Bioethics Education: I. Medicine

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I. MEDICINE

Education in medical ethics is as old as medical education itself. The Hippocratic school of medicine of fourth-century B.C.E. Greece is best remembered for the Hippocratic oath, which has provided moral guidance to students of medicine for more than two millennia.

For most of medicine's history, efforts to inculcate ethical precepts relied on the apprenticeship model, through which medical students were guided in the simultaneous development of their knowledge, technical skill and judgment, and evolving sense of proper professional conduct (Bosk). Direct observation and emulation were the primary methods apprentices used to develop clinical judgment regarding right action.

In the second half of the twentieth century, however, the emerging field of biomedical ethics catalyzed a radical reexamination of the ways in which students learn to understand and manage ethical issues that arise in professional medical practice. Initially, this effort was led by nonphysician humanists—philosophers, theologians, and others—who developed interests in applied ethics and the medical humanities. In the early 1970s, medical schools, led by Penn State University, hired these humanists and began to offer first elective, then required, ethics courses for medical students. Rather than concentrating on the importance of mentorship and role modeling, these courses were rooted in a philosophical model, stressing ethical concepts such as autonomy and the importance of learning to apply ethical principles to discern the proper course of action. Lectures and seminars became the dominant method used to teach these cognitive skills. Unfortunately, with rare exceptions, the content of ethics training, particularly in the clinical years, has been either on the extreme ends of life or on technological innovations rather than on the day-to-day work of doctoring or justice-based concerns. Starting in the late 1990s, the difference in goals and methods between an apprenticeship model and a philosophical model of teaching medical ethics began to blur as programs focusing on professionalism arose. These programs concentrate more on physician character and offer the opportunity for medical ethics to focus more on the mundane ethical issues of doctoring.

The Growth of Medical Ethics Education

A series of empirical studies in the 1970s and 1980s documented the rapid growth of teaching programs. In a 1974 survey, 97 of 107 responding medical schools reported teaching medical ethics (Veatch and Solitto). Only six of these schools, however, reported a required exposure to medical ethics. In 1982 a majority of physicians reported that they had never received formal education in clinical ethics, and many felt inadequately prepared for common ethical problems in medicine (Pellegrino et al.). A 1985 study found that 84 percent of U.S. medical schools had some form of human values curricula during the first two years (Bickel). By 1989, 43 of 127 U.S. medical schools reported separate required courses in medical ethics (Miles et al.). In 2000, of the 125 American medical schools, 46 reported separate, required courses in medical ethics, 104 taught medical ethics as part of a required course, and 44 had separate electives in medical ethics; the numbers for teaching in medical humanities were 8, 87, and 51, respectively. The 2002 Association of American Medical Colleges (AAMC) graduation survey found that between 70 and 80 percent of students felt they had received adequate training in medical ethics.

It was not until the latter part of the 1980s that educators began to advocate explicit teaching in medical ethics during residency training. This is a critical formative period, because it is during their residency that physicians first acquire decision-making responsibilities, and thus can fully appreciate the relevance of medical ethics to patient care. In 1984 researchers found that residents in 40 percent of internal medicine residencies had no formal exposure to clinical ethics teaching (Povar and Keith). Two reports by the American Board of Internal Medicine and American Board of Pediatrics in the 1980s provided strong impetus to the development of teaching programs during the residency years. Since then, a growing number of other boards have issued recommendations regarding the teaching of medical ethics during residency. Moreover, residency requirements in medicine, surgery, pediatrics, and obstetrics-gynecology all require education in medical ethics, and the 2003 description of general competencies promulgated by the Accreditation Council for Graduate Medical Education (ACGME) requires that all residents "demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices" (ACGME website).

There was a long tradition of teaching medical deontology (study of moral obligation) in both Europe and Latin America, particularly in Catholic medical schools. But the 1980s saw in these countries, as in North America, a steady expansion of the number and scope of medical ethics programs. In Great Britain, the General Medical Council created a committee in 1984 to study the teaching of medical ethics in British medical schools and make recommendations. The resulting 1987 "Pond Report" recommended that the teaching of medical ethics be encouraged in medical school, but no specific guidelines were advocated (Institute of Medical Ethics). While initially little progress was made, a later study found that most medical schools included ethics education (Goldie).

