IV. UNITED KINGDOM

This entry surveys the development of medical ethics in Britain in the twentieth and early twenty-first centuries and some substantive medical ethical issues arising in these periods. It describes the involvement of important organizations concerned with medical ethics, the development of academic courses in the subject, and the establishment of a largely charitably sponsored independent nongovernmental national bioethics committee and of national forums for teachers and students of bioethics. It suggests that a typically British antitheoretical, commonsense, and situational approach to medical ethics is gradually modifying so as to include at least some theoretical issues in the teaching and study of medical ethics.

Medical Ethics at the Beginning of the Twentieth Century

Respect for the professions and for the churches—especially, in England, the established Anglican church—were well-entrenched characteristics of British society at the beginning of the twentieth century, and medical ethics conformed to these cultural realities. Thus the normative standards of medical ethics were left almost entirely to the profession itself to establish and maintain. It did so largely in conformity with Hippocratic medical tradition, the ethical norms of the British protestant churches (including prohibition of active euthanasia and of abortion except to save the life of the pregnant woman), and a reliance on selecting "gentlemen" of good and honorable character to join the profession. The Medical Act of 1858 had, at the instigation of the newly established British Medical Association, established the General Medical Council to protect the public by controlling admission to the medical register on the basis of explicit medical educational standards, including ethical standards, both to exclude "quacks" (unqualified practitioners claiming to be doctors) from practicing medicine and to ensure that only those orthodox practitioners who had attained the prescribed standards were admitted to the register of medical practitioners.

Moreover, qualified medical practitioners who fell below the prescribed standards were liable to disciplinary action, including removal from the register (and thus loss of their professional livelihood) if they were found guilty of "infamous conduct in a professional respect." Among the infamous activities that could result in removal were the carrying out of abortion or active euthanasia, and having a sexual relationship with a patient. Other matters of considerable ethical concern to the General Medical Council included abuse of alcohol and drugs, fee splitting, "covering" for medical practice carried out by unregistered persons, convictions in the courts that would bring dishonor on the medical profession, abuse of the financial opportunities afforded by medical practice, improper denigration of professional colleagues, advertising for the doctor's own financial advantage, and canvassing for patients. Thus, at the beginning of the twentieth century, British medical ethics was almost entirely the prerogative of the medical profession and was concerned with protection of patients and of the public health, and with maintenance of its own honor and dignity.

Social Justice and Healthcare: 1911, 1946, and Beyond

If concerns about more equitable distribution of healthcare were not part of the medical profession's medical ethics agenda at the beginning of the twentieth century, they undoubtedly were a concern for the reforming liberal government elected with a large parliamentary majority in 1906. By 1911 David Lloyd George, then chancellor of the exchequer and later prime minister, achieved passage of his National Insurance Act; this provided working people (not their families) with medical and unemployment insurance, which was funded by compulsory contributions from workers, employers, and government (Braithwaite; Fox). The medical profession, though not opposed to the principle of such general provision of healthcare, fought the government on grounds of inadequate fees and inadequate protection for patients' choice of doctor; more than 27,000 doctors threatened to withhold their services. By 1913, however, after compromising with the doctors, Lloyd George had won the day (Lloyd; Lawrence).

The extension of medical care to the general population remained a popular political objective in Britain, and a 1942 report by Sir William Beveridge led, via the 1946 National Health Service Act, to the Labour government's establishment of the National Health Service (NHS) in 1948. This offered preventive as well as curative medical care to every member of the British public; it was provided in response to need, free at the time of that need, and financed by taxes (Bruce; Klein; Webster). While the objectives and provisions of the NHS remain widely accepted, early expectations that widespread healthcare would produce a healthier nation with reduced requirements for healthcare have never been achieved. On the contrary, concerns about increasing, yet inadequate, health expenditure multiplied, especially from the 1970s (Maxwell); a government committee chaired by Sir Douglas Black produced a 1980 report showing vast inequalities of health status in the population correlating with economic and other social disadvantages. Conservative government policy in the 1980s was more concerned to reduce costs than to remedy such discrepancies, but the New Labour governments of the 1990s and early 2000s was explicitly committed to reducing health inequalities and committed considerable additional funding to the National Health Service for this purpose.

