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Letters to the Editor

A Skills-Based Approach to Teach Clinical Ethics

McCullough, Melissa T. PhD

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doi: 10.1097/ACM.0b013e31819398cd
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To the Editor:

In the current debate of possible methods for medical ethics education, a theme emerges: ethics education should move to a skills-development platform. Proposals include focusing on teaching reasoning and analysis skills and how to apply those skills to particular issues as an alternative to a sole focus on moral theories and principles.1 Proponents also argue that where medical schools in both the United Kingdom and the United States go wrong is in treating medical ethics like a scientific body of knowledge and that educators should discourage the use of jargon such as the four principles, consequentialism, and deontology and instead encourage students to use their own words to discuss the issues.2 Fiester3 recently presented a similar view, suggesting that current trends in teaching clinical ethics by using what she refers to as the “principlist paradigm” (i.e., using the four principles as a checklist for dealing with ethical dilemmas) are failing students. Furthermore, she maintains that this approach can lead to clinicians’ being inadequately prepared for the complex ethical dilemmas they face in practice and can even contribute to the loss of more common ethical intuitions and behaviors as students are indoctrinated to the ethics discourse that the principlist paradigm promotes.

A skills-development approach could include (1) exposing students to simulated ethical dilemmas to help students in reconciling the theory they have learned with their intuitive ethics, (2) coupling teaching innovation and development with either formative or summative assessment, and (3) combining communication and ethics strands where possible, as separating ethics from communications into distinct curricular entities may be disadvantageous to learning clinical ethics for practice.

Reforming ethics teaching in this way will have its challenges, but it would better help students to tap into their own ethical intuitions and vocabulary and in turn provide students with a better grounding in clinical ethics that would arguably lead to enhanced patient-centered care. Clearly, skills-based teaching should be an important part of ongoing innovations in ethics teaching, assessment of such innovations, and research about both.

Melissa T. McCullough, PhD

Lecturer in medical education, School of Medicine, Dentistry and Biomedical Sciences, Centre for Medical Education, Queen’s University, Belfast, Northern Ireland; ([email protected]).


1 Lawlor R. Moral theories in teaching applied ethics. J Med Ethics. 2007;33:370–372.
2 Cowley C. The dangers of medical ethics. J Med Ethics. 2005;31:739–742.
3 Fiester A. Viewpoint: why the clinical ethics we teach fails patients. Acad Med. 2007;82:684–689.
© 2009 Association of American Medical Colleges