Can Ethical Behavior Be Taught?
Medical schools know how to teach anatomy, among many other subjects, and accurately assess their students’ knowledge of the subject. The same cannot be said of ethics, although there has been widespread agreement about the importance of ethics education since at least 1985. That’s when the Liaison Committee on Medical Education (LCME), jointly sponsored by the Association of American Medical Colleges and the American Medical Association, established standards requiring that “ethical, behavioral, and socioeconomic subjects pertinent to medicine” be taught in medical programs across the United States.
The new requirement sparked an explosion in medical ethics education, but when the dust cleared, researchers found a startling amount of variation among the programs created. By 2000, 79% of U.S. medical schools required students to take a formal ethics course, but those courses involved 10 different course objectives, eight different teaching methods, thirty-nine different content areas, and six different methods of assessing students. Five years later, in 2005, a comprehensive literature search found the situation unchanged. Medical ethics instruction was almost universal, but there was little agreement about the content, monitoring or quality of what was taught.
Today, more than 30 years after the LCME requirement was instituted, questions remain about the best way to prepare fledgling physicians for the ethi- cal challenges they will face in practice.
QUESTION 1: Which issues do physicians need to consider?
The topics addressed in ethics classes tend to follow the headline issues—right to life, right to die, designer babies. Questions about genetic testing, infertility treatment, end-of-life care, organ transplants and patients’ rights abound. But researchers have found a mismatch between the kinds of ethical questions that make the news and the ones physicians have to grapple with on a daily basis. According to a 2016 AAMC News article, “While the bioethicists identified assisted reproductive technology and preconception genetic testing as priorities in the education of bioethics trainees, the clinicians pointed to abortion, childbirth, contraception, infectious diseases, and sexuality as the areas that most frequently generated ethical questions.”
PBI Education faculty member Catherine Caldicott, MD, has studied and taught medical ethics for more than 15 years. She says it’s the everyday issues that tend to cause problems for physicians. “Most of the ethical violations we see among students at PBI are for things like inappropriate relationships with patients, cloning notes, financial improprieties, falsifying CVs and con- trolled substance diversion,” she said.
Caldicott’s experience is supported by nationwide research. Every five years, the Ethics and Boundary Assessment Services (EBAS), combs through board orders around the country to identify the key ethical issues confronting physicians. The latest survey identified five areas of concern:
KEY ETHICAL ISSUES NOW BEFORE BOARDS
• Boundary Violations — including inappropriate relationships with patients and staff, as well as verbal and non-verbal harassment
• Fraud — everything from fraudulent billing and coding to falsification or alteration of documents
• Professional Standards — quality assurance issues; negligent performance of duties; safety concerns; improper diagnoses and/or treatments; improper client/patient management; and improper records and documentation
• Substance Abuse — drug and alcohol misconduct or violations
• Unprofessional Conduct — inappropriate behavior; prescription forgery; aiding and abetting unlicensed activity; practicing with revoked/suspended license
QUESTION 2: How do you tie classroom discussions to actual experience?
Ethical questions tend to be messy. Real patients have complicated lives, emotions and relatives that often defy neat textbook answers. To help students learn to deal effectively with such complexities, medical schools try to bring “real-world” issues into the classroom, where students can safely work through them. The closer to reality, the better. The most common approach is to present written scenarios, but some programs also employ actors or use videos to heighten the authenticity of the situation.
Ideally, this approach should carry through to residents’ work with actual patients, suggests Mildred Solomon, EdD, president of The Hastings Center in New York and director of a fellowship in medical ethics at Harvard Medical School. “Create continuing opportunities for residents to bring real-life cases into the classroom and to talk about moments when they were not sure about what the right thing was to do,” she advises.
“It is hard for residents to talk about what is distressing them, but it’s important for them to know that their mentors are open to hearing about moral distress and uncertainty.” It’s sound advice, not often followed, which leads to the next question.
QUESTION 3: Do students learn what they are taught in the classroom or what they see in practice?
It’s one thing to bring ethical questions back to the classroom. It’s quite another to bring what students learn in the classroom out into their work with patients. In her previous work teaching third- year medical students, Caldicott learned first-hand about the so-called “hidden agenda.” After working with attendings seeing patients, she said, “These students would come into ethics class and say, ‘You can tell us what the right thing to do is till you’re blue in the face. We’re going to behave the way our attendings tell us to behave. And what they were being told was very different from what they were being taught in classroom.”
QUESTION 4: How do you teach someone to be ethical?
The goal of ethics education is not to teach students how to be ethical human beings—that’s some- thing “typically instilled well before an individual reaches medical school,” note the authors of the 2009 article,“Time for a unified approach to medical ethics.” What ethics courses try to teach are decision-making skills—how to think through ethically challenging situations and make the right choice.
Published guidelines offer some help, of course, and most hospitals now have bioethicists on staff to provide even more. But such supports are intended primarily for those big issues, not the everyday challenges physicians face. What students need to learn is how to reach ethical decisions on their own and act accordingly.
The widely accepted Four Component Model, developed in 1983 by psychologist James Rest, suggests the best way to ensure such an outcome is to encourage the development of four essential abilities—ethical sensitivity, reasoning and judgment, motivation, and commitment. Research has shown that students can improve their grasp of the first three and that teachers can accurately assess their progress using established tests. The fourth element, commitment, raises an additional thorny question.
THE FOUR COMPONENTS OF ETHICAL DECISION MAKING
1. Ethical Sensitivity is the ability to recognize when a situation involves an ethical decision. You can’t re- solve a challenge if you don’t know it exists, said Caldicott, adding, “There are lots of people in medicine and other professions who are pretty ethically tone deaf.” Significantly, people from one culture can be insensitive to ethical issues in another—a growing problem in our multi-cultural society.
2. Ethical Reasoning and Judgment enables individuals to sort through potential actions and choose the best option. There are numer- ous ways to go about this. You might base your reasoning on fundamental principles, like autonomy, justice, beneficence and non-maleficence. Or you might think about rights and responsibilities as defined by a professional code. Some ethicists argue for a blend of the two. The best way to sharpen this ability is by talking with peers about options and decision-making criteria, the dominant approach to teaching ethics in the classroom.
3. Ethical Motivation is where things start to get tough. You’ve decided what you should do, but now you have weigh your decision against other values and priorities. Are you as motivated to do the right thing as you are to keep your job? You know you should tell patients about a mistake you made, but other concerns—fear of lawsuits, disciplinary action or the demands of superiors—may interfere. Only those with a strong professional identity, who have internalized the values of their profession, are likely to make the ethical choice, says noted ethicist Muriel Bebeau.
4. Ethical Commitment is actually doing what you’ve decided to do, and so far at least, no one has found a way to teach such moral back- bone in the classroom or assess it on a test. “Lots of students say, ‘I’ve seen unethical behavior and I would never do that.’ But they don’t really know until they face the situation,” said Caldicott. “You may do well on test, but in real life, in real time, when someone presses your buttons, or something hap- pens in your blind spot and you lack awareness, that’s where the problems occur,” she explained.