Share this article on:

Speaking Up: An Ethical Action Exercise

Dwyer James PhD; Faber-Langendoen, Kathy MD
doi: 10.1097/ACM.0000000000002047
Innovation Report: PDF Only


Health care professionals encounter situations in which they need to speak up to prevent harm, ensure better care, and/or address unprofessional behavior. Speaking up is often difficult, especially for medical students; nonetheless, it is a skill students must practice, so they can better advocate for patients.


The authors have designed an ethical action exercise and incorporated it into a required bioethics course that meets concurrently with third-year clerkships. The exercise requires students to speak up to try to correct, resolve, or improve one situation during a clerkship. The exercise involves overt action, but students determine how, where, and when to act.


In 2013-2014, 111 students at State University of New York Upstate Medical University completed the exercise. Most spoke up about situations in which they thought that some aspect of patient care could be improved (n = 78; 70%); others spoke up when they perceived unprofessional conduct (n = 32; 29%). Although most students found speaking up to be difficult (n = 96; 86%), speaking up often led to improved care (n = 46; 41%). As a result of completing the ethical action exercise, two students reported becoming less likely to speak up in the future, whereas 64 students reported becoming more likely.

Next Steps:

Going forward, the authors want to address three issues: the development of lasting habits, the role of culture, and connections with other initiatives to improve care.

Acknowledgments: The authors wish to thank Gregory Eastwood, MD, and Thomas Curran, MD, for integrating the ethical action exercise into the Clinical Bioethics course. They also wish to thank the students who have completed the exercise for their engagement, including the two anonymous students whose reports serve as examples in this Innovation Report. The authors also wish to thank Jessica DeJohn Barbuto and Lauren Zahn for providing administrative support.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: On March 21, 2016, the institutional review board (IRB) at the State University of New York Upstate Medical University deemed this study (874247-1) to be exempt from IRB review according to federal regulations.

Previous presentations: Part of this work was discussed in a lecture titled, “What’s missing in medical ethics education?” at the Center for Biomedical Ethics, National Taiwan University, Taipei, Taiwan, December 21, 2016.

Correspondence should be addressed to James Dwyer, State University of New York Upstate Medical University, Center for Bioethics and Humanities, 618 Irving Avenue, Syracuse, NY 13210; telephone: (315) 464-8455; e-mail:

© 2018 by the Association of American Medical Colleges