The moral development of medical students - Wiley Online Library

Medical Education 1993, 27, 26-34

The moral development of medical students: a pilot study of the possible influence of medical education D. J. SELF, D. E. SCHRADERt, D. C. BALDWIN JRS & F. D. WOLINSKYS Departments ofHumanities in Medicine, Philosophy, and Pediatrics, College of Medicine, Texas A & M University, College Station, Texas, tDepartment of Education, Cornell University, Ithaca, N e w York, $American Medical Association, Chicago, Illinois and §Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana

Summary. Medicine endorses a code of ethics and encourages a high moral character among doctors. This study examines the influence of medical education on the moral reasoning and development of medical students. Kohlberg’s Moral Judgment Interview was given to a sample of 20 medical students (41.7% of students in that class). The students were tested at the beginning and at the end of their medical course to determine whether their moral reasoning scores had increased to the same extent as other people who extend their formal education. It was found that normally expected increases in moral reasoning scores did not occur over the 4 years of medical education for these students, suggesting that their educational experience somehow inhibited their moral reasoning ability rather than facilitating it. With a range of moral reasoning scores between 315 and 482, the finding of a mean increase from first year to fourth year of 18.5 points was not statistically significant at the P 6 0.05 level. Statistical analysis revealed no significant correlations at the P < 0.05 level between the moral reasoning scores and age, gender, Medical College Admission Test scores, or grade point average scores. Along with a brief description of Kohlberg’s cognitive moral development theory, some interpretations and explanations are given for the findings of the study.

ethics, med; attitude of health personnel; students, med/psychol; attitude to health; thinking; pilot projects

Introduction The Flexner Report (1910) led to major emphasis of medical education on the acquisition of scientific and technical knowledge, rather than on the teaching of values and attitudes. Pellegrino, however, has pointed out that medicine is, and has always been, inherently a moral enterprise (Pellegrino & Thomasma 1981). This is substantiated by even a casual review ofthe historical and contemporary codes of ethics of organized medicine (Burns 1977;Reiser et al. 1977;Bulger 1989). Most descriptions of the essential characteristics or qualities of medical staff include the qualities o f high moral character and following a code of professional and ethical behaviour as important considerations. Thus, the relationship of medical education to the moral development of medical students deserves careful consideration. Instruments for gathering empirical data on the development of moral reasoning in doctors and medical students have not been available until recently. As a result of the work of Kohlberg and his colleagues, however, several instruments for assessing moral reasoning development have been developed that are appropriate for use with medical students (Kohlberg 1984; Rest 1979; Gibbs & Widaman 1982). Relatively few moral reasoning studies have been conducted with medical students. Most of these have been cross-sectional, or ‘slice of time’, in nature, representing one point in medical

Key words: *morals; *educ, med, undergrad; Correspondence: Donnie J . Self PhD, Department of Humanities in Medicine, Texas A&M University Health Science Center, 164 Reynolds Medical Building, College Station, Texas 77843-1 114, USA.

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Moral development of medical students education. The most extensive studies have been done by Sheehan, Baldwin, Self and Dyer, some of which have not been published (Sheehan et al. 1981; Baldwin et al. 1991; Self et al. 1992a8cb; A. Dyer, personal communication). Benor et al. (1984) have attempted to relate moral reasoning to the medical school admissions process while several other reports involve pre- and posttesting medical students, and relating changes in their moral development to the teaching of medical ethics. The most extensive studies of this nature have been undertaken by Self et al. (1989, 1992b)and by Galaz-Fontes etal. (1989). Thereis also one report in the literature of a successful intervention with undergraduate premedical students in a medical ethics course (Goldman & Arbuthnot 1979). To date, however, there have been no published longitudinal studies on the moral development of medical students in the USA. As a result, very little is known about the relationship of medical education to moral reasoning and moral development. Earlier studies have explored the changes in the attitudes of students during medical education, indicating an increase in cynicism and loss of idealism (Eron 1955; Christie & Merton 1958). More recent studies report an increase in detachment and a decrease in empathy of medical students during their professional education (Zabarcnko & Zabarenko 1978). The relationship between attitudes and moral reasoning, however, is not well understood. There are considerable data from the research of Kohlberg on the general moral development of young adults of comparable age to typical medical students (Colby & Kohlberg 1987a). These data suggest a general increase in moral reasoning skills with maturity. Other research reports, notably by Rest (Rest et al. 1978; Rest 1986). corroborate a steady incrcasc in moral reasoning as a function of increasing age and level of education. This report addrcsses the relationship of moral reasoning to medical education. The hypothcsis of this study is that the mcdical education cxpericncc inhibits the normally expected increase in moral reasoning of medical students. Stated in the null form, the study hypothesizes that there will be no significant increase in the moral reasoning scores of mcdical students from their first to fourth years. This is based, in part, on the view that the rigid,

