Teaching Ethics in Medical Schools

My attention has wandered recently to this editorial in Clinical Medicine, concerning the place and content of ethics education in the undergraduate medical curriculum.  There’s nothing Earth-shattering in there, but the piece does draw out a few persistent problems with teaching ethics within the medical degree:

There is much debate about the design of ethics courses for medical students. Some of the questions concern how ethics education should be assessed. There is currently a great deal of interest in multiple choice questions and computer-marked approaches to assessment. But how appropriate are these as a way of assessing the kinds of skills required for ethics? Ethics in practice is about thinking through a problem, making an argument, being able to give good reasons for the chosen way forward and so on. It is in essence about argument and judgement.  Is it appropriate to assess these skills using these methods? No philosophy course would be examined in this way.  While having a number of practical advantages, such approaches may have a narrowing effect on the curriculum leading it to be focused more on facts and less on the development of the skills and attitudes that doctors are going to need.  A second set of questions in ethics education, given the importance of practice, is how much should teaching be around real cases and close to practice and how much should it be focusing on principles, literature, theory and so on?  Finally, there is the question of who should be teaching ethics?  Should it be taught by experienced clinicians, by people with an academic training in ethics, by people at the cutting edge of bioethics research, or by some combination of all of these?

The assessment question is very important for ethicists; there’re arguments for medical law to be taught at least partially by exam, and possibly by MCQ – but ethics without argument is not really ethics, and exams – especially in the form of MCQ and OSCEs, both of which I’ve met in medical schools – are unsatisfactory.  (Admittedly, OSCEs are less bad then MCQs, but you still have to rush people through and can’t have much of a conversation.)  As for the question of who should teach, and what should be taught: well, my inclination is that you need at least some significant input from an ethicist, and preferably an ethicist with a philosophical background.  It’s very easy to teach ethics badly; but it’s not much more difficult to teach it well if you’re philosophically literate.

But all this is secondary, I think, to the question of what to teach; and this brings us into tricky problems of what ethics is, what applied ethics is, and so on.  There’s a part of me that’s suspicious of the whole idea of teaching applied ethics without “Philosophy Department Ethics” in the background – my worry here is that you end up with something either etiolated, confusing, or just plain misleading.  There’ve been too many occasions, for example, when I’ve heard medical students told that the Categorical Imperative is essentially the same as “golden rule” ethics; it’s one thing to simplify universalisation, but quite another to get it so wrong.  And while I can see that Principlism has the advantage of simplicity and accessibility – and granted that medics want to be medics rather than philosophers – I think that it’s likely to be etiolated.  On the pother hand, some sort of ethics does seem desirable.  The best way out of this puzzle, I think, is that students learn to think critically about their own actions – that’s much more important than being able to tick boxes about autonomy, beneficence and justice without ever really thinking about what they mean.  In fact, I’m willing to put my neck out and suggest that critical insight into action actually means that we don’t have to bother with the Principles.  The problem, though, is fitting it into the timetable.

Were I king, my medical ethical curriculum would be based around long discussions in small groups over red wine or tea, talking about things that’ve been in the news or that students have encountered.  There’d be a vague direction over the term, but we’d meander.  Students would be encouraged to read a lot – not just on ethics, but generally.  There’d be no exam, because I’d be interested primarily in getting students to think and to worry – but to worry in the right way – and you can’t examine those.  They’d leave medical school with a rich and productive confusion.  And there’d be armchairs.  Big, leather armchairs.

What could possibly go wrong?

  • Keith Tayler

    Sitting in armchairs quaffing wine might be one very enjoyable way of doing philosophy (done it decades), but it is limited and of little use in applied ethics. Discussing some areas of bioethics such as cloning, eugenics, genetic privacy, etc during the cool hours in armchairs has its place. Not sure ethicists add much to the discourse, however, as far too many of them engage in science fiction and pseudo-science. I also have my doubts about whether undergraduate medics should spend their time discussing these matters on medical ethics courses. These are topics of general public interest and should not be made esoteric by teaching them to medics in tightly controlled institutions. But that of course is all part of the mysterious process of becoming a member of a “profession” (pity this does not have greater priority on med. ethics courses)

    As I have said in an earlier posting, bioethics and medical ethics/law courses have little or nothing to do with the real world situations about which medics might have to make ethical judgements. The quasi-judicial processes of complaints procedures, ombudsman system, employment tribunals, union and professional ’powers’ shape the “decision space” in which most medics work. Friendship, loyalty, loss of individualism, small group dynamics, etc. greatly influence our decision-making. Indeed, ethical transgression is not always easy to identify in situations where we have become, for example, “epistemicly enslaved” or too trusting of ones colleagues. I could go on – but you get the picture.

