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Case-based seminars in medical ethics education: how medical students define and discuss moral problems
  1. Thomas M Donaldson1,
  2. Elizabeth Fistein1,
  3. Michael Dunn2
  1. 1General Practice Education Group, Institute of Public Health, University of Cambridge, Cambridge, UK
  2. 2The Ethox Centre, University of Oxford, Oxford, UK
  1. Correspondence to Mr Thomas M Donaldson, General Practice Education Group, Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK; tmd28{at}doctors.org.uk

Abstract

Discussion of real cases encountered by medical students has been advocated as a component of medical ethics education. Suggested benefits include: a focus on the actual problems that medical students confront; active learner involvement; and facilitation of an exploration of the meaning of their own values in relation to professional behaviour. However, the approach may also carry risks: students may focus too narrowly on particular clinical topics or show a preference for discussing legal problems that may appear to have clearer solutions. Teaching may therefore omit areas generally considered to be important components of the curriculum. In this paper, the authors present an analysis of the moral problems raised by medical students in response to a request to describe ethically problematic cases they had encountered during two clinical attachments, for the purpose of educational discussion at case-based seminars. We discuss the problems raised and compare the content of the cases to the UK Consensus Statement on core content of learning. The authors also describe the approaches that the students used to undertake an initial analysis of the problems raised, and consider possible implications for the development of medical ethics education.

  • Applied and professional ethics
  • education for health care professionals

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Introduction

Discussion of cases encountered by medical students has been advocated as a component of medical ethics education.1 Suggested benefits include: focus on the actual problems that students confront, active learner involvement, and facilitation of an exploration of the meaning of their own values in relation to professional behaviour.1–3 Accordingly, this approach is used in two of the seminars in medical ethics and law (MEL) that medical students at the University of Cambridge attend during attachments in obstetrics and gynaecology, and in paediatrics. Two weeks before each seminar, tutors invite students to submit written accounts of problematic cases that they have encountered (figures 1 and 2). A sample is selected by the tutors for further discussion with the whole group. The accounts themselves are not marked or used for assessment, although students are expected to produce an ‘ethical case report’ at the end of the paediatrics attachment.

Figure 1

Case request for obstetrics and gynaecology seminar.

Figure 2

Case request for paediatrics seminar.

The method carries risks as well as benefits. In comparison with alternative approaches used in other seminars (discussion of hypothetical vignettes or illustrative cases encountered by educators) it is less systematic. Students may not encounter relatively uncommon but nonetheless important issues during a short attachment. There may be factors associated with certain types of ethical problem that make them more visible to students, and discomfort with the ‘grey areas’ of moral problems may encourage students to raise more clearly ‘legal’ problems which carry a greater likelihood of eliciting clear advice from tutors.

Evidence from the Netherlands suggests that medical students are able to provide a wide variety of ethically problematic cases, appropriate for teaching medical ethics.1 We wished to investigate whether this finding translates to a UK medical school and how well the variety of cases raised by students maps onto the curriculum, in the context of the revision of the UK Consensus Statement on core content of learning.4 5 We set out to address the question: how do medical students, in presenting cases for discussion at ethics seminars, define, describe and discuss ethical problems encountered during clinical attachments? In presenting our findings, we hope to stimulate debate about how this teaching method might contribute to medical ethics education.

Method

We conducted a primarily qualitative textual analysis of accounts of problematic cases submitted for discussion at case-based law and ethics seminars. As we were interested in finding out more about the kinds of cases that students wanted to discuss, we did not ask the tutors to alter the way they normally request cases from the students. The wording used in the requests are shown in figures 1 and 2.

The difference between the two requests is due to the fact that the paediatric department requires students to write up an ethically interesting case during the attachment (a separate exercise, undertaken in the week after the seminar and assessed by a different tutor), whereas the obstetrics and gynaecology department does not.

At four seminars held during 2009, students were asked to provide written consent if they agreed to the inclusion of their anonymised accounts in a research project. As the aim of this study was to understand the range of issues that students find problematic and would like to discuss further, all accounts submitted, not just those chosen for discussion, were eligible for inclusion.

Thematic analysis is useful for summarising key features of a body of data and producing a description of the data set.6 This method was chosen to describe the types of problems raised and the language used to discuss them. Categories were derived from the data and not from theory, in order to avoid imposing themes onto the analysis that might obscure important factors raised by medical students. Data were coded and initial categories were developed by TD and EF, who then compared findings to ensure confirmability. TD used these categories to describe themes within the data-set and to develop hypotheses. These hypotheses were reviewed, in conjunction with illustrative data excerpts, by EF and MD, who attempted to disconfirm initial assumptions and develop alternative hypotheses to improve the credibility of the findings.

