Introduction
The State of Clinical Ethics in the UK
The Value of Clinical Ethics Education
Introducing Clinical Ethics into a Medical Curriculum
Results
Learning Clinical Ethics Using Student Cases and Ethical Frameworks
For some students, using their own cases to learn clinical ethics highlighted the relevance of the frameworks to practice settings:it is a very practical way of learning about ethics. No amount of teaching could replace this experience (2014/2015).it allowed me to see the practical aspect of things we learned in class (2012/2013)it allowed me to have real practical experience with engaging with the tool (2014/2015)
However, a minority of students implicitly presented a mismatch between what they were taught through the coursework and what they witnessed on the wards. In particular one student queried the relevance of the frameworks in terms of influencing practice in light of the rise of protocols and policies, “I do not think that people analyse scenarios in this nature, it is more guideline orientated in practice, either you can do something or you can’t” (2015/2016).I enjoyed applying a clinical tool to an ethical scenario I had experienced myself as I found this more interesting and relevant than using made up scenarios (2014/2015).The scenario aspect helps in hospital placements because it shows how quickly and easily the tools can be applied in real life (2012/2013)
The feedback from the students also suggested that once they were aware of the application and relevance of clinical ethics, it secured students’ future engagement with the frameworks:applying the tool to a scenario that I had seen made the tool seem relevant and necessary for clinical practice (2017/2018)I enjoyed applying the tool to my scenario as it enabled me to learn how I would use it in clinical practice (2017/2018)I think the ethical tool I used can apply to most ethical situations that arise in clinical setting. Therefore it relates by being of use clinically (2014/2015)
Although it is worthwhile noting that one student did question the value of learning about the frameworks and the application to real life experiences, “it is so specific to one scenario its difficult to know how the tool will help me in the future” (2013/2014). That said, the majority of students made connections between learning clinical ethics using their own cases during their training and informing their future practices:It related to my placements as these type of scenarios are experienced regularly. This coursework has allowed me to appreciate how these scenarios could be analysed during placement in the future (15/16)I feel that I could easily apply my ethical tool on-the-go, having studied it in more depth (15/16)
Students also enjoyed their learning being centred on their own ethical case rather than a hypothetical case, and found it enhanced their learning experience:Because my scenario was a situation that actually happened to me, it meant I could reflect on how I could act in the future. Which I hope will be useful for my future practice (2014/15)I found it refreshing to write about ethics and law in context of a real life scenario. I feel I have gained skills about ethics and law to carry forward into clinical practice (2014/2015)
For some students, the application of the framework to their own scenario supported their wider PPVE learning, as it “gave context to theory” (2012/2013). In particular, students referred to their ability to learn and engage with ethics, law and professionalism topics within the wider curriculum,actually applying the tool to a clinical situation that I’ve experienced. It is much more useful to apply these tools to our own experience rather than a made up scenario (2012/2013)I also found that analysing a situation that had actually happened to me to be very enlightening (2014/2015)It was helpful to apply the ethical tool to my own scenario and made it more enjoyable working through a scenario I had been confronted with in clinical practice (2014/2015)
Clinical ethics also was presented in the feedback as supporting students’ ability to understand and retain their ethics, law and professionalism learning:I enjoyed the applying part of the coursework the most. It helped me to learn certain concepts in detail and also understand ethics better (2017/2018)helped me understand some new aspects of PPVE which I did not now previously (2014/2015)
Students also claimed that the clinical ethics activities helped to integrate their learning of ethics into their wider clinical learning outside of the classroom, which they seemed to value:I enjoyed relating PPVE concepts to my personal experience, I feel this allowed me to retain information better (2015/2016)I liked applying the tool to a real life situation it was a better way to learn and understand it (2015/2016)
In turn, the relevance of the ethical frameworks to wider clinical practice, was mutually beneficial to the learning of clinical ethics. Some students enjoyed critiquing the ethical frameworks against the needs and demands of clinical practice:relates to experiences in hospital (2015/2016)I think that it brings a lot of my learning together rather than it all being compartmentalised (2015/2016)directly relevant to clinical placements and therefore very useful (2015/2016)
It appeared that students appreciated learning clinical ethics using their own cases and applying ethical frameworks to help structure their analysis of their own cases. Many students valued the practical nature of clinical ethics in terms of applying a framework to support decision-making in the face of ethical uncertainty, and made reference to the relevance of clinical ethics to clinical practice, suggesting that they perceived learning clinical ethics as equipping them for practice.I enjoyed this piece of coursework and think it has made me consider the tools in a more critical way. Rather than just using the tools in my future practise, I will try to look at what is missing from each tool, and how I might need to actually adapt the tool to make it different in different cases (2012/2013)Applying the ethical tool and further exploring how the tool could be improved by identifying its limitations (2016/2017)I enjoyed applying the ethical tool the most and critiquing the tool with regard to current practice (2016/2017)
Learning Clinical Ethics to be Prepared for Practice
