Medical Ethics Education Must Include Studentsʼ Moral Dilemmas within the Clinical Setting

Ethics education for students in the health care professions has become increasingly prominent in recent years, with nearly all U.S. medical schools now providing some form of it. While belief in the need for ethics instruction for health professions students is wide-spread, its implementation does not reveal consensus about its objectives, teaching methods, or anticipated results. A common framework would help to ensure that these students receive the ethics education they need. As part of such a framework, more emphasis should be given to the moral dilemmas that students personally face during their training, particularly their clinical training. Circumstances in which students feel ethically compromised or uncomfortable within the clinical setting have been classified by Bissonette and colleagues1 in a category called “student boundaries.” Student-boundary cases are not often discussed as part of formal ethics training programs, which tend to focus almost exclusively on clinical patient cases.2 This is certainly true at my institution; a recent study I made of the kinds of ethics education offered there showed that such education in the student-boundaries area has a low priority. Why this low priority? One could argue that the present lack of emphasis is appropriate, since Bisonette et al. learned from the students who participated in their study that student-boundary situations were among the least frequent of their ethics-related experiences—why teach about something that the students themselves say they encounter infrequently? However, one could also argue that self-reported frequencies of student-boundary issues may be artificially low: students may hesitate to report moral dilemmas for fear of recriminations or other punishments for “questioning the system.” One could also argue that the priority allotted to teaching about student-boundary situations is low because the moral issues involved are pervasive in the education of health professionals. In other words, student-boundary dilemmas are dealt with, but are just not categorized as such. I do not think this position is persuasive, however. I maintain that student-boundary cases receive the least attention because health-professions students generally are not asked about their personal feelings about ethics dilemmas—or any others—and ethics is taught purely with the goal of mastering concepts and applying them in medical practice. While there may be various explanations for the lack of emphasis on student boundaries in ethics education for health professionals, more attention should be paid to teaching about this topic: no matter how pervasive student-boundary moral issues are or are not in health-professions education, nevertheless ethical considerations are most vivid to students in the student-boundary context, because this context involves the students' personal moral commitments. Thus, there is a unique opportunity here for teaching the concepts of ethics, since they will “come alive” as students struggle to understand the moral implications of what they are experiencing. Also, the focus on situations that are tangible to students may give the students greater confidence and skill in being alert to, understanding, and sensitively acting upon what they experience in their medical training and later in practice. In other words, students will gain practice in moving from the particular situation to general principles and applying what they know about ethics to guide them in their professional and personal lives. Isn't that what ethics education is all about?