This piece was originally published on Bill of Health, the blog of Petrie-Flom Center at Harvard Law School.

There has been too little evaluation of ethics courses in medical education in part because there is not consensus on what these courses should be trying to achieve. Recently, I argued that medical school ethics courses should help trainees to make more ethical decisions. I also reviewed evidence suggesting that we do not know whether these courses improve decision making in clinical practice. Here, I consider ways to assess the impact of ethics education on real-world decision making and the implications these assessments might have for ethics education.

The Association of American Medical Colleges (AAMC) includes “adherence to ethical principles” among the “clinical activities that residents are expected to perform on day one of residency.” Notably, the AAMC does not say graduates should merely understand ethical principles; rather, they should be able to abide by them. This means that if ethics classes impart knowledge and skills — say, an understanding of ethical principles or improved moral reasoning — but don’t prepare trainees to behave ethically in practice, they have failed to accomplish their overriding objective. Indeed, a 2022 review on the impact of ethics education concludes that there is a “moral obligation” to show that ethics curricula affect clinical practice. Unfortunately, we have little sense of whether ethics courses improve physicians’ ethical decision-making in practice.

Ideally, assessments of ethics curricula should focus on outcomes that are clinically relevant, ethically important, and measurable. Identifying such outcomes is hard, primarily because many of the goals of ethics curricula cannot be easily measured. For instance, ethics curricula may improve ethical decision-making by increasing clinicians’ awareness of the ethical issues they encounter, enabling them to either directly address these dilemmas or seek help. Unfortunately, this skill cannot be readily assessed in clinical settings. But other real-world outcomes are more measurable. Consider the following example:

Physicians regularly make decisions about which patients have decision-making capacity (“capacity”). This determination matters both clinically and ethically, as it establishes whether patients can make medical decisions for themselves. (Notably, capacity is not a binary: patients can retain capacity to make some decisions but not others, or can retain capacity to make decisions with the support of a surrogate.)

Incorrectly determining that a patient has or lacks capacity can strip them of fundamental rights or put them at risk of receiving care they do not want. It is thus important that clinicians correctly determine which patients possess capacity and which do not. However, although a large percentage of hospitalized patients lack capacity, physicians often do not feel confident in their ability to assess capacity, fail to recognize that most patients who do not have capacity lack it, and often disagree on which patients have capacity. Finally, although capacity is challenging to assess, there are relatively clear and widely agreed upon criteria for assessing it, and evaluation tools with high interrater reliability. Given this, it would be both possible and worthwhile to determine whether medical trainees’ ability to assess capacity in clinical settings is enhanced by ethics education.

Here are two potential approaches to evaluating this: first, medical students might perform observed capacity assessments on their psychiatry rotations, just as they perform observed neurological exams on their neurology rotations. Students’ capacity assessments could be compared to a “gold standard,” or the assessments of physicians who have substantial training and experience in evaluating capacity using structured interviewing tools. Second, residents who consult psychiatry for capacity assessments could be asked to first determine whether they think a patient has capacity and why. This determination could be compared with the psychiatrist’s subsequent assessment. Programs could then randomize trainees to ethics training — or to a given type of ethics training — to determine the effect of ethics education on the quality and accuracy of trainees’ capacity assessments.

Of course, ethics curricula should do much more than make trainees good at assessing capacity. But measuring one clinically and ethically significant endpoint could provide insight into other aspects of ethics education in two important ways. First, if researchers were to determine that trainees do a poor job of assessing capacity because they have too little time, or cannot remember the right questions to ask, or fail to check capacity in the first place, this would point to different solutions — some of which education could help with, and others of which it likely would not. Second, if researchers were to determine that trainees generally do a poor job of assessing capacity because of a given barrier, this could have implications for other kinds of ethical decisions. For instance, if researchers were to find that trainees fail to perform thorough capacity assessments primarily because of time constraints, other ethical decisions would likely be impacted as well. Moreover, this insight could be used to improve ethics curricula. After all, ethics classes should teach clinicians how to respond to the challenges they most often face.

