Case Study Approach to Teaching Biomedical Ethics

Ann Lewis Boyd

Hood College, Frederick, MD. U.S.A.

Cases can be simple or complex, involving one person or many with conflicting interests. Along the spectrum of complexity, it is the intention of the teacher to make the human situation clear using the drama of the case. For example, a person with advanced cancer may elect to try chemotherapy to see if the cancer will respond, but later when it is clear that the cancer is advancing, she may decide to stop the chemotherapy. This case seems simple at first glance. However, the patient and doctor are making decisions affecting her life every step along the way. Her family and friends may be very concerned if she stops chemotherapy as a sign that she has given up and wants to die. The balance of autonomy of the patient and that of the doctor and the role of the family are all important in this example. Who should decide what is best for this patient? How is that decision reached? What is the dynamic between doctor and patient, doctor and family, patient and family?

Teaching medical ethics in any culture or curriculum is often complicated by assumptions and experiences of students and teachers as illustrated by the story above. One may hold an expectation, often unspoken, that there are right and wrong answers to situations that correlate with some standard, or ethical code of conduct which merely need to be learned and applied. The impression is further complicated when students are already specialized in a particular discipline, such as science, business, or medicine. The process of specialized education necessitates learning many details and skills appropriate to practice the profession. Medical students are typically engrossed in the details of the specialized field and may even be annoyed that an ethics course is required or suggested. Some people make the basic assumption that ethics is nothing more than a code of conduct about how a particular professional person ought to act, which leads students to assume there are right answers to any ethical question just as they have become used to expect “correct” answers in their main subject. Some specialized courses are taught in this way although, scientists should know better, given the constant development and paradigm changes in science’s history, not to mention epistemic limitation. It is also true that just being able to perform a certain skill, or repeat a correct answer to a formula such as the amount of drug to give to a patient of 120kilogram weight, is not demonstrate a understanding of the drug, how the dose was determined, and what side-effects it may have. Good scientists and medical experts understand that they are in largely the same situation as ethics, and develop a certain skeptical attitude about claiming too much “truth” from their work. When the professor of ethics suggests the student consider how one thinks and processes cases where conflicts and concepts are more vague, the students may lose interest or become frustrated. Therefore, it is necessary that the objectives of the "Medical ethics" course be explained as well as the methods of teaching. Specific goals, methods, and explaining methods and objectives clearly models good communication and respects the student as a person. It is important to recognize that every person, including our students, “know” about morality without being experts. Students might become excited in knowing they were asked to explore their moral sense and reasoning in a serious way and to experiment with it using the case studies. Where is the proper place of a medical ethics course in the curriculum of medical education? What methods of teaching will promote the moral development of the physician in ways that maintains harmony and balance between the professional code of conduct and the complex moral issues of modern medicine?

Unmasking myths about ethics:

Myths about ethics lurking within the minds of students and teachers need to be unmasked. A myth is a story constructed to transmit an understanding of a practice but with imaginary or unverifiable existence. Myth may also mean an ill-founded belief held uncritically by an interested group. For example, some educators claim that medical ethics is a course in which physicians are trained to always do the right thing. The myth is that there is a prior sense of knowing the right thing to do in a given situation. If such a prescriptive behavior does exist, can it be learned by rote? Therefore, one person might claim that ethics must be taught, and another that ethics cannot be taught. As a person matures in a culture, he/she learns what the norms of that culture are and what is considered good or bad. The relative measure of good and bad across various cultures may differ significantly but there also may remain upon close examination certain fundamental principles that cut across cultural boundaries. Teaching ethics courses can open the mind and vision of students to situations that they have not previously encountered and prepare them to evaluate and process information in ways that lead to consistent and moral conclusions¹. The point is not to prescribe what action to take in a set of given situations (the myth), but to raise dilemmas posed by technological progress in which all persons will not agree on what the ethically right conduct is or why it is preferred over an alternative action. It is simply the case that in most medical contexts, there are conflicting normative claims between doctors, patients, and the resources of society. Students bring to the course the normative values of his/her life experience, but that does not mean that he/she cannot learn to dialogue with others about ethical situations. Respecting and learning to hear different viewpoints often increases awareness and sensitivity to other persons and may also reinforce the values already held². Why is this so important? It helps overcome one’s own errors, and increases our respect for all persons.