This was primarily a qualitative study, and themes were selected on the basis of salience of content rather than the frequency with which they occurred. However, some quantification was undertaken in order to identify which types of problem were raised most frequently, giving an indication of the issues that students tend to characterise as being a source of concern.

Findings

We collected a total of 71 accounts over a period of three months. Students mentioned a range of factors to indicate that their case had problematic elements. Forty accounts mentioned more than one factor. Indicative factors raised by more than one student are listed in table 1.

Table 1

Issues identified as the source of a problem

Students also used a range of approaches to frame and discuss the problems they had identified. We have referred to these as analytical themes, to distinguish them from the indicative themes listed above.

Indicative themes: features of cases identified as morally problematic

Features of cases identified as morally problematic can be classified along two axes: morally contentious clinical activities and generic problems that might occur across a range of clinical activities.

The clinical activities mentioned most commonly were: (1) termination of pregnancy, (2) child protection, (3) withholding/withdrawing treatment and (4) treatment of children affected by life-threatening illness or infants born at the limits of viability.

The single most common generic indicator of a moral problem was awareness of inter-personal disagreement ranging from tension within the patient's family to conflict between members of a family, between clinicians and between clinicians and patients. The following are illustrative examples:

What I found most interesting was listening to the argument between the consultant and the SpR [junior doctor], the latter of which argued that he would not have signed the form for a termination of pregnancy under such grounds.

and

However, her husband was very upset and angry to see his wife in this situation and believed that the medications would not work. He became verbally very aggressive with the doctor, demanding that his wife needed a caesarean section to remove the pain.

Analytical themes: approaches to describing and discussing problems

We identified three approaches used by students to describe and discuss the problematic aspects of their cases: ethical-philosophical, legal-regulatory and practical-operational.

The ethical-philosophical group included accounts that explicitly used terms related to morality (eg, what ought or should be done), ethical theory (eg, the nature of a doctor's duty to be honest or whether a good outcome would justify a decision), or mid-level ethical principles. Also included were cases that posed questions about distributive justice. Illustrative examples were:Is it ethical for the GP to ‘side’ with the mother in promoting a termination? … Does the fact that, in retrospect, the GP was proved right mean that their giving of advice should be considered a morally appropriate course of action?

andA 43-year-old lady with three children … and her 26-year-old new partner have come to a fertility clinic … hoping to receive some fertility advice and treatment. Should they be allowed any?

Given the nature of the exercise and instructions to students, we expected that a significant number of accounts would fit into this subgroup. However, only 13 accounts were framed in this way, even when the category was interpreted very broadly. A further five accounts appeared to contain an implicit normative judgement. These were brief factual descriptions of cases where women requested termination of pregnancy, presented without any accompanying discussion of ethical theory or principles. The implicit normative judgement can be inferred from the fact that these cases were submitted as examples of ethical problems. An illustrative example was:The reason for seeking a termination was that the father's identity was unknown. Miss X had split up with her previous boyfriend and was now with a new partner, but the gestational age (by both ultrasound and LMP [last menstrual period]) was such that either man could possibly have been the father. Miss X was happy to keep the child of her new partner, but wanted a termination if the previous partner was the father. The possibility of paternity testing was mentioned, but given the time delay might limit the option of abortion, she decided to opt for an elective TOP [termination of pregnancy].

Despite labelling their cases as ethical problems, the majority of students focussed either on the doctor's legal obligations or on other issues that appeared, on the face of it, to be difficulties with clinical judgement or with communication.

Twenty-eight cases were discussed in legal-regulatory terms, focussing on the legal obligations of the doctor. The students were interested in the application of the law and the questions that they posed suggested an underlying desire to focus on legally safe medical practice, that is, what can be done within the limits of the law, rather than questioning what should be done. Examples included:… the decision facing the doctor when he/she needs to weigh up whether to use more force to deliver a baby against the risks of injury and litigation. What is the degree of protection in these circumstances?

andIf a doctor has a reasonable belief that a child is at serious risk of immediate harm (eg, from continuing abuse), then they have a legal duty [to act in the best interests of the child] (defined in the Children Act of 1989).

Finally, 18 cases were discussed in practical-operational terms, displaying a focus on clinical reasoning and communication skills. Some students posed questions about how to ensure the best health outcome when two or more treatment options both carry risks as well as benefits, displaying a desire to identify the clinically indicated course of action. Examples included:

Is this an acceptable complication to the procedure?

and

Ethical issue: giving powerful medication in someone suspected of not having true epilepsy versus the risk that it might be true epilepsy.