    There is not much point in just discussing these issues from an armchair. When I taught ethics I attempted to place students in simulated situations to assess their awareness of a situation and how they coped in ’real-time’ (were they aware that the ICT system they were using contravened the DPA?, etc.) The technology has moved on since then and it would now be possible to assess individual in quite complex ‘virtual’ environments. Using computers to mark worksheets is 1970s technology, which is where a lot of bioethics and medical ethics is still sitting.

    Of course attention to detail and the minutiae of the everyday are not sexy (it‘s like hospital hygiene, not sexy but essential). It is difficult to teach students about the workplace because they need to have some experience of it (that also goes for the teachers). Teaching applied ethics to young undergraduates is a bit of a waste of time (it’s all theory without the experience).

    Anyway, you are welcome to your glass of wine and armchair, but all you will do is pass on the habit of thinking in armchairs. McIntyre in correct – “The notion that the moral philosopher can study ’the’ concepts of morality merely by reflecting, Oxford armchair style, on what he or she and those around him or her say and do is barren.“ The notion that you can do applied ethics from the same position is doubly wrong.

  • Unsurprisingly, Keith, I disagree…

    I accept that there’s a need to make sure that students are familiar with, say, the NHS’ procedures, my worry about concentrating on them too much is that you end up with an impoverished account of ethics – a bunch of students who think that ethics is about how not to get sued, and what to do if and when they are. At best, you end up with a version of ethics that never looks much beyond endless consent questions. You also end up with a confusion of ethics and policy.

    The other advantage of the philosophical approach is that it allows students to get their heads around the principles that motivate questions. I can’t comment directly on your real-time approach, but I wonder whether concentrating on cases and simulations leads to an obscuration of why the problems are problematic in the first place. You can learn any number of case studies and “appropriate” – i.e. GMC approved – responses, without really knowing the first thing about good conduct. (It’s kind of a moral version of the Borges story “Funes the Memorious”.)

    I’m also a defender of the science fiction approach. Take, for example, the problem of abortion. The violinist example provided by Thomson provides a nice method of examining the salient moral points without getting too hung up on the detail; it allows us to home in on a precise aspect of the moral state of affairs, and then it’s up to us to go back and apply this aspect. The same applies to other science fiction examples. Just as good SF literature really isn’t about laser guns and aliens, but about the world we know, so the same applies to thought experiments in ethics.

    I’m surprised by the MacIntyre quotation – what’s it’s provenance? After all, the idea of cool reflection on the concepts of morality goes back at least as far as Plato, and probably further – couldn’t we read Homer or Sophocles as providing fictionalised thought experiments about some aspect of human life in order to get at the reality from a more abstract standpoint? Couldn’t we say the same about even Abraham’s conversation with Yahweh in Genesis 18? All of these examples, I think, could count as Bronze-age sci-fi and armchairism. Without the armchairs, we’d have no reason to think about the real cases, and almost certainly no tools to bring to them.

    I really don’t think you can have clinical ethics without a vigorous wild hinterland of more philosophical biomedical ethics…

  • Keith Tayler

    I think there is a place for what you call the “philosophical approach”, but I am not convinced it makes much difference when it matters. There is evidence that being made aware of the ethical issues has little or no affect upon people’s behaviour. (See Darley, John M., and Batson, ’Jerusalem to Jericho: a study of situation variables in helping behaviour’, Journal of Personality and Social Psychology, 1973, 23. 100-108: Latane, Bibb. and Darley, John M, ’The Unresponsive Bystander: Why Doesn’t He Help’, (New York, Appleton-Century Croft, 1970) Throughout my career I have been in situations where people, including myself, have acted unethically. The reason for this is usually environmental, i.e. the situation prevents them from thinking and acting correctly. This state of affairs can last indefinitely and is of course an important part of bureaucratic rationalisation. I have meet numerous civil servants who have a extremely good knowledge and understanding of ethics and the law but would not dream of exercising them in their jobs (okay, they are beyond help, but you see similar behaviour in medics and other professions).

