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Academic Medicine:
doi: 10.1097/ACM.0b013e31819a8b30
Ethics Education

Increasing Bioethics Education in Preclinical Medical Curricula: What Ethical Dilemmas Do Clinical Clerks Experience?

Kelly, Emily MD, MSc; Nisker, Jeff MD, PhD

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Author Information

Dr. Kelly is a resident in Family Medicine, The Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Canada.

Dr. Nisker is coordinator of Medical Ethics and Humanities and professor of Obstetrics and Gynecology and oncology, The Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Canada.

Correspondence should be addressed to Dr. Nisker, The Schulich School of Medicine & Dentistry, The University of Western Ontario, 339 Windermere Road, London, ON N6A 5A5; e-mail: (Jeff.nisker@lhsc.on.ca).

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Abstract

Purpose: The increase in bioethics education in preclinical curricula enables medical students to recognize ethical issues and determine right action. The authors sought to explore the ethical dilemmas medical students experience during clinical clerkships.

Method: Following an e-mail invitation, 100 of 104 graduating medical students allowed their final ethics assignment, a written description of an ethical dilemma experienced during clinical clerkship, to be analyzed. After all identifiers were removed, the narratives underwent qualitative analysis and were then reanalyzed using Jameton's determinants of moral action.

Results: Four themes emerged: the clinical service rotation, target, source, and nature of the ethical dilemma. For many clinical clerks, the ethical dilemma arose because they recognized an ethical issue but neither brought it to their supervisors nor resolved it themselves for fear of incurring disfavor. The source of the ethical dilemma was most frequently the student's supervisor (46%), which may explain why, although all narratives demonstrated the Jameton criteria of “moral sensitivity” and 76% demonstrated “moral judgment,” only 24% indicated “moral motivation” and only 4% suggested “moral courage.” Patients were the most frequent target (76%), followed by students (14%). Students reported informed consent (18%) and inadequate care (17%) as the most common types of dilemmas under the nature theme.

Conclusions: Clinical clerks' experiences of ethical dilemmas might be mitigated if residency education and professional development mirrored the increase in preclinical ethics education, if ethics training included encouraging students to discuss ethical issues as they arise, and if educators developed innovative models of student evaluation.

When medical students become members of clinical teams, they enter into complex relationships with patients, family members, consultants, residents, nurses, and one another. These relationships may immerse students in ethically charged situations.1 The increase in bioethics education in the preclinical curricula of many medical schools2 allows clinical clerks to identify ethical issues and determine right action.

Narrative approaches to bioethics center on the stories of patients and caregivers and on their relationship to illness and health care.1,3–7 Students may learn right action from the story itself1,3–5 or through its illumination of ethical theories or principles.1,7 Narratives can assist caregivers in explaining the deeply personal experiences of their patients, their colleagues, and themselves.1,3–7

Medical education programs have used student narratives to assess the training of health professionals,8,9 to examine performance,8 and to promote self-awareness.10 Through the analysis of medical student narratives, the authors of this study explored the ethical dilemmas that some medical students experienced during their clinical clerkships.

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Method

As a required part of their evaluation in the course Medical Ethics and Humanities, final-year medical students at The Schulich School of Medicine & Dentistry, The University of Western Ontario, write a narrative describing an ethical dilemma they experienced during clinical clerkship. After the 104 students had received their grade (all “complete”), we invited them through e-mail to allow us to analyze their narratives for this study. We obtained approval for the secondary use of these narratives from the research ethics office of The University of Western Ontario.

We removed all information that could identify the students before compiling the narratives for analysis. We then subjected each narrative to qualitative analysis, beginning with line-by-line coding11 and supported by NUD*IST6 software (QSR, Doncaster, Australia). According to the method of Strauss and Corbin,11 themes emerge from the open and axial stages of qualitative analysis, with individual phenomena grouped together according to the qualities they hold in common, in an organic process of constant comparison between the narratives and the emerging themes. To accomplish this, one of us (E.K.) studied all the narratives several times, line by line. As the analysis continued, we merged similar categories and split complex categories in an iterative process.11 Verification of the themes occurred when we had neither orphan themes remaining nor narratives forced into themes that were unsuitable for them.

