Kenneth Kipnis
University of Hawaii at Manoa Honolulu
History of the Ethics in Health Care Project

In the late 1980’s, faculty at the John A. Burns School of Medicine of the University of Hawaii shifted their curriculum to a problem-based learning model (PBL). Drawing heavily on materials developed at MacMaster University in Canada, a rapid change ensued and the first PBL class graduated in 1993.

While the technical content of a PBL curriculum is not unlike that of traditional medical education, there are four broad objectives that lead to prominent differences. One objective of the PBL curriculum was to reduce information overload. The core of medical knowledge—what every physician needs to know—has never been defined. And even if it could be, the boundaries would change before it could be mastered. Accordingly, the new curriculum based curricular requirements on the demands of well-chosen clinical problems. A second objective was to organize the curriculum into interdepartmental modules. Instead of a separate medical ethics course, ethical issues would be woven into the fabric of clinical problems. The third objective was to incorporate nontechnical goals in the training process, including ethics. The fourth was to emphasize self-directed learning. Students were to acquire the skills to become independent lifelong learners, both individually and collectively.

In practice this meant that the first two years of medical school were organized around small group tutorials instead of lectures. These sessions were led by a tutor whose job was to facilitate discussion, to provide a role model of critical thinking and self-examination, and to ensure that essential learning issues were addressed. Each week, students and faculty worked through a carefully drafted "health care problem" (an HCP), with faculty serving as facilitators instead of lecturers. The problems were written to mirror the clinician’s experience of a patient: Page 1 would describe the patient’s initial presentation; page 2 additional history, the results of laboratory analyses, and so on. At each step students shared whatever knowledge they had, conjectured about what might be going on, deliberated about what to do, and generated a list of "learning issues" on the blackboard: questions they needed to research and answer in order to understand and treat the patient’s problem. At the end of the initial session, the learning issues were assigned to students in the tutorial who then fanned out to research the questions, reporting back to the group at the next session. In addition to pertinent readings, students had access to expert faculty. The students also had clinical skills sessions and a weekly 90-minute colloquium where resource faculty discussed issues in greater depth with the entire class.

In the old curriculum, all second year students took a two-week medical ethics lecture-discussion course. With the transition to PBL, it became unclear how ethics was going to be integrated into the new curriculum. In 1991, The Queen’s Medical Center in Honolulu provided funds for the development of a medical ethics strand for the new curriculum. A team consisting of a physician (Dr. Anita Gerhard, a professor of psychiatry) and a philosopher (myself) had lead responsibility. Within a year, a set of medical ethics objectives was submitted to the MD curriculum committee. By 1995, the ethics strand was in place as a systematic and comprehensive approach to medical ethics, seamlessly integrated into the four-year problem-based curriculum.

Broadly, ethics courses can be "problem driven" or "theory driven." In a problem driven course, students are confronted with dilemmas they are likely to encounter in the course of professional practice. The felt need to know what to do in the face of such problems motivates students to master the knowledge required, both practical and theoretical. Theory-driven courses, on the other hand, seem to be favored by many academic philosophers. Here the instructor tries to provide the student with some theoretical knowledge-base first. Only then is the student allowed to apply that knowledge to problems.

It appears that the problem-driven approach is vastly preferable, especially in professional schools. In the first place, there is no consensus in the philosophical literature about which ethical theories are most worthy of application in professional contexts and no shared confidence that any of these accounts will, even in general, pick out professionally validated courses of action when applied. But secondly, and even more important, the attempt to instruct beginning professional students in ethical theory is commonly met with alienated attention, as there are often no clear applications of these accounts at the levels of abstraction where they are characteristically taught. Finally, since any fair review of ethical theory has to cover competing accounts, and since the competing accounts often will point toward contradictory courses of action, expertise in professional ethics can come to look suspiciously like disingenuous skill in rationalization: "If you take a Natural Law approach, you can keep the patient alive but if you make this clever act-utilitarian move, you can let the patient die." Problem-based learning is essentially problem-driven. There may be no better way to teach professional ethics.

This brief paper provides an overview of our project. I will describe four elements of the ethics curriculum: the questionnaire, the core value exercise, the core value application exercise, and the HCP modifications and supplements.

The Questionnaire

The Questionnaire was administered to all members of the entering class during orientation. They took it home but had to return it within a few days. The instrument consisted of a consent form, a sheet for demographic data and a battery of 13 medical ethics cases. Each described a problematic situation and several courses of action from which the student had to pick the one best representing what a responsible physician should do under those circumstances. In order to fix on that precise question, a prior question asked the student what he/she would do. These preliminary answers were not tracked. Concern had to be focused instead on the good physician: an abstraction the class would create collectively. The cases commonly mentioned the standard strategies for finessing such dilemmas, noting that these had already been attempted and had failed. The fact-situations therefore required bottom-line decisions. To keep the focus on ethics, students were also advised that none of the listed courses of action were contrary to law in their jurisdictions. They were told they must answer each question.

