Bioethics education now takes place outside universities as well as within them. How should clinicians, ethics committee members, and policymakers be taught the ethics they need, and how may their progress best be evaluated?
Socrates, perhaps the West's first "applied ethicist," consistently pressed the question, Can virtue be taught? The Hastings Center has been much concerned with similar questions: What can education in bioethics realistically hope to achieve--improvement in practice and character, or merely in people's ability to talk about practice and character? How might bioethics education best be conducted--by didactic courses run by academics traditionally concerned with ethics, by mentoring and example provided by experienced practitioners, by some combination of both, or by some new structures altogether? What's the best way to assess how well various attempts at bioethics education are working--by having students write papers or by giving them "moral development" tests?
A good deal of work on these questions appeared in the early 1980s, but the constituency for bioethics education has grown so remarkably in the ensuing decade that the theme needs to be revisited. In the 1980s people with an interest in bioethics were primarily affiliated with academic institutions. While academics are still at the core of the study of bioethics, the field has become a rapidly "expanding circle," now including practicing health care professionals who have not had bioethics in their professional training, members of ethics committees who might or might not be professionals, and policy makers and interested citizens as well. Bioethics' expanding circle now embraces people who take part in an occasional lecture or discussion as well as scholars involved in graduate education and advanced research; bioethics training goes on in hospitals, nursing homes, and community centers, as well as universities. This outreach to new participants and expanded settings parallels a movement throughout the United States promoting lifelong learning. But the spirited interdisciplinary dialogue among widely varied people is so particularly characteristic of bioethics that it imparts a special feeling of excitement and nourishes continued curiosity.
A Core Curriculum
A natural starting point for research into the pedagogy of bioethics is to identify the areas of the field with which every serious student should be acquainted. Six such key areas are:
1. The History of Medical Ethics and Bioethics. From Greek medicine to contemporary health care, medical ethics draws on a rich heritage. Tracing the history of the practice of medicine, the development of codes of ethics, and the progression of ideas regarding such issues as reproduction and death and dying is necessary for an understanding of the field.
2. Theoretical Foundations and Methods of Analysis. Religious traditions and philosophical theories have significantly influenced bioethics. An appreciation of the nuances of moral argument as well as an understanding of standard moral theories and newer approaches such as communicative ethics, narrative ethics, and feminist ethics remain essential elements of understanding the field and taking part in its ongoing conversation. Students of bioethics should be acquainted with these resources, both against the backdrop of the concerns that originally prompted them and as tools that can be used to illuminate cases or policies.
3. Comparative Analyses and Scope of the Issues Encompassed by the Term 'Bioethics.' One problem in this field is first to distinguish and then to relate the perspectives provided by such areas as law, public policy, and religion, tracing both their differences and what they have in common. Abortion provides a handy illustration. If the approach to the issue is through analysis of Roe v. Wade, Webster, or Casey, one is attending to how the issue is configured in terms of the discourse and values of the law; if the focus is on how various resolutions of the issue might be implemented practically, a public policy perspective is employed. If papal or denominational authority is invoked or explored, religious and theological conceptions are being turned to for their particular kind of illumination. An understanding of bioethics requires knowledge of all these perspectives, as well as an ability to understand the system in which these perspectives come together, revealing the complexity of the problems and of their possible solutions.
Developing a good sense of the scope of bioethics also requires the ability to identify the field's special topics, which range from the beginning to the end of life--and beyond. Recently, large-scale topics such as environmental ethics, the human genome project, and international health care issues have become the concern of bioethics. But finer grained, "day-to-day" issues are still central--for example, should a nursing home patient undergo "chemical restraints," or should a medical student call herself "doctor" before receiving her degree?
4. Moral Issues of Professionalism. Dilemmas regarding the moral duties of those in specialized fields have often been studied rather abstractly, through the discussion of general ethical principles or philosophical theories. Today, as ethical issues facing health care professionals become more complex, many academic institutions are offering courses exclusively on the special context of the professional-patient relationship. Bioethics programs seeking to offer solid education should address professional issues directly. A particularly pressing current example is the question of how health professionals should deal with current health care policies that may conflict with personal perceptions of what professional duties entail.
