18 Dec, 09 | by Iain Brassington
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?