Donnie J. Self

The moral development of medical students: a pilot study of the possible influence of medical education

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. Kohlbergs 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≤ 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 Kohlbergs cognitive moral development theory, some interpretations and explanations are given for the findings of the study.

Evaluation of teaching medical ethics by an assessment of moral reasoning

Summary. This study assessed the hypothesis that the formal teaching of medical ethics promotes a significant increase in the growth and development of moral reasoning in medical students. Results indicated a statistically significant increase (P ≤ 0.0005) in the level of moral reasoning of students exposed to a medical ethics course compared to the control group that was not exposed to the medical ethics course. When the posttest scores were adjusted by subtracting the pretest scores, the differences were even more significant (P ≤ 0.0002). This study confirmed similar findings of another study using a different instrument of assessment. Brief discussion is given of the fundamental premise that the appropriate function of teaching medical ethics in our modern pluralistic society is to improve students’ moral reasoning about value issues regardless of what their particular set of moral values happens to be.

The amount of small-group case-study discussion needed to improve moral reasoning skills of medical students.

PURPOSE: To examine how much exposure to small-group case-study discussion is necessary to significantly increase moral reasoning skills. METHOD: For the classes of 1991-1998 at Texas A&M, using Rests Defining Issues Test, the authors tested groups of students for moral reasoning skills both before and after the students participated in small-group case-study discussions of medical ethics. RESULTS: From 960 students asked to participate, the authors collected complete data for 729 students (75.9% response rate). Small-group case-study exposures ranged from 0 to 44 hours. Groups of students exposed to 20 hours or more demonstrated a significant increase in their moral reasoning scores. Groups with less than 20 hours of exposure demonstrated no significant increase in their scores. CONCLUSION: This study indicates that moral reasoning skills are teachable and measurable, and that small-group discussion significantly increases moral reasoning skills. Further studies are needed to increase the generalizability of these findings.

Ethics Consultation: The Least Dangerous Profession?

Whether ethics is too important to be left to the experts or so important that it must be is an age-old question. The emergence of clinical ethicists raises it again, as a question about professionalism. What role clinical ethicists should play in healthcare decision making – teacher, mediator, or consultant – is a question that has generated considerable debate but no consensus.

The Influence of Gender on Conflicts of Interest in the Allocation of Limited Critical Care Resources: Justice Versus Care

After noting that the principle of autonomy has been inadequate for the resolution of many of the complex and difficult moral dilemmas involving conflicts of interest in the allocation of limited critical care resources, this paper analyzes the concepts of justice and care as alternative solutions to moral problems and applies them to the issue of repeat organ transplants to a single recipient. These concepts are found to be the basis of the notions of moral reasoning and moral orientation, respectively, which serve in moral development theory as two fundamentally different ways to approach moral problem solving. Following an elaboration of moral reasoning as found in Kohlbergs cognitive moral development theory, the influence of gender on moral reasoning is investigated. The empirical data show that women (mean Defining Issues Test score, 47.18) score significantly higher (P < or = .0001) than men (mean Defining Issues Test score, 41.77) in the use of moral reasoning based on the concept of justice for resolving moral dilemmas. Following an elaboration of moral orientation as found in Gilligans moral theory of the ethics of care, the influence of gender on moral orientation is investigated. The empirical data show that women use the concept of care significantly more often (P < or = .0139) than their male colleagues in resolving moral dilemmas. From these data it is concluded that men are more likely than women to use justice in the resolution of moral dilemmas, such as the conflicts of interest in the allocation of limited critical care resources, but that if women do use, or are required by the social system to use, justice in the resolution of moral dilemmas, they do a better job of it than men.

Retention of moral reasoning skills over the four years of medical education.

Background: There has been increased interest in moral reasoning of medical students. No longitudinal studies have addressed retention of these skills. Purpose: This study was conducted to demonstrate whether moral reasoning skills developed in a medical ethics course would be retained in subsequent years. Methods: The Defining Issues Test was used for assessment of moral reasoning. First‐year students were pretested, taught a medical ethics course during the 1st semester, and posttested at the end of the 4 subsequent years. Results: After documenting the significantly increased, p ≤.00025, moral reasoning skills, this study demonstrates retention of these moral reasoning skills at the end of 2nd year, p ≤ .00001; 3rd year, p ≤. 00001; and 4th year of medical education, p ≤ .00001. Conclusion: This study demonstrates that the teaching of medical ethics can be rigorously measured and tested and that it can have a sustained positive influence on the moral reasoning skills of medical students.

