Ethical sense, medical ethics education, and maieutics

Abstract

Context

The toolbox of instructional methods available to medical ethics educators is richly stocked and well-catalogued. However, the history of ideas relating to its contents is relatively under-researched in the medical education literature.

History

This paper proposes an approach to professional medical ethics education that adapts the ancient maieutic, question-asking method associated with Socratic dialogue, and particularly its uptake in educational theory developed by nineteenth and twentieth century American pragmatic philosophers, who in turn were profoundly influenced by the eighteenth century Common Sense school of philosophy from the Scottish Enlightenment.

Theory

The ‘ethical sense’ postulated in this article is a distant echo of moral sense in Scottish Enlightenment thought. However, ethical sense as posited here is not the natural faculty variously theorised by Scottish Enlightenment philosophers such as Francis Hutcheson and Thomas Reid, but derives from the pre-understandings of students with respect to professional medical ethics.

Conclusions

The ethics educator can engage the ethical sense of students through maieutic ‘teaching and learning by asking’ in relation to actual clinical narratives, beginning not with the teacher’s questions but importantly with those of the learners based on what they would need to know in order to determine the professional ethical obligations entailed.

Keywords:

• Ethics education
• maieutics
• phrónēsis
• professional medical ethics
• teaching for understanding

Introduction

The toolbox of instructional methods available to medical ethics educators today is richly stocked and well-catalogued. From small group discussions, to interactive lectures, to devised theatre role-play, and beyond, each has its strengths and limitations, all constrained according to the curricular and institutional contexts, and best used in combination (Dowie and Martin 2010; Fenwick et al. 2013; Goldie 2000; Institute of Medical Ethics 2019; Stirrat et al. 2010).

Practice points

• The maieutic approach proposed here is suitable for undergraduate and postgraduate learning in professional medical ethics.

• It is adaptable both to small group learning and larger groups in a seminar context, as well as to workplace learning from the clerkship phase to postgraduate training and beyond.

• It equips learners for unfamiliar professional ethics situations in clinical practice.

• It centres on the deliberative ethical questions posed by the learners.

• Teacher expertise in ethics is essential to the approach.

The processes by which we apprehend the right and the good, the wrong and the bad, has exercised the greatest of minds down the ages, yet the history of such ideas is relatively under-researched in the medical education literature. A recent exception is the Medical Teacher article in which McCullough et al. (2022) discuss the eighteenth century Scottish physician and ethicist John Gregory, who is uniquely significant in the history of medicine and professional medical ethics, and the authors demonstrate Gregory’s relevance for contemporary medical education.

This paper seeks to add to the discussion of Scottish Enlightenment thought in relation to professional medical ethics education today. The eighteenth century Scottish influence upon the American Founding Fathers and the institutions they established is profound, and not least in the field of education (Fleischacker 2019). There is also a direct link from the Scottish philosophy of the period to American pragmatic philosophy, which in turn had a major impact on the development of educational theory (McDermid 2015).

Allied to such theory, an ethical sense approach to professional medical ethics education is proposed here. This ‘ethical sense’ is a faint echo of Scottish Enlightenment moral sense, but without the metaphysics of morals. Rather, the ethical sense postulated in this article is the modest claim that students arrive at medical school having already encountered professional ethical concepts, to however limited an extent, such as confidentiality, consent, capacity, and so on. They are thereby sensitised to at least the fact of such professional obligations. Their sense of these constitutes the individual pre-understandings that shape their respective interpretative horizons (Gadamer 1975, p. 261, 217).

This professional ethical sense is a horizon that the medical educator can engage so as to enlarge the understanding of learners. Again, the notion of professional ethical sense as discussed here makes no claims to innate ideas, or the operation of moral conscience, or to an instinctual moral compass, or to socially derived norms acquired by the learner. It is not an appeal to a measurable form of intelligence quotient, or trait theory, or universal moral grammar. Rather, the professional ethical sense referred to here is constituted by the student’s prior learning in professional ethics, including any assumptions or indeed misconceptions that the student may possess.

