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487

TEACHING AND LEARNING ETHICS

Helping medical students to find their moral compasses:

ethics teaching for second and third year undergraduates
S Roff, P Preece
...............................................................................................................................

J Med Ethics 2004;30:487–489. doi: 10.1136/jme.2003.003483

The paper describes a two week course that has been pressure to act unethically and/or witnessed a
clinical teacher acting unethically.
offered as a special study module to intermediate level Nearly a decade ago Feudtner, Christakis, and
(second and third year) undergraduate medical students at Christakis8 reported self perceived ‘‘ethical ero-
Dundee University Medical School for the past five years. sion’’ among a third of the third and fourth year
medical students enrolled at six Pennsylvania
The course requires students to research the various aspects medical schools in 1992–93 who responded to an
of ethical dilemmas that they have identified themselves, anonymous postal survey. They concluded: ‘‘To
and to ‘‘teach’’ these issues to their colleagues in a short prevent ethical erosion, ethics education during
the clinical years should be refocused upon the
PowerPoint presentation as well as to prepare an extended clinical dilemmas that students confront as
3000 word essay discussion. The course specifically asks clinical clerks, and attempt to provide timely
students not to disclose their own ethical positions, as these and practical guidance. Teachers should strive to
promote discussions about real occurrences
are probably still in formation and the objective is to directly involving students.’’ (p 678) (see also
promote critical thinking capacity in ethical and moral Perkins, Geppert, and Hazuda9).
issues as a prelude to the development of practical skills in There is a consensus that students need to
develop and use ‘‘moral compasses’’10 to cope
dealing with clinical problems. The course is easy to with real ethical and moral dilemmas that they
resource for the school and has received universally high face from their earliest training. And there is
evaluations from the students since its inception. agreement that the students themselves can
usefully generate the issues to be explored from
........................................................................... their own growing exposure and experience.11–14
As students progress, and become clinically
experienced, the use of case based scenarios that

E
thical dilemmas arise very early in the they can analyse from a combination of their
medical student’s course and are not evolving knowledge of principles and philoso-
restricted to clinical issues. Several studies phies together with their own experience is
have reported the willingness of medical stu- recommended.15 16
dents to plagiarise and to cheat in examina-
tions.1–3 Some observers have suggested that poor BACKGROUND
ethical behaviours can come to constitute a Our interest has been in developing a special
‘‘hidden curriculum’’ in medical schools,4–6 and study module to introduce neophytes to the
can translate into poor ethical attitudes in the principles and practice of medical ethics as they
clinical years. For instance Rennie and Crosby1 move into their substantive clinical experi-
found that about a quarter of the students they ences—to help them develop their moral com-
studied in a Scottish medical school had written passes. The core curriculum in ethics and law in
or would consider writing ‘‘nervous system all phases of our three phase undergraduate
examination normal’’ in a patient’s notes even course is delivered as an integral part of the
when the examination had not been performed, systems teaching which is required by the
although far fewer would be prepared to forge a General Medical Council (GMC). The core
doctor’s signature on a piece of work. Another components address the topics shown in box 1.
See end of article for
authors’ affiliations study of 386 second, third, and fourth year One of the present authors (Preece) served as
....................... students at an English medical school found that coordinator of the Ethics and Law Theme in the
in a third of vaginal or rectal examinations GMC recommended undergraduate curriculum
Correspondence to: for the first seven years from its inception, and
Mrs S Roff, Centre for
undertaken by second year students and a half of
Medical Education, those undertaken by third year students, the found that systems centred delivery greatly
Dundee University Medical student did not know if consent had been enhanced the students’ appreciation that ethics
School, 484 Perth Road, obtained—although this reduced to 5% for the are all pervasive in the practice of medicine.
Dundee DD2 1LR, UK;
[Link]@[Link] fourth year students.3 It was estimated that a
quarter of intimate examinations on sedated or COURSE DESCRIPTION
Received anaesthetised patients had been carried out We took the opportunity provided by the
20 February 2003 without written or oral consent by the second introduction of special study modules into the
In revised form and third year students. Hicks et al5 reported that undergraduate curriculum (a recommendation
11 July 2003 of the UK GMC in Tomorrow’s Doctors published in
Accepted for publication half of 108 clinical students a year from the end
4 September 2003 of their training at the medical school of the
....................... University of Toronto felt they had been under Abbreviations: GMC, General Medical Council.

