Relevance of the rationalist-intuitionist debate for ethics and professionalism in medical education

Ethics without borders: an analysis of national and international guidelines on ethics in basic medical education

BACKGROUND

It has been widely recognized that ethics is central to the practice of medicine. Since physicians' identities are heavily influenced by their basic medical training, education in ethics during this period would facilitate their professional development. To enable this, some global and national organizations have published guidelines detailing the aspects of ethics that need to be taught to medical student. However, it is not known how many such guidelines exist and to what extent they concur or differ.

AIM

This study aims to identify and examine the content of existing national or international guidelines on the inclusion of ethics in basic medical education, in the English language. By doing so, it hopes to explore and highlight the similarities and differences regarding their pedagogical goals and their prescribed content, thereby contributing to a more holistic understanding on the state of medical ethics education.

METHODS

Data collection was performed through systematic searches on Google and on scientific databases. The guidelines that fulfilled the inclusion criteria were thematically analyzed using the method proposed by Braun and Clarke (2006). The resulting themes and sub-themes were grouped and characterized.

RESULTS

Thirteen guidelines (ten national and three international) fulfilled the inclusion criteria. Among these, two major approaches can be discerned: value-based and norm-based. Value-based guidelines tend to be more globally applicable, because they endorse more abstract and universal principles. Norm-based guidelines, on the other hand, are more context-specific and have a practical focus. Understanding this distinction could facilitate discussions on different perspectives in ethics education.

Analyzing the Evolution of Medical Ethics Education: A Bibliometric Analysis of the Top 100 Cited Articles

Ethics education plays a pivotal role in healthcare by providing professionals and students with the essential competencies to navigate intricate ethical challenges. This study conducts a comprehensive bibliometric analysis of the most-cited articles on ethics education, investigating parameters such as citation count, document types, geographical origin, journal analysis, publication year, author analysis, and keyword usage. The findings reveal a substantial impact characterized by high citation counts and the influence of a prominent publication focusing on the hidden curriculum and structure of medical education. Moreover, the analysis demonstrates a discernible increase in research output since 2000, signaling a growing recognition of the significance of ethics education in the healthcare domain. Notably, specific journals, particularly those dedicated to medical education and ethics, emerge as major contributors in this field, publishing many articles. Renowned authors have made noteworthy contributions, and emerging themes encompass the ethical implications of virtual reality and artificial intelligence in healthcare education. Additionally, undergraduate medical education garners significant attention, emphasizing the importance of establishing ethical values and professionalism early. Overall, this study highlights the imperative of interdisciplinary collaboration and the necessity for effective ethics education programs to equip healthcare professionals with the requisite skills to navigate complex ethical challenges. The findings inform educators, curriculum developers, and policymakers about enhancing ethics education and ensuring the ethical competence of future healthcare practitioners.

The Microethics of Communication in Health Care: A New Framework for the Fast Thinking of Everyday Clinical Encounters

In almost every clinical interaction, clinicians must navigate interpersonal challenges with near-instantaneous responses to patients. Yet medical ethics has largely overlooked these small, interpersonal exchanges, instead focusing on "big" ethical problems, such as euthanasia, brain death, or genetic modification. In 1995, Paul Komesaroff proposed the concept of microethics as a nonprinciplist approach to ethics that focuses on "what happens in every interaction between every doctor and every patient." We aim to develop a microethics framework to guide everyday clinical encounters, with a special focus on communication with patients and family members. We will advance three core insights: First, communication is an ethical act in ways seldom considered. Second, microethics is an essential lens through which to view the ethics of communication. Third, virtue can bridge reflective and automatic processes. Our intuitionist framework for microethics is thus based on this understanding of the role of virtue, and we propose six virtues that contribute to the goal of healing communication.

Virtue and care ethics & humanism in medical education: a scoping review

PURPOSE

This scoping review explores how virtue and care ethics are incorporated into health professions education and how these factors may relate to the development of humanistic patient care.

METHOD

Our team identified citations in the literature emphasizing virtue ethics and care ethics (in PubMed, NLM Catalog, WorldCat, EthicsShare, EthxWeb, Globethics.net , Philosopher's Index, and ProQuest Central) lending themselves to constructs of humanism curricula. Our exclusion criteria consisted of non-English articles, those not addressing virtue and care ethics and humanism in medical pedagogy, and those not addressing aspects of character in health ethics. We examined in a stepwise fashion whether citations: 1) Contained definitions of virtue and care ethics; 2) Implemented virtue and care ethics in health care curricula; and 3) Evidenced patient-directed caregiver humanism.

