Giving Voice to Values as a Professional Physician

An Introduction to Medical Ethics

Ira Bedzow

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429757891
• Edition: 1
• Topic: Betriebswirtschaft
• Subtopic: Business allgemein

Giving Voice to Values as a Professional Physician provides students with the theoretical background and practical applications for acting on their values in situations of ethical conflict. It is the first medical ethics book that utilizes the Giving Voice to Values methodology to instruct students in medical ethics and professionalism.

In doing so, it shifts the focus of ethics education from intellectually examining ethical theories and conflicts to emphasizing moral action. Each section of the book explains how moral decision-making and action can be implemented in the healthcare arena. Medical ethics cases are provided throughout in order to assist students in giving voice to their values and developing skills for professional action. The Giving Voice to Values methodology, and the cases in this book, do not focus on the big questions of academic ethics, but rather on the ethics of the everyday, even if the challenges presented are difficult. In other words, the ethical questions students will have to face, in this book and in medical education and practice, are about how to interact with others, whether they be patients or colleagues, who might have different ethical positions.

The book provides a unique guide for professional identity formation and the teaching of ethics in medical schools.

1

Ethics, professionalism, and Giving Voice to Values

Before the mid-nineteenth century, medical ethics was thought to be a personal ethics that was derived from a physician’s understanding of his role, and its requisite duties, in society. Moral traits, or virtues, were delineated to characterize what constituted a good physician, and individuals endeavored on their own to develop good characters and uphold the values of the profession. For example, Benjamin Rush, a Founding Father of the United States and Surgeon General in the Continental Army, gave a lecture in 1801 entitled, “On the Vices and Virtues of Physicians,” which described the moral virtues that are consistent with being a good physician and which vices physicians should avoid.

As the medical profession attempted to gain professional autonomy (which in this case means the autonomy of physicians as a group to self-regulate who could be admitted into the profession and not the autonomy of individual professionals to assert their own values), the view of what constituted proper professional practice changed from focusing on the personal development of individual physicians to creating a uniform set of norms to which all professionals should adhere. In 1847, in order to create such a standard that would be consistent for physicians, the American Medical Association (AMA) published its first Code of Ethics. In doing so, the AMA changed the practice of medicine from being based in personal moral character to being based on a standardized professional code of conduct. The code established a model which attempted to standardize ethical decisions for medical situations, giving professional consensus moral authority over any person’s individual conscience. As such, the AMA Code took primacy over a physician’s personal, religious, or moral beliefs and values in an attempt to bolster the authority of the profession. (Though, the current AMA code does allow for conscientious objection when a certain practice goes against a physician’s personal, religious, or moral beliefs.) This transition changed how professionals viewed medical ethics, since under the authority of the Code, questions of medical ethics were reframed in terms of what to do in a situation and not necessarily which values one should adopt and convey as a physician.

While today, most if not all health care professions and specialties have codes of ethics specific to them, there has been increasing emphasis on explicit instruction and adoption of professional values and the development of professional (or moral) character traits. This emphasis is relatively new in medicine. The term “professionalism” as a way to connote humanistic and moral values, such as altruism, duty and service, accountability, and excellence, only started to be used in the 1990s, though the concept began to take shape in the mid-1980s. ¹ This is not to say that before the 1980s physicians did not try to develop personal moral values and apply them in their medical practices. Many doctors did just that, but as part of their own moral development and growth. Today, however, there is a push to formalize professionalism as an educational competency and a priority for clinical practice.

The importance of professionalism in the current health care environment cannot be stressed enough, and explicit instruction geared towards the development of proper professional habits must come early and must be reinforced often. Quality of care is becoming a greater priority, medical technology is becoming more and more sophisticated, and society is becoming more culturally and religiously diverse, leading to tensions between values among stakeholders. As such, professionalism has become a greater part of one’s educational and employment responsibilities than ever before.

Because recognition of the importance of professionalism is widespread, professionalism has become a required competency in undergraduate and in graduate medical education. All medical schools across the country are attempting to introduce the subject into their curricula both longitudinally across the four years of medical school and horizontally among different courses and clerkships. Given the relationship between medical ethics and professionalism, most professionalism training begins with courses in medical ethics during the preclinical portion of the curriculum, which is then reinforced in practice during students’ clinical rotations. Yet, the scholarly literature shows that there is actually an erosion of professionalism and humanism among medical students and residents as they proceed through their education. ² This phenomenon is not due to a lack of awareness, since the need to develop ways to nurture medical students’ compassion is well recognized, nor is it a result of a lack of available resources. Rather, it is due, in part, to the inability to provide a means to combine the teaching of ethical theories and professionalism concepts with skills and tools for habit formation that can be demonstrated through observable behaviors. As David Thomas Stern has noted, “While educators have made great strides over the past 50 years in assessing knowledge, and over at least the past 20 years in assessing skills, the assessment of behaviors and professionalism has lagged.” ³ Instruction of professional skills and the inculcation of professional habits is more difficult than teaching clinical knowledge and training students to develop proper clinical skills and behaviors, since professionalism also includes an affective component, where students’ attitudes and motivations toward adopting those behaviors include personal identification with the values those behaviors express. What has ultimately been lacking, therefore, is a truly transformational approach to professionalism education, in which the focus is not just on knowledge acquisition, but also on affective and behavioral change.

