MEDICAL SCHOOL INTERVIEW GUIDE — NHS and Medical Knowledge

Medical Ethics

WRITTEN BY
MEDISTUDENTS TEAM
SEPTEMBER 20, 2021

Unlike previous sections, which have provided possible questions and suggestions on how to answer them, in this section we’ll focus on background information about why medical ethics are important and the role the General Medical Council plays, before outlining the key principles of medical ethics. This will provide you with information to develop your knowledge of medical ethics and suggestions for further research, to support you to confidently discuss topics and respond to scenarios which involve ethical considerations or dilemmas, within your medical school interview.

Why are medical ethics important?

Ethical considerations play an important role within healthcare; as a doctor you’ll have a duty to uphold patient trust and respond to situations in a moral way. Within your medical training and your future career, you’ll experience ethical dilemmas and be required to make decisions which take into account ethical reasoning. Moreover, as a registered doctor, you’ll be required to follow the standards set by the General Medical Council (GMC) (outlined below); therefore making it essential that you’re aware of the ethical implications of these and use them to inform your decision-making when faced with ethical dilemmas. 

What role does the General Medical Council (GMC) play? 

As mentioned above, the GMC sets the standards which doctors are required to follow, including the ‘professional values, knowledge, skills and behaviours’ expected. Its role, as set out in the Medical Act 1983, is to ‘protect patients and improve medical education and practice across the UK’. As well as responsibility for setting the standards for doctors, it also oversees medical education and the registration of doctors qualified to practise medicine in the UK. All practising doctors must hold a provisional, full, specialist or GP registration; you can find out more about the medical register, including the different types of registrations, here

The GMC website provides guidance that will support you as a medical student and throughout your future career; two key documents that you should be aware of are ‘professional behaviour and fitness to practise’ and ‘good medical practice’ (which sets out the ‘professional values and behaviours’ expected from any doctor registered with the GMC), both of which we explore in more detail below. You’ll also find guidance that covers a range of specific areas, including professionalism, confidentiality and young people, that are worth exploring further. 

Professional behaviour and fitness to practise (as a medical student)

As outlined in the Medical Act 1983, the GMC is required to ‘promote and maintain proper professional standards and conduct’; they provide guidance on ‘fitness to practise’, both in relation to registered doctors and medical students, and ensure that these standards are upheld. Where there are concerns about ‘fitness to practise’, proceedings for registered doctors fall under the GMC, whereas individual medical schools are responsible for investigating medical students. The ‘professional behaviour and fitness to practise’ document provides guidance to medical schools dealing with concerns relating to students’ fitness to practise or professionalism; however, it is also a useful document for students or potential students, as it details behaviours which may lead to ‘fitness to practise’ proceedings.

The GMC identifies the following as ‘impaired fitness to practise in medical students’:

  • Misconduct, including issues relating to ‘honesty, trustworthiness or character’, for example:
    • ‘Cheating or plagiarism’
    • ‘Drug or alcohol misuse’
    • ‘Aggressive, violent or threatening behaviour’
  • Cautions and convictions
  • Adverse physical or mental health, for example:
    • ‘Failure to comply with reasonable adjustments to ensure patient safety’
    • ‘Failure to be immunised against common serious communicable diseases (unless contraindicated, for example, due to an underlying health conditions)’
  • A determination by a responsible regulatory body that fitness to practise is impaired

Good medical practice

‘Good medical practice’ sets out the expectations for doctors and medical students, and the standards by which their ‘fitness to practise’ can be judged and held to account (see above). It also notes your accountability in relation to your ‘professional practice’ and being able to ‘justify your decisions and actions’. 

The guidance outlines what it means to be a ‘good doctor’, including making patient care your first concern, taking action to protect patient safety and maintaining patient trust in you and the profession by ‘being open, honest and acting with integrity’. It also highlights how you should build positive relationships with patients and colleagues, treating each as individuals, and ensuring that they receive ‘good care and treatment’. 

Additionally, the GMC has produced ‘achieving good medical practice: guidance for medical students’, which outlines the standards expected, ‘both inside and outside of medical school’, and demonstrates how the principles of ‘good medical practice’ relate to medical students.