Voluntary Euthanasia: 1936 and Beyond

A quite different issue of healthcare ethics—voluntary euthanasia—has been of public concern in Britain for almost as long as the issue of justice in the provision of healthcare. Medical proposals for its legislation had appeared early in the twentieth century; and in 1936, following the creation of the Voluntary Euthanasia Society, the House of Lords debated and rejected a proposal to legalize voluntary euthanasia, which would have provided the legal right to request and be given medical assistance to die when suffering from incurable and fatal illness. Despite the admission by Lord Dawson, an eminent doctor, that euthanasia was carried out by many doctors (Dawson), he and another medical peer, Lord Horder, opposed the bill on the grounds that its proposals involved too many legal formalities and that, in any case, euthanasia was a matter best left to the discretion of doctors. (Many years later state archives were opened and revealed that Lord Dawson had deliberately accelerated the death of the dying King George VI, allegedly in order to enable the quality morning newspapers to report it first rather than risk the death being announced by a less-suitable evening newspaper.)

Euthanasia remains an intermittently burning public issue. Further proposals to legalize it were rejected by the British Parliament in 1969 and 1990; and in 1988 the British Medical Association (BMA) declared that, while allowing patients to die was properly a matter of medical discretion, active killing, even if requested by the patient in circumstances of severe and incurable suffering and disease, was always unacceptable and should remain illegal (BMA, 1988a). In 1992 a British doctor was convicted of attempted murder for administering undiluted potassium chloride to a long-standing patient of his who, in intractable pain, had repeatedly requested him to end her life (Brahams). His sentence of one year's imprisonment, however, was suspended, and the General Medical Council, while admonishing him, permitted him to continue practicing ("Decision on Dr. Cox," 1992). After the verdict a British Medical Journal editorial called for a royal commission to study active and passive euthanasia (the editorial's subtitle was "The Tide Seems to Be Running for Euthanasia" [Smith], and a Lancet editorial criticized the BMA's "unsympathetic public line" on euthanasia ["Final Autonomy," 1992]).

Nevertheless, the British debate about such cases and about the legalization of euthanasia in the Netherlands (e.g., Keown; Otlowski) did not result in any relaxation of British law. Two cases from 2002 clearly demonstrate the legal situation in the United Kingdom. On the one hand, refusal of life-prolonging treatment was undoubtedly a legal right: The High Court had admonished doctors for ignoring the instructions of a Ms. B. to cease treating her with artificial ventilation; after the doctors complied, she died. On the other hand, neither euthanasia nor assisting suicide was a legal right: On the same day that Ms. B. died, a Mrs. Pretty lost her case before the European Court of Human Rights to be helped to commit suicide (Boyd, 2002; JME, 2002). The distinction between killing and assisting suicide (legally forbidden) and withdrawing life-sustaining treatment at a patient's instruction (legally required) had once again been reaffirmed.

Experimentation on Human Subjects: 1947 and Beyond

Medical ethics in Britain—as in all parts of the civilized world—was given a shocking impetus after World War II by the revelations at the Nuremberg trials of Nazi medical war crimes, and the 1947 Nuremberg Code on Human Experimentation was as readily accepted within Britain as elsewhere (see Doyal and Tobias). In the early 1960s, however, Maurice H. Pappworth, an English physician, claimed that many orthodox medical research investigations were unethical, and in a book first published in 1967 he enraged the British medical establishment by likening examples of British medical research to the research of the notorious Nazi doctors. Whether cause and effect or coincidence, in the same year the Royal College of Physicians (RCP) published a recommendation that all clinical research proposals should be subject to ethical review; this advice was widely circulated by the British government's Department of Health and Social Security. Over the next few years "ethical committees," or research ethics committees (RECs), were established in the majority of hospitals and other institutions conducting medical research.

