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Department of Medical Humanities
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NEWSLETTER
 
medical humanities newsletter
The Bioethics Center, University Health Systems of Eastern Carolina
Department of Medical Humanities, The Brody School of Medicine at East Carolina University
 
 
 
Values and Virtues in Medicine: How Should They Be Taught?
Loretta M. Kopelman, Ph.D.

Different expectations about the goals for humanities courses in medical and other professional schools may stem, in part, from the sometimes vague connotations associated with the words “humanities,” “humanitarian,” “humanism,” and “humane.” While these words have a variety of meanings, they indicate the importance of responding to human needs or recognizing human accomplishments. According to ancient and modern codes and covenants, good doctors should show fidelity to their patients, maintain their confidences, try to relieve suffering, and promote people’s well being. Humanities programs in medical and other professional schools were sometimes initiated with the hope that they would help instill these qualities. Many humanities teachers, however, draw a line between teaching humanities courses and trying to make students more humane or virtuous.

Humanities subjects can be traced back without interruption to medieval courses given in the religiously dominated cathedral schools and universities. These courses presupposed that human needs and accomplishments from many different cultures, religions, and ages were worthy of serious study. These medieval humanities courses were not necessarily incompatible with the religious domination of these schools and universities. Between the Renaissance and the present day, however, teachers of humanities subjects became less dependent upon religious institutions, and rebelled against accepting religious dogmas or articles of faith as a part of their studies or teachings. This rebellion forms part of the heritage of humanities teachers (and scientists) who sometimes become prickly at suggestions that they teach students to be better people with the “right” set of values. For many humanities teachers, the assumption that teachers should make students better people with the “right” character seems to be a throwback to times when schools and universities were dominated by religious groups with circumscribed views on what values and virtues were to be tolerated. It was a time when someone might be denied advancements or appointments for failing to have the “right” views. As late as the eighteenth century, for example, one of history’s most influential and important philosophers, David Hume, never obtained an academic appointment because he refused to say he believed in the existence of God.

In contrast, since ancient times, professional associations have tried to ensure that members will behave according to certain “professed” values and virtues, often expressed by a morally binding professional oath. Such promises serve to assure those seeking care that professionals are not only competent but also trustworthy. Physicians, for example, should be worthy of trust not only for their scientific judgments and skills, but also as advisors and advocates for patients.

Medical students therefore must at least learn what professional behavior is expected of them and, at best, internalize the values and virtues of a humane physician. They should learn, stualong with knowledge and skills, the relevant professional duties, goals, virtues, and values. These include fidelity, honoring confidences, relieving suffering, and promoting well-being and respect. Pellegrino and Thomasma [1] and Gert, Culver, and Clouser [2] have traced the links between public morality and medical ethics arguing the ideals, duties, goals, or values reflected in medical ethics are similar to those in ethics generally. Thus, students who internalize the values and virtues of the humane physician become better or more humane people.

In what follows, I will discuss different, possibly incompatible, expectations about humanities disciplines such as philosophy, literature, and history. In the first section, I consider the view that humanities instruction should have epistemological goals, and should not directly set out to make students better people. After considering criticisms of this view, I turn to other approaches.

Epistemological Teaching Goals

John Dewey wrote in 1929, “...the aim of education is to enable individuals to continue their education—[and] the object and reward of learning is the continued capacity for growth [3]. Teachers should, he argued, focus upon having students develop skills and habits of mind that will enhance their creativity and problem-solving abilities with respect to issues they are likely to meet [3, 4]. Teachers cannot anticipate all future problems that students will encounter. Consequently, instructors should not just give them ready-made answers, but prepare students to identify the problems they are likely to encounter and to gain the skills and dispositions to solve those problems. Through a free exchange of ideas, students can learn the value of creatively rethinking issues, methods, and solutions. They will need this originality in addressing some of the problems looming ahead for them. For example, creative approaches are needed to solve the conflicts about protecting patients’ confidentiality that arise in controlling the AIDS pandemic, and in using the information emerging from the Human Genome Project.

