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Abstract
In this paper, we put forward the view that emotions have a legitimate and important role in health professional ethics education. This paper draws upon our experience of running a narrative ethics education programme for ethics educators from a range of healthcare disciplines. It describes the way in which emotions may be elicited in narrative ethics teaching and considers the appropriate role of emotions in ethics education for health professionals. We argue there is a need for a pedagogical framework to productively incorporate the role of emotions in health professional ethics teaching. We suggest a theoretical basis for an ethics pedagogy that integrates health professional emotions in both the experience and the analysis of ethical practice, and identify a range of strategies to support the educator to incorporate emotion within their ethics teaching.
- Education
- Education/Programs
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Background
Medical ethics teaching in most Western settings focuses on teaching processes and principles for ethical reasoning and decision-making.1–3 Students are taught to identify the principles at stake in any given ethical situation, and, where they compete, weigh them up to determine the ethically best course of action.4 ,5 This approach to ethics education is based on two key ideas: that good ethical decision-making is rational and systematic, and that ethical decision-making (or problem-solving) is the essence of ethical practice.6 The mid-level ethical principles of Beauchamp and Childress7 are commonly used as the basis for this teaching across the range of health professions, although other normative ethical theories, such as deontology and human rights, are also used in such teaching. Other approaches to ethics education take a broader view of what capacities and qualities are needed for ethical practice. Among these are virtue ethics, ethics of care and narrative ethics. In virtue ethics, which is sometimes used in ethics teaching for medical students, the focus is more on development of moral virtues and action in accordance with these, rather than on decision-making per se.8–10 Ethics of care is sometimes used in nursing ethics education, although less so in other health professions. Ethics of care specifically rejects the idea of ethical principles and reasoned decision-making, emphasising instead the ethical primacy of the one-to-one caring relationship.11–13 Narrative ethics is the most recent of these broader approaches, and is increasingly being used for teaching across medicine, nursing and a range of allied health professions.14–16 In narrative ethics, personal experiences and emotional responses to those experiences form part of the ethical reflection. Stories are recognised as a vehicle for understanding and making sense of situations, feelings and human responses.17
This paper has arisen out of the experience of the authors in running a narrative ethics education programme for ethics educators from a range of health professions. We reflect on the role of emotions in teaching ethics and argue for more explicit and systematic consideration of emotions, especially in ethics teaching, which takes itself to be primarily teaching ethical reasoning and decision-making. The paper draws upon interviews conducted with the educators before the programme began, and their feedback after participating.
During the narrative ethics programme, we noted an apparent dissonance between educators’ descriptions of their approaches and goals in ethics teaching in interviews prior to their participation in the workshop, where emotions were rarely mentioned, and their responses in the narrative workshops where emotions were a major component of the discussion. Based on our analysis of this apparent dissonance, we suggest there is a need for a coherent ethical and pedagogical framework to locate the appropriate roles of emotion in ethical deliberation and practice. This is not an argument for adopting emotivism or subjectivism as the meta-ethical basis for health professional ethics, or ethics teaching. The task of the framework would be more complex: to take seriously the emotions inherent in ethically good clinical practice, and in particular, the heightened emotions evoked by ethically challenging clinical situations. These emotions are felt by practitioners and must be taken account of in an ethical decision-making process. We argue that the appropriate approach is not to ignore or completely set aside these emotions, but to recognise them, reflect on them and use them to enhance ethical decision-making. We offer some suggestions as to what such a framework might look like, where ethical reasoning is informed by both principles and emotions. One main implication of our view is that the emotional aspects of clinical practice should be deliberately incorporated into the teaching of ethics. This means that emotions will be evoked in the classroom, and practical strategies to appropriately manage these emotions are required. We go on to offer some suggestions on this matter.
The narrative ethics education project
The Narrative Ethics Education Project involved ethics educators in different healthcare disciplines within the Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne. The primary aim of the project was to introduce to an interdisciplinary group of health professional ethics educators a narrative ethics approach to teaching that had previously been developed by two of the authors.18 The approach involved the use of purpose-written first-person narratives written by health professionals, patients or their carers about an ethical issue they have experienced in a health setting.19 The programme had two parts: first, a consultation phase designed to gather information about the formal aims of health current professional ethics curricula, and second, workshops for educators on the narrative ethics approach.
