Goals of Bioethics Education Research Paper

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Abstract

The ﬁrst bioethics courses were offered in the 1960s, and with them began a still ongoing debate on the goals of bioethics education. Should ethics education equip students with the necessary tools to make ethically sound decisions, or should the aim be more ambitious: to produce virtuous professionals? Or could ethics education even be a cure for all that is morally wrong within the practice of medicine?

Nowadays, the debate on goals still continues, but the themes are roughly the same as, say, 20 years ago. Important reasons for this slow progress seem to be a lack of consensus on underlying theoretical meta-ethical assumptions and imprecise use of concepts, especially when it comes to teaching bioethics in the context of medical professionalism.

Introduction

Suppose that you are asked to design an introductory bioethics course for future doctors. What would you want to teach them, and why? Should you aim to transfer knowledge, develop reasoning skills, or build their character perhaps? And if you choose to stick to knowledge transfer, what would you want to teach them? Is it sufﬁcient for doctors just to have a general overview of the most important ethical themes, or should they have an in-depth understanding of all kinds of underlying philosophical, economical, legal, psychological, or sociological issues?

From an educational perspective, deﬁning your goals (the “what”) is a requisite for determining your methods, tools, and the kind of teachers you need (the “how”), and the design of your assessment. Sometimes, especially when your teaching is about practical matters (“repairing your own bike” or “learning to master basic functions of a laparoscope”), setting the goals can be quite easy – and there is often already a body of literature on goals and methods to rely on. When it comes to teaching bioethics, however, the problem is that “[t]he literature reveals a lack of consensus about the primary goal of medical ethics education,” as Eckles and colleagues wrote in an important oversight article (2005, p. 1145).

This lack of consensus is regarded as problematic for at least two reasons. The ﬁrst of which is didactic. Just the fact that bioethics has to be taught, every day, to tens of thousands of students worldwide makes one realize that every ethics educator has to have a well-thought out plan of what he or she is doing – and this involves having a grounded view of the goals of teaching.

The second reason has to do with the importance of ethics, or of moral competency. Hafferty and Franks (1994, p. 862) note that “Ethics occupies a central place in clinical decision-making. As such, its presence is critical to the professional development of the physician” – the hidden assumption being that doctors are not morally competent by nature, and that ethics education is thus a necessary ingredient of the professional development of doctors. Given this importance of ethics, it would be good to have a broad consensus on the goals of bioethics education.

This research paper focuses on the discussion of the goals of bioethics as it has developed since the 1960s. The exploration is systematic, although it starts with a very brief historical overview of the development of bioethics teaching during the last 50 years. The topics that are addressed are, apart from its history, the terminology and the importance of goals, an oversight of the contemporary debate on goals, difﬁculties with goal setting, no-goals (goals that should not be chosen), and tricky goals (possible legitimate goals that should be handled with care). The paper ends with a short discussion and conclusion.

But before heading off, three remarks should be made. First, this research paper focuses heavily on medical bioethics. The scope of bioethics is far broader than medical ethics, but the discussion on goals for the greater part takes place within the context of medical ethics teaching. Most of the positions and arguments are, however, not typical for medical ethics education, and are also relevant for other types of bioethics education. The second remark concerns the meaning of the word “education.” “Education” is used here to address formal teaching initiatives – lectures, workshops, assignments, and the like – and the educational goals that are being discussed are formal goals – goals that are written down in ofﬁcial documents and that are communicated with students within the context of their formal education. Thirdly, unless stated otherwise, the words “goals” and “aims” are used interchangeably.

A Brief History Of Bioethics Education

Bioethics teaching, in the formal sense of the word, took off in the 1960s. Since the times of Hippocrates, physicians have been aware of the fact that their work contributed to a moral goal (the preservation of health and human life), that their work can have a huge impact on the lives of their patients, and that all this required moral rules and a certain moral, “professional” attitude.