A 1991 study in Canada found that fifteen of the sixteen Canadian medical schools provided medical ethics education and some sort of examination, with the number of required hours ranging from 10.5 to 45 (Baylis and Downie). Almost all of the schools used physicians as instructors and focused on specific ethical issues (e.g., euthanasia), as opposed to ethical theory or professional codes of ethics. The College of Family Physicians of Canada and the Royal College of Physician and Surgeons of Canada require ethics training, and there is increasing interest in continuing education in bioethics (McKneally and Singer).

In numerous other countries, medical schools have developed curricula in medical ethics. At Lagos University in Nigeria, two-day workshops were initiated in 1982 for fourth-year students, at which lawyers, doctors, and patients all participated in lectures and discussions of issues in medical ethics (Olukoya). In Australia, medical graduates are required to understand basic medical ethics principles, and in the early 2000s educators promulgated a core curriculum (Working Group).

During this period of rapid growth in formal medical ethics education, a wide variety of activities were subsumed under the general heading of "ethics programs." There was great variability in the establishment of explicit curricular goals, the identification and support of teaching faculty, the teaching methods that were employed, and the attempts (if any) at evaluation of educational success. Although a degree of consensus evolved for some areas, important areas of controversy remain.

Goals

Ambitious and diverse goals have been proposed for medical ethics education, including increased awareness of ethical issues; a cultivation of basic ethical commitments; more humane medical practice; tolerance of conflicting views; development of analytic skill in moral reasoning; enhanced intellectual development in ethics and the humanities; positive attitudes toward patients; less paternalism in clinical practice; higher professional conduct; and improved clinical decision making (Callahan; Miles et al.).

Despite this dauntingly heterogeneous list, a consensus has developed regarding some core objectives. First, the primary goal of clinical ethics education is to prepare physicians to deal effectively with ethical issues in clinical practice. Accomplishing this requires that students learn to:(1) recognize ethical issues as they arise in clinical care and identify hidden values and unacknowledged conflicts; (2) think clearly and critically about ethical issues in ways that lead to an ethically justifiable course of action; and (3) apply the practical skills needed to implement an ethically justifiable course of action. Each of these objectives in turn requires that the students possess specific knowledge, attitudes, and skills.

To recognize ethical issues as they appear in clinical care usually requires a positive attitude concerning the importance of the humanistic and value-laden aspects of medical care. For example, a physician's decision regarding chemotherapy for a woman with breast cancer involves the physician's awareness of the biomedical issues and of the morbidity and mortality of the disease, as well as of the patient's own views regarding continued life, her body image, and the morbidity of treatment. Recognizing the presence of an ethical issue also requires knowledge of the nature of common ethical issues and how they arise in clinical practice.

Finally, proficiency in recognizing these issues requires students to learn certain behaviors. Highly motivated students who understand the importance of autonomy and recognize the ways in which patients' values are frequently ignored or overridden will still have difficulty incorporating respect for autonomy into care unless they become skilled in eliciting their patients' personal values, concerns, and goals.

A general consensus was also developed in the 1980s regarding most of the core content areas for medical ethics education. In the 1985 report of the DeCamp Conference (Culver et al.), leading physicians and ethicists proposed "basic curricular goals in medical ethics, " stressing knowledge and ability as the primary targets of medical ethics education in medical schools. Among the seven items in the "minimal basic curriculum" are the ability to obtain a valid consent to treatment or a valid refusal of treatment, knowledge of how to proceed if a patient refuses treatment, and knowledge of the moral aspects of the care of patients with a poor prognosis, including patients who are terminally ill. Notably absent from this "core list, " because of a lack of consensus, were issues related to financial aspects of medical care (including distributive justice and access to healthcare), doctor's societal obligations, and questions related to abortion. Interestingly, the U.K. and Australian consensus statements on core curricula are much broader and include both issues of resource distribution and physicians' role in society in their purview. (Whether this influences what is taught is unknown.) Building on these earlier reports, subsequent teaching programs increasingly stressed the importance of ensuring that educational goals are appropriate to students' specific level of training and future career choices. Courses for first- and second-year medical students, who have limited clinical experience, generally focused on developing an awareness of the complex moral issues that arise in contemporary medicine and on developing skill in moral reasoning. In contrast, teaching programs for physicians in subspecialty residency programs tended to focus on the specific issues that those physicians were already encountering in their fields of practice and the specific knowledge, attitudes, and skills needed to address those problems.

