Ethics in the medical undergraduate curriculum: encouraging thinking in the midst of cramming facts

Over this autumn school term, members of our Education Advisory Group are sharing thoughts and ideas based on their own experience of how bioethics and debate can be useful in education contexts. This post is written by Anneke Lucassen, Professor of Clinical Genetics and Honorary Consultant Clinical Geneticist at the University of Southampton and Member of the Nuffield Council on Bioethics, and Angela Fenwick, Associate Professor in Medical Ethics and Education at the University of Southampton.

Studying medicine often starts off with establishing an enormous fact based armoury. Students must get to grips with science subjects such as anatomy, physiology, pharmacology and learn how different organs and parts of the body interact and how they can go wrong. Students then need to be able to apply their knowledge and understanding to clinical practice. Into this mix they also need to develop the critical thinking skills which will allow them to engage and deal with ethical and legal issues- both routine and rare ones. Despite many changes in medical undergraduate curricula over the last 20 years, creating enough space for consideration of difficult issues- which can’t be easily solved by drawing on facts - remains a challenge.

At Southampton University most of the teaching, learning and assessment of clinical ethics and law takes place in the last 3 years of the medical curriculum in an attempt to encourage students to critically engage and see the relevance of ethics and law at a time when they are focussed on clinical realities. The learning outcomes are formulated from a nationally agreed core content developed by practitioners and led by the Institute of Medical Ethics.

In a packed curriculum, our perennial challenge is to try and illustrate the importance of our subject in clinical medicine and to overcome perceptions that ethics is either not relevant (not “real medicine”) or that it is just common sense, requiring little effort or need to attend teaching sessions. As one fourth year student reported in a recent study undertaken by one of our dissertation students last year: "There’s this inherent thing that it’s common sense, it’s fine I understand it, I could talk about it, I could write an essay on that… So to have lectures on it when medical students feel, whether it’s right or wrong, that there’s more important stuff to learn about for exams which are more imminent…”.

We are presented with a contradiction: on the one hand students report that ethical thinking is just using one’s common sense. On another, they want an answer – the correct fact – to the ethical problems we pose for them. As one student put it: “I think it’s hard for us because we’re used to it when there is an answer. You’re kind of used to knowing the answer or not knowing the answer".

Knowing that there is a ‘right’ answer, even if you don't know it – because you can always then learn it – is understandably comforting. We regularly hear: ’tell us what the law says and then this is what we will do’, or, ‘ethics is too vague, if we know what the law says this will tell us about ethics’. This need to search for ‘the answer’ seems to hold some students back from working through a problem or a dilemma and prevents them from building an argument for their favoured action or approach to an issue. The idea that reasoning skills need to be practised, rather than just learned, is also sometimes difficult to grasp.

At the same time the students are fearful of the law. Perhaps because they receive little formal training in it, they think that it contains rules they are not aware of but can be learnt. In Southampton the students all have to write an essay around an ethical issue in their final exams. One year we set a question about a man having an acute anaphylactic reaction but, because he had made an advance decision witnessed by a solicitor, many students favoured not treating the anaphylaxis despite the advance decision not being relevant to that particular situation: they worried about a legal point without first thinking the problem through.

Our approach is to help students apply ethical and legal principles to real life cases or to constructed, but realistic, cases, to ground their learning in practice. The Nuffield Council’s educational resources such as those on personalised medicine and dementia provide helpful cases to draw on and ideas on how to use them. These, alongside the never ending supply of issues and cases reported in the news, or experienced by colleagues, are used to demonstrate the relevance of good ethical thinking to their future practice as doctors.