The COVID-19 pandemic has underlined the importance of ethical expertise for hospitals and healthcare providers. The same is true of future clinicians.
“Students seem to now sense more fully the vital importance of ethical considerations in medical care,” reports Robert Klitzman, MD, a professor of psychiatry and director of the online and in-person bioethics master’s and certificate programs at Columbia University.
Ethics education “should be a lifelong process, not only a one-time course in medical school,” says Maya Sabatello, LLB, PhD, an associate professor of clinical bioethics at Columbia University. Look closer at some current approaches:
• Ethics training is timed to coincide with the transition to clinical practice. Hearing about ethical principles several years before ever encountering an actual patient is not ideal. “Students often find it hard to apply classroom lessons to the emotionally fraught moral quandaries they face,” Klitzman observes.
Case examples are a tried-and-true way to stimulate discussion of ethics. “However, learning about ethics through direct experience, and by observation, is often more powerful, and with longer-term impact,” Sabatello offers.
Real-life clinical practice does not always match what students learn in the classroom. “Unfortunately, they see physicians who, not uncommonly, fail to optimally follow ethical principles. This can lead to jadedness and disillusionment,” Klitzman laments.
For instance, new clinicians may observe patients who are poor or from certain ethnic and racial groups receive worse care. “Students may feel that these disparities are somehow acceptable because these persist without much comment,” Klitzman says.
Not all clinicians are respectful to all patients every time. Patients do not always understand procedures adequately. “Ethics education should explore challenges to optimal ethical behaviors,” Klitzman suggests.
That way, students enter clinical practice already aware that competing pressures on clinicians exist. “Training should address ways of overcoming these barriers. It should also examine larger systemwide impediments to ethical care,” Klitzman adds.
More pre-medical and medical students, residents, fellows, and other physicians are taking bioethics courses and obtaining certificates and master’s degrees in bioethics, according to Klitzman. “The field is rapidly growing. That is helping physicians and hospitals take better care of their patients.”
Louise P. King, MD, JD, teaches professionalism to incoming first-year students at Harvard, using a case-based format.
“The focus is very much on discussion. Their favorite part of ethics is interacting with their peers,” says King, an assistant professor of obstetrics, gynecology, and reproductive biology.
When students repeat the course in their third year, they are asked to share ethically nuanced case examples with the group from their own clinical experience. “The key is having everybody, including senior leadership, being very open to hearing from students on everything they are seeing,” King reports.
Ethics training is most effective when it correlates to what the trainee is exposed to in the clinical setting, says Autumn Fiester, PhD, associate chair for education and training in the department of medical ethics and health policy at the University of Pennsylvania Perelman School of Medicine. “For many years, it has been clear to me that medical students are far more receptive to bioethics training in their fourth year of medical school,” Fiester says.
By that time, students have experienced some clinical training. In contrast, in the first year, students are steeped in book learning. Even in the fourth year, after two and a half years of clerkships and electives, many bioethics issues remain theoretical, according to a study on which Fiester worked.1
Fiester and colleagues argued bioethical training should be postponed until residency. “It is surprising that it is taking the field so long to tailor bioethics training to student need,” she notes.
A lot of bioethics training in medical school still occurs “at a time that’s convenient for the curriculum planning. It is not correlated to what students need to know, and when,” Fiester adds.
• Instructors are looking at ethics more broadly. “Ethics education calls for consideration of values and principles that are beyond medicine per se,” Sabatello explains.
Much training narrowly focuses on topics such as informed consent. “Medical ethics needs to be taught across contexts, including disability ethics, race/ethnicity, and community engagement,” Sabatello offers.
Sabatello says education should focus on “ethics action, highlighting the responsibility to speak up against injustice in medical practice and healthcare, and to act to make a change.”
• Ethics training is tailored to specific specialties. “Our goal has been to introduce a rigorous framework around which we could measure success in the teaching of ethics. This continues to be a work in progress,” says Alexander Langerman, MD, SM, FACS, director of the second-year medical student clinical ethics course at Vanderbilt University Medical Center in Nashville. The ethics curriculum is based on these core ethics competencies, specific to various clerkships:
- Medicine: advance planning and end-of-life discussions;
- Surgery: informed consent;
- Pediatrics: the patient/family/provider triad;
- Obstetrics and gynecology: women’s autonomy, unborn child’s interests, and partner’s rights;
- Neurology/psychiatry: decision-making capacity.2
During their clerkships, students encounter a surprisingly wide range of ethical topics. Some were not initially included in the key competencies. “Many involved the challenges of real medical care, where you encounter ethical dilemmas with no ‘right’ answer,” says Langerman, core faculty at Vanderbilt’s Center for Biomedical Ethics and Society, where he directs the surgical ethics program. For example, patients’ social support or cognitive abilities can pose challenges to the use of potentially life-saving therapy. Faculty continually tweak the competencies to better prepare students for difficult cases. “We are doing so methodically. We’re also continuing to update our methods for assessment of understanding,” Langerman says.
Ethics educators are well-aware many demands compete for students’ time. “Ethics doesn’t lend itself well to multiple choice. Yet we can’t also expect a five-page dissertation,” Langerman notes.
Faculty tried asking students for short narratives on relevant ethical topics, but grading such submissions objectively was difficult. Currently, faculty are fine-tuning a new method: Asking students to apply analytic frameworks to cases. “This will most closely approximate how physicians use ethics to help make clinical decisions,” Langerman says.
- Stites SD, Rodriguez S, Dudley C, Fiester A. Medical students’ exposure to ethics conflicts in clinical training: Implications for timing UME bioethics education. HEC Forum 2020;32:85-97.
- Langerman A, Cutrer WB, Yakes EA, Meador KG. Embedding ethics education in clinical clerkships by identifying clinical ethics competencies: The Vanderbilt experience. HEC Forum 2020;32:163-174.