How can we know that ethics education produces ethical doctors?

Abstract

This article examines the challenges that medical ethics education faces, given its aim of producing ethical doctors. Starting with an account of the ethical doctor, it then inquires into the key areas of medical students’ ethical development, viz. knowledge, habituation and action, and describes more specific outcomes in these areas. Methods of teaching aimed at achieving specific outcomes are also discussed. The authors then turn to some difficulties that stand in the way of achieving the desired outcomes of medical ethics education, and survey what has been achieved so far, by considering a number of studies that have evaluated the efficacy of a range of medical ethics courses. The article concludes by suggesting that medical ethics education should give attention to the problems of evaluation of ethics curricula as the discipline comes of age.

Practice points

• The aim of medical education is to develop doctors who are reflective, empathetic, trustworthy, committed to patient welfare and able to deal with complexity and uncertainty.

• Medical ethics should be multidisciplinary and multi-professional, academically rigorous, grounded in research, and fully integrated into the medical curriculum.

• Attention to evaluating ethics education is increasing, but there is a paucity of evidence regarding the effectiveness of medical ethics courses, and there are numerous problems in assessment design.

• The challenge of training ethical doctors lies in a rigorous evaluation of medical ethics teaching based on clearly defined outcomes and valid assessment methods.

Notes

Notes

[1] Dr Hawthorn was Chair of the Medical Ethics Committee of the British Medical Association between the world wars.

[2] Miller (1990) first proposed a pyramid of learning focused on increasing professional authenticity. See also Shumway & Harden (2003) for a detailed representation of assessment of learning outcomes for physicians.

[3] Rest's defining issues test (DIT) is a self-administered test in which subjects are presented with short vignettes or dilemmas and asked to select their answers on a multiple-choice basis. For a discussion of the DIT and its application, see Rest et al. (1999).

[4] Self et al. (1992) remarked that the appropriateness of the evaluation approach that had been used in assessing the teaching of medical ethics hinged upon two premises: the first is a distinction between teaching moral values and teaching moral reasoning about values; the second ‘involves accepting the… claim that the appropriate function of teaching medical ethics in our modern pluralistic society is to improve students’ moral reasoning about value issues regardless of what their particular set of moral values happens to be. … Accepting these premises is to hold that ethics is basically a principled or rule-governed approach to rational decision-making about value issues. Not everyone accepts this position’. However, it is unclear that an acceptance of the two premises requires accepting the idea of principlism, or the claim made by Self and her colleagues that ‘(m)edical ethics is a principle-based approach to rational decision-making’. But, ending on a judicious note, Self et al. advocate that ‘alternative methods of teaching medical ethics need to be compared and contrasted in order to identify the most effective and efficient approaches.’ In our opinion, the study does indeed make ‘an important beginning in demonstrating that sound empirical assessment can be carried out on the effectiveness of teaching medical ethics’.

[5] Harold Fredrick Shipman was convicted and sentenced to life imprisonment in the UK, on 31 January 2000, for the murder of 15 of his patients while he was a general practitioner at Market Street, Hyde, near Manchester, and for one count of forging a will. Police also investigated allegations that he may have murdered many more patients while he was a GP in Hyde and Todmorden. The Shipman Inquiry, led by Dame Janet Smith, subsequently produced six reports published between 2002 and 2005 that indicated that Shipman may have been responsible for the deaths of some 200 of his patients.

[6] In a report on the literature and a prospective study of the use of standardized patients to measure outpatient clinical practice, Glassman et al. evaluated the quality of 20 consenting physicians at two outpatient settings using 27 trained standardized patients. The study, which developed a method of measuring the quality of outpatient care, was also designed to evaluate, vis-à-vis the “gold standard” of reports by standardized patients, the validity of other methods of assessing the quality of care, such as abstraction of medical records from standardized patient visits and physicians’ responses to clinical vignettes corresponding to the SPs’ presentations (see Peabody et al. 2000, 2004).

[7] A similar statement has been produced for Australasian medical schools (Association of Teachers of Ethics and Law in Australian and New Zealand Medical Schools Working Group 2001).

Additional information

Notes on contributors

Alastair V. Campbell

ALASTAIR V. CAMPBELL is the inaugural Chen Su Lan Centennial Professor of Medical Ethics at the Yong Loo Lin School of Medicine, National University of Singapore (NUS), and director of the Centre for Biomedical Ethics. He has published extensively in both medical ethics and pastoral theology.

Jacqueline Chin

DR JACQUELINE CHIN is a research fellow at the NUS Centre for Biomedical Ethics. She is also an adjunct lecturer in the NUS Department of Philosophy.

Teck-Chuan Voo

MR VOO TECK CHUAN is a research assistant at the NUS Centre for Biomedical Ethics, and a PhD candidate in the NUS Department of Philosophy.