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Teaching ethics

Easter 2008

From triple helix - Easter 2008 - Teaching ethics [pp8-9]

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Key Points

Recent research into medical ethics teaching in UK medical schools concluded that although ethics is now an accepted component of the curriculum, 'more can be done to ensure that the recommended content is taught and assessed optimally'.

The author argues that 'bedside ethics' teaching alone is insufficient and a solid grounding in fundamental theory helps cultivate a professional disposition and approach that lessens the prospect of ethical problems arising in the first place.

Ethics is never morally neutral, and the views and behaviour of teachers and the culture within each medical school are highly significant influences. We should be alert to the 'hidden curriculum'.

Setting the scene

The place of ethics in the undergraduate curriculum continues to be a hot topic in UK medical schools. For many years now, few have disputed that medical students should be introduced in the classroom to the wide array of ethical issues in medicine. This early exposure provides necessary ethical foundations upon which to build during subsequent training. In an effort to provide some guidance and uniformity across the UK, a 1998 consensus statement outlined the core undergraduate curriculum for ethics and law. [1] In the intervening decade though, much has transpired – Harold Shipman, the Bristol Royal Infirmary and Alder Hey scandals, not to mention the many remarkable technological advances in medicine. Fresh, up-to-date guidance is desperately needed.

Research

Recently, two researchers from the Peninsula Medical School investigated the current situation, looking at the learning, teaching and assessment of ethics in UK medical schools, and also the training and expertise of the teachers. [2,3] Mattick and Bligh analysed completed postal questionnaires from 22 of the 28 UK medical schools, looking at answers relating to each school's approach to ethics teaching, staffing matters, and assessment. [4] Participants also described the particular strengths and weaknesses of their ethics teaching, and identified their future concerns.

Mattick and Bligh's conclusion was that, although ethics is now an accepted component of the medical curriculum, 'more can be done to ensure that the recommended content is taught and assessed optimally'. [5] Whilst agreeing with this, my own investigations lead me to conclude that several areas require further exploration.

Bedside ethics

Medical ethics teaching is designed to produce sensitive doctors who are well-equipped to recognise and resolve the ethical dilemmas they face in medical practice. [6] One lingering area of debate, however, concerns the importance of a thorough appreciation of the theoretical or philosophical base that underpins medical ethics discourse. Only half of Mattick and Bligh's respondents specified providing a conceptual or theoretical understanding of ethics as an objective of ethics teaching. [7] This is in keeping with my initial research: all too often, very little theory is covered and the level of philosophical sophistication among medical students is not consistently high. Integrating theory into clinical scenarios was found to be more popular with students, whereas formal or systematic emphasis on ethical theory and principles was generally considered to be uninspiring. [8] This raises concerns about downplaying the importance of theory. Ethical principles are giving way to 'bedside ethics'.

A basic understanding of medical theory is necessary for students to become good and capable doctors. Likewise with ethics: might not students fail to recognise ethically sensitive issues if they are placed in a clinical setting prior to being introduced to general ethical theories and principles in the classroom? [9] Moreover, a solid grounding in fundamental theory arguably helps to cultivate a professional disposition and approach that lessens the prospect of ethical problems arising in the first place. [10]

Whilst it is plainly not advantageous to have ethics teaching wholly divorced from clinical reality, some issues do require a familiarity and understanding of basic ethical principles. Can one fully appreciate the importance of obtaining informed consent from patients without rigorous exploration of the principles of autonomy and paternalism? A detailed understanding of fundamental theory therefore lies at the core of ethics education and, assuming it is given some clinical relevance by the individual teacher, any scepticism about its value seems misplaced.

Who's teaching what?

Although it may be accepted that contemporary medical ethics education should not impose a particular ethical perspective, ethics by its very nature is not a morally neutral discipline. Nor is ethics taught in a vacuum: beliefs invariably are defended and encouraged depending on one's ethical standpoint. This central issue needs careful unpacking if we are to gain an accurate understanding of medical ethics teaching in this country.

