Design Bioethics, Not Only as a Research Tool but Also a Pedagogical Tool

This article refers to:

Design Bioethics: A Theoretical Framework and Argument for Innovation in Bioethics Research

As highlighted by Pavarini et al. (2021), researchers in the field of bioethics have to remain critical and reflexive on the methodology and on the tools they use for their research purpose because they are necessarily rooted in preliminary theoretical commitments. Since Bioethics is a rather “new” research field, it has mostly borrowed methods and tools from other fields. “Design bioethics” however, is a domain in which bioethics can develop its own purpose-built engineered tools.

While Pavarini et al. (2021) mainly focus on the importance of rigorous and well thought out development of design bioethics for research purposes, our interdisciplinary team is currently working on the use of purpose-built digital tools for teaching purposes. We investigate the use of serious games in medical education, their impact, and the ethical challenges they raise (Sader et al. 2021). It is important to identify the advantages and weaknesses of such teaching tools in order to optimize their implementation and transferability. It is also important to identify possible ethical issues raised by the use of such games and address them ahead of their implementation in “real life clinical setting” (Kim and Werbach 2016).

Serious games as a pedagogical tool are more and more used in medical education (Gorbanev et al. 2018). A serious game is a digital environment in which players can make choices in realistic complex situations under uncertainty. Players’ decisions have consequences in the game and players receive critical feedback on their choices. They can try out various choice path and while doing it gain knowledge about how to make more appropriate choices. There is a wide range of applications for such tools. For instance, one can use a serious game with the aim of improving moral competences (Katsarov et al. 2020). Or as we do (Sader et al. 2021) one can use serious games for debiasing physicians who are likely to be influenced in their practice and clinical reasoning by unconscious cognitive mechanisms (anchoring bias, confirmation bias etc.).

Serious games as teaching tool have many advantages. There is a “fun” component of playing which makes this pedagogical medium attractive. The immersive component of the game allows to make more embodied decisions which are close to players’ true reactions in the real world (Buzady 2017; Gorbanev et al. 2018). This virtual reality experience increases users’ attention and openness to critical feedback (Gorbanev et al. 2018, 2019; Katsarov et al. 2020; McCall and Baillie 2015; Schrier 2015). Serious games also allow players to explore, at their own pace, various chains of consequences. They provide an equal-quality teaching to large groups of students and can flexibly be implemented in a variety of settings (at home, in class) and timeframes. Serious games also allow for feedback adjusted to individual players’ choices in the game.

Despite all these advantages, given that by design, serious games are predefined in their aim, preliminary epistemological choices, and theoretical content, it can limit pedagogical flexibility and raise ethical issues. It is important to be aware of these issues ahead of the decision to include a serious game in a teaching curriculum. Such knowledge provides the opportunity to carefully weight the reasons for or against the use of a given serious game, or of specific design features of a game, and to find solutions to address potential ethical issues. In what follows, we will showcase some of the main issues that might arise and how they may be addressed.

CONFIDENTIALITY

When playing a digital serious game, users will probably need to log in with their personal identification information. In the medical context, students may be physicians following a continuous training and they may be worried about being judged or possibly disadvantaged at their workplace if they score badly in the game (McCall and Baillie 2015; Schrier 2015). Thus, a double issue needs to be addressed here: actual confidentially and trust, that is, students’ belief that confidentiality is secured. This issue is particularly problematic since, as we shall see below, it is important to collect data on users’ behavior in the game in order to assess the relevance of the content and the pedagogical value of the teaching tool.

To address these problems, transparency and informed consent from players are needed. Moreover, confidentiality may require that an independent education unit or an external company is mandated to process and anonymize users’ data.

CONTENT LIMITATION AND RIGIDITY

By design, serious games only allow for scripting a limited number of chain of consequences. Therefore, only selected information and teaching goals can be included in such a tool. Moreover, the development of a digital serious game is costly, and once developed, further content adjustments are difficult to make. This limitation and rigidity may not be problematic if the teaching content is unlikely to change (Gorbanev et al. 2018). But this is not the case in the medical field, especially when the teaching is based on knowledge and theories from bioethics or cognitive psychology. These are moving fields in which long-standing debates occur relating to basic theoretical commitments such as what are the required moral competences for physicians, or what biases influence medical practice. Game designers’ choices of content may seem arbitrary and may soon become obsolete.

One way to address this issue, is to plan a strategy of longitudinal feedback, while designing the game and while including the game in a teaching curriculum. Well-thought objective efficacy measures help to identify when a given serious game is outdated and how future games could be adapted and improved.

RISKS OF TECHNOLOGY OBSOLESCENCE

Given the quick advances we see with software, compatibility issues with existing computers and operating systems may arise. And after several years of use, software obsolescence and vulnerability to malware may pose security issues.

It is therefore important to make a careful choice of technology, to plan continuous updates, and to elaborate cyber risk mitigation measures.

RISK OF GENERATING DISCOMFORT AND MISUNDERSTANDINGS

Depending on the content of the game, it may be disturbing for a player to make the “wrong” choice and be confronted with adverse consequences. Students may misunderstand or disagree with the automatic feedback provided by the game. Or even worse, students may misunderstand the instructions of the game, or choose an option of the game with a different motivation or rationale than the one envisioned by the game designer, and thus receive a mismatching feedback comment.

To address this difficulty, high-standard quality checks may be conducted before using the game in a teaching curriculum. Moreover, since misunderstandings and discomfort are more likely to go unnoticed in serious game teaching than in ordinary in-class teaching, it seems important to plan an effective strategy of longitudinal feedback (Dieckmann et al. 2009). This may be done either technically (ex: possibility to leave commentary in the tool or on an online platform) of by complementing the use of the tool with a face-to-face teaching session.

SOFT MANIPULATION

Some serious games are used to set traps for educational purposes (McCall and Baillie 2015; Schrier 2015). For instance, powerfully immersive games may softly manipulate users’ choices in order to induce “wrong” decisions and thereby, create an awareness experience. This is the case of games designed for making users aware of their own cognitive biases (Barton et al. 2016), and consequently, more willing to address the issue and to develop practical response solutions. Even though these pedagogical methodologies can be justified, their application may be disturbing for students who are not completely free to avoid wrong choices within a teaching context.

Therefore, a tailored feedback is most needed, not only to help participant make something out of this uncomfortable experience, but also in order to explain and justify why they have been led to such decision paths.

LIMITED TAILORED FEEDBACK

It may happen that the tool does not generate sufficient gain of knowledge to be pedagogically satisfactory. Feedbacks and recommendations implemented in serious games rarely exceed a few sentences. If the teaching aims are complex (ex: to improve critical ethical thinking or to mitigate the biases of participants), students may need tailored inputs that the tool does not provide. For instance, if students become aware of one of their bias while playing in a serious game, they may need to think of a way to avoid the expression of that bias in their ordinary medical practice (ex: by preparing a scripted response to specific situations).

In these cases, the tool should be thought as part of a more embedded pedagogical strategy including face-to-face teaching session which allow for human interactions and flexible adjustments.

To conclude, serious games are useful teaching tools but in order to avoid inefficiencies and adverse effects designers have to remain critical and reflexive on the methodology. This involves reflection about their pedagogical aims and assumptions, adjustments to the pedagogical framework, and planned feedback and quality assessments. Some of our comments are generalizable beyond serious games to any kind of design issues for bioethics curricula.