Humanities courses can and should help teach students to anticipate moral and social issues they are likely to meet and help them structure solutions to these problems. All medical students, for example, will almost certainly experience conflicts over their duties to maintain a patient’s confidence and to prevent domestic violence. A good humanities teacher makes students aware of such conflicts, how to articulate the values and other issues at stake, and the methods to solve such problems. Teachers should try to give students the critical skills to recognize such problems and methods to evaluate critically within a free and open exchange of ideas.

Several techniques advocated by Dewey to help make students develop their potential and become better problem- solvers have been adopted and are now standard for teaching bioethics and humanities in medical and other professional schools [5, 6]. First, small interactive groups are preferable to lectures. In small groups, students can be challenged to give reasons for their views, and can explore issues more carefully. Second, systematic in-depth exploration of a few issues that are important to the students is better than superficial knowledge in many areas. This technique complements the first because it helps instructors track students’ views and ask challenging follow-up questions. Students should learn how to probe deeply. Third, discussion should be focused primarily on issues relevant to the problems that students will encounter in their professional lives. Topics and readings should be tailored to general curricular goals and to the problems that students are likely to encounter in their professional lives. Some important ways to do this include drawing upon students’ experiences and using readings from appropriate professional journals. The focus should be on what is useful to solve genuine and anticipated problems [7, 8]. Ideally, students should have opportunities to reflect about what they learn. Unfortunately, some do not get this chance. As Ethan Canin wrote about his own medical training, “learning medicine was like trying to drink water from a fire hose [9].”

Good Problem-Solving to What End?

There is a logical difficulty, however, when advocates of this view claim to avoid values and adopt only “neutral” or “objective” epistemological goals. No one can make students better at identifying and solving problems without clarifying better in what way, and this involves values. Suppose a doctor, frustrated by his patients’ long stories, moves his office near the waiting room and leaves his door open. As he hoped, this silences most of his patients. He found a “good” solution, given his personal goal of thwarting patients’ long narratives; however, it is a bad solution professionally since he is ignoring important aspects of the doctor-patient relationship. If good problem solvers are not good people, they can do great harm. Teachers are, of course, aware of this. For example, in the Hippocratic Oath pledging, doctors promise to use their knowledge of poisons not to harm people.

It is disingenuous, then, to pretend that most teachers have only epistemologic goals and do not care how students use their knowledge. One common response is that teachers should, nonetheless, be neutral, but can still be unbiased while hoping that most students will want to do what is right. The instructor should offer an objective clarification of the issues, options, arguments, and their consequences, but, in this view, teachers should not try to make students more moral. In Loretta M. Kopelman, Ph.D. the following passage, K. Danner Clouser [7] defends this approach:

    "Some try to saddle him [the ethicist] with the task of inspiring others to be moral, as though it were his job either to motivate people to be moral or to invent a theory of ethics contrived somehow to stimulate people to be moral. This effort, of course, is a perversion. He is more an analyst than a preacher, more a diagnostician than a therapist, more a scholar than an essayist. The ethicist can only assume that you want to do the moral thing, but that you are just not sure in a complicated situation what that would be. It is not his job to make you want to be moral."

According to this view, the role of the ethicist is to remain neutral as students sort through complex issues, clarify ideas, evaluate arguments, and gain knowledge and skills to solve problems. Unfortunately, this response fails because there is no way for teachers of humanities, science, or any other subject to be as neutral or objective as this solution suggests. Instructors cannot analyze, justify, explain, criticize, or teach from an entirely neutral or value-free stance.