The primary purpose of the questionnaire was to introduce students to the subject matter of medical ethics. In choosing answers, students imaginatively place themselves in the physician’s role, measuring themselves against the demands of the case. The challenge of the questionnaire gets students’ attention and the dramatic immediacy generates a felt need for a better understanding of professional responsibility. Although students are admonished not to discuss the questionnaire prior to completion, there was considerable discussion subsequently.

A secondary purpose of the questionnaire is to evaluate the curriculum. A reasonable way to determine effectiveness is to see if students’ choices at the end of instruction are a better reflection of informed professional opinion than they were prior to instruction. A baseline measurement is therefore essential. To this end, about half of the cases—the "consensus cases"—were ones for which courses of action could be shown to be professionally favored by reference to official professional standards, consensus documents and the medical ethics literature. The remaining cases—the "knife-edge cases"—were ones in which informed opinion was either split or unknown. We administered post-tests at various stages of the curriculum and compared students’ initial responses to the consensus cases with the later responses given after the curricular intervention. Some discussion of the curriculum’s efficacy is set out below.

The Core Value Exerciese

Students undertook this 90-minute exercise during the first ethics colloquium, several weeks after the completion of the questionnaire.

It is commonplace that if people are not asking the same questions, they will not arrive at the same answers. It may be that the primary reason doctors have difficulty reaching consensus on questions of professional ethics is that, in general, systematic discussion about professional ethics is commonly confused with four other types of conversation. When problematic situations arise, physicians can choose to discuss their legal obligations, applicable institutional policies, their personal morality, or (what is sometimes different) their personal values. Discussions of professional ethics differ importantly from all of these. Understanding and bracketing these four other perspectives can, therefore, help to mark off the different intellectual space within which physicians can fruitfully reflect on questions of professional responsibility. In Hawaii, with its striking cultural and moral diversity, these ground rules are absolutely essential.

Law and Institutional Policy: Law and institutional policy involve standards that are typically imposed externally upon members of the profession. Lawyers, judges and legislators are commonly authoritative sources of information regarding legal obligations. And the hospital’s handbook or its administrators are commonly authoritative regarding institutional duties. While it is wise to determine how these rules apply, the duties that such external norms create are not the same as professional obligations. It is often said that the law creates a minimum ethical standard, but this is not so. A court, for example, can order a journalist to disclose the identity of a confidential source. Yet reporters typically go to jail rather than violate professional confidentiality. In such a case, a clear professional obligation conflicts with an equally clear legal obligation. Therefore the two cannot be the same. If legal or institutional rules are confused with professional obligations (as they often are), physicians will be unable to appreciate the tensions that can arise between the two. But if the profession is alive to the possibility that externally imposed rules can demand unprofessional conduct, the organized profession can work to change the rules so that conscientious practitioners won’t have to face tragic choices between acting unprofessionally, and violating laws or institutional policies. As important as these rules are, they are not the same as ethical standards.

Personal Morality: A "morality" can be understood as a set of beliefs about one’s obligations. There are plainly many such sets of beliefs: The morality of the ancient Romans and the morality of George W. Bush for example. For many, morality is uncritically absorbed in childhood, coming to consciousness particularly when they encounter others whose moralities differ.

There are still parts of the world in which all members of a community are participants in a common morality. But moral pluralism is now plainly a permanent part of the modern social order, and nowhere more than in Hawaii. As important as our moralities are in social life, they are of limited use to professionals. There are situations in which personal morality can conflict with professional ethics. For example, a Jehovah’s Witness physician will be conscientiously opposed to blood transfusions. If she were the only doctor on duty at a time when a patient needed to be transfused, then a choice would have to be made between being a good Jehovah’s Witness and being a good doctor. Accordingly, clarity about one’s personal morality is not the same as responsible clarity about medical ethics. The two can differ. I do not suggest that physicians need not reflect on their personal morality; only that personal morality is not the same as professional ethics.

Personal Values: Values are commonly appealed to as part of a explanation of rational personal conduct. It is always reasonable to ask of an action: What good is it intended to promote? While some may wear shoes to avoid hurting their feet (embracing the value of being pain-free) others may judge that their feet look better in shoes (embracing aesthetic values). We cannot appeal to personal values to inquire about what physicians in general ought to do, since "medicine" has no personal values: only individual physicians do. When a physician must decide whether to attempt to resuscitate a patient, personal values should have nothing to do with the question. Indeed a key part of professionalism involves knowing how and when to set personal values aside. While medical students have much to gain by becoming clear about their personal values, this clarity is not the same as responsible certainty about professional ethics.