Teaching and learning by asking – ‘QBL’ rather than PBL

The dialogical approach to engaging the professional ethical sense of students proposed here can be traced to nineteenth and twentieth century pragmatist theories of education. The principal architects of American pragmatism—Charles Sanders Peirce (1839–1914), William James (1842–1910), John Dewey (1859–1952), and George Herbert Mead (1863–1931)—reworked Scottish Enlightenment notions and were explicit about doing so. Their various pragmatist conceptions of education related to the philosophy of education, individual and social psychology of education, and educational theory and practice (Mead 2008, p. 1–2). This paper touches upon the latter in relation to Dewey, Ella Lyman Cabot (1866–1934) and Mortimer Adler (1902–2001), each of whom advocated a question-asking approach to teaching and learning. As an instructional procedure reaching back to antiquity, this method is known as maieutics.

The term ‘maieutic’ comes to us from Socrates, through Plato, where the metaphor of midwifery is deployed in Theaetetus (150b–151c) to describe the Socratic method of dialogical questioning so as to facilitate the birth of ideas, to be a midwife to understanding. However, maieutic method as will be illustrated here is an adaptation of classical Socratic questioning. While the latter is well-suited to some forms of ethics education, what this article sets out is not the teacher-led questioning that seeks to elicit students’ presuppositions with a view to challenging them in a dialogue of methodic, creative provocation, a ‘calling forth’ as intellectual challenge.

Rather, the context here is particular to learning professional ethics as opposed to discussion of moral ‘issues’ or ‘dilemmas’ (Rhodes 2002). In the maieutic mode of professional ethics education set out here, the instructor seeks to enable students to identify gaps in their knowledge of the professional ethical contours of a clinical situation with a view to decision-making in clinical practice. Importantly, the students generate their own ethical questions aided by the teacher’s facilitation, and the teacher then uses these questions to guide discussion towards the intended learning, asking follow-up questions as further prompts. Thus far, then, the approach seems comparable to teaching ethics using PBL (Heidari et al. 2013; Tysinger et al. 1997). However, unlike PBL, the specialist ethical knowledge of the teacher is essential to the process; the method is suitable for more than small group sizes; and, as will be explained, it does not necessitate alternating phases of discussion with self-directed study.

Through rendering explicit their own ethical questions, or indeed misconceptions, students are actively doing the groundwork, turning over the soil prior to further discussion, rather than being passive recipients of information. The method thereby helps to equip learners for the process of thinking things through in future practice when presented with unfamiliar professional ethical situations. This maieutic approach does share with classical Socratic method its emphasis on questions (including the teacher’s follow-up prompts), the promotion of dialogue, and its starting point of students registering within themselves what they do not know. WKC Guthrie (2013, p. 68) puts this as follows:

The essence of the Socratic method is to convince the interlocutor that whereas he thought he knew something, in fact he does not. The conviction of ignorance is a necessary first step to the acquisition of knowledge, for no one is going to seek knowledge on any subject if he is under the delusion that he already possesses it.

This is not so as to embarrass, humiliate, or otherwise undermine the learner, but rather to foster understanding in depth (Marton and Säljö, 1976).

This article now outlines in brief a ‘history of ideas’ account of Scottish Enlightenment theories of moral sense and Common Sense that contributed to the development of American pragmatic thought, before turning to maieutics in the pragmatist educational theory and practice of Dewey, Cabot, and Adler. Lastly, three real clinical narratives are detailed in the final section of the article with a view to illustrating a maieutic approach within a professional medical ethics curriculum centred on students generating their own sets of ethical questions.

Moral sense and the Common Sense School of Scottish philosophy

McCullough (1998) and others have demonstrated that the modern concept of professional ethics in medicine originated from John Gregory in his lectures as Chair of Medicine at the Edinburgh School of Medicine, first published anonymously in 1770 under the title Observations on the Duties and Offices of a Physician, and on the Method of Prosecuting Enquiries in Philosophy. The term ‘medical ethics’ came afterwards from the English physician Thomas Percival in the title of his book published in 1803, while in the intervening period Benjamin Rush (the American physician, Founding Father, and student of Gregory in Edinburgh) published his similarly titled Observations on the Duties of a Physician in 1789 (Haakonssen 1997).