5. The Cultural Contexts of Bioethics. It is crucial to understand the contexts in which bioethical issues arise, both to solve problems and to understand the system in which such problems occur. For example, in recent years statutes and regulations have come into conflict with the religious and social notion that parents should be able to make decisions regarding their children. The much-publicized case of the twelve-year-old boy who sought to "divorce" his parents provides a particularly striking instance of this trend. Resolving such issues involves mediating legal, social, and religious concerns and understanding the contexts in which they arise.
6. Resources in the Field. Students in any discipline need to know where to locate and retrieve information. Because bioethics is an interdisciplinary field, this is sometimes particularly challenging. Being acquainted with leading books and journals both in bioethics and in related fields, as well as with on-line computer services, is a vital part of securing access to the important resources in this active field.
These six areas and their interrelationships are important to everyone who wants to know something about bioethics. It seems reasonable to suggest that the ethics committee member and the policy maker should have, at the least, a beginning understanding of these six areas, while an ethics consultant or advanced student would be expected to have a more thorough and sophisticated grasp of each of them.
Translating Theory into Action
The overall goal of students of bioethics, whether lay or professional, should be to acquire the ability to apply what they have learned when making actual as well as theoretical decisions. This is easier said than done. A vivid example of the difficulty of combining action with theory was reported by one bioethicist who had consulted with a hospital ethics committee that had dutifully undergone over a year of work on ethics education. Despite this considerable investment of effort and time, they were unable to take action on the first case a physician referred to them. Clearly, in light of the practical focus of bioethics, it is not enough to teach participants in the health care system to talk about ethics; it is necessary to teach them to apply and understand the relationship of theory, morality, and practical consequences.
The objectives stated in the 1980 reports on the teaching of ethics continue to be useful to anyone trying to apply theory to practice. Those objectives are: (1) to stimulate the moral imagination, (2) to recognize ethical issues, (3) to develop analytical skills, (4) to elicit a sense of moral obligation and personal responsibility, and (5) to tolerate and resist disagreement and ambiguity.
To reach these goals, bioethics courses need to pay attention to both content and process. 'Content' refers to the facts we learn, 'process' to the manner in which we apply what we have learned. Taking seriously the interdisciplinary character of the field provides a wealth of resources for richly integrating both concerns.
By utilizing materials from such fields as anthropology and sociology, for example, bioethics programs can provide information on the cultural processes involved as we frame our individual community and universe. As they come to understand the effects of culture, students will also learn about the concerns of cultural subgroups as they involve health care.
The translation of theory into practice also involves focusing on the learned skills of effective interaction or group process. For example, ethics committees need to know how to move effectively through an agenda, understand and practice conflict resolution, and set priorities among responsibilities.
The humanities are also important bridges between content and process. Both content and process can be brought into perspective through the dramatic impact of literature, poetry, and other forms of storytelling. A reading of Camus's The Plague may stimulate intense discussion about epidemics, professional responsibility, and AIDS. Reflection on Oliver Sachs's The Man Who Mistook His Wife for a Hat can provide new meaning to the discussion of the relationship between the patient and the practitioner. William Carlos Williams's "The Use of Force" compellingly raises questions about the role of power and gender in constructing medical interactions.
To enhance both content and process, methods sensitive to the situation of adult learners should be emphasized. Programs should be carefully planned according to the students' needs and time constraints, and interdisciplinary teaching should be utilized whenever appropriate.
Program Evaluation Strategies
While evaluation is an important component of teaching, the traditional ways of evaluating students, such as tests and research papers, are not always appropriate for the adult learners who make up a majority of those participating in nonacademic bioethics programs. Additionally, perhaps because of a lack of broad consensus about its goals and methods, bioethics itself does not have any universally agreed-upon evaluation tools. Bioethics education is often taken to aim at some practical end--perhaps enhanced moral development. Yet even given this goal, efforts to measure moral development have met with mixed reviews, and efforts to develop new methods of revealing moral growth continue. For example, a promising evaluation technique pioneered by the philosopher and educational theorist Kenneth Howe consists in having students write analyses of the same case study before and after instruction, with the results compared by evaluators who are blind to the fact that they are assessing pairs of responses written by the same students at different times. In addition to evaluating students, Howe's technique suggests ways of providing a "baseline" understanding of student competence in moral thinking against which change can be measured, and in terms of which educational strategies and teachers can be assessed--clearly, an important feature of any program.
Some bioethicists have suggested that program design and evaluation should adopt shared structures and standards, paving the way toward some kind of universal certification of bioethical competence that might carry weight analogous to certification in the medical specialties. This would require that some outside source be authorized systematically to evaluate programs, teachers of programs, or graduates of programs in ways analogous to that in which physicians are board certified.
