A Plea for Ethics: Suggestions for Implementation in the Medical Curriculum

The aim of education is to enable individuals to continue their education.

The object and reward of learning is the continued capacity for growth.[1]

Ethical issues do pervade our daily practice.[2] [3] People interact with doctors because of existential problems which may be threatening to them. On these crossroads, choices have to be made. The sometimes far-reaching consequences of these choices imply a moral responsibility which is ours to live up to. But we may not always be sensitive to the moral issues at hand. And we may lack the competence to deal adequately with them. Several available avenues have already been used with the common objective of making ethics an inherent and inseparable part of good clinical medicine. The main thrusts lie in ethics research, teaching, as well as committees and consultation activities. Clinical ethics teaching encompasses a vast field of cognitive and behavioral skills, including examination of individual character virtues.[3] Officially, ethics is considered an essential prerequisite for medical education up to the level of specialist accreditation.[4] [5] However, medical specialists in general seem at a loss when asked how ethics must be taught. What indeed are the effective means of imparting professional values, attitudes, and behaviors within a health service that is increasingly sensitive to society's expectations including the financial pressures posed on the current health care system.[6]

In practical terms, a medical professional must demonstrate concern for the best interests of the patient as a whole, and must in addition be able to reflect on his own behavior, comprehend the reasons for choices, and be able to explain those to others.[7] Already we expect our residents to carry out their professional responsibilities while being sensitive to a diverse patient population, and in accordance with ethical principles.[4] [8] Appropriate questioning supports self-reflection and enhances communication with others. It is no longer sufficient just to ask if the things that are done, are done correctly. It is also imperative to ask if the right things are done. To grapple for the best possible alternative, ethics is concerned not only with what (reflecting goals and results), but also with how and why (reflecting motives).[7]

The central paradox in medicine is the tension between self-interest and altruism

Although it is probably true that the majority of young physicians in training are acquainted with medical ethics, the need for advanced formal training has been recognized and will be instituted. The ideal practical ethics teaching program can be summarized with the “5 C's” of clinically based teaching, using cases as the focus, establishing continuity throughout the medical curriculum, coordinating the teaching with the learner's other objectives, and utilizing clinicians as instructors and role models.[3] [9]

Focused curricula can be developed that have a measurable impact on medical house officers and resident's knowledge and confidence in addressing ethical issues.[8] [9] Other teaching modes, such as strong role modeling and mentoring by more experienced teachers, open the ever-present possibility of favorable behavior-influencing actions and reinforcement during periods of residence and fellowship programs.[5] The objective of this article is to demonstrate current issues and the pitfalls of ethics teaching. Suggestions will be made to enhance critical ethical reflection for both trainees and established doctors.