Material to Gregory’s invention of professional ethics was the Scottish moral philosophy of the day centred on the notion of sympathy. While there were differing models of this—reflected in the varied accounts of, among others, Anthony Ashley-Cooper (third Earl of Shaftesbury, 1671–1713), Francis Hutcheson (1694–1746), David Hume (1711–1776), Adam Smith (1723–1790), and Thomas Reid (1710–1796)—there were continuities, such as an emphasis on the underlying beneficent tendency towards the welfare of others that constitutes sympathy (McHugh 2018). Some regarded this as arising from an innate moral sense (like Shaftesbury and Hutcheson), while others took a different view of moral sense (like Hume and Smith) (Fricke 2019). But as proponents of the moral sentiment school of thought, contra other views of human nature and morals in currency at the time (such as the egoistic accounts set out by Thomas Hobbes and Bernard Mandeville), one way or another they all took the sensibility of sympathy as the summoning power for our moral actions, as opposed to reason alone (Haakonssen 1997, p. 33; Hume 1739, p. 245) (Hume’s important qualification in the word ‘alone’ is easily overlooked). Here ‘sentimentalism’ stands in contrast to ‘rationalism,’ which treated the faculty of reason as the primary motivating force in moral action (Gill 2007).

The moral sense movement was a component of the broader Common Sense school of thought, principally associated with Shaftesbury, Hutcheson, and Reid, though again with varied accounts. The ordinary language usage of ‘common sense’ is not to be confused with Common Sense philosophy (capital letters are used here to make the distinction). By ‘sense,’ the claim is that there are pre-theoretical givens not mediated through a process of reasoning, analogously with our experience of the bodily senses. This is reflected, for example, in the Common Sense realism that the world we perceive to be around us does actually exist, and so, as a pre-theoretical judgement beyond the realm of proof and about which we have no cause to be sceptical, it is simply to be accepted as a first principle. Reid (1764, p. 58) put this position as follows:

If there are certain principles, as I think there are, which the constitution of our nature leads us to believe, and which we are under a necessity to take for granted in the common concerns of life, without being able to give a reason for them; these are what we call the principles of common sense; and what is manifestly contrary to them, is what we call absurd.

By ‘common,’ the claim is that this human characteristic is ‘a faculty (or set of faculties) that is held… by all normally functioning human beings’ (Greco 2014, p. 144). It is therefore not, as Immanuel Kant put it, ‘an appeal to the opinion of the multitude’ (Kant 1783, p. 12; Carus 1902, p. 6). The faculty of moral sense, then, is in turn a Common Sense mode of moral judgement. That is, there are ‘moral distinctions independent of the mind… [and] we can know these independent realities’ (Norton 1975, p. 524). In Reid’s words, ‘The moral sense is therefore the power of judging in morals’ (Reid 1788, p. 479).

From Scottish Common Sense to American pragmatism

Scottish Enlightenment thought has been declared as ‘probably the most potent single tradition in the American Enlightenment’ among European influences (Schneider 1946, p. 246), spreading ‘a rich intellectual table from which the Americans could pick and choose and feast’ (Howe 1989, p. 580). Hutcheson was the foremost respected Scottish philosopher in America in the early eighteenth century, his first publication from 1725 being a textbook at Harvard College in the 1730s (Fiering 1981, p. 299), while Reid is described as ‘by far the most important Scot to the American university from the late eighteenth century onwards’ (Fleischacker 2019, p. 325). Both also held the Chair of Moral Philosophy at the University of Glasgow, separated by 18 years.

The link to American pragmatism begins with the 19th-century American philosopher and founder of the pragmatist movement, Charles Sanders Peirce (McDermid 2015). Pragmatism is itself a diversified philosophical tradition broadly dealing with the relation between our concepts and practices, the condition that the objects of our conception have traction upon our doing, and an operational approach to intellectual activity in varied contexts (Hookway 2012, p. 3). There is correspondingly no position that equates to ‘the pragmatist understanding of common sense’ (McDermid 2015, p. 232).

Peirce was an admirer of Reid’s thought and ‘was determined to reinvigorate the tradition of common sense philosophy’ through his own modulation that he described as critical Common-sensism (McDermid 2015, p. 215). As McDermid explains, this is a relativising move, in that while we accept our Common Sense notions implicitly, ‘it does not mean that the truth of such beliefs is absolutely guaranteed, that they are error-proof, or that they are permanently immune from revision’ (McDermid 2015, p. 218). Peirce’s friend William James relativised Common Sense in a different way as being one of three lenses, alongside science and philosophy, that are separately essential to their particular spheres of life. In their respective domains each is the best modality according to criteria of, as James put it, ‘their naturalness, their intellectual economy, their fruitfulness for practice’ (James 1907, p. 190).

