Undergraduate medical ethics education currently focuses on ethical concepts and critical thinking skills, implicitly positing the key challenge for doctors as identifying an ethically-appropriate action option in specific circumstances. The Australian core curriculum is typical, with its statement in the introduction to the document that

[t]his core is concerned primarily with equipping students to recognise and understand important ethical issues, to know how to make decisions about those issues, and to have a better basis for knowing what should be done (in any given situation) and why.1

The intern’s story presented in this paper throws into question the appropriateness of this primary emphasis on moral reasoning. The story was told during an interview for an ongoing study investigating junior doctors’ ethical challenges. (By “junior doctors” I mean doctors in their early years following graduation from medical school; I use the Australian terminology of “intern” to refer to a doctor in their first year after graduation. The study was approved by the hospital’s Human Research Ethics Committee and the intern consented to publication of the data. “Maggie” is a pseudonym.) The story highlights that the fundamental ethical problem for junior doctors need not be identifying an ethical course of action. In this case, the junior doctor’s difficulty lay in acting in accordance with the values that she reflectively embraced, rather than in reasoning about what she morally ought to do. It was implementing her ethical beliefs while working in the pressures of the hospital setting that posed the fundamental difficulty for her, not critical thinking about the moral justifiability of the various possible action options.

Recognising this aspect of junior doctors’ ethical challenges suggests the need for a new direction in medical ethics education. From this perspective, learning moral principles and critical thinking skills will be insufficient to enable junior doctors to act ethically. Additional knowledge and skills for dealing with the pressures of hospital work that will act against them behaving in accordance with their ethical convictions are necessary to complement the decision-making skills that currently form the focus of ethics teaching. This intern’s story thus suggests a need for greater emphasis on implementation skills in ethics core curricula.

I assume throughout the discussion that ethics education aims to produce ethical practitioners. This is to some degree controversial.2 Miles and colleagues, for example, in their widely-cited review of medical ethics education’s “coming of age” posit ethics teaching’s objectives in more diffuse terms around recognition of issues, examination of values and use of philosophical knowledge.3 However, many other ethics educators compellingly claim students’ ethical practice as the appropriate outcome of ethics education.2 4^–6

I also assume that undergraduate medical ethics education currently comprises primarily material on ethical concepts and critical thinking skills. I make this assumption based on the content of published national medical ethics core curricula and the limited literature on what ethics educators are doing in practice. However, it is possible that this literature does not comprehensively reflect the ethics programmes being taught and that educators in some medical schools are already including in their teaching the additional elements that I advocate in this paper.

MAGGIE’S STORY

Twice in the last week I’ve had to do pregnancy tests on unwilling girls with abdo[men] pain … So they’re both young girls who came in with belly pain. … You always sort of ask about their menstrual history and their sexual history and whether they think there’s any chance that they could be pregnant. But then you don’t trust a word of what they say anyway! Like that’s just generally what happens because, you know, like the worst possible thing would be that they’re pregnant unbeknownst to them and they have an ectopic pregnancy which ruptures and then which is potentially life-threatening. Really very serious. And it’s certainly something that you would just not want to miss. Like it would be fatal for the patient and fatal for your career to have missed that…

In the first case I pretty much just went back and said “oh look, you know, for all women who are of your age who come in with belly pain we have to do a pregnancy test”. Like I pretty much just told her “you have to do this”. And then the second time, that was harder … because she came in with her girlfriend. And so at the time when I’d asked her, she was like “well, you know, this is my partner”’. And I said “oh well”, you know, I think, I said something like “oh well you’d be busted if you were pregnant!” or something. They had, like they laughed, … we had a good rapport. But then ultimately I was sort of still left with this problem, and in the end my registrar was like “nup, just do the pregnancy test then discharge her once you know that she’s not pregnant”. Which is what I did but, which was just not the right thing to do. And I don’t know.

Interviewer: Why was it not the right thing to do?

Well, I think that I, what I should have done is gone back and told her that she, that we had to do a pregnancy test.

Interviewer: So you did it and she didn’t know that you’d done it?

And she didn’t know that … I’d done it, yeah. …We’d taken the blood already for the other tests … because we thought she had an infection and stuff. And she knew that she was getting those tests. And then when I like I explained to my reg[istrar] “oh, you know, she’s got a female partner and she says that there’s no chance she could be pregnant” and she’s [the registrar] like “nah, nup, just do it anyway”. And “once you know she’s not pregnant you can send her home”. And I think, I should have gone back and said “oh look, we have to do this pregnancy test” and if she wanted to sort of vehemently disagree and, I dunno, document that she would not, that she had refused the pregnancy test then that would have been alright. But in the end we did it and it was negative and so she went home. But if it had been positive then I mean that would have been terrible. Yeah. Well I, obviously it was terrible either way but yeah. ... And I think that probably I only did it the way I did because I was pretty confident that she wouldn’t be pregnant. So I wouldn’t be caught! So that’s, which is, but I dunno, that’s 4am logic for you.

