The Nuffield video library in medical ethics and law

Anyone who has tried to make videotape recordings for use in teaching medical ethics will appreciate Len Doyal's achievement. The Nuffield Video Library in Medical Ethics and Law consists of six tapes, each containing about 45 minutes of wellstructured and relevant material. A handbook of useful reprinted articles is also included. The tapes are dedicated to the memory of John Dawson who died at a tragically young age. John Dawson made a tremendous contribution to practical medical ethics in Britain. His clear-headed enthusiasm was a support and stimulus to many of us working in this field. I found it both a sadness and a pleasure to see him on the third of these tapes performing with his characteristic energy. Each tape is a five-course meal. The starter is an introduction to the topic given by Len Doyal himself. The entree is a case presentation in which a senior clinician describes a particular patient whose care raised ethical problems relevant to the theme of the tape. The main course, the clinical perspective, is an interview between Len Doyal and an experienced doctor in which some of the theoretical issues raised in the introduction are looked at in more detail. The pudding is a role-play of an interview between doctor and patient, and the meal ends with a brief summary and conclusion. The tapes as a whole represent the menus for a week; assuming the restaurant staff have an evening off. The topics of the six tapes are as follows: informed consent and good medicine; telling the truth and good medicine; confidentiality and good hospital medicine; informed consent and good psychiatry; and informed consent and good general practice. The assumption is that good medical practice requires a sensitivity to, and an ability to think about, the ethical aspects of medicine; this is an assumption with which few of the readers of this journal will disagree. On the whole Dr Doyal is more concerned to raise ethical issues and to identify the main principles involved than to promote a particular ethical viewpoint. No sustained discussion of medical ethics, however, can be ethically neutral and these tapes present the prevailing perspective in medical ethics (if not the prevailing practice): that it is patients' autonomy which is of prime importance. The choice of topics shows a central concern with what might be broadly considered the doctor-patient relationship: the focus is on consent, confidentiality and truth-telling. The first thing to be said about these tapes is that they are interesting. The interviews with, for example, Anthony Clare or John Dawson are simply fun to watch; and some of the role-play scenes are gripping. Their value however, stands or falls with their merit as aids to teaching. Each tape is designed to form a unit which can, in theory, be watched from start to finish with suitable pauses for discussion. I doubt, however, whether many teachers of medical ethics will want to use the tapes in this way. I find that video material is most effective in seminar teaching when it is fairly short and when it is only a part of the teaching session. I serve the courses, rather than the meals, to my students. In a seminar on consent, for example, which I run with first-year clinical medical students while they are working on the surgical wards, I have used two sections of the first tape. On some occasions I have chosen the role-play which involves a surgeon trying to persuade a woman to have a mastectomy rather than a 'lumpectomy'. This acts as a stimulating starting point to the seminar and leads students directly into thinking about models of the doctorpatient relationship and what the different models mean in practice. The other part of this tape which I have used is the interview with the surgeon, Mr John Cochrane. Essentially Mr Cochrane argues for the importance of obtaining informed consent prior to surgery from both ethical and legal standpoints. In addition he proposes a simple structure for thinking about the risks of surgery: the risks of any operation involving a general anaesthetic; the special risks of this particular operation, and the alternative treatments. Simple though this is it provides medical students with a way of organising their thoughts. The value, I find, in showing the video is that the main message, the importance of taking informed consent seriously, comes from Mr Cochrane. This is important because a central problem in teaching ethics to medical students is that it is those students who engage least with such teaching who need it most. When I, a psychiatrist with a special interest in ethics, stress to such students the importance of informed consent it is easy for them to ignore my message. But when a senior and successful surgeon, who looks like a senior and successful surgeon, gives the message it has more impact. With thirty 'courses' to choose from, teachers of health care ethics will find that these tapes contain much of value for their seminar teaching.