To summarize the argument so far, discussion about professional obligations in medicine is not the same as discussion about legal and institutional obligations, personal morality, or personal values. If responsible consensus is to be achieved in the profession, it is necessary for physicians to learn to bracket, to some degree, their personal moral and value commitments and to set aside, temporarily, consideration of legal or institutional rules and policies. I will now take up the question of how one might do this.

Core Professional Values and Professional Ethics: Professional ethics involves disciplined discussion about the obligations of professionals. Such a discussion can begin with a distinction between personal values, already discussed, and what can be called "core professional values." A physician can prefer (1) chocolate ice cream to vanilla and (2) confidentiality to universal candor. But while the preference for chocolate is merely personal, the preference for confidentiality is a value doctors ought to possess. The distinction between personal values and "core professional values" is at the heart of the approach we took in the curriculum. To appreciate the ethical claims of professionalism, physicians must learn to set aside personal values and morality, set aside what the legal system and their employers want them to care about, and take up instead the question of what the responsible physician ought to care about, the broad purposes that each medical professional should have in common with colleagues. In discussing the professionally favored resolution of ethically problematic cases (see the description of the core values application exercise below) physicians can ask -- together -- how medicine’s core professional values ought properly to be respected in the circumstances of practice.

The "core value exercise" begins with a brief talk about professional ethics, summarized above. The class is then divided into groups of about 6-8 and asked to generate a core value list in about 10-15 minutes. Each person in the small group can nominate a candidate core value but these may be added to a group’s list only if each member can enthusiastically endorse it as expressive of an important ethical commitment of medicine. Every group member has a veto.

After the group work is completed, a single group is asked to set forth a value receiving strong support within that group. This is written on the blackboard. The other groups are then asked for any of their core values that roughly correspond to the one on the board. These are entered below the first. When all of the variations on the first are entered, a second group is called upon to list a second core value unlike those in the first group. Once again variations are solicited from the remaining groups. This process is continued until each group’s values are listed on the blackboard. It is almost always a surprise for students to see how much consensus there is within the room.

It is sometimes necessary to poll the class if it appears that values endorsed by a small group might not have unanimous and enthusiastic support from the whole class. Often students will identify a means of achieving some good (continuing education often comes up) instead of the good itself (competency or, better yet, the good of the patient). The means can be entered as such on the class list.

No claim is made in class that these lists are complete or ethically binding. The exercise is effective, especially if coupled with the core value application exercises to be described below, in identifying and, over time, developing matured values that are, as it were, "celebratable" by members of the profession. The manner in which the list is developed ensures shared ownership, at least by those participating in the process which is wholly transparent. As such, the list has far more value as a pedagogical tool than any list an instructor might implore them to take seriously: Reinforcement is collegial rather than pedagogical. But notwithstanding this ownership, the values do not have binding ethical force unless, among other conditions, they also represent what reasonable persons would want their physicians to care about, and unless the programs that educate physicians conscientiously equip students with the knowledge and skills they need to secure and further those values in the course of professional practice.

The account of professional ethics that is presupposed here is predicated on the legal monopoly that professions enjoy with respect to the distribution of their specialized services. Accompanying the legal privileges that doctors have are reciprocal responsibilities. Licensed physicians have the exclusive right to practice in part because they are believed to be reliably committed to certain significant social values. A representative core value list developed by a medical school class is attached as Appendix A. Though the terms are the students’ own, philosophers who teach medical ethics will readily recognize familiar concepts that are characteristically treated in their courses. Within a few days of the exercise, copies of the class core value list are distributed to all students.

Core Value Application Exercise

The follow-up core value application exercises were repeated at colloquia about 4-6 times during the four-year course of study. After one or two sessions, the exercise became a routine drill for students, requiring very little stage- setting. Taking about 90 minutes, it is prefaced by a brief introduction reviewing the basic concepts described above and by distribution of the most recent version of that class’s core value list. The 60 students were divided into four groups, each receiving a medical ethics case related to those the other three groups received. In about 15 minutes, each group is to focus on the question of how their core values should be furthered and respected in the circumstances of their assigned case. They are not to appeal to their personal moralities, to law, to institutional policies or to their personal values. New core values can be added to the list and old ones deleted or clarified only provided there is enthusiastic consensus for the amendment.