The idea, however, that physicians need formal education to fulﬁll special moral responsibilities was not widespread until the 1960s. “At that time,” as Shotter and colleagues recall, “it was said that ‘ethics could be picked up on a ward round.’ [.. .] It was doubted that ethics could be taught and apparently both teachers and taught were unaware that ethics (moral philosophy) and ethics (moral theology) were established subjects, unremarked in university faculties” (Shotter et al. 2013, p. 663). If there were lectures on ethics, they seemingly had a purely top-down instructional character: future doctors were simply told what they had to do, and what to refrain from.

It would quickly become clear, however, that relying on the professor’s authority, Hippocratic tradition, and informal learning (“picking up ethics on a ward-round”) were not sufﬁcient any more in order to cope with the moral aspects of an increasingly complex job in an increasingly complex sector in an increasingly complex society. The “old” way of doctoring presupposed a set of shared values, both within the profession and in society, and this foundation started to crumble down during the twentieth century (Cruess et al. 2008). Other developments that made it increasingly problematic to rely on answers given in the past are ongoing specialization, a shift towards the more technical side of medicine (resulting in less attention for the patient as a person), the rise of technology (raising all kinds of new, unprecedented issues), the rise of patient autonomy, and the rise of institutions such as insurance companies (Miles et al. 1989, p. 706). As a consequence, dealing with ethical questions became increasingly complex. New questions had to be explored, new answers to old questions had to be formulated, and methods of formulating answers needed to be redesigned – and it turned out that doctors were not always well-equipped to do that.

According to some authors, the introduction of bioethics, however, came with a price: a tendency to make “ethics more scientiﬁc” (Cowley 2005, p. 739), i.e., a tendency to present ethics as a body of value-neutral knowledge and skills that can be applied when necessary. In this positivistic view, according to Hafferty and Franks (1994), there is no fundamental difference between knowledge about anatomy and knowledge about autonomy. This type of ethics teaching will focus on skills development and knowledge transfer (and not on character formation), on the individual patient–doctor relationship (and not on organizational, community, or societal issues), and on observable behavior (and not on values as decency, kindness, sacriﬁce, and love). As a result, this kind of education could actually make students stop reﬂecting about ethics, Hafferty and Franks warn (1994).

At the start of the 1990s, bioethics teaching was “coming of age”, as Miles and colleagues put it (Miles et al. 1989). Their paper was one of the ﬁrst literature studies to appear giving an oversight of the theoretical and practical (curriculum comparison) state of the art (see also Eckles et al. 2005). But not only bioethics teaching was coming of age – bioethics teachers also started to professionalize. They unite and try to reach consensus about the aims of their teaching, on both a national and an international level. One example of these efforts is the 1998 Consensus Statement by Teachers of Medical Ethics and Law (updated in 2010 Stirrat et al. 2010), the result of a UK-wide initiative. A recent example of a global initiative is the UNESCO Bioethics Core Curriculum (UNESCO 2008), based on the principles described in the Universal Declaration on Bioethics and Human Rights. Both the Consensus Statement and the UNESCO Bioethics Core Curriculum contain paragraphs on education goals, as discussed below.

Another important development is the rise of medical professionalism, combined with the emergence of competency models for medical education. As a reaction to diminishing public trust (Cruess et al. 2008), medical associations took the initiative of publishing binding competency models that describe the generic competencies that each doctor should master. These models can be seen as an answer to the question “What do physicians need to be able to do for effective practice?” (Frank 2005, p. 8) and signiﬁcantly broadened the scope of formal medical education. According to the Canadian CanMEDS model (created in 1996 and updated in 2005; adopted by several medical associations around the globe), doctors should not only be “medical experts,” but also become competent as “managers,” “health advocates,” “scholars,” “collaborators,” “communicators,” and “professionals” – this latter role being the “home for concepts of ethical practice” (Frank 2005, p. 8). Since models such as CanMEDS form the basis of education programs of (future) physicians worldwide, bioethics can now be taught under the ﬂag of medical professionalism, and models such as CanMEDS provide the possibility of offering an integrated, ongoing ethics curriculum (Verkerk et al. 2007).

