempts to re- focus the professions towards the ethical and
societal origins that each profession intends to serve. Underpinned by
perspectives of philosophy, psychology and sociology, each book will
offer practitioners fresh viewpoints about how their character and pro-
fessional context can inuence their professional practice.
Books in the series include:
Ethics and the Good Teacher
Character in the Professional Domain
Andrew Peterson with James Arthur
Ethics and the Good Doctor
Character in the Professional Domain
Sabena Jameel, Andrew Peterson and James Arthur
For more information about this series, please visit:
www.routledge.com/ Character- and- Virtue- Within- the- Professions/
book- series/ CVP

iii
Ethics and the Good Doctor
Character in the
Professional Domain
Sabena Jameel, Andrew Peterson
and James Arthur

iv
First published 2022
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
605 Third Avenue, New York, NY 10158
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2022 selection and editorial matter, Sabena Jameel, Andrew Peterson
and James Arthur; individual chapters, the contributors
The right of Sabena Jameel, Andrew Peterson and James Arthur to be identied
as the authors of the editorial material, and of the authors for their individual
chapters, has been asserted in accordance with sections 77 and 78 of the
Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilised
in any form or by any electronic, mechanical, or other means, now known or
hereafter invented, including photocopying and recording, or in any information
storage or retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or registered trademarks,
and are used only for identication and explanation without intent to infringe.
British Library Cataloguing- in- Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging- in- Publication Data
A catalog record has been requested for this book
ISBN: 978- 0- 367- 68511- 9 (hbk)
ISBN: 978- 0- 367- 68512- 6 (pbk)
ISBN: 978- 1- 003- 13788- 7 (ebk)
DOI: 10.4324/ 9781003137887
Typeset in Times New Roman
by Newgen Publishing UK

v
Contents
Acknowledgements vi
Introduction 1
1 The professions and character 12
2 Ethics and medical practice 23
3 Medical practitioners: personal and ideal character
strengths 37
4 Medical practitioners, ethical dilemmas and the
perspectives of medical educators 62
Conclusion, recommendations and further research 83
References 87
Index 96

vi
Acknowledgements
This book is the second in a series of texts that examine Character and
Virtues in the Professions. Each book in the series is dedicated to a spe-
cic profession and brings together reviews of existing literature and
sources of empirical data – including data collected in various projects
by the Jubilee Centre for Character and Virtues – to provide new
insights for both pre- and in- service professionals, as well as acting as
an educational resource to inform future professional decision- making
and practice.
As we make clear from the outset, this book draws extensively on
data and analysis from one of a number of research projects on virtues
in the professions conducted and reported on by the Jubilee Centre that
were all led by the Centre’s Director, James Arthur. For this reason,
we owe our sincere gratitude to those colleagues whose data collection,
analysis, recommendations and overall insight on the project, including
in the resulting report, has made this book possible. In particular, our
thanks and acknowledgements go to Kristján Kristjánsson, Hywel
Thomas, Ben Kotzee, Agnieszka Ignatowicz and Tian Qiu. We are also
grateful to our colleagues at Routledge – in particular Anna Clarkson,
Sarah Hyde and Will Bateman – for their interest and support in this
series and book.
Sabena Jameel
Andrew Peterson
James Arthur
newgenprepdf

1
DOI: 10.4324/9781003137887-1
Introduction
Introduction
This book, and the main study from which the data contained within it
is drawn, are premised on the idea that what constitutes a ‘good’ doctor
necessarily involves more than technical skills and medical knowledge.
While it would not make sense to conceive of a good doctor who does
not possess the requisite medical knowledge and technical skills, what
patients often desire from their doctors – and indeed what doctors often
expect of themselves – is a professional who cares, who is compas-
sionate, who empathises, and who they can trust to make an informed
judgement. Professional qualities have long been at the heart of the
medical profession, and are often framed in some way or other within
key documents underpinning medical education. The General Medical
Council’s Generic Professional Capabilities Framework and Outcomes
for Graduates documents, for example, structures the outcomes expected
of medical school programmes around three categories – ‘professional
values and behaviours’, ‘professional skills’, and ‘professional know-
ledge’ (GMC, 2017, 2018). Moreover, of all the professions within and
without those specically concerned with healthcare, it is the medical
profession that we place the highest ethical expectations on (Paterson,
2013). Because of the intimate relationship between a doctor and their
patients, trust is vital, particularly given that at key moments, lives, and
indeed the quality of lives, are literally in the hands of doctors. It is
perhaps for this reason that public shock and anger is so fervent and
passionate when doctors transgress the trust invested in them.
Recognising that medical practice involves an ethical dimension and
represents an essentially moral undertaking is one thing; explicating
the precise nature of this ethical and moral dimension is another, and
perhaps more difcult and contentious, matter. As we examine in later
chapters, a large body of literature now exists that considers the moral

