Article Text

Design thinking in medical ethics education
  1. David Marcus1,
  2. Amanda Simone2,
  3. Lauren Block3
  1. 1 Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York, USA
  2. 2 Medicine, Allina Healthcare, Minneapolis, Minnesota, USA
  3. 3 Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York, USA
  1. Correspondence to Dr Lauren Block, Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY 11042, USA; lblock2{at}


Background Design thinking (DT) is a tool for generating and exploring ideas from multiple stakeholders. We used DT principles to introduce students to the ethical implications of organ transplantation. Students applied DT principles to propose solutions to maximise social justice in liver transplant allocation.

Methods A 150 min interactive workshop was integrated into the longitudinal ethics curriculum. Following a group didactic on challenges of organ donation in the USA supplemented by patient stories, teams of students considered alternative solutions to optimise fairness of organ distribution and ethical implications of changing the current model. Facilitators led students through DT steps of empathy, defining the team’s point of view, ideating on potential solutions, prototyping a specific idea and testing the idea through oral presentation, with questions and answers by peers and faculty. The curriculum was evaluated with presurveys and postsurveys including quantitative and open-ended items.

Results 100 first year medical students participated. Before the session, 75.3% of students had no practical experience with DT. Following participation, students reported an increased understanding of the current liver transplant allocation system (p<0.01) and an increased appreciation of shortcomings of the current organ allocation system (p<0.01). After the session, 73.8% of students felt that DT could be used to approach complex health system problems.

Discussion Students participating in a DT workshop displayed improved knowledge and attitudes toward organ transplantation and DT. In this pilot study, DT showed promise as a student-led approach emphasising collaboration and creativity in ethics curricula in medical education.

  • education for health care professionals
  • education/programmes
  • transplantation

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Design thinking (DT) is a process for creative problem solving which uses diverse data sources to develop creative solutions to problems.1–3 Originating in the business world, DT has been applied to medical education to emphasise interdisciplinary collaboration, creativity and communication skills.4 DT consists of discrete steps including empathising with potential stakeholders, defining the problem, ideating potential solutions, prototyping a specific solution and testing this solution.1

The Romanell Report evaluated various pedagogical approaches used in medical ethics education in the USA.5 Though DT has been gaining popularity as a novel pedagogy in medical education, its use in medical ethics education has not yet been described.

We applied DT as an experiential learning strategy to a workshop on ethical implications of liver transplantation. Our objectives were to encourage students to empathise with patients and other stakeholders, brainstorm solutions to the ethical problem of scarce resource allocation, develop DT skills and evaluate DT as an educational pedagogy in medical ethics. Using DT principles, students proposed ways to transform the existing US liver allocation system into a more just system. In this manuscript we describe the development and evaluation of this workshop applying DT principles to medical ethics education.


Liver transplant session

The DT workshop was developed and introduced into the ethics and professionalism curriculum at one US medical school. The ethics curriculum is a 4-year series of case-based sessions designed to help medical students develop a value-based framework for ethical decision-making. Ethics sessions are built around the ethical pillars of autonomy, beneficence, non-maleficence and social justice. The session on liver transplantation, framed around the principle of social justice, occurs during the liver block alongside sessions on cirrhosis during the first year of medical school.

The workshop, ‘Equitable Organ Allocation: Designing for an Ethical Imperative’, was introduced as a 150 min session in 2018. Prework included readings on DT principles and regional variation in transplantation access. In a 60 min large group, students were introduced to challenges of designing a fair system to allocate the scarce resource of organs for transplantation and disparities in the current system. Guest speakers included two transplant recipients and the mother of a deceased organ donor, who shared stories of the promises and obstacles of organ transplantation, followed by an opportunity for students to ask questions. A brief framing talk by an ethics faculty member oriented students to the current system and its inherent challenges.

Students then moved immediately from the large group to a workshop room with small group tables, where teams of five were introduced to the 90 min student-led DT challenge. Students were asked to consider how best to redesign the current organ allocation system to ensure fair distribution and less waiting time, while reflecting on the ethical ramifications of altering the current system. A workshop guide provided students with instruction through the steps of DT. Ethics, educational and hepatology faculty and guest speakers were present to guide students and answer questions. Each step was applied to the problem of ethical allocation of transplant organs. Students empathised with stakeholders relevant to transplantation, including organ donors and recipients through readings and stories from families. Students defined their team’s point of view, ideated potential solutions and ideas, prototyped one specific idea and tested the idea through oral presentation of proposals to peers and a panel of ethics and hepatology faculty, followed by questions and answers by peers and faculty. Table 1 details the DT steps and instructions for students at each step. Effort was made to retain core DT principles of empathising with potential users, innovation for sustainable change, collaboration and effective communication.6 7

Table 1

Stages of the design process and student instructions

Study design

In this pilot study, we aimed to evaluate whether this novel session was associated with changes in student-reported knowledge of the ethical implications of current organ allocation system and knowledge and attitudes toward DT. A student survey (online supplementary appendix) including open-ended items was used to evaluate the session as a whole. Students completed confidential surveys immediately before and after the session, which included quantitative and open-ended items assessing knowledge and attitudes about the liver transplantation system and principles of DT. Participants included first year medical students at Zucker School of Medicine (ZSOM) who completed the surveys.