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hierarchical, authoritarian structure of medical education does not promote tolerance €or differing values, support the conceptual exploration of the fundamental values in medicine, or encourage the cognitive conflict that have been found to be important elements in moral reasoning growth and development. Rather, medical education seems to promote an environment focused on convergent thinking, getting the ‘right’ answer, and maintenance of the rules and regulations of the system, which according to cognitive moral development theory encourages a ‘conventional level’ moral ethos.

Methods The study involved an examination of the change in moral reasoning of 20 medical students who were tested at the begining of their first year and again at the end of their fourth year of medical education. The sample represented 41.7% of the students for that class. The students were recruited as non-paid volunteers after appropriate informed consent. The project was approved by the Institutional Review Board. Although this was not a random sample of medical students, thus creating a potential bias in the data, the original sample represented nearly halfofthe students for that cohort and there were no statistically significant differences between them and the rest oftheir class-mates with regard to age, gender, grade point average scores, or Medical College Admission Test scores. Thus, they appear to be comparable to the other medical students. The implied comparison is based on reports in the literature which demonstrate a correlation between an increase in moral reasoning and an increase in age and educational attainment as previously noted. The instrument used for both the pre-test and post-test mcasuremcnt of moral reasoning was the Moral Judgment Intcrvicw (MJI) developed by Kohlberg (1984). It consists of a 45-minutc, scmistructurcd, oral, tape-recorded intcrvicw in which subjects are asked to rcsolvc a scries of three hypothetical moral dilemmas. Each dilemma is followed by a systematic set of opcncndcd probc questions designed to enable the subject to reveal the logic of his or her moral reasoning.

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D.]. Selfet al.

The dilemmas include the well-known Heinz dilemma of a man considering whether or not to steal a drug to save the life of his wife when all legal means have been exhausted. This forces one to think about the issues of life versus law. This dilemma is followed by the judge’s dilemma of what punishment to give Heinz after Heinz is caught and found guilty of stealing the drug. This forces one to think about the issues of conscience versus punishment and the relationship of legality to morality. The third dilemma is one of a 14-year-old boy considering whether or not to defy his father’s authority when his father breaks a contractual agreement that his father had made with him earlier. This forces one to think about the issues of contract versus authority. Following each dilemma a series of structured probe questions are used to change the circumstances of each dilemma a little to see if one’s view of morality and the logic of one’s moral reasoning changes with the circumstances. A transcript of the interview is scored, yielding two numerical values. One score, the global stage score, represents a category describing the stage structure of a person’s reasoning in Kohlberg’s cognitive moral development theory (Kohlberg 1976). The other score, the weighted average score, is a continuous score that ranges from a possible low of 100 to a maximum high of 500 and is correlated to the stages in cognitive moral development theory. All interviews were scored by the same scorer, thus eliminating the possible problems of inter-rater reliability between scorers. The scorer for this study had been trained by Kohlberg at Harvard University and had a reliability of 100% within a whole stage and 75% within a third ofa stage when compared to the training protocols in the scoring manual. Kohlberg’s theory, which provides the theoretical basis for this study, has been described in summary and in detail elsewhere (Kohlberg 1969, 1981). For purposes of review, the following brief summary is abstracted from a study reported in Academic Medicine (Self et al. 1989). Theoretical overview