It’s useful to be aware of both documents, as ‘good medical practice’ provides the standards which doctors must meet, which is ultimately your aim as a potential medical student, and is still relevant before you become a registered doctor; and, ‘achieving good medical practice: guidance for medical students’ relates this specifically to medical students and offers ‘practical tips on how you can meet the requirements [...] set out’

Within the following section, we’ll explore some of the key principles identified in the ‘good medical practice’ guidance but also provide links to the ‘achieving good medical practice: guidance for medical students’ document, where there are particular tips or advice that will be useful in your interview discussions.

Key principles of 'good medical practice'

The ‘good medical practice’ guidance is divided into four sections, focusing on doctors’ responsibilities in relation to each area. It’s worth exploring the whole document, to gain a deeper understanding of all of the responsibilities highlighted, however, the following are some of the key duties outlined in each section:

  • ‘Knowledge, skills and performance’ – this includes a doctor’s duty to ensure the following:
    • That their professional knowledge, skills and competence are kept up-to-date
    • That they provide a ‘good standard of practice and care’
    • That they’re aware of and follow up-to-date regulations and guidance
    • That they record their work and maintain records in line with data protection legislation
    • That they work within their competence limits
    • That they gain consent before carrying out any examinations or procedures
    The ‘competence’ and ‘consent’ sections below explore the responsibilities outlined within this section in relation to each of these topics.
  • ‘Safety and quality’
    This section provides guidance on doctors’ responsibilities to keep patients safe, including complying and contributing to systems designed to monitor and improve safety, and offering support if they suspect the rights of ‘vulnerable adults or children and young people’ are being ‘abused or denied’. It also outlines their responsibilities in relation to their own health, including immunised and what to do if they suspect they have a serious condition that could be passed on to patients.

    In addition to this, the ‘safety and quality’ section details doctors’ responsibilities in relation to ensuring the safety of patients, which is explored further in the ‘ensuring patient safety' section.
  • ‘Communication, partnership and teamwork’
    The ‘communication, partnership and teamwork’ section provides guidance on working collaboratively with colleagues, providing training, support and mentoring for colleagues and students, and treating both colleagues and patients ‘fairly and with respect’. Doctors’ responsibilities in relation to the fair treatment of patients is explored further in the ‘treating patients fairly’ section below. You’ll also find ‘confidentiality’ and ‘objections to procedures’ sections below, which examine the duties relating to these areas, as outlined in this section of the GMC guidance.
  • ‘Maintaining trust’
    This section focuses on doctors’ responsibilities to ‘treat patients and colleagues fairly and without discrimination’, which is covered in more detail in the ‘treating patients fairly’ section below, as well as their duty to ensure that ‘reasonable adjustments’ are made to meet the needs of disabled patients. It sets out guidance for if a patient ‘suffers harm or distress’ and for communicating information with patients, which are explored further in the ‘making mistakes’ and ‘honest communication’ sections.

    In addition to this, the ‘maintaining trust’ section of the GMC guidance provides information regarding doctors’ duties in relation to legal or disciplinary proceedings and their honesty in financial matters. You can also find further guidance relating to this in the GMC’s ‘financial and commercial arrangements and conflicts of interest’.

Below you’ll find more information about the key principles identified within each section, which will inform your ethical judgements, and support you to demonstrate your ethical awareness and discuss ethical scenarios within your medical school interview.

Professionalism

Professionalism is an overarching theme of the ‘good medical practice’ and ‘fitness to practise’ guidance. As a student you’re expected to act in a way that does not bring the profession into disrepute, and failure to do this can result in ‘fitness to practise procedures’; the GMC outlines ‘key areas of concern’ in regards to medical student’s professionalism and behaviours which could lead to ‘fitness to practise procedures’

As we’ve emphasised in previous sections of this guide, assessment of your personal values is an important aspect of your medical school interview, and a vital element of being a medical professional; you’ll be expected to demonstrate values fitting with that of the profession, including honesty and integrity, during your interview and throughout your training and future practice. The ‘achieving good medical practice: guidance for medical students’ document provides practical advice on how you demonstrate your honesty as a medical student.

