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Process factors facilitating and inhibiting medical ethics teaching in small groups
  1. Miriam Ethel Bentwich1,
  2. Ya'arit Bokek-Cohen2
  1. 1 Faculty of Medicine, Bar-Ilan University, Safed, Israel
  2. 2 Achva Academic College, Arugot and Bar-Ilan University, Israel
  1. Correspondence to Dr Miriam Ethel Bentwich, Faculty of Medicine, Bar-Ilan University, PO Box 1589, Safed 120000, Israel; Miriam.Bentwich{at}


Purpose To examine process factors that either facilitate or inhibit learning medical ethics during case-based learning.

Methods A qualitative research approach using microanalysis of transcribed videotaped discussions of three consecutive small-group learning (SGL) sessions on medical ethics teaching (MET) for three groups, each with 10 students.

Results This research effort revealed 12 themes of learning strategies, divided into 6 coping and 6 evasive strategies. Cognitive-based strategies were found to relate to Kamin's model of critical thinking in medical education, thereby supporting our distinction between the themes of coping and evasive strategies. The findings also showed that cognitive efforts as well as emotional strategies are involved in discussions of ethical dilemmas. Based on Kamin's model and the constructivist learning theory, an examination of the different themes within the two learning strategies—coping and evasive—revealed that these strategies may be understood as corresponding to process factors either facilitating or inhibiting MET in SGL, respectively.

Conclusions Our classification offers a more nuanced observation, specifically geared to pinpointing the desired and less desired process factors in the learning involved in MET in the SGL environment. Two key advantages of this observation are: (1) it brings to the forefront process factors that may inhibit and not merely facilitate MET in SGL and (2) it acknowledges the existence of emotional and not just cognitive process factors. Further enhancement of MET in SGL may thus be achieved based on these observations.

  • Education for Health Care Professionals
  • Ethics

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Ethical conduct is a major keystone of medical professionalism.1–3 Consequently, most medical schools include medical ethics teaching (MET) as a basic and mandatory module for their medical students. As part of MET, many medical schools now use a combination of lectures to introduce knowledge-based key concepts and complex theoretical topics, together with small-group learning (SGL) carefully designed for interactive debate and discussion.4 For MET, SGL usually involves groups of 8–10 students who discuss cases and their underpinning theories, so that they have the opportunity for precise interactive discussion about these cases.5

SGL can be conducted using three main techniques: problem-based learning (PBL), case-based learning (CBL) or team-based learning (TBL). PBL is active learning stimulated by presenting a problem, query, or question that learners then seek to solve.6 PBL goes beyond mere problem solving as the main reason for the learning.7 It facilitates students' critical thinking, self-directed learning, collaboration and communication skills.8 Indeed, PBL has been implemented in many medical curricula worldwide for nearly 40 years.9 The essence of CBL is the rationale that realistic cases are the best way to teach medical ethics to students, as the strategy presents predetermined realistic vignettes, each designated to focus on specific ethical issues.10 Different studies have argued that CBL is a particularly effective learning method.11–13 It should be noted at this point, however, that the distinction between PBL and CBL in medical education scholarship (including MET) remains somewhat blurred and the two titles are thus sometimes used interchangeably. Finally, TBL is defined as an “active learning strategy that combines pre-class, guided self-learning with highly interactive, small-group learning in class”.14 Similar to the former SGL methods, there are research data that show that the application of TBL to MET improves student performance and increases their engagement and satisfaction.15

Despite the variance in the definitions of, and distinctions between, these methods, and their different modalities (eg, face-to-face, video or virtual), they all share two core characteristics: (1) case scenarios or clinical vignettes as the basis for the discussions;16 ,17 (2) an active learning approach via substantive discussions between group members.18