Differently still, Dewey, who as a student at The Johns Hopkins University took Peirce’s class on logic (Dykhuizen 1973, p. 30), embraced Common Sense as ‘a body of facts that are so basic that without systematic attention to them ‘science’ cannot exist, while philosophy is idly speculative apart from them because it is then deprived of footing to stand on and of a field of significant application’ (Dewey and Bentley 1949, p. 272–273). This is reminiscent of Reid’s comment that, ‘Philosophy… has no other root but the principles of Common Sense; it grows out of them, and draws its nourishment from them: severed from this root, its honours wither, its sap is dried up, it dies and rots’ (Reid 1764, p. 22). Moreover, when Dewey writes of his approach to the teaching of ethics, that, ‘The end of the method, then, is the formation of sympathetic imagination for human relations in action,’ there is a clear resonance with the Scottish sympathy theorists (Dewey 1893, p. 316).

Lastly, Dewey’s friend George Herbert Mead developed a social psychology theory around understanding the perspectives of others (Mead 1932, p. 165), postulating the ‘generalised other,’ which has a direct affinity with the moral sentiment school and Adam Smith’s ‘impartial spectator’ (Mead 1934, p. 154; Smith 1931, p. 378).

Maieutic ethics education in Dewey, Cabot, and Adler

In 1893, Dewey published ‘Teaching ethics in the high school’ in Educational Review, where he recommended the use of questions as a way of teaching ethics specifically with a view to equipping the learner for real-world interaction. He adds (p. 315–316):

Above all, however, it should be made clear that the question is not what to do, but how to decide what to do… The object is to get them into the habit of mentally constructing some actual scene of human interaction, and of consulting that for instruction as to what to do… The whole point, in a word, is to keep the mental eye constantly upon some actual situation or interaction… The thought which underlies the method is that if instruction in the theory of morals has any practical value it has such value as it aids in forming, in the mind of the person taught, the habit of realizing for himself and in himself the nature of the practical situations in which he will find himself placed.

Dewey used this approach with college students where, importantly, the questions were student-led.

The deliberative moment of ‘deciding what to do’ is a component of phrónēsis, or the moral capacity of practical wisdom—deliberation that is directed towards action with respect to human goods—that is particularly associated with Aristotle’s epistemology and his account of the intellectual virtues in the Nicomachean ethics (Book 6, chapter 5; Dowie 2000). While in the context of this paper the learner’s deliberation is not followed through with the action that phrónēsis entails, it is nevertheless the necessary precursor. Again, this exercise of deliberation in ‘QBL’ substitutes the independent study component of PBL.

Key aspects of Dewey’s account for the maieutic approach proposed here may be expressed as follows:

1. The teacher has expertise in ethics.

2. The situation under discussion is real.

3. The students generate their own sets of questions by means of their professional ethical sense.

4. These deliberative questions are directed towards what the student would need to know in order to decide what to do.

5. The educational goals are directed towards developing skills for approaching the practical situations in which the students themselves will be placed professionally.

In 1906, Ella Lyman Cabot brought to the ethics education literature the expression ‘everyday ethics’ in the title of her manual for teachers, reflecting its pragmatist purpose. Her work was respected by Dewey, who partly influenced her writing, and by other leading philosophers of the day (Kaag 2011, p. xi). She too centred her method on the asking of questions, although teacher-led in her case. In what today might be described as a ‘flipped classroom’ approach, she would set questions in advance for learners to discuss among themselves, and also to be answered in writing and handed in before the class discussion. This design is informative for the maieutic approach proposed here in terms of the purpose of maieutic questions—those of the students in this case. Key objectives set out by Cabot (1906, p. 348) may be expressed as follows:

• To bear upon real experience.

• To delineate the professional ethical contours of the case.

• To call out from students what they already appreciate, if perhaps not yet fully thought through.

• To develop reasoning and ‘to awaken imagination and sympathy.’

• To clarify underlying ethical norms.

This ‘leading out,’ eductive mode of education proposed in this article is not to be mistaken for the attempt to draw out from students what is not there—‘none of us knew anything, and so we all taught each other’—rather it is a calling forth of what the students already possess, not through the challenge of intellectual provocation, but through the professional ethical sense that derives from their prior learning, assumptions, and even misconceptions.