Nonetheless, development and practice of these committees was recognized to be variable, and in 1984 the RCP published guidelines for RECs, updated in 1990 (RCP, 1990a), as well as reports titled Research Involving Patients (1990b) and Research on Healthy Volunteers (1986). In 1991 the Department of Health published the first of its own guidelines for RECs. In both sets of guidelines the advice is detailed; it is designed, in the words of the RCP document, "to maintain ethical standards of practice in research, to protect subjects of research from possible harm, to preserve their rights, and to provide reassurance to the public that this is being done. In achieving these objectives ethics committees should remember that research benefits society and that they should take care not to hinder it without good cause. Ethics committees also protect research workers from unjustified criticism." (RCP, 1990a, p. 3). While the RCP guidelines were widely accepted in Britain as the national standard for ethics committees, and while research on human subjects must be submitted to RECs, there was and remains considerable doubt about what proportion of British ethics committees actually implement them (Nicholson; Gilbert, Fulford, and Parker; Neuberger).

In a 1997 government technology assessment review, Richard Ashcroft and colleagues expressed concern about the need to take careful account of the cultural and religious backgrounds of research participants. Revised guidelines on research were issued by the Department of Health in 2001, and new European legislation in the form of a "Clinical Trials Directive" was expected to take effect across the entire European Union in 2004. When this is incorporated into U.K. law, it is likely to include a statutory role for RECs for the first time; human research will thus catch up with animal research, which has been legally regulated in the United Kingdom since 1876.

Abortion: 1938 and Beyond

Another major medico-moral issue of British concern has been abortion. Under the Offences Against the Person Act of 1861, procuring an abortion was a felony punishable by life imprisonment. In 1938 an English obstetriciangynecologist, Alec Bourne, challenged the law by reporting himself to the police after carrying out a therapeutic abortion on a girl who had been the victim of multiple rape. He was found not guilty on the grounds that the patient's life, in the sense of her mental well-being, was at risk if the pregnancy continued; just as "child destruction" (as the act calls it) to preserve the life of the mother was legally permissible under the Infant Life Preservation Act of 1929, so abortion for the mother's well-being might be lawful (see Mason, McCall Smith, and Laurie). In the 1967 abortion act the law was liberalized to permit abortion in cases in which two doctors certify that the continuation of the pregnancy would be a greater risk to the life or health of the pregnant woman, or her existing children, than a termination; or that termination would prevent grave permanent injury to the physical or mental health of the pregnant woman; or that there is a substantial risk that the child would suffer serious physical or mental disability.

In practice many British doctors, accepting that during the first three months of any pregnancy the risk of continuing to normal birth is greater than the risk of therapeutic abortion, agree to abortion for any woman who after deliberation continues to request it. The upper limit of gestation at which abortion is permitted was reduced by the Human Fertilisation and Embryology Act of 1990 from twenty-eight weeks to twenty-four weeks. No upper limit applies in cases in which the mother's life is seriously threatened and in cases in which the child, if born, would probably be seriously disabled. Significant, though minority, opposition to abortion persists both within the medical profession and among the public. In Northern Ireland, a part of the United Kingdom, opposition to abortion among the Protestant as well as the Roman Catholic population is sufficiently widespread for the Abortion Act not to apply there.

"Official" British medical ethics, as represented in this context by the General Medical Council, the British Medical Association, and the Royal College of Obstetricians and Gynaecologists, accepts abortion when carried out according to the law while recognizing any doctor's or nurse's right of conscientious objection. Such practitioners are expected to inform their patients of their moral objections to abortion, to advise them that they may seek assistance elsewhere, and to give information about sources of such assistance if requested (BMA, 1988b).

Reproductive Technology: 1978 and Beyond

In July 1978 the pioneering work of Patrick Steptoe and Robert Edwards led to the birth of the world's first "test-tube baby"—and to a paradigm shift in bioethical thinking about human reproduction and genetics. From 1982, when the British government appointed a Committee of Inquiry into Human Fertilisation and Embryology (Warnock), until the passing of the Human Fertilisation and Embryology Act in 1990, the British public and the British medical profession were gripped by a vigorous debate about the moral issues associated with in vitro fertilization (Snowden, Mitchell, and Snowden; Council for Science and Society; Bock and O'Connor; Bromham, Dalton, and Jackson). As with abortion, the central moral issue was seen by many to be the moral status of the embryo/fetus, though other issues included possible adverse physical and psychological effects on children conceived artificially and also on the women involved with such techniques, especially in the case of surrogacy. Feminist concerns included the continuing debate about access by single heterosexual women and lesbian women to reproductive technology (Hanscombe and Forster; Chadwick).