The active learning approach employed in SGL is inspired by constructivist educational theory.5 In constructivist epistemology, knowledge is acquired through a process that is structured by the personal experiences of the learners. Learners integrate new experiences and information with their existing understandings.19 Constructivist learning theory is a derivative of constructivist epistemology, wherein the desired focal learning occurs by changing the mental representation of information of the learner.20 To achieve an effective learning process, learners must undergo a mental processing of new material and then integrate it with their previous understandings; this process produces a new cognitive structure that is unique to each learner and contingent on their own process of information construction.21

In contrast to the traditional teaching technique where the student is a passive learner attending lectures,5 an active learning approach, as inspired by the constructivist theory, has the following four elements:21 (1) the teacher is a guide and facilitates learning; (2) the teaching provides opportunities to expose inconsistencies between the learners' current understandings and their new experiences, thereby providing the opportunity to develop new schemes; (3) learning should be active using relevant problems and group interaction and (4) time is needed for adequate reflection on the new experiences.

Active learning through SGL is particularly important for the MET of medical students since the provision of professional healthcare is facilitated by technical and scientific knowledge acquisition, and also by enhancement of future clinicians' ethical sensitivities and analytic abilities.22 Such enhancement is expected to take place through actively discussing the ethical issues involved in the practice of medicine both in an abstract way of learning the theoretical dilemmas encapsulated within them, but also in terms of the real dilemmas emerging from the fictional cases the students examine.23 In other words, SGL (whether CBL, PBL or TBL) should facilitate students' analytic and critical thinking, so they will be able to critically examine and discuss fictional cases and uncover and reflect on the ethical issues and dilemmas embodied in those cases.

One particular model of critical thinking, which was specifically designed for clinical medical education (including MET), was suggested by Carol Kamin et al.24 ,25 Inspired by, and based on, two previously developed separate pivotal models by Garrison and Newman to use for critical thinking,26 ,27 Kamin et al suggested five stages of critical thinking, each of which includes indicators of surface processing (shallow learning) and in-depth processing (deep learning). These five stages are: Problem identification, problem definition, problem exploration, applicability and integration (see table 1).

Table 1

Summary of Kamin’s guide to codes of five critical-thinking stages

Interestingly though, while much research has focused on evaluating the knowledge and understanding of MET (including the use of SGL), studies examining the actual process of learning taking place in MET are scant and their conclusions are limited. For example, one study examined the processes occurring within groups of students discussing ethical dilemmas. However, the students' arguments were merely counted and their wordings were checked, rather than being evaluated for their correctness or appropriateness.28 Specifically, there seems to be a deficiency in research that accounts for any process factors that may either engage or disengage students from MET in SGL. This deficiency is particularly important since there are troubling findings in several studies about the effectiveness of MET taught using SGL.29 Indeed, with respect to the constructivist educational approach which inspired SGL, Hrynchak and Batty call attention to the fact that “while the approach has shown promise, research in the effectiveness of this teaching approach has thus far yielded a lack of strong evidence of enhancement of learning”.5 On the theoretical level, therefore, accounting for these factors can potentially shed further light on the sources for the troubling findings about the effectiveness of SGL for MET. On a more practical level, acknowledging these factors may also assist in significantly enhancing the use of SGL in MET.

In this project, we examine and reflect on the process factors that engage or disengage students in SGL of medical ethics, by performing qualitative research using microanalysis. This analysis, informed by Kamin’s critical thinking model and the constructivist learning theory, reveals the coping and, particularly, the evasive strategies that appear in the learning process employed by students during sessions of SGL in MET.


Participants and sampling

MET in our medical school is based on lectures that are designed to frame key topics and concepts. Each lecture is immediately followed by CBL that aims to solicit students' discussion and reflection on a fictional case and its ethical dilemmas. Each team has 10 students registered for a mandatory course in medical ethics and medical humanities that is running throughout the preclinical stage of our 4-year graduate programme. For this study, we filmed three randomly selected small groups (out of six groups in the course) during the final three small-group sessions of MET designed for these first-year students. The duration of each videotaped session was 40–45 min and the total number of participants was 30.


