From the Educational Trenches III: Let’s have a nice little discussion

by Rob Houtepen, HES.

Your average ethicist prefers a really thorough case discussion. You know:

• Let’s have all the relevant facts on the table
• Can we spot and single out the real moral problem?
• Is there anything in all the surrounding noise and rumble that might be of remote interest to discuss the moral problem?
• Now for the main course, feasting on moral arguments and theories
• On to the moral conclusion
• When we’re progressive and the students would like to have dessert please, we’ll see what kind of action would be required to implement the moral conclusion

The works. Takes at least an hour per case and leaves the ethicist comfortably in a referee position, passing out judgments including the Final Verdict.

Now here’s some key elements of what we do:

• Have ten to fifteen students prepare their own case, within a limited set of themes pertaining to their practice experience in that specific clinical period, for an ethics discussion of somewhat more than two hours (Problem Based Learning: students first have think for themselves a bit, do some reading and acquire a basis eagerness to contribute something to the discussion)
• Start with the open question if they have spotted anything having to do with medical ethics in the media in the past month. Followed up by casual observations and remarks from all sides. (Relating to their life world and to society as the bigger arena, reminding them that ethical issues are broader and more pervasive than the ones scheduled for this specific meeting, experiencing that ethical debates may be sexy and more generally getting them in an easygoing and curious mood) At present, the news on euthanasia (in dementia, in ‘normal’ aging, in psychiatry, by mobile teams, in a specialized euthanasia clinic) and medical privacy (prince Friso; the VUMC intensive care) is such that half of an ethics session in Psychiatry or Occupational Medicine may be filled with it, to the utmost enjoyment of students.
• Encourage more general open discussions on the themes at hand, rather than successively discussing all the cases. Preferably, the prepared cases are brought up within the general discussion and any other practice experiences from all students present (not only the ones who prepared a specific case within the theme) are equally welcome. (Engaging all students in a lively discussion that is simultaneously practice based and from a broader perspective than the strictly clinical one)
• Have a laugh now and then and do some joking around, partly by ironic references to cliché images of doctors or ethics: nod nod, wink wink. (Having a kind of conversation that students are accustomed to in medical practice and feel comfortable with)
• After the general discussion, giving a short opportunity to each of the students who prepared a case on the theme discussed to add a take home message from their reflection on their case (Giving the students the feeling that it is their own responsibility and decision to claim attention to the work they’ve done)
• As a discussion leader:

- Communicate your time strategy to the students to make them attuned to the amount of time spent on the media discussion, the theme discussions and the case discussion

- Employ questions as your main ‘intervention’

- Restrict your teaching activities to short interventions

- Occasionally provoke students with Sophistic interventions or mild ridicule of medical presuppositions, preferably from a virtual patient perspective

- On the other hand, occasionally display solidarity with doctors against false perceptions and claims from ‘outsiders’, including patients

- Quietly guard the basic themes of the discussion

- Contribute to the mood of the discussion, aiming for a productive rhythm of intensive seriousness and relaxation

One need not necessarily be an expert philosopher to do this. On the contrary, a philosophical predilection might even go against the grain of much of the foregoing. A doctor on the other hand, even when trained in ethics, might pass up on too many opportunities to play the outsider questioning them doctors (wannabees) about their practices and convictions. In my view, each and every one of the elements of our discussions mentioned is vital to the subtle endeavor of both working with and influencing their habitus.

From the Educational Trenches: Theory and Practice

by Rob Houtepen (HES)

After having outlined my own view on ethics education in my previous entry, I’d like to explain in brief to which current paradigms I want to offer an alternative.

In medical ethics, the dominant paradigm is the one of ‘applied’ ethical argumentation. It’s all about the ability to first define the specifically moral problem in a practical situation and then employ concepts and theories with a background in philosophical ethics to weigh the morally relevant arguments concerning the problem. And it’s philosophical ethics, again, that defines what the nature of a moral problem sui generis is, if properly understood. In this paradigm, ethics is not necessarily prescriptive in the simple sense of the word, since it will always encourage further ethical reflection and personal moral responsibility. But it does imply that there is one paradigmatic way of defining and tackling moral questions.