The second myth is that there is no one ethical code that applies universally; therefore it is not realistic to teach ethics since we cannot agree on what is ethical. This is the tension and debate about relative and standard based ethical discourse³. There are ethicists on both sides of the debate, but it is also true that international conferences and governing agencies apply fundamental concepts across cultures. Without a set of normative standards or principles that focus on the humane treatment of persons, there would be no international discourse, no international research, clinical trials, or collaboration. It may be true that the general guiding principles of the Nuremberg Code, Helsinki Accord, and Belmont Report are not endorsed in every culture in the same manner, but that is no reason to abandon discussion or reflection. In fact, as Helsinki proves, international guidelines are often the results of a cross-cultural agreement on the universal basics of ethics. Furthermore, continuous change of people, information, and thought means that every culture is pluralistic. Therefore it is not helpful to merely dismiss ethics as something set by time and culture without regarding the basic status of human persons as fundamentally consistent, sharing a basic humanity. While plurality and diversity should be respected and carefully evaluated in a flexible manner, it does not follow that there are no fundamental ethical principles that need to be considered in evaluating the good or right action as modern medicine and science increasingly challenge societies with new developments. In fact, when we reflect seriously, we see that we always take some “universals” for granted and use them in practice, such as our aversion to killing and torture. This is why we feel that actions violating these moral intuitions need to be marked as exceptions, and must be duly justified.

The third myth is that ethics courses interfere with the normal progress in professional education. In this claim, there is the idea that science and medicine progress according to certain methods that work within the methods of the disciple. Therefore, ethics is reduced to merely a matter of professional conduct learned from the mentor-professional. When a student training to be a physician takes the first course in medical ethics, it is important not to use too much philosophical language and fail to connect with the student. Again the case study can help overcome this barrier. A student of many years’ experience in science or medicine may sense ethics as intrusive and interfering with their chosen area of study if a connection between practice and theory is not make very fast. When ethicists are unaware of the validity of the scientific enterprise and offer criticism without appreciating the beauty of the scientific or medical development, conflict may emerge. Therefore teachers ought to show sensitivity to the disciplinary "ways of knowing" and remain questioning about the application to patients. An attitude of respect for the students as persons with professional training provides a model for how important the "other person" is and shows the students that treating them with respect matters. The implication is that each student will learn to treat his/her future students, patients, and colleagues with mutual respect, because he wishes to be treated the same way.

The fourth myth is that "only Western based philosophies are ethical." This notion grows out of the dominance of certain principles and standards used in ethics literature and conference presentations. For example, the set of principles, autonomy, beneficence, nonmaleficence, and justice get a lot of attention. The moral theories of J.S. Mill, I. Kant, and T. Aquinas, namely, Utilitarianism, Respect for Persons, and Natural Law, respectively, have provided general guidance for ethical discourse along with the four principles for hundreds of years. That does not mean that such standards and principles are the best ones or that all persons should adopt them. It does not even mean that this set is the best or only way to make these theories practical, or that such a set will guide reliably under all circumstances. However, we all live in an international community, and seek to serve humanity by means of medicine. Therefore we search across cultures for common perspectives about how to best achieve the overarching goals of medicine in ways that retain the harmony between professional practice and care of human patients.⁴ Therefore, it is important that internationally based dialogue be open to other normative standards, principles, and philosophies. Enlarging the debate across diverse philosophical traditions expands the depth and application of ethics to diverse cultures, peoples, and situations. Such international conversation also helps us to understand better what our theories are about and how principles make sense in practice. There may be no one moral standard or principle that covers all situations, all times, all persons; and therefore, whatever the favored norm of a person or culture might be, we all need humility when approaching ethical dialogue. Ethics is within ourselves, theories and principles can hardly be better than the people.