Based on 30 years of replicated research, Kohlberg’s theory provides three levels of moral development known as preconventional morality, conventional morality, and postconven-

tional or principled morality. Each level contains two stages. In the preconventional level, stage 1 is an authority-punishment stage in which what is considered right is whatever the authority figures say to do, and the reason for doing it is to avoid punishment. Stage 2 is an egoistic instrumental exchange in which what is considered right is whatever meets one’s own needs, but with a sense of fairness in terms of equal exchange between parties in agreement. For example, a ‘what’s in it for me’ attitude or ‘I’ll scratch your back, if you’ll scratch mine’ approach to morality pervades this stage. In the conventional level, stage 3 morality is concerned with mutual interpersonal expectations, peer relationships, and interpersonal conformity in which what is considered right is what is expected by people close and important to you. Stage 4 involves a concern for societal maintenance and a conscience orientation in which one fulfills one’s agreed-upon duties and contributes to the welfare of the whole group, institution or society. Right is defined in terms of that which maintains a smoothly running society and avoids the breakdown of the system. In the postconventional or principled level moral reasoning, stage 5 emphasizes individual rights such as life and liberty, but endorses a social contract which protects all people’s rights with a commitment that is freely entered upon to serve the greatest good for the greatest number. It is based upon a rational calculation of the best welfare of all humankind. Lastly, stage 6 is based on a commitment to universal ethical principles ofjustice, equality, autonomy and respect for the dignity of all human beings as individual persons. Although laws and social agreements are usually valid because they are based on these principles, when they violate these principles, one acts in accordance with the principles. What is right is that which is required by a personal commitment to these universal ethical principles of justice, equality, autonomy, dignity and respect of persons. The validity of Kohlberg’s system has been well established cross-culturally and under a wide variety of socio-economic situations in scores of studies in 26 cultures. The studies come from both Asian and Western cultures, in both the Northern and Southern hemispheres, and include both longitudinal and cross-sectional

Moral development of medical students studies (Snarey 1985; Rest 1986). According to the theory, people proceed through these stages as they mature. The sequence is invariant, although the rate and end-stage reached vary with the individual. It is important to understand that the theory is based upon the claim that only the structure or justification the person uses determines the stage score. Scores are not assigned based on the content or a particular set of values or moral beliefs that the person holds. What is being tested by the MJI is the person’s structure of moral reasoning and not the person’s particular set of moral beliefs or values nor the person’s actual behaviour. For example, one could be scored at stage 4 while holding either conservative or liberal values. Indeed, whether one holds conservative or liberal values is immaterial to the structure of the reasons one uses in supporting one’s values. Kohlberg’s cognitive moral development theory is not without its limitations and difficulties. Some of the theoretical problems have been reviewed by Reed (1987), Blum (1988) and Gillon (1979). One problem not often noted is the tendency in cognitive moral development theory to equate moral reasoning and justice reasoning. In the earlier description of the theory above, it was noted that the higher stages in Kohlberg’s theory rely on universal ethical principles, especially the principle of justice. Ultimately Kohlberg’s theory is a justice-based theory with the principle of justice being the highest form of morality, although Kohlberg argues that the theory includes the components of both justice and care. The correlative principles of equality, autonomy and respect for the dignity of all human beings are derived from the concept of justice grounded in the moral philosophies of Kant and Rawls (Kant 1956, 1959; Rawls 1971). Kohlberg’s notion of the impartiality of moral obligations to act toward all human beings without special consideration to friends and relatives is based on this concept of justice. Thus what moral reasoning tests purport to measure is a subject’s use of or appeal to various forms of justice reasoning when resolving moral dilemmas, with justice reasoning being thought to be equivalent to moral reasoning. This equivalency is a widely held assumption throughout much of cognitive moral development work.

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Whether justice and moral reasoning are equivalent or not, the approach of cognitive moral development is that ethics is fundamentally a principled approach to rational decisionmaking about value issues. But not everyone accepts this position. There are those who hold that ethics is not and ought not to be a principlebased, rule-governed, rational decision-making endeavour. Gilligan and Noddings believe that ethics is basically non-rational (as opposed to irrational) and based on a commitment to caring for others rather than on principles for rulegoverned, rational decision-making (Gilligan 1977, 1982; Gilligan & Attanucci 1988; Noddings 1984). Theirs is an ethic of care approach in which morality is governed by a concern for and responsiveness to others which espouses a condemnation of all exploitation, violence and harm.