We then reanalyzed the narratives using Jameton's determinants of moral action.12 According to these determinants, we considered narratives to contain “moral sensitivity” if the student displayed the ability to identify a moral dilemma, “moral judgment” if the student could judge right action from wrong, “moral motivation” if the student indicated a commitment to the pursuit of perceived right action, and “moral courage” if the student did not choose an easier action in place of the perceived right action.12

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Results

Four of the 104 students declined participation. As described in Table 1, four major themes emerged from the qualitative analysis: (1) the clinical service rotation during which the ethical dilemma occurred, (2) the target of the ethical dilemma, (3) the source of the ethical dilemma, and (4) the nature of the ethical dilemma. In some narratives, the student described more than one ethical dilemma.

Table 1
Table 1
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Theme one: Clinical service on which ethical dilemma occurred

The clinical service on which the ethical dilemma occurred was almost always stated explicitly in the narrative, and, in the few narratives in which it was not stated, we could ascertain the clinical service from the description of the ethical dilemma. Figure 1 illustrates the frequency of ethical dilemmas experienced on each clinical rotation. The rotation that combined the intensive care unit (ICU) with general internal medicine was the setting in which ethical dilemmas most commonly occurred (27%), followed by surgery (20%), obstetrics-gynecology (14%), and oncology (10%).

Figure 1
Figure 1
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Theme two: Target of the ethical dilemma

The target refers to the person whom the medical student perceived as receiving unfair, disrespectful, insensitive, or cold/inhumane treatment. This person was most frequently the patient (Figure 2). The following excerpt from Student A illustrates lack of respect for a patient who had just died:

Figure 2
Figure 2
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Tamponade was a very unlikely cause for this patient's arrest. The anesthesia resident used this opportunity to practice his pericardiocentesis technique […] I became quite angry at what had gone on […] the resident never identified that this was a human being that had dignity, family, and feelings

The clinical clerk was the second-most-frequent target of the ethical dilemma, as illustrated in this narrative of Student B:

The senior that I was working under was very tough on all the clerks, but in particular on one of my colleagues. While I felt that it was unfair of the senior to consistently demean, single out and belittle that clerk in front of everyone else, if I spoke up in his defence, then I'd become the new scapegoat

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Theme three: Source of the ethical dilemma

The source of the ethical dilemma refers to the person whose behavior affects the target and provokes the ethical dilemma (Figure 2). The most common source of the ethical dilemma was the consultant, resident, or another member of the medical team—almost always the resident. Similarly to Student A and Student B, Student C reported the resident as the source:

The patient's long and troubled (and continued) relationship with alcohol had landed him with end stage liver disease. He was often passed over on our daily rounds, for lack of time, and boredom, it seemed on the part of our consultant. According to him, the patient had brought his own grievous situation upon himself, and there was nothing we would do about it.

However, in 27 narratives, the students identified themselves as the primary source of the ethical problem, and in another two narratives the student narrators identified other students as the source.

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Theme four: Nature of the ethical dilemma

The most common category in the theme of the nature of the ethical dilemma, according to the student narratives, concerned consent for treatment. (Figure 3). For example, Student D wrote that

Figure 3
Figure 3
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A very sick gentleman was to undergo a necessary but very high risk procedure. I was delegated the task of obtaining consent […] However, it became clear to me that the patient had no comprehension of the situation or the risk of the procedure. The patient would not be autonomous in the decision to undergo surgery.

The second most common categories were inadequate care and do-not-resuscitate orders. We derived the inadequate care category from narratives suggesting prejudice against certain patient types, usually substance abusers, the elderly, and those with chronic illness, as Student C's excerpt (above) illustrates. Other categories included

* error/dishonesty, in which someone, often a member of the medical team, makes, but does not disclose, an error;

* abuse of patient, in which someone, often a member of the medical team, treats a patient physically or verbally in a disrespectful manner;

* abuse of student, in which someone treats a student in a physically or verbally disrespectful manner;

* resource misallocation, in which funding or personnel is not available to a patient, or in which queue jumping unfairly occurs because of the relationship of the patient to the doctor;