    I think that medical ethics and law should address these issues. Philosophical discussions are of little use, and the use of thought experiments only give the impression that something is being done. I agree with Williams that most TEs are “fantastic” and as he showed in ’The Self and the Future’ (Problems of the Self, CUP, pp.46-63) they are open to different interpretation. The TE seeks to reduce the complexity of the world. We need to be hung up on the detail – it‘s all in the detail. Of course, as Williams points out, something happens when we add the detail, “To make the example realistic, one should put in more detail; and, as often in moral philosophy, if one puts in the detail the example may begin to dissolve.” (Limits of Phil. p 180) Sitting in an armchair having a discussion might appear to be ’complex’, but that is to make the same mistake as many AI researchers when they took chess problem solving as being the paradigm for ’intelligence’. (It is the everyday detail AI cannot handle – AI systems can deal with ethical and legal TEs better than most professors (they are especially good at ‘trolley problems‘)) As for the classical TEs: they made some pretty bad mistakes with TEs – hares in races, birds in cages, people in caves, etc., etc., etc., Philosophy has its place in armchairs but it is of little use in the real world (on this I agree with Wittgenstein).

    I am not suggesting that students are ‘only’ made aware of the complaints procedures and the myriad of other regulations and bodies that shape their decision-space. But I would like to see far more emphasis placed upon them and some ’philosophical’ and legal analysis of them (dammit – they do it on the Continent). Believe you me, I have no desire to produce medics that think that ethics is about how not to be sued and how to work within the rules. I see evidence of that in the profession, especially among those that have done the courses, so I think my approach of getting medics to be aware of and question the regulations keeps them engaged in an active ethical discourse throughout their working lives. I have no interest in teaching students to rigidly apply the approved GMC response. They should know it, but, as with most professional bodies, I have usually been at odds with the approved methods.

    Back to the armchair. As I said, there is a place for it but it needs to be occupied by other ‘philosophers’ – not just bioethics and medical ethicists. Oh yes, the MacIntyre quote, (pay attention Brassington – I have told you before) it is from the preface of After Virtue.

  • tom bull

    hi,

    thought you might interested to hear how the medical ethics teaching is done at Newcastle Uni, which is where I am currently in my final year.

    We are introduced to the four principles approach in our first year and have one or two seminars thinking about popular ethical issues – euthanasia, organ donation etc – and that is more or less it for the first four years.

    In our final year, we have just submitted an ethics essay as part of this term’s assessment and it had to be based on a clinical dilemma we had witnessed or taken part in. This seems like a good way of combining the two ideas in the comments above – we were encouraged to refer to different moral philosophies to compare the solutions they suggested but at the same time the cases discussed were likely to be very common, everyday dilemmas as we had to have experienced them ourselves.

    In the same 3 week part of our course we had a number of small group sessions looking at challenging situations we are likely to face in our first year of work which was useful but we also had a deep into the night armchair group discussion (without the deep night or the armchairs but we was a free flowing discussion of ideas about an ethical case picked by ourselves). The second session was less directly useful but was much, much more interesting so there’s a place for both the approaches.

    I think where our course falls down at the moment is that we are only taught about the four principles – our essay guidance this year then required to “not forget that there’s more to ethics than four principles” – it’s a shame we never got exposure to the other philosophies earlier in the course. So our ethical reasoning skills were probably not fully developed by the end of the assignment!