The issues were resolved in an extensive government bill that, unusually, offered alternative clauses on the most contentious issue of all: research on, followed by destruction of, the human embryo. Members of Parliament (MPs) were given a free vote (i.e., without any party pressure to vote in one way rather than another) and asked to choose between allowing such research for up to fourteen days of embryo development, as recommended by the Warnock Committee majority report, or forbidding all such research on human embryos except when done therapeutically—that is, to facilitate transfer of the embryo into the uterus of a woman. (The latter is the position of the Roman Catholic church, though it is worth noting that the eminent Jesuit theologian John Mahoney had argued in 1984 that the early embryo is "unlikely to be possessed of a soul and personhood in its existence at the simple cell-multiplication stage prior to diversification" [p. 85]). After cliff-hanging public, professional, and parliamentary debate, the MPs accepted research for up to fourteen days of embryonic development and established the national Human Fertilisation and Embryology Authority to monitor and control all such activities.

Informed Consent: 1985 and Beyond

Of the many other medico-moral issues that have exercised both healthcare professionals and the public in Britain, two legal cases are particularly notable: the Sidaway case on informed consent to treatment and the Gillick case on treatment of minors without parental consent. In the Sidaway case, finally determined by the House of Lords in 1985, the plaintiff complained that her surgeon had been negligent in not warning her of the small risk of spinal nerve root damage, which had occurred. Their lordships decided by a majority to uphold the existing English legal doctrine according to which a doctor is not negligent if acting in a way supported by a body of reasonable medical opinion (the "Bolam test"). Nevertheless, by indicating what reasonable doctors could be expected to do in certain circumstances (for example, answer their patients' questions and warn them of any substantial risks!), the judges brought English law "edging toward" the American "reasonable patient standard" whereby the requirements of a reasonable person in the patient's situation would determine what information was required (Kennedy and Grubb)—though not all legal commentators agreed that even this modest degree of change was achieved in the case (Brazier).

In the Gillick case a mother asked the court to rule that doctors should not be allowed to give medication (birth-control pills) to her children under the age of sixteen without obtaining parental consent. Once again the case went to the House of Lords, which in 1986 rejected Mrs. Gillick's claim; it ruled that a doctor ought to try to persuade the minor to involve the parents in the consultation, but if the patient refused—provided the doctor had good reason to assess the minor as having sufficient maturity and understanding—treatment could be prescribed without involving the parents (Kennedy and Grubb).

In the early 2000s increased emphasis on the need for doctors to obtain informed and explicit consent from patients in relation to use of and retention of tissues after surgery or postmortem became more stringent in response to two NHS scandals. Thus the reports of two inquiries, one into defects in pediatric cardiac surgery at a Bristol hospital (Bristol) and the other into storage of pediatric pathology specimens at a Liverpool hospital (Royal Liverpool, 2001), recommended (among a host of improvements) explicit informed-consent procedures for the retention of all tissues and organs (for research or teaching) removed for therapeutic or diagnostic purposes. These recommendation were put forth despite professional concerns that such explicit procedures would often cause unnecessary additional distress to recently bereaved families or to parents whose children were about to have surgery. The general trend in the early 2000s was to explicit and "fully informed" consent for all interventions (see, e.g., Doyal and Tobias), despite professional and philosophical concerns that such moves toward ever-greater "accountability" were excessively undermining trust in medical and other professionals, which though "old-fashioned" was nonetheless ultimately in the public interest (O'Neill 2002a, 2002b).