Methods
The views and responses of project participants were collected in both phases of the project, following approval from the University of Melbourne Human Research Ethics Committee. The consultation phase included in-depth, semi-structured interviews with 12 ethics educators from the disciplines of medicine (5), dentistry, psychology, physiotherapy, nursing (one each) and social work (3) at the Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne. The interviews focused on the aims and objectives, content, and mode of delivery of their ethics curricula. In addition, educators were asked to reflect on the strengths, deficiencies and opportunities for future development of their curriculum. Each interview was conducted by one of the members of the project team (the authors of this paper), and then transcribed and thematically analysed.
Two workshops using a narrative approach to ethics teaching were delivered to a total of 44 ethics educator participants, mostly from the Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne, including participants who had been interviewed in the consultation phase. The workshops comprised a combination of whole group interactive teaching about the theory of narrative ethics and ethics teaching, as well as small group sessions in which participants took part in a discussion of a narrative, just in the way students would do when used in a teaching context. The aim was to give the participants first-hand experience of this method of teaching ethics. Three members of the project team took the role of small group facilitators, and one took notes on both the small group discussions and the comments made by participants in the whole group feedback session. In addition, written feedback was provided by 33 of the 44 participants at the end of the workshop. Verbatim quotes from participants used in this paper have been de-identified by use of participant numbers (P1, P2 etc). However, this only applies to interview quotes as the written feedback from the workshops was anonymous.
Interview findings: emotion, ethics and rationality
The predominant theme from the interviews with ethics educators was that ethics education should teach students about rational thinking. This included providing students with a ‘toolbox’ of skills and abilities to recognise, think about and then respond to ethical issues they might encounter in practice. Educators talked about students ‘learning to think about’ and ‘sort through’ ethical issues (P1). They described ethics teaching as ‘providing a framework for understanding’ (P2), a means for ‘thinking about values in a logical way’ (P3) and a ‘language for speaking about ethics’ (P3). Educators described the need for students to ‘bring reasoning’ to conflicts between ethical principles, or ‘some kind of structure, (because) it's not just common sense’ (P4). They also discussed the need for healthcare students to be able to both recognise and reflect on human values, as ‘they are obliged to deal with those issues as part of their professional activity’ (P5). This extended to students ‘knowing themselves’ and ‘what their own morals and values and beliefs are so that they are able to actually consider someone else's point of view’ (P6).
Emotions were rarely explicitly raised, although they emerged indirectly in a discussion of ‘feelings’ in three interviews in which educators described the need to prepare students for both their own and their patients’ feelings in clinical practice:
I wouldn't like to generalize but… (nurses)… in my experience often get very emotional about many of the issues, particularly postgraduate nurses – because of their experience of the power relationships which operate within health care systems. And sometimes they get very… they rebel against that. Which is a natural thing. (P7)
In the quote above, the educator seems to be suggesting that students need to be ready to deal with anger or frustration generated by some of the ethical issues in the provision of nursing care. Another educator similarly commented on assisting medical students to deal with their own negative feelings about the clinical environment in their future practice:
Ethics education…should…provide resources to deal with what is going to happen as opposed to providing sophisticated conceptual tools for thinking about big ethical issues. Students need to know there will be a dark period in their clinical practice, and it is important for them to be able to figure out how they can respond and have resources so they are not overwhelmed by the environment. (P8)
A third educator noted the need for students to learn to set aside negative feelings about particular patients:
Out in the field you need to be up front about the way people might react and feel, but you have to go through the process irrespective of what the outcome might be or what you think of the person. (P9)
All of these comments refer to negative emotions in students or health professionals (anger, dislike, despair) and frame emotions as integral to practice, but as problematic in some way, acting as a possible barrier or hindrance to ethical practice.
