Abstract
It is now just over four years since I received a call from the Editors of this journal, then in its gestational stage, asking if I would become a member of its editorial committee and, to earn my keep, write a regular feature in the journal. The brief I was given was to choose a topic of interest and relevance to everyday clinical practice and provide an ethical analysis that could be read by busy clinicians with a short attention span for reading academic ethics papers. Thus the Five-Minute Focus (FMF) was born, although I have unfortunately never been able to condense the content sufficiently for the average reader to actually complete it in five minutes. This issue includes the 16th and, at least for now, last FMF on ethics with the focus moving to law in future issues, and it is with mixed feelings that I place the reins in the capable hands of Sarah Fovargue and Jose Miola.
My initial enthusiasm for the project suffered a brief setback when I realized how difficult it was to be succinct in my writing. For ethicists it is a challenge to write a paper of less than 3000 words. Concepts need clarification, arguments must be expounded and refuted, and cases compared. There is a risk in short papers of being superficial or muddying the water by sweeping generalizations. However, in my own clinical practice I am likely to reach for the brief synopsis of current evidence or clinical guidance rather than the detailed systematic review. Hence for this series my clinician self has disciplined my ethicist self to be brief and, I hope, to the point. The subjects covered have been chosen for a variety of reasons: some have been topical, for example pandemic influenza and co-payments; some have been of personal academic interest such as conceptions of autonomy and best interests; and others have been core components of undergraduate medical ethics curricula including confidentiality and end of life decision-making. Over the four years we have provided a comprehensive, although not complete, coverage of the ethical issues that arise in the day-to-day practice of medicine. I hope that they will provide a useful practice and teaching aid for both students and qualified doctors.
While reviewing the literature in preparation for each FMF I have been struck by the development of empirical research in the field of clinical ethics, as is also reflected in the number of high-quality papers that the journal has published in its empirical ethics section over the past four years. The variety and complexity of ethical dilemmas that arise in clinical practice have attracted the attention of sociologists, psychologists and even neuroscientists. As the Editors commented in the first issue of the journal, 1 medical ethics has become a truly interdisciplinary field which has not only enriched the academic debate but has strengthened the link between theory and practice. The development of centres dedicated to interdisciplinary ethics research, such as the recently launched London and Brighton Translational Ethics Centre, 2 is taking the field of clinical ethics into a new and exciting era. Clinicians and health-care researchers will benefit from this systematic consideration of both emerging and established ethical dilemmas that have a direct impact on their work.
A separate development in the field of clinical ethics, and one which the journal has also highlighted, has been that of clinical ethics support, which in the UK has been manifest in the increasing number of clinical ethics committees. These committees respond to an identified need on the part of clinicians for help in dealing with ethical difficulties that they encounter in their work. The need for ethics support has been recognized by organizations such as the Royal College of Physicians 3 and the Nuffield Council on Bioethics. 4 Although well established in North America, clinical ethics committees are a more recent phenomenon in Europe but are now part of the infrastructure of many hospitals and in some countries are expanding into community and social care settings. In providing advice to clinicians on difficult ethical issues, these committees need access to relevant research and analysis and, because of their proximity to clinical practice, they are also in a position to identify key questions for further research. Committees and other forms of ethics support are themselves a legitimate focus of empirical research and ethical analysis, for example investigating the role of patients in clinical ethics consultation. 5
Clinical ethics appears now to be established as an academic field that has strong links to clinical practice. The subjects of its enquiry, emerging technologies, use of limited resources, the meaning of health and disease, and the patient–clinician relationship, are intrinsic to the practice of medicine. Clinicians therefore need to engage in the debate, be aware of the evidence and understand the underlying concepts. The aim of the FMF has been to provide an accessible introduction for busy clinicians and a signpost to further consideration of the issues. I hope that I have been moderately successful in realizing this aim. It is now time to hand you over to the lawyers!