It does not follow that maieutic questioning is antithetical to teacher input with respect to expert knowledge. More than 70 years after Cabot, Mortimer Adler took up Deweyan themes in the development of his educational manifesto in which he set out three distinct modes of teaching and learning, each of which is essential to their separate educational goals (Adler 1982). The first is didactic instruction; the second is supervised activity (‘coaching’); and the third mode is maieutic dialogue in a seminar context, the goal of which is ‘enlargement of the understanding’—what today would be classified as ‘teaching for understanding.’ Dewey was one of three dedicatees in Adler’s book, and another was Robert Maynard Hutchins, who in 1930, as president of the University of Chicago—the home of Dewey and Mead—introduced Socratic dialogue and questioning to the undergraduate College curriculum, under Adler’s guidance, whom he had newly recruited (Ashmore 1989, p. 99). In strikingly similar language to that of Cabot, Adler wrote that teaching by asking questions ‘stimulates the imagination and intellect by awakening the creative and inquisitive powers’ (1982, p. 29).

Although the maieutic approach for such enlargement of understanding as proposed here begins with dialogue between students in generating their own questions, this segues into dialogue between the teacher and students, with the teacher also asking follow-up questions. Adler commented on the nature of this maieutic teacher-talk, emphasising that it is both declarative and interrogative so as to avoid ‘uninterruptedly talking at students, on the one hand, and… persistently questioning students, on the other hand’ (Adler 1988, p. 302). He explained that this turns on the purpose of the teacher-talk. Declarative speech that is didactic has the function of imparting information for its own sake, but when maieutic it has the function of leading up to and clarifying a question. By the same token, interrogative speech can also function rhetorically in a didactic rather than dialogical mode.

Maieutics in the professional medical ethics curriculum

When presented with a gap in our knowledge, we can certainly discern within ourselves questions that require an answer, regardless of what is sometimes referred to as the ‘learning paradox’—the conundrum of knowing what one does not know. Rather, in the terms of the Confucian analect, ‘This is wisdom: to recognize what you know as what you know, and recognize what you do not know as what you do not know’ (Confucius 2003, analect 2.17).

The maieutic approach proposed here draws upon the methods of Dewey, Cabot, and Adler in engaging the professional ethical sense of learners. In a classroom context, it is ideally deployed in a teaching space where participants can break into small discussion groups. The class size limit is set by the scope for the instructor(s) to interact with all the discussion groups before engaging the whole class.

Building on Dewey, Cabot, and Adler, the overall approach proposed here for classroom teaching, and which can be adapted to clinical teaching settings, is both eductive and inductive:

1. The teacher presents the class with details from a real clinical case appropriate to the level of knowledge.

2. The case entails substantive professional ethical obligations as intended learning.

3. Before the educational event, the teacher prepares a list of key questions directed towards deciding what to do, the content of which constitutes the intended learning.

4. In small discussion groups, students are tasked with generating their own sets of ethical questions arising from the real clinical case narrative.

5. Teacher interaction with the small groups eductively draws out their own questions and inductively steers the students towards key questions that have been identified in advance.

6. Teacher interaction with the small groups takes the form of both declarative and interrogative talk in a maieutic mode.

7. The teacher may intermittently pause small group discussion to take soundings from the class as a whole and to provide further declarative or interrogative prompts as may be required.

8. Key questions are scribed for the class during this process.

9. After an appropriate interval the teacher resumes whole class discussion around these key questions in order to establish the intended learning.

Particularly with junior undergraduate students, there is scope for considerable distance between the student-generated questions and teacher-prepared questions, perhaps reflecting the curiosity of the learner over what is ethically more salient. The teacher can still respond to such questions constructively, whether in a declarative or interrogative maieutic mode, while maintaining a necessary focus on the substantive ethics content. Some aspects of this will be higher up the educational agenda than others, so that the educator prioritises these within the time constraints of the teaching session.

However, so much of professional ethics education in medicine takes place not in the planned curriculum of the classroom, but through opportunistic teaching in the clinical workplace, from the clerkship phase to postgraduate training and beyond. When adapting a maieutic approach to those contexts, the dynamic remains unchanged in the shift from intended learning to opportunistic learning. The students or trainees are again prompted to identify relevant ethical questions, followed by honing these into key questions as identified by the educator.