Two educators talked specifically and positively about emotions in relation to their aims and practices of ethics teaching. One expressed the view that:
Students get very socialised and they behave as their bosses want them to and even if they're feeling uncomfortable, they still do that and it's trying to give them some skills to work out that they're feeling uncomfortable about where they're going and what to do. (P2)
This suggests that ‘feeling uncomfortable’, though it may be experienced negatively by the health practitioner, is not necessarily ethically negative; it may be a sign that there is an ethical issue, which the practitioner needs to address. Another educator, in responding to the interviewer's question about what sort of person would the health professional course produce, discussed links between empathy and emotion in health practice:
It's the sort of person who is sensitised to the need to incorporate into their doctoring the skills of empathy which we define as the capacity to enter into the experiencing world of the patient and all family members in order to understand what they are going through….To know how to deal with somebody who is to be given bad news we have to have some idea what they are experiencing…So if there is an ethical dilemma or decision to be made (we need) not to make it only with rules but to be able to use elements of empathy to approach the ethical question. (P4)
Workshop findings: ethics teaching and emotionality
The main difference between educators’ views about ethics teaching expressed in interviews, compared with their views during and after participation in the narrative ethics workshops was the attention given to emotions. The narrative approach in the workshops evoked a keen engagement with emotions in ethics teaching from a number of perspectives. First, there was an emotional engagement with the narratives themselves on the part of the health educator participants. One participant suggested that the narrative approach ‘highlights emotional undercurrents informing the story’, and therefore, promotes ‘emotional engagement.’ Another positively noted ‘the emphasis on feelings and values compared with fact helps to demonstrate that ethics is not static.’ Second, this evoked strong responses about the role of emotions and ethics in clinical practice and the need for students to be aware of the emotional impact of situations where there may be ‘no clear-cut right answers’. Third, it prompted considerable discussion of emotions in the teaching context, how to manage emotions when they arose and how to include them in ethics curricula.
Although all participants were very positive about the narrative approach, when asked about whether they could envisage using a narrative approach in their teaching practice, some participants had concerns. Some commented that some students would be reluctant to engage with the process, perhaps due to the ‘degree of self-disclosure’ required. There was also an underlying apprehension in relation to the perceived ‘riskiness’ of the approach, which would need to be addressed before it could be implemented. Concerns were expressed about students ‘becoming emotionally upset’; ‘going places they can't cope with’; ‘raising issues that open them up to unexpected emotion’; and the ‘possibility of emotional melt-down’. Participants expressed uncertainty about how to address or manage both the emotions within the stories and the potential emotional responses of students during class discussions. They were particularly concerned with students ‘feeling safe’, ‘ensuring participant safety’ (this could well apply to teachers as well as students), and ‘providing adequate support for students’. Many expressed a need for more training in how to ‘better lead discussions, how to handle unexpected and unwanted potential emotions’, and making required skills more overt in order to facilitate ‘dealing with catharsis situations’. Despite these reservations, and the perennial concern about making time in an already crowded curriculum there was an overwhelmingly positive response from participants to the idea of using this emotion-evoking method of ethics teaching.
Discussion
A key theme to emerge from this project was the prominent role of emotion in the workshop phase of the Narrative Ethics Education Project, when it had barely surfaced in the preparatory interview phase. Our reflection on this was that, when given the opportunity to experience and reflect on narrative ethics teaching, participating educators felt that emotions had an appropriate and important place in ethics teaching. This raises two questions. The first question, which may be particular to the context of the Narrative Ethics Education Project, is why this occurred. Why did emotions not feature in the interviews about the formal ethics curricula, when participants attributed such importance to them during the workshops? The second more general and fundamental question is whether it is appropriate to explicitly include emotions in ethics teaching.
In relation to the first question, the absence of reference to emotions in the interviews is in itself not surprising. Current medical ethics teaching focuses largely on the cognitive realm with an emphasis on rational thinking and decision making.2 Students are taught a process for weighing-up of potentially competing ethical principles in order to decide on the most ethical course of action. The cognitive approach to ethics teaching does not refer to emotions, and may even seek to actively exclude emotions as a hindrance to ethical decision making.5 ,20 One explanation for the educators’ positive response to the emotionality of the narrative workshop discussions is that the narratives worked to take them into the real world of clinical practice. The educators knew from their own clinical experience that the clinical world is an emotional place. A number of studies, including Kasman,21 provide evidence for this; these studies found a wide range of positive and negative emotions expressed by junior doctors: positive emotions of pride, gratitude, happiness and compassion, and negative emotions of anxiety, guilt, sadness, anger and shame, all triggered by interactions with patients and colleagues. Evidence of the emotionality is also found in the rich literature of patients’ stories of their illness experiences,22 ,23 and stories by doctors and other healthcare practitioners of their clinical work.24 ,25 If this explanation is correct, then what the educators were doing was linking emotion with clinical practice, rather than directly with ethics. The connection with ethics may then have been a pragmatic one: ethics teaching should be practical and address real-life clinical practice, so emotion has a place in ethics teaching because emotions are an inevitable part of clinical practice. This account of the place of emotion in ethics teaching does not necessarily place positive value on emotion as a component of ethical decision-making or ethical conduct; emotions may still be seen as an interference, but one which should be actively addressed in ethics teaching, rather than ignored. We suggest that this needs further investigation.
