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Abstract

• Teaching ethics incorporates teaching of knowledge as well as skills and attitudes. Each of these requires different teaching and assessment methods.
  
• A core curriculum of ethics knowledge must address both the foundations of ethics and specific ethical topics.
  
• Ethical skills teaching focuses on the development of ethical awareness, moral reasoning, communication and collaborative action skills.
  
• Attitudes that are important for medical students to develop include honesty, integrity and trustworthiness, empathy and compassion, respect, and responsibility, as well as critical self-appraisal and commitment to lifelong education.

In recent years, an international consensus has emerged that ethics and health law should be essential components of medical curricula.^1-3 In line with this, teachers of medical ethics and law in UK medical schools have recently published a model for a core ethics curriculum.⁴ In Australia, concern for ethics teaching has developed, in part, as a result of the findings of the Doherty Report⁵ and through the Australian medical school accreditation process. The Australian Medical Council's statement, Goals and objectives of basic medical education,⁶ specifies that graduates completing basic medical education "should have knowledge and understanding of the principles of ethics related to health care and the legal responsibilities of the medical profession", and that graduates should have "an appreciation of the complexity of ethical issues related to human life and death, including the allocation of scarce medical resources".

There is, however, less consensus as to what ethics should be taught, how it should be taught and who should teach it. In part, this is because ethics offers not so much a discrete or limited area of content, but a place for the consideration of values and for dialogue across boundaries and between different perspectives. In addition, there are many different ways to think about and analyse ethical issues in practising medicine, from a "principlist" approach through to virtue ethics, narrative ethics and ethics of care (Box 1).

Despite this diversity, there is a core of skills and knowledge related to ethics that is as fundamental to the practice of medicine as basic sciences or clinical skills. This core is concerned primarily with equipping students to recognise and understand important ethical issues, to know how to make decisions about those issues, and to have a better basis for knowing what should be done (in any given situation) and why. Consideration of questions such as "What are ethical reasons and how do they differ from other reasons?", "What does 'informed consent' mean and how does it work in practice?", and "How do people wish to die?" is an essential component of medical education that falls within the domain of ethics.

As members of the Association of Teachers of Ethics and Law in Australian and New Zealand Medical Schools (ATEAM), we offer here a position statement on an ethics core curriculum for Australasian medical schools. We believe that this curriculum meets the goals outlined by the Australian Medical Council.⁶

Background to the development of our position statement

Our outline of an ethics core curriculum arose out of a meeting in June 1999 of teachers of ethics and law in medicine from 10 universities in Australia and New Zealand. The meeting covered a wide range of issues, with participants exchanging views on the teaching of ethics, based on personal experiences and informal consultations within their own institutions. Following this meeting, three separate working parties developed statements on the knowledge, attitudes and skills considered desirable for students to acquire from an ethics curriculum. The whole group met again in July 2000 and agreed to develop and refine the initial statements from the working parties by an email exchange of views. The core curriculum outlined here is the consensus statement that resulted from this process.

During our meetings and subsequent consultations, it became apparent that most of the existing Australasian ethics courses are strongly congruent with one another and with other existing statements, such as the consensus statement by teachers of medical ethics and law in UK medical schools.⁴

We see our consensus statement very much as a living document, open to challenges and revisions as changes in medicine and society raise new and different ethical questions and as medical education continues to evolve.

Content of a core curriculum

Knowledge

Skills

More specific skills (those of ethical awareness, moral reasoning and ethical practice) are also required to translate this knowledge into practice. Ethical awareness relates to the ability to recognise ethical issues present in a medical setting. This requires students, in practising medicine, to maintain and develop sensitivity to issues involving their patients. Skills in moral reasoning involve the ability to analyse ethical issues in a medical setting, to construct arguments and counterarguments that are valid and sound, and to examine and interpret the arguments of others. The specifically moral nature of these arguments requires that students have some familiarity with ethical theory and principles. After weighing competing claims and interests, justification for a particular moral position can be offered. Skills of ethical practice concern a range of skills necessary for ethically sensitive practice. They include the ability to communicate about ethical issues with patients, their relatives and other healthcare professionals; effective negotiation and collaboration with patients, their families and other members of the healthcare team; and skills necessary to implement ethical decisions in the face of institutional constraints. Students' relative powerlessness in the medical hierarchy can often inhibit them from presenting a dissenting ethical view, and so they need to be able to recognise and analyse an institutional culture, with specific attention given to how students might act ethically in the face of it.^12-14