* learning over healing, in which pressure for the student to learn a clinical skill takes precedence over good patient care (illustrated by Student A, above);

* hard decisions, in which a traditionally complex ethical choice must be made between two equally difficult options;

* boundary issues, in which a breach of patient-physician boundaries occurs through lack of self-disclosure, physical demonstration, or gifts;

* lack of confidentiality, in which disclosure of information private to the patient-physician relationship has been inappropriately shared;

* company sponsorship, in which the interface of a pharmaceutical company with clinician education or patient care is inappropriate; and

* prenatal screening, in which the ethical implications of prenatal screening, such as the tension between how persons living with disabilities may be viewed and reproductive autonomy, come to bear.

In Table 2 we describe Jameton's determinants of moral action12 and the frequency with which these determinants occurred in the medical student narratives, providing an example from a student narrative to illustrate each determinant. All narratives displayed moral sensitivity; 76 displayed recognition of what a good corrective action would be (i.e., moral judgment), and 24 displayed moral motivation to undertake that action. Only four of the narratives indicated that the student had taken action to resolve the ethical problem (i.e., moral courage). The excerpts from the narratives of Student B and Student C illustrate a common concern that fear of reprisal may have inhibited what the student perceived to be right action, as will be explored below.

Table 2
Table 2
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Discussion

An increasing emphasis on bioethics in preclinical medical curricula enables medical students both to identify ethical issues and to understand how to address them. The analysis of these narratives suggests that clinical clerks experience ethical dilemmas when they perceive that an ethical issue exists but that they are not empowered to address the issue. This finding may explain the decline in the narratives from expressing moral sensitivity (100%) and moral judgment (76%) to moral motivation (24%) and moral courage (4%). Although the ethical dilemmas may result from the students' perceptions of an ethical problem they would like to resolve rather than a real problem that they are prohibited from resolving, the dilemmas are real to the students as illustrated in the emotional nature and power of many of their narratives. For example, although the students' fear—of negative repercussions should they bring their perceived ethical issues (e.g., lack of informed choice) to their supervisors' attention—may be perceived rather than necessary, the students are still immersed in the ethical dilemma because of their perception and feelings of disempowerment.

The fact that many of the ethical dilemmas described by the medical students relate either to their perceptions of unfair, disrespectful, insensitive, or cold treatment of patients or to more traditional issues (e.g., informed consent and end-of-life decisions) may result from their preclinical ethics curriculum, which concentrates largely on feminist13,14 and virtue ethics15 approaches that focus on professional relationships. These approaches encourage the students to focus on relationships14 and professional obligations, making them—as illustrated in student narratives—both acutely aware of their relationships with and obligations to their patients, and extremely sensitive to suboptimal relationships they perceived to have experienced with their consultants and residents.

The most common clinical service rotation during which medical students experienced an ethical dilemma was the combined general internal medicine/ICU rotation. This high number of dilemmas may result from the complex ethical issues inherent in end-of-life decision making that is more likely to occur during this clinical service or from the pressure to free beds as reflected in the idea (in the nature of the dilemma category) of inadequate care. The finding of the ICU as a common location for medical students to experience ethical dilemmas is consistent with an American study of ethical issues in medical education.16

Students cited consent for treatment (in nature of the ethical dilemma) as problematic more often than they cited other types of dilemmas (Figure 3). This high frequency may reflect the facts that the informed choice process is part of the care of all patients, that supervisors routinely charge clinical clerks with the responsibility of procuring consent, and that the medical students in this study had internalized the necessity of informed choice. Further, the frequency of clinical clerks reporting that they faced ethical dilemmas regarding consent for treatment suggests that their understanding of the requirements of informed choice may be different from that of their supervisors. In addition, the narratives suggest that as the signing of the consent form does not usually occur until the night before a surgical or medical procedure, the student's concern regarding inadequacy of a patient's understanding of the procedure may be sublimated to other concerns, including potentially wasting the surgeon's operating room time and incurring the disfavor of supervisors. Again, our results are similar to those of an American study, in which issues of consent represented 14% of ethical issues identified by students.16