Adapting this eductive and inductive process in the clinical setting is best suited to teaching contexts in which the patient is not present, and where sufficient time resource is available. For example, it could take place immediately after learners have observed a consultation, or following a ward round, whereas in ‘corridor teaching’ there may be temporal urgency (Pearce 2003). It also provides scope for students or trainees to select an ethical case from their own experience in the setting, as an alternative to the standard case presentation, where space is allocated in the working week for such discussions.

Examples of clinical situations and maieutic ethical questions

Three actual clinical narratives are presented below, one in orthopaedic surgery, one in psychiatry, and one in paediatric otology, together with a list of key questions based on the intended learning for the session. The rationale for selecting these particular examples is to illustrate the use of maieutic ethical questions across contrasting clinical specialties.

1. Pulmonary embolism

   Table

   Clinical situation

   Maieutic ethical questions

   Ms K, aged 33 years, presented to the hospital emergency department with severe right knee pain following a twisting injury while playing hockey for her club. She was unable to weight-bear and the joint was swollen. The knee was unstable when examined by the consultant orthopaedic surgeon. Further examination and MRI scan showed a rupture of the anterior cruciate ligament within the knee joint. Ms K was informed of her condition, and operative and non-operative treatment options were discussed in detail. Having considered the risks and benefits, Ms K gave consent for a surgical anterior cruciate ligament reconstruction as she required a quick recovery and wished to return to competitive sports. She was scheduled for surgery two weeks later, discharged from the clinic with adequate analgesia, and fitted with a temporary knee brace. She was advised to mobilise with crutches as much as possible. Unfortunately, on the day of surgery, Ms K developed sudden onset of right-sided pleuritic chest pain with shortness of breath. History-taking established that Ms K did not mobilise herself sufficiently for fear of hurting her knee. An urgent CT pulmonary angiogram confirmed the diagnosis of pulmonary embolism (PE). As a result, the surgery would be delayed until she had recovered from the PE. Ms K was unhappy with the situation and believed that the orthopaedic consultant was at fault.

   How do professional standards in clinical communication relate to this case? What are the elements of communicating risk to patients How do these relate to giving advice to Ms K What is important about the consultant’s notes in this respect In terms of professionalism, how should the consultant respond What are the criteria of negligence and how do they relate to this case Aside from medical treatment, in what other ways can doctors be negligent How relevant is what other doctors would do in advising a patient What responsibilities does Ms K have in the management of her injury

2. Patient declining change in medication

   Table

   Clinical situation

   Maieutic ethical questions

   Mr E, who is aged 42 years, and has been diagnosed with schizophrenia and obsessive-compulsive disorder, presents to the hospital psychiatric outpatient clinic with worsening auditory hallucinations and compulsions causing him to check repeatedly the lock on his room in the residential rehabilitation unit where he is housed, and this is impacting severely on his daily life. His ability to participate in the recreational activities offered there is significantly impaired by these symptoms, and the staff are increasingly concerned for his welfare. The psychiatrist at the clinic recommends a low dose of fluoxetine for his compulsions (the antidepressant also known as Prozac^©). However, due to Mr E’s previous experience of disturbing side effects from increased doses of clozapine (an antipsychotic medication prescribed in treatment-resistant schizophrenia), he is adamantly opposed to any change in his pharmacological treatment, and feels that he will be better off continuing with his current regimen, and will talk to the staff at the unit whenever he has problems with his symptoms. The psychiatrist suggests that she could write a prescription for the medication, so that Mr E can have the option to change his mind at any time if he so wishes, though he continues to insist he would not use it.

   Can a schizophrenic patient have capacity to make decisions? Under what circumstances could a patient be compelled to take medication What are Mr E’s rights in this situation What is the psychiatrist’s duty of care towards Mr E How does medical paternalism relate to this case In term of professionalism, what is the point of the prescription if Mr E won’t use it What might be Mr E’s concerns with respect to the rehabilitation unit staff How do Mr E’s preferences relate to the situation How does Mr E’s quality of life relate to the situation What contextual features are relevant to the situation