The Organization of Medical Ethics in Britain

At the beginning of the twentieth century, the final arbiter of medical ethics was the General Medical Council (GMC), a regulatory body largely composed of doctors. In the early twenty-first century, while the GMC's role remained pivotal, it was in the process of becoming a smaller organization with a larger representation of nondoctors and an organization far more open to influence from outside the ranks of the medical profession than ever before. In 2003 the GMC was reduced from 104 members to 35, of whom 19 were elected and 2 appointed by the medical profession, while 14 were nonmedical ("lay") (and thus comprising 40% of the GMC in contrast to the previous 25%). The lay members continue to be appointed by the Privy Council (a group of the United Kingdom's "great and good" appointed by the monarch and relatively independent of the government of the day, though many will have been appointed by virtue of their high office in current or previous governments). The GMC, as it notes itself on its web site, is "not here to protect the medical profession—their interests are protected by others. Our job is to protect patients."

The GMC licenses doctors to practice, and it can withdraw or put conditions on a doctor's license if a complaint is upheld. It is responsible for standards of medical education, including education in medical ethics, for quasi-judicial assessment of complaints against doctors, and for provision of advice on ethical standards and professional conduct. This advice used to come in a very slender volume, "the little blue book" (e.g., GMC, 1992), but more recently the GMC has provided a broader range of advisory booklets with more extensive "guidance on good practice," of which the core is covered in Good Medical Practice (GMC, 2001). This advice is sent to every registered medical practitioner and is also available to everyone on the GMC web site.

Although it has no official authority in matters of medical ethics, the British Medical Association, which is the doctors' professional association and trade union, provides considerable guidance on these issues to its members, to the government, and to the public. It has a multidisciplinary Medical Ethics Committee and an ever more impressive Medical Ethics Department of permanent staff. It provides individual advice and analysis to its members as requested, provides analysis and advice to government and official bodies, and publishes books relevant to medical ethics (e.g., BMA, 1993, 2001a, 2001b). (The BMA even experimented with what may have been one of the world's first computer programs offering doctors medico-moral advice [Sieghart and Dawson]).

Other professional influences on medical ethics are exerted during medical education by individual teachers, themselves influenced not only by the GMC and (often) the BMA but also by the Medical Research Council (a government run organization that funds and or carries out much of the UK's medical research program) and specialty organizations; the latter include the Royal Colleges of Physicians, Surgeons, Obstetricians and Gynaecologists, General Practitioners, Psychiatrists, and so on, all of which offer advice and guidance on medical ethics relevant to their specialties. So, too, do the medical malpractice organizations, such as the Medical Defence Union and the Medical Protection Society. In addition the employment contracts of most doctors in Britain exert some legally binding ethical pressure on their behavior. For example, general practitioners, though they are independent contractors, are required by their contracts with the NHS to provide emergency care in their vicinity whether or not those needing such care are registered with them; and they are also required by their contracts to accept "difficult to place patients" for a minimum of three months, when required by the NHS to do so. And surgeons in NHS hospitals, according to their contract of service, must, under normal circumstances, obtain written consent from their patients prior to operating. In addition there is a strong tradition in British medicine of consultation, especially with more experienced colleagues, about any difficult medical problem, including difficult medico-moral problems. A noteworthy if embryonic development at the end of the twentieth century was the creation of clinical ethics committees at some hospitals, set up to provide analysis and advice about particular ethical problems arising in clinical practice (not in research), to advise on ethical aspects of hospital policy matters, and to have at least some educational function (see, e.g., "Clinical Ethics Committees Supplement," 2001).

Nonmedical influences on British medical ethics include the range of forces typical of a modern Western democracy. The most important is undoubtedly the law, which, as noted above, has a major role in defining the arenas within which the medical profession may make its own choices about medico-moral issues. Nurses have undergone a metamorphosis from doctors' handmaidens to independent health professionals and have become increasingly influential in British healthcare ethics, especially through the activities and pronouncements of their disciplinary body, the (United Kingdom) Nursing and Midwifery Council or NMC (e.g., NMC), and of their professional association and trade union, the Royal College of Nursing or RCN (e.g., RCN 1991, 2001).

