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Abstract

Technological advances and more pertinently their increasing interaction with health care have made ethics look like the proverbial tortoise in the race between the hare and the tortoise. Nonetheless, clinical ethics and its teaching are gaining centrality in the medical education curriculum. This is because of the complexity of treatment that has increased the burden on the patient to understand the intricacies of the health-care process and, simultaneously, for doctors to understand the patient’s dilemma. The teaching of clinical ethics, besides developing knowledge base and skills, should focus on bringing about an attitudinal change. The technique must focus on sensitization, respecting rights of others, and reﬂection by a process of developing experiential practice. While most of the developed nations are well entrenched in the practice of clinical ethics, the converse is true in the developing nations. Institutional mentoring is the way forward.

Introduction

The last few decades have seen technology make huge inroads, in the areas of diagnostics and therapeutics in health care. This has inevitably led to an increasing gap between how medicine is taught and how it is practiced. This has resulted in an urgent need to change the curriculum and provide new skills to address and incorporate the increased body of knowledge and practice. While physicians across the globe may have similar know-how about the technology in health care, clinical ethics teaching varies from country to country. To be well grounded in clinical ethics methods and consultation, a thorough training is required for a physician to be able to identify ethical issues arising in the context of health care, to be able to analyze the ethical issues, and to be well versed with methods to resolve such ethical issues or conﬂicts (Jonsen et al. 1998).

The practice of imparting medical knowledge seems to be uniform across many countries barring some exceptions for local diseases, depending on its occurrence in that community. Ethics teaching and discussion, on the other hand, have pervaded developed countries more signiﬁcantly than developing countries. As treatment modalities become more and more complex, and the outcomes not always positive and certain, there is an increased choice-laden burden requiring greater understanding from the patient. While technological imperative makes it routine for hospitals in developing countries, to adapt these modalities in health care and education, there is no ethical imperative deﬁning basic minimum training in clinical ethics. Bioethics education and clinical ethics skills are essential or core areas in the curriculum while training residents, doctors, and postgraduates alike (McCrary 2001).

History And Background

Countries where ethics teaching is not developed rely on codiﬁed ethics in the form of dos and don’ts for doctors. But ethics is not as simple, nor can one have a codiﬁed answer for every ethical problem that arises. This reﬂects in the lack of uniform content for the practice of clinical ethics. The latter half of the twentieth century witnessed the ﬂourishing of ethical principles and the principlist approach. Autonomy, beneﬁcence, non-malfeasance, and justice almost promised to resolve any ethical complexity (Cotler 2013).

Advances in technology and the possibility of prolonging life brought up more questions than answers such as who should receive life support treatment, for how long, and when was the appropriate time to withdraw such treatment. Some countries like the USA started teaching ethics in the medical curriculum in the 1970s, and this was done by philosophers and religious persons. In 1976, in the benchmark case of Karen Ann Quinlan (the right to die case), the New Jersey Supreme Court promoted the utilization of “ethics committees” in the clinical setting (Aulisio et al. 2004). This was one example of judicial activism moving the ﬁeld forward in ethics. This marked a transition of treatment decisions from vesting only with the treating physician to a collaborative responsibility with ethics committee members who are expected to understand the shared values.

Conceptual Clarification

One of the goals of clinical ethics education is to improve quality of patient care by identifying ethical problems, analyzing the problems in the given context, and resolving them (Singer et al. 2001).

There is no clear-cut direction how to address the ethical issues when one ethical principle or theory or value conﬂicts with another. This impasse can often be settled by clinical ethics consultation. Clinical ethics in today’s avatar has evolved to address the complex ethical issues that arise at the patient’s bedside due to different values which the patient, his family, and physicians share. Clinical ethics education should equip the learner to help resolve ethical issues that come in the way of doing the best for the patient.

While clinical ethics education has made signiﬁcant progress in the curriculum of medical schools in the USA and all over Europe, Australia, and New Zealand, it suffers from neglect in many developing countries. It is taught in pre and paraclinical years and without reinforcement in clinical and internship years. As a result, the notional teaching does not imbue conﬁdence in the students that it is applicable in clinical settings. Since there are not many ethics courses, the teachers who give the training are not well versed with the larger picture, newer concepts and methodologies. There is a gap in the way clinical ethics education is expected to be given and actually given. The urgent need is to bring medical ethics into focus and orient it in the daily health-care settings. In many countries, clinical ethics consultation has become a key factor in the health-care delivery system.

Clinical Ethics Education

Education Process

In the preceding section we have established the need for ethics-trained professionals in countries where clinical ethics has not yet fully developed. In this section we will attempt to show how not only the curriculum content but even its transaction will need rethinking. We will also establish that the gap in clinical ethics teaching between nations can be mitigated through a process of collaborative academic mentoring.