Results The original sample consisted of 22 (45.8%) of the 48 first-year students in the College of Medicine. Complete moral reasoning data preand post-medical education were collected on 20 of the 22 original subjects representing a 9.1% sample loss. The analyses were restricted to those 20 subjects (41.7% of the students for that class) for whom complete data were available. Demographic data were also obtained, including age, gender, undergraduate grade point average scores, and Medical College Admission Test scores. As Table 1 indicates, the weighted average scores (WASs) ofthe medical students ranged from 315 to 482 during the first year, and from 341 to 454 during the fourth year. The mean increase from the first year to the fourth year of the study of 185 WAS points was not statistically significant at the P 6 0.05 level, thus supporting the null hypothesis. From this, it can be inferred that the medical education experience somehow inhibited the normally expected growth in moral reasoning development of these students. O f additional interest is the finding that the range of moral reasoning WASs narrowed between the first and fourth years. During the first year, the students’ WAS spread was 167, which corresponds to approximately one and a half moral development stages. During the

D . ] . Selfet al.

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Table 1. Statistics on MJ1 moral reasoning data of medical students 1st year

4th year

Range

Mean

Range

Mean

Mean change

Weighted average score

315-482

378.2

341454

396.6

18.4

1.11 not significant

Global stage score

3.0-5.0

3.9

3.5-4.5

4.0

0.1

1-40 not significant

&value*

*t-value computed using pooled estimate of common variance

fourth year, the WAS spread was 113 points, or approximately one stage. Taken together, these represent a theoretical difference between years 1 and 4 of approximately three-quarters of a global stage - a significant reduction in moral reasoning variance. Table 2 demonstrates the correlation matrix of demographic characteristics with changes in moral reasoning WASs and Global Stage Scores. There were no significant correlations at the P < 0.05 level between the change in moral reasoning WASs or global stage scores and either age, gender, Medical College Admission Test scores, or grade point average scores. Therefore, it is unlikely that any sampling biases related to these factors attended the study outcome. As an aggregate, these data provide little information to explain the failure of medical students to grow in moral reasoning during the period. Nor do they offer possible directions for educational changes which would enhance medical students’ moral reasoning development during these years. Therefore, data on individual subjects were examined to provide insight into trends of development which might prove useful

in developing programmes for medical students or for changing the structure of medical education. Table 3 describes the medical students’ individual demographic characteristics associated with their moral reasoning scores. These data may provide an explanation for the lack of change in some individuals, the growth in others, and the regression in still others. Overall, the subjects scored in Kohlberg’s conventional level of moral reasoning, although five subjects (5, 7, 10, 16 and 18) scored in the postconventional level on the pretest. Of those students who were postconventional, three regressed to the conventional level at year 4 of medical education, although another three progressed to a postconventional level. There were no significant gender differences between either the conventional subjects or the postconventional subjects, in that some subjects from both genders regressed and some subjects from both gender did not and all who regressed did so to the same extent, namely, half a stage. Similarly, some subjects from both genders progressed to the postconventional level.

Table 2. Correlation of demographic characteristics with changes in global moral reasoning stage scores and weighted average scores Change in weighted average score Correlation coefficient P-value Age Gender* MCAT GPA

-0.217 -0.125 -0.303 -0.094

*Men coded as 1. women coded as 2.

0.179’ 0.300 0.097 0348

Change in global stage score Correlation coefficient P-value

-0.009

0.485

0.055 -0.298 0.007

0.408

0.101 0.488

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Moral development of medical students Table 3. Demographic data and moral reasoning scores of medical students

Weighted Weighted average average

Global stage

Global stage

Change in

score score Change score score global Identity Age number (4th year) Gender MCAT GPA (1st year) (4th year) in WAS (1st year) (4th year) stage

01 02 03

04 05 06

07 08 09 10 11 12 13 14

15 16 17 18 19 20

24 35 28 25 26 34 26 25 25 31 25 24 26 24 24 34 28 26 32 34

Male Male Male

Female Female

Female Male

Female Female Female Female

Female Male Male

Female Female

Female Male

Female Female

53 62 57 52 55 44 53 63 47 58 56 52 56 73 60 66 51 73 55 51

2.15 3.35 3.20 2.79 3.32 2.85 2.61 3.25 2.93 3.55 3.75 3.72 3.45 3.17 3.89 2.76 2.75 3.24 3.13 2.82

