REFLECTION ON THE EVOLUTION OF MY ATTITUDES AND APPROACH TO TEACHING “MEDICAL ETHICS”

As an undergraduate, I studied medicine and arts, majoring in philosophy and English at the University of Melbourne, Australia. After thoroughly enjoying my year of medical internship, I returned to university to complete an honours year in philosophy in the hope this would help me to decide whether to continue a career in medicine or pursue my passion for philosophy. After what felt like a lifetime of indecision as I struggled to balance the competing demands of my interests in the humanities and sciences, it was a relief to discover certainty within my heart during this honours year; I loved medicine, but a life of intellectual inquiry was the one for me.

Embarking on a PhD in applied ethics, and mindful of the limited job opportunities in this field, I nevertheless swore early on that no matter what, I’d never resort to “teaching ethics to medical students.” No doubt, I was influenced by the dismal “ethics” classes which I had experienced as a medical student, and the type of impoverished ethics teaching that I characterise as “pseudoethics.” My own intellectual snobbery was also influential; philosophical ethics seemed an obviously superior field to that of “medical ethics.” I felt that nothing could be less personally rewarding and less professionally impactful than summarising “the four principles” for a crowd of students who would rather be learning “real medicine.” I write this narrative in the hope of prompting reflection by others who may be in a similar position, and hesitant to invest time – if not their career – in ethics, for fear of such a desperate fate.

15 years later, I have the privilege and joy of leading one of the most robust ethics, law and professionalism programs for medical students in Australia. Over the past decade, I’ve had to navigate my own biases about ethics, medicine and teaching, as well as external challenges impacting my teaching plans and objectives, while striving to design, develop and deliver effective and appealing ethics curricula for medical students. If there’s one thing I’ve learned, it’s that there is no single formula that will guarantee success in teaching ethics to medical students; everyone must tailor their curriculum to their unique context. Even when you feel confident that you have a reliable learning activity or assessment task, cultural shifts between student cohorts, staff changes, or a pandemic can necessitate significant alterations to your curriculum and approach to teaching.

Early on in my teaching career, I worried most about what to teach medical students about ethics. It seemed irresponsible to leave out discussion of the grounding ethical theories, great thought experiments and ongoing debates about seminal issues, and indeed impossible to teach anything worth teaching without these components. All too soon, I began to understand the appeal – and hence the ubiquity – of the “four principles” approach to medical ethics teaching. Principlism is more easily distilled into a one hour “introduction to ethics” class and can be more readily applied in analysis of cases by students than a similarly abbreviated account of virtue ethics, for example.

However, when I joined Deakin University in 2016 and discovered a much more spacious ethics curriculum, I realised more time was useful, but not the solution to all my ethics teaching challenges. I began to focus more on how to teach, and how to design curricula in which teaching could have an impact. In particular, I worried how best to engage and retain the interest of medical students in the ethics program. For some medical students, ethics can seem a distraction from precious study time as they anxiously cram scientific knowledge and prioritise clinical skills development. With class attendance optional, I soon found little comfort in having curriculum time at the end of semester when many students stayed home to study for exams.

Paying greater attention to the quality of my teaching and learning resources, and focusing more on my broader engagement with students in the program has been valuable in several ways. I soon learned that investing hours of time in fancy slide sets or elaborate learning activities rarely had proportionate benefits in students’ satisfaction or achievement of learning outcomes. Instead, I found that taking the time to make curricula easy for students to navigate, clearly and simply communicating assessment expectations, and pre-emptive action to identify and address potential questions or concerns led to better engagement and satisfaction. Students also seemed happy with basic slides and simple case discussions, so long as the key learning points were clear, and the real-world relevance of learning was apparent.

When considering potential improvements to our program, I now reflect less on what and how I teach, and more on why we teach ethics to medical students. Every program will espouse goals of developing ethical and professional medical practitioners, fostering virtuous conduct and attitudes and so on. These are important goals, and a good ethics curriculum can and should play a key role in achieving them. However, so much of the formation of students’ characters has already occurred, and their experiences in the clinical environment as students and practitioners will typically exert a stronger influence on their values and behaviours than the classes formally dedicated to ethics. What, then, is the point of our ethics teaching?

What can we provide in our teaching and assessment of ethics that will offer more than the basic conceptual and theoretical knowledge that might be acquired through reading a textbook, and more than the practical application of such knowledge which may be more effectively demonstrated in the clinical setting – assuming of course that preceptors there are suitably competent? This vital question now informs the rationale for my own teaching – why do I teach ethics? – and from this, shapes the content and methods of much of my teaching.

The “why” will be different for everyone. Personally, I teach in order to equip medical students with what I believe are essential skills they need to practice medicine ethically, and to support ethical decision-making and action by others. These skills comprise critical thinking, reasoning, and the ability to identify ethical considerations and to communicate clearly when discussing ethics. With these skills, students may be more capable of continuing their ethics education and training as independent learners in the clinical environment, and may be less susceptible to the risks of the “hidden curriculum” of medicine.

Regardless of the foundational concepts, principles or issues being explored in a particular class or assessment task, I strive to stimulate engagement with and evaluation of these skills. While these skills may well be taught and learned in the clinical environment, an explicit focus on their development is less likely in that context. Furthermore, these are skills that educators with specific ethics training and experience are perhaps best equipped to teach at the foundational level. This, in short, is an opportunity for my teaching to have a real impact on students, and hence on the individuals and communities they will one day serve as doctors. I also find this way of teaching more aligned with my earlier career aspirations of engaging in and fostering intellectual inquiry.

I occasionally wince when marking student papers that glibly refer to ‘the four pillars of ethics’ and appear to show that we have, after all, merely taught them psuedoethics. Nevertheless, majority of our students frequently astound me with their insights and the rapid progression of their skills in ethics over the four years of our program. Rather than becoming resigned to teaching ethics to medical students, as I feared when I first obtained an academic job, I have become ever more delighted by this responsibility. Teaching has proven to be an intellectually rewarding experience, and one that I firmly believe has a real and positive impact in the world.