The three groups of students were videotaped during three consecutive SGL sessions in MET as part of the medical ethics and medical humanities course being taught by the first author. All the sessions concerned ethical issues pertaining to genetics and reproduction. We chose to focus the study on these sessions for two reasons: (a) the subjects involved were particularly rich, thereby potentially allowing for richer ethical discussion and (b) the sessions were carried out at the end of the first year, so by then, students could be expected to know their way around in any ethical discussions. Each group was led by a PhD candidate with a background in bioethics and medical ethics and further trained in facilitating CBL sessions. Two of the sessions used written case scenarios and one session followed the screening of an edited version of My Sister's Keeper, a feature film. In all the sessions, the tutors were provided with relevant guiding questions. Both the case scenarios and the guiding questions were constructed by the first author and revolved around the ethical issues pertaining to key related themes, such as oncogenetics, abortion, prenatal diagnosis and a therapeutic designer baby.30–35 Further details of the case scenarios and the film, together with examples of the guiding questions, are presented in box 1. Altogether, nine sessions were videotaped and the verbal narratives were transcribed. All emotional expressions (smiles or laughter) were also noted next to the verbal expressions offered by each participant.

Box 1

Description of case scenarios used and key ethical issues discussed

Session 1: Oncogenetics, genetic information law and new eugenics

The case is about a bachelorette woman aged 22 of Ashkenazi origin (European Jews). Given a history of breast cancer in the family (her mother was diagnosed at the time with breast cancer) and her above-mentioned ethnic origin, she has a high risk of carrying the BRCA 1/2 mutation (associated with significantly higher risk for breast/ovarian cancer). She therefore decides to seek oncogenetic counselling.

Key ethical issues: (1) The dilemma in conducting a test for BRCA 1/2 mutations in such a case and the arguments for and against it. (2) Information disclosure to a next of kin (sister) if the woman tests positively: ethical and legal perspectives. (3) Discussing the issue of abortion—namely, whether to recommend it (if asked) and why, in a situation where the sister tests herself and undergoes prenatal diagnosis (PND) for the fetus, resulting in positive results for both. (4) PND as a form of new eugenics—where should the line be drawn (if at all)?

Session 2: Abortion and PND—Klinefelter syndrome

A pregnant woman aged 36 is referred for genetic counselling given her (relatively) older age and preliminary test results in the second trimester indicating higher risk for a fetus with Down syndrome. Amniocentesis/amniotic fluid test (AFT) results received in the 21st week of pregnancy reveal a fetus with Klinefelter syndrome. This syndrome may be reflected in a varied spectrum of clinical symptoms, from being infertile to having lower IQ.

Key ethical issues: (1) To what extent should physicians recommend an abortion or abstention from it and why? (2) Religious differences regarding abortions—why do they matter for the physician and what’s their limitation? (3) Possible tension between the religious faith of physicians and their professional role. (4) Discussion of information disclosure to patients.

Session 3: My Sister’ s Keeper—designer baby and its implications

The parents of a little girl diagnosed with leukaemia decide to bring into the world a saviour sibling through a designer baby in order to help their sick daughter with transfusions of umbilical cord blood, platelets and bone marrow; until the younger daughter allegedly refuses to provide a kidney donation, asking the court for an emancipation of her body.

Key ethical issues: (1) Ethical, psychological and social issues the film raises. (2) To what extent do you agree with the medical staff's acceptance of the parents’ consent as legal guardians of their daughters, where would you have drawn the line and why, whose autonomy is it? (3) Conflict of interests: between whose characters it occurs and to what extent should it concern us from a medical ethics perspective? (4) Based on the discussion thus far, what is your stance regarding a therapeutic designer baby and why?