Many public pressure groups, patient groups, and special medical interest groups exist to try to influence the profession, the media, Parliament, and the public on such matters as healthcare ethics issues. Important examples include the Patients Association, the College of Health, the Consumers Association, MIND (which promotes the interests of the mentally ill), MENCAP (which promotes the interests of the mentally disabled or impaired), CERES (Consumers for Ethics in Research), Gene Watch (which is concerned with the ethics and risks of genetic engineering), and the local community-health councils and their successor organizations, the Patient Advocacy and Liaison Services (PALS), which protect patients' interests. Also important are several "right-to-life" activist groups such as the Pro-Life Alliance, LIFE, and The Society for the Protection of the Unborn Child, and "on the other side," the Voluntary Euthanasia Society and the Abortion Law Reform Association. And the media constantly, often daily, publish and broadcast on medical ethics issues.

From a plethora of possible examples, one media event is particularly worth noting: the prestigious BBC Radio Reith Lectures, given in 1980 by Ian Kennedy, then a lecturer in academic law (later to become a professor of medical law and ethics and a knight of the realm). Published in 1981 under the profession-provoking title The Unmasking of Medicine, the lectures brought into the arena of intelligent public discussion many of the standard themes of medical ethics, and argued forcefully that while doctors had special training and expertise in technical medical matters, they had no such training and expertise in moral matters. Even if they had had such training (which Kennedy advocated), they had no right to assume that moral decisions in medical practice were solely for doctors to make, in the way that technical decisions in medical practice might be. The resulting public and professional debate did much to achieve Kennedy's objective of bringing medical ethics "out of the hushed halls of Academe into the noisy market place of ideas" (Kennedy, 1981, p. xi).

The study and development of medical ethics in Britain has also been promoted by the Institute of Medical Ethics (IME). Originally named the Society for the Study of Medical Ethics, it was founded in the early 1960s by a Church of England priest, the Rev. (later Dean) Edward Shotter, who at the time had pastoral responsibility for medical students in London. Shotter soon recruited two other Protestant clerics, both from Scotland, who were to become influential in British medical ethics: Kenneth Boyd (Boyd, 1979, 1992; Boyd, Callaghan, and Shotter; Smith and Boyd; Gallagher and Boyd) and Alastair Campbell, founding editor of the IME's Journal of Medical Ethics from 1975 to 1980 and one of the earliest British contributors to the academic medical ethics literature (Campbell, 1972, 1978, 1984; Campbell and Higgs) and a Jesuit and psychologist Brendan Callaghan. Also recruited by Shotter was a secular Jewish doctor-philosopher, Raanan Gillon, who served as editor of the Journal of Medical Ethics from 1981 to 2001. Among the IME's activities have been the establishment of multidisciplinary ethics study groups within most of the British medical schools, various research projects, and the founding of two publications, the aforementioned Journal of Medical Ethics (1975) (by the end of the century the most highly cited journal in its field) and the Bulletin of Medical Ethics (1985; shortly afterward, the latter became independent of the IME, and it continues to be edited by its owner-editor, another Shotter medical recruit, Richard Nicholson).

Other organizations stimulating the early development of healthcare ethics in the United Kingdom were the medical ethics and or medical law centers at some of the universities. Pioneer centers in Britain included those at King's College, London; the University of Wales at Swansea; the University of Manchester; and the Universities of Birmingham, Hull, Oxford, St. Andrews, Leeds, and Warwick; the University of Wales at Cardiff; and the Universities of Glasgow and Bristol. Since the 1990s there has been considerable further expansion in the number of universities providing healthcare ethics, or law and ethics, teaching and research in the United Kingdom, and these have been joined by a few centers offering courses in medical humanities. In addition, the Society for Applied Philosophy is concerned with philosophical illumination of "areas of practical concern" that often include issues of healthcare ethics; it publishes the Journal of Applied Philosophy.

Of the various academic disciplines with an interest in medical ethics that has stimulated its development, and apart from law and theology as already mentioned, health economics has been particularly important in relation to resource allocation. Alan J. Williams (1985, 1996), Alan Maynard (1986; Maynard and Bloor), and Anthony J. Culyer (1992, 2001), from the Centre of Health Economics at York University, and Gavin Mooney and Alistair McGuire (1988) have been especially influential, particularly Williams, with his advocacy of the maximization of quality-adjusted life years (QALYS) as the centrally relevant criterion for health-service resource allocation.