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488 Roff, Preece

practising gynaecologist reviews her practice in relation to

Box 1 Core components of Dundee ethics abortion. There is an historical review of ‘‘bad medicine’’
curriculum from Tuskegee through Nuremberg to the evolving protocols
of the post war period. These are all interactive seminars
N Confidentiality lasting one to two hours, and the students participate readily.
N Consent While each of the expert panel presenting runs his or her own
seminar, the clinical convenor of the course (Preece) is
N Truth telling
present throughout to facilitate integration and synthesis of
N Ends of life issues the material.
N Allocation of resources The students choose to sit in a circle and comment on how
N Research ethics this promotes discussion. We strive for a non-threatening
educational environment, reminding students that they are
not required to ‘‘expose’’ their personal positions, but to show
the capacity to ‘‘think ethically’’ within the medico-legal
199317). For the past five years we have offered a special study
framework that they are likely to work in within the UK.
module in Medical Ethics and Law for second and third year
After the initial few days of ‘‘information gathering’’ the
undergraduates in our Scottish medical school. The topics
students identify the issues they wish to research for
covered in this are listed in box 2, which shows that the
themselves. This might be something directly addressed by
module sets out to provide a deeper and expanded coverage
the panel or an area that was raised but not explored in depth
of items in the core ethics curriculum.
by the ‘‘experts’’. One example was the issues raised by the
These topics use an eclectic range of ethical approaches
views of patients who are Jehovah’s Witnesses in relation to
which includes the teaching of classical ethical principles and
blood transfusion. Another has been a review of different
theories, as well as clarification of values and strategies for
religions’ values about death and dying and the disposal of
analysing options to facilitate decision making.
the deceased. The ethics of animal experimentation came up
We can only accept 20 enrolments each year out of 320
one year. Genome related and genetic technology issues are
potential participants, in order to facilitate learning in
increasingly addressed. The students have five working days
seminars and small groups. In these groups the numbers of
plus the weekend to prepare their 3000 word essays and their
participants ranges from two to five. The course has regularly
presentations for the plenary meetings on the last two days of
been oversubscribed. Our learning objectives are primarily to
the course. The course convenors are easily accessible during
help the students develop critical thinking skills for the
this period to provide guidance, and the presenters are
analysis of ethical and medico-legal issues. We believe that
available by email and telephone if students want to explore
they are in the process of forming their own ethical and
moral values as they progress through their undergraduate their topic more fully. All our students have internet access as
learning and we do not ask them to make these explicit at well as the use of a reasonable medical library. We also
this stage. We require them to identify an issue and examine remind them that when they present their own analyses at
it as an ethical dilemma, presenting all sides of the argu- the end of the two weeks, they are teaching their colleagues,
ments involved. This is presented as a short (10 minutes) which requires them to organise their material in a way that
PowerPoint (Microsoft) presentation to the rest of the group will promote learning.
at the end of the two week session, and as a 3000 word essay
on the issue of their choice. This, together with the electronic STUDENT PERCEPTIONS OF THE COURSE
database literature search they undertake to develop their In their course evaluations, the students respond very
analysis, promotes the development of generic presentation positively. They enjoy the opportunity to discuss the issues
skills, as does the requirement that they reference their with practising experts: ‘‘The opportunities to discuss
reports in a standard (Vancouver) citation mode. philosophical aspects of medicine were extremely enjoyable
For the first four days of the 10 day teaching cycle, we and gave us the chance to use thinking and material which
present a panel of multidisciplinary speakers who have a we would not normally have the opportunity to use during
specialist competence in various topics. Our former director our medical course!’’ They appreciated the non-threatening
of drug development speaks on the ethics of clinical trials. A environment: ‘‘I enjoyed the opportunity that we were
specialist in palliative care from our regional hospice talks allowed to discuss any issue that we wished to. It was so
about end of life issues. A clinical oncologist considers issues good that we were shown such freedom to discuss any issue
of truth telling and confidentiality. Our chaplain addresses that we were particularly interested in.’’ They appreciated the
issues of allocation of resources in personal time manage- time for research and the diversity of topics, although some
ment as well as in our government funded health system. A would have liked longer to work on these. They realised that
medical adviser to a medical defence organisation and a they were developing generic presentation and teaching
surgeon examine the issues of consent and accountability. A skills. Many students suggested that this was a way of
thinking that was different from the approach normally
required to succeed in medical school: ‘‘It gave you a chance
Box 2 Topics presented in ethics special study
modules
Box 3 Typical presentation topics
N Historical examples of bad medicine
N Research ethics (Nuremberg to Helsinki) N Allocation of resources: organ transplantation
N Allocation of resources N The ethics of abortion
N Truth telling N The ethics of eugenics and genetic selection
N Abortion N Doctors and the death penalty
N Consent and professional accountability N Euthanasia: a growing moral problem
N Euthanasia N Maternal-foetal conflict