3. Infant born with lack of hearing

   Table

   Clinical situation

   Maieutic ethical questions

   Patient W is a girl aged 14 months who was born with profound bilateral sensorineural lack of hearing as a result of a rare genetic condition, and both her parents are also Deaf. She presented to the hospital otology department to be assessed for cochlear implant surgery (comprising an internal radio signal receiver connected to an electrode array stimulating the auditory nerve, and an externally worn microphone, speech processor, and radio signal transmitter). She was considered an excellent candidate for bilateral implants with a high likelihood of success. With the services of a sign language interpreter, discussion with her parents revealed that they were very reluctant to go ahead, and only agreed to the assessment on the urging of their family doctor, whom they did not wish to disappoint, and not wishing to appear neglectful of their child. They knew of other implant recipients who had later abandoned use of the devices, and who now rely on sign language and lip reading, as they do themselves. They felt the normal surgical risks of placing the implants were not acceptable given that the external unit might ‘end up at the back of a drawer.’ They would rather wait until their daughter was old enough to be involved in the decision-making process. They also objected to the implicit view that Deafness is a disability requiring essential treatment, which they feel is a form of discrimination (however unintended) against Deaf culture and contributes to negative societal experiences of Deaf people.

   What are the ethical contours around patients in general declining therapy for treatable conditions? What values are being engaged in patient W’s situation, and how do they collide How can these situations be taken forward practically and in a professional manner What are the ethical contours around parents declining therapy for their children At what age would patient W be capable of sharing in the decision-making process What would be the criteria for patient W being able to participate in the decision What are possible sequelae of her receiving cochlear implants later rather than sooner What do clinicians have to consider in terms of discrimination against Deaf people What are the parents’ rights in relation to such discrimination

Conclusion

This article brought a ‘history of ideas’ approach to professional ethics education in the medical curriculum with respect to the ‘teaching and learning by asking’ method in pragmatist conceptions of education. This in turn derives from the nineteenth and twentieth century American pragmatist reworkings of Scottish Enlightenment approaches to Common Sense philosophy.

A distant echo of eighteenth century moral sense was proposed here in the more mundane postulate of ethical sense, deriving from students’ pre-understandings of medical professionalism through their prior learning. The maieutic approach to engaging the professional ethical sense of students has ancient roots in Socratic questioning, but is adapted here in line with Dewey’s educational theory, together with that of Cabot and Adler, so that students generate their own sets of ethical questions through dialogue in relation to real clinical cases that have professional ethical ramifications. This maieutic approach is a form of teaching for understanding that is best deployed in conjunction with other tools of professional ethics education in the planned curriculum, and can be adapted to opportunistic teaching in the clinical setting.

Having discussed some theoretical underpinnings to the approach, what might be possible directions for empirical research? While the proposal that immediately suggests itself would be some form of outcome evaluation, it is important first to rule out the attempt to investigate the efficacy of the approach in terms of the professional ethical practice of students or trainees. This would not only be problematic to operationalise, but more fundamentally it confuses practical ethical reasoning with ethical motivation.

However, there are studies in non-healthcare educational contexts that find statistically significant improvement in the ethical reasoning scores of students through teaching by traditional maieutics, which takes the form of Socratic challenge by the educator. Further research, then, on the adapted maieutic approach proposed here would be to compare with other instructional methods in relation to educational test performance of medical students, or metric-related test performance. Suitable measures could be across a variety of ethics assessment instruments, or by means of validated clinical ethical scenario-based inventories scoring students on the faculties of ethical sensitivity, ethical reasoning, and ethical decision-making.

Glossary

Ethical sense: The ethical pre-understanding of the learner, including any assumptions or indeed misconceptions.

Maieutics: The interlocutive, instructional method that is associated with Socrates and based on dialogical questioning.

Phrónēsis: The deliberative process of ethical reasoning oriented towards agentive practice.

Acknowledgements

The author gratefully acknowledges Mr John Dent, Dr Allan Beveridge, and Dr Jack Beattie for their insightful comments on the clinical cases. He also wishes to thank the anonymous referees for their invaluable feedback.

Disclosure statement

The author reports no competing interests, is solely responsible for the content and writing of the paper.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

The author reported that no funding was obtained in support of the research and composition of this work.

Notes on contributors

Al Dowie

Al Dowie is the Professor of Medical Ethics and Law at the University of Glasgow in the School of Medicine, Dentistry & Nursing. He is Associate Editor for History and Medical Humanities for the Journal of the Royal College of Physicians of Edinburgh.