Currently, early medical ethics education consists of teaching students ethical terms and theories, as well as professional codes and rules regarding different aspects of medical practice, so that students can understand the general ideas behind ethical controversies or challenges that they may face in clinical practice. The pedagogical assumption behind this method of ethics instruction is based in Lawrence Kohlberg’s cognitivist theory of moral development. While Kohlberg’s theory primarily relates to the moral development of children, it is applied to the ethical and professional development of students in the following way: When they enter the professional community, students are still at the pre-conventional reasoning level, where they perceive professional and medical ethics challenges from their own egocentric frame, reasoning through cases from their own perspectives and experiences. Through giving students professional codes and laws, and by having students talk about ethical cases, students will reach the conventional reasoning level, where they learn to recognize and apply the social conventions of the profession. When they enter the clinical stage of their education, students will obey social rules but are also expected to learn how to apply moral principles to particular situations, recognizing the nuances of their experiences. In this post-conventional level, their professionality and ethical habits will be based in their ethical thinking rather than considering what to do situationally or through simply imitating their teachers and colleagues. In the Kohlbergian methodology, moral action stems directly from moral thinking. If a person is able to determine the right course of action, he or she will automatically follow it. Also, Kohlberg assumed that once a person reaches a higher level of moral reasoning, he or she will apply it uniformly across different situations and will not slide backwards to lower stages.

While there is much to the Kohlbergian model for medical ethics education, it has been challenged by empirical studies that have tested the behavior of students in their clerkship years. For example, Hegazi and Wilson assessed moral judgment competence in 880 medical students in Sydney, Australia, over two different studies to determine whether moral development occurs during medical school or not. ⁴ Participants completed Lind’s Moral Judgment Test, which is based on Kohlberg’s stages of moral development. They found that students did not apply moral principles consistently over different contexts. Rather, students decreased in moral judgment competence with respect to applying ethical principles to medical scenarios but remained at the same level of competence for non-medical scenarios. ⁵ Similarly, Feitosa et al., observed regression of moral judgment competence in medical students in Brazil, and stagnation, with a tendency to regression, of moral judgment competence for medical students in Portugal from the first semester to their eighth semester of medical school. ⁶ Also, Slováčková, and Ladislav observed a significant decrease in moral judgment competence for 310 Czech and Slovak and 70 foreign national students at the Medical Faculty of Charles University in the Czech Republic. ⁷

This disconnect in terms of what students are learning in their preclerkship ethics courses and how they are acting during their clerkships raises questions about the existence of a “hidden curriculum,” where students are learning unprofessional and unethical social conventions through observing how faculty and residents behave. The regression is explained by positing that these conventions have a much stronger influence on students’ professional identity, since they perceive these behaviors as the actual conventions to obey rather than identifying with the overt instruction that they receive in the classroom. The notion that students learn professional and ethical behavior through their environment, rather than through direct instruction of ethical theory, is supported by John Haidt’s social intuitionist theory of moral action.

Haidt’s Social Intuitionist Model advances the idea that moral reasoning is subsequent to an automatic process, where decisions are made quickly, effortlessly, and unconsciously, rather than being intentional and effortful, and only after a decision is made does the person think about the ethics of it. ⁸ In other words, moral reasoning serves to give rationalizations for conclusions rather than giving reasons for them. Haidt’s theory holds that there are five sets of intuitions that ground morality, namely, harm/care, fairness/reciprocity, authority/respect, purity/sanctity, and in-group/out-group. ⁹ Moral development occurs through a process whereby the five moral intuition sets interact with an external social environment that promotes particular values. As opposed to the Kohlbergian view that moral development is being hindered by an immoral hidden curriculum, in this model, moral development is a consequence of how one’s environment interacts with a person’s moral intuitions. In other words, one theory’s hidden curriculum is the other theory’s situational influences. The difference between the two terms is that in the Kohlbergian approach, the “morally inappropriate” environment interferes with student’s moral development, whereas in Haidt’s theory, the environment inculcates different moral values that students learn as part of their moral development. ¹⁰ Therefore, under Haidt’s interpretative scheme, the medical students in the above studies do not demonstrate moral regression or segmentation; rather, their moral judgment did develop, albeit according to the values presented in their new environment.

