comprehension, certaine aptitudes et certaines faqons de penser ... such as "One Flew Over the Cuckoo's. Nest" ... The answers have confirmed rather than ...
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Richard G. Tiberius
Teaching and Learning Medical Ethics SUMMARY
SOMMAIRE
Three main questions are central to teaching and leaming medical ethics. Can ethics be taught? If it can, what are some of its teachable components? And what teaching methods are appropriate? The author supports the concept of ethical competence as the basis of an ethical practice. Ethical competence is a set of insights, skills, understandings, ways of thinking which can be taught. The parallel is drawn between these kinds of competencies and the components of rigorous thinking characteristic of the training and experience of medical problem-solvers. Finally the author takes up four common criticisms of this approach. (Can Fam Physician 1981;
Trois questions essentielles se posent dans l'Ftuideet ` l'enseignement de l'ethique medicale. Peut-on enseigner. l'thique? Si oui, quelles en sont les composantes pouvant etre enseigndes? Quelles s les m6thodes d'enseignement appropri&es? L'aut*ar > appuie le concept de la competence comme base de l'ethique medicale. La competence suppose un . ensemble de qualitds comme la perspicacit6, la comprehension, certaine aptitudes et certaines faqons de penser, pouvant etre enseign6es. On trai; X la parallele entre cette sorte de competence et c*e; qui caracterise la pensee rigoureuse acquise par Ia formation et l'experience de personnes habilitdes 3 resoudre des problemes d'ordre medical. Finallement, l'auteur repond a quatre critiques habituelies de cette approche.
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Dr. Tiberius is a research associate in the Division of Studies in Medical Education and an assistant professor In the Department of Family and Community Medicine at the University of Toronto. Reprint requests to: 4th Floor, McMurrich Bldg., Faculty of Medicine, University of Toronto, Toronto, ON. MSS 1A8.
NTHE LAST FEW years the media and the performing arts have become fascinated with ethical issues in medicine. Feature articles dealing with these issues regularly appear in our CAN. FAM. PHYSICIAN Vol. 27: MAY 1981
newspapers and magazines. Radio, TV, film and theatre, too, are on the bandwagon. Recent successes include Jonathan Miller's internationally acclaimed BBC TV series on the body, which deals in part with ethical issues; the popular TV production and play "Whose Life is It Anyway?" by Brian Clark; Academy award winning films such as "One Flew Over the Cuckoo's Nest", "Hospital", "Coma", and "All that Jazz"; and the TV medical series which increasingly turn their attention to ethical issues. This media exposure is paralleled by a growing patients' rights movement and increasing litigation.. It is no wonder that questions are being asked, both in the public sphere and in the un-
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iversities, about the ethical taiing r our physicians. A few years ago all terviewer for a local CBC news s asked me about the ethical trainig our doctors. Her opening questionwa*v ,very direct: "Are our doctors t cal?" "Well, yes," I stammered,- !4 mean, of course they are all good tors." Next she wanted to know if t had any special training in th "Usually not," I had to admit. "'Soour doctors are ethical without special training, then why do yoU:i bother to teach ethics?" she con-.c cluded. I was trapped. Why in44 ' should we teach ethics or should phyr sicians endeavor to learn ethics if the ' are already ethical? In the last few years I have givlnft
anyKl-
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some serious thought to her question and to several other questions about the teaching and learning of medical ethics. The answers have confirmed rather than shaken my belief in the value of teaching medical ethics.