Attempts to teach medical ethics through "professionalism" began in the late 1990s. Professional organizations, such as the American Board of Internal Medicine and the ACGME, define professionalism in terms of virtues such as altruism, respect for others, honor, integrity, accountability, competence, and duty/advocacy. These statements typically stress physicians' public role in promoting health in terms of quality and access as much as they stress individual patient care (ABIM Foundation). Interesting the 2001 AAMC graduate medical student survey assessed professionalism separately from medical ethics, reflecting some confusion between the two content areas.

Methods

Given the diverse objectives of ethics education, it is no surprise that a variety of methods have been developed to help students develop the knowledge, attitudes, and skills needed to become proficient in dealing with ethical issues in clinical practice. Teaching methods have ranged from large group lectures providing conceptual and historical overviews of issues in medical ethics, to seminar room discussions of "paper cases, " to participation in discussions of actual cases encountered during clinical rotations, to participation in ethics consultation programs, with each of these supplemented by readings and in some cases videotapes or films. During the clinical years and the years of residency training, there has been a slow but steady increase in the use of practical teaching exercises, with an emphasis on the communication skills deemed necessary for the identification and resolution of ethical problems. Achieving a thorough conceptual understanding of the doctrine of informed consent, for example, is increasingly understood to be of limited value if physicians are not able to explain information clearly to patients. More recently, end-of-life ethics education has been highlighted through the growth of palliative care education, both at the medical school level and during residency (EPERC).

By the early 1990s, there was widespread agreement that in almost all settings instruction should be primarily case-based, because using real or detailed hypothetical cases emphasizes the difference that clinical ethics can make in actual patient care. Moreover, there is some empirical literature supporting the use of case-or problem-based education in promoting students' knowledge of professional judgments regarding ethical issues. In addition, case discussions allow for integrating moral reasoning with the other tasks of patient care.

Some educators, however, have raised concerns about overreliance on the use of the case method in teaching medical ethics (Barnard; Kass). Case discussions typically emphasize problem solving and ethical dilemmas, and they may ignore essential issues of clinical ethics, such as what constitutes informed consent in routine office care. Critics point out that cases typically deal with either the beginning or end of life or an exotic use of technology. Issues of daily practice or resource allocation are typically ignored. In addition, by concentrating on what should be done in a specific case, participants often ignore the institutional or interpersonal factors that may have led to the problem.

Analyzing the institutional factors that lead to family– physician conflict or how to treat families more respectfully in the intensive care unit may be more important in improving ethical care than teaching house staff about when it is ethically justifiable to override surrogate decision makers (Goold; Levine and Zuckerman, 1999, 2000). Institutional factors play an important and frequently overlooked role in influencing ethical decisions and behavior; discussion of institutional reforms may constitute an essential part of medical ethics education. Finally, while the cases presented often raise intellectually interesting ethical dilemmas, in practice, ethical conflicts are often attributable to communication problems.

In general, mirroring debates in moral philosophy, considerable disagreement remains about the importance of theory to ethical analysis. Tom L. Beauchamp and James F. Childress, authors of one of the most widely used texts in medical schools, emphasize the important role of the principles of respect for autonomy, nonmaleficence, beneficence, and justice, both as a framework for identifying moral issues and as a structure for moral justification. Others, such as K. Danner Clouser, argue against a primary stress on principles, for both theoretical and pedagogical reasons. In addition to intellectual concerns about the nature of proper moral justification, Clouser and others stress the importance of training students to attend to the highly specific biotechnical, psychological, and social complexities of individual cases in their moral reasoning, reporting that through a series of case discussions, students often arrive inductively at general precepts that they can then apply to other cases.