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Ethics teaching for second and third year undergraduates 489

after each of the courses, the participating students have

Box 4 Criteria provided to rate student completed an evaluation questionnaire. They have also been
performance invited to provide feedback as free text. The delivery of the
course has regularly been modified to respond to the
N Attainment of course objectives in course work students’ suggestions, as well as to those of the contributors.
N Interest Overall rating of the course has been consistently high.
As course convenors, one of whom (Preece) has 40 years of
N Motivation clinical experience and one of whom (Roff) is a lay member
N Reliability of the GMC’s Fitness to Practice Committee and Unrelated
N Attendance Live Transplant Regulatory Authority, we offer this descrip-
tion as being of a course that is easily replicable in many
other schools where panellists can be identified from the
clinical and teaching staff, and from related professions such
to ‘think’, something that you forget to do in medicine.’’
as the hospital chaplaincy. In it, we have found more profit at
Many thought the course should be mandatory rather than
this stage in the students’ development, to elicit their values
optional for those few able to be enrolled: ‘‘It should be made
about ‘‘real occurrences’’ rather than more theoretical
a significant part of the core curriculum! Fantastic!’’ Perhaps
analyses comparing competing ethical theories. The inter-
the biggest vote of confidence was the virtually complete
linking of case based scenarios (usually real) with ethical
attendance at all sessions over the years the course has been
theory, is a powerful learning tool in these modules, as
running, even though it starts at 9.30am and is a fair walk for
recommended by Macrina20 and Schwartz, Preece, and
many students from their accommodation. They appreciated
Hendry.21 It offers neophytes to medicine the chance to
the relatively tight timetable of the course, with the
develop and use their ‘‘moral compasses’’ in the recognition
presentations clearly listed and always beginning punctually.
of ethical issues and their resolution in practice.
They enjoyed the role of the clinical convenor and his
accessibility over coffee and lunch throughout the two weeks. .....................
Several students have opted to undertake related Electives Authors’ affiliations
Projects in their fourth year studies. S Roff, P Preece, Centre for Medical Education, Dundee University
Medical School, UK
ASSESSMENT
In the assessment, the criteria for the presentations revolved
REFERENCES
around the generic skills of presenting and teaching as much
1 Rennie SC, Crosby JR. Are ‘‘tomorrow’s doctors’’ honest? Questionnaire study
as the content and critical thinking skills evidenced by the exploring medical students’ attitudes and reported behaviour on academic
presentation. Box 4 lists the criteria from the school for this. misconduct. BMJ 2001;322:274–5.
The 3000 word assignments were usually of a high 2 Anderson RE, Obenshain SS. Cheating by students: findings, reflections and
remedies. Acad Med 1994;69:323–32.
standard for students of their level and the assessment 3 Baldwin DC Jr, Daugherty SR, Rowley BD, et al. Cheating in medical school: a
criteria focussed on demonstration of critical thinking and survey of second year students at 31 schools. Acad Med 1996;71:267–73.
analytical skills, as well as presentation skills with particular 4 Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the
structure of medical education. Acad Med 1994;69:861–71.
reference to footnoting the evidence base for their analysis. It 5 Hicks L, Yin Y, Robertson D, et al. Understanding the clinical dilemmas that
has been interesting to note that participants have never shape medical students’ ethical development: questionnaire survey and focus