Other cases in this group posed practical questions about handling communication with patients or relatives who disagree with the doctor, perhaps because of religious or cultural differences. Examples included:

Mrs X and her husband were strict Muslims, and this strongly influenced their decision-making. Early in the consultation, they stated their preferred course of action for the pregnancy. They stated that they wished for the pregnancy to occur with as little medical intervention as possible. The wishes of Mr and Mrs X posed some difficulty for the consultant involved.

Discussion

Indicative themes

The students submitted accounts covering a broad range of clinical activities, reflecting similar findings from the Netherlands.1 Given that the accounts only concerned experiences during attachments in paediatrics and in obstetrics and gynaecology, it is striking that the indicative themes relate closely to 10 of the 12 content areas of the updated core content of learning for MEL.5 Problems connected with medical research and audit were not mentioned, and this is perhaps unsurprising, given the nature of the seminars. More surprising was the observation that just four cases had a mental health element: two accounts of the management of illicit substance use during pregnancy, one of gaining consent to an intimate examination from a woman diagnosed with a mental disorder, and one of the treatment of an adolescent with an eating disorder. Perhaps this reflects the fact that placements with the specialist child and adolescent mental health services, perinatal psychiatry and an antenatal psychiatric liaison service are included in the psychiatry attachment, during which another (vignette-based) MEL seminar takes place. This suggests that ‘real case-based seminars’ organised during four or five appropriately selected clinical attachments, could potentially be used to deliver the core content and, perhaps, begin to link the different strands of the whole medical curriculum together.

The students had not seen the updated core content for learning before submitting their accounts, so the degree of match with the Consensus Statement also suggests that this is a framework for teaching and learning that addresses the concerns of students.

An interesting feature of our analysis of the indicative factors is the frequent mention of inter-personal conflict or tension. One explanation is that discussion of ethical principles within a clinical team often seems to take place when disagreement or conflict occurs. This demonstrates a possible weakness with the real case-based approach. If ethical education is confined to certain types of cases—those associated with conflict—it is possible that students will conclude that ethical deliberation is not needed outside this context. Conflict is often a good indicator that divergence of values has occurred, but absence of conflict does not exclude the possibility that decisions have been based on evaluations that might legitimately and productively be questioned.7

Analytical themes

Our analysis of the language that the students used to describe and discuss moral problems led us to conclude that, while students appear able to draw upon an understanding of ethical and legal frameworks to describe problems, there was little evidence within their accounts that they were thinking about how to apply ethical theories to assist decision-making. Most students had not attempted any ethical analysis in order to reach an answer as to what ought to be done. Indeed, some students expressed explicit confusion on the subject, for example:

How are end of life decisions made at this age … and on what evidence and ethical principles are these decisions based?

When students did use ethical language in order to analyse their case, they were not always consistent or rigorous. They tended to use a ‘pick and mix’ of different theories to justify their conclusions and to apply ethical frameworks without challenging assumptions. These are problems that may have occurred unknowingly through relative inexperience, or may be something that students have learnt from clinician role-models. As one student put it, ‘people select the theory that best suits them at a given time’.

Some students used the Four Principles approach and this appeared to enable them to attempt a more thorough discussion of the moral problems raised in their cases.8 An illustrative example is included below:

The ethical principles of beneficence and non-maleficence must be balanced in this case. Cardiac surgery would offer the chance of a cure, but if it were unsuccessful this would be an unnecessary intervention that would affect J's quality of life. Since the absolute risks of surgery and the possibility of a cure are unknown, it may be difficult to weigh up beneficence and non-maleficence to determine what is in the patient's best interests. In this case, experienced doctors made the judgement, but should the parents have more autonomy?

The way the students applied this approach illustrates some strengths and weaknesses of principlism. It provides a clear framework with which to describe the case in ethical terms, which many of the students did very competently. However, principlism has been criticised for failing to develop a genuinely coherent approach to balancing or ranking competing prima facie duties that derive from their four mid-level principles.9 The students appeared to find this aspect of analysis the most difficult as none of them attempted to weigh and balance the principles or suggest a course of action. This has the potential to lead the students to conclude that ethics is about describing situations where there is uncertainty about what to do, rather than actually providing guidance as to how to decide on a course of action.

The observation that 28 accounts were described in primarily legal-regulatory terms led us to reflect that this may be connected with the wording of the instructions sent to students (figures 1 and 2), requesting that they prepare cases of ‘ethical and/or legal interest.’ Relatively few (13) students discussed their cases in ethical terms, leading us to hypothesise that where law and ethics are taught as one subject, students preferentially engage in legal discussion, which appears to present more opportunities for clear-cut answers regarding the actions they must or must not take. Alternatively, given our observation that students tend to identify ethical and legal problems as having arisen when conflict has occurred, they may have formed the impression that thinking ethically means thinking about how to practice defensive medicine, particularly if the doctors involved in the case express concern about possible legal action.