Attitudes

However, increasing concern about the dehumanising and detrimental effects of institutional practice and the medical education process itself has led to recognition of the importance of promoting humanistic qualities and behaviour in medical ethics education.¹⁶ A broad community consensus on unacceptable professional behaviour also exists. Awareness and discussion of professional values, attitudes and behaviours should be fostered among students and their teaching staff, both to minimise direct patient harm and to recognise and reduce individual and cultural factors that may erode professional trust.

Attitudes that are important for medical students to develop are those that promote patients' interests through the doctor-patient relationship, the interests of colleagues through professional relationships, and students' own well-being (Box 3). These attitudes are core components of professional identity; placing them within the ethics curriculum does not imply ethical ownership, but is a mechanism to ensure explicit teaching in this area.

Teaching methods

There is no single "best" method by which ethics should be taught and, indeed, the evolution of ethics education has profited enormously from curricular experimentation and innovation. However, all forms of teaching must remain cognisant of the centrality of the individual's experience, or narrative, and must also be committed to the notion of dialogue between individuals and between professions, perspectives and ideologies. This creates the basis for the incorporation of multiple perspectives and multiple teachers into ethics programs.

Although the conceptual and theoretical knowledge of ethics can easily be introduced through readings, lectures, seminars or computer-assisted instruction, ethics education is fundamentally discursive, and thus it is essential to facilitate at least some learning of ethics knowledge in small groups. Small-group learning using case studies and problem-solving exercises can be used both to amplify and extend more didactic teaching methods and also to reinforce the relevance of ethics to medicine (Box 4).¹⁹

Professional, clinical and social issues can also be taught by integration with clinical teaching in a number of other settings, including:

• formal "ethics" ward rounds;²⁰

• formal "ethics" grand rounds and unit meetings;

• discussion of ethical issues within clinical seminars;

• ethics journal clubs.

The teaching of attitudes deserves particular mention. The capacity to clarify and critically evaluate one's own values and to integrate personal and professional values in the life of the student and doctor should be an essential part of the medical school curriculum. Teaching methods that have been employed successfully to accomplish these tasks include:

• values journals or portfolios;

• discussion of cases, with particular emphasis on critical appraisal of personal and professional values and attitudes;

• debriefing sessions that allow for reflection and discussion of attitudes and behaviours encountered in the day-to-day experience of medical students.

Role modelling by teachers is a crucial influence on the attitudes and behaviour of future doctors.^21,22 The unconscious assimilation of professional culture and the ethical capitulations that have been seen as necessary for advancement within that culture can be better recognised and dealt with in educational programs that explicitly aim to include these elements. Teachers of ethics can play an important role in modelling the very nature of ethics: the teaching process should be perceived as being emotionally supportive and academically encouraging, should be tolerant of multiple perspectives, should be interdisciplinary, and should actively involve clinicians as co-instructors and as role models for students. This also underscores the responsibility of teachers to develop as an ethical community and be alert to, and respond to, unethical behaviour among themselves and their students.

Deeper and more focused learning of specific issues through elective courses in ethics should also be available, either as part of the medical curriculum or through interfaculty cooperative arrangements. Advanced elective modules in ethics that may be taken during the degree are an efficient way to offer courses for students with a particular interest in ethics.

Finally, although it is essential to introduce ethics within the medical curriculum, ethics may be best learnt when individuals are faced with real-life ethical issues in clinical practice. For this reason, education in ethics should continue through postgraduate and vocational training and continuing education. Ethical, legal and institutional issues are now addressed in structured-release sessions within the Commonwealth-supported National Curriculum for Junior Doctors in the Prevocational Years.²³

Assessment

There is no single method for assessing ethics knowledge and skills. A number of methods have been used, including written case reports, objective structured clinical examinations²⁴ and group assessment of students' self-directed, problem-based learning skills. Skills of problem-solving, cooperation and self-motivation may be assessed by such means as self- or peer-ratings, assessments by tutors, literature searches, diaries or portfolios.^25,26

The critical issue is not so much the method of assessment, but whether the assessment instrument is well designed and appropriate to the task. The challenge for ethics educators is to develop valid, relevant, rigorous and reliable measures for assessing ethics and for evaluating the incorporation of ethics into practice.

