Ir Med J. 2009 Mar;102(3):69-70.
Healthcare ethics, widely regarded as a pillar of professionalism, is often ill-served by the implementation of adequate academic structures to support it. In this paper we describe the development of a clinical ethics module for medical students which emphasizes the key concepts of Care, Competence and Communication, and describe student feedback arising from this. Students strongly appreciated the clinical model for ethics teaching as well as the need for further initiatives to integrate the humanities aspects appropriately. Feedback also pointed to the well-documented need for assessment procedures and academic supports for ethics programmes.
In a 2004 survey in the US, one-fifth of medical schools provided no funding for ethics teaching, and 52% did not fund curricular development in ethics1. In the UK, a similar survey showed an urgent need for full-time—rather than part-time or voluntary—teachers, funding for books and journals, and additional teaching materials2. Experience in France parallels this3. The situation in the Republic of Ireland is little better, with few dedicated substantive appointments in the majority of medical schools, and little by way of requirement for formal academic credits in ethics for medical students. There is an onus on medical schools to develop an appropriate vision of ethics research and of undergraduate and postgraduate education as well as the appropriate structures to support these. We have already described the imperative to ensure that clinical ethics teaching is adequately grounded in both clinical practice and in the humanities. This educational philosophy aims, among other goals, to ensure due consideration of the ‘hidden curriculum’, and to avoid an undue dependency on the ‘principlism’ of Beauchamp and Childress4. It also aims to give a stronger voice to the perspectives of clinicians in the academic development of ethics.
This course in medical ethics was a new development in the School of Medicine, Trinity College Dublin, and preceded any requirement for formal academic credits in ethics. Its title MedLine Ethics, characterises our belief that, just as in other areas of medicine, there is a very significant repository of evidence-based literature to support good ethical decision making, as well as excellent review and discussion papers, in virtually all major, and specialty, medical journals. The course highlights the three key features which we hypothesize to underpin clinical ethics – Competence, Care and Communication.
Competence reflects the need to ensure that decision-making is well-founded; being informed on the outcome of tube-feeding in dementia5, for example, or appreciative of a possible favourable impact of antibiotics in palliation6. Care represents the imperative to ensure appropriate mobilisation of specialties, from recognizing the high level of misdiagnosis of those thought to be in a persistent vegetative state7, to wider awareness of the care options for those with dementia and feeding difficulties8. Both of these components are important for rescuing clinical ethics from the artificial dichotomies beloved of the media and, at times, of non-clinician ethicists9. Finally, Communication is a key element of good clinical ethics practice10, and is particularly important (and nuanced) for those with cognitive and communication difficulties, which occur commonly in the diseases of later life. A benefit of this triad of qualities is to lend a therapeutic as well as analytic quality to clinical ethics interchanges11.
This course was run as a series of five or six symposia, pairing an overview of a specific conceptual topic by a philosopher theologian (on for example care, autonomy and justice in a pluralist cultural contest) with a presentation by a senior clinician on their insights into how clinical ethics affects their everyday practice, covering topics such as care of prisoners12, tube-feeding in dementia, and information sharing with patients and relatives13. The key text on the reading list was Complications, a series of essays by a philosopher who subsequently trained as a surgeon14, while a range of other accessible peer-reviewed resources were also suggested. In keeping with the MedLine theme, the assignment was a 2,000 word essay on a clinical ethics topic grounded in at least 10 clinical ethics papers cited by MedLine. Summative student evaluations were conducted each year (2004–7). Students valued the clinical input highly across all years (e.g. 72% in 2007). There was considerably less appreciation for ethical concepts (e.g. 35% in 2007). Notwithstanding that distinction, the course did encourage critical thinking and reflection. Students rose to the challenge of the assignment, in terms of articulating ethics at the interface between concepts and contexts, and this was reflected in the marks for their essays. However, the proximity of an uncredited, time-consuming course close to examinations became problematic and ethics fatigue was evident by year 3. In consequence, adjustments in approach in 2007, which increased attendance and participation, had a positive effect on morale and on the perceptions students had of the relative success of the course.
This is the first report in the Irish biomedical literature of the development and evaluation of clinical ethics teaching. It is important that students should develop a perceptiveness which helps them understand the overt and sometimes not so overt ethical principles and value frameworks underlying practice and develop an articulacy in supporting, sustaining and defending professional practice15. For example, the very act of trying to create a sense of helping vulnerable patients to think through and understand the implications of assessment and treatment has in the past been negatively called paternalism, something widely argued in the ethics literature to be antithetical to patient autonomy. Less factionalized contemporary perspectives on autonomy and care in ethics would suggest that clinicians may indeed be honouring the dignity and autonomy of patients in the support given to vulnerable patients.
Many of the ethical dilemmas which have been highlighted through the courts in the last few years have often represented elements of failure of competence, care and communication. Clinical ethics teaching should recognise the importance of these three pillars of good practice in creating a therapeutic environment within which trust can be developed between clinician and patient16. Contrary to popular portrayals, ethical dilemmas tend to occur in a timeframe whereby there is room for knowledge acquisition, confidence building and a sense of ongoing participation in decision making. Teaching should facilitate students in developing an articulacy in conceptual analysis, pointing towards appropriate resources and disciplines. As this paper illustrates, it is also necessary to give full academic credit and supports to students and to teachers, in order to do justice to the intellectual discipline of ethics and the contextual complexities of good clinical practice.
Acknowledgements
We are grateful to Prof M Junker-Kenny for her advice throughout the course, and to Drs Shaun O’Keeffe, Declan Lyons, Regina McQuillan and Stephen Higgins for their contributions. Dr Russell was funded for the development of small group teaching in Clinical Ethics for 3 years by the Broad Curriculum , and then by the School of Medicine, TCD.
C Russell1, D O'Neill2
1School of Religions,Theology and Ecumenics, Trinity College Dublin, Dublin 2
2Aois agus Eolas, the Centre for Ageing, Neuroscience and the Humanities, Trinity Centre for Health Sciences, Adelaide and Meath Hospital, Tallaght, Dublin 24
Email [email protected]
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