If this is the core of teaching in medical ethics, teachers and texts with a background in philosophical ethics will have to teach medical students how to grasp properly what a moral problem is and what kind of arguments are suitable to tackle such problems. The main task is to demonstrate in practical cases how moral argumentation is conducted when the rules of ethics are applied. The main disadvantages of such an approach are that performing ethics is turned into a very predominantly rationalistic exercise and that medical students receive the message that they need ‘outside help’ to sort out the moral issues in their domain. In this paradigm, ethics teaching is not a matter of nurturing debates that are inherent in medical practice and competencies innate to medical students. Rather, students are made to understand that they will lack in moral competency if they will remain unable to employ the tools of moral argumentation, imported into medicine from the domain of ethics. It’s a process of deskilling and then reskilling.

A more traditional but minority paradigm highlights the native virtues of doctors. Although virtue ethics is commonly understood to be the offspring of the Aristotelian tradition in philosophical ethics, the Aristotelian emphasis on virtues as qualities to be learned from excellent practitioners offers room for a certain emancipation of moral practice in relation to philosophical ethics. In the virtue paradigm, becoming a morally competent doctor is not primarily a matter of studying ethics texts. It’s a combination of learning from good practitioners and reflecting on practice in the light of the moral ideas inherent to the practice.

A problem of this paradigm is the strong paternalist feel that often goes with it: doctor knows best. When medical virtues are operationalized, lists are drawn up that paint the overall picture of a doctor as a saintly figure in saccharine TV series, rather than a person of flesh and blood. If such virtue ethics is the core of ethics teaching, there is a danger that doctor’s power and doctor’s inadequacies remain unchallenged in many respects. When advocated by ethicists on the other hand, rather than doctors themselves, virtue ethics runs the risk of turning into a rather repetitive exercise: finding the right middle between two potential moral excesses. Among philosophical ethicists, the general Aristotelian competency of practical rationality (phronèsis) always threatens to trump attention to the complexities and sensitivities that may be pertinent to particular situations.

Sensitivity and particularism abound in the third and most uncommon paradigm for medical ethics. Care ethics has sprung from feminist ethics and from nursing several decades ago, but it has also been defended as a genuine alternative basis for medical ethics. Its focus is neither on cognitive competencies, nor on character, but on addressing patient needs in specific circumstances and in the context of a caring relationship based on mutual dependency. It emphasizes the development of caring sensitivities and the collaborative practice of exploring and balancing the potentially unspoken or conflicting care needs at hand in a particular situation.

The general problem of care ethics is that it does not offer much heuristic power: its emphasis on particular needs and situations makes it hard to develop general directions and tools for moral action. The lessons of care ethics are, nearly by definition, restricted to the particulars of situations. It’s hard to envisage how learning experiences can be generalized without repeating a mantra of caring sensitivities and mutual engagement and dependency. A specific problem in teaching care ethics to medical students is that it does not fit in easily with the division in tasks and responsibilities between doctors and nurses. Medical students tend to identify with situations of decision making concerning treatment rather than dealing with the everyday amenities of care.

The Politics of Public Health and Public Health Law

by David Townend (Associate Professor of the Law of Public Health and Care, HES)

Many of the members of HES are engaged in the metamedica of public health. However, what is the future for public health when our understanding of genetics makes medicine and pharmacy an increasingly tailored, individual-centred activity? Once we know that a particular drug therapy is only effective for particular individuals, and we are all different, is that the end of 'public health' as we know it?

I am not sure about this. Whenever someone says 'we are all individuals', I recall the lines from the Monty Python film The Life of Brian. Brian gives an impassioned speech to the crowd gathered outside his window.

Brian: "You're all individuals."

Crowd: "Yes, we're all individuals."

Brian: "You're all different."

Crowd: "Yes, we are all different."

One Man: "I'm not."

To me, that is something of the nature of Public Health. It has always been about individuals together. The influenza epidemic in 1918 can be seen as a single event, but equally it is a series of individuals all being affected by influenza. It is at the same time an individual experience and a collective issue. And the same is true of the modern threats, of obesity or cancer, and of failures in the supply of water or of starvation. Health is both an individual and a collective experience.

To define something as 'public health' is not, at its heart, a medical action. It is a political action. To say that influenza, or obesity or cancer, or clean water or food supply is a matter of public health is to change it from an individual problem to a political problem. Further, to move from the individual to the public, political claim is also to require a solution. It is a statement about equality and equity. Together we acknowledge this problem and the need for a collective solution.