On Why Goals Are Needed

“Goals are tricky,” Clouser wrote in one of the ﬁrst texts on teaching bioethics. “One never knows how general or how speciﬁc to make them. Should they be ultimate (‘enrich life’), or proximate (‘instill a sense of the evolving of history and its inﬂuence on us’) or immediate (‘knows the names of the generals on both sides in the Civil War’)?” (Clouser 1980, p. 15). The literature on educational goals reﬂects this diversity in both types of goals and in degree of preciseness. Formulations of goals range from broad statements such as “a sound understanding of ethical principles and practice is now considered to be an essential outcome of undergraduate medical education” (Shotter et al. 2013, p. 664) to the highly speciﬁc 3-page list of aims that can be found in the updated Consensus Statement (Stirrat et al. 2010, pp. 57–59).

Let’s start with the question of preciseness. At ﬁrst sight, it makes sense to make a distinction between abstract ﬁnal goals and more precise, detailed, and concrete sub-goals, as they are being called here. One could argue that an undergraduate student should have “a sound understanding of ethical principles,” but that leaves the question of which principles should be learned open. Sub-goals give an answer to that question; they make it possible to determine what should be taught and when. One could decide, for example, that the overall goal of an educational bioethics program is to get acquainted with the most important medical ethical issues. The goal already indicates that the program will probably be focused on the transfer of knowledge: ethical issues, possible positions and viewpoints, underlying theories, and supporting justiﬁcations (the standard set-up of most bioethics textbooks). But if it comes to organizing the curriculum (what to teach when), sub-goals are needed: it could be decided to teach informed consent in year 1, medical research in year 2, and end-of-life decisions in year 3.

Somewhat surprisingly, the distinction between ﬁnal goals and sub-goals is not being made in the literature on bioethics education [although Stirrat and colleagues make a distinction between “aims” and “content” (Stirrat et al. 2010, p. 57)], and concepts such as “goals,” “aims,” “outcomes,” and “objectives” are commonly used interchangeable without much further explanation. This could be an indication of an unjust indifference towards educational theories; for example, in other ﬁelds of medical education, it is quite common to distinguish between outcomes and objectives (a distinction roughly comparable with our distinction of ﬁnal goals and sub-goals; see Harden 2002), and more complex taxonomies, such as Bloom’s, are frequently used to order and classify goals.

Thus, one important reason for deﬁning goals is that they help to set up and organize an ethics curriculum. But there are other important reasons to take the task of setting goals very seriously. First of all, when discussing goals, educators are not only thinking about what should be taught (and for what reason), but also thinking on what should not be taught (see the No-Goals section below). Discussing goals also helps to make a distinction between what should be taught in any case (e.g., “core curriculum,” “consensus statement”), and what is important but not essential.

Setting goals is helpful when it comes to evaluation, comparison, and justiﬁcation of a program. Goals (the “what”) lead to the selection of teaching methods (the “how”) and assessment. A set of carefully formulated goals makes it easier to explain to students what is going to happen and why, to compare one’s own curriculum with that of others, and gives third parties, such as accrediting organizations, insight into what is going to happen. In the context of evaluation, two of the most important questions one could ask is whether the formulated goals suit the learners’ needs, and whether the selected methods and assessment tools really match the selected goals.

Lastly, goals at least have to reﬂect ideas about what an ethical doctor or ethical practice should look like, and how to educate them – and as such they reﬂect not only a view on education but also on medicine, doctors, and their role or relations with society, and a view on a broad range of ethical–philosophical issues such as moral motivation, practical reason, the status of moral facts, moral justiﬁcation, and the role of emotions.

As is shown in the following section, goals developed by a teacher who is deep into Aristotelian virtue ethics (and will focus on character formation) will be quite different from those developed by a neo-Kantian, who will probably be more interested in the development of moral reasoning skills.