Can Ethics Be Taught? Is there any conceivable education we could provide which would improve the ethics of medical students? Many of our students and faculty answer this question with a categorical 'No'. The major support for this opinion is the belief that morality is the result of predispositions for good or evil which are either inborn or are the result of behavior patterns acquired so early in life that there is nothing we can do to alter them. Morality, according to this belief, is a matter of predispositions manifested as good conscience or intentions. Those who commit ethical transgressions are unethical because they are bad, i.e. not well-intentioned, simply the rotten apples in the barrel. This belief transforms the confusing struggle to live a moral life into a simple blackand-white battle between evil doers (like Darth Vader of Star Wars) and persons of good conscience. The problem with a view postulating inherently good and evil persons is that it lulls us into ethical complacency under the false assumption that well-meaning persons are safe-guarded from unethical behavior by their good intentions. The falseness of this assumption has been amply demonstrated in experiments by Milgraml and Zimbardo2 in which ordinary well-meaning persons were induced to commit inhumane acts under certain demanding social and psychological conditions. In the Milgraml experiment ordinary Americans, from all walks of life, volunteered for an experiment in which they were asked to take the role of teachers whose task it was to deliver painful electric shocks to learners whenever the learner made mistakes on a learning task. The learners were actually hired by the experimenter to make mistakes regularly and then to scream in mock pain when the shock was administered. (Unknown to the "teachers", the machine was unconnected). Despite the learner's screaming and shouts to "Please let me out of here. I can't stand it!" almost two814
thirds of the teachers obeyed the experimenter and continued to increase the voltage to the very highest value even when the gauge indicated that a "lethal voltage" was being administered. Zimbardo's research was similar.2 The subjects in his experiment, first year university women, delivered painful shocks to learners on the request of an experimenter. The interesting feature of Zimbardo's experiment is that half of the subjects, who wore hoods covering their heads and were in other ways "deindividuated", delivered shocks of much longer duration than the other half of the subjects whose individual identities were preserved. The interpretation of these ethical transgressions as inborn or resulting from childhood dispositions becomes shaky when we consider that behavior could be changed by a hood or a set of psychological constraints. In medicine we know that good practice is not simply a matter of good intentions. Well-meaning but incompetent physicians are dangerous to their patients' health. There is such a thing as ethical competence; wellintentioned physicians who lack the insight, skills, and ways of thinking included in ethical competence may be well-meaning but ethically dangerous. Physicians who lie to their patients, either to save them from stressful news or to facilitate a placebo effect or for some other reason, usually do so with the patient's interest, as they see it, uppermost in their minds. I have known physicians who have changed their positions on lying after reading Professor Bok's philosophic analysis of lying3, as a result of being forced to examine the broader consequences of lying. Their ethical position, by their own estimation, had improved. But their intentions did not change: they were, and still are, persons of good conscience. Physicians who allow their students to practice pelvic exams on comatose patients, who take biopsies or laboratory tests for scientific interest not essential to patient care, who sterilize the retarded routinely, who disclose confidential information, may be wellmeaning but are unaware that they are dealing with major ethical and often legal issues. If the CBC reporter should ever call again, I would still maintain that our
doctors are good, in the sense of wellmeaning, with good intentions. I know too many of them to say otherwise; the average doctor is a caring professional with a good conscience. But I would add that they are not free from ethical transgressions. This is not a contradiction. It is simply a way of stating that good intentions are not enough to ensure morality. In addition physicians should be ethically competent.
What Can Be Taught? Recent attempts to define a teachable set of competencies for approaching ethical problems have produced a set of insights, skills and ways of thinking that are really very similar to the set of tools already in the physician's mental toolbox. Indeed, the components of morality can be organized easily under three headings which are strikingly similar to the three major categories of medical problem-solving: problem formulation, diagnosis or assessment, and therapeutic intervention or management. Yet, ironically, physicians rarely see the parallels between rigorous analytical thinking in the ethical domain and in the scientific domain. I am arguing for a definition of ethical competence which is much closer to the scientific thinking that underlies their medical competence than to a reliance on inherent predispositions. The category of problem formulation in medicine has a parallel in ethics which could be described as ethical awareness or perception. This category includes such specific competencies as awareness of ethical issues (ability to distinguish them from economic, political, or medical issues), awareness of one's values and the values of others, ability to identify with others, insight into the feelings of others, knowledge of certain facts and their consequences, a sense of ethical
responsibility.4 The category of diagnosis or assessment in medicine is parallel in ethics to the concepts of reasoning, deliberating, and articulating an ethical argument; this second category includes such skills as the ability to uncover hidden assumptions, to test logical correctness of conclusions, to make helpful distinctions, to employ useful concepts, to locate and compile information from reliable sources, to examCAN. FAM. PHYSICIAN Vol. 27: MAY 1981
ine those sources critically, to formulate rationally a set of ethical rules and principles to which the individual commits himself or herself, to tolerate ambiguity. Finally, the category of therapeutic intervention is parallel, in the ethical domain, to the concept of ethical action, which incorporates such specifics as the moral courage to act, experience in resisting social pressure, experience in making ethical decisions and in knowing where to seek help.