A reason for the common occurrence of inadequate care as an ethical dilemma may be the importance to clinical clerks of patients' psychological health and family member involvement, because of their recent preclinical training in this area,17 combined with their perception that their supervisors believe the increasing time-efficiency imperatives may eclipse the psychosocial aspects of care.18 Further, these students who had been educated in the covenant model—not only in the physician-patient relationship governed by a covenant19 but also in the medical educator-medical student relationship20—may have found themselves in the dilemma of not being able to ensure that their patients had the clinical care and professional relationships the students felt they deserved. These results of our study were similar to those of a British study indicating that inadequate care comprised 22% of the ethical issues identified.21

One might have anticipated that all medical students would demonstrate moral sensitivity12 and that most would demonstrate moral judgment,12 considering both the objective of their assignment and the fact that students received more than 100 hours of narrative-based ethics education in their preclinical years.1 To understand why relatively few students, even among those who demonstrated commitment to right action, acted to correct what they perceived to be unethical situations, one needs first to appreciate that some right actions do not involve the same risk of adversity as others and, thus, may not be perceived by the students in their narratives as requiring moral courage.16 For example, the excerpt above from Student A regarding a resident's lack of respect for a patient who just died reflects the clinical clerk's respect for the dignity of even deceased human beings, but the clinical clerk did not perceive that the situation was important enough to require moral courage. This is likely different than the perceptions of Students C and D (excerpts above), who experienced ethical dilemmas because they felt they did not possess the moral courage to act in the best interests of their patients (Student C's patient was ignored and Student D's patient was not able to sign informed consent) or to act in the best interests of another clinical clerk, as poignantly expressed by Student B (excerpt above), who could have defended a fellow clinical clerk from a senior resident but did not because “if [he or she] spoke up in his defence, then [he or she]'d become the new scapegoat.” The latter examples form the basis of the more troubling explanation for lack of moral courage, described in many of the narratives, that arise from the power differentials that exist between medical students and their supervisors and the resulting fear that students harbor of negative repercussions should they choose to exhibit moral courage. Medical students perceive these negative repercussions as extending beyond their evaluation, to jeopardizing both their opportunities to perform procedures they believe are necessary to become “good” doctors (e.g., lumbar punctures)22 and their acceptance into the medical “club” or culture.16 Indeed, in many of the narratives, students wrote that they felt conflicted about whether to act in what they perceived to be the best interest of the patient (and family members) or to protect themselves and the learning that would be of help to their future patients. These factors may make moral courage an unreasonable expectation of clinical clerks. It is also possible that some students simply did not write about their decision to do the right thing. However, it is likely that these final-year medical students would have camouflaged their indifference in their final ethics assignment.

Research has shown that students' fears of not doing what they perceive to be ethically appropriate may add to other numerous psychological stresses that medical students experience.23 Although the increase in ethics education in many preclinical ethics curricula cannot promote moral courage in clinical clerkship unless changes are made as to how clerks are evaluated (suggestions below), ethics education can provide medical students with an understanding of right action and sensitivity to the ethical issues they will encounter on clinical services, and ultimately foster moral courage once these students become residents and consultants. However, with understanding and sensitivity to ethical issues comes the obligation that medical students try to influence what they perceive to be unethical practice regarding both the patients for whom they care and the educational relationships in which they and their peers exist. Factors such as each medical student's confidence, past performance, and aspiration for a competitive residency position may influence whether the student complies with the obligation or endures the ethical dilemmas. Although medical students should be expected always to be responsible for their own moral decisions, we hope that as supervisors become more receptive to medical students' ethical concerns, the students will have even greater responsibility for ethical decisions with the medical teams.