But bioethics currently lacks anything equivalent to a professional board. There is neither a broad base of necessary knowledge for which valid testing methods could be established, nor a rigorous, universal, and equitable examination system, nor a continual evaluation of measurements and outcomes. Additionally, there is no system of responsible surveillance of training programs. Most fundamentally, there are serious questions concerning whether, in principle, competence in ethical reflection is sufficiently like masteery of a medical specialty to make certification an appropriate goal.
Offering a certificate of course completion, as some institutions do, should not be confused with the lengthy process of certification on the medical model; such certificates carry nothing like the substantial connotation of the medical certification process. At the same time, however, a certificate attesting to course completion might have enhanced value if it reliably served as an indication that education conducted along the lines discussed in the core curriculum section had been achieved.
Three groups are particularly involved in the "expanding circle" of bioethics education: those clinicians already in practice who have not had bioethics training, ethics committee members (who sometimes are also clinicians), and policy makers.
Clinical Models. While many clinicians have ethics training in their professional programs, it is also important to focus on bioethics education that occurs primarily in the clinical context. This often includes both formal and informal programs. Becoming familiar with the six core areas of bioethics education is as important for clinicians as for lay people. It is particularly important that those working in a clinical setting be given the opportunity to understand their own values and to learn how to explore the ethical and cultural values of their patients. Additionally, as decisions regarding patients become more complex and involve more people, it is urgent that those in clinical settings be able to work well together when collective moral opinion is important.
Bolstering morally important emotions, such as the desire to help others generally and the skills and attitudes of empathy, is as pertinent to clinical ethics education as is enhancing critical thinking and ethical analysis. Programs also need to focus on teaching what might be called moral procedures: How might an effective informed consent be best elicited? How should a useful discussion about advance directives be structured? Discussion of such topics as uncertainty and how it affects decisionmaking (particularly in its moral components) is often explored through case analysis, a useful tool in most bioethics programs. Conducted in concert with others who often hold diverse views, clinical case discussion allows participants to learn to tolerate ambiguity and the built-in uncertainty of the theories and practice of health care.
Clinical issues which lend themselves to ethical discussion can be large-scale problems with wide policy implications, such as euthanasia, or they can be smaller, more mundane issues, such as whether to accept gifts and trips from pharmaceutical companies. All are important in the clinician's moral life.
Ethics Committees. Although ethics committees have existed in some health care institutions for more than ten years, many have been formed more recently. As the Joint Commission on the Accreditation of Health Care Organizations now requires that health care institutions establish mechanisms for responding to ethical issues, it is likely that scores of brand-new committees will soon be established. The bioethics education of their members is particularly challenging since the committee often brings together persons from diverse health care fields as well as members of the administration and sometimes the community. Generally, these committees require of new members a strong interest in bioethics, which expresses itself in their willingness to attend meetings regularly, to contribute to the work of the committee, and to learn or continue to learn about bioethics.
While there should be no requirement at this early stage of development of ethics committees that their members achieve a specified level of knowledge of the subject material, self-education is one of the primary functions of ethics committees. In that regard, it is appropriate to expect members to acquaint themselves with the six core areas of bioethics within their first twelve to twenty-four months of membership. Those members who are not familiar with health care and its language, issues, and structure should familiarize themselves with these elements in roughly the same period of time.
Education about matters of practice and procedure is also important. Do members understand techniques of conflict resolution, leadership theory, and group dynamics? How will the group accommodate the fact that members have differing educational needs and different time structures in which to learn? In what settings should education take place? Should it be formal or informal? And who will pay for the time or cover the obligations of the clinicians serving on such committees?
While these questions show that education in this context presents a challenge, the ethics committee is also a dynamic and exciting emerging forum in which bioethics education can take place.
Education for Policy Makers. Many people involved in bioethics education serve dual roles. For example, when clinicians serve on ethics committees that formulate policies for their institution, they become policy makers as well as clinicians. Many persons also affect policy making in other roles--members of legislative bodies, their staffers and advisors, representatives of the media, corporate executives.
Educational programs for these audiences range from one-shot lectures to considerably more sustained efforts. Whatever their duration, it is important that these programs be of high quality. Those who design and offer them should have a thorough understanding of the six core areas discussed previously. Collaborative, interdisciplinary planning sessions that include representatives of the targeted audience are often very useful.
