On the moral responsibility of medicine

The profession has a collective duty to ensure that the next generation of doctors is educated and that medical research occurs

How far does our responsibility as doctors to protect and promote health go?

Responsibility is complex: In medicine, obligations such as acting in patients’ best interests (beneficence) or avoiding harm (non-maleficence) are more stringent than the duties that lay people have to help others and avoid harming them.

There are useful signposts along the route to responsibility. The Medical Council’s ethical guide is one; our professional colleges are another source of guidance. And our ongoing education from the time we are undergraduates to the time we retire will ideally have a continuous thread of what it means to be professionally responsible.

Doctors can be held to account for their professional role responsibilities: To be accountable or responsible for an action, two conditions must be met. First, the person must have control over the act in question. The act must be voluntary in that they wanted to perform it or could have chosen to act otherwise. Second, there is a knowledge condition: To be held responsible the person must have had the relevant knowledge to act.

Responsibility is moral when the relevant action is one that breaches or upholds general moral norms, such as preventing harm or promoting the welfare of others. Since medicine is a practice for protecting and promoting the health of others, it is inherently moral and therefore entails moral responsibilities.

A recent ‘perspectives’ piece in The Lancet offered the following: “These responsibilities lie at the heart of medicine, providing its moral foundation. Some doctors meet their responsibilities treating individuals with diseases, some teach or do research, while others safeguard or promote the health of populations. These responsibilities arise from the social role of doctors that is enshrined – but not always clearly delineated – in social, legal, ethical, and professional standards and norms. The health and wellbeing of the patient is, according to various codes, the pre-eminent responsibility of medicine, and it is for patient care that doctors are primarily held accountable.”

According to the author, Dr Wendy Rogers of the Department of Philosophy and Department of Clinical Medicine at Macquarie University in Sydney, making the care of the patient our first concern raises difficult questions about the boundaries of medical responsibility.

“How far should doctors go in furthering the health of patients or populations for whom they are responsible, and for which populations are they responsible and why? What are the boundaries of their responsibility, and how and where does it slip over into something else, such as supererogatory acts or political activism?” she asks.

I have always felt that patient advocacy was a central part of a doctor’s work. For me, this means speaking out and making representations for your patient (with their permission, of course). For those moments when we falter in the face of a need to publicly advocate, the words of the late Aidan Halligan are a useful mantra: “What we permit, we promote.”

What about collective responsibilities in medicine? The profession has a collective responsibility to ensure that the next generation of doctors is educated and that medical research occurs.

“There are explicit expectations that clinicians should support education by teaching students, and research by practising evidence-based medicine. The profession as a whole has a duty to provide clinicians, researchers, and educators and encourage those with aptitude and enthusiasm to take up those roles,” Rogers says.

Which brings me, with readers permission, to a request. One of our key leaders in Irish medicine in recent years is Prof Mary Horgan, the first female President of the RCPI. She has achieved so much in her first term in office. On the educational front she has succeeded in introducing some 80 additional training posts in basic specialty training in medicine, obstetrics/gynaecology and paediatrics.

During the Covid-19 pandemic, she ensured the College adapted to the needs of its membership by introducing education via webinars, and initiated remote training assessments. Under her leadership and with the hard work of colleagues and staff the RCPI became the first postgraduate medical college in Ireland and the UK to stage exams using remote invigilation.

The prescience of the College to have a President who was also a specialist in infectious diseases in post at the beginning of a global pandemic is nothing short of impressive! But seriously, Mary’s leadership skills have been hugely important in steering the ship during this challenging time for the profession and for the health service.

Like any successful institution, the RCPI needs to look at itself with a view to renewal. Mary has presided over significant changes in governance at the College and among its six faculties and institutes. And a new Institute of Medicine will strengthen infrastructure in its 17 specialties.

There is an election coming up for the Presidency of the RCPI. I’d like to ask Fellows to consider voting in Mary for a second term. She has achieved a huge amount, but there is important unfinished business to be steered through along with inevitable challenges to be met.