For different reasons, feminist theorists, virtue theorists, and casuists also have argued for less emphasis on theoretical principles. Rather than viewing cases as ways to illustrate principles, for example, casuists argue that they are the primary locus of moral meaning (Arras). Rather than using short, theoretically driven hypothetical cases, casuists encourage the use of real cases that illustrate the complexities and uncertainties of clinical practice. John D. Arras stated that these cases "display the sort of moral complexities and untidiness that demand the (nondeductive) weighing and balancing of competing moral considerations and the casuistical virtues of discernment and practical judgment (phronesis )" (p. 32). Feminists have argued for greater attention to social, economic, and political factors and their effect on the nature and dynamics of healthcare (Sherwin). Finally, according to Alisa L. Carse, virtue theorists and feminist theorists suggest that bioethical discussions should address questions such as 'What kind of person ought I be?' and 'What traits and capacities ought I to develop?' In an attempt to enhance students' moral imagination and empathy, and to stress the narrative aspects of medical ethics, educators include literature and film in teaching bioethics. These resources force students to critically reflect on the larger context and meaning of their work and, according to William T. Branch, to "conceptualize and generalize their behavioral changes into their mental structure of knowledge, skills and values" (p. 505).

Technological innovations also have spawned new approaches to teaching medical ethics. Computers and the Internet allow, for instance, attempts to combine ethics education with communication skills (an example is the MedEthEx Online website). Interactive DVDs dealing with difficult issues force the learner to confront challenges to their position in a structured manner. Telemedicine allows students at distant sites to interact in real time with faculty trained in medical ethics.

Most programs have adopted eclectic approaches to teaching medical ethics. In the preclinical years, a combination of lecture and small group case-based discussions predominate. Film and short stories are often used to promote self-reflection and discussion. In the clinical years, ethics education is usually structured as case-based small group discussions. Communication skills are often integrated with ethics education, and the focus of the discussion is practice-based.

The different programs, unfortunately, have some common limitations. First, as noted above, until very recently, the day-to-day life and behavior of physicians received little attention. The curricula are designed by faculty who are often unaware of the issues that students actually confront. (Student-run programs have focused more attention on issues that students are concerned about, such as "abuse" or being asked to violate their personal conscience.) Similarly, issues that are not directly applicable to patient care are discussed less frequently. Thus, for example, the medicalpharmaceutical-industrial complex and the ethical issues that it poses to both physicians and patients gets short shrift. Second, mirroring the lack of work in philosophy of medicine, there is little discussion of what it means to be a doctor in today's society. Third, the programs are, in general, cognitively physician-focused. Thus, despite the (re)inclusion of the humanities that has been taking place, students' ability to be empathic or to think creatively about ethical options may not be challenged. Attempts to integrate ethics, the humanities, and the social sciences in medical education may help with this situation.

Faculty and Program Development

As in other areas of medical education, the evolution of teaching in medical ethics has been heavily shaped by the availability (or, for many programs, the scarcity) of qualified faculty. Throughout the 1970s and early 1980s, a central debate involved the question of whether medical ethics teaching should be done primarily by physicians or by those trained in the humanities, such as philosophy or religious studies. Mark Siegler, for example, stressed the ways in which the knowledge and professional experience of clinicians was central to an understanding of the true complexities and realities of clinical-ethical problems and their possible solutions. He therefore urged that primary teaching responsibility should lie with the physician-ethicist. Respected clinical teachers who emphasize the importance of medical ethics can be important role models who can help shape students' ethical sensibilities. On the other hand, strong reasons for using nonphysicians to teach medical ethics have been offered. First, many important aspects of the identification, analysis, and resolution of ethical problems in medicine do not fall within a physician's own specialized training or expertise, but depend instead on the intellectual background and analytic skills of individuals trained in other disciplines. Second, involving nonphysicians in teaching medical ethics can help sensitize students to the importance of other viewpoints and improve physicians' ability to communicate with nonphysicians—two primary educational goals. This controversy regarding who should teach has largely been replaced by a consensus that a variety of disciplines have important and distinct contributions to make.

The limited number of trained faculty, more than disputes regarding the academic background of those faculty, restricted the growth of ethics education. Many programs depended on faculty who, despite an interest in medical ethics, had little formal background in the field. Over time, this problem has abated as the number of faculty with prior training in ethics has increased. Moreover, in part to address this shortcoming, both short courses and longer master's programs in medical ethics have been developed around the world. The growth of healthcare providers with graduate training in ethics reflects the degree to which medical ethics has become integrated in the culture of medical education.

In their attempts to develop ethics curricula, medical ethics faculty have encountered a number of other barriers, including financial and time constraints, students' attitudes toward medical ethics, and the lack of reinforcement by other faculty (Strong, Connelly, and Forrow). Ethics teaching programs occupy a tenuous position in most medical schools. Although the inclusion of ethics test questions in certifying exams has improved this situation a bit, ethics training is rarely viewed as central to the education of physicians in the way that the "basic sciences" and traditional biotechnical clinical training are.