2 Introduction
2
work of doctors, including how workplace environments and healthcare
systems impact on such work. In this regard, the medical profession is
not unique, with broadly comparable interest also evident in the moral
dimensions of a number of professions. Yet, as is increasingly attested in
the available literature and as is often featured across public media, over
the last several decades the work of doctors has become more and more
inuenced by the pressures of market logic and, to some extent, regula-
tory accountability. To put it simply, doctors’ work in environments in
which meeting externally set targets, allocating limited resources, and
increasing need for such resources, all place signicant pressures on
doctors’ ability to enact their moral qualities. These pressures, in turn,
contribute to pressures on retention, with a recent rapid review of the
‘workforce crisis in medicine’ identifying concerns around ‘low morale’,
‘disconnect’ between doctor and patient expectations, ‘unmanageable
change’, and lack of personal and professional support’ (Andah et al.,
2021: 4– 5; see also West and Coia, 2019).
The giving of serious attention to medical ethics curriculum in the
UK can be traced to the Institute of Medical Ethics’ (IME) Pond Report
on the Teaching of Medical Ethics (Institute of Medical Ethics, 1987)
and to the GMC’s report Tomorrow’s Doctors: recommendations on
undergraduate medical education (1993) that contained much on educa-
tion in ethics and professionalism. In 1998, the IME and GMC worked
together to develop a model core curriculum for teaching medical ethics
and legal issues to undergraduate medical students (Ashcroft et al.,
1998). Notably, given our interest here in virtue- based approach to pro-
fessional ethics, in the 2009 iteration of the core curriculum, the words
‘character’ and ‘virtue’ were not mentioned at all, but were alluded to
in references to ‘skills, attitudes and behaviours’. Following a review in
2017– 2018, a further revised core curriculum was published in 2019 with
the aim to ‘equip students to identify ethical and legal issues in medical
practice, have a critically reective approach to those issues, and be able
to give a reasoned justication of the actions they would take in line
with the knowledge, attitudes and skills in the rest of this document’
(IME, 2019: 2). Again, the terms ‘character’ and ‘virtue’ do not feature
explicitly in the curriculum. Nor, for that matter, do the concepts of
‘judgement’ and ‘wisdom’. Under the heading of ‘professionalism’, the
curriculum advocates that students should be able to:
• Critically examine and apply General Medical Council
guidance, principally relating to- the need to promote best prac-
tice and respect for patients, colleagues, and other healthcare
professionals

Introduction 3
3
• professional standards expected of students
• respecting the different beliefs of patients, students and other
• duty of candour
• maintaining professional boundaries with patients
• conscientious objection and its limits
• potential conicts of interest use of social media
• Discuss the importance of trust, integrity, honesty and account-
ability in all professional relationships
• Recognise the limitations of their practical skills and know-
ledge, and to know how and where to seek appropriate sources
of support [including when working abroad or in resource-
poor environments]
• Identify and appropriately respond when there is cause for con-
cern, when things could be improved, and when they go wrong
• Apply professional guidance across all clinical contexts,
including while working abroad and in resource poor
environments
• Consider the extent to which expected professional conduct
extends into private life.
(IME, 2019: 7)
In somewhat of a contrast, the General Medical Council’s Generic
Professional Capabilities Framework emphasises a more developed and
detailed conception of professional values and behaviours. While the
terms ‘character’ and ‘virtues’ are not used explicitly (character and
virtue do not necessarily align easily with educational frameworks that
are easily mapped to codied competencies and assessment), under
the domain of professional values and behaviours the following are
expected:
• acting with honesty and integrity
• maintaining trust by showing respect, courtesy, honesty, com-
passion and empathy for others, including patients, carers,
guardians and colleagues
• treating patients as individuals, respecting their dignity and
ensuring patient condentiality
• taking prompt action where there is an issue with the safety or
quality of patient care, raising and escalating concerns where
necessary
• demonstrating openness and honesty in their interactions with
patients and employers – known as the professional duty of
candour