And so in the new public health chapter that opens with greater understandings about the individuality of medical and health problems, the political activity that is 'public health' remains at the fore. It remains the pursuit of ensuring that health and well-being are provided for all regardless of their genetic predispositions. It is a matter of ensuring that there is no discrimination through the observation of genetic difference. It is about ensuring that drug and other therapies continue to be pursued for all. We do not stop seeing obesity or cancer as a public health issue because we know that it is highly individual in its character, because in great part the public health aspect of these diseases and conditions is the access to healthcare and the development of responses to the problems.

If anything, as we understand the individuality of disease, the need to maintain a 'public health' is paramount, because an appeal to the 'public health' is an appeal in the public interest. The public interest concerns, at its heart, the recognition that individually we are concerned, quite naturally, with our own individual interests and, instinctively, at best with the interests of our families and those who are our immediate neighbours. The public interest ensures that we are forced to look beyond our immediate, personal world to see our connectedness with other people. This is not simply an enforced altruism. It is in our own best interests that we treat the interests of others as equally important as our own interests. If we do not, then what claim do we have on other's resources when we are in need?

And this is where the Law of Public Health takes a form and shape. Law, and the Rule of Law, is also the vehicle of the public interest. Its claims to fairness and justice are not merely rhetorical claims. Courts, lawyers and the machinery of Law do not have to subjugate themselves to the interests of the powerful. Law creates its own narrative, its justificatory story-line about how justice appeals in each claim to its justificatory authority. Indeed, Law is the only response to the almost inevitable exasperation in modern democratic society when confronted by the sight of injustice and inequality, of unfairness and the victory of greed and oppression - 'what can we do about it?' What we can do is reclaim the Rule of Law.

The Rule of Law - the active pursuit of the fairness and justice claims of Law, worked out, in particular through robust, impartial and rigorously observed procedural Law - is centrally important to Public Health. The Rule of Law ensures that the political activity of Public Health, locally, nationally and internationally, finds fair and just translation into policy and action. It is the only real mechanism that enables individuals to call the political and economic classes to account.

Of course, I am not claiming that Courts and Lawyers are not themselves part of that political and economic class. Clearly they are. Often, procedural, substantive, and remedial Law is manipulated to ensure that the interests of the political and economic classes are not only protected and furthered, but are given a veneer of normative respectability through the blessing of the Law. But at the same time, because Law needs to use a language of fairness and justice in order to create the veneer, it leaves itself open to account in its definition of 'fair' and 'just'. That is the opportunity for the political activity of Law. That is the moment when the inequalities that require us to recognise a need for 'public health' can be raised; when the shout for fairness and justice can be heard above the clamour for self interest.

When Sir Joseph Bazalgette engineered the sewerage system in London, or Dr John Snow saw the waterborne nature of cholera, they were engaged in the political activity of public health. When we vaccinate or engage in health promotion campaigns, when we research and identify a new threat to people's health and well-being, we are engaged in political activities. Public Health Law is equally political. It is about ensuring that individuals, regardless of their economic voice, enjoy the universal aspiration to health and well-being. It is the vehicle for ensuring that we all can equally respond "yes, we're all individuals."

From the Educational Trenches: It's all about Habit Formation

By Rob Houtepen (HES)

Rob is responsible for the program in clinical ethics and health law in year 3, 4 and 5 of the Maastricht Medical School (r.houtepen@mastrichtuniversity.nl).

The discourse about teaching and end terms is usually framed in terms of knowledge, competencies, behavior and attitude. Thus, medical ethics teaching is supposed to account for itself in those terms: aiming always for comprehensible rationality, preferably for practical utility and arguably for sufficient empathy. But the universal experience from ethics teaching in medical schools is that:

1. Except in dramatic cases, it’s hard to attract and keep attention from these very intelligent and motivated, but practically minded and not too reflective students.
2. Ethics is perceived by the students at most as a worthwhile addition to the core of medicine, rather than part of such core
3. It’s realistic to be skeptical about the manner and degree to which ethics will function in practice as the desired (self) reflective critical component of a practice that is dominated by stimuli to achieve a high turnover of sufficiently satisfied patients. These stimuli are both administered by the system as a whole and by the current doctors working in it.