Although a minority of students found explaining their reasoning around cases particularly challenging:it helps me to deal with dilemmas in a more logical way (2015/2016)it just enabled me a systematic way of thinking about decisions for the future (2016/2017)the ethical tool will help me work through the domains and help me come to a justified decision about a scenario in the future (2016/2017)
In turn, the ethical frameworks meant that students were able to break down a case that was ethically challenging, as well as recognise their emotional responses to cases:explaining reasoning behind choice (2015/2016)I found it difficult to explain how the tool brought me to the outcome (2015/2016)
The student feedback on applying an ethical framework to a real-life case suggested that students were reflective whilst making their decision. Furthermore, students were able to reflect upon their own decision-making process. For some students, using an ethical framework highlighted overlooked elements of the case being analysed. Implicit in students’ feedback therefore was the value of using a framework to arrive at an ethically-informed decision:giving me a deeper appreciation of how ethical dilemmas can be broken down and able to come to a more thought through decision (2015/2016)it made me realise that my own beliefs are powerful when I am judging whether something is right/wrong, and to step back and look carefully at the possible outcomes (2015/2016)
Students described how their opinions shifted whilst working through the various components of the ethical frameworks, which suggested an openness and flexibility within their decision-making skills:I enjoyed seeing what different tools are out there and the benefits of a considered decision and the importance of getting ethical decisions right (2013/2014)applying it to my scenario and reflecting on my own opinion and seeing how there were aspects of the patient care I had missed (2015/2016)I really enjoyed applying the ethical tool, and seeing how working my way through it helped me to see the situation from different points of view, and actually made me change my original thoughts on what the most acceptable outcome should be (2012/2013)
Equally, the clinical ethics activities provided students with the opportunity to examine others’ decision-making when faced with the same case:applying the tools to my scenario as it allowed my opinion to change (2014/2015)seeing how my own opinions were shaped as I did it (2012/2013)it was useful to work through my particular scenario, and see how it can help you to change your mind (2012/2013)
Clinical ethics was presented by students as supporting students’ decision-making skills in the future by providing them with a ‘tool kit’ that they could draw on in clinical practice:it has also enhanced my understanding of ethical decision making in healthcare” (2012/2013)considering why a doctor might make a certain choice and what might be reasons not to make those choices. Allowed me to look at clinical decision making in more detail (2017/2018)made me realise how open ethical situation is to being interpreted differently (2013/2014)
The notion of clinical ethics as equipping students for practice and providing a ‘tool kit’ was also reflected in how students’ chose which ethical framework to use in their coursework. Students emphasised the clinical relevance of some ethical frameworks and how applicable the frameworks would be for future practice:it has shown me that when I may come across tricky ethical situations in practice, that tools are available to help analyse what to do (2015/2016)allows for use of a tool which is now familiar to be deployed in real world settings (2014/2015)it has allowed me to think about how to approach any ethical decisions I face in the future, whether that be in the hospital or the community (2014/2015)
The clinical ethics activities compelled students to make a decision, which demonstrated to them progression in their learning, whilst also generating an opportunity to integrate their wider learning:I chose the tool I found most interesting and most clinically relevant to me when I am a doctor (2012/2013)I wanted to choose an ethical tool that I would use in the future – so easy to remember and relevant to all scenarios (2014/2015)I also wanted to use a tool that I would easily be able to use in practice, so I chose one that was easy to remember (2013/2014)
However, the practical nature and focus of the coursework meant for some students that the written component was a limitation and unnecessary:having to think critically about an ethical decision and actually make a decision rather than simply listing pros and cons of each outcome (2015/2016)I found that coming up with a plan of action based on codes of practice and regulations was the most enlightening part of the coursework (2014/2015)
Within the student feedback, clinical ethics was presented as supporting the development of ethical practitioners. Students perceived clinical ethics as providing a tool kit that they could draw on when qualified and on the wards. Students were reflective in and around their decision-making, and demonstrated sensitivity towards others’ perspectives, and an awareness of the importance of making ethical decisions. Consequently, it was inferred from the feedback that students perceived learning clinical ethics as helping them to become ethical practitioners.I think that it would be useful to do 10 min presentations instead…I feel that ethics is better spoken about and discussed…a 10 min presentations in front of a panel would have still taught me what I needed to know without spending hours on trying to write about them (2015/2016)
Learning Clinical Ethics to Become ‘Ethical’ Practitioners
Ethical Awareness
To some extent, the feedback suggested that students had developed an expanded view of their cases, which incorporated other people’s perspectives that they would not previously had considered. In some extracts, it can be inferred that engaging in clinical ethics had shifted and challenged students’ usual way of thinking about clinical cases:I enjoyed applying the tool to my scenario and seeing different things which I wouldn’t have normally seen (2013/2014)applying the ethical tools to my case was interesting as it taught me more about all aspects of the case (2017/2018)I enjoyed applying the tool to my own scenario and reflecting on aspects of the dilemma that I had not considered previously (2014/2015)