The GMC provides further specific guidance in relation to professionalism, including topics such as ‘personal beliefs and medical practice’ and ‘doctors’ use of social media’. Furthermore, ‘achieving good medical practice: guidance for medical students’ outlines what you’ll need to learn in order to achieve ‘true professionalism’ as a medical student, including developing ‘healthy ways to cope with stress and challenges’, applying ‘ethical and moral reasoning to your work’ and dealing with ‘personal bias’.

Competence

Within the ‘knowledge, skills and performance’ section, it specifies the importance of being aware of your limitations, in terms of your competence, and ensuring that you work within these. The ‘achieving good medical practice: guidance for medical students’ document sets out further practical advice about your responsibilities as a medical student in relation to working within your competence level and ensuring that you have adequate support and supervision whilst on placement. 

During your interview, you could be asked about the dangers of performing examinations or procedures when you lack the competence to do so, or given a scenario in which you’re asked to perform a task which is beyond the scope of your competence, perhaps during an emergency, which presents further ethical complications. The British Medical Association (BMA) provides an example of the potential pressure to exceed your competence level during electives in ‘resource-poor settings’, which you may find useful for considering how you would respond in scenarios such as that. Remember to use the guidance provided by the GMC to support your response to these types of scenarios and ensure that you are abiding by your duties as a medical student.

Consent

A further piece of key ethical guidance to be aware of within the ‘knowledge, skills and performance’ section is the need for medical professionals to obtain consent before carrying out any examination, investigation or treatment. The same is true of medical students and, in addition to this, you must ensure that patients are aware that you’re a medical student to allow them to make ‘an informed decision about whether they want you to be involved in their care’.

Provided they are able to do so, all individuals have the right to make their own decisions regarding their treatment and care – this is sometimes referred to as a patient’s right to autonomy – and, therefore, ‘consent is a fundamental legal and ethical principle’.

The GMC provides further guidance on ‘decision making and consent’; making yourself familiar with this will further support you to respond to ethical questions and scenarios. There are some key sections in particular which we’ll discuss further.

Exceptions

Medical professionals must respect a patient’s decision regarding their treatment, provided they meet the criteria outlined below, even if they disagree with their choice. There are some exceptions, including treatment provided under mental health legislation, which can mean patients are ‘required by law to comply with assessment or treatment because they present a risk to themselves, to their health or others’. Medical emergencies can also be exempt from requiring consent; if a patient is unconscious or lacks capacity (see below), treatment that is ‘immediately necessary to save their life or to prevent a serious deterioration of their condition’ can be provided without consent. Further guidance on consent for treatment during an emergency is provided by the GMC here.

Criteria

In order for a patient to have the right to make the final decision on their treatment, there are some key criteria that must be met, including:

  1. The patient must have the capacity to make the decision.
    Sometimes referred to as a ‘competent adult’, this refers to an adult who has the mental capacity to make decisions; adults who are not proven to be ‘competent’ may need support to make a decision or for someone to make the decision on their behalf. See the ‘capacity to make decisions’ section below, which also discusses decision making for children.
  2. The patient must have sufficient information to make the decision
    Within the ‘communication, partnership and teamwork’ section of the guidance, it clearly outlines doctors’ responsibility to ‘work in partnership with patients’ and provide them with sufficient information to support them to make a decision about their medical treatment, including finding out what is relevant and important to them as an individual. Patients need to be aware of the consequences of their decisions, whether they choose to have or decline treatment, in order for them to make an informed decision, and the GMC outlines a doctor’s duty to provide this.
  3. The patient must make the decision freely (without influence from external pressures)
    The GMC guidelines state that if a ‘patient can’t make a decision freely, they won’t be able to consent’. They give examples of pressures patients may experience, from ‘partners, relatives or carers’ as well as their ‘beliefs about themselves and society’s expectations’, and provide guidance on what medical professionals should do if they suspect this is the case for a patient. Potentially you could be given a scenario within your interview just like this, in which a patient is being pressured to make a decision which you believe is not their own, and asked how you would deal with this as a doctor; having a clear understanding of the ethical issue this raises, and the guidance on how to deal with this, will support you to confidently respond to this type of scenario.

Capacity to make decisions

As outlined above, a key consideration in relation to a patient’s ability to give consent to medical staff, is their capacity to make an informed decision; where it’s judged that a patient cannot make an informed decision, responsibility for this must fall to someone else. 