4 Introduction
4
• being accountable as an employee to their employer and
working within an appropriate clinical governance framework
• managing time and resources effectively
• being able to self- monitor and seek appropriate advice and
support to maintain their own physical and mental health ν
demonstrating emotional resilience
• demonstrating situational awareness ν reecting on their
personal behaviour and its impact on others
• demonstrating awareness of their own behaviour, particularly
where this might put patients or others at risk.
(GMC, 2017: 8)
Since its inception in 2012, the Jubilee Centre for Character
and Virtues based at the University of Birmingham has conducted
numerous studies that have sought the views, perceptions and
explanations of professionals themselves in order to interrogate and
explore the ethical dimensions of professions in England, each led by
the Centre’s Director, Professor James Arthur. In this book, we draw
on data from one of these studies – Virtuous Medical Practice – to
present and analyse how doctors at three stages of their careers – (rst
year) Undergraduate Students, Graduating Students, and Experienced
Doctors (we explain each of these categories below) – understand the
moral dimensions of their work. While we add some additional ana-
lysis to the ndings, including reporting additional qualitative data
from the study and entering into conversation with relevant research
literature published since the study, this book draws extensively
on the original research report produced by the projects: Virtuous
Medical Practice (Arthur et al., 2015a). The Centre’s work on the
ethical dimensions of medical practice as a profession has also been
detailed in various articles and books published by Centre members
on medical practice itself (see for example, Kristjánsson, 2015a) and
on the professions more widely (for example, Arthur et al., 2015b,
2017a, 2018b, 2019b; Harrison and Khatoon, 2017; Kristjánsson
et al., 2017a, 2017b).
The aim of this introductory chapter is two- fold. First, we provide
summary details of the main project drawn upon in our analysis. For
reasons of space and concision, we present a summary of the main
aims, research questions and methods for each of these projects. The
detailed aims, research questions and methods of each of these project
can be found on the Jubilee Centre’s website.1 Second, we set out the
structure of the book, including the focus and broad content of each of
the chapters that follow.

Introduction 5
5
The project
The Virtuous Medical Practice project was a two- year study, in Great
Britain, involving rst- year undergraduate medical students (referred
to throughout as Undergraduate Students), students who had recently
graduated from their course (referred to throughout as Graduating
Students) and doctors with at least ve years of experience (referred
to throughout as Experienced Doctors). The overarching aim of the
Virtuous Medical Practice project was to identify which personal virtues
medical students and experienced doctors understood themselves as
holding and to investigate how these could inuence their professional
lives. Specically, the study examined how an understanding of the
virtues inuenced doctors’ moral thinking and possible conduct, and
how the environment in which doctors train and work can inuence
them in becoming good doctors.
The main research questions that guided the project were:
• Which virtues and values are held by members of the medical pro-
fession in the UK?
• How do doctors develop these virtues and values?
• How do virtues and values shape medical practice?
• How do these virtues and values relate to the expectations of the
medical regulatory bodies?
• What are the implications of virtue- based medical ethics for ethics
education in medicine?
• How can virtues and values be developed through doctors’ initial
training and continuing education?
The project’s research design incorporated self- reporting measures of
personal and professional character, as well as ethical dilemmas and exten-
sive interviews with doctors at different stages of their careers and med-
ical educators. The project comprised a mixed- methods, cross- sectional
design. As explained in the project’s nal report (Arthur et al., 2015a),
this design enabled the project team to examine: (1) what medical students
and doctors said about character and medicine; (2) how considerations to
do with character inuence medical students’ and doctor’s thinking about
moral dilemmas in medicine; and (3) the contextual factors that may shape
and inuence medical students’ and doctors’ character.
The project collected quantitative data through a survey and qualita-
tive data through semi- structured interviews. The interviews enabled the
project team to develop a better understanding of the conditions under
which virtue can be enacted and how better to create circumstances