The clinical ethics activities required students to draw on their own ethical dilemmas, and in turn had fostered some students to develop an ‘ethical lens’ whilst on clinical placements. The feedback suggested that students had gained insight into the ethical components of their clinical placements, and the clinical ethics activities had encouraged them to engage with the placements in a different way:I enjoyed applying the ethical tools the most as it made me think in a way I normally wouldn’t (2014/2015)It highlighted to me the need to think of the wider considerations when trying to make an ethical decision (2013/2014)it made me consider dilemmas that I had never thought of before. It was an insightful learning experience (2012/2013)
The emphasis of the clinical ethics activities on developing students’ ethical awareness and fostering an ‘ethical lens’ to their clinical placements was also reflected in the feedback when students were asked what they found most challenging during the clinical ethics activities. Some students reported struggling to identify a case for discussion that they considered had an ethical dimension:opens your eyes to all ethical dilemmas that you may not have seen before (2015/2016)It has made me more aware of ethical scenarios that I face in hospital (2014/2015)allowed me to put my hospital experience into context and consider ethical dilemmas which might sometimes be overlooked (2013/2014)
When examining the feedback closer to understand this challenge for the students, it appeared that some students perceived medical specialities as providing more or less ethical cases:I found it challenging to think of a scenario. I felt like I hadn’t seen many ethical situations in clinical practice (2015/2016)finding a scenario that was a genuine ethical dilemma. Rarely does something morally questionable happen (2013/2014)I felt that it was quite hard to find an ethical dilemma as I feel I didn’t come across many (2012/2013)
In addition to this, these same students tended to ‘overlook’ and were dismissive of the ‘everyday ethics’ challenges that permeate medical practice. This was confirmed when students attended placements in the same medical specialities and emphasised that the clinical ethics activities had given them an appreciation of the ethical aspects of everyday practice:finding a scenario since it took a while. I think it depended on which rotations you had seen so far (2015/2016)I found finding a scenario very stressful and difficult given the rotations I had done (2015/2016)
very applicable, we encounter similar issues on the wards and in clinics. The dilemmas are not always big but they are important for those involved with the care and the patient (2012/2013)very relevant to everyday practice, particularly in GP setting (2012/2013)has given me more of an appreciation of how ethics comes into all clinical decision making and all those aspects need to be considered in all environments (2013/2014)
Ethical Reflection
Students also suggested that the clinical ethics activities prompted them to reflect on their own and others’ practices whilst learning:allows me to think about ethical issues that arise in hospital routinely and allows me to reflect on this (2015/2016)I enjoyed the opportunity to stop and reflect in detail on a clinical experience (2014/2015)helpful in terms of thinking about ethical scenarios that I have encountered in hospital etc. Often don’t necessarily take the time to think about them and about how they could be resolved in the future (2015/2016)
Some students also made the association between the opportunities to reflect on ethical aspects of their wider learning during placements with their future practices,The coursework made me think about the ethical consequences of my actions on placement (2012/2013)it makes me consider the ethics of everyday things a lot more and wonder if some of the situations you see on the wards were analysed using an ethical tool would the outcome be the same as the ones that are taken clinically (2012/2013)
it helps to improve upon my reflection skills for future hospital practice (2014/2015)It will help [me] think in a more ethically critical way when approaching situations in hospital (2012/2013)I will try to reflect more on my observations in hospital, community e.g. was a consultant’s clinical decision/behaviour appropriate in a certain situation (2012/2013)
Ethical Practices
For some students, they viewed the ethical frameworks as being able to assist them in their future practices, in particular their decision-making:Helps you consider how you would handle ethical scenarios whilst on placement around the hospital (2015/2016)I will try to apply the ethical tool to other histories I take in hospital (2014/2015)Feels mainly applicable to clinical work. Stimulates thought-processes whilst on placements and helps students to question proceedings (2014/2015)
Whilst others referred to how learning about clinical ethics would support their general healthcare practices, including working as part of a multidisciplinary team:I think looking at ethical situations that are commonplace in clinical settings can go a long way to informing my practice and ethical decision making further down my career (2014/2015)I hope it will assist me in making ethical decisions in the future (2015/2016)It will help me address better future ethical dilemmas in the hospital setting (2012/2013)
Some students also considered their engagement in the clinical ethics activities had assisted their development as an ‘ethical’ practitioner:Having to read about the ethical tools and their applications has been incredibly helpful especially in terms of understanding how we can use them in daily practice (2012/2013)the session helped to interact with other healthcare professionals which I think is particularly useful for when I become a doctor and will have to work as part of a team with multiple members of staff (2017/2018)The interdisciplinary discussion was both rich, thoughtful and rewarding and helped break down some barriers (2016/2017)
Within the student feedback, it was apparent that students recognised the benefits of learning through and engaging in clinical ethics activities, and acknowledged the rewards from this learning and engagement to them as medical students and as tomorrow’s doctors.Helps to consider my personal ethical perspective and how I aim to be once I begin practise (2015/2016)it helps in shaping me as a better future doctor overall (2014/2015)