Not all (or perhaps even most) aspects of clinicians’ ethical decision-making are amenable to these kinds of evaluations in clinical settings, meaning other types of evaluations will play an important role as well. But many routine practices — assessing capacity, acquiring informed consent, advance care planning, and allocating resources, for instance — are. And given the importance of these endpoints, it is worth determining whether ethics education improves clinicians’ decision making across these domains.

This piece was originally published on Bill of Health, the blog of Petrie-Flom Center at Harvard Law School.

I recently argued that we need to evaluate medical school ethics curricula. Here, I explore how ethics courses became a key component of medical education and what we do know about them.

Although ethics had been a recognized component of medical practice since Hippocrates’ time, ethics education is a more recent innovation. In the 1970s, the medical community was shaken by several high-profile lawsuits alleging unethical behavior by physicians. As medical care advanced — and categories like “brain death” emerged — doctors found themselves facing challenging new dilemmas and old ones more often. In response to this, in 1977, The Johns Hopkins University School of Medicine became the first medical school to incorporate ethics education into its curriculum. Throughout the 1980s and 1990s, medical schools increasingly began to incorporate ethics education into their curricula. By 2002, approximately 79 percent of U.S. medical schools offered a formal ethics course. Today, the Association of American Medical Colleges (AAMC) includes “adherence to ethical principles” among the competencies required of medical school graduates. As a result, all U.S. medical schools — and many medical schools around the world — require ethics training.

There is some consensus on the content ethics courses should cover. The AAMC requires medical school graduates to “demonstrate a commitment to ethical principles pertaining to provision or withholding of care, confidentiality, informed consent.” Correspondingly, most medical school ethics courses review issues related to consent, end-of-life care, and confidentiality. But beyond this, the scope of these courses varies immensely (in part because many combine teaching in ethics and professionalism, and there is little consensus on what “professionalism” means).

The format and design of medical school ethics courses also varies. A wide array of pedagogical approaches are employed: most rely on some combination of lectures, case-based learning, and small group discussions. But others employ readings, debates, or simulations with standardized patients. These courses also receive differing degrees of emphasis within medical curricula, with some schools spending less than a dozen hours on ethics education and others spending hundreds. (Notably, much of the research on the state of ethics education in U.S. medical schools is nearly twenty years old, though there is little reason to suspect that ethics education has converged during that time, given that medical curricula have in many ways become more diverse.)

Finally, what can seem like consensus in approaches to ethics education can mask underlying differences. For instance, although many medical schools describe their ethics courses as “integrated,” schools mean different things by this (e.g., in some cases “integrated” means “interdisciplinary,” and in other cases it means “incorporated into other parts of the curriculum”).

A study from this year reviewed evidence on interventions aimed at improving ethical decision-making in clinical practice. The authors identified eight studies of medical students. Of these, five used written tools to evaluate students’ ethical reasoning and decision-making, while three assessed students’ interactions with standardized patients or used objective structured clinical examinations (OSCEs). Three of these eight studies assessed U.S. students, the most recent of which was published in 1998. These studies found mixed results. One study found that an ethics course led recipients to engage in more thorough — but not necessarily better — reasoning, while another found that evaluators disagreed so often that it was nearly impossible to achieve consensus about students’ performances.

The authors of a 2017 review assessing the effectiveness of ethics education note that it is hard to draw conclusions from the existing data, describing the studies as “vastly heterogeneous,” and bearing “a definite lack of consistency in teaching methods and curriculum,” The authors conclude, “With such an array, the true effectiveness of these methods of ethics teaching cannot currently be well assessed especially with a lack of replication studies.”

The literature on ethics education thus has several gaps. First, many of the studies assessing ethics education in the U.S. are decades old. This matters because medical education has changed significantly during the 21st century. (For instance, many medical schools have substantially restructured their curricula and many students do not regularly attend class in person.) These changes may have implications for the efficacy of ethics curricula. Second, there are very few head-to-head comparisons of ethics education interventions. This is notable because ethics curricula are diverse. Finally, and most importantly, there is almost no evidence that these curricula lead to better decision-making in clinical settings — where it matters.

This piece was originally published on Bill of Health, the blog of Petrie-Flom Center at Harvard Law School.
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Health professions students are often required to complete training in ethics. But these curricula vary immensely in terms of their stated objectives, time devoted to them, when during training students complete them, who teaches them, content covered, how students are assessed, and instruction model used. Evaluating these curricula on a common set of standards could help make them more effective.