Academic Courses, Degrees, and Chairs

The first British academic course in medical ethics seems to have been started by the ancient City of London guild, the Worshipful Society of Apothecaries (still a medical licensing body), when it instituted a diploma course in the philosophy of medicine in 1978, first taught by the Oxford philosopher Michael Lockwood. An annual one-week "intensive course in medical ethics for medical and nursing teachers" was started in 1983 at Imperial College, London, in cooperation with the IME, and in 1984 the Centre of Medical Law and Ethics at King's College, London, initiated a one-year postgraduate diploma in medical law and ethics, upgraded in 1987 to a master's degree. In 1985 the University of Wales introduced a highly popular part-time M.A. in healthcare ethics, and in 1987 the University of Manchester offered a multidisciplinary M.A. in healthcare ethics, administered by its Centre for Social Ethics and Policy. Since then various other British universities and colleges have developed a wide variety of courses in healthcare ethics.

British medical schools were slow to introduce the formal study of medical ethics; the Scots led the way at Edinburgh University and Glasgow University, with King's College Hospital in London being the vanguard in England under the leadership of the doctor-ethicist Roger Higgs. Full-time philosophers were appointed to teach the subject at medical schools at Liverpool and at the London Hospital; and St. Mary's Hospital Medical School London was the first to appoint a (part-time visiting) professor of medical ethics. Birmingham University Medical School appointed a veterinarian, David Morton, to the joint chair of biomedical science and ethics.

Although medical schools were stimulated into some activity by the report of an IME working group (Boyd, 1987) urging that they introduce the critical study of medical ethics, such teaching became widespread only after the GMC told medical schools that medical ethics and law should be part of the core medical curriculum and therefore compulsory for all medical students (GMC, 1993). In 1998 most of the teachers of medical ethics in U.K. medical schools, and others, published a consensus statement on the contents of a core curriculum in medical ethics and law in medical schools (Teachers of Medical Ethics).

By the early 2000s, however, although there were several professors of medical ethics holding personal chairs, and while many medical schools had at least one full-time teacher of medical ethics, the only established chair of medical ethics in a U.K. medical school had been established in 1996 at the University of Bristol Medical School, with Alastair Campbell holding the position until his retirement in 2003. While female let alone feminist influences cannot be said to characterise British medical schools, influential exceptions in the realm of medical ethics included Ruth Chadwick, Jenifer Jackson, Janet Radcliffe Richards, Donna Dickenson, Bobbie Farsides, Heather Draper, and Ann Sommerville, along with leading medical law and ethics specialists Margaret Brazier and Sheila Mclean.

Three National Groups Formed in the 1990s

At the beginning of the 1990s three national groups concerned with medical ethics were established. The first, the U.K. Forum for Health Care Ethics and Law, was designed to bring together the increasingly numerous and various academic and other organizations, teachers, and students in Britain concerned with healthcare ethics. The second was the Nuffield Council on Bioethics, a national independent and nongovernmental multidisciplinary committee established by the private philanthropic Nuffield Foundation, to review the ethical issues raised by medical research, starting with those involving genetic manipulation, The third was the Association for Healthcare and Medical Ethics Teachers, founded for medical ethics teachers in British medical and nursing schools.

The Nuffield Council on Bioethics has flourished, becoming as near to a national committee on bioethics as the United Kingdom seems likely to have. While it remains selfappointed and unofficial this enables it to be independent of government, and its funding seems secure now that the government's Medical Research Council and the Wellcome Trust have joined the Nuffield Foundation in supporting it. Helping to account for the high respect with which it is held are its independence and multidisciplinarity, as well as the high caliber of its reports and discussion documents, on subjects including ethical aspects of genetic screening, xeno-transplantation, stem cell therapy, health research in developing countries, the patenting of DNA, genetics, and human behavior (all available through the organization's web site). Also likely to be relevant to the development of medical ethics in the UK is the creation in 2002 of the Association for Medical Humanities.

Continental Influences

Three continental European influences on the British approach to medical ethics are also important to note. The Council of Europe has an international bioethics committee and has produced a Convention on Human Rights and Biomedicine, which is legally binding on signatory states (Council of Europe) and is in effect an extension of its European Convention on Human Rights. A protocol to the convention banning human reproductive cloning is in effect, and protocols on organ transplantation, medical research, and the embryo and genetics are being developed. The United Kingdom has not signed on to the convention, in part because it forbids a form of scientific research that is accepted in the United Kingdom: the production of human embryos for the purpose of research.

