In recent years, ethical misconduct in research, clinical care, education and between peers in the health professions has been a source of mounting concern.
Speculation about the reasons for these moral lapses center around an increasingly commercialized and competitive health care system, which results in pressure for cheaper and quicker student learning and for increasing clinical faculty productivity.
But regardless of the reasons, Deans and Associate Deans today are concerned.
To name just a few things, they worry about cheating on tests, scientific misconduct, sexual harassment, and failure to respect patients and other health professionals—problem behaviors which are exhibited by faculty as well as students.
As a result, education in ethics and professionalism has become a requirement for accreditation in all the major health professions.
Also, it has become clear that such education is ideally carried out using interprofessional materials and instructors, and in interprofessional settings, virtual or real. The obstacles, however, are forbidding.
Socializing students into the health professions is a daunting task. At bottom, it means helping them form a professional identity, acquire the tools of ethical analysis, and develop the skill and motivation to act according to the highest moral standards.
Students moving from undergraduate school to graduate training in the health professions do not automatically understand that they are stepping across a threshold in which service to others takes precedence over self interest.
They are beginning a journey of moral education, which requires a supportive environment, mentors, models of conduct, inspiring teachers and compelling materials.
Forming a professional identity means internalizing an ethos of altruism and service, developing a commitment to lifelong learning and expertise, and participating in the self-regulation which society grants to professional groups devoted to the welfare of their constituents.
There are many criticisms of traditional education in ethics and professionalism.
Some argue that basic morality is learned at home and that ethics education has no real effect on values, character, or behavior. It is not true, however, that students learn everything they need to know about being a good person at home or in church or in some religious community.
One’s original beliefs and values are important but they are not universally true, nor should they be the basis of every action.
Learning to respect the values and world views of others—and learning how to act when values and world views clash—requires knowledge of ethics, cultural humility, and conscious effort to apply both in professional life.
There are other, often apt, criticisms of education in ethics and professionalism: there is little evidence that knowledge of ethics translates into ethical behavior; ethics education is boring; it affects the intellect but not the emotions; it is logistically difficult to get students from different professional schools together; and there is a paucity of good teaching materials.
At the University of Texas- Houston, the McGovern Center for Humanities and Ethics, working with Archimage Design Studio, has developed an online and hard-copy fictional text which addresses several of these problems.
Modelled on the genre of the choose-your-own adventure novel, The Brewsters is a nonlinear story about three generations of a family involved in the health care system (www.meetthebrewsters.com).
Students readers decide to become a character in each of three Acts, and they play out the storyline from the point-of-view of that character. They take on the roles, for example, of medical student, patient, dental or nursing student or epidemiologist.
They make choices from that point of view in ethically sensitive situations, and these choices have consequences for the fate of their character and the shape of the plot.
The story is written in three Acts: Professionalism, Clinical Ethics, and Research Ethics. Each act is followed by a short section of didactic themes (e.g. codes of ethics, ethical principles, conflict-of-interest, accepting gifts from industry or patients, duty to report, etc.). The Brewsters is assessed by short pre- and post-tests.
Our health science center in Houston has six professional schools—nursing, medicine, dentistry, public health, biomedical science, and bioinformatics.
The Brewsters is now a required exercise for all 1,000 students who enter these schools annually. Assessments reveal significant knowledge gains, and student reaction has been very positive.
“This story tricks you into learning,” wrote a student in Public Health.
“It is one thing to read material and look and pictures, but it is a whole other to be immersed into something that actually feels real,” noted a nursing student. “. . . . [students] don’t even realize that they are learning about ethics and instead think that they are reading a very interesting story.”
We have found that interaction and fictional immersion are significant factors in interprofessional learning about ethics in health care. Online activities can be followed up with small group discussions or even a theatrical appearance of the story’s characters performed live by professional actors. It is no secret that students like to be entertained in immersed.
Educational innovations should take this to heart: serious games, fiction and online interaction can yield humanistic forms of learning with strong potential to shape the hearts and minds of our future health care providers.
Thomas R. Cole, Ph.D., is Director of the McGovern Center for Humanities and Ethics at the University of Texas-Houston Health Science Center
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