RESULTS

Eight hundred eleven citations were identified, 88 intensively reviewed, and the final 25 analyzed in-depth. We identified multiple key themes with relevant metaphors associated with virtue/care ethics, curricula, and humanism education.

CONCLUSIONS

This research sought to better understand how virtue and care ethics can potentially promote humanism and identified themes that facilitate and impede this mission.

Moral Elevation, Physician Role Models, and Selected Markers of Professional Identity Formation and Well-Being: A Secondary Analysis from Two National Surveys

OBJECTIVES

Moral elevation is the underlying emotion that arises when witnessing admirable acts, and it is theorized to be the psychological mechanism driving the impact that positive clinical role models have on medical students' professional identity formation (eg, growth in professional virtues, higher sense of meaning, and well-being). This proof-of-concept study explores the development of the Moral Elevation Scale in Medicine by testing the association of moral elevation with various markers of professional identity formation.

METHODS

A secondary data analysis of two nationally representative samples of 960 medical students and 2000 physicians was performed. Respondents completed validated measures of moral elevation as well as markers of professional identity formation, including patient-centered virtues (empathic compassion, interpersonal generosity, mindfulness) and measures of well-being (life meaning, life satisfaction, spirituality, burnout).

RESULTS

The study obtained adjusted response rates of 56.2% (1047/1863, physician survey) and 48.7% (448/919, student survey). The national estimates for mean moral elevation in medical students and physicians are 4.34/5.00 and 4.22/5.00, respectively. In medical students and physicians, high moral elevation was associated with higher empathic compassion (student odds ratio [OR] 1.30, 95% confidence interval [CI] 1.02-1.67; physician OR 1.22, 95% CI 1.23-1.65) and, similarly, generosity. In addition, higher moral elevation in the physician cohort was associated with greater life meaning (OR 2.03, 95% CI 1.25-3.32) and similarly spirituality.

CONCLUSIONS

In medical students and practicing physicians, self-reported experiences of high moral elevation with physician role models were associated with higher self-reported measures of patient-centered virtues, spirituality, and life meaning. Our Moral Elevation Scale in Medicine demonstrates preliminary promise as a measure to assess environmental precursors needed for virtue development in professional identity formation, but further reliability and validity testing of this measure is needed.

"Can virtue be taught?": a content analysis of medical students' opinions of the professional and ethical challenges to their professional identity formation

BACKGROUND

Efforts have begun to characterize the ethical and professional issues encountered by medical students in their clinical years. By applying previously identified taxonomies to a national sample of medical students, this study seeks to develop generalizable insights that can inform professional identity formation across various clerkships and medical institutions.

METHODS

In a national survey of medical students, participants answered an open-ended survey item that asked them to describe a clinical experience involving an ethical or professional issue. We conducted a content analysis with these responses using the Kaldjian taxonomy of ethical and professionalism themes in medical education through an iterative, consensus-building process. Noting the emerging virtues-based approach to ethics and professionalism, we also reexamined the data using a taxonomy of virtues.

RESULTS

The response rate to this survey item was 144 out of 499 eligible respondents (28.9%). All 144 responses were successfully coded under one or more themes in the original taxonomy of ethical and professional issues, resulting in a total of 173 coded responses. Professional duties was the most frequently coded theme (29.2%), followed by Communication (26.4%), Quality of care (18.8%), Student-specific issues of moral distress (16.7%), Decisions regarding treatment (16.0%), and Justice (13.2%). In the virtues taxonomy, 180 total responses were coded from the 144 original responses, and the most frequent virtue coded was Wisdom (23.6%), followed by Respectfulness (20.1%) and Compassion or Empathy (13.9%).

CONCLUSIONS

Originally developed from students' clinical experiences in one institution, the Kaldjian taxonomy appears to serve as a useful analytical framework for categorizing a variety of clinical experiences faced by a national sample of medical students. This study also supports the development of virtue-based programs that focus on cultivating the virtue of wisdom in the practice of medicine.

Cultivating Physician Character in Diagnostic Radiology Through Virtuous Caring and Collaborative Professionalism

In the contemporary environment of patient- and value-centered care, it is no longer sufficient to limit the definition of an "excellent radiologist" to someone who is skilled at image interpretation. Since diagnostic radiologists are physicians, they are held to a certain character standard expected of a physician, whose primary objective is to serve the best interest of patients. An "excellent radiologist," then, is better defined as one who is both skilled at interpreting medical imaging and embodies the attributes of physician character. The concept of physician character can be understood as the interplay between the practice of the care-related virtues, such as empathy, compassion, and kindness, and cooperative efforts with nonradiologist health care team members, termed collaborative professionalism. The very nature of the work of diagnostic radiology, aided by advances in technology, increasingly isolates the radiologist from both patients and other care providers, making it difficult to find opportunities for virtuous care and collaborative professionalism. Using the moral intuitionist model of character development as a conceptual framework, we first delineate the challenges that diagnostic radiologists face in demonstrating virtuous caring and collaborative professionalism. Then, we explore strategies that diagnostic radiologists can employ to overcome these barriers, thereby cultivating their own physician character and setting an example for other radiologists, medical students, and trainees. Finally, we will examine some of the limitations of applying this theoretical model to the real world.