The answer to the second question, about deliberately including emotions in ethics teaching, has both theoretical and practical aspects. In practical terms, we suggest that incorporating emotions into ethics teaching will have benefits for both medical educators and students. Addressing emotions as part of ethics teaching reflects clinical practice, where ethical issues arise in an emotion-laden context, and better prepares students for when they become clinicians. In the workshops, the emotive dimensions within the narrative and participants’ emotional responses to the narratives about practice facilitated a discussion of ethical principles and human values, responses and perspectives. The discussions were lively and engaged. In theoretical terms, this could be explained by the notion that ‘bodily feeling’ may be important because it could constitute a somatic expression of ‘taking a moral standpoint’.26 The emotion within a story, as distinct from a case-study written in a deliberately distanced and non-emotional way, facilitates engagement and provides a marker or flag for an ethically important aspect of the clinical situation. This engagement would enhance the learning experience for students.
There is an important gap, however, between explaining why emotions surfaced in discussion of a narrative, and claiming that emotionality should be seen as a valid, even necessary part of health professional ethics education. Our view about the valid place of emotions in ethics teaching stems from a theoretical understanding of what emotions are, and how they are involved in decision making. In the social sciences, as in medicine and medical ethics, emotions were traditionally seen as a disturbance to strategies of rational decision making. That is, rationality was seen as superior in decision making. More recently, this rational orthodoxy has been questioned by empirical and conceptual work in many disciplines.27 Sociologists,28 psychologists29 and neuroscientists30 have argued that, far from hindering rational decision making, emotions are a necessary and positive ingredient in decision making. Gigerenzer posits that gut feelings may even be superior to the deliberate weighing of gains and possible harm31; Klein has shown how emotions are crucial for intuitive decision making about risk in professional practice in health and other high risk occupations.32
While high-intensity emotions may interfere with reasonable decisions, emotions of lower intensity are often used as a valuable advisor in decision making,29 and might sometimes be the only way to make reasonable decisions when time is short and full information is not available,32 a circumstance which is common in clinical decision making, especially in ethically fraught circumstances.
We take the view that emotions are not merely affective states, but also have a cognitive and value component. Nussbaum33 argues that emotions embody specific beliefs and reveal values and beliefs that are salient to a person's flourishing. For this reason, as Molewijk et al34 highlight, emotions form a critical component of moral deliberation. Our position, then, is that ethical deliberation should include explicit consideration of the emotions of those involved in deliberating. The aims of this is to enhance both ethical decision making and ethical practice, by enabling practitioners to make well-informed reflective decisions that they are emotionally able to act on. Molewijk et al suggest that consideration of emotions would involve consideration of the facts causing the emotion, the moral thoughts that accompany the emotion. They also imply, in the three questions they pose for use in deliberation, consideration of the outcomes of acting entirely on the basis of the emotion, or entirely against the emotion, or somewhere in between.
In addition to having a valid role in decision making, emotions are increasingly being seen as something we have control over. Popular conceptions of emotion often include the notion of passivity; our emotions are seen as happening to us.35 However, many philosophers take the view that we have a great deal of choice and control in our emotional lives.36 Some of these theorists argue that we can deliberately develop various emotional capacities and thus shape our emotional responses.37 This draws on Aristotle's notion of habituation: the idea that ‘it is possible to develop various emotional capacities by engaging in actions which are characteristically associated with particular emotions...and, after some time and effort, the emotions themselves may come more naturally’37 (pp. 137–141). This implies health professionals are able to intentionally shape their emotions, at least to some extent, and to make use of their emotions for a variety of purposes. The further implication is that health professionals could reasonably be held accountable for at least some of their emotions, and could be seen as having a responsibility to cultivate and express some emotions, if that will assist in fulfilling their ethical obligations.
We suggest that this provides a theoretical basis for an ethics pedagogy that integrates health professional emotions in both the experience and the analysis of ethical practice rather than simply tolerating emotions as the unavoidable context. In our experience, a narrative approach to ethics teaching facilitates this integration, but there may be many other effective approaches. The key is to teach in such a way that emotions arise and are reflected upon in a structured way with students understanding what they are doing and why. Whatever educational strategy is used, it clearly cannot simply involve some sort of algorithm for elucidating the ethical meaning of an emotion, or a set of rules for distinguishing ‘good’ or ‘relevant’ emotions from ‘bad’ or ‘irrelevant’ emotions. Emotions are deeply influenced by cultural, gender and social environment, so that there cannot be a set ‘meaning’ attached to any emotion. Each health professional will have to work for themselves how to understand and interpret the significance of their own emotions. Hence, a more appropriate approach is to provide a guide for reflection: a series of questions for the students or practitioners to ask of themselves. Molewijk et al take this approach34 (p. 260) to some extent, but their questions do not cover the full range of ethically salient features of emotions. We propose the following set of questions as a framework for teaching critical ethical reflection on emotions:
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What sort of emotion/s am I feeling?