326 315 367 348 438 360 443 364 350 482 353 38 1 342 400 379 405 330 435 404 341

Apart from the regression of the postconventional subjects, the general trend in the data was that there was no significant change - either in growth or regression - in the student’s moral reasoning during their 4 years of medical education. Forty-five per cent (n = 9) of the subjects showed no change in their global stage score. In fact, although there were no statistically significant changes in WASs as a group, 35% ( n = 7) of the individuals demonstrated substantive change in their WASs (generally defined in the literature as greater than 33 WAS points). The mean change in WASs was 18.5 points, indicating that there was a positive trend and suggesting some changes were occurring in medical students’ moral reasoning -yet these changes may not be toward positive development. Specifically, only 10% (n = 2) of the subjects decreased substantially in WAS points (33 points or more), while 15% (n = 3) decreased by halfa global stage score between year 1 and year 4. In examining gender differences in WASs, two men and two women regressed. The regression

375 360 444

401 447 387 454 427 369 430 37 1 403 341 417 403 361 348 404 429 361

+49

+45 +77 +53 +9 +27 +11 +63 +19 -52 +18 +22 -1 +17 24

+

-44

+18 -31 25 +20

+

314 3 314 314 415 314 415 314 314 5 314 4

314 4 4 415 314 415 4

314

314 314 415 4 415

4 415 415 314 415 4

4 314 4 4 4

4 4

415 314

0 +0*5 +1.0 +05 0 +0.5 0 +1.0 0 -0.5 +0.5 0 0 0 0 -0.5 +0.5 -0.5 +0.5 0

was more marked in women (x = -48 points) than in males (x = -16 points). In the three cases where the regression was greater than 33 points, the scores were among the highest in the sample. In examining regression in global scores, two women and one man regressed. The regression in each case was half a stage. As with the WASs, those who regressed scored among the highest in the sample.

Discussion Although this was not a random sample of medical students, the participants were 41.7% of the class, and there was no reason to think that they were not comparable to the other medical students since there were no statistically significant differences at the P S 0.05 level between the two groups with regard to age, gender, grade point average scores, or Medical College Admission Test scores. However, although this small sample size makes it difficult to make broad generalizations, the results obtained here suggest

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0.1.Selfet al.

trends to be expected in a larger study. Clearly, additional research needs to be done to investigate, characterize and understand more fully the relationship between medical education and moral development. Although it is possible that the student selection process at the school where the study was conducted inadvertently selects students less susceptible to moral growth, this seems intuitively unlikely and is empirically unsubstantiated. Similarly, while the curricula and teaching staff of other medical colleges might exert a more positive influence on the moral development of their students, there is no reason to believe this is the case while there are plausible reasons to believe this is not the case. The curricula of all medical colleges are highly regulated by accrediting bodies such that generally all medical students take similar subjects in about the same sequence, and frequently use the same textbooks or related teaching materials. So while this pilot study represents only a small sample from one school, the results suggest that concern is warranted, and that more research is needed to explore the relationship of moral development and medical education. The results here indicate that the moral reasoning of medical students does not significantly increase over the 4 years of medical school and that what change there is in moral reasoning during the medical education years is not significantly related to grade point average scores or Medical College Admission Test scores. The trends in the data demonstrate that the range of moral judgement scores of the students decrease after 4 years of medical education, indicating a strong socializing factor of the medical experience. The fact that the majority of the postconventional subjects regressed to conventional reasoning and the fact that those subjects scoring in the lower conventional reasoning range moved to the higher conventional reasoning range indicate a movement towards homogeneity in moral thinking that may be due to the medical education experience. The fact that other subjects in the USA with similar age and educational level do not experience such a narrowing-range effect, implicates qualities of the medical educational system. Of course, with only two points of measurement at the beginning and end of medical education there is no way of

