By Stacey Kusterbeck
Many medical schools offer electives or pathways that allow medical students to develop knowledge and skills in bioethics. “These are largely designed to create ethically competent clinicians, perhaps those that can provide ethical leadership within an institution. But I am actually not aware of many MD programs that are aiming to train future clinical ethicists,” says Janet Malek, PhD, an associate professor at Baylor College of Medicine’s Center for Medical Ethics and Health Policy.
In Malek’s experience, medical students often state that they hope to participate on ethics committees and contribute to ethical policy-making as part of their careers. “They may serve in a volunteer capacity on a clinical ethics consultation service. But few will end up having part of their salary covered by this kind of work,” says Malek.
Students in Baylor College of Medicine’s ethics pathway say that they are very interested in the ethical issues that can arise in practice. “They want to continue to engage with these questions when they are out in the ‘real’ world,” says Malek.
If students have made the investment to go through medical school and residency, they generally want to practice medicine rather than go into clinical ethics. “It is expensive to buy out their time for clinical ethics work,” says Malek. “Professional clinical ethicists often have degrees in philosophy, law, or theology rather than medicine, and, so, see ethics as the focus of their career pathway instead of a side project.”
Given the overload of material medical students are expected to cover, it is challenging to make room in the curriculum for education on clinical ethics consultation. “These sessions are often held during lunches or in the evenings,” says Malek. “Some institutions have elective rotations that allow students to dig more deeply into these areas, but I suspect these are in the minority.”
Some medical schools are making changes to help students and trainees gain ethics expertise. “In order to prepare the next generation of physician ethicists, it makes sense to establish a pipeline,” says Paul J. Hutchison, MD, MA, HEC-C, associate professor of medicine and bioethics and director of clinical ethics at Loyola University Medical Center.
As a medical student, Hutchison had a strong interest in ethics but felt he needed more in-depth instruction. Hutchison took a year away from medical school between his second and third years to earn his master’s degree in philosophy. “Some schools are offering better paths to getting degrees in ethics, such as allowing students to work toward a degree in medical ethics while simultaneously getting their MD. That’s a step in the right direction,” says Hutchison. Medical and graduate school curricula have become more asynchronous and virtual, allowing students to do more on their own schedule. This makes a dual-degree program more feasible.
“After medical school graduation or completion of residency, young physicians are finally making money. To step back and make less money, or pay tuition to attend classes, is an unrealistic expectation,” says Hutchison.
Some residency programs allow trainees to select a specialty track, such as quality improvement, research, or ethics. This permits trainees to gain relevant experience with “on-the-job training” rather than taking time away from the traditional pathway to pursue these interests. “Individuals pursuing a career in medicine are absolutely slammed in every moment of their lives for seven years at least. Students have to give up what little time they have to do something extra,” explains Hutchison.
Finding ways to integrate supplemental training in bioethics, in parallel to their education and training, should be the focus of schools and training programs, in Hutchison’s view.
At Loyola University Chicago’s Stritch School of Medicine, in residents’ second year, they can choose an elective track in clinical ethics. “We have reflection sessions over lunch each month to focus on topics that they experience as new physicians. We target situations that are high-yield,” says Hutchison. Some recent topics include:
• virtue ethics and the basic principles of biomedical ethics;
• family requests for potentially inappropriate treatment;
• nuances in the diagnosis of death by neurologic criteria.
“Residents act as a sounding board for each other. They have a group of ethics champions that they can call upon. We want to make sure that they have exposure to the experts at their own institution. We are trying to establish a savvy group of clinical ethicist residents for our program,” says Hutchison.
For participants, earning a distinction in clinical ethics could put them at a competitive advantage. “Future employers know they can serve as an ethics resource at the institution,” says Hutchison. The program has been successful. Hutchison also is seeing an increase in demand for ethics expertise among medical students. More medical students and residents are asking for an ethics-related research project. Allowing the students and trainees to work together on empirical ethics research creates a culture of ethics awareness at the institution. This carries over into patient care rounds in the hospital.
“We want to help more individuals to head down that pathway,” says Hutchison. “Hopefully, their practice patterns will reflect the lessons that they learn along the way.”
In Hutchison’s experience, “There is only so much you can do to teach a medical student ethics.” Faculty can teach general theories of medical ethics, but students do not yet have the experience to apply it. Faculty can talk about ethical dilemmas, but until students actually have to make decisions in clinical practice, it is hard to apply the concepts. “Ethics education during residency training is incredibly formative and should be available to motivated physicians,” argues Hutchison.
At Vanderbilt Medical School, faculty made a point of embedding ethics training in clinical clerkships.1 The goal is to closely align ethical competencies with the other key skills students are learning on a rotation. “With this approach, ethics education is part of clinical learning,” says Alexander Langerman, MD, SM, FACS, director of the Surgical Ethics Program at Vanderbilt University Medical Center and course director of the Foundations of Clinical Care Ethics Curriculum at the Vanderbilt Medical School.
For example, on the combined neurology/psychiatry clerkship, the ethics session focuses on capacity assessment. “This draws from students’ understanding of the diseases they encounter in the wards, and ethical concepts such as autonomy and substituted judgment,” explains Langerman. Likewise, during the medicine clerkship, the session focuses on end-of-life decision-making.
“With so much focus on science and physiology — appropriately so — medical students don’t often think of ‘ethics’ as a research track,” says Langerman. “During the ethics training session, we discuss not just the ethical issues, but the research that informs our understanding of how to manage and address these ethical issues.” For instance, on the surgery clerkship, a big topic among students is the role of trainees in the operating room. Students want to know how this should be discussed with patients. “Here, we draw from empirical ethics research on patient preferences and studies on surgeon-patient communication,” says Langerman. Faculty also promote potential ethics-related projects at the medical school research fairs and via other listings of research opportunities on campus.
Additionally, the Center for Biomedical Ethics and Society at Vanderbilt offers a certificate program in biomedical ethics. Students complete advanced coursework, rotate on the ethics consultation service, and conduct a longitudinal research project. “We’ve had tremendous success in these research projects, with certificate students making substantial contributions published in high-impact journals such as JAMA Internal Medicine and the New England Journal of Medicine,” reports Langerman.
- Langerman A, Cutrer WB, Yakes EA, Meador KG. Embedding ethics education in clinical clerkships by identifying clinical ethics competencies: The Vanderbilt experience. HEC Forum 2020;32:163-174.