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What are my emotions about? (Are they directed towards myself, other people or some feature of the situation?)
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Why am I feeling these emotions?
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What emotions are others feeling, and how does this help me understand my own emotions?
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How do these emotions relate to other ethically salient features of the situation? Consider ethical principles such as non-harm and respect for autonomy, virtues such as honesty, compassion and integrity, obligations of the health practitioner and rights of the patient and family.
These questions could be used for both personal and team ethical deliberation, and would be appropriate for small group teaching as well as personal journaling or similar educational strategies. The questions are open-ended, and many different, quite nuanced kinds of outcomes are possible. For example, in discussion of a situation in which a social worker feels deeply distressed by a clinical situation where a patient is refusing treatment, the outcome may be an understanding that the distress is coming mainly from a past bad experience. On this basis, ethical deliberation may suggest that rather than attempt to get the patient to change her mind (which was his initial response), the social worker's main ethical obligation here is to focus more clearly on this patient's situation: to find out if any of the things that went wrong with communication and provision of care in that past experience are involved here, and if so, how to address them. The emotional response has not been ignored, but neither has it been the overriding factor. The key processes are an acknowledgement of the emotion and a critical reflection of it.
Educators’ concerns about the impact of emotional aspects of narratives and students’ possible emotional reactions within such ethical analysis also need to be considered. In our programme, we identified a range of strategies to support the educator to incorporate emotion within their ethics teaching. At a curriculum level, educators need to identify the curriculum structure required to support this approach. For example, students working in a small group with a positive supportive ethos provide a safe place for expressing and experiencing emotion. Adequate time in the curriculum and sensible time-tabling is also necessary. Educators also need appropriate preparation. Assisting students to recognise emotions as an ethical dimension in clinical practice requires educators to focus on the process of asking questions about ethics in clinical practice, rather than focusing exclusively on ethical solutions based on weighing up principles. Genuine curiosity about students’ stories and experiences is an important element of this. Educators need to be willing and able to model the process of experiencing, expressing and reflecting on emotion, and to be comfortable with open-ended outcomes.
Conclusion
Our project on using narrative ethics in ethics education demonstrated a dissonance between the stated goals of ethics education and the role of emotionality when educators discussed narratives about practice. This gap raised the question of whether emotions have a legitimate place in ethics, and in ethics education. In this paper, we have put forward the view that emotions do indeed have a legitimate and important role. We do not suggest that emotions constitute or determine ethical values, but we do argue that emotions have a place alongside and integrated with ethical reasoning based on principles. Our experience is that narrative ethics is an effective way of giving space for emotions to arise, be acknowledged and discussed. Other approaches to teaching ethics may also achieve this aim. Whatever approach is taken, there are two key requirements. One is to have a sound method of making sense of emotional responses and incorporating them into ethical reasoning and ethical practice. The other is an underlying theoretical framework that informs educators and students about how and why emotions matter in ethics. This paper provides an account of both.
In addition to a sound theoretical and pedagogical base, trained and confident educators are needed to deal with the educational and pastoral concerns raised by participants in our workshops. Educators need to have clear aims, be able to create positive learning experiences for their students, and be willing to take the risk of entering into a challenging domain. If this can be achieved, there will be benefits for educators and students alike, and ultimately for the patients for whom these future health professionals will provide care.
Acknowledgments
We acknowledge the contributions of all the participants in the Narrative Ethics Education Project. We are grateful to Emma Barnard for administrative assistance.
References
Footnotes
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Contributors The manuscript has been read and approved by all the authors. The requirements of authorship have been met and each author believes that the manuscript represents honest work. All authors included on this paper fulfil the criteria of authorship.
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Funding University of Melbourne Faculty of Medicine, Dentistry and Health Sciences.
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Ethics approval University of Melbourne.
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Provenance and peer review Not commissioned; externally peer reviewed.
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