On the Alleged Neutrality of Teachers

Values are things having importance, worth, significance, utility, or merit to us in some way, and value judgments necessarily guide curriculum choices in all subjects about topics, readings, methods, and skills. Medical students no longer learn about the long-discarded humor theory of disease or how to prepare cups to draw out bad humors. Some skills and tests have become so specialized that they are not considered valuable to teach routinely to all medical students. Learning how to use the microscope, once the very symbol of medical school education, may soon be dropped entirely from the required curriculum. Instead of pretending that teachers avoid using values, instructors should try to identify and justify them. Their values influence every aspect of the curriculum including what theories, issues, readings, and skills are presented, thereby shaping students’ beliefs, views, and values.

Consider the impact of teachers in picking cases for discussion, for example. Defenders of paternalism in medicine, in their desire to promote the duties of beneficence, may focus on cases where professionals need to intervene on behalf of incompetent or impaired people in order to protect them from themselves or from irresponsible surrogates. Opponents of paternalism, in contrast, may focus only on cases where competent people are being manipulated or coerced by others. One group of medical students objected that an infectious-disease instructor nurtured prejudicial attitudes among future physicians because all his cases and slides about sexually transmitted diseases were of African-American people.

The order in which cases are presented may also powerfully influence (and reflect) belief. Scientists know that generalizations based only upon case reviews should garner suspicion because our unintended biases affect how we describe situations, collect data, interpret results, and apply the resulting information. The same problem can arise in selecting humanities cases for discussion. A sympathetic case history about a needy patient with AIDS can build empathy for all patients with this disease, while an unsympathetic story about someone with AIDS can erode support for them as a group. A vivid atypical case may be more influential than the aggregate data in influencing people’s thoughts and judgments. This shows the power of selection, use, and comparison of cases.

Therefore, it is a dangerous myth to suppose that there is a value-free way to select and use cases. The same point could be made with respect to the selection of theories, skills, readings, topics, or methods in teaching humanities, sciences, medicine or anything else. In the end, students need to learn how to be humane clinicians from their faculty. As physician-author Perri Klass writes, “Well, you can absolutely memorize your textbooks, you can earn a perfect score on every multiple-choice test, but none of that leaves you equipped to take care of patients. Clinical medicine has to be learned as an apprenticeship [10].” If teachers do not identify and justify their values, unwarranted biases are more likely to infect their choices and those of their students.

The quest for a free exchange of ideas, moreover, contains value assumptions having moral and political implications. Some cultures do not want such an exchange of ideas, preferring to impose a particular set of religious, political, social or cultural norms. Those of us in favor of a free exchange of ideas and the epistemologic goals in teaching, such as those advocated by John Dewey, not only should concede that some values are necessary but also should identify and justify them. Some of these values include the importance of a free exchange of ideas, the benefit of making students better problem solvers, and the value of teaching certain topics, methods, readings, or skills.

Whose Values Should Be Used?

I have argued that humanities teachers cannot refuse to help teach values and virtues on the grounds that their teaching must be neutral, objective, or value-free. No teaching is value-free. What approaches are useful? Some teachers try to inspire students through religious values and virtues. In our multicultural society, however, a particular religious doctrine is unlikely to be very successful with all students or faculty, and may even be illegal in some state institutions. Similarly, a fully formed and articulated moral theory may meet opposition from faculty and students who favor different ranking of important values.

Approaches that inspire and motivate some seem futile or counterproductive to others. If teachers and members of a profession can agree upon a unifying but minimal set of acceptable behavior, values, and virtues, then I believe schools should encourage diverse pedagogic approaches within certain limits. The key concepts, doctrines, and rules of professional ethics have remained remarkably stable over time. In this century, however, they have been changed to include respect for patients’ autonomous and competent decisions [11]. Presumably, everyone agrees that people should not lie, cheat, steal, or be disrespectful to patients. Simply adopting a minimal standard, however, generally only informs students of what they ought not to be or do, which they probably already know. It fails to tell them what they ought to aspire to be or do. Encouraging a diversity of approaches within limits, however, may solve this problem.