When dealing with a patient who is judged to lack decision-making capacity, it’s useful to separate them into the following broad categories, to explore the considerations:

  1. Children & young people (under the age of eighteen)
    Parents have ‘parental responsibility’ which means that they have the legal authority to make decisions on behalf of their children. However, some potential problematic areas are:
    1. A young person may still refuse treatment, this can create problems if medical staff and/or those with parental responsibility disagree. It would be possible to overrule their decision if treatment was judged to be in their best interest, and particularly if was life-saving, however, legal advice would need to be sought and it would still present ethical issues.
    2. Under the age of eighteen, young people can be considered competent to make an informed decision; however, the age at which they can do this will differ between patients. This can be problematic, as at what point a patient can exercise their right to make decisions and give consent will change, and may cause conflict with parental consent.
    3. Issues could also arise if medical professionals and those with parental responsibility disagree over the treatment of a child or young person; in instances such as these a second opinion or even legal advice may be needed. A high profile example of this is the Charlie Gard case, which we cover in the ‘current topics’ section.
    The General Medical Council’s ‘0–18 years: guidance for all doctors’ provides guidance on making judgements on what is in the best interest of the child and how to involve their responsible adults in making decisions on their behalf. It provides advice on ethical dilemmas that may arise when treating children and young people under the age of 18, including: what to do if there are disagreements with parents/those with parental responsibility about a child’s treatment; support for assessing a young person’s capacity to make a decision and what to do if they subsequently refuse treatment; guidance on providing advice and treatment to young people under the age of 16 in relation to contraception, abortion and STI without parental consent; and linking to this, children and young people’s right to confidentiality and when information should be shared with a parent or carer.
  2. Adults lacking the capacity to make decisions
    The Mental Capacity Act (2005) sets out in legislation how adults’ capacity to make decisions should be assessed and how to deal with situations in which this is deemed to be lacking. It is worth noting that the act applies to anyone over the age of sixteen.

    The following are some key factors from the Mental Capacity Act (2005), in relation to adult capacity:
    1. A competent adult’s right to make their own decisions includes those which medical professionals may disagree with; this does not necessarily mean that they lack the mental capacity to make such decisions, and unless assessed to be, they should not be treated as such.
    2. The guidance is clear, it should be assumed that an adult is able to make their own decision, until proven otherwise. This is especially important for patients with particular health conditions, which it may be assumed would affect their mental capacity to make decisions.
    3. Wherever possible, individuals should be supported to make their own decisions. This may mean identifying additional support that may be required to enable them to do this.
    4. Where a decision has to be made for a patient who lacks capacity, this must be in their best interest and of ‘overall benefit to them’. The GMC further states that ‘decisions should be made in consultation with those who are close to them or advocating for them’.
    Further information, including how mental capacity is assessed, can be found on the NHS website here.

Ensuring patient safety

Within the ‘safety and quality’ section, there is a focus on doctors’ responsibilities in relation to ensuring the safety of patients; however, as the ‘achieving good medical practice: guidance for medical students’ document emphasises, this is the responsibility of everyone working within a healthcare setting including medical students. This consists of creating a culture in which colleagues can ‘raise concerns openly and safely’, as well as taking ‘prompt action if you think that patient safety, dignity or comfort is or may be seriously compromised’. It also provides guidance on how medical professionals should carry out these responsibilities, in a range of circumstances, including concerns about colleagues’ ‘fitness to practise’.  

Within your medical school interview, you could be given a scenario in which a patient’s needs aren’t being met or they’re being put at risk, and asked how you would respond. By familiarising yourself with this guidance from the GMC, including the additional ‘raising and acting on concerns about patient safety’ guidance, you’ll have a better understanding of your duties and how best to proceed in this situation. The guidance within the ‘achieving good medical practice’ document provides further advice on your responsibilities as a medical student and what you should do if your concerns relate to your friends or peers.

Treating patients fairly

The guidance on doctors’ responsibilities to treat patients, and in fact colleagues, fairly is explicit; patients must be treated as individuals and their ‘dignity and privacy’ respected. While the ‘communication, partnership and teamwork’ section highlights that patients should not be discriminated against, the ‘maintaining trust’ section of the GMC guidance expands on this further, stating that personal views should not affect a doctor’s ‘professional relationship or the treatment [they] provide’. It also emphasises the importance of avoiding discrimination within the allocation of treatment and ensuring that priority is based on clinical need.