• References

• 1 Dewey J. Democracy and education New York: Macmillan 1916:117 in Kopelman LR: Values and virtues: Should they be taught?. Acad Med 1999; 74: 1307-1310
• 2 Connelly JE, DalleMura S. Ethical problems in the medical office. JAMA 1988; 260 (06) 812-815
• 3 Pellegrino ED, Siegler M, Singer PA. Teaching clinical ethics. J Clin Ethics 1990; 1 (03) 175-180
• 4 Doyal L, Gillon R. Medical ethics and law as a core subject in medical education. A core curriculum offers flexibility in how it is taught-but not that it is taught. BMJ 1998; 316 (7145): 1623-1624
• 5 The Ethics Committee of the American Academy of Otolaryngology-Head and Neck Surgery. Methodologies of teaching. Otolaryngol Head Neck Surg 1996; 115 (03) 258-261
• 6 Paice E, Heard S, Moss F. How important are role models in making good doctors?. BMJ 2002; 325 (7366): 707-710
• 7 Verkerk MA. , de Bree M, Jaspers F. Reflectieve professionaliteit. Naar een invulling van het CCMS-competentiegebied ‘professionaliteit’. Tijdschrift voor Medisch Onderwijs 2005; 24: 162-167
• 8 Angelos P, DaRosa DA, Derossis AM, Kim B. Medical ethics curriculum for surgical residents: results of a pilot project. Surgery 1999; 126 (04) 701-705 , discussion 705–707
• 9 Sulmasy DP, Marx ES. Ethics education for medical house officers: long-term improvements in knowledge and confidence. J Med Ethics 1997; 23 (02) 88-92
• 10 Papadakis MA, Teherani A, Banach MA. , et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med 2005; 353 (25) 2673-2682
• 11 Ethics Committee of AAO-HNS. Chapter 12: obligations to patient, profession, society, family, and self. Head Neck Surg 1996; 115: 241-249
• 12 Huddle TS. ; Accreditation Council for Graduate Medical Education (ACGME). Viewpoint: teaching professionalism: is medical morality a competency?. Acad Med 2005; 80 (10) 885-891
• 13 Erde EL. The inadequacy of role models for educating medical students in ethics with some reflections on virtue theory. Theor Med 1997; 18 (1-2): 31-45
• 14 Davis D, O'Brien MAT, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes?. JAMA 1999; 282 (09) 867-874
• 15 Singer PA, Pellegrino ED, Siegler M. Clinical ethics revisited. BMC Med Ethics 2001; 2 (01) E1
• 16 Coulehan J, Williams PC. McCrary SV, Belling C. The best lack all conviction: biomedical ethics, professionalism, and social responsibility. Camb Q Healthc. Ethics 2003; 12: 21-38
• 17 Charon R. To render the lives of patients. Lit Med 1986; 5: 58-74
• 18 Branch Jr WT, Kern D, Haidet P. , et al. The patient-physician relationship. Teaching the human dimensions of care in clinical settings. JAMA 2001; 286 (09) 1067-1074
• 19 Derksen W. Vruchtbare “nutteloosheid”: het belang van algemene vorming in de context van beroeps-gerichte academische opleidingen. Tijdschrift voor medisch onderwijs 2004; 23 (01) 57-63
• 20 Coulehan J. Adventures in medicine. Am J Med 2006; 119 (07) 622
• 21 Heard SR, Schiller G, Aitken M, Fergie C. McCready Hall L. Continuous quality improvement: educating towards a culture of clinical governance. Qual Health Care 2001; 10 (Suppl. 02) ii70-ii78
• 22 Shalit R. When we were philosopher kings. The New Republic. Available at: http://www.thenewrepublic.com/archive/04/042897/shalit042897.html . Accessed April 28, 1997
• 23 Zaner RM. Conversations on the Edge. Washington, DC: Georgetown University Press; 2004
• 24 Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice Hall; 1977
• 25 Kopelman LM. Values and virtues: how should they be taught?. Acad Med 1999; 74 (12) 1307-1310
• 26 Covey SR. Principle Centred Leadership. New York, NY: Simon & Schuster; 1990
• 27 Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med 1994; 69 (11) 861-871
• 28 Althouse LA, Stritter FT, Steiner BD. Attitudes and approaches of influential role models in clinical education advances in Health Sciences Education. Adv Health Sci Educ Theory Pract 1999; 4 (02) 111-122
• 29 Wright SM, Kern DE, Kolodner K, Howard DM, Brancati FL. Attributes of excellent attending-physician role models. N Engl J Med 1998; 339 (27) 1986-1993
• 30 Bass MJ, Buck C, Turner L, Dickie G, Pratt G, Robinson HC. The physician's actions and the outcome of illness in family practice. J Fam Pract 1986; 23 (01) 43-47
• 31 Branch Jr WT. Supporting the moral development of medical students. J Gen Intern Med 2000; 15 (07) 503-508
• 32 Kenny NP, Mann KV, MacLeod H. Role modeling in physicians' professional formation: reconsidering an essential but untapped educational strategy. Acad Med 2003; 78 (12) 1203-1210
• 33 Beaudoin C, Maheux B, Côté L, Des Marchais JE, Jean P, Berkson L. Clinical teachers as humanistic caregivers and educators: perceptions of senior clerks and second-year residents. CMAJ 1998; 159 (07) 765-769
• 34 Wear D. On white coats and professional development: the formal and the hidden curricula. Ann Intern Med 1998; 129 (09) 734-737
• 35 Allen I. Committed but Critical: An Examination of Young Doctors' Views of Their Core Values. London, United Kingdom: Health Policy and Economic Research Unit, BMA; 1997
• 36 World Medical Association. International code of medical ethics. London, United Kingdom: 1949
• 37 Leget C. Avoiding evasion: medical ethics education and emotion theory. J Med Ethics 2004; 30 (05) 490-493
• 38 Goswami A. The Self-Aware Universe, How Consciousness Creates the Material World. New York, NY: Penguin-Putman; 1995
• 39 Tronto JC. Moral Boundaries: A Political Argument for an Ethic of Care. New York, London: Routledge; 1993
• 40 de Bree M. On akrasia and bullshit. Some (im-)possibilities of educating non-professionals. In: Meek MF, Pienaar CH. , eds. Plastic Surgery Surrealisms. Groningen, The Netherlands: UMCG; 2006: 143-147
• 41 Easwaran E. Words to live by 4th ed. Tomales, CA: Nilgiri Press; 2005: 351
• 42 Ward CM. Defining medical ethics. Br J Plast Surg 1993; 46 (08) 647-651
• 43 Gawthorp LC. Why teach ethics?. Perspectives Prof 1988; 7 (02) 1-3
• 44 Sulmasy DP, Ferris RE, Ury WA. Confidence and knowledge of medical ethics among interns entering residency in different specialties. J Clin Ethics 2005; 16 (03) 230-235
• 45 Perkins HS, Geppert CMA, Hazuda HP. Challenges in teaching ethics in medical schools. Am J Med Sci 2000; 319 (05) 273-278
• 46 Coulehan J, Williams PC. Vanquishing virtue: the impact of medical education. Acad Med 2001; 76 (06) 598-605
• 47 Seedhouse D. Ethics: The Heart of Health Care. 2nd ed. Chichester, United Kingdom: Wiley; 1998
• 48 Wyschogrod E. Saints and Postmodernism. Revisioning the Moral. Chicago, IL: University of Chicago Press; 1990: 22
• 49 Nussbaum MC. Upheavals of Thought. The Intelligence of Emotions. Cambridge, United Kingdom: Cambridge University Press; 2001
• 50 Cox H. When Jesus Came to Harvard, Making Moral Choices Today. New York, NY: Houghton Mifflin Company; 2004
• 51 Coulehan J. Viewpoint: today's professionalism: engaging the mind but not the heart. Acad Med 2005; 80 (10) 892-898
• 52 Singer PA, Robb A, Cohen R, Norman G, Turnbull J. Performance-based assessment of clinical ethics using an objective structured clinical examination. Acad Med 1996; 71 (05) 495-498
• 53 Pellegrino ED. Altruism, self-interest, and medical ethics. JAMA 1987; 258 (14) 1939-1940
• 54 Geraghty K. Guarding the Art: Edmund D. Pellegrino AMA Virtual Mentor 2001 ;3(11)
• 55 Tardy Jr ME. Ethics and integrity in facial plastic surgery: imperatives for the 21st century. Facial Plast Surg 1995; 11 (02) 111-115
• 56 Verbrugge A. Process thinking of managers robs the world of its soul. [Opinion and Debate] NRC/Handelsblad. June 18, 2005
• 57 Charon R. The patient-physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA 2001; 286 (15) 1897-1902