In general, it is good to evaluate curricula. But there are several reasons to think it may be particularly important to evaluate ethics curricula. The first is that these curricula are incredibly diverse, with one professor noting that the approximately 140 medical schools that offer ethics training do so “in just about 140 different ways.” This suggests there is no consensus on the best way to teach ethics to health professions students. The second is that time in these curricula is often quite limited and costly, so it is important to make these curricula efficient. Third, when these curricula do work, it would be helpful to identify exactly how and why they work, as this could have broader implications for applied ethics training. Finally, it is possible that some ethics curricula simply don’t work very well.

In order to conclude ethics curricula work, at least two things would have to be true: first, students would have to make ethically suboptimal decisions without these curricula, and second, these curricula would have to cause students to make more ethical decisions. But it’s not obvious both these criteria are satisfied. After all, ethics training is different from other kinds of training health professions students receive. Because most students come in with no background in managing cardiovascular disease, effectively teaching students how to do this will almost certainly lead them to provide better care. But students do enter training with ideas about how to approach ethical issues. If some students’ approaches are reasonable, these students may not benefit much from further training (and indeed, bad training could lead them to make worse decisions). Additionally, multiple studies have found that even professional ethicists do not behave more morally than non-ethicists. If a deep understanding of ethics does not translate into more ethical behavior, providing a few weeks of ethics training to health professions students may not lead them to make more ethical decisions in practice — a primary goal of these curricula.

One challenge in evaluating ethics curricula is that people often disagree on their purpose. For instance, some have emphasized “[improving] students’ moral reasoning about value issues regardless of what their particular set of moral values happens to be.” Others have focused on a variety of goals, from increasing students’ awareness of ethical issues, to learning fundamental concepts in bioethics, to instilling certain virtues. Many of these objectives would be challenging to evaluate: for instance, how does one assess whether an ethics curriculum has increased a student’s “commitment to clinical competence and lifelong education”? And if the goals of ethics curricula differ across institutions, would it even be possible to develop a standardized assessment tool that administrators across institutions would be willing to use?

These are undoubtedly challenges. But educators likely would agree upon at least one straightforward and assessable objective: these curricula should cause health professions students to make more ethical decisions more of the time. This, too, may seem like an impossible standard to assess: after all, if people agreed on the “more ethical” answers to ethical dilemmas, would these classes need to exist in the first place?

But while medical ethicists disagree in certain cases about what these “more ethical” decisions are, in most common cases, there is consensus. For instance, the overwhelming majority of medical ethicists agree that, in general, capacitated patients should be allowed to make decisions about what care they want, people should be told about the major risks and benefits of medical procedures, patients should not be denied care because of past unrelated behavior, resources should not be allocated in ways that primarily benefit advantaged patients, and so on. In other words, there is consensus on how clinicians should resolve many of the issues they will regularly encounter, and trainees’ understanding of this consensus can be assessed. (Of course, clinicians also may encounter niche or particularly challenging cases over their careers, but building and evaluating ethics curricula on the basis of these rare cases would be akin to building an introductory class on cardiac physiology around rare congenital anomalies.)

Ideally, ethics curricula could be evaluated via randomized controlled trials, but it would be challenging to randomize some students to take a course and others not to. However, at some schools, students could be randomized to completing ethics training at different times of year, and assessments could be done before all students had completed the training and after some students had completed it.

There are also questions about how to assess whether students will make more ethical decisions in practice. More schools could consider using simulations of common ethical scenarios, where they might ask students to perform capacity assessments or seek informed consent for procedures. But simulations are expensive and time-consuming, so some schools could start by simply conducting a standard pre- and post-course survey assessing how students plan to respond to ethical situations they are likely to face. Of course, saying you will do something on a survey does not necessarily mean you will do that thing in practice, but this could at least give programs a general sense of whether their ethics curricula work and how they compare to other schools’.

Most health professions programs provide training in ethics. But simply providing this training does not ensure it will lead students to make more ethical decisions in practice. Thus, health professions programs across schools should evaluate their curricula using a common set of standards.