expressed their personal position throughout the five years of group study. BMJ 2001;322:709–10.
the course; they appreciate and comply with the requirement 6 Braunack-Mayer AJ, Gillam LH, Gillett GR, et al. An ethics core curriculum for
Australasian medical schools. Med J Aust 2001;175:205–10.
to analyse ethical dilemmas ‘‘in the round’’ without indicat- 7 Coldicott Y, Pope C, Roberts C. The ethics of intimate examinations—teaching
ing their own position—tentative or otherwise. tomorrow’s doctors. BMJ 2003;326:97–101.
8 Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical
erosion? Students’ perceptions of their ethical environment and personal
CONCLUSIONS development. Acad Med 1994;69:670–79.
Our panel of presenters have been loyal to the course 9 Perkins HS, Geppert CMA, Hazuda HP. Challenges in teaching ethics in
throughout its five years. They often comment on the quality medical schools. Am J Medical Sci 2000;319:273–8.
10 Swenson SL, Rothstein JA. Navigating the wards: teaching medical students to
of the discussion and the pleasure they get in working use their moral compasses. Acad Med 1996;71:591–4.
through the issues with the students. Coming as they do from 11 Christakis D, Feudtner C. Ethics in a short white coat: the ethical dilemmas
widely differing specialties, which require very different medical students confront. Acad Med 1993;68:249–54.
12 Bissonette R, O’Shea RM, Horwitz M, et al. A data-generated basis for
approaches and personalities, these individuals give the medical ethics education: categorizing issues experienced by students during
students unique stimuli. This is analogous to the experience clinical training. Acad Med 1995;70:1035–7.
reported by Munn et al18 where actual practitioners in a range 13 Huijer M, van Leeuwen E, Boenink A, et al. Medical students’ cases as an
of specialties concerned with the Genome Project brought empirical basis for teaching clinical ethics. Acad Med 2000;75:834–39.
14 Siegler M. Training doctors for professionalism: some lessons from teaching
unique educational merit to teaching neophytes. clinical medical ethics. Mt Sinai J Med 2002;69:404–9.
The case for effective ethical education of medical students 15 Nilstun T, Cuttine M, Saracci R. Teaching medical ethics to experienced staff:
is reinforced in the report by Demmer et al19 of ‘‘a disturbing participants, teachers and method. J Med Ethics 2001;27:409–12.
16 Modell SM, Citrin T. Ethics Instruction in an Issues-Oriented Course on Public
lack of familiarity with the ethical principles of genetic Health Genetics. Health Educ Behav 2002;29:43–60.
testing’’ (p 2596) among a group of Canadian physicians 17 General Medical Council. Tomorrow’s Doctors. 1993.
compared with medical students. We have not undertaken 18 Munn M, Skinner PO, Conn L, et al. The involvement of genome researchers in
high school science education. Genome Res 1999;9:597–607.
any formal testing of the educational effectiveness of the 19 Demmer LA, O’Neill MJ, Roberts AE, et al. Knowledge of ethical standards in
course, nor of its actual impact on the development of the genetic testing among medical students, residents and practicing physicians.
students’ ethical thinking, much less practice. In the British JAMA 2000;284:2595–6.
system junior doctors do not begin to choose specialties until 20 Macrina FL. Scientific integrity: An introductory text with cases. 2nd edn.
Washington DC: ASM, 2000.
two or three years after graduation, and so it is too early to 21 Schwartz L, Preece PE, Hendry RA. Medical Ethics: A Case-based Approach.
know if the course has influenced these choices. However, Edinburgh: Saunders 2002.

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Helping medical students to find their moral

compasses: ethics teaching for second and
third year undergraduates
S Roff and P Preece

J Med Ethics 2004 30: 487-489

doi: 10.1136/jme.2003.003483

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