After our interview, I emailed Maggie to thank her for her time. Her response included the following passages:

An idea that occurred to me … is the preparedness of junior doctors for their professional and ethical challenges, ie, how well does medical school prepare you for the ethical dimension of practice?

Initially I thought that junior doctors may feel well prepared for (at least some of) the ethical challenges in their work, as a result of professional ethics/social medicine training in medical school … I also frequently notice myself recognising ethically significant moments. For example, I remember a time that (against my registrar’s advice) I went back to discuss Hep B and Hep C testing with our patient rather than just “adding the test”.

But during the interview I described a time I had done a pregnancy test without consent—something I (reflectively) oppose! Clearly the times I’d reflected upon this before I hadn’t considered how easy it seems to “just do the test” when it’s 4am and you want to get a well patient home. Hmm….!

ALIGNING ACTIONS WITH VALUES

In both the interview and the email, Maggie indicates that she does not approve of the course of action that she took. She describes the second pregnancy test as “just not the right thing to do” and frames testing without consent overall as “something I (reflectively) oppose”. The situation thus involves a mismatch between her reflected views about appropriate patient care and her actions when that actual patient care situation arises. She seems genuinely to believe that informed consent to pregnancy testing is ethically necessary but nonetheless does a test without patient consent. Working in the middle of the night and keen to “get a well patient home”, the patient’s status as autonomous does not dictate her actions despite her commitment to this ethical ideal. Maggie’s “hmm…!” suggests an ongoing lack of comfort with her action.

The content of medical ethics education, with its focus on ethical concepts and decision-making frameworks such as Beauchamp and Childress’ four principles,7 implicitly posits ethical practice as achievable via ethical reasoning. The assumption is that a student who embraces appropriate values, such as non-maleficence and respect for patient autonomy, and can reason systematically with them is well-equipped to practice ethically.

But Maggie’s story indicates that embracing values and acquiring reasoning skills are not in fact sufficient to ensure ethical practice. Maggie easily identifies what she morally ought to have done—going back to the patient to explain and giving the patient the option of refusal which she would then document. However, subject to “4am logic”, this was not the way she acted. The ethical principles that she embraces and the action that her reflective reasoning identifies were subjugated to the organisational demands of her situation. Under pressure from her registrar to “just do it [the test] anyway” and confident that the patient is not actually in danger of ectopic pregnancy, she acts in a way that does not align with her ethical commitments.

In a further email, Maggie specifically identifies organisational pressures for efficiency as a key influence in creating a gulf between actions and values. She observes that “there are so many pressures within the healthcare system to just ‘get the job done’ regardless of the ethical impact on individuals”. Maggie’s story thus suggests that ethics educators’ task cannot be fully achieved merely by facilitating students’ embracing of appropriate ethical principles and reasoning skills. Unless students can also manage the conflicting demands of their organisational situation as junior doctors, including dealing with the pressures for efficiency that they will encounter in their hospital practice, they may not be able to act in accordance with the ethical principles that their education promotes. Maggie’s story highlights that ethical practice sometimes requires an additional skill: the ability to combat the “4am logic” that unreflectively privileges “just get[ting] the job done”.

IMPLEMENTATION SKILLS

Maggie’s story indicates that ethics core curricula’s present emphasis on knowledge of ethical concepts and skills of moral reasoning could be made more effective in terms of enabling ethical practice if greater emphasis was placed on action in the hospital context. Substantial skills for actually implementing their ethical decisions under competing organisational pressures need to be developed by students. Junior doctors would benefit from these implementation skills being as well-articulated, researched, and taught as the standard knowledge components of core curricula around ethical concepts and classic issues. For example, what exactly are the “skills necessary to implement ethical decisions in the face of institutional constraints” that the Australian curriculum mentions?1 How can they most effectively be developed? Maggie’s experience suggests that significant emphasis on this aspect would complement junior doctors’ knowledge of ethical concepts and skills of moral reasoning to better enable the ethical practice at which ethics education aims.