Supplemental material

Data analysis

Due to few labelled surveys, we were unable to pair all presurveys and postsurveys. To maximise useable data, unpaired t-tests and χ2 tests were used to compare presurvey and postsurvey data. Student knowledge of the steps of the DT process was assessed by calculating the average of the per cent of students correctly identifying each step before and after the session. For qualitative questions, thematic analysis was performed using an inductive approach consisting of open coding as described by Braun and Clarke in 2006 and 2014 without a prespecified coding frame.8 We selected thematic analysis as a flexible research tool enabling a rich and complex yet detailed analysis of themes. Analyst triangulation was conducted by having two researchers independently reflect on extracted themes and quotations, further developing these themes. Themes were pooled until saturation was reached. Disputes were resolved by consensus. A third researcher reviewed final themes for consistency with the original research question.9


One hundred and two students participated in the workshop during the 2017–2018 academic year. Response rate for the preworkshop and postworkshop surveys was 91.2% (93/102) and 84.3% (86/102), respectively.

Among the students surveyed, 90% (81/90) felt they learnt something new about the organ donation system through the assigned readings. Regarding design theory, 75.3% (70/93) of students had never had any practical experience with or exposure to DT or design theory, highlighting the novel nature of this teaching modality in medical education.

Following the session, students reported significantly increased understanding of the current allocation system for liver transplantation based on a 1–5 Likert scale (presession=2.3, postsession=3.7, p<0.01). Survey results revealed increased appreciation of shortcomings of the current allocation system for liver transplant in the USA after the session (presession=2.8, postsession=4.2, p<0.01). After the session, 73.8% (62/84) of students felt design theory could be used to approach complex health system problems (students rating 4–5/5 on a 5-point Likert scale). After the session, 98.1% of students were successfully able to order the steps of design theory, compared with 61.1% beforehand.

Themes from student-reported learning included insights into issues with the current organ donation system in the USA, the challenges and barriers involved in finding a better solution, understanding the organ donation process in New York and appreciation for DT as a way to solve complex problems. Themes from student suggestions for improvement included desire for more background information on the current organ donation system, desire for more guidance from faculty during the session and request for more time dedicated to the session (table 2).

Table 2

Themes and quotes from student responses to design thinking workshop


DT has garnered attention as a tool in medical education to redesign curricula and encourage students to solve problems using creativity and collaboration.1 2 We applied DT to the ethical problem of how best to allocate the scarce resource of organs for transplantation to meet the needs of the population. Following a session including readings, patient stories and a DT workshop, students reported improved knowledge about the organ allocation system and displayed improved knowledge and attitudes about DT.

The workshop allowed students to explore three key aspects of DT: desirability, feasibility and viability. Students reimagined an existing system for allocation of a scarce resource, brainstormed the effects of potential solutions on various stakeholders, explored the feasibility of these solutions and present facilitators and barriers.10 The workshop format used limited faculty resources. Students used problem solving to engage with the topic and negotiated in their small groups to choose and develop a single idea. Students practised the skill of presenting their idea orally to fellow students and faculty, a key skill in medical training. While other ethics sessions have focused on autonomy, non-maleficence and beneficence, this session focused on social justice via resource allocation. Comments showed an appreciation for justice. Several students noted the motivation to sign up to be organ donors.

Limitations of this project include a single pilot session in a single medical school. This evaluation was limited to student knowledge and attitudes; facilitators were not surveyed. Though we planned for paired presession and postsession surveys, several unlabelled surveys forced us to use an unpaired t-test, limiting an understanding of individual changes in knowledge and attitudes. We did not evaluate each student project, limiting our understanding of student skills. Retention of this information was not evaluated.

Future work will include an evaluation of student proposals to assess student skills in DT principles. A final exam question will ask students to apply DT principles to another ethical problem, further evaluating skill and knowledge retention.

We applied DT to a medical ethics workshop to allow students to explore a complex healthcare problem involving resource allocation. Use of a DT model allowed for hands on training in social justice, suggesting a role for DT in medical education to allow critical thinking by students on complex problems in healthcare.


The authors wish to thank Dr. Bon Ku.


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • Presented at This work was presented as a poster at the Society of General Internal Medicine National Meeting in Washington, DC on 9 May 2019.

  • Contributors DM and LB conceived the study. AS and LB analysed the data. DM, AS and LB drafted the manuscript. DM, AS and LB approved the final draft. DM, AS and LB agree to be accountable for all aspects of the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The research protocol was approved by the Hofstra University Institutional Review Board and the ZSOM Educational Research Committee. All participants provided survey consent to participate.

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

  • Data availability statement Data are available upon request.

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