The challenge of implementing the curriculum

Some medical schools already have dedicated staff teaching ethics with recognised allocation of curriculum time, while others face a number of challenges in reaching the aims we have outlined. These challenges include the following:

(a) Shortage of skilled staff. There are no uniform qualifications for teaching ethics in medical schools. Staff require not only a good understanding of moral philosophy, but also familiarity with (and confidence in dealing with) the medical environment. It is difficult to stipulate specific qualifications required, but, as with all university teaching, a higher degree with a major focus on ethics or an appropriate topic is highly desirable.

(b) Competition for curriculum time. Many Australasian medical schools have revised their curricula in recent years. There continues to be pressure of curriculum time on all aspects of medical teaching. We have not stipulated the number of contact hours required to successfully implement the core curriculum, as this will vary with methods of teaching, available staff and other factors. An integrated curriculum will incorporate many ethical issues into existing topics — for example, a clinical term in surgery should include teaching on ethical aspects of informed consent to surgical treatment. The issue is not so much competition for extra time, but judicious collaboration with clinical colleagues.

Perhaps the greatest challenge facing implementation of a core curriculum in ethics is that of gaining recognition of the skills and expertise required to teach ethics. Until ethics is accepted as an essential domain in medicine, no less important or specialised than anatomy or pharmacology, support for an ethics core curriculum may be lacking. However, given the relatively recent recognition of the need for teaching of communication skills, we trust that support for teaching of ethics is not far behind.

Conclusion

References

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Authors' details

Centre for the Study of Health and Society, University of Melbourne, Melbourne, VIC.
Lynn H Gillam, MA(Oxon), PhD, Lecturer in Health Ethics; and Research Fellow, Ethics Unit, Murdoch Children's Research Institute, Melbourne.

Clinical School, St Vincent's Hospital, Melbourne, VIC.
Edwina F Vance, MB BS, MBioethics, Fellow.

Otago Bioethics Centre, University of Otago Medical School, New Zealand.
Grant R Gillett, DPhil(Oxon), FRACS, Professor of Medical Ethics.

Clinical Unit in Ethics and Health Law, University of Newcastle, Newcastle, NSW.
Ian H Kerridge, MPhil, FRACP, Lecturer in Ethics;
John McPhee, BCom (Hons)(Leg Stud), Consultant in Health Law;
Peter Saul, FFICANZCA, MA, Clinical Lecturer in Ethics;
David E Smith, MB BS, GradCertBioethics, General Medical Practitioner;
Henry M Wellsmore, MAE, MSocSc, Lecturer in Ethics.

School of Medicine, Flinders University, Adelaide, SA.
Bogda Koczwara, FRACP, MBioethics, Coordinator, Personal and Professional Development;
Wendy A Rogers, MRCGP, PhD, NHMRC, Sydney Sax Research Fellow, Department of General Practice;
Brian F Stoffell, BA(Hons), PhD, Director of Medical Ethics.

School of Community Medicine, University of New South Wales, Sydney, NSW.
Paul M McNeill, LLB, PhD, Associate Professor of Ethics and Law in Medicine.

School of Medicine, University of Tasmania, Hobart, TAS.
Christopher J Newell, MA(Hons), PhD, Senior Lecturer.

School of Medicine, University of Queensland, Brisbane, QLD.
Malcolm H Parker, MB BS, MLitt(Hons), Senior Lecturer in Ethics and Professional Development.

Department of Medical Education, University of Sydney, Sydney, NSW.
Merrilyn Walton, BSW, MSW, Associate Professor of Ethical Practice.

School of Medicine, James Cook University, Townsville, QLD.
John S Whitehall, MB BS, FRACP, Associate Professor; and Domain Chair of Ethics and Personal Development, Director of Neonatology.

Reprints will not be available from the authors.
Correspondence: Dr A J Braunack-Mayer, Department of Public Health, University of Adelaide, SA 5005.
annette.braunackmayerATadelaide.edu.au

©MJA 2001
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