Data analysis

Qualitative microanalysis of the transcribed recorded sessions was used to identify common themes in the participants' narratives.36 To ensure the reliability of our qualitative analysis, at the beginning of the data analysis, each of the two authors conducted an initial classification of the students' utterances for 10% of a randomly transcribed session sample to assess inter-rater reliability. The two authors reached a consensus on 90.5% of these items during this preliminary phase. Then, one author who specialises in medical sociology and content analyses classified the remaining utterances; the other author, an experienced ethicist and researcher who teaches medical ethics at the university (including the course in which these respondents were participating) read the utterances and commented on them. Unclear excerpts during the preliminary coding by the authors, as well as cases of disagreement about to which category and coping theme they belonged, were discussed until agreement was reached. The narratives were then analysed using a constant comparison approach, which involves reading the narratives using an iterative process to detect quotes with common motifs and then classify them into relevant themes.37

Ethical considerations

The study was approved by the ethics committee for our Faculty of Medicine (approval No 02-2014). Consent was gained from the students participating in the study, after providing them with an explanation of the goals of the study and the method used to collect data, fully emphasising its voluntary nature. Given the particular sensitivity of the study to issues of privacy due to the video recording of these group sessions, students were assured that the recordings would not be shown to anyone else other than course staff and research assistants. None of the students refused to participate in the study; however, if students did not feel comfortable about exposing their faces in the video recording, they were allowed to sit in spots where the camera could not fully capture their faces. Finally, to secure the confidentiality of the students, in this article, we refrain from linking excerpts from students' comments and reactions to particular students. In a similar vein, we purposely refrained from indicating the year in which the video recording was made, so it cannot be linked to a particular class or a particular year.


We detected utterances that related to the content of the dilemmas and utterances that reflected the process the learners were undergoing during each session. The present article focuses on the 12 thematic process factors we detected. Of these, six reflect a proactive coping with the dilemma and the remaining six illustrate various kinds of evasive efforts. Altogether, we found 665 instances of process factors that reflected either coping strategies or evasive strategies. While the majority of the utterances on process factors were coping strategies (372), there were also many utterances related to evasive strategies (293). Table 2 presents the different themes of the process factors that were found for each of the strategies together with excerpts from the transcribed sessions that illustrate each factor.

Table 2

Frequencies and sample excerpts of coping and evasive strategies

Table 3 presents the direct correspondence that can be found between the deep and shallow phases in Kamin’s model and the cognitive coping and evasive themes we witnessed among our students. It should be noted that the emotional techniques of humour, smiles and slang, or expressing fear about the ramifications of counselling patients are not echoed in Kamin’s model,24 ,25 as that is a cognitive oriented model and therefore, these aspects are not presented in table 3. In the ‘Discussion’ section that follows, we further elaborate on and explain the direct correspondence between Kamin’s model and our suggested coping and evasive strategies. Based on this correspondence or linkage, we also substantiate the division between the two types of strategies, while also noting the deficiencies found in Kamin’s model in comparison with our depicted coping and evasive strategies employed by the students.

Table 3

Coping/evasive strategies and corresponding phases in Kamin’s model


Our study shows that medical students can engage in both coping and evasive strategies when discussing ethical dilemmas during CBL in small groups. We found there was direct correspondence between most of the deep phases in Kamin’s model and the cognitive coping themes we witnessed among our students. We also found the same correspondence between most of the surface phases depicted in this model and our captured evasive themes. This correspondence in findings clearly attests to the validity of our data analysis and its classification into various themes for both coping and evasive strategies.

Thus, for their coping themes, by discussing ambiguities and linking relevant facts, students were able to deepen the dilemmas and reframe the dilemmas. At the same time, the need to reframe dilemmas appeared to serve the students' pursuit of a precise justification of their stance. Further interpretation of the text or video with which they were engaged might provide the grounds for students to deepen the dilemmas. Information seeking could be triggered by new information provided or questions presented by students to acquire new information, while admitting to not knowing the right solution might be triggered by their acknowledging ambiguities or admitting the answer was unknown. Exploring additional considerations might be grounded in linking relevant facts and performing an overall synthesis on the theoretical level. On the practical level, this coping strategy could be based on exploring possible practical solutions. In addition, by performing this second coping strategy, students could offer justifications for their stances. Finally, familiarisation simply corresponds to drawing on personal experience through which the student was able to feel familiarised with the subject matter being presented.

