Very well, then: let’s allow that the quality of argument in bioethics – and clinical ethics in particular – is not of high quality. What should be done about it?
That’s a hard question, though it’s predictable and wholly justifiable that it should be asked. And, to be honest, I don’t know offhand. I might have a few germs of ideas, but nothing that I’d be prepared to mention in public. That doesn’t mean that I can’t look at other ideas, and test them out. One such idea is mooted in this paper by Merrick et al: in essence, they propose a sort of debating competition. They begin by explaining – with some plausibility – some of the factors that make it a bit hard to get full-blooded engagement with ethics in the medical curriculum:
As educators, we have observed additional challenges medical students face in their ethics education, which echo others’ experiences. First, because of the prodigious amount of information medical students are presented with during their first two years of training, they typically adopt a strategy of selectively reading assignments, attending large lectures, and participating in small group discussions. In this context, ethics appears to be deprioritized, because, from the students’ perspective, it is both more demanding and less rewarding than other subjects. Unlike other subjects, ethics requires students to reflect on their personal moral sensibilities in addition to understanding theory and becoming familiar with key topics and cases. Yet, also unlike other courses, poor marks in ethics rarely cause academic failure, given the way performance in medical school curricula is typically evaluated. Thus, ethics is both more demanding—because of the burdens of self-reflection—and less rewarding—because excellence in ethics does not contribute significantly to grades or test scores.
Second, medical students face challenges in how they individually conceptualize the value of ethics in the medical context. Although many indicate that morality is important to them, they also suggest that it is a subject matter that relates to their personal, as opposed to professional, actions. Instead, students often conflate the domains of institutional policy and health law (especially risk management and malpractice litigation) with medical ethics. Although these domains are obviously also of essential concern for future physicians, they remain distinguishable from ethical issues likely to emerge in practice. Consequently, rigorous and effective ethics education within the medical school context faces the challenge of distinguishing ethics from other aspects of professionalism.
Too often, ethics gets run alongside communication skills training (well, it’s all about getting informed consent, isn’t it? Eh? Eh?); and I’ve lost count of the number of times I’ve been asked to prepare multiple choice questions for ethics assessment. (Standard answer: nope. It’s got to be an essay of some sort, or it’s not worth doing.)
So what to do? The paper, as I’ve already said, suggests a quasi-competitive debating competition, in which teams of students are given a problem, and a limited time to make a case in response to that problem. An opposing team then has a limited amount of time to place a counterargument. Then they swap roles, so the counterarguing team gets to make the argument, and the previous arguers now become counter-arguers. Judges can ask questions, and assign a score. “The basic aim of the MEB curriculum,” the authors say,
is to help students learn how to produce and present an argument for an ethical position in response to a realistic clinical situation.
Hmmmmm.
Every now and again I get asked to help judge debating competitions – sometimes for academic institutions, sometimes for non-University bodies, sometimes for others (*cough* Instituteofideas *cough*). I used to be happy to help out. But I’m not so sure now.
Basically, the problem is this: that the model for debating contests is, presumably, based around the idea that debate is an effective way to whittle bad ideas away from good; if each participant is a doughty falsificationist, and equally able in debate as his opponent, then at the end of a process of debate, we’ll be closer to the truth of the matter than we were at the start. So far, so good. But there’s a handful of fairly obvious problems with that model. First, that doesn’t lend itself to the idea that there is a winner and a loser in any particular debate. Second, a shoddy argument presented by a good speaker might win a competitive debate over a good argument presented by a diffident speaker. We might hope that a competent judge would account for that, but it’d be better if there wasn’t any need to solve what looks to be a structural problem to begin with. Third – which is related, but probably more importantly when it comes to ethics – someone with a good understanding of the moral arguments and who is a decent orator might stand a fair chance of winning an argument; but it doesn’t follow that a good orator who’s won an argument has any particular understanding of the moral arguments. Debating contests reward people for being good at debate; but that’s presumably not the true end of ethics education. Fourth, this kind of strategy is possibly OK in politics, in which the point of oratory is to persuade people to adopt a certain cause; and so debating competitions might provide training for that. (I suspect that that’s something like the rationale behind things like the IofI’s competition in schools: it’s directed at developing a certain set of skills, with one eye on a vivacious public debate. Whatever my private suspicions of the IofI generally, that doesn’t seem like a bad idea.) But ethical debate is qualitatively different. It isn’t really about winning converts. Or, at least: one might hope that a convincing argument would have moral gravity and attract agreement, but the mood of the thing is different.
When it comes to putting ethics into the curriculum, too, debating contests represent a strange way to go about things. That they’re contests is one of the strangenesses: I can imagine that there might be competitive anatomy of pharmacology quizzes, but they wouldn’t be – would they? – curricular. What’d really matter is that every student knew their way around the body and the chemistry set; any competitive element would be for the pub after the exam. Yet this is being touted as a curricular activity, which is a bit odd. OK, it gives an incentive to do well… but if someone needs to be incentivised to think about moral problems in a complex way, something’s gone quite awry (though possibly it’s gone awry long before the first day of medical school).
My bigger concern, though, is with the very idea of a debating contest, and it’s a concern that is related to the third point I made a moment ago.
I’ve met some superb debators who could argue compellingly that black’s blue if that’s what you asked of them; and if you interrupted and asked them to present the exact opposite case, they’d be able to do that without pausing for breath. These people are all excellent speakers – and excellent contrarians. If I told my competitive debater students that Thursday is the day after Wednesday, they’d doubtless be able to construct a highly appealing rebuttal. (None of this is directed against any of my debate-competitor students. They’ve been academically excellent, and excellent debaters as well. Still, we can’t deduce from that that their academic excellence is attributable to the skills developed by competitive debate. It might be that the kind of background that makes you a good debater is also going to set you up well for academic success. That’s for another day.)
What’s nagging away at the back of my mind is the sense that there’s nothing much riding on the outcome of a debate qua staged event. You don’t have to care at all for the position for which you’re arguing; it might be better if you don’t, especially if the terms of the thing are that you’re assigned a position from which to argue. (Is euthanasia permissible? Here’s what I want you to think: now go and think it!) You certainly are at a disadvantage if you spend a lot of time wondering whether a proposition is true; all that matters is whether the motion is winnable. For another, ethics is rather like natural science inasmuch as that you start with a hypothesis, then work out how to test and demonstrate the truth of that hypothesis… and (vital, this) might be surprised by how the argument actually turns out. Just as a bench scientist might have an intuition that the common cold is caused by a bacterium, set out to show it, and be forced to accept the surprising conclusion that it isn’t, so the ethicist might find herself in a similar position. And in the ethics case and the natural science case, “I don’t know, and here are some interesting reasons why it’s a hard problem” is a valuable contribution. A debater, by contrast, requires certainty, or at least the illusion thereof.
Third, it’s not always possible to do the kind of conceptual analysis that ethics requires in a formalised competitive debate. What does a word like “dignity” or “professionalism” or “compassion” or whatever mean? You can argue for a motion that respect for dignity requires this or that, but that won’t really get to the core of what the word actually does in debate.
Upshot: a debating competition is a potentially interesting way to get ethics into the curriculum, and to get students to take it seriously. But it might also just mean that students end up doing ethics-like things.
You now have seven minutes to articulate the opposite position, and then someone will judge which of us is correct.