A comparison of the moral reasoning of physicians and clinical medical ethicists.

BACKGROUND. Because of the increasing controversy over who should provide ethics consultations, this study investigated differences in the moral reasoning and moral orientations of physicians and clinical ethicists. METHOD. From 1987 through 1990, extensive interviews were conducted with 39 physicians and 50 clinical medical ethicists (26 philosophers and 24 theologians) who were at 32 medical centers in 14 states from all sections of the United States. The interviews were used to gather selected demographic characteristics (age, gender, and profession–physician or ethicist) for the 89 individuals as well as to determine their scores for moral reasoning and moral orientation. Polyserial correlations and multivariant analyses were then performed between the demographic characteristics and the data on moral reasoning and moral orientation. RESULTS. The physicians consistently scored lower than the clinical ethicists in their moral reasoning skills in terms of both moral stage score (p < .01) and weighted average score (p < .01). However, the physicians were found not to be significantly different (p < .05) from the clinical ethicists in their moral orientations toward justice or care in terms of recognition, predominance, or alignment. No significant relationship was found between age and moral orientation. A significant relationship was found between age and stage of moral reasoning, with the older individuals scoring higher. No significant relationship was found between gender and stage of moral reasoning. A significant relationship was found between gender and moral orientation: the women were more likely to recognize elements of care in moral dilemmas and the men more likely to recognize elements of justice. CONCLUSION. This study provides initial evidence that clinical medical ethicists, whether philosophers or theologians, may be better skilled than physicians to do ethicists consultations. To the extent that higher levels of moral reasoning correlate with superior skills in performing clinical ethics consultations, this study shows the value of bringing philosophers and theologians into the clinical setting.

Teaching medical humanities through film discussions.

Following a brief consideration of two contrasting purposes for teaching the medical humanities, a description is given of a film discussion elective course. In contrast to the usual teaching of medical ethics which is primarily a cognitive activity emphasizing the development of a code of principles such as justice, autonomy, and beneficence, the film discussion elective was primarily an affective activity emphasizing the development of an ethical ideal of caring, relatedness, and sensitivity to others. The pass/fail elective, offered for one credit each quarter for two quarters, met once a week for one hour for twenty-four weeks. Each week a film was shown followed by a group discussion. A wide variety of social issues were covered. The objective of the course was to increase the ethical sensitivity of the medical students through promotion of introspection and reflection on social issues. A brief discussion is given of the importance and appropriateness of using film to promote the affective focus of medicine on the relief of suffering. Examples are given of how the course achieved its objective. A detailed description of the resource materials is provided.

An analysis of ethics consultation in the clinical setting.

Only recently have ethicists been invited into the clinical setting to offer recommendations about patient care decisions. This paper discusses this new role for ethicists from the perspective of content and process issues. Among content issues are the usual ethical dilemmas such as the aggressiveness of treatment, questions about consent, and alternative treatment options. Among process issues are those that relate to communication with the patient. The formal ethics consult is discussed, the steps taken in such a consult, and whether there should be a fee charged. We conclude with an examination of the risks and benefits of formal ethics consults.

The pedagogy of two different approaches to humanistic medical education: cognitive vs affective.

The enormous growth in medical humanities programs during the past decade has resulted in an extensive literature concerning the content of the discipline and the issues that have been addressed. Comparatively little attention, however, has been devoted to the structure of the discipline of medical humanities concerning the process or the theoretical aspects of the pedagogy of teaching the discipline. This report explicitly addresses the pedagogical aspects of the discipline by comparing and contrasting two different basic approaches to the discipline referred to as the classical humanities approach and the humanistic psychology approach which roughly approximate the cognitive and affective approaches respectively. These two approaches are compared and contrasted in terms of their goals, objectives, methods of implementation, philosophical assumptions and evaluational techniques.