What Teaching Methods? The third major question is one of method: how do we teach these components or competencies? Since the competencies are so varied, we should expect the teaching methods to be varied as well. The kind of ethical consciousness or awareness included in the first category could be aroused by such methods as formal study in medical ethics, value clarification exercises, small group discussions, exposure to literature or film, and the ethical example of faculty or colleagues. The reasoning skills enumerated in the second category could be facilitated through a formal course in ethical philosophy and logic, in which students would have the opportunity to think about ethical problems and to receive specific feedback on the rigor of their thought process and articulation. Finally the specific objectives under the category of ethical action are perhaps best served by small group sessions in which students have an opportunity to practice making moral decisions and to interact with a variety of resource persons from different disciplines who represent different points of view (medical specialists, philosophers, lawyers, government officials, social scientists, clergy, patients, other health care workers) who provide knowledge of how to use human resources. An understanding of the psychological forces influencing ethical action such as Zimbardo's2 concept of deindividuation, may be useful in increasing students' resistence to the distorting influence of these forces.
Four Arguments Against
Teaching Ethical Competence Although many writers4'7 agree on CAN. FAM. PHYSICIAN Vol. 27: MAY 1981
the list of ethical competencies offered above, a number of critics consider these kinds of competencies inappropriate learning objectives for physicians or consider the whole approach of teaching ethical competence to be wrong-headed. The four most common criticisms, in my experience, are advanced by 1. those who prefer teaching codes of ethics. 2. those who prefer religious teaching as a basis for morality. 3. those who feel that scientific medicine contains an inherent ethic. 4. those who feel that there is no need to teach ethics since physicians will "pick it up" during their professional lives anyway-by the traditional information channels. Ethical codes. One of my colleagues once commented to me: "We should be teaching and learning the ethical codes. They represent the distilled wisdom of 2000 years of thinking about morality in medicine." He viewed the approach that focuses on ethical thinking as an overambitious attempt to make philosophers out of medical students. According to his view medical students need only a set of guidelines amply provided by the ethical codes. Codes such as the CMA Code of Ethics or the Hippocratic Oath serve some useful function in ethics similar to that of a number of equally useful rules in medical practice such as 'treat high fever with aspirin'. But relying solely on such rules without understanding the nature of the problem in depth is like practicing what Asimov described as black box medicine: if the liquid in the little glass rod moves past 37°C give the patient the pill marked A. It results in superficial treatment just as relying on ethical codes results in shallow ethics. The problem with codes or rules is that, since they cannot cover all cases, interpretation is necessary. The quality of the interpretation in turn depends on the interpreter's ability to think ethically. So we are back again to ethical thinking. Such time-honored codes as the Ten Commandments are interpreted within an entire context of Judeo-Christian theology including hundreds of pages of scripture which provide the spirit of the rules through parables, stories and examples. Principles I and II in the CMA Code admonish us to "consider first the
wellbeing of the patient" and to 'honor your profession." It is difficult to argue against these self-evident generalizations, but if we consider a specific case, such as one in which the wellbeing of the patient is in conflict with the traditional values of the profession, the code gives us no help in adjudicating between principles I and II. An example is the case of Mrs. Powley refusing permission for corrective surgery on her son who had a 90% chance of losing the use of his leg for life without the surgery, while the risk to his life of the surgery was minimal. Since she had just lost her husband and two sons in an accident, she could not bear the thought of endangering the life of her remaining son, no matter how minimal the risk to his life or how great the price to the quality of his future life. A decision for patient care which would be honorable to the profession in this case goes against the patient's wishes. Principle IV advises us to protect our patients' secrets. What if the patient's secret is that he abuses his children or wants to kill someone or has VD? Which patient should be "honored" when a mother presents with a request for the sterilization of her retarded teenage daughter? If the retarded girl is the patient, how would we go about deciding what is in her best interest? Religion. A second criticism of the approach taken in this paper is based on a preference for religious education as a basis of medical ethics. Religious education often provides the motivation, inspiration, and reward for pursuing a moral life, and is therefore usually a good complement to ethical study. In addition, some religions teach rigorous moral thinking so that the faithful may come to understand, to articulate, and to define-as well as to believe-the tenets of the faith. Moreover, the tenets of faith for some religions are compatible with the values and aims of the broadest approach to ethical truth: "to seek at least a basic set of rules that all rational men would agree to as moral rules and could urge anyone to follow."9 But not all religions are so compatible in their methods, aims and values with those of a broad-based, rational, philosophic approach to ethics. Certain religions, sects, and cults have no intention to appeal to all rational beings. They are directed at a much 815
