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.