The History and Bioethics of Medical Education

"You've Got to Be Carefully Taught"

Madeleine Mant, Chris Mounsey, Madeleine Mant, Chris Mounsey

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000379778
• Edition: 1
• Topic: Historia
• Subtopic: Historia del siglo XX

The History and Bioethics of Medical Education: "You've Got to Be Carefully Taught" continues the Routledge Advances in the History of Bioethics series by exploring approaches to the teaching of bioethics from disparate disciplines, geographies, and contexts. Van Rensselaer Potter coined the phrase "Global Bioethics" to define human relationships with their contexts. This and subsequent volumes return to Potter's founding vision from historical perspectives and asks, how did we get here from then? The patient-practitioner relationship has come to the fore in bioethics; this volume asks: is there an ideal bioethical curriculum? Are the students being carefully taught and, in turn, are they carefully learning? This volume will appeal to those working in both clinical medicine and the medical humanities, as vibrant connections are drawn between various ways of knowing.

Part 1
The Ethical Toolkit
Pedagogical Responses and Meaning-Making in Bioethics

1 Bioethics Teaching Methodology for Medical Residents, and Nursing and Biomedical Engineering Students

Vittoradolfo Tambone and Giampaolo Ghilardi

Introduction

Campus Bio-Medico University is a modern university founded in 1993 in Rome. Its faculties include Medicine and Surgery, Engineering, Nursing, Medical Radiology and Radiotherapy Techniques, Food Science and Human Nutrition. Its many postgraduate courses include master’s and medical residency programs, Continuing Medical Education courses and Ph.D. programs in Medicine and Engineering.

Bioethics is taught in every faculty, reflecting its defining role in the philosophy upon which the university is founded. As stated in its Charter of Purposes:

[t]he university, in carrying out high level scientific research, inspired by a passion for truth and the common good, and promoting unconditional respect for the life and dignity of every human person, aims to respond to the needs and development of today’s society, integrating humanistic knowledge with scientific and technological knowledge.¹

The pivotal role of ethics in the university’s governing philosophy is further expressed in its Charter of Purposes’ position on reductionism – analyzing complex scientific phenomena through studying their basic elements – in biomedical research and practice:

[r]esearch and teaching activities shun all forms of reductionism² and promote the elaboration of a cultural synthesis that harmonizes the various sciences in the search for truth and that favors the unity of knowledge and the development of personal character in all its facets.³

Bioethics is also at the root of the Charter of Purposes article defining the university’s commitment to offering a humanistic education:

[t]o offer the opportunity to reflect on the meaning of life, in a profound vision of the human being and to lay rational foundations for ethics and professional codes of conduct, the university integrates the study of scientific and technical subjects with courses in the humanities including philosophy, theology and bioethics.⁴

These excerpts from the Charter of Purposes illustrate the university’s level of commitment to bioethics and its perception of bioethics as an integral part of the teaching and practices throughout the institution, beyond the specific obligatory courses. At Campus Bio-Medico University, bioethics was central to the principles of its founders and therefore continues to be the guiding principle behind its teaching methodologies. Thus, questions of bioethics and their role in our teaching and practices are constantly being evaluated and updated.

On the Nature of Bioethics and Its Translation in the Curriculum

Since bioethics deals with ethics and life, we structured a curricular path where students begin by studying anthropology, where the focus is on humans and their nature, and where they explore such topics as the meaning of physiology, truth⁵ and how we can achieve it, the value of the body, what it is like to be alive as humans, death and the meaning of suffering and dying for humans, humans and technology, etc. The next area studied is ethics, where we introduce the fundamental ideas of good and bad, right and wrong, the double effect principle, the idea of duty, the normative idea of nature, deontology, etc. These courses provide the basics (both in knowledge and practice in reasoning) that prepare students to begin studying bioethics.

Our current curricular path derives both from years of experience and from our theoretical analysis of bioethics as an outstanding example of interdisciplinary science, for interdisciplinarity could be said to be at the core of the epistemological constitution of bioethics. What precisely is meant in this context by interdisciplinarity needs to be carefully examined and understood.

We can distinguish between at least three models for describing the ways in which interdisciplinarity is a part of bioethics:

• The first model: in order to develop a moral reasoning concerning the latest technological and scientific advancements related to some aspects of our lives, we need to deal with different disciplines. Here we have a simple statement of fact.
• The second model: at a deeper level, in bioethics, differently from ethics, we need the interdisciplinary contribution of different sciences in order to understand the issue under consideration. Sciences provide an understanding of the object of moral reasoning and without the technical specifics of the problem at stake we cannot proceed to an ethical evaluation. Although the engagement with interdisciplinarity mentioned here is richer than in the sense discussed above, it tends to resolve the ethical dimension within the scientific domain of the discussion, as if it were merely about the technical possibilities we can deploy. In this framework, it is as if the bioethical argumentation could be achieved by the simple plurality of voices present in the debate. What is missing is the specificity of the moral dimension which needs to consider not just what we are talking about (and this can be, and should be, assessed through the contribution of sciences) but also what is good and what is bad about it. The discussion is thus upgraded to the moral level, addressing the question of what we should do and why we should proceed that particular way, rather than another.
• The third model: this type of interdisciplinarity occurs when different sciences are brought into the discussion and each of them, according to its specific nature, offers a different evaluation, be it a moral judgment, a juridical assessment, or a psychological or technical analysis. Here we have, in addition, with respect to the second model, a clear orientation toward an evaluation, although there still remains the risk of surrogating a specific moral judgment into the polyphony of voices.⁶