The European Union also has an international bioethics committee, but more importantly for U.K. bioethics it has distributed significant funding for bioethics research projects if these involve cooperation between member nations. This has resulted in several U.K.–led projects involving such areas as education in bioethics, ethical aspects of HIV/AIDS, stem cell research, virtue ethics and chronic illness, and neonatal research. The United Nations Educational, Scientific and Cultural Organization (UNESCO) also has an international bioethics committee and has produced a (nonbinding) Universal Declaration on the Human Genome and Human Rights, which was adopted by the United Nations. Academic bioethics in the United Kingdom is also influenced from continental Europe through participation in the European Association of Centres of Medical Ethics and the European Society for Philosophy of Medicine and Health Care.

Religious Influences on Medical Ethics

Religious organizations are influential in medical ethics in Britain, both at a personal level, affecting the decisions of patients, healthcare workers, and others concerning medico-moral issues, and as a result of institutional activities. Relevant institutions include the Church of England Board for Social Responsibility (see, e.g., Dunstan, 1987; Dunstan and Seller); the (Roman) Catholic Bishops' Joint Committee on Bioethical Issues (see, e.g., Catholic Bishops' Joint Committee); the (Roman Catholic) Linacre Centre (see, e.g., Linacre Centre); the (evangelical Protestant) Christian Medical Fellowship (which holds regular meetings and publishes the Journal of the Christian Medical Fellowship); and the Jewish Chief Rabbinate (one of whose members, Lord Immanuel Jakobovits, obtained the first doctorate devoted to Jewish medical ethics; see Jakobovits).

The National "Flavor" of Medical Ethics in Britain

While it is always risky to generalize, a pragmatic, situationist, commonsense, antitheoretical, and antiregulatory approach tends to characterize the British approach to medical ethics (as to do many other aspects of British life—though resistance to regulation may be being increasingly overridden). Despite this national reluctance to theorize, however, it is gradually being acknowledged that some theoretical under-pinning is needed even for commonsense ethical decisions. In the context of medical ethics, a distinction is increasingly recognized between two medical ethical concepts ("Two Concepts," 1985). The first is traditional medical ethics, in the sense of promulgating and enforcing within the medical profession certain medico-moral norms—what Gordon R. Dunstan called "the obligations of a moral nature which govern the practice of medicine" (1981, pp. xxviii–xxxi). This sort of medical ethics has characterized medical education and practice since Hippocratic times. The second, more recent sort—philosophical or critical medical ethics—sets out to examine rigorously, and in the light of argument, justification, and counterargument, the issues of medical ethics, including the claims of traditional medical ethics.

Prompted from without as well as from within, the British medical profession has, since the mid-1970s, increasingly accepted the latter medical ethical concept as a proper part of medical thinking and education. Evidence for this includes the General Medical Council's greatly increased interest in medical ethics since it held a conference on medical ethics teaching in 1984; publication by the British Medical Journal in 1985–1986 of a series of twenty-six articles under the title "Philosophical Medical Ethics" (Gillon, 1985–1986); publication of The Pond Report on medical ethics teaching (Boyd, 1987), recommending such teaching in medical schools; the GMC's requirement that medical ethics and law should be part of the core medical curriculum (GMC, 1993); publication of the consensus proposals for the core curriculum (Teachers of Medical Ethics); the increasing teaching of critical or philosophical medical ethics in medical schools; and the increased attention paid to critical medical ethics by the British Medical Association.

But virtually all involved in the British medical ethics scene agree on one issue: the central importance of real cases, manifesting real medico-moral problems, in their real human context, for any adequate critical study, teaching, or understanding of the "humanized version of ethics" called for by the moral philosopher Jonathan Glover (1999).

raanan gillon (1995)

revised by author

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INTERNET RESOURCES

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U.K. Department of Health. 2003. "Research and Development." Available from <http://www.doh.gov.uk/research>.