smaller group of believers who have accepted their doctrines, and of whom they demand unthinking obedience. Such religious training is not compatible with the ethical competencies I have outlined in this paper. Scientific medicine contains an inherent ethic. This point of view is well illustrated by the physician who, faced with an ethical dilemma involving a patient refusing treatment,,'solved' the dilemma by declaring that, as a physician, he would do what was medically right, as if medicine contained some inherent ethical directives. An ethical issues involves conflict between persons who hold different value assumptions. These value conflicts cannot be resolved by an appeal to medical science. Mrs. Powley, in the example cited above, did not want her son to undergo surgery although the physicians strongly advised her to accept it on the basis of assumptions they held about the quality of his future life. An ethical dilemma arose here because Mrs. Powley held some assumptions which conflicted with those held by the physicians treating her son. Medical science can provide us with the probability that the boy will lose the use of his leg if it goes uncorrected, but medicine cannot tell us whether it is right to allow it do so. A review of past injuries of this sort may yield information that the risk of surgery is minimal and the prognosis excellent, facts which may influence the mother's decision, but cannot be used to justify some moral right of the physician to countermand her wishes. In most cases, of course, the value assumptions of the physician and the patient are compatible. In such cases the ethical dilemma is reduced to a purely medical one of how best to proceed. If the term "medically right" has any meaning it is with regard to this kind of search for what has come to be called the "treatment of choice", rather than the search for the solution to a value conflict. Physicians will "pick it up" along the way. Finally, there are those who argue against the necessity for a deliberate and costly effort to teach ethics
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because "it will happen anyway" through the normal channels of continuing medical education. Unfortunately, the usual channels (see below) have not been able to deliver the complex skills, awareness and understanding which form the basis of ethical competence. A colleague of mine made an interesting comparison: "If ethics were a new drug or medical procedure, its publication in the media would have been preceded by an onslaught of information in the medical literature and information communicated by the drug sales representatives. But when the media raise ethical issues, the medical literature does not provide us with the tools to deal with them." Moreover, even if the professional societies and universities should emphasize medical ethics for their CME programs, an introduction at such a late date in the physician's career may be too late: The doctor becomes increasingly accustomed to a life which does not allow for leisurely contemplation. He must continually choose between remedies even when he has poor basis for making a choice. The doctor is likely to be propelled increasingly in the direction of quick decisions which at times resemble reflex responses. In this pragmatic, frenetic existence he may quickly absorb the moral atmosphere around him without questioning it. It is my conviction, therefore, that ethical problems must be integrated into the doctor's life at the earliest possible moment. I do not believe that it will be effective to bring up such matters relatively late in the medical career, although the doctor will certainly require constant reinforcement throughout his professional life.6 Apparently teaching medical ethics is not going to 'happen anyway' without some concerted effort to make it happen. There has been little progress to date in teaching ethics in the medical schools. Last year's series of workshops at the annual meeting of the College of Family Physicians of Canada included one devoted to the teaching
of medical ethics. During discussion at this workshop, all of the physicians revealed that there was very little in their previous education or professional experience to guide them in ethics-and our group was represented by physicians from all over Canada! Only in the last few years have medical schools across North America begun searching for methods of organizing curricula for medial ethics.5' 7, 10 I hope that these efforts will be successful. But even if they are, they will not guarantee ethical physicians anymore than achievement of clinical competence guarantees caring ones. Clinical competence is only the basis of good patient care. I have maintained in this article that there is also a learnable set of competencies which is the basis of ethically competent practice. We are now in the middle of the difficult task of designing educational programs to teach this basic ethical comi) petence.
References 1. Milgram S: Obedience to Authority. New York, Harper & Row, 1974. 2. Zimbardo P: The human choice: Individuation, impulse, and chaos, in Arnold WJ, Levin D (eds): Nebraska Symposium on Motivation. Lincoln, Nebraska, University of Nebraska Press, 1969, pp. 237308. 3. Bok 5: Lying: Moral choices in public and private life. New York, Pantheon Books, 1978. 4. Wilson JB, et al: Introduction to Moral Education. Middlesex, England, Penguin, 1967, pp. 192-202. 5. Veatch RM, Clouser KD: New mix in the Medical Curriculum. Prism, 1973. 6. Lasagna L: Some ethical problems in clinical investigation, in Mendelsohn E, Swazey JP, Taviss I (eds): Human Aspects of Biomedical Innovation. Cambridge, Mass., Harvard University Press, 1977, p. 108. 7. The Committee on the Teaching of Bioethics of the Hastings Centre: The Teaching of Bioethics. Hastings on Hudson, New York, 1976. 8. Veatch RM: Case Studies in Medical Ethics. Cambridge, Mass., Harvard University Press, 1977. 9. Clouser KD: Some things medical ethics is not. JAMA 1973; 223:787-789. 10. Russell A: Applied ethics: A strategy
for fostering professional responsibility. Carnegie Quart 1980; 28:1-7.
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