Economic constraints are a limiting factor in ethics education. Ethics education, conducted in small groups, is very faculty intensive. Moreover, at the same time that ethics has become integrated into medical schools, funding for teaching programs has decreased. This has happened during a period in which physicians are under increasing pressure to generate income. Thus, trained faculties' availability for teaching may again become a rate-limiting factor in ethics education.

Evaluation

Evaluation, both of teaching programs themselves and of individual students, is still in flux. Most formal courses have included a pass–fail grading system based on class participation and written exercises, usually either papers or in-class essay examinations. These efforts convey to students the importance of medical ethics in the medical school (as has the addition of questions to the national boards and many of the specialty boards).

Efforts to develop formal and valid evaluation techniques have remained hampered, however, by uncertainty about what specific teaching goals are most important, about how best to measure whether any of those goals have in fact been accomplished, and about what is realistic to expect from ethics courses. (Similar constraints plague efforts to teach professionalism [Arnold].) Underlying the challenge of evaluating the impact of teaching medical ethics is a deeper debate regarding what teaching ethics does. Ethics as an academic discipline can be taught; one can evaluate a student's knowledge of ethical concepts and cognitive skills. Philosophers in undergraduate ethics courses have done this for centuries. Most attempts at evaluation in medical school have tried to measure this aspect of the ethics curriculum using essay or short-answer tests.

In arguing for the importance of formal ethics education, teachers of medical ethics typically have emphasized more ambitious goals, such as improving students' ability to address ethical issues in clinical practice or promoting humanistic qualities such as integrity. Efforts at evaluation, however, have not always distinguished among residents' attitudes, knowledge, or behavior. Moreover, there are numerous methodological problems, particularly in evaluating ethical behavior or character, problems that are compounded if one tries to determine whether improvements are attributable to formal ethics teaching. Some faculty involved in ethics programs question whether stricter standards of evaluation should be required of their curricula, arguing that courses in the traditional areas of anatomy, biochemistry, and physiology have rarely, if ever, been required to prove their ultimate effectiveness.

Attempts to develop innovative methods of evaluation have included measuring students' moral reasoning, evaluating students' behavior by nonphysicians (such as nurses or patients), and using formal tools such as the Objective Standardized Clinical Examination. These exercises have attempted to move beyond merely evaluating cognitive skills to analyzing students' actual behavior. Although these efforts show a great deal of promise as formative educational tools, few schools use these tools as summative evaluation methods. Limitations in their psychometric properties and the large number of raters needed for reliable ratings have limited their general use.

Conclusion

While formal teaching programs in medical ethics were practically nonexistent in 1970, by the early 1990s there was extraordinary diversity both in the United States and elsewhere in formal teaching activities from the undergraduate to the postgraduate level. Bioethics education in the early twenty-first century is an accepted part of education for students in almost all medical schools and for residents in many programs.

Nevertheless, despite this growth and an evolving consensus that began in the 1980s regarding some core goals and teaching methods, many questions remain only partially answered. What should the primary goals of such teaching be—analytic ability, behavioral skills, or actual practice? What is the relationship between professionalism and medical ethics? How should those goals vary according to the developmental stage of the health professional and according to the person's specific field of practice within medicine? How can (or should) the attention on ethical attention be expanded beyond conflicts at the beginning and end of life to the day-to-day activities of doctoring? Who are the most appropriate faculty members to lead teaching efforts in various settings? What teaching methods are most effective and efficient in accomplishing curricular goals in each of the various settings? Finally, what is the proper role of formal evaluation efforts, both of individual students and of overall teaching programs? What methods of evaluation are both valid and feasible?

The difficulty in finding answers to these questions ensures that designing and implementing effective medical ethics education will remain challenging well into the twenty-first century.

robert m. arnold

lachlan forrow (1995)

revised by authors

SEE ALSO: Casuistry; Conscience, Rights of; Literature and Bioethics; Medical Ethics, History of; Medicine, Anthropology of; Narrative; Nursing, Profession of; Professionalism and Professional Ethics and other Bioethics Education subentries

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