Although you won’t be responsible for making these types of decisions about patients’ treatment as a medical student, you still have a duty to ensure that you don’t allow your ‘opinions or views [to] affect the way you treat patients and others or the information you give them’.

Within your interview, a possible scenario could be the treatment of a patient who’s lifestyle may be considered a contributing factor in their condition. There may be more to your answer in a scenario such as this, for example you may need to discuss how you would support or advise the patient to make positive changes; however, in terms of ethical considerations, the guidance is clear that ‘you must not refuse or delay treatment because you believe that a patient’s actions or lifestyle have contributed to their condition’. The GMC’s ‘communication, partnership and teamwork’ and ‘maintaining trust’ sections outline the guidance in relation to treating patients fairly and without discrimination.

Confidentiality

Medical professionals and medical students have a duty to ‘treat information about patients as confidential’. Moreover, it is an expectation from patients that the information that they share with healthcare professionals will remain confidential. Being able to trust doctors is essential within healthcare and confidentiality is at the centre of this. A lack of confidentiality or a breakdown in this trust would have a devastating effect on a patient's relationship with medical staff, whereby they may not feel comfortable to seek medical help or share important information regarding their medical concerns. 

While confidentiality is a ‘legal and ethical duty’, you are able to ‘disclose personal information without breaching duties of confidentiality’ within certain circumstances. The GMC provides guidance on situations in which it is possible to share confidential information and the steps that should be taken when doing so, including issues concerning consent. 

Familiarising yourself with this guidance will support you to deal with scenarios involving confidentiality within your medical school interview, and ensure that you’re responding in line with the legal and ethical duties of medical professionals. 

You can find further guidance from the GMC, including in relation to ‘patients' fitness to drive and reporting concerns to the DVLA or DVA’ and ‘reporting gunshot and knife wounds’, within the confidentiality section of their ethical guidance for doctors.

Objection to procedures

Within the ‘communication, partnership and teamwork’ section, guidance is given in relation to a doctor’s duties if they have a ‘conscientious objection to a particular procedure’, including providing adequate information to allow their patient to seek an alternative doctor or arranging for a colleague to act in their place. Within your interview, you may be asked if healthcare professionals are permitted to object to performing procedures, or given a scenario where this is the case; therefore, it’s useful to be aware of what the legal requirements are and what the process would be to act on this. 

The important element to draw your attention to within this, is the responsibility of doctors to ‘not imply or express disapproval of the patient’s lifestyle, choices or beliefs’; this is essential for maintaining positive relationships with patients and treating them fairly and without discrimination. This is extended further within the ‘maintaining trust’ section of the GMC guidance, to include a duty to ‘not express your personal beliefs (including political, religious and moral beliefs) to patients in ways that [...] are likely to cause them distress’. These would be essential points to bring into discussions surrounding ‘conscientious objection’. 

Another consideration is, that while you have the right to ‘conscientious objection’ as a medical student, you must still achieve the capabilities set out in the ‘outcomes for graduates’ guidance. 

You can also find further information on what to do in instances where you object to carrying out a procedure because of your beliefs, or in which a patient requests or refuses one because of their beliefs, in the ‘personal beliefs and medical practice’ guidance.

Making mistakes

As part of the ‘maintaining trust’ section of the guidance, doctors’ responsibilities in situations where ‘things go wrong’ are addressed, with an emphasis on being ‘open and honest with patients’ about what has happened and the likely consequences of it. Similarly, it notes their duty to respond to complaints ‘promptly, fully and honestly’ and to ‘not allow a patient’s complaint to adversely affect the care or treatment’ provided.  

Although you won’t have direct responsibility for care as a medical student, you have a duty to inform your supervisor, who will support you to deal with the situation, if ‘you think any aspect of care that you are involved in has gone wrong’. A key aspect of the guidance for both doctors and medical students is the need to be honest with patients and offer an apology when things have gone wrong. 