Goals: Virtues, Skills, And Mixed Goals

What should be the aim of bioethics education? Roughly three positions can be distinguished, the ﬁrst two being the view that education should aim for the acquisition of reasoning skills and theoretical knowledge, and the view that education should lead to virtuous doctors. The skills/knowledge position is often associated with “modern” ethical theories that focus on the right, such as Kantian or utilitarian theories. Broadly speaking, these theories focus on procedures and offer criteria to determine whether an action is morally right or wrong. They do not, however, offer a picture of the good: they say nothing about how the character of a morally good doctor could look. This is where the virtues position comes in. Virtue based theories (going back to the work of Plato and Aristotle) do not offer criteria for rational decision-making procedures, but concentrate on the question of how to build and maintain a morally sound character.

A virtues approach will thus go much “deeper” than a skills/knowledge approach, in the sense that according to the latter position, ethics is about doing good: the act is the main focal point of ethical consideration (Kantians would like to test the underlying rules and principles; utilitarianists will look at the consequences). A virtue approach would stress that education should not focus on the act, but on the development of the virtuous character of a physician: it is not about doing good, but about being good. A virtues approach will typically pay more attention to the formation of habits and emotions, and stress the importance of sensitiveness, self-reﬂection, and self-knowledge. This will have consequences for the formation of the goals of an educational program (Noddings 2012).

The virtues position and skills/knowledge position are often presented as being incompatible – this is the reason that Eckles and colleagues call this the virtue/skills dichotomy in bioethics education (Eckles et al. 2005). In practice, however, teachers often select a third position: a mixed, in-between set of ﬁnal goals, aiming at both knowledge/reasoning and character development. Maybe the virtue/skills dichotomy is not so absolute as often perceived or presented. This section discusses these three views.

Knowledge And Reasoning

According to the view of knowledge and reasoning, “in general, the goal of ethics education should be to provide a set of skills for ethical analysis and decision making … [t]o equip physicians with a knowledge base and a skill set to make ethical decisions in the course of patient care” (Eckles et al. 2005, pp. 1145–6). This view is quite widespread. UNESCO, for example, formulates the goals of its Bioethics Core Curriculum as follows: “Students should be able to identify ethical issues in medicine, health care and life sciences; Students should be able to provide rational justiﬁcation for ethical decisions; Students should be able to apply the ethical principles of the Universal Declaration on Bioethics and Human Rights” (UNESCO 2008, p. 7). Clouser sees an important role for the application of knowledge and reasoning skills when it comes to what he calls “ground preparation”: “the ability to deﬁne, explicate, classify, and distinguish elements and aspects of a ﬁeld so as to uncover the moral questions and the morally relevant factors” (Clouser 1980, pp. 56–57).

Ethical knowledge and reasoning skills are thus presented as value-free, and they are seen as tools that can be used when necessary. Hafferty and Franks therefore call this view “ethics-astechnique” (Hafferty and Franks 1994, p. 864). Improving the soundness of a person’s character is therefore not a goal in education, as (is being assumed) students enter medical school in a good moral condition, and no signiﬁcant changes will take place during medical training. Authors such as Hafferty and Franks take this position to be naive and potentially dangerous.

However, from an educational point of view, the knowledge/skill position can seem very attractive. Identifying the goal of ethics education is relatively easily, and the teaching and assessment methods can be relatively straightforward (lectures, literature study, written exams, etc.). Another advantage might be that this view on ethics education seems the most “exact,” the most “scientiﬁc” and “objective,” and thus ﬁts the attempts being made to “connect” with the positive science in order to become acceptable for students and physicians (Hafferty and Franks 1994; Cowley 2005).

Virtues

Despite these seeming advantages, various authors are critical about the idea that ethics education should only focus on acquiring skills and knowledge. The main idea is that merely having these “tools” does not automatically lead to employing these tools and knowing how to use them in practice. Clouser compares this kind of bioethics education with sexual education: theoretically knowing what to do doesn’t necessarily makes a person competent in practice (Clouser 1980). As a consequence, medical ethics education should not only aim at making doctors competent in ethical reasoning, but should be far more ambitious: character formation and the development of virtues is the ultimate goal of ethics education. Not pursuing this goal, but sticking to the skills/knowledge position, is potentially dangerous.