Turning to the themes of evasion, denial or reduction of dilemmas could be based on ignoring/exhibiting impatience with ambiguities or not being willing to explore other possible explanations. Offering an easy solution corresponds to suggesting impractical solutions. Ignoring the tutor's questions and irrelevant information was likely to be reflected in repeatedly asking for information that could not be provided, had already been said, or not making inferences about it; all of these behaviours may culminate in the student's lack of synthesis. In addition, specifically offering irrelevant information could also be manifested in a student's drawing on irrelevant personal experience. Refusing to discuss dilemmas is also reflected in an unwillingness to explore other possible solutions/explanations for the problem, leading to irrelevant or obscuring justification for the students' stances. Finally, seeking contrasting/illogical information is often part of complaining and it may also be reflected in the student's unwillingness to do self-assessment.

Furthermore, analysis and interpretation of these findings shows how the different themes that were uncovered for coping and evasive strategies can be understood as process factors that are either facilitating or inhibiting MET in SGL. Thus, as one may recall, SGL is supposed to enhance MET by facilitating students' analytic and critical thinking, so they will be able to critically examine and discuss fictional cases to uncover and reflect on the ethical issues and dilemmas embodied in these cases. Indeed, the coping strategies that were uncovered in this study, such as deepening the dilemma or reframing it, together with information seeking and exploring additional considerations related to the case in point, precisely display a student's ability to critically examine and reflect on the ethical issues involved in the given CBL.

On the other hand, constructivist learning theory may be understood as explaining the relevance of evasive strategies employed by students to inhibit their ability to take advantage of SGL in MET fully. According to element No 2 of this theory, teaching involves providing the opportunities to expose inconsistencies between current understandings and the new experiences of learners, thereby providing them with the opportunity to develop new schemes. Element No 3 of constructivist learning theory emphasises that learning should be active by using relevant problems and group interaction. However, the large number of evasive utterances that our study revealed implies that using an SGL approach for MET is not automatically effective in providing students with the opportunities to expose various types of incongruent stances. Although the tutor did describe the dilemma in detail, these students nonetheless could ‘escape’ from investing cognitive and emotional efforts in six different modes. In addition, their evasive modes might have undermined the supposed ‘active’ nature of the learning process performed in SGL. Any form of evasion may also imply that the learner has a passive rather than an active state of mind.

Our analysis also entails certain refinements of the model proposed by Kamin et al, since the emotional aspects involved in the learning process are not accounted for in Kamin's model. These refinements also correspond with the recent attempts to formulate a theoretical framework for integrating emotions into both the experience and the analysis of ethical practice overall.38 ,39

One emotional theme that emerged in our data analysis was fear of taking moral responsibility for the ramifications of counselling the patient, signified by sayings such as “why do I make decisions which I am not supposed to make, this is not my child, it is not my family, they have to decide.” This emotion is acknowledged in the concept of moral distress that encapsulates a moral emotion, insofar as it is founded on moral angst or conflict. It usually involves a crisis of conscience, leaving the clinician feeling powerless, threatened, confused or even guilty. Moral distress emerges when the clinician or the nurse recognises a moral issue and believes she or he is responsible for her or his own actions in the situation. It may also arouse a conflict between the clinician's beliefs and his or her values and professional commitments.40 ,41

