Character Education in Medicine: to act ethically
How does one “be” ethical? How does one “have” good character? All that matters on the stage of life is behaviour. If this is correct, does one just act ethically, or to use poor English, “act ethical”? Is it real if it isn’t felt? If the behaviour is good, but the thoughts and the feelings aren’t there, is it fake? Dishonest? Untrue? Unethical in itself?
The thoughts and feelings of the actors, while individually important and can lead to behaviour, are in themselves of no consequence to the audience viewing the play. Mother Teresa, for prolonged periods in her life (Van Bieman, 2007), felt the absence of Jesus. Despite this, she continued to care for the world’s most desperate. She acted appropriately, heroically, piously, despite feeling this vacancy. Do her behaviours when she was spiritually lost mean less?
Behaviour can change feelings, which can then lead to changes in cognition. This is rarely pushed nowadays: CBT is truly “big C, little b, therapy”. Cognitive therapists (Padesky, 1995) most traditionally work from the thought / belief down the line, hoping to change feelings, then watch the behaviour blossom. This is satisfying to be sure, and cleaner, and perhaps more fitting with us culturally. It seems right. It’s more solidly transferable from situation to situation. We have, however, proven that changes in behaviour can and do lead to emotional change, which lead to cognitive realignment.
So, for the first point, behaviour must be changed. What we really want, let’s be clear, is a safe, productive learning environment, a student that learns the material and graduates, the graduate who is a productive member of our society, a safe colleague that can truly help people. Behaviour is really the only measurable outcome. Attendance and test scores are easily measured. There are fuzzier aspects that are a bit more difficult to gauge, but we do it all the time: ability to work in a team, interpersonal skills, clinical effectiveness. The quickest way to get a behaviour change is to demand it, to demonstrate and enforce proper behaviour. While we have a play that is acceptable occurring on stage, we can work on what’s going on inside the performers’ heads.
I feel that character, and ethics, are best taught “between the lines”. Ethics and morals class is important, but cannot affect a student as much as a situation where every single module in every single class is ethics based. Lickona (1991) proposes an entire school curriculum based on ethics. Character can be taught as easily during anatomy class as during an ethics class. A relentless presentation of ethically based material cannot but surely chip away at those cognitive mountains, to shape shovelful by shovelful that landscape. But more than content, the students must see and feel action themselves. They have to witness the ethical, moral behaviour. The teacher, on whom society has bestowed the dominant power role in the classroom and on the ward, must be of impeccable character. Her every movement, interaction, and reaction, should teach the essential values. Role modelling happens every minute of the day.
Lickona (1991) has clearly shown that formally placing character education in the elementary and high school curriculum has made a profound impact on schools and students. Violence rates have dropped, and grades have improved in traditional academic subjects. Perhaps we can engender the growth of more socially aware, caring people, starting with younger children. Our world could be a nicer place for all of us. Clearly teaching values and clarifying moral issues is paramount and deserve a formal place during the teaching day, and an actual formal place in the pre-university curriculum. But is our job all done by the time students reach medical school? Need we look at character, morality, values, ethics training? Are their cups full? Catch ’em while they’re young, or it’s too late?
To most effectively change behaviour, it is important to access the affective domain. Affect comes before action, and after cognition. It often appears to be the emotional sphere that drives cognitive learning in medicine. What is more motivating than that person in pain, reaching out for help? It also drives character development, in much the same way. We as teachers need to access the affective part of the process as best we can. It is best to work “from both ends”. Changing cognitions affects AFFECT. We must remember, however, that you can also work backwards, as changing behaviour also invokes this change, and perhaps quicker. So I propose the teacher plays dirty! Yes, it’s more philosophically sound to change cognitions to change affect, and therefore create ethical behaviour. But slower.
Lickona has been a paradigm changing force in the public school system. Some of Lickona’s (1991) principles/ strategies that have rung true to me, and that could be very useful in the medical school setting include: a) demanding and expecting excellence b) building fellowship / membership in the class c) discuss ethical / moral situations, the teacher using the Socratic “why” method to advance moral development d) role playing to reframe issues e) teaching to solve conflicts.
An example of exploring character, and integrity in a clinical situation:
Years ago a young associate physician (not actually my “student”, but a staff physician) on encountering a situation of child abuse was determined to fire the accused perpetrator from his practice. All the above “points” were used: although the physician had the right to terminate the relationship, he was requested to delay and consider. (ie, Here behaviour was changed prior to a change of heart, or mind). The ethical and moral situation was thrashed out, largely using the “why” method, and sharing. Modeling was demonstrated throughout.
Through looking at medical care in other settings, for example care afforded offenders in jail, and “what if”, and “why” questions, the practitioner came to realize that the accused non prosecuted non sentenced offender did himself merit good medical care. The physician came to realize that he was labeling, pre-judging, and sentencing this man, the punishment being withdrawal of health care. The use of these strategies led to an acceptable outcome. This merely accused person had originally been “convicted” in the practitioner’s eyes, and heart. After deep reflection and moral struggling, the physician realized that he had made errors in both perception and feeling. When challenged, he realized that even if convicted, this fellow still deserved compassionate health care. Tears were involved, and the physician remained frightened. This is the benefit of a group practice: the physician can put feet on the ground, and walk, knowing there’s a safety net (other staff physicians, and capable support staff, down the hall).
Sharing here allowed improvement in interviewing techniques, and perspective sharing. The major impact of this strangely, was a time saving. We got to the same place, but faster, and in a more emotionally satisfying, more complete and solid manner. Further, there is some question whether or not the discontinuation of the above relationship would be at all acceptable ethically, or even legally. A great deal of grief from all perspectives was saved, due to these strategies. The clear review we made of ethical criteria that applied to this moral issue helped him sort things out and come to a solid decision in a clinical situation.
Lickona, T. (1991) Educating for Character: How our schools can teach respect and responsibility. New York: Bantam
Van Bieman, D. (2007, Ap 23). Mother Teresa’s Crisis of Faith. Time. Retrieved Nov. 12, 2012 from http://www.time.com