By Stacey Kusterbeck
As the medical director for ethics at Houston’s Ben Taub Hospital, Holland Kaplan, MD, sees many new clinicians struggle with everyday ethics issues. “In my role as a teaching attending at Ben Taub, I work directly with residents and medical students and witness the moral distress they describe firsthand, surrounding issues like what constitutes a safe discharge or how to provide treatment to a patient who is refusing care,” reports Kaplan, an assistant professor of clinical ethics and general internal medicine at the Center for Medical Ethics and Health Policy at Baylor College of Medicine. At Ben Taub, the ethics service saw more than 120 consults last year on issues ranging from whether a patient has decision-making capacity to whether it is appropriate to not offer lifesaving therapy. One contributing factor for many of those consults is the inadequate ethics training received by medical students and residents, says Kaplan.
To provide more effective ethics training, some medical schools are testing and implementing new methods and approaches. “We wanted to develop ethics education that was resident-led, case-based, and could be integrated into an existing didactic structure. We wanted to provide residents with a structured analytical approach to managing ethical issues,” says Kaplan.
Kaplan and colleagues implemented an “ethics morning report” program. Every two weeks, internal medicine residents present ethically complex cases instead of the usual morning report. Residents learned to do ethical analysis on cases and to present those cases using a new format. The cases were presented using the four-box method, a widely used tool for ethical reasoning that evaluates cases based on four categories: medical indications, patient preferences, quality of life, and contextual features (such as confidentiality or resource allocation). Faculty revised the original four-box method, which often is used in clinical ethics consultation, to apply to internal medicine cases.
A faculty member or chief resident guided the residents in doing ethical analyses, preparing the case presentations, and using the four-box method. “It took some time to get buy-in from the residents to use this method. After several months of the case conferences, though, they started to get the hang of it. They found it helpful to have a structured approach,” says Kaplan.
Residents presented cases from their own practice that involved one or more ethical dilemmas. The ethics morning reports mirrored the format of the standard clinical morning reports that residents were accustomed to. The clinical morning reports begin with recognizing the clinical problem and then determining a treatment plan. Similarly, the ethics morning reports began with recognizing the ethical issue, then determining the optimal course of action. “The biggest benefit of the ethics case conferences is that residents are presenting cases that they themselves have experienced. It is much easier to demonstrate how ethics is relevant to the daily practice of clinical medicine when it is applied to a real patient case,” says Kaplan.
During the 2022-2023 academic year, 24 ethics morning reports were held. Residents presented on ethical issues involving futility, decision-making capacity, goals of care, and identifying the correct surrogate decision-maker. The residents selected ethically complex cases to present. Many selected cases revolved around what to do when there are no safe places available for a patient to discharge to. “This is not something that is traditionally taught in medical training,” says Kaplan. The researchers surveyed 75 internal medicine trainees about their experience with the ethics morning reports.1 Most (73%) agreed that the intervention helped them to achieve learning objectives for ethics education.
“Case conferences are a teaching approach that residents are familiar with and that most find engaging. The format can be easily integrated into the existing didactic structure of many training programs,” says Kaplan. The same case-based approach to ethics education also could be used in the hospital setting. “Whether ethicists are providing education to physicians, nurses, social workers, or other staff, using cases will make the ethical issues being discussed feel much more relevant,” says Kaplan.
Another group of researchers wanted to learn more about the current state of medical ethics education and interviewed ethics curriculum educators at 11 U.S. medical schools.2 Overall, ethics education varied widely in terms of course content, methods of instruction, and assessment. Contact hours ranged from six to 137.5 hours. “Little had changed since a decades-old study of medical school training in ethics,” observes John Encandela, PhD, one of the study authors, a professor of psychiatry and executive director for evaluation and assessment at the Center for Medical Education at Yale School of Medicine. That previous 2004 study showed wide variability across schools regarding what a medical ethics curriculum entailed and the level and type of institutional resources that were allocated to ethics education.3 The 2024 study mirrored those findings. “What was new since the earlier investigation was the extent to which medical ethics had been subsumed within larger topical areas, such as professionalism and broader humanistic concerns. These areas are undeniably important. But those we interviewed believed that medical ethics should have an equally prominent place within the school curricula,” says Encandela. Most schools integrated ethics into larger courses instead of teaching ethics independently. Respondents thought that medical ethics often had been integrated into, and thereby somewhat diluted, within more general topics.