The inability of clinical clerks to resolve ethical dilemmas because of their lack of power to do so is similar to the findings that Jameton12 reported in his research on the determinants of the moral action of nurses in hospital settings in the early 1980s. Through his in-depth interviews with nurses, he found “moral distress” to be a common accompaniment to nursing practice.12 More recently, research has shown that clinical ethicists not only suffer moral distress but also carry its long-term consequence in an increasing burden of “moral residue,”24 the long-term psychological effect of failing to perform an ethical action.25 However, not all medical students seemed to experience moral distress. For example, although all narratives demonstrated moral sensitivity using Jameton's12 criteria, only 24 of the narratives exhibited moral motivation. This lack of moral motivation may result from the perception among students that if time and other constraints limit their supervisors' interest in, for example, ensuring informed choice, it must not be important. We could anticipate this mirroring of role models' perceived lack of motivation to consider ethical issues, because medical students frequently mirror the characteristics of those who train them.18,26,27

This mirroring of poor behavior raises questions regarding the future teaching of professionalism in undergraduate medical education. For example, Chen and colleagues28 draw attention to and suggest using the “mental model” for teaching professionalism, including appropriate physician-patient relationships, to medical students. However, the results of our research suggest that the education of faculty and residents should also include using this mental model to help increase professionalism in the medical educator-medical student relationship. Parker and his coworkers29 encourage using “the pyramid of professionalism” to study the professional behavior of medical students as a basis for recommending remedial action for those who have demonstrated unprofessional behavior. Our research suggests that the professionalism of medical educators toward medical students should undergo similar scrutiny, and continuing professional development programs for consultants and residents should be put into place. We recommend a required mechanism to empower medical students to bring their concerns safely to an ombudsman or neutral medical educator. Such programs would serve to mitigate the student indifference observed in our research and could be a shield against the reported moral erosion of medical students as they progress through training.30,31 Student indifference, like fear of negative repercussions, can discourage moral decision making before students even contemplate approaches to remedying difficult situations.

Other possible tools to increase moral courage are innovative student assessment and learning strategies. Methods of evaluation used in other disciplines—for example, peer (not supervisor) assessment32—reduces the power differential between medical students and their supervisors. Innovative learning strategies, such as those embraced in feminist pedagogy,33 role modeling,18,26,27 and mentoring34 have the common element of diminishing the power structure within the educator-student relationship, from a power-over (or hierarchical) model to a power-with model, that allows emotional vulnerability, disclosure of error, and disagreement with superiors.35 A power-with model would mitigate many of the ethical dilemmas reported by the medical students in our research as well as their abandonment of moral motivation and moral courage. Researchers have demonstrated the effectiveness of a feminist pedagogical approach, emphasizing the relational quality of power,14 to increase the empowerment of women inside the workplace and in their broader lives at home.33 Role modeling18,26,27 and mentoring,34 which also emphasize the relational quality of power, can turn the potential disempowerment of needing to please supervisors (in order to get the opportunity to learn clinical skills and a good evaluation) into empowerment.26,27,32,33

As this analysis of medical students' experiences of ethical dilemmas during their clinical clerkship includes only the experiences of medical students in one Canadian medical school that provides a narrative bioethics curriculum, it is not representative of the experiences of all clinical clerks. Although medical students can anticipate experiencing ethical issues during their clinical training, these issues need not become ethical dilemmas if all members of the clinical team acknowledge them and if clinical clerks are empowered to work to resolve them. If clinical clerks are not empowered to help resolve or, at least, comment on ethical dilemmas as part of their clinical education, we contend that increasing preclinical ethics education promotes students' awareness of, and sensitivity to, ethical issues, but it may also increase their experience of ethical dilemmas, moral distress, and moral residue. An increase in bioethics education in postgraduate curricula and faculty development programs should occur in step with the increasing emphasis on bioethics in undergraduate curricula in order for clinical clerks to avoid ethical dilemmas and the accumulation of moral residue.24

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Conclusions

Similar to nurses12 and clinical ethicists,24 medical students lack the authority to resolve situations they perceive to be unethical, and they experience ethical dilemmas that may result in moral distress12 and moral residue.24 Clinical clerks' experience of ethical dilemmas might decrease if the education of their supervisors paralleled the increase in ethics education in preclinical curricula and if ethical training at all levels were to include ways of empowering clinical clerks to address ethical issues. After postgraduate and continuing professional development programs in ethics develop, medical education leaders should evaluate their effects on reducing the frequency and impact of medical students' experiences of ethical dilemmas.

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