By arguing for the importance of implementation skills, I do not mean to imply that changing individuals’ practice is the only way of addressing junior doctors’ ethical difficulties. The structure and culture of the hospital setting itself play a key role in creating the ethical challenges that junior doctors face. As Chambliss highlights, it is institutional structures that create individual practitioners’ dilemmas: “ethical problems in health care are inseparable from the organisational and social settings in which they arise … they are in fact often fundamental, if unintended products of that system”.8 Ultimately, junior doctors’ ethical difficulties would perhaps be most effectively addressed by systemic changes to the hospital context itself. However, such structural changes will only ever eventuate slowly. Thinking in terms of how individual doctors ought to respond to specific ethical problems is thus also important for medical students. Educators need to prepare students for the challenges of the current institutional setting, with its pressures and hidden ethics curriculum,4 and focusing on junior doctors’ individual agency is an important part of this preparation.

As a starting point for a greater emphasis on implementation skills in the medical ethics curriculum, I suggest two skills essential for implementing ethical decisions: the ability to recognise ethically important situations as they arise in one’s day-to-day work and the ability to voice concerns appropriately. The skill of recognising ethical issues in practice is mentioned specifically in the Australian core curriculum1 and the UK document similarly advocates “enabling students to understand that ethical … [issues] occur in everyday practice”.9 However, Maggie’s story and the results of studies indicating that many junior doctors do not perceive ethical issues in their practice 10 suggest that according greater prominence to this skill in undergraduate teaching is necessary. Junior doctors need to be able to recognise ethically-fraught situations as they are encountered, rather than only on later reflection or not at all. Equipping students and junior doctors to recognise ethically significant situations in the hospital context as they arise will not of course be sufficient to enable ethical practice but is a necessary component in facilitating it.

One existing suggestion for teaching this skill of recognition is the writing of and engagement with first-person narratives about experiences in the clinical context.11 Guillemin and Gillam argue that this reflective process helps to produce “ethical mindfulness”, a set of abilities and predispositions that enables sensitivity to ethical considerations as well as self-awareness and courage in ethically-challenging situations.11 Although their focus is on postgraduate ethics education with health professionals, the method would presumably also be feasible for use with students involved in clinical placements and certainly with junior doctors.

A second essential implementation skill that junior doctors need for ethical practice is the ability to assess when and how to speak up. By “speaking up” I mean sensitive questioning and discussion of concerns rather than challenging senior doctors or administrators confrontationally. Although whistle-blowing is now increasingly included as a topic in medical ethics education,9 junior doctors need skills in speaking out on a much smaller scale. While presumably few junior doctors will encounter problems of a magnitude that warrants involving those outside the organisation, the experiences of junior doctors suggest that day-to-day dilemmas about speaking up are extremely common in junior doctors’ hospital work.12^–14 Research suggests that medical students are strongly disinclined to speak up, even when they believe that they should,15 and that the current curriculum’s approach has little effect on students’ reticent attitude to voicing their concerns.16

Against this kind of cultural background, to facilitate junior doctors acting in line with the values that they reflectively embrace, ethics education needs to equip them with appropriate skills and attitudes around speaking up. This aligns with the view posited by some doctors and educators that advocacy, both for individual patients and for communities, is a key element of medical professionalism.17^–19 Teaching students to speak up will not of course alleviate the pressures involved in hospital work that can prevent junior doctors acting in line with their ethical convictions. Individual junior doctors questioning and discussing their concerns will not change the structural features of the hospital that create ethical difficulties like Maggie’s. However, skills in speaking up are nonetheless a crucial element of ethics education. Unless learning about the ethical thing to do is accompanied by acquiring the ability to speak up, ethics education runs the risk of setting students up for experiences of moral distress in which they know what an ethical outcome would be but cannot bring it about. Ethics education involving skills for engaging with situations in which unethical things are occurring will not change the pressured nature of junior doctors’ work but it is necessary to enabling them to engage with ethically-problematic situations in ways that they can look back on positively.

Dwyer’s suggestions provide a useful starting point for content that could constitute speaking up as a central skill in the ethics core curriculum. Dwyer suggests that

[i]n trying to decide whether to speak up in a particular case, students should consider the nature and certainty of their judgment, their specific role in the situation [ie, the level of involvement that is required of them in the unethical behaviour], the potential harm to patients, the probable effectiveness of speaking up, and the likely cost to themselves if they do speak up.20

Dwyer emphasises that “doubts about the effectiveness of speaking up should not occasion a retreat into silence but a search for the most effective way of voicing one’s concerns”.20 He sees speaking up as a “habit” that is “important for the good practice of medicine” and thus the responsibility of the medical student to develop.20 The experiences of junior doctors like Maggie suggest that unless ethics education includes helping students acquire this habit and other skills for realising their values in real life hospital practice, its ability to enable students to act ethically in the early postgraduate years will be compromised.