6 Introduction
6
conducive to virtue, both within the workplace and without. The survey2
consisted of ve sections (four for starting undergraduates), surveying:
1 Respondents’ views on their own character. This comprised a list of
24 character strengths, derived from the Values in Action Inventory
of Strengths (VIA- IS) (Peterson and Seligman, 2004) from which
respondents were asked to identify the six which ‘best describe the
sort of person you are’.
2 Respondents’ responses to a set of moral dilemmas in their profes-
sion. This comprised six situational judgement tests (Patterson and
Ashworth, 2011; Lievens and Patterson, 2011) designed by a panel
of experts (n = 15) in medical education who adapted well- known
dilemmas from the literature and designed a wholly new set of
answer responses specically for this study.3 Dilemmas were used as
they (a) promise to offer a credible way to gain an insight into moral
functioning and development, and (b) can ideally be designed so as
to activate more than simply moral reasoning skills (Kristjánsson,
2015, chap. 3). Nevertheless, responses to dilemmas serve as an
indication, rather than guarantee, of action or understanding of
moral sensitivity in a real, particular situation. They do not, in and
by themselves, measure virtue, nor do any such denitive measures
exist elsewhere, but when combined with data from interviews and
self- reports, they may contribute to an overall understanding of
virtue in professional practice.
3 Respondents’ views on the character of the ‘ideal’ professional in
their profession. This comprised the list of the 24 VIA- IS character
strengths presented again, with participants being asked to ‘choose
the six which you think best describe a good doctor’.
4 Respondents’ views regarding their work or study environment. This
section adapted questions from a Europe- wide workplace survey
(The Eurofund Working Conditions Survey, 2012) with additional
questions on ethical issues in the workplace.
5 A set of demographic questions.
Data were collected using an e- survey, the data from which was trans-
ferred to SPSS version 21, checked, cleaned and readied for analyses.
Analyses included descriptive analysis, cross- tabulation, correlation and
factor analysis. Analyses were also developed to deal specically with
the results of sections 1 and 3 (respondents’ views on character) and
section 2 (moral dilemmas).
For the semi- structured interviews, the research team devised a
themed set of questions for interviews4 with participants in the three

Introduction 7
7
career stages, based around the main research questions. These included
questions around:
• reasons for choice of career;
• characteristics of a good professional (i.e. doctor);
• factors that can help – or hinder – being that kind of professional;
• views on the inuence of character on everyday professional practice;
• the inuence of the professions’ code of conduct/ standards; and
• the inuence of education and training in developing the strengths
necessary for good professional practice.
In addition to the interviews with medical students and doctors, the
study also included semi- structured interviews with medical educators, for
whom a separate set of questions was devised. These interviews focused on:
• their role in educating future doctors;
• their view of a good professional in their eld;
• how this has changed in the course of their career;
• how students are assessed for entry;
• whether the character strengths required change and why;
• what informs their teaching in relation to the virtues; and
• how their stage of education can be developed.
In order to ensure good geographical representation, data were
gathered from participants at four sites. These sites clustered around
medical schools in the south of England, the midlands, the north of
England and Scotland. First- year students were surveyed on entry and
nal year students were surveyed shortly before graduation. Interviews
were also conducted with educators at these four medical schools.
Practising doctors in the four regions were recruited principally with
the assistance of The Royal College of General Practitioners and the
Royal College of Physicians, who agreed to email links to the survey to
members in those regions.
The total number of interview and survey respondents, by career
stage and gender, are presented in Tables 0.1 and 0.2:
As shown in Chart 1.1, amongst practising doctors, general
practitioners were the largest group in the survey sample (GMC
approved single specialities). It should be noted here that the spread
of numbers across the specialities prevented comparisons being made
between them.
Interview participants were chosen purposively from survey participants.
An invitation to interview was based on the completion of a willingness to

8 Introduction
8
be interviewed section on the questionnaire. Analysis of interview data was
thematic, using a constant comparison (Glaser and Strauss, 1967) within
a modied framework approach (Richie and Spencer, 1994). Codes were
created both horizontally and vertically and then developed into categories
and themes. Categories were rened and coding reviewed throughout the
process for which the NVIVO software was used.
Table 0.1 Total number of respondents by career stage
Career stage Number of surveys
completed
Number of interviews
conducted
Undergraduate students 122 23
Graduate students 152 24
Established doctors 275 28
Educators n/ a 10
Table 0.2 Total number of survey respondents by career stage and gender
Career stage
Undergraduate
students
Graduate
students
Experienced
doctors
Gender Female % 60.7% 67.1% 51.6%
Male % 39.3% 32.9% 48.4%
Chart 1.1 Experienced doctors by speciality.

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