My research into the ethical standpoint of individual teachers revealed that medical ethics is being taught from a variety of different perspectives. Ethics teachers are a decidedly diverse group. [11] A wide range of attitudes and beliefs exists – utilitarian, virtue ethics, religious or otherwise. The content and approach taken to medical ethics teaching cannot fail to be influenced, however subtly, by the particular teacher's philosophical leanings. For example, the utilitarian approach embraced by Professor Julian Savulescu at the University of Oxford and Professor Jonathan Glover at King's College London lies in sharp contrast to the Aristotelian perspective of Dr June Jones at Birmingham University and the Christian approach of Dr John Lennox at Green College Oxford.

Hidden curriculum

Another area that could be investigated is the ethos or 'hidden curriculum' of each particular institution. [12] It can be argued that it is the medical school's culture and the subtle values and behaviour of its teachers that ultimately determine a student's own values and behaviour. [13] This reinforces the need to consider the ethical perspectives of individual ethics teachers, [14] and also means that any ethics curriculum must take into account the broader cultural milieu within which it exists. [15] Those who teach ethics must focus on the formation of their students' characters and the cultivation of desirable attitudes not only by teaching about virtue, but by serving as positive role models. Negative role modelling by those who lack ethical sensitivity and exhibit inappropriate behaviour is destructive and can single-handedly undermine the formal ethics training of medical students. [16] The hidden curriculum is something, therefore, that we cannot afford to ignore.

Further scope

An exploration of links with other programmes and faculties (law and philosophy for example) or of other institutions where medical ethics is being taught would have been useful, and arguably would further have enhanced the Peninsula study. [17] The University of Manchester, for example, offers a BSc in Health Care Ethics and Law, which is open to medical students who take a year out of their medical degree. Similar options are available at Imperial, Birmingham, Leeds, and Bristol to name but a few.

Non-medical institutions also offer ethics-related degrees. My own faculty, St Mary's University College, offers an MA in Bioethics, which several CMF members (including medical students) have undertaken. Middlesex University also runs an MA programme in Ethics and Law in Healthcare Practice. The Centre for Professional Ethics offers an MA and Postgraduate Diploma in Bioethics and Medical Law. These are all important pieces of the UK's ethics jigsaw puzzle, and offer scope for additional research into ethics teaching to be undertaken.

Conclusion

Mattick and Bligh's conclusion that ethics 'now has an established place within the undergraduate core curriculum' [18] may be somewhat premature. Whilst ethics undoubtedly is firmly established at the majority of medical schools – with Leeds, Birmingham and Oxford being notable models – several institutions continue to tack it on as a mere 'addendum' to the curriculum, viewing it as 'form' rather than 'substance'. The Peninsula study goes some way to isolating many of the manifold challenges facing ethics educators today. Nonetheless, much more work needs to be done before we can see the complete picture that is UK medical school ethics teaching.

References

  1. Consensus statement by teachers of medical ethics and law in UK medical schools. J Med Ethics 1998; 24:188-92
  2. Mattick K, Bligh J. Med Educ 2006; 40(4):329-32
  3. Mattick K, Bligh J. J Med Ethics 2006; 32:181-5
  4. Mattick K, Bligh J. Art cit: 182 (Table 2)
  5. Mattick K, Bligh J. Art cit: 181
  6. The most recent BMA handbook contains a comprehensive list of objectives of ethics teaching: British Medical Association. Medical Ethics Today. London: BMJ Publishing Group, 2004:653
  7. Mattick K, Bligh J. Art cit: 182
  8. Mattick K, Bligh J. Art cit: 183
  9. Hundert EM. Am J Psych 1987; 144:839-46
  10. Barnard D. Arch Intern Med 1988; 148:1836-8 Cf. Cowley C. J Med Ethics 2005; 31:739-42
  11. Mattick K, Bligh J. Art cit: 183
  12. Hafferty FW. Acad Med 1998; 73:403-7
  13. Hafferty FW, Franks R. Acad Med 1994; 69(11):861-71
  14. Anne Maclean argues that teaching utilitarian theory can actually be detrimental to students in a corrupting sense. Maclean A. The Elimination of Morality: Reflections on Utilitarianism and Bioethics. London: Routledge, 1993
  15. Hafferty FW, Franks R. Art cit: 861
  16. Singer P et al. BMC Medical Ethics 2001; 2:1
  17. Mattick K, Bligh J. Art cit: 182, table 2 (questions 15 and 16)
  18. Mattick K, Bligh J. Art cit: 185


Article written by Wendy Hiscox

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