Most medical schools used a “horizontal integration” approach, with ethics training concentrated in the preclinical phase (the first year and a half to two years of the curriculum). There were varying degrees of ethics integration in subsequent phases of the curriculum. As a result, ethics content typically is “frontloaded” in the earlier years of training and focuses largely on theoretical knowledge. “Ethics content gets often-limited attention and reinforcement in the later clinical years. Consequently, theoretical knowledge is often disconnected from clinical application,” says Encandela.
Only a few schools used comprehensive vertical integration, with ethics content included in all phases of medical school curriculum. Medical schools that have successfully vertically integrated ethics into the curriculum can provide guidance to other schools looking to do something similar, suggest the study authors. “There is an evident need for well-designed vertical integration across the curriculum phases,” according to Encandela.
Medical students often receive very limited education on ethical issues involving end of life. “Medical students and even new residents report feeling unprepared to work with dying patients, and wish they had more exposure during their training,” observes Ryan Jenkins, MD, a clinical assistant professor in the Department of Pediatrics at University of Michigan.
Discussions that elicit patients’ end-of-life goals are emotionally challenging for all involved. “Having these difficult conversations about patients’ goals and figuring out how your medical interventions can accomplish these goals even in the setting of anticipated death, is just as important a part of end-of-life care as the provision of medicines or interventions,” says Erin Gentry Lamb, PhD, associate professor of bioethics at Case Western Reserve University.
Students may have personal experiences with death and dying. “But because death and dying experiences and practices are so individualized and vary significantly across cultures, those personal experiences likely provide limited translation into the clinical realm,” observes Jenkins.
Jenkins and Lamb created a humanities intervention to teach end-of-life concepts to preclinical second-year medical students.4 Although key end-of-life ethical issues (such as advance directives or do-not-resuscitate orders) were not an explicit focus, ethical concepts were included in the materials and discussions. The course covered these end-of-life ethics issues:
- the need to think critically about autonomy (for example, how dying patients’ decisions often are strongly based on their loved ones’ needs or desires);
- questioning when and how death may be beneficent; and
- exploring the consequences of doctors’ failing to initiate end-of-life conversations.
All the students who took the course reported feeling more comfortable and more confident in working with dying patients. “That said, most humanities interventions in medical education have positive student self-reports,” acknowledges Jenkins. The researchers hoped to validate the self-reports with more robust measures of effectiveness (such as an end-of-life standardized patient experience and longitudinal measures of death anxiety). Students who completed the intervention showed mixed results in terms of its effectiveness. Students reported lower death anxiety during a standardized patient encounter but reported higher death anxiety when measured a month later.
“Students may be more comfortable with real-life performance as a result of having greater knowledge. On the other hand, students may be more aware of how diverse and challenging end-of-life experiences can be — and how much they still have to learn,” suggests Jenkins.
Stacey Kusterbeck is an award-winning contributing author for Relias. She has more than 20 years of medical journalism experience and greatly enjoys keeping on top of constant changes in the healthcare field.
References
1. Kaplan H, Kahl A, Lim J. Incorporating an analytical approach to ethical reasoning into an ethics case conference for residents. Med Sci Educ. 2024;34(6):1283-1288.
2. Chen HA, Silva-Rudberg J, Encandela J. A survey of medical ethics curricula at 11 US medical schools. Med Sci Educ. 2024;35(2):929-938.
3. Lehmann LS, Kasoff WS, Koch P, Federman DD. A survey of medical ethics education at U.S. and Canadian medical schools. Acad Med. 2004;79(7):682-689.
4. Jenkins R, Lamb EG. Learning end-of-life care: Outcome measures of a medical student humanities curriculum. Med Teach. 2025; Jun 13:1-8. doi: 10.1080/0142159X.2025.2515988. [Online ahead of print].