  • @Tom – Thanks for that. I like the idea of the extended discussions! It is a great shame that you only got the 4Ps early on; not only is it the case that there are other approaches – I’d say that principlism isn’t even an approach, since the interesting questions arise only when you’ve got a conflict of prima facie obligations. But that’s just my simmering resentment of Beauchamp and Childress coming through…

    @Keith – Hmmm. I suspect that we have different accounts of what ethics teaching is for; at the very least, I’m curious to know what you mean in your allusion to affecting people’s behaviour. I certainly don’t think that it’s the job of the ethics teacher to get students to more of this and less of that, unless the this in question is critical reflection: more than that is the job of the activist. You can’t teach people to be better people in the lecture hall, not least because it’s not clear what being a better person involves. It’s a big enough job to get them to appreciate the difficulty involved in being a better person.

    And on this point, though I’m frequently sympathetic (or at least provoked by) MacIntyre, I think that the claim about barrenness is probably wrong. It’s not barren; it’s an important part of applied philosophy. Not the whole story, perhaps, but important nonetheless. (For my own part, I’m kind of taken by Anscombe’s idea that moral evaluation has to be kata ton orthon logon: according to what’s reasonable. But for that, you need an account of reasonability. Theory and practice kind of come together.)

  • Keith Tayler

    I certainly do not think it is the job of philosophy and ethics to make “better people” (as I say, I am with Witts on this). However, medical ethics might have a place in making medics more aware and indeed critical reflective about their work. If they constructively questioned their seniors, managers, professional bodies, etc., and understood more about the decision-space they worked in, their ’behaviour’ would change. My concern is their ’behaviour’ in the workplace – what goes on in their heads when they are working is a philosophy of mind problem. Getting them to be more critically aware needs more than ethics. What that means, of course, is that medical ethics and law courses should be stopped and new interdisciplinary courses should take their place. Don’t worry – there would still be a place for ethics; the difference being you would have to share the armchair with ‘others’.

    I never found Anscombe particularly ‘rational’ because kata ton orthon logon, as is so often the case, was translated as being “in accordance with the correct rational standard”, i.e. her correct rational standard (very often completely wacky). As for “theory and practice kind of come together.” I could wish you good luck in this if I thought ethical ‘theory’ was possible or indeed desirable. Obviously I do not, but even if I did (there was a time when I did) I have yet to encounter anybody who has managed to put together theory and practice. (Sit down Marx you know you failed) “…kind of come together” is about as far as it gets, but that is like saying you are closer to getting to the moon because you have climbed a tall mountain.

  • Dr Gubernaculum

    In such a detailed and cramped course such as medicine, it would be difficult nay impossible for a course to go into the details required to satisfy our philosophy friends. What I would like the course to do is at least challenge the studenst and get them to think. The way to teach it is a difficult one. My experience of tutorials with medical students is that you get a mix of those who want to take over the discussion and those who remain quiet and want to tick the box that they have been. We now have a problem with medical students that they no longer are supposed to think but remember. Knowing the fifteen top causes of atrial fibrillation is important but it is the ability to use that knowledge when you have the patient in front of you is when the art comes in. We want ethics courses to broaden minds not restrict them to’ what do I need to know to pass this and get onto the next stage’.
    The next problem is who. I am sorry Iain but we need people who have training in ethics but have also been at the coal face so to speak instead of just seeing a piece of coal once. We need furure doctors who are able to work in the NHS and are able to, as Keith says, question what they’re doing and what others are doing.This is not going to be done completely in an undergraduate setting but should at least be the spark to continued learning.
    The teaching should not be in the form of a course but should be spread through the curriculum with each branch raising more than enough issues to teach about.
    It does raise the question, though, do we have enough clinical ethicists to teach such courses and how long is the annual leave, pay and do I get biscuits with my coffee?

  • Keith Tayler

    @Dr Gubernaculum

    I agree. As I have said in other postings, medics need quality training throughout their career. Undergraduates need an ‘introduction’ to what it might be like. When they have some experience they should be able to build on it with a deeper understanding of the ethical and legal issues.