Reading the excellent study by Yolanda Witman (2008) on medical leadership convinced me that those problems can only be addressed sufficiently by introducing the concept of the ‘medical habitus’. It reminded me that the so called ‘hidden curriculum’ in medical education is as powerful today as it has always been. The standard initial student motivation is ‘helping people by solving their medical problems’. As long as they do not feel themselves sufficiently competent in medical problem solving, they are not really open to any messages that might detract them from this pursuit. In fact, anything outside the paradigmatic patient coming to the doctor for a ‘real’ (i.e. clearly somatic) medical problem (“What can I do for you now within the limits of my possibilities?”) usually fails to draw their attention anyhow: so much for prevention, care and social aspects. And a person with authority, to them, is either a doctor or someone who clearly promises to make them a better doctor, i.e. medical problem solver.

Witman researched how peer group pressure works among doctors in hospital medicine. She derived her core concept of ‘habitus’ from the French sociologist Pierre Bourdieu: the mental structure that individuals develop within a certain structured social environment, the way they are inclined to perceive and value the world and to act accordingly. A habitus develops in interaction between the personal and the social, within the social space of a specific practice. This social ‘field’ is also contested in a way that leaves room for variation and change. The medical habitusis an ensemble of enduring, largely unconscious schemes of perception and evaluation that stimulate and direct a doctor’s action. It contains values and inclinations which are rooted so deeply that they no longer require conscious processes or rational choices at the everyday level. This habitus is, to an important extent, literally embodied: it is molded into a specific pattern of action, movement, demeanor etcetera. It is the typical doctor’s radiation of rationality, goal orientation, self assurance and openness. This is developed from role models and among the peer group, typically ‘between the lines’.

The concept of habitus is foundational and overarching in relation to cognition, competence, behavior and attitude. It denotes the interplay and pattern of these elements and how they are secured into a self evident basic attitude. For doctors this should include an academic attitude, a patient directed attitude and an attitude of accountability. You do not develop such an attitude on your own and in an empty space, but as a functional adaptation to a specific role in a specific practice.

I have come to the conclusion that ethics education (as well as education in academic thinking, but that’s another chapter) should be directed at influencing the developing habitus of medical students. And I’m convinced that this will not work on a diet of ‘applied ethics’. It’s all about habit formation, a habitus encompassing the values that ethics would like to see firmly established in doctor’s actions: mutual trust, patient directedness and accountability. There’s more to that.

From The Educational Trenches A personal statement as to why and what

By Rob Houtepen (HES)

Rob responsible for the program in clinical ethics and health law in year 3, 4 and 5 of the Maastricht Medical School (r.houtepen@mastrichtuniversity.nl).

‘Practice what your preach’ were the first words of my first contribution to this website. Well, that’s all nice for others, but I prefer preaching about my own practice. After more than 10 very intensive years as an initial outsider in medical education, I feel a need to collect my thoughts in public. I’m afraid it will already take several articles to clarify what I’m on about. I intend to publish those in Dutch, but I hope writing a regular blog will help to organize my thoughts.

The subject of this blog is teaching ethical reflection in a problem based learning group, since my experience mainly derives from that practice. It’s not really intended to be self advertisement. In fact, it coincides with the results of an analysis of the evaluation forms of a number of those groups. These showed that, on average, I got slightly lower scores than my colleagues in the program that I’m responsible for. A bit puzzling and worrying, but then again, I’m the norm (if only because of the large number of groups that I do and my responsibility for the format) and I sincerely congratulate all my colleagues in performing above the norm. So I’m just the most experienced, not necessarily the best. And I can assure you that the program I’m responsible for will never attain a high score in student evaluations. So I guess I’m the weakest link trying to think through this weakness.

It’s all meant to be serious stuff, though, and the first installment is one hundred percent academic and dry. But from then on a peculiar penchant for heavy handed irony and low comedy ought to enlighten my texts. The program is outlined below, but I can definitely promise that it will not be followed in that particular order or even with those particular subjects and titles. It just gives you a clue what I’m on about. An excellent way to prevent me from putting all of this into practice is to react to the content: I’d like to be on a collaborative adventure here.