The second emotional theme was the use of humour, laughter, smiles and slang. Humour plays an important role in the regulation of stressful situations42 ,43 by decreasing stress hormones like serum cortisol, 3,4-dihydroxyphenylacetic acid and epinephrine.44 The nursing and education literature acknowledges the positive impact of humour on learning by reducing tension in nursing clinical practice.45–54 Humour facilitates an increased attention span and retention, reduces stress levels, improves performance and enhances problem solving and teamwork, by building collaborative relationships between tutors and students and the coping strategies necessary for effective teamwork.48 ,55–58

Successful SGL requires an environment that is characterised by an informal tone, enabling a relaxed and familiar climate.45 ,47 ,51 ,59 ,60 Hence, SGL is further facilitated by humour, which allows the participants, in a relative short timeframe and with a minimum of effort, to (1) mutually reinterpret their experiences; (2) entertain, reassure and communicate them; (3) convey their interest in one another; (4) pull the group together by transforming what is individual experience into collective experience and (5) strengthen the social structure within which their group functions.61 Slang functions in similar ways to humour in reducing tension, as it discharges strong emotions too often catalysed and evoked during clinical care.62 Slang may also help clinicians deal with feelings of hopelessness that may occur with patients and any situations over which they have no control.63

Based on the above discussion on emotion-based coping and evasive strategies, these strategies may also link to process factors that both facilitate and inhibit MET in SGL. Specifically, among our coping strategies, use of humour and slang is aimed at decreasing both anxiety and moral stress; hence they constitute an emotional facilitator of the learning. Finally, of all our evasive strategies, fear of taking moral responsibility for the ramifications of counselling the patient constituted an emotional strategy that possibly reflected moral distress. Such moral distress, if unhandled, may prevent the student, like the clinicians, from really dealing with the ethical dilemma that has triggered this distress.

The practical implications of our study are threefold. First, we emphasise the significance of the process factors in MET within SGL, which has received only scarce research and scholarship despite their crucial role in successful medical ethics learning; second, we call attention to the emotional responses of these students as part of the learning process; third, we recommend that MET should be improved by (a) encouraging students' coping efforts on dilemmas during SGL; (b) discouraging students' evasive efforts on dilemmas during SGL. The students can thus become aware of both coping and evasive strategies by receiving the explicit guidance of the tutor at the beginning of each SGL session.

Study limitations and future research

We used an inductive system of analysis that might have yielded conclusions contingent on the context. Hence, we acknowledge the possibility that examining CBL discourse is likely to lead to different findings at other times or in different ethnocultural settings. Also, as this study was cross-sectional, long-term CBL outcomes cannot be evaluated. Finally, interpersonal differences between learners will prevail in MET as in any other realm; we did not look for individual learning styles and hence did not take into consideration that coping or evasive modes of learning can vary for different personality traits, personal learning styles and/or familial medical history. Similarly, we did not control for socially desirable responses as part of the impression management tactics found in group dynamics.64 Future studies may be needed to focus on the interactional cues to the coping and evasive strategies that the students were observed to employ. Such studies would help to illuminate whether there are approaches used by tutors that facilitate the types of coping strategies that we associated with deep learning or, alternatively, whether there are approaches that students tend to respond to with evasive strategies.


In conclusion, our research project is useful for enhancing medical ethics curricula. Any MET performed in a small group environment should not overlook those process factors that are highly influential on learning processes, in general, and MET, in particular. The effectiveness of SGL can be further advanced by directing students towards intensified coping modes of learning, including acknowledgement of the importance of emotional coping, while discouraging evasive modes of response. It is our hope that our findings and recommendations will contribute to better ethical understanding by tomorrow’s clinicians.


The authors express their sincere gratitude to all the students who participated in the study.



  • Contributors MEB contributed substantially to the design of the work and the acquisition of data. Both authors contributed substantially to analysis of the data, drafting and revisions of the paper/manuscript and approve the version to be published, agreeing to be accountable for all aspects of the work.

  • Competing interests None declared.

  • Ethics approval Research Ethics Committee, Faculty of Medicine, Bar-Ilan University.

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

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