    Medical ethics in the this country is rather strange. In the USA doctors, nurses, etc., are far more envolved in courses, and case studies are used more than armchairs (not saying we should totally adopt the US model). Bioethics and medical ethics in the UK forgets it is ‘applied’ ethics. I agree with Iain that it is difficult/impossible to apply philosophy; but that realisation should get applied ethicists thinking about what other disciplines can medics use in their training. For example, ICT will increasingly dominate the NHS – for better or worse? The ethical, legal and operational issues of ICT are for the most part ignored and/or poorly understood by medical ethicists. Of course most of the students would be very interested in the finer details of the systems they will be using. Is it applied ethics? Yes of course it is. But, following Williams, the finer the detail the less it becomes an ‘ethical’ problem and the fewer ethicists you need.

  • @ Dr Gub – I’m wholly in agreement with you about the importance of getting students to think; where I think I part is with the coalface demand. You don’t need clinical experience to talk meaningfully and richly about, say, justice or a conflict of beneficence and autonomy; and you don’t need clinical experience to cook up a scenario to demonstrate problems. (Hell, you could even knock on a clinician’s door and say “I want to illustrate this sort of thing… any idea of the kind of illnesses that might fit the bill?”)

    @ Keith – I’m not sure that I said that it’s impossible to apply philosophy – or, at least, that’s not quite what I meant – though of course it may be tricky to apply it directly, and maybe even tricky to see how the indirect applications work.

    Nor am I sure about your “learning what it’s like” approach; we don’t train champion cyclists by teaching them what it’s like to pedal quickly; we give them the ability to do so themselves. To an extent, I think the analogy holds with medical students. In fact, I’m much less interested in getting them to be able to solve moral problems as to be able to spot them – that strikes me as the crucially important skill. Once you’ve spotted a problem, you can go and talk about it with acknowledged experts or those with more experience.

    Where I do agree with you is in respect of the desirability of a wide and deep engagement from students – and the same applies irrespective of their degree: I’d love for English students to be more scientifically literate, even though they aren’t scientists, for example. The distinction and demarcation of philosophy, science, sociology, history and all the rest is recent and not all that welcome: any reasonably self-aware academic in whatever field knows that what they do is frequently a bit of a splurge; your discipline may tell you your starting point and the nuances of your preferred approach, but that’s about all. But this brings us back to the problem I mentioned in the OP, and which Dr Gub echoed: given that there’s only 5 years in a medical curriculum, it’s not easy to see how to cram in everything we’d want.

    I know that in my world, we’d make room for the armchairs. But in my world, illness is only an abstract problem, so there’s plenty of room…

    (Incidentally: I had a much more coherent reply a moment ago, but the sumbission system ate it. This is the slightly pissed-off reproduction.)

  • tom bull

    I don’t think it is true to say medical students are no longer supposed to think but to remember. My current experience would suggest it is the reverse. The demands on us to learn long list of facts about anatomy and physiology are disappearing rapidly – the current 1st and 2nd year students at Newcastle will not see any prosected bodies during their anatomy teaching, most of which has given way to clinical reasoning.

    There is a strong emphasis now on teaching how to access and to evaluate the information you require as you require it. Certainly our final year is very much geared towards preparing us for how to acquire skills for being competent as a junior doctor and how to gradually accumulate the more advanced medical knowledge as we progress.

    From this point of view the suggestion from Iain that courses aim to make us spot an ethical issue and who to approach to discuss it would fit much better with the way the whole course is constructed at present than to try to teach detailed ethics.

  • Keith Tayler

    The main point I made in my first posting to this blog was that med. ethics courses should be more geared to getting students to spot problems in the workplace. I am not after ethcial problem solvers – I have said many times I would like to keep ethics out it for as long as possible.

    So I think we agree. Of course we disagree about how to get there, but I don’t think that is possible.

  • Dr Gubernaculum

    First, I am delighted that Tom is being taught to think. Perhaps, the students I see don’t get that luxury.
    Iain, the reason why I mentioned the need for a wee light on a helmet looking at compressed carbon, was that we need to make the content relevant and integrated and a clinician with ethics training is best suited for this. I would love medical students to have training in philosophy etc but that aint gonna happen in the same way James Taylor is not gonna be knighted.

  • brooksmory

    To provide students with positive indications to understand the ethical issues are also important, our teachers and also strengthens critical thinking about the bad practices and to provide positive support for a constructive critical reflection.