The core competencies required to be transferred in clinical ethics education include the following:

Ethics assessment skills: Besides knowledge on the theoretical aspects, students of clinical ethics also need to hone certain skills that are useful to evaluate and tease out conﬂicting values in a given clinical situation.
Operational skills: These are facilitatory skills essential to the process of working out differences and include organizing meetings, facilitating discussions, and maintaining records.
Communication skills and interpersonal skills: Clinical ethics education must include training in communication skill. The various aspects of active listening, developing patience to intercultural usage of language, nonaggressive tone and tenor, mediation, and conﬂict resolution skills are some of the important skill building domains (Larcher et al. 2007) and are necessary to bring all parties to the discussion table. The approach should be nonaggressive and no confrontationist.
Professionalism skills: Professionalism is a central or core competency expected in a medical graduate. This is even more pertinent in clinical ethics education. Punctuality, compassion, care and concern, respect for others, transparency, accountability, and professional integrity are essential components of a clinical ethicist’s repertoire, such that all stakeholders feel equally respected and assured of conﬁdentiality.

Active learning is a process which engages learners actively by doing, experiencing, and reﬂecting. These are critical components of learning. Clinical ethics education encourages an empathetic approach of the student. Educational training is easier if the process involves transference of knowledge and skill. It conforms to two of the three major domains of learning: the cognitive, where knowledge building is essential, and the psychomotor, where skill building is essential.

It is the third domain, the affective, where the learner is expected to undergo a change of attitude, which in clinical ethics should include development of empathy. Inducing change in the affective domain is the hardest of all. The affective domain comes into play, when behavioral change is essential, and not merely transference of knowledge or skills. Clinical ethics education should ignite the affective domain as much as it enhances the psychomotor domain, as the learner has to undergo a change in the way she thinks and behaves. Educational tools that are more likely to achieve this goal include reﬂection on personal experiences, case scenarios, role playing, standardized patients, narration and essay writing, feedback on performance, and small group discussions (Thomas 2009).

Ethics education by cultivating reﬂection through role-play, video clips, shared experiences, and reading of short stories or poems forms a backdrop on which a well-formulated and facilitated discussion moves a person from a rigid dogmatic opinion to a ﬂexible value-oriented decision and helps see the other’s point of view. Internal reﬂection and discussion help one see layers of ethical complexities and clarify values while making a decision. Reﬂective practice is an active, dynamic action-based and ethically rich skill, placed in real time and dealing with real, demanding, and difﬁcult situations. It bridges the gap between the theory and complex practice (Moon 1999). In a clinical ethics teaching setup, students should be given case vignettes to discuss in small groups, make presentations on the ethical issues, and suggest options to resolve these. Case vignettes help students to reﬂect, analyze, and present their arguments lucidly.

There is a vast literature on clinical ethics and methods, but clinical ethics education has not received adequate attention. Since clinical ethics involves applied aspect of ethics and not mere transference of ethical theories and principles, Aristotle’s method of phronesis – a sustained mentorship – could be a good starting point for clinical ethics education (McGee 1996). Mentoring is a very useful tool for clinical ethics education, at all levels, from individual to institutional. Mentoring helps peer development, enhances goal achievement and sustenance, and reduces competency decay over time. Individual mentoring must be established at the start of the curriculum transaction and nurtured over the course of the program and continued beyond. Clinicians would likely play a better role model and mentor in this situation. Institutions from developed countries with vast experience in clinical ethics “in the ﬁeld” can collaborate with institutions that lack the expertise, thereby meaningfully contributing to enrichment for both the mentor and the mentee.

Though there are different methods of clinical ethics practiced in different parts of the world, most revolve around four basic concepts (American Society for Bioethics and Humanities [ASBH] 1998):

Summarize the case and elicit moral views of all stakeholders.
Analyze and identify the ethical issues and value conﬂicts.
Apply ethical theories and principles and explain ethical dimensions.
Justify and offer morally acceptable solutions.

Assessment drives learning, says the well-known adage. Having imparted the skills and competencies to the clinical ethics student, these need to be evaluated by simulated case deliberation and discussion. Clinical ethics teaching must be evaluated from the point of view of content, validity, and signiﬁcance and be customizable to the specialty of practice. Evaluation must meet the gold test of reliability and validity. The program needs to be periodically evaluated and accredited for content validity and accuracy.

Conclusion

The mind is not a vessel to be ﬁlled, but a ﬁre to be kindled. – Plutarch

Clinical ethics education should be based on the current theories of learning. The focus of education strategy should shift from didactic learning to interactive adult learning, small group discussion, and reﬂection. Once trained, the clinical ethicists should be mentored to reinforce attitudinal change.

The coming years must see the assimilation of clinical ethics education in the respective divisions of health care and various specialties. In a seminal article in 2001, Singer et al. (2001) expressed their hope that a decade later the focus would shift from ethics courses, committees, and ethics consultations to realization by medical students and physicians that clinical ethics is an integral part of clinical medicine and its rightful place is between the sick patients and the healing physicians.

Nearly a decade and a half later, clinical ethics education has not progressed uniformly across the globe, and some developing countries still have a long way to go. Some countries have not perceived hiatus in the clinical ethics education; they have neither clinical ethics courses nor clinical ethics committees. To illustrate, the ﬁrst clinical ethics course in India was started in the Centre for Ethics, Yenepoya University in India in 2012 thanks to collaboration with the Department of History, Philosophy, and Ethics of Medicine, at the Johannes Gutenberg University of Mainz, Germany.

The global inequity in clinical ethics education can be mitigated by institutional collaborative mentorship program for capacity building. It is hoped that many institutes follow this lead in starting clinical ethics courses and many physicians unhesitatingly add it to their repertoire of necessary skills in order to deliver quality patient care.

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