knowing what happened to the moral reasoning of these students in between the measurements. For example, it could be that there is a steady increase in moral reasoning during the first 2 years followed by a steady decrease in moral reasoning during the last 2 years of the medical course or vice versa. These questions can only be answered with a longitudinal study measuring moral reasoning at each of the 4 years of the medical course. Such a study is currently under way. The findings regarding gender differences fail to support the argument by Gilligan (1982) that Kohlberg’s moral reasoning theory is gender biased. Both men and women scored similarly on the pre- and post-data, and both a man and a woman were scored a t the postconventional level of moral reasoning in this sample (stage 45-5.0). What is of interest is not that there are no gender differences in the WAS or global stage scores, or in the number of subjects of each gender who change stage, but that changes, when they occur, are somewhat more likely to be more substantial for women than for men. The data do not provide adequate information to explain this finding readily, except that those who regressed scored among the highest in the sample. This raises some interesting questions about how medical education or the moral atmosphere of medical education may be differentially perceived by men and women who are at postconventional levels of moral reasoning. Despite the recent criticisms by Gilligan and Noddings, and in light of Kohlberg’s acknowlegement that a care ethic has indeed widened the moral domain, the results of this pilot study maintain their importance. Additional studies need to examine whether or not justice is inhibited by the development of care in medical students. Even if morality is understood as a rule-governed, rational decision-making endeavour, Kohlberg’s theory about moral reasoning is still limited in that it is only one component of the complex issue of morality. Rest has pointed out at least four components ofmorality (Rest 1986). These include recognition or interpretation of an issue as a moral issue; judgement about what is right; priority of moral values over other personal values; and perseverance or ego strength to implement one’s moral intentions. Kohlberg’s

Moral development

theory only deals with the second component of moral judgement. So even if Kohlberg’s theory were an accurate and complete understanding of moral reasoning, there still are other important aspects of morality that have to be taken into consideration and need to be studied. However, Gillon (1979) challenges Kohlberg’s theory not on its psychological foundations of adequacy but on its philosophical foundations. Basically he points out the need for a coherent defence of why higher stages are better than lower stages, i.e. why is Kantian (stage 6) morality with reliance on the principles ofjustice and autonomy superior to or better than the egocentric hedonism ofstage 1 or the enlightened self-interest of stage 2? This has been the centre of debate in moral philosophy since before the time of Socrates and has not been settled by Kohlberg or his followers. Nevertheless, since the medical profession appears to accept the importance of moral character and the pursuit of a high moral code of ethics for its members, then closer attention needs to be given to the structure of medical education and the influence it has on the moral growth and development of the students entering the profession. Well-defined, clearly established techniques are available for improving students’ moral reasoning. Early studies by Blatt & Kohlberg (1975) and subsequently replicated by many others (Blasi 1980) have shown that moral reasoning stage change can be stimulated by structured moral dilemma discussions which create cognitive conflict by pitting arguments at one stage of reasoning against arguments at a different stage of reasoning. Recent studies have reported significant increases in the moral reasoning of students in medicine by the formal teaching of medical ethics in the curriculum (Self et al. 1989; Self et al. 1992a,b). These studies indicated that small-group, problem-oriented, case study moral dilemma discussions were the most effective in this regard. The work of Rest (1988) has shown that contrary to popular belief it is not developmentally too late for moral reasoning growth to occur in young adults. Thus, it appears possible that the moral reasoning and moral development of medical students could be enhanced by improvements in the structure of medical education.

of medical students

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Conclusion This study describes a method appropriate for assessing the influence of medical education on the moral reasoning and development of medical students. It suggests that the moral growth and development of medical students appears to be inhibited during their education. These results need to be replicated by others in different settings, both within and outside the medical profession. Since the sample size is small and non-random, it is difficult to draw definite conclusions or broad generalizations from this study. Rather these results should be considered a pilot project suggesting trends to be further explored in larger studies. Additional research needs to be done to investigate, characterize and understand more fully the relationship between medical education and moral development. In particular, longitudinal studies need to be implemented to determine if moral development resumes subsequent to medical education. If these findings are found to be an accurate reflection of the state of medical education, then serious attention needs to be given to how to alter the structure of medical education so as to have it promote the moral development espoused as important to the medical profession.

Acknowledgment This work was supported in part by a grant from the American Medical Association’s Division of Medical Education Research and Information.

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