However, some students clearly were able to distinguish between thinking about morality and thinking about legality, as demonstrated by their questioning of the morality of acts that they knew to be legal, for example:

A 16-year-old-girl … had an abortion 3 months earlier … someone needs to find a way to get through to her that this is not a form of contraception. Should the doctor grant her request for an abortion?

This demonstrates how these ostensibly ‘legal’ cases can usually be re-framed in the seminars to produce a discussion of ethics (what should be permissible) as well as the application of the law to determine what the doctors concerned could lawfully have done.

The observation that many cases were discussed in terms of optimal clinical outcomes led to an initial hypothesis that these students had simply failed to identify a moral problem. Further reflection produced an alternative hypothesis, still grounded in the data, that these questions arose because students perceived a moral imperative to strive to ensure the best outcomes possible. This apparent perception has interesting parallels in a number of schools of thought, including Kantian, consequentialist and Aristotelian ethics, providing an avenue for discussion with students who tend to think in practical terms. This might include encouraging them to think more deeply about their reasons for holding themselves accountable to a duty to ensure the best clinical outcomes, or to analyse the case using the utilitarian calculus, challenging them to think more about the relationship between one patient's health and the overall happiness of that patient and of other people. It could also include introducing them to a concept used in Aristotle, who described eudaimonia (the good life) as ‘activity of the soul in the way of arête’.10 As ‘arête’ can be translated as ‘virtue’ or refer to excellence in one's profession, the students could be encouraged to think more about their own striving for clinical excellence and what personal qualities they may need to develop to achieve this goal.

Following from this data-grounded discussion of the strengths and weaknesses of the case-based approach, we suggest that a number of additional strategies may enhance teaching using this model.

First, students need to be equipped with an understanding of ethical theory such that they can recognise the character of the conflict that they identify as being indicative of an ethical dilemma. Importantly, however, the purpose of medical ethics education is not to make moral philosophers out of our medical trainees. It is important, therefore, that theoretical insight remains closely tied to students' own experiences and the cases they have presented. As we have suggested above, the identification of clinical outcomes as an ethical concern could be considered in terms of consequentialist theories, on the one hand, or alternative theoretical accounts of doctors' duties, on the other hand. An additional teaching method that could provide a useful counterpoint by building on the students' interest in clinical excellence would be to ask them to consider what a virtuous doctor would do in this situation, thus providing a method for introducing students to virtue theory. This would also help to shift the emphasis away from situations of conflict and towards careful and explicit attention to character, moving ethics education into the daily life of the clinician, rather than reserving it for a small number of challenging cases.

Secondly, the limited application of ethical analysis and judgement, and the overarching focus on conflict and uncertainty, in students' case presentations emphasise the importance of ethical skill-building in medical ethics education. This is to recognise that case discussions and theoretical insight are only the starting point for helping students to think through, and resolve, the practical ethical dilemmas that they themselves highlight. Ethics education must enable the students to develop the ‘critical appraisal skills in ethical reasoning’11 needed to move from simply describing an ethical dilemma to facilitating deliberation, thinking through theoretical disputes and identifying a justifiable resolution to the problem. Introducing students to thought experiments, case comparisons, conceptual analysis and logical reasoning would provide students with the tools to tease apart good arguments from bad arguments, as well as to identify ways of resolving the conflicts and uncertainty that they identify as being indicative of ethics in practice.

In conclusion, the ‘real cased-based approach’ appears to be an effective means of delivering the core content of learning. When students begin to reflect on and analyse cases in advance of seminars, this has potential to enrich their learning experience. However, they will need encouragement and support from tutors (a) to become adept at recognising the need for moral reasoning in the context of apparently uncontroversial decision-making and (b) to go beyond describing the features of cases and begin to consider how to resolve ethical problems as they arise in practice. Therefore, it is important that the submission and consideration of ethical case reports is supported by skilful seminar leaders and, where appropriate, additional learning exercises.

Acknowledgments

The authors would like to thank the following people whose support made this study possible: Angela Murphy, Ethics and Law Curriculum Administrator, University of Cambridge; James Brimicombe, Data Manager, General Practice and Primary Care Research Group, University of Cambridge; Dr Roddy O'Donnell, Consultant Paediatrician and MEL Course Tutor, University of Cambridge; Dr Melita Brownrigg, General Practitioner and MEL Course Tutor, University of Cambridge; the Stage 2 medical students, University of Cambridge School of Clinical Medicine; the reviewers, whose constructive criticisms have improved this paper.

References

Footnotes

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the University of Cambridge Psychology Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.