Project on the Good Physician: Further Evidence for the Validity of a Moral Intuitionist Model of Virtuous Caring

THEORY

In the Project on the Good Physician, the authors propose a moral intuitionist model of virtuous caring that places the virtues of Mindfulness, Empathic Compassion, and Generosity at the heart of medical character education.

HYPOTHESES

Hypothesis 1a: The virtues of Mindfulness, Empathic Compassion, and Generosity will be positively associated with one another (convergent validity). Hypothesis 1b: The virtues of Mindfulness and Empathic Compassion will explain variance in the action-related virtue of Generosity beyond that predicted by Big Five personality traits alone (discriminant validity). Hypothesis 1c: Virtuous students will experience greater well-being ("flourishing"), as measured by four indices of well-being: life meaning, life satisfaction, vocational identity, and vocational calling (predictive validity). Hypothesis 1d: Students who self-report higher levels of the virtues will be nominated by their peers for the Gold Humanism Award (predictive validity). Hypothesis 2a-2c: Neuroticism and Burnout will be positively associated with each other and inversely associated with measures of virtue and well-being.

METHOD

The authors used data from a 2011 nationally representative sample of U.S. medical students (n = 499) in which medical virtues (Mindfulness, Empathic Compassion, and Generosity) were measured using scales adapted from existing instruments with validity evidence.

RESULTS

Supporting the predictive validity of the model, virtuous students were recognized by their peers to be exemplary doctors, and they were more likely to have higher ratings on measures of student well-being. Supporting the discriminant validity of the model, virtues predicted prosocial behavior (Generosity) more than personality traits alone, and students higher in the virtue of Mindfulness were less likely to be high in Neuroticism and Burnout.

CONCLUSIONS

Data from this descriptive-correlational study offered additional support for the validity of the moral intuitionist model of virtuous caring. Applied to medical character education, medical school programs should consider designing educational experiences that intentionally emphasize the cultivation of virtue.

Role Models' Influence on Specialty Choice for Residency Training: A National Longitudinal Study

BACKGROUND

Role models in medical school may influence students' residency specialty choice.

OBJECTIVE

We examined whether medical students who reported clinical exposure to a role model during medical school would have an increased likelihood of selecting the role model's specialty for their residencies.

METHODS

We conducted a 5-year prospective, national longitudinal study (2011-2016) of medical students from 24 US allopathic medical schools, starting from the middle of their third year. The primary outcome measure was type of residency specialty choice 4 years after graduation. Main predictors were the clinical specialty of a student's most admired physician and the relative importance of 7 potentially influential factors for specialty choice in the fourth year of medical school.

RESULTS

From 919 eligible participants, 564 (61%) responded to the first survey; 474 of the respondents (84%) completed the follow-up survey. We excluded 29 participants who were not in their fourth year by the time of the follow-up survey. Of the follow-up respondents, 427 (96%) had specialty data 4 years after graduation. In our multivariate models, exposure to an admired generalist physician prior to medical school (odds ratio [OR] = 2.21, 95% confidence interval [CI] 1.03-4.73) and during medical school (OR = 2.62, 95% CI 1.69-4.05) had the strongest odds with respect to training in a generalist residency 4 years after graduation. Role model exposure also predicted specialty choice among those training in surgical and radiology, ophthalmology, anesthesiology, and dermatology (ROAD) specialties.

CONCLUSIONS

Personal exposure to role models in medical school is an important predictor of residency training in that role model's specialty.

Virtue in Medical Practice: An Exploratory Study

Virtue ethics has long provided fruitful resources for the study of issues in medical ethics. In particular, study of the moral virtues of the good doctor-like kindness, fairness and good judgement-have provided insights into the nature of medical professionalism and the ethical demands on the medical practitioner as a moral person. Today, a substantial literature exists exploring the virtues in medical practice and many commentators advocate an emphasis on the inculcation of the virtues of good medical practice in medical education and throughout the medical career. However, until very recently, no empirical studies have attempted to investigate which virtues, in particular, medical doctors and medical students tend to have or not to have, nor how these virtues influence how they think about or practise medicine. The question of what virtuous medical practice is, is vast and, as we have written elsewhere, the question of how to study doctors' moral character is fraught with difficulty. In this paper, we report the results of a first-of-a-kind study that attempted to explore these issues at three medical schools (and associated practice regions) in the United Kingdom. We identify which character traits are important in the good doctor in the opinion of medical students and doctors and identify which virtues they say of themselves they possess and do not possess. Moreover, we identify how thinking about the virtues contributes to doctors' and medical students' thinking about common moral dilemmas in medicine. In ending, we remark on the implications for medical education.