Given the implications of each of these models, it is necessary to define clear criteria for navigating the complex and deep waters of bioethics. This can be achieved by distinguishing the contributions of disciplines called in to help assess bioethical problems. By so doing, we can appreciate that while sciences can provide descriptive assessments, ethics offers moral evaluations. While the former tells us how things are, the latter tells us how things ought to be. We need to keep these differences between science and ethics⁷ in mind while teaching bioethics since they must be highlighted and respected.

Essentially, it is one thing to understand and see how things are, and for this, the different sciences are not only useful but also necessary. It is another thing to understand how things should be. In order to achieve this second level of knowledge, ‘simple science’ is insufficient. We need an understanding of the model, of what is good, of what is worthy to be achieved, and what is bad, what we must avoid. These types of knowledge require a different argumentative finesse that can be found in ethical reasoning.

Triple Why, at the Root of the Argument

It can be a fatal mistake to attempt to put out a fire by throwing water on the flames, for we must first find the source of the fire and then treat it according to its nature. Bioethics, as a branch of ethics, arises deep within us and for our teaching to be effective we must improve our awareness of the ethical understanding and needs of our students. We realized after the first few years of teaching (beginning 25 years ago) that medical doctors, who upheld strong bioethical principles on concrete topics, did not know how to explain ‘why’ they thought that way. They were able to manage flames but not the hotbed. This ethical weakness made them vulnerable to manipulation. This newfound awareness led us to change our teaching strategy. We created a new teaching format entitled ‘Why, Why, Why.’ This format requires that every medical and engineering student must be able to explain why he or she upholds a certain position in bioethics by answering the question ‘Why?’ at least three times while explaining their thinking.

This ‘Why, Why, Why’ method is based on a sound and long-standing practice, which can be traced back to Aristotle,⁸ who explained that to know something means to be able to clarify the causal chain that brought this ‘something’ into the light. He made it clear that in order to explain why something is done one way, rather than another, we should be able to give a detailed account of at least four forms of causality: efficient cause, final cause, formal cause and material cause. In line with Aristotle, the “master of those who know” (“il maestro di color che sanno”), as Dante⁹ described him in his Divine Comedy (and James Joyce reiterated in his Ulysses), we felt the urgency to encourage our students to look for causes, to give them the framework to seek the foundations of their opinions. Having said this, we must add that we are well aware that an 18-year-old is not capable of making an ethical judgment on a professional issue without adequate preparation.

We found that every year our new students were different from their colleagues from the previous years. We also recognize that they are different from one another. We think that this phenomenon is not exclusively Italian but common at least throughout the Western world. While preserving a strong individualistic imprint that becomes increasingly important and effective as they mature, the students also share certain common characteristics. One regular element among them (we are referring here to Noether’s concept of regularity)¹⁰ is being increasingly appreciative and having less and less reflexive ability. Putting it in philosophical terms, we could say that we find the vis aestimativa (instinct) more developed than the vis cogitative (cognition), the former being directly connected with the perception of what is good and what is bad in the practical/operational sense – a power we share with higher animals – while the latter is specific of humans and is concerned with universal objects.¹¹

In other words, the estimative/appreciative dimension is that of Turing machines and animals, where an input corresponds deterministically to an output. If we show a dog a good hamburger, he will immediately eat it happily. It does not matter, for example, if it is not time to eat or if he is on a diet. This is why an animal can be domesticated. One author of this paper recalls being stopped by the police at an airport and being taken to a room to be interrogated and searched. Faced with his amazement, the policeman simply asked him what substance he was carrying. Even more surprised, our author asked the policeman why he thought he was carrying drugs? The answer was simple: “the dog said so.” So, our author asked: “but can’t the dog make a mistake?” realizing too late that he should not have asked that question, because the policeman became angry and replied forcefully “the dog is NEVER wrong!”¹²

Returning to our ‘Why, Why, Why’ teaching method, we could present students with a statement, such as: abortion is ethically unacceptable. We do not discuss the judgment but ask ‘Why?’ The student might answer, for example, “because the embryo is a human person.” We do not discuss the truthfulness of this statement, but rather ask again, ‘Why?’ One possible reply from the student here might be, “because the homeobox genes show me that it is a living being and its DNA shows me that it is a human and every human living being is a person and I refuse every kind of discrimination.” We still have not started to discuss or even to explain any ethical principles nor have we applied an...