While policy members should understand the six core areas, it is especially important that they explore such concepts as justice, fairness, and the public good, and grapple with issues such as access and rights to health care. Understanding the structure of moral argument is fundamentally significant. But programs targeting this group should invite more than a purely academic discussion. Communicating clearly--with special vigilance against the encroachments of jargon--is essential. The ultimate goal of programs for policy makers is to increase the possibility that people with the potential of influencing public affairs have a solid understanding of pertinent ethical issues.
Political and Practical Realities
Bioethics is distinguished by the engrossing, lively, and intellectually stimulating character of its problems. Because its issues are typically debated in the newspapers, on television, and in public opinion pools, many persons feel they instinctively "know" bioethics. This fact often generates controversy over what it takes to be bioethically knowledgeable; for instance, many still argue that moral decisionmaking is altogether a product of family values or instinct, and not the subject of a relatively autonomous intellectual field. Strong religious conviction, political stance, and technological fervor can turn educational programs into political tools and inspire passionate controversy.
Controversy can also erupt over the question of who is to lead these educational programs. Some are headed by those who have political power in the establishment but little serious knowledge of the issues; such a situation can reduce the chance of achieving well-designed and well-thought-out programs. Programs can also rise or fall because of the lack of personal or institutional power, resources, or public relations. They can disintegrate because of a lack of understanding of group dynamics. They can also fail because of a lack of credibility. Time constraints are often the enemy of effective programming. For example, covering the educational needs of a continually open hospital with its many shifts is a formidable, if not insoluble problem. Other problems revolve around the fact that participants may have decidely different levels of education. Designing programs that will meet the needs of the beginner as well as of the person more sophisticated in bioethics is a constant challenge.
A final concern worth noting is lack of funding for bioethics. Although programs are proliferating throughout the country, many do not have a permanent, long-term financial base. Corporations, hospitals, and insurance companies, in addition to the public sector, must be encouraged to sponsor and fund programs.
Bioethics is a late arrival on the intellectual scene. While there is broad agreement that its advent has invigorated the academic disciplines from which it sprang, it has always striven to do more than that: it aims at improving the character of our moral understanding and moral behavior in the practice and policy of health care. As the field matures and bioethics education attracts different and growing audiences, reflecting on the ancient problem of what it means to "teach virtue" remains as central and significant a problem for bioethics as it was for Socrates.
[Barbara C. Thornton is associate professor, Department of Community Health Sciences, University of Nevada, Reno; Daniel Callahan is director of The Hastings Center; James Lindemann Nelson is associate for ethical studies at The Hastings Center.]
[1.] For example, Daniel Callahan and Sissela Bok, eds., Ethics Teaching in Higher Education (Hastings-on-Hudson, N.Y.: The Hastings Center, 1980) and K. Danner Clouser, Teaching Bioethics: Strategies, Problems and Resources (Hastings-on-Hudson, N.Y.: The Hastings Center, 1980).
[2.] Pat Wingert and Eloise Salholz, "Irreconcilable Differences," Newsweek, 21 September 1992, pp. 85-90.
[3.] Callahan and Bok, Ethics Teaching, pp. 64-69.
[4.] Albert Camus, The Plague (New York: Random House, 1947).
[5.] Oliver Sachs, The Man Who Mistook His Wife for a Hat (New York: Simon & Schuster, Summit Books, 1970).
[6.] William Carlos Williams, "The Use of Force," in William Carlos Williams, The Doctor Stories (New York: New Directions, 1984).
[7.] The complete project report includes a selected bibliography of articles on evaluation and research as well as some citations to selected articles on the teaching of bioethics. Kenneth Howe reports his work in "Evaluating Philosophy Teaching: Assessing Student Mastery of Philosophical Objectives in Nursing Ethics," Teaching Philosophy 5, no. 1 (1982): 11-22.
[8.] An example of controversy inspired by technology is presented in "Leaving the Field," Hastings Center Report 22, no. 5 (1992): 9-15, in which Renee Fox and Judith Swazey, well known for their work regarding the social and ethical issues of organ transplantation, announce that they have chosen to discontinue this work, in part, because they want to separate themselves from what they see as an overly zealous medical and societal commitment to the endless perpetuation of life and a refusal to examine the issues of technological excess.…