Strategy of teaching that mirrors the clinical practice of medicine:

My strategy is to engage the student in a series of cases that mirror typical clinical situations. From each case, students are asked to recognize and analyze the facts, issues, and ethical concepts. Case studies challenges the student to reflect on the conflicts of interest, the doctor-patient relationship, the duties and responsibilities of the physician and the human drama of the patients. The engagement gained in case studies is used to trump the mental attitude of “just tell me what to do.” By engagement, I intend to bring the student into discussion with the teacher and with other students. I hope each student will take the dialogue seriously, participate in it fully, and develop their individual answers to cases while maintaining respect for other viewpoints. Each case is carefully chosen to represent a real situation but one in which there are multiple issues, facts, and concepts. Conflicting claims among patients means a moral judgment is necessary in order to act. Why one action is better than another must be reasoned carefully and defended logically and morally. The defense of a posed action requires some grounding moral principle or theory to justify a proposed action. Students may use an argument that is Utilitarian, based on trying to do the most good overall without harm. The student may not know this is Utilitarian logic. The teacher takes this as an opportunity to label their normative basis: that they are trying to determine what will happen if they take a proposed action. By this method, you can identify the moral reasoning already in the student. This is where the student feels the need to think rationally and logically. If students recognize within their own moral reasoning the basic tenants of a moral theory, it is then easier to teach about the theory or standard or principles.

I have each student write about the case for a grade, but then they are required to form small discussion groups and choose one action as best. Reaching consensus brings diverse values into the discussion and helps enlarge the perspective of all participants. Consensus is not a majority vote but an agreement that one proposed action is better than other proposals and why. How the group reaches agreement is important and should be reported to the full class. At the end of the discussion, if consensus has not been reached, the reason should be given, such as what central normative principle was more important to one subset of the group than to others. This helps the students to look at the issues more deeply and try to find the common concepts within the case. In large classes where it may not be practical to form small working groups, it may be effective to use a panel of students who are negotiating a consensus for the entire class.

The cases are selected to fit the topics covered. In the beginning, the centrality of doctor-patient relationship may be reflected in a case that involves only one patient who makes a request to his doctor to forego chemotherapy for advanced cancer. If the doctor and patient agreed, what was the basis of their agreement? How did the doctor respond to the patient? Should the doctor and patient reach a decision independent of anyone else, or are there other persons who should be involved? Suppose that the doctor does not approve of the patient's request? What duty does the doctor have to the patient that allows him to deny the patient's request? Could the patient see another doctor? These are straightforward questions that can be the basis of conversation among students so that each student becomes comfortable with discussing what is important in such situations. It also allows the student to articulate what is important in the broader concept of the doctor-patient relationship.

As the course progresses through different topics, such as international testing of vaccines, the concepts and issues may become more complex. However, the progressive nature of the discussion should carry forward. A case such as the need for an organ transplant for two patients of equal need and ability to pay but with only one organ available highlights the pressures of limited resources and allocation strategies. If there is only one organ available for transplantation, then which patient will receive it must be determined. How? Why should one and not the other patient receive the organ? The justification might be “first come, first serve” meaning that the person who qualified for the organ first is the one who gets it. This reason is based on equal treatment of both patients of equal need. Another answer might be, Patient A got the organ because he had been very productive, had given much to the community, and if he lives longer by getting the organ, he will continue to contribute to the society. This answer suggests that there is more social worth to some persons than others, and regardless of equal medical need, one person may get priority for the organ transplant. Other answers are certainly possible, but these two give examples of ethical reasoning.

Case studies are intended to simulate real situations that occur in medical practice. The cases should not be so foreign to real clinical situations that the students will not be interested or will find the exercise trivial. However, the case should contain conceptual issues that provoke discussion: that is to say the answer should not be obvious. The point of a case study approach is to engage students in sorting out the issues and concepts and to make them feel how they act in decision-making. One answer is not necessarily right and all others wrong, for this would eliminate the need for discussion. Students should understand that the grade given for a case study is not based on the "right answer" as much as it is based on the "rationale-justification and reason" provided to support their proposed action. It is important that students realize that two opposing points of view can both be graded with high marks.

The benefits of using the case study approach are fivefold: (1) students learn to reason independently as they write their individual assessment of the case; (2) using a variety of cases within a semester simulates the array of situations students may face in the future; (3) group work exposes the student to other points of view with the potential of enlarging their perspective; (4) sharing in dialogue with other students raises awareness of plurality and diversity of moral perspectives among individuals, thereby raising sensitivity; and (5) reaching consensus teaches each student that they can be part of a functional team rather than having to make all decisions alone. Overall, the student gains an experience as a moral agent, using reason and dialogue to determine what is ethical and good.