Within your interview, you may be given a clinical scenario in which an element of care does not go to plan, in which case you would use the GMC guidance to justify how you would deal with the situation. However, you may alternatively be given a more general scenario about making mistakes, or asked a direct question about how you deal with this; although you would not be legally required to follow the GMC guidance here, it does still provide useful guidelines of how you should respond, allowing you to demonstrate your ethical awareness, honesty and integrity, which are important qualities for a future medical professional. 

How to answer questions relating to ‘mistakes and failures’ is also covered in the ‘personal insight’ section of this guide. You can also find further guidance from the GMC, relating doctors’ responsibilities when dealing with mistakes, in ‘openness and honesty when things go wrong: The professional duty of candour’.

Honest communications

Within the ‘maintaining trust’ section, the GMC highlights the need to ‘act with honesty and integrity’ and ensure that ‘your conduct justifies your patients’ trust in you and the public’s trust in the profession’. Being honest in your communications, both with patients and colleagues, is touched on throughout the guidance, and an important factor in maintaining positive relationships and trust in the medical profession. 

‘Achieving good medical practice: guidance for medical students’ provides further guidance for students interacting with patients, including being honest if you don’t know something and being aware of potential barriers to communication. 

‘Good medical practice’ also outlines duties relating to maintaining confidentiality when speaking publicly or on social media; with further guidance on social media use in the ‘doctors’ use of social media’ guidance. In addition to this, ‘achieving good practice: guidance for medical students’ provides a ‘dos and don’ts’ guidance on medical student’s use of social media. 

Communication is a key skill for medical professionals and therefore it’s a common assessment point across all medical school interviews. While there is a wide variety of direct and indirect questions and scenarios you may experience in relation to communication, and in particular communicating with patients, the critical point from the ethical guidance is the need to be honest in your communications and to maintain confidentiality. You can find more support on preparing for questions relating to your communication skills in the ‘personal attributes’ section of our guide.

Additional guidance and resources from the GMC

The GMC website also has the following resources which will support you to develop your ethical awareness in preparation for your medical school interview:

  • Ethical hub – resources to help you to apply the GMC ethical guidance to your future practice as a doctor, including:
    • Further information on mental capacity, including assessing and maximising patients’ capacity.
    • Adult safeguarding information; for example, exploring the ‘underlying principles’ and different types of abuse.
    • Information on making your practice accessible for patients who have learning disabilities.
  • Learning materials section – providing a variety of learning materials ‘to help put the principles in [the GMC] ethical guidance into practice’, including:
    • Case studies
    • Decision tools
    • Articles
    • Question and answers
    • News
    • Videos

The ethical guidance for doctors section also provides some additional guidance, to that covered so far, which you may particularly useful, including:

Some considerations if you’re given an ethical scenario or question

Some final things to remember if you are presented with an ethical scenario or question during your medical school interview:

  1. During your medical training you’ll develop skills to enable you to identify and respond to ethical issues and you’ll be able to draw upon your tutors at medical school and your mentors during your clinical placements, to support you with ethical dilemmas. Therefore, don’t be afraid to say you would discuss concerns or ask for support from a tutor or mentor, if presented with an ethical scenario during your interview; in some cases this may be necessary. However, ensure that you discuss what your ethical concerns would be and your responsibilities in relation to these, even if you would need help to execute them or to know the procedures for doing so.
  2. You can’t prepare for every ethical question or scenario you may receive. Linking to the above point, it’s important that even if you don’t know the procedure or exactly what is required of you, that you demonstrate ethical awareness, explore what considerations the situation would present and highlight that you would draw upon guidance to ensure that you carried out your duties correctly.
  3. Not all situations are straightforward when it comes to the ethical considerations, and where disagreements do occur, often both sides will feel that they are doing what’s best, which can present challenges. It’s important in scenarios such as this that you focus on maintaining positive relationships with patients and those close to them or involved in their decision-making, with the aim of working in partnership with them, but ultimately follow the guidance and use this to support you.
  4. Finally, ensure that you have a good understanding of the core ethical guidance, as outlined in the ‘good medical practice’ document, and how this will apply to you as a student, by using the ‘achieving good medical practice: guidance for medical students’. Your familiarisation with these two documents will support you to respond to ethical scenarios or questions within your interview and to be able to demonstrate your understanding of your duties and responsibilities.
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