If Haidt’s Social Intuitionist Model is correct, then a Kohlbergian approach, where educators provide a stronger foundation in moral theory to students in medical ethics classes would not be effective in creating humanistic professionals. What is required is a change of culture in hospitals so that medical students’ intuitions develop through exposure to the professional culture that we want to exist rather than the one that exists at present. Any education in moral theory would only provide justification after-the-fact for choices made; it would not inculcate medical ethics thinking or professionalism in an environment where it does not exist already.

These finding are not particular to medical ethics education. In the book, Lost in Transition: The Dark Side of Emerging Adulthood, ¹¹ the authors discuss the results of interviews they conducted with 230 young adults to determine what issues were facing America’s youth. Based on their interviews, the team saw that the way in which young adults thought about ethical questions in the abstract did not relate to the way they actually acted in situations where they could have implemented their abstract thinking. The interviewees were able to answer questions concerning extreme cases of right and wrong, implying that they were able to think about morality and make moral decisions. Yet, when asked about their own personal lives, they did not rely on any moral reasoning when answering even basic questions. Rather, they deferred to how they felt or how they regularly acted in those types of situations.

This example seems to support Haidt’s social intuitionist theory, yet there is a different explanation which can account for why people revert to personal experiences to justify their actions yet still use moral thinking when considering abstract cases. It can also explain the change in moral judgment competence of students when faced with medical scenarios but not nonmedical scenarios. This alternative explanation allows for Kohlbergian prescriptivity, in that there is a definite trajectory of moral development that medical ethics and professionalism should promote, while accepting Haidt’s descriptive observations of how one’s social environment influences a person’s moral development. ¹² The disconnect between students’ ability to reason in abstract and their inability to apply ethical thinking to their own lives should be understood in terms of what is called the moral gap between thinking and acting. Living ethically is about both moral thinking and moral action – the two are distinct, with different skills needed to do either well. Having one set of skills does not necessarily entail that you have the other. In order to come up with a moral decision and to act on it, people must think about how to evaluate different moral choices, as well as the personal and situational factors that affect which choices one can implement. Coming up with the right answer of “what should be done” does not easily translate to the right answer of “what I can do.” When students deliberate on “what should be done,” they may reach an answer that they do not know how to implement or are unable to implement, given their practical knowledge, personal strengths and weaknesses, or their role in the group that faces the moral challenge. When “what should be done” conflicts with “what I can do,” students will revert to answering the question “what I can do” based on what they have seen done or have done in the past. It is not that students cannot come up with moral decisions; it is that they cannot conceive of a plan to enact them and give voice to their values. However, if students are trained to imagine how they can act in a way that aligns with their values in different situations and can practice doing so, they will be able to develop skills and “moral muscle memory” to make it easier to do so in the future. In a sense, they will be learning how intellectual moral competence (the Kohlbergian approach) can be complemented by awareness of the social-intuitionist approach so that students are able to expand their view of what is possible and “re-wire” instinctive, emotional responses. This will make values-driven action more likely, since they will be aware of the environmental challenges and opportunities that may be present and have tools to act in that environment, rather than simply knowing what should be done without knowing how to do it – or worse, simply accepting inaction out of a sense of inefficacy.

The uniqueness of professionalism education

Professionalism education is particularly challenging because unlike other medical education competencies, the objective criteria for demonstrating professionalism is not clear cut in terms of providing operational definitions. Many definitions for professionalism can be found, from short descriptions, such as:

Medical professionalism is a belief system in which group members (“professionals”) declare (“profess”) to each other and the public the shared competency standards and ethical values they promise to uphold in their work and what the public and individual patients can and should expect from medical professionals, ¹³

to longer definitions, such as the one laid out in the Physician Charter, authored by the ABIM Foundation (American Board of Internal Medicine), in conjunction with the ACP Foundation (American College of Physicians) and the European Federation of Internal Medicine, which includes a definition, fundamental principles, and professional responsibilities. ¹⁴ Despite the numerous definitions (and attempts to assess student professionalism), however, most faculty and students rely on intuition rather than objectivity, and adapt Justice Potter Stewart’s definition for pornography (“I know it when I see it”), thereby relegating professionalism to a category that is subjective and lacking of clearly defined parameters.

While the requirements for any assessed competency in medical education should be clear, complete and concise, with multiple opportunities for students to be observed, evaluated, and given feedback, professionalism as a competency currently has no standard either for instruction or assessment. This is because professionalism is unique in two respects. First, professionalism is not strictly a matter of knowing content or performing certain behaviors. It entails identifying with certain beliefs, principles, and values, is associated with having certain attitudes towards those beliefs, principles, and values, and is manifest in certain behaviors. While behavior can be observed and assessed, such as measuring a ...