Hafferty and Franks present another argument for adopting the virtues approach. Basically, they argue that the virtue/skills dichotomy discussion completely misses the mark. They say that it is just not the case that medical students enter their training with a “sound moral character” as Miles and colleagues thought, that this character will remain unchanged, that the type and quality of this character is sufﬁcient to guarantee a morally sound application of the learned ethical techniques, and that medical training only changes or adds elements at the knowledge/skills level. Instead, as Hafferty and Franks argue (1994); see also (Stirrat et al. 2010 and Saunders 2010), medical training can be seen as a continuous process of character formation; all teaching, both formal and informal, is also moral teaching. Thus, when it comes to ethics education, the question is not whether it should be focused on knowledge and skills or on virtues. Moral character formation is everywhere – and is not only restricted to bioethics classes. The question should therefore be whether the hidden or informal curriculum (as these socialization processes are being called) leads to morally better physicians and, if not, how these processes can be “neutralized” by formal bioethics education.

So, if one is willing to adopt the virtues approach, what are these virtues that should be developed by ethics education? How can education help (future) doctors to develop, improve, and maintain these virtues? How should a moral education program (centered on the character formation of individual doctors) address important bioethical issues that are more on a social or political level (such as healthcare rationing)? Unfortunately, when it comes to answering these elementary questions, the literature largely keeps silent. Of course, there are lists of virtues [doctors should, for example, be(-come) altruistic, honest, caring, compassionate, self-critical, etc. (see Cruess and Cruess 2008; Frank 2005)]. But these lists always seem to be somewhat arbitrary and unsystematic, deﬁnitions of virtues are often lacking, and the literature is notoriously vague on how such virtues can be developed and how progress can be measured.

Virtues, Skills, And Theory

At least two strategies of crossing the virtue/skills dichotomy are possible. One could argue, for example, that virtue development necessarily includes the development of virtues and skills. One cannot act virtuously without having the right tools. Learning theory then becomes a sub-goal, necessary to achieve the higher goal of virtuous activity. Another strategy could be to argue that students, while working on their skills set, also develop something of a moral character.

In practice, authors often argue for a mixed goals set when it comes to bioethics education, containing knowledge, skills, and virtue elements (the latter being, for example, virtues themselves, but also Bibliography : to emotions, sensitivity, self-reﬂection, self-knowledge, etc.). Clouser, for example, mentions the following goals: ‘stimulating the moral imagination’, ‘recognizing ethical issues’, ‘developing analytical skills’, ‘eliciting a sense of moral obligation and personal responsibility’, and ‘tolerating and resisting disagreement and ambiguity’, (Clouser 1980, pp. 15–6; see also Elliott 2007, p. 39).

Goals: Why Striving For Consensus?

We have seen that the issue of setting goals is a very important element in designing a bioethics curriculum, that the discussion on goals has been going on for 50 years already, and that consensus on goals still doesn’t exist. This raises at least two questions: why is it so difﬁcult to reach consensus? And, why is reaching consensus deemed so important anyway?

To start with the latter question: it seems that there are at least two types of answers. First, lack of consensus is undesirable because it is seen as a sign of underdevelopment of bioethics teaching as a discipline. Consensus about the ﬁnal goals seems to be considered one of the signs that ethics education “has come of age” (Miles et al. 1989; see also Eckles et al. 2005). Thus, consensus documents, such as UNESCO’s Bioethics Core Curriculum or the Consensus Statement, are presented as being a step forward in the development of the ﬁeld of bioethics education. Secondly, there are more pragmatic reasons: joint research or exchanging materials becomes easier when everyone tries to reach the same goals.

