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.