After the small group work, the four-case package is distributed to everyone. Following the reading of each case, a student reporter presents the results of the small group to the whole class, setting out the favored practical response to the problem and the core values that support that choice. Dissenters may register conflicting views. In practice, ethical dilemmas occur only as a consequence of two or more conflicting core values—in which case prioritization is called for—or as a consequence of ambiguity in a core value—in which case disambiguation is called for. Questions may be put to the group for clarification, but general discussion is deferred until all four presentations are complete. At that point there is opportunity for comments and criticisms, sometimes involving visiting experts who, except for requests for clarification, will have been silent until this point. Any agreed-upon changes in the class core value list will be reflected in the handouts at the next ethics colloquium. Topics for ethics colloquia have included information management, pediatrics, geriatrics, death and dying, scarce resource problems and nurse-physician conflict.

What has been striking is the degree to which (1) consensus is reached by students in the context of this process and (2) how often that consensus mirrors consensus in the profession and in the literature, when it exists. Because of this, very little traditional instruction is required. More important, there is evidence as well of an emerging alignment of the class around common values that are choice worthy from a societal point of view, and of cooperative participation in a common set of strategies for reaching agreement on ethical questions. The pedagogy described here aims at the development of ethical competence in the collectivity even while equipping the individual student with critical thinking skills that are applicable to ethical problems and founded on the core values of the profession.

Modifications of and Supplements to the Health Care Problems

The HCPs discussed in the tutorials were also a vehicle for ethics instruction. Cases in reliably regular use were reviewed for actual and potential ethical content. Many were rewritten, taking care to keep technical elements intact. For example where a bone marrow transplant was indicated for an juvenile identical twin with leukemia, we added the donor twin’s refusal to permit the bone marrow extraction. Though the donor twin relents on the next page, permitting the extraction, an ethical question—Under what circumstances should such a refusal by a minor donor be honored?—makes it to the blackboard as a learning issue. A student must then research it and report back to the group next time. A reading list with relevant citations is distributed by the tutor at the end of the session and these and other materials pertinent to the ethical issue were available as reprints in a learning resource center.

Note that this approach is largely self-instructional. Students learn to be teachers. It is not necessary for tutors to be competent in ethics for this process to be effective. Nevertheless we prepared condensed overviews for the tutors which were sometimes handed out to students at the end of discussion. The modifications and supplements to the HCPs mirrored the presentation of ethical issues in the context of clinical practice and, more important, insured systematic contact by students with some medical ethics literature.

Evaluation and Concluding Reflections

Subsequent to its implementation, several events served to compromise the curriculum. For personal reasons, the project co-director, Professor Anita Gerhard, permanently left the Medical School. At the same time, a lengthy period of financial exigency and administrative turmoil prevented replacement and, in the absence of knowledgeable ethics leadership within the Medical School, the curriculum languished and eroded.

Earlier, we had begun to use the "consensus cases" in the questionnaire to develop a scale to monitor instructional efficacy at various stages of curriculum implementation. In one study, a group of first year students who received the questionnaire prior to the core values exercise was compared with a second group who received it several months afterwards. Scores for the group who had had the core values exercise first were significantly higher. In fact, the 90-minute exercise raised scores as much as a full-semester medical ethics course taken earlier as an undergraduate. Data were also gathered from the first PBL class at graduation, before implementation of the ethics curriculum. We compared the scores of a subsequent class at the end of two years after having had the ethics exercises. Students in the second group performed significantly better.

Elements of our approach have been implemented at medical schools in Scotland, Michigan, New York, and elsewhere. Though few traces of our curriculum survive at the John A. Burns School of Medicine today, it may be that these instructional strategies could play a useful role in other places.

Core Value List: Medical School Class of 1998

What should responsible physicians care about? What are the deepest and most important ethical commitments of medicine?"

ENDS:

Do no harm, intend no harm, no net harm.

Alleviate suffering, unnecessary suffering

Promote health and well-being of patient

Promote health of public

Respect patient’s rights -- basic human rights -- as a patient; respect patient’s wishes; promote patient participation in decision-making; maintain patient dignity; respectful attitude toward all patients.

Non-discrimination

Integrity, responsibility for decisions.

Doctor-patient trust: respecting patient’s rights, maintaining patient dignity, confidentiality (means)

Empathy (possible core value)

MEANS:

Maintaining competence, continuing education

Empathy

Confidentiality, respecting privacy

Endnotes

1. Dr. Anita Gerhard, former Professor of Psychiatry at the John A. Burns School of Medicine, contributed importantly both to the project and to this paper. An earlier version was presented at the Spring, 1995 meeting of the Society for Health and Human Values at Loyola University in Chicago.