Goals Of Medical Ethics

Ambitious and diverse goals have been proposed for medical ethics education, including increased awareness of ethical issues; a cultivation of basic ethical commitments; more humane medical practice; tolerance of conflicting views; development of analytic skill in moral reasoning; enhanced intellectual development in ethics and the humanities; positive attitudes toward patients; less paternalism in clinical practice; higher professional conduct; and improved clinical decision making (Callahan; Miles et al.).

Despite this dauntingly heterogeneous list, a consensus has developed regarding some core objectives. First, the primary goal of clinical ethics education is to prepare physicians to deal effectively with ethical issues in clinical practice. Accomplishing this requires that students learn to: (1) recognize ethical issues as they arise in clinical care and identify hidden values and unacknowledged conflicts; (2) think clearly and critically about ethical issues in ways that lead to an ethically justifiable course of action; and (3) apply the practical skills needed to implement an ethically justifiable course of action. Each of these objectives in turn requires that the students possess specific knowledge, attitudes, and skills.

To recognize ethical issues as they appear in clinical care usually requires a positive attitude concerning the importance of the humanistic and value-laden aspects of medical care. For example, a physician's decision regarding chemotherapy for a woman with breast cancer involves the physician's awareness of the biomedical issues and of the morbidity and mortality of the disease, as well as of the patient's own views regarding continued life, her body image, and the morbidity of treatment. Recognizing the presence of an ethical issue also requires knowledge of the nature of common ethical issues and how they arise in clinical practice.

Finally, proficiency in recognizing these issues requires students to learn certain behaviors. Highly motivated students who understand the importance of autonomy and recognize the ways in which patients' values are frequently ignored or overridden will still have difficulty incorporating respect for autonomy into care unless they become skilled in eliciting their patients' personal values, concerns, and goals.

A general consensus was also developed in the 1980s regarding most of the core content areas for medical ethics education. In the 1985 report of the DeCamp Conference (Culver et al.), leading physicians and ethicists proposed "basic curricular goals in medical ethics," stressing knowledge and ability as the primary targets of medical ethics education in medical schools. Among the seven items in the "minimal basic curriculum" are the ability to obtain a valid consent to treatment or a valid refusal of treatment, knowledge of how to proceed if a patient refuses treatment, and knowledge of the moral aspects of the care of patients with a poor prognosis, including patients who are terminally ill. Notably absent from this "core list," because of a lack of consensus, were issues related to financial aspects of medical care (including distributive justice and access to healthcare), doctor's societal obligations, and questions related to abortion. Interestingly, the U.K. and Australian consensus statements on core curricula are much broader and include both issues of resource distribution and physicians' role in society in their purview. (Whether this influences what is taught is unknown.) Building on these earlier reports, subsequent teaching programs increasingly stressed the importance of ensuring that educational goals are appropriate to students' specific level of training and future career choices. Courses for first- and second-year medical students, who have limited clinical experience, generally focused on developing an awareness of the complex moral issues that arise in contemporary medicine and on developing skill in moral reasoning. In contrast, teaching programs for physicians in subspecialty residency programs tended to focus on the specific issues that those physicians were already encountering in their fields of practice and the specific knowledge, attitudes, and skills needed to address those problems.

Attempts to teach medical ethics through "professionalism" began in the late 1990s. Professional organizations, such as the American Board of Internal Medicine and the ACGME, define professionalism in terms of virtues such as altruism, respect for others, honor, integrity, accountability, competence, and duty/advocacy. These statements typically stress physicians' public role in promoting health in terms of quality and access as much as they stress individual patient care (ABIM Foundation). Interesting the 2001 AAMC graduate medical student survey assessed professionalism separately from medical ethics, reflecting some confusion between the two content areas.

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