However, it can be questioned whether reaching consensus is possible and, if so, whether this would be a good thing. One could argue, for example, that consensus on bioethics education is not very likely to be reached because the discussion is about bioethics education, and as the philosopher Nel Noddings notes, “the history of education reveals a continuing debate on the aims of education” (Noddings 2012, p. 205). In other words, a lack of consensus on goals within the ﬁeld of bioethics education is a sign that things are normal. An ongoing discussion on the fundamentals of a discipline could even be interpreted as a sign of vitality, commitment, and reﬂection – and not per se as a sign of underdevelopment.

When analyzing the literature on goals, two other types of causes seem to occur that make it difﬁcult to reach consensus. The ﬁrst has to do with the concept of bioethics itself: bioethics is a multidisciplinary ﬁeld, and thus the target audiences of bioethics education are diverse. A bioethics course for nurses has other goals (and teaching methods) than a course for clinical researchers. The daily practice and professional responsibilities of a clinical geneticist differ from that of medical engineers. If the target audience is so wide, developing adequate goals that apply to everyone is only possible when they are formulated in very general, and thus quite meaningless, terms. In this case, the actual consensus discussion will be transferred to the level of sub-goals.

The second type of causes is about underlying assumptions (or “position problems”). A major position problem was discussed above: should bioethics education focus on character or on skills/knowledge development? Another position problem is the question of whether bioethics education should be broad or deep. This is the question of how philosophically advanced a bioethics curriculum should be. Bioethics teaching becomes “deep” if there is a considerable focus on philosophical ethics in terms of ethical theory and meta-ethical issues. As is discussed below in the section on Tricky Goals, the broad/deep issue is controversial. On one hand, there is the position that doctors should not be turned into philosophers (Clouser 1980). On the other hand, some authors warn against an oversimpliﬁcation of the philosophical–ethical part of bioethics education (Cowley 2005).

No-Goals

What should not be taught? Miles and colleagues argue that “medical ethics should not, in our pluralistic society dictate a single moral viewpoint … In this view, medical ethics emphasizes process, not answers” (Miles et al. 1989, p. 707). Clouser seems to hold a similar position, and stresses that bioethics education cannot be a form of bioethics indoctrination. Bioethics education should not push for the adaption of “a particular position on a particular issue,” and it also should not present “a philosophy of life, replete with recommended values and ways of living” (Clouser 1980, p. 19). This may sound uncontroversial, but one could argue that the more virtue-oriented approaches of bioethics and medical professionalism teaching do just that: they have to picture what a virtuous physician looks like in terms of values, ideals, and attitude. And one cannot ignore the fact that there is a relationship between culture and bioethical positions. “Western” cultures, for example, often stress the rights of the individual, liberal conceptions of freedom, and the importance of autonomy – and this is reﬂected in professional laws, practice, bioethics education, and bioethics textbooks. In a way, all bioethics education is inevitably a form of socialization.

UNESCO’s position differs a bit from that of Clouser and Miles. UNESCO’s proposal for a core curriculum “does not impose a particular model or speciﬁc view of bioethics.” As such, it is “open” for diversity – thus staying away from possible accusations of (Western) cultural indoctrination. However, UNESCO also claims that the core curriculum “articulates ethical principles that are shared by scientiﬁc experts, policy-makers and health professionals from various countries with different cultural, historical and religious backgrounds” (UNESCO 2008, p. 3). UNESCO thus seems to base itself on what Beauchamp and Childress would call a normative “universal” or “common morality” (Beauchamp and Childress 2009, pp. 3–5). As such, UNESCO’s curriculum is not purely procedural, and, just as is the case with other consensus-based curricula, departs from the pragmatic idea that if experts have reached consensus on an issue, this consensus is the best base to depart from.

Let’s now turn to another no-goal: the idea that transmitting of ethical or philosophical knowledge is a goal in itself. The aim of ethics education should not be “turning the medical students into philosophers,” as Clouser writes: the aim should be to help students understanding professional problems from a philosophical perspective, and not to teach philosophy for the sake of it (Clouser 1980, p. 19). Clouser adds another argument: students should not be taught all of the ins and outs of central ethical issues, because this will kill their intellectual curiosity. Instead of telling them “all the details, pro and con on all the major moral issues,” teachers should have them “develop the knack of rigorously pursuing such issues on their own” (Clouser 1980, p. 19). From this perspective, the respected goal of knowledge transfer can be a dangerous one, because it could kill the curiosity of students – which could result in less ethically reﬂective doctors.

