Books: Tough Choices: Stories from the Front Line of Medical Ethics

‘Being a doctor is not just a job … it possesses a moral dimension not found in nearly all other jobs. Hence why there is no professor in baking ethics, or painting and decorating ethics …’

As doctors, but especially as GPs, we know that decision making does not occur in a clinical vacuum but in the context of patients’ beliefs and their own systems; two children both the same age both presenting with a fever and rash may elicit very different responses from the GP if one child is fully up to date with their immunisations and the other has not had MMR due to parental choice.

Daniel Sokol may be familiar to many of us from his BMJ columns, but for those of us who do not know him he is a leading medical ethicist and barrister specialising in (whisper it) medical negligence. Tough Choices: Stories from the Front Line of Medical Ethics is a collection of his thoughts and observations on medical ethics and the law.

This book can be read either for the sheer pleasure of Sokol’s writing — each chapter serves as a mini-vignette so that one can read the chapters in any order, or as a crash course in ‘medical law for dummies’ as he highlights important cases that should inform the way we all practise day to day. The shift away from ‘doctor knows best’ in Bolam v Friern Hospital Management Committee (1957), for example, where it was held that ‘a doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art’, to the resounding judgment of Bolitho v City and Hackney Health Authority (1996), in which it was held that, actually, a doctor can be found guilty of negligence even if they acted in accordance with their peers if it can be ‘demonstrated that the professional opinion is not capable of withstanding logical analysis’.

What does this mean? That medical opinion is no longer above the law. I was most interested to learn that, in the US and in some parts of Europe, clinical ethicists are a standard part of the clinical team in large hospitals but virtually non-existent in the UK. Indeed in one scene we are told of a clinical ethicist being bleeped during coffee for an urgent clinical ethics consultation. Before the sceptics among us baulk at such a concept we may wish to pause and reflect how much anguish, time, and legal costs may have been saved in the cases of Charlie Gard and Alfie Evans, and in countless other cases, had a clinical ethicist been part of the team, part of the hospital culture from the moment the patient was admitted.

Sokol speaks eloquently and knowledgeably of the ethical and moral challenges that doctors face, and carefully considers each time each viewpoint; as GPs we know only too well that saying ‘no’ to that ‘lost’ diazepam script or the request for a treatment or investigation not clinically needed is part of the job. Yet the focus on autonomy in medical ethics has historically always been on the patient’s autonomy. Sokol reflects that ‘Doctors are advocates for patients. They must act in the best interests of their patients and respect their autonomy. Yet these are not absolute injunctions. Doctors are moral agents whose autonomy is also deserving of respect. Complying with the requests of patients must not undermine clinicians’ moral and professional integrity.’

It may be of interest to know that in addition to being a leading barrister in his field Sokol is also an amateur magician. It reminded me how in medicine, as in law I suspect, how one presents something to the patient can be a powerful determinant of the outcome. Beyond the placebo effect, beyond the science even, there is ‘magic’ in a fluid, fluent consultation, in getting a rare diagnosis right, in getting a common diagnosis right, in supporting a patient through a bereavement, in improving the lot for our patients. Sokol reflects thus: ‘In our hectic, time-starved schedule, it can be difficult to pause and ponder on the wonder inherent in our work. But it is there, and it is worth noting.’

• © British Journal of General Practice 2019