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.