Case studies also have disadvantages, including the risk that students will take the case as a paradigm example of the “proper clinical behavior” and try to apply the answer to other similar cases. The case is an example intended to engage the student in reasoned dialogue, not to prescribe a correct answer. The other disadvantage is that where there are conflicting opinions, students may conclude that any answer is right as long as it is justified by some principle, standard, or reasoned argument and endorse some form of ethical relativism/nihilism/sophism. This is not intended but may be a limitation of the methodology. Finally, cases are rarely inclusive of every anticipated experience open to the future doctor. Medicine evolves in technology and in ethical issues, such that there is never the expectation that a single course with several cases can present a comprehensive coverage of every future situation. Therefore, it is the method of recognizing the ethical issue, the concept, separating issues from facts, and learning to decide by a reasoned analysis that is taken from the class rather than a prescriptive “ethic of practice.” This makes it even more important to emphasize how students learn about themselves and how they act or ought to act as moral physicians.

Teachers should be sensitive to the needs of patients and physicians. Physicians and scientists work to produce a new treatment or the care of an individual patient, respectively. It is also the duty of the scientists and physicians because they are citizens! to have a vision of the larger long-term health interests of the people within the society and to participate in crafting health-care policies. The teacher of medical ethics must impart a care for both dimensions into the educational experience.⁵

Does an ethics course produce more ethical scientists and physicians?

By way of illustration, I taught a course in Science and Ethics to a group of graduate students working in academic, government, and private biotechnology companies this academic year. Each student wrote reflection papers at the end of a course on selected topics. Many students elected to write about whether or not ethics can be taught and if so, what effect it has on "adults." The design of the course was a series of practical cases and readings from the literature about current topics, such as the AIDS epidemic, organ transplantation, embryonic stem cell research, reproductive technologies, genetic testing, genetic therapy, and human subjects research. Small groups of students evaluated each case and made recommendations for a “policy” to guide further research in medicine. At the end of the semester, each student was asked to rate the importance of each topic covered in the course. The topic rated highest in the course was “can ethics be taught?” Only 12% of the students expressed doubt about the effects of “teaching ethics” based on their belief that moral development occurs in childhood and the moral character of a person is essentially fixed by the time they are graduate students or practicing professionals. One student said, “a dishonest person will act dishonestly and taking an ethics course will not change what kind of person he/she is.” The foundation is already set, students have previously developed normative values and their exposure to a series of cases does not alter that developmental effect. In contrast, 87% of the students maintained that ethics can be taught and that we are continually developing morally. The majority of the students asserted that taking an ethics course does help because it raises issues they had not preciously encountered or expected. How ethics is taught is vitally important. Ethics discourse can only be sensitive and politically tolerant where students are allowed freedom to explore their intuitive sense of morality. Every student and teacher in the process encounters the possibility that learning something means being willing to change ourselves.

It is intended that students will recognize the complexity of real life and the moral puzzles in medical practice by means of the case studies. Hopefully the students will be better prepared for situations of human drama and armed with logical tools to make a moral judgment and justify the proposed action. Students rate the value of taking an ethics course high when they engage in the cases thoroughly. Students say they become more aware of facts, more alert to dilemmas, and more prepared to practice their profession. The analogy offered by one student was that of simulator training for airline pilots. They get to practice the situation and their mental skills before putting real persons at risk. In similar manner, discussing and thinking carefully about the HIV-AIDS epidemic, organ transplantation, end of life care decisions, genetic medicine, doctor-patient relationship, confidentiality, informed consent, and a host of medical issues related to limited resources and human need does more than inform students, it challenges all of us to search our reason and morality for what is good.

Summary:

As students engage the material in the topics discussed, they read selections from the literature, and discuss cases among themselves, they practice the skills they will need to be ethical professionals. It is clear that students may approach the material with different degrees of interest, motivation, or skill. That is true also of the world in which ethical debates are played out in news articles, international conventions, and the literature. Certainly we ought to be encouraged that all students do not agree on a moral or ethical action as that reflects the reality of ethics in the world.

Reference Notes