Project on the Good Physician: A Proposal for a Moral Intuitionist Model of Virtuous Caring

THEORY

In the Project on the Good Physician, the authors endeavor to advance medical character education by proposing and testing a moral intuitionist model of virtuous caring that may be applicable to physician training. This model proposes that the moral intuition to care/harm motivates students to extend care to those in need.

HYPOTHESES

Hypothesis 1: Medical students will report stronger preferences for the intuition to Care/harm over other moral intuitions in clinical decision making. Hypothesis 2: Care/harm will have the strongest correlation with Generosity than the other moral intuitions. Hypothesis 3: There will be positive associations between Care/harm and the caring virtues (Mindfulness, Empathic Compassion, and Generosity). Hypotheses 4-5: The virtue of Empathic Compassion (or Mindfulness) will moderate the relationship between Care/harm and Generosity. Hypotheses 6-7: Neuroticism (or Burnout) will negatively moderate the association between Care/harm and Generosity (or between Empathic Compassion and Generosity).

METHOD

The authors used data from a 2011 nationally representative sample of U.S. medical students (N = 500) to test the relationship between the moral intuition to Care/harm and physician caring virtues. Moral intuitions were assessed using the Moral Foundations Questionnaire, whereas physician virtues were measured using scales adapted from validated constructs.

RESULTS

The authors found that students reported stronger preferences for the intuition to Care/harm over the four other moral intuitions. Each moral foundation was weakly but significantly correlated with Generosity, yet Care/harm had the strongest correlation among them. Neuroticism and Burnout did not weaken the link between Care/harm and the virtues.

CONCLUSIONS

Data from the descriptive-correlational study reported here offer preliminary support for the construct validity of an educational model that targets the moral intuitions. The article concludes with a discussion of the implications of a moral intuitionist approach for medical character education and offers three hypotheses for future empirical research.

Measuring 'virtue' in medicine

Virtue-approaches to medical ethics are becoming ever more influential. Virtue theorists advocate redefining right or good action in medicine in terms of the character of the doctor performing the action (rather than adherence to rules or principles). In medical education, too, calls are growing to reconceive medical education as a form of character formation (rather than instruction in rules or principles). Empirical studies of doctors' ethics from a virtue-perspective, however, are few and far between. In this respect, theoretical and empirical study of medical ethics are out of alignment. In this paper, we survey the empirical study of medical ethics and find that most studies of doctors' ethics are rules- or principles-based and not virtue-based. We outline the challenges that exist for studying medical ethics empirically from a virtue-based perspective and canvas the runners and riders in the effort to find virtue-based assessments of medical ethics.

Medical student opinions on character development in medical education: a national survey

Background

Recently United States (US) medical schools have implemented curricular reforms to address issues of character in medical education. Very few studies have examined students’ opinions about the importance of character development in medical school. This cross-sectional study assessed US medical students’ opinions regarding character-focused education and their experiences receiving character feedback from educators. We mailed a questionnaire to 960 third year medical students from 24 medical schools. Respondents received a second questionnaire during their fourth year. Students answered three items that assessed their opinions regarding character development in medical education. They also indicated the frequency of positive/negative feedback regarding their character traits. We also tested associations between these opinions and various demographic, religious and spiritual characteristics. We used the χ² test to examine bivariate associations between each demographic/religious characteristic and students’ opinions on character development or feedback.

Results

Excluding 41 ineligible respondents, the adjusted response rate for the first questionnaire was 61 % (n = 564/919) and 84 % (n = 474/564) for the follow-up questionnaire. Twenty-eight percent of students agreed that one could be a good physician without being a good person; 39 % agreed that educators should focus on science instead of students’ characters; 72 % agreed that it was educators’ responsibility to train students to have good character; 1 % of students reported no positive feedback from faculty regarding character traits; 50 % reported no negative feedback.

Conclusions

US students in clinical clerkships receive predominately positive feedback from educators regarding character traits. A majority of medical students, regardless of demographic and religious characteristics, are receptive to the role of character development in medical education. This finding suggests that character-based approaches toward ethics and professionalism training may find renewed receptivity among medical students despite recent “professionalism movement” fatigue.