I: It’s about habit formation

II: Ethical theory and educational practice

III: In between different professions

IV: Practice, norms, rules and values

V: The core values of medicine

VI: The three goals of academic thinking education

VII: The habit of critical thinking

VIII: SMILEE, an educational philosophy

IX: GRGE (HE&HL): reflections on a format

X: Diversity and the elusive patient

XI: Slow Ethics

XII: The role of the ethics teacher in a problem based discussion group

XIII: What should assessment in an ethics program look like?

XIV: Medicine as a practice: what should that mean?

XV: Learning from discussion and deliberation

XVI: The legal model as a paradigm for the medical model of decision making

XVII: On the importance of reading reflective books

XVIII: Having a laugh with student evaluations in numbers

A little reflection never hurt anybody

by Rob Houtepen, Co-ordinator of the ethics and law program in the Maastricht medical school

‘Practice what you preach’ is not the worst of mottos. And since HES preaches critical reflection to lots of Maastricht students in lots of different programs, it would be somewhat disquieting if we never put such reflection to work on our own educational activities. Our contributions are of course always evaluated by students in the thorough quantitative manner that Maastricht has a reputation for. But every one who is responsible for important parts of the curriculum is by nature an extremely busy person, so it’s always very tempting to respond to commentary by making only minor alterations, if at all. Also, course coordinators expect each content provider to be responsible for their own contributions, so the content of the HES part of educational programs is to a surprising degree an individual matter. All this, whilst we preach to students that critical reflection should be an integral element of the shared academic practice.

This is why, for the second time, HES has designated an entire day for critical reflection on our own educational practice. We’re not going to talk numbers, but mission. A surprisingly difficult question, for example, is what our key goals are in the broad specter of ‘academic thinking’ activities that we offer. Or what the ‘global’ of the ‘Global Health master’ is supposed to mean. Or the ‘health’, for that matter. And then again how ‘academic thinking’ and ‘global health’ relate, really?

We will therefore assemble on December 6 for critical reflection on our shared mission in education, our operational goals and the means we employ to that effect. This will take place in the idyllic setting of the Jekerdal, the most green and beautiful part of Maastricht.

Goals of the day are:

- to reflect jointly on our specific mission in the broader educational programs of FHML

- to explore how contributions in one program might profit from contributions and experiences in other programs

- to explore what kind of key tools (goals; concepts; theories; texts) we need to develop to realize our ambitions

The program for the day is:

Morning session:

Global Health: what would make this a true and coherent HES program?

Diversity: from stereotypical focus points to all out (self)critical thinking and attitude

Afternoon session:

Academic thinking: key messages, problems and questions

Tools for academic thinking: developing our own introductory texts that do the job

All this because no professional practice can last without critical reflection. Truly.

A New Website for HES

by David Townend (Health, Ethics and Society: Health Law)

The Department of Health, Ethics and Society has a new website, and with it this new Blog.

http://www.maastrichtuniversity.nl/hes

Health, Ethics and Society is a relatively new interdisciplinary department in the Faculty of Health, Medicine and Life Sciences in Maastricht University. It brings together a number of former departments and the Institute of Ethics under one department. In practice that means two things:

first, we have colleagues in the one department who approach health in society questions from different, complimentary disciplines;

second, we bring those interdisciplinary approaches to our teaching and research.

We have colleagues who have their disciplinary roots in philosophy and ethics, in anthropology and gender studies, in medical history, in sociology and law. We work in an interdisciplinary way through developing courses and research together, and through the common life of the department - the colloquia and general discussions about news and developing issues.

You can see many of the funded research projects that we are either co-ordinating or participating in on our website; you can also see information about our courses and the degree programmes to which we contribute.

What will this blog contribute to health, ethics and society?

Through the blog, we want to develop some of our teaching and research ideas. We will comment on different developments in our field, perhaps from one point of view, perhaps reflecting discussions in the department. The authorship of the post will be clear at the top of each post. We will also use it to publicise new events (seminars, Ph.D. promotions, etc.). You can follow these using the RSS feed.

We welcome your comments, within the usual rules that we reserve the right to remove content that is obscene, illegal, and the like. And we encourage academic challenge to our views.

We look forward to hearing from you, and we hope you will look forward to hearing from us.