For example, while I was meeting with a small group of third year medical students on their pediatric rotation, one student made a racist “joke.” I initiated what I hoped was a calm discussion of the difference between generalizations, bias, and prejudice. We discussed the basis for and dangers of racial generalizations and stereotyping, how each of us would want to be treated, and some of the current data on the gender, racial, and ethnic bias in assigning costly treatments [12]. Another student made a similar “joke” to his resident, who bellowed that the student’s remarks were entirely unacceptable, especially in a professional setting. Arguably, the resident was more successful at immediately altering behavior. My goal, however, was to address one student’s attitudes while teaching the other students in the class about some ways to respond to prejudice. Faculty also alter students’ prejudices towards patients by having them get to know their patients as fully situated individuals with unique talents, responsibilities, needs, and desires. Perhaps the most powerful way that students are taught professional values and virtues is by example. Clinicians’ actions teach students what their profession expects of them. Showing little tolerance for prejudicial remarks and “jokes,” expressing concern for students, patients, and families, taking the time to get meaningful informed consent, keeping up with the literature, and demonstrating respect and empathy will shape what students become and do.

If education is never value-neutral and if diversity within limits is useful, then the tension between those wishing to teach values and virtues directly and those who do not, may be more apparent than real. Our diversity can be our strength, as Dewey maintained. Different approaches can be useful because they allow faculty and students to explore options and learn from each other’s successes and failures. Some faculty may successfully incorporate into an elective curricula inspirational, motivational, religious, or spiritual approaches in the nonrequired curriculum in trying to make students more humane or humanitarian. Others find this mode of instilling values and virtues very problematic. This debate in medical education is part of a larger and continuing dialogue about the nature and purposes of education, and the effective means to accomplish chosen goals.

(Note: This essay was originally published in Academic Medicine 12, 14 (1999): 1307-1310. We thank the editors for allowing us to reprint the article.)

REFERENCES

1. Pellegrino, E.D. and Thomasma, D.C. The Virtues in Medical Practice, New York: Oxford University Press, 1993.

2. Gert, B., Culver, C.M., and Clouser, K.D. Bioethics: A Return to Fundamentals, New York: Oxford University Press, 1997.

3. Dewey, J. Democracy and Education, New York: The Macmillan Co., 1916.

4. Dewey, J. The Quest for Certainty, New York: G.P. Putnam’s Sons, 1929.

5. Kopelman, L.M. Philosophy and Medical Education. Acad. Med. 70, no. 9 (1995): 795-805.

6. Clouser, K.D. Philosophy in Medicine: The Clinical Management of a Mixed Marriage. The Society for Health and Human Values 1972, reprinted in 1975, the Council of the Society for Health and Human Values.

7. Clouser, K.D. Medical Ethics: Some Uses, Abuses and Limitations. NEJM 293 (1973): 384-388.

8. Culver, C., Clouser, K.D., Gert, B., Brody, H., Fletcher, J., Jonsen, A., Kopelman, L.M., Lynn, J., Seigler, M., and Wikler, D. Response to Letters to the Editor on Basic Curriculum Goals in Medical Ethics, NEJM 313 (August 15, 1985), 456-457.

9. Canin E. The Carnival Dog, the Buyer of Diamonds. In: The Emperor of the Air. Boston, MA: Houghton-Mifflin, 1988.

10. Klass P. A Not Entirely Benign Procedure. New York: Signet/Penguin, 1987.

11. American Medical Association, Principles of Medical Ethics, Council on Ethics and Judicial Affairs, Code of Medical Ethics: Current Opinions with Annotations, 1998-1999 edition, Chicago, 1998.

12. Kopelman, L.M., Lannin, D.R., Kopelman, A.E., Preventing and Managing Unwarranted Biases Against Patients, Surgical Ethics, Laurence B. McCullough, James W. Jones, and Baruch A. Brody (eds), Oxford University Press, 1998, pp. 242-254.