Tricky Goals

Besides no-goals (goals that should not be chosen), there are goals that should be handled with care: the tricky goals.

Many bioethics courses and bioethics text-books start with a discussion of moral theories: consequentialism, virtue ethics, deontology, and, often in the case of medical professionalism education, social contract theories. The premise here is that it is impossible to be(-come) an ethical doctor if you are not familiar with these theories. However, as time is limited, and medical students should not be transformed into philosophers, these theories are usually addressed quite brieﬂy. But here, as Saunders argues, lies the trickiness, because it could lead to “caricature and simpliﬁcation”, which can have a (Saunders 2010) negative impact on the student’s attitude towards ethics. So, ironically, pursuing the knowledge goal in this simpliﬁed way leads to just the kind of beliefs on ethics that bioethics teaching is expected to prevent.

The second type of tricky goals has to do with ethics teaching becoming “medicine’s magic bullet”, as Hafferty and Franks wrote: “Problems ranging from the breakdown of the physician-patient relationship to medicine’s loss of advocacy, the emergence of the patient-as-consumer, and the moral complexities of technological medicine have prompted calls for a greater emphasis on the formal teaching of ethics in medical schools” (Hafferty and Franks 1994, p. 861). More than a decade later, Cruess and colleagues defend the importance of educating medical professionalism by pointing towards the damaged social contract between medicine and society (Cruess et al. 2008). Other authors point to all kinds of misery on the level of individual healthcare professionals that have to be “repaired” by bioethics education, such as moral distress, “ethical erosion,” relativism, cynicism, and a-moralism. The irony (or naivety) is, of course, that the impact of formal bioethics education is probably being overrated, and that a “failure” of bioethics education could lead to moral erosion, and to a diminishing trust in bioethics education. Miles and colleagues therefore already recognized that medical ethics education is “not a solution to [these] problems,” and that they have to be addressed “through other reforms” (Miles et al. 1989, p. 707).

History shows that the call for more bioethics education is often a response to a moral crisis. However, quite often, this call comes not (or not only) from bioethicists, but from society or the medical profession itself. The third type of tricky goal is related to the second, although it is probably better characterized as a no-goal. While discussing the value of professional medical codes (another typical response to “ills in the practice of medicine”), Beauchamp and Childress wrote that “The articulation of professional norms in these circumstances has often appeared to protect the profession’s interests more than to offer a broad and impartial moral viewpoint or to address issues of importance to patients and society” (Beauchamp and Childress 2009, pp. 7–8). In this context it could sometimes be that the goal of bioethics education (or education of medical professionalism) is the protection of interests and positions – bioethics education is being misused, then – and that the ultimate goal of any educational activities is not primarily that of moral improvement of medical practice.

Conclusion

Within the ﬁeld of bioethics education, there is not even consensus on the question of whether there is consensus on educational goals (compare Miles et al. 1989 and Eckles et al. 2005). Nevertheless, the positions in the debate have crystallized during the last two decades: there is the virtues school, the knowledge/skills school, and a mixed school inbetween. Each school can be criticized, and each position can be developed further; in particular, the virtues approach hasn’t reached its fullest potential. The debate and the development seems to have stagnated, however, and could use input from neighboring disciplines, such as philosophy (when it comes to the development of the philosophical meta-ethical assumptions behind the three positions), educational theory (when it comes to the formulation of goals), moral psychology (when it comes to testing the empirical assumptions behind the virtues approach), and medical professionalism (when it comes to connecting and integrating with other areas of student and resident education). It may be that the conclusion should be, at this moment, that the discussion on the development of goals is, in reference to Clouser, not broad and not deep enough. It also might be the case that the pursuit of consensus (consensus being the end of a discussion) may even block further development of the ﬁeld in this respect.

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