In the late 1970s, an accomplished resident presented a case to me concerning a middle-aged man who recently attempted suicide. Married and the father of two teenagers, he had tried to end his life because of a legitimate fear that his bisexuality was about to be exposed by a long-term lover. However, in what he believed was a final note to his wife, he attributed his act to a hostile political atmosphere ruinous to his career. The resident’s formulation and acute treatment had been excellent. However, she ended by noting—almost nonchalantly—that she would soon inform the patient’s wife about the true reason for his actions. My surprise was so obvious that she asked what was wrong. I raised the issue of confidentiality, and she replied that it was because of his "monumental secret" that he tried to kill himself and that the only course for averting a repeat attempt was "to get everything out in the open." She believed that anyone who disagreed would be "wrong."
Struck by how cavalier this resident was about ethical dimensions of clinical care, I wondered what she had been taught in that regard. A review of the literature suggests it was likely quite circumscribed. As Miles et al. (1) noted, the "coming of age" of ethics education is a relatively recent phenomenon. In 1983, only nine U.S. medical schools required separate courses in medical ethics, a number that rose to 43 in 1989, while 100 schools discussed medical ethics within more general courses. A 1992 survey (2) of 136 directors and 95 chief residents of psychiatric training programs revealed that nearly all believed that teaching ethics was of critical importance and should be part of the core curriculum. However, 19% had no planned ethics education. Roberts et al. (3) subsequently found that 46% of psychiatric residents received no training in ethics during their clinical years in medical school and residency. Predictably, many (75%) had faced an ethical dilemma that they felt unprepared to meet, and over 90% indicated ethics education would have helped them do so. These findings are particularly disappointing given that the American Medical Association mandated ethics instruction during residency training since the early 1990s (4), and the subsequent iterations of this requirement by the Accreditation Council for Graduate Medical Education (ACGME) articulate clear didactic obligations for achieving that goal. The 2004 revision by the ACGME requires training programs to ensure that application and teaching of the AMA’s Principles of Medical Ethics with Special Annotations for Psychiatry is "an integral part of the educational process," and to promote trainees’ ability to relate to patients, families and colleagues with "compassion, respect and professional ability." Didactic curricula must include the study of "medical ethics as applied to psychiatric practice," and residency programs must ensure that residents obtain competency in six areas, including "professionalism," as manifested through "adherence to ethical principles" and "sensitivity to patients of diverse backgrounds."
Coincident with the seeming difficulty to advance these training goals, recent decades have witnessed a growing need to provide medical ethics education, given diverse factors affecting the substance and process of general medical practice (e.g., social activism and technological advances that sparked enquiry into related bioethical issues). Another motivation for enhanced attention to ethics education has been an observed, disturbing relaxation of basic Hippocratic tenets among trainees. Feudtner et al. (5) discuss an "ethical erosion" in medical students who reported acting in ways they considered unethical, Roberts et al. (6) present findings of a student assessment program that indicated a "subtle form of misconduct" in those who misrepresented data in clinical documentation, and Osborne and Martin (7) report on students’ concerns about collusion with consultants exhibiting questionable ethical behaviors. Suggested explanations included pressure on students to be team players even if they thought they were acting unethically (5), the impact of negative behavior by senior staff (8), and trainees’ transient relationships with patients, possibly undermining their feeling of responsibility toward them (9). One student (10) observed that medical education simply ignored the ethical dilemmas she repeatedly encountered in the clinical setting, thereby implicitly condoning questionable behaviors.
These observations suggest a clear need for academic psychiatrists to respond to deficits of ethics education. Residents desire such instruction (2, 4), particularly given hidden, stressful ethical dilemmas they encounter (11), and objective data demonstrate its benefit to medical students (12) and house officers (13). The question is how academic psychiatrists can help provide this crucial component of medical education. I believe we can do so by meeting the core responsibility of helping each trainee develop as a moral agent and recognize how integral and essential that role is to medical care. This entails providing them with a didactic underpinning for the development of moral agency that addresses both substantive and process issues and with informal instruction that responds to what Stephenson et al. (14) describe as unarticulated "processes, pressures, and constraints" falling outside the formal curriculum that often convey negative values. I will address each of these issues in an attempt to describe the ethical commitment of academic faculty toward psychiatric education—noting at the outset that, because development of moral agency in trainees is not confined to the residency years, my remarks will include discussion about general ethics education.
According to Pellegrino et al. (15), the principal goal of medical ethics education is to improve quality "in terms of the process and outcome of care." This requires reconciling an objective determination of patients’ medical needs with their "values, perception of what is good, life situation and plans, religious beliefs, and ethnic and cultural values." Appreciating and responding to the difficulties that may arise when attempting to guide medical treatment according to a patient’s particular values requires the development and cultivation of moral agency—the ability to recognize, assess, and respond to ethical dilemmas, decide what constitutes right and wrong care, and then act accordingly.
Trainees develop moral agency by learning how to apply theory and practical knowledge to ethical issues confronting them, accepting accountability for their actions, and advocating for policies and systems that support ethical care. Moral agency therefore requires substantive knowledge, as well as appreciation and ongoing analysis of one’s own values. As Swenson and Rothstein (16) observe, ethical education must pay attention "to students as ethical actors [emphasis added] in specific clinical contexts," in addition to focusing on analytic thinking. In that same vein, Feudtner and Christakis (17) emphasize how "the nature of the odyssey" of students’ day-to-day immersion in the world of medicine is "an emotive mixture of social and cultural elements" that shapes what kind of doctors they become, including their understanding of ethical aspects of care.
The degree to which ethics educators should attempt to develop trainees’ character, in the service of promoting moral agency, has been debated. Culver et al. (18) contend that "the basic moral character of medical students has been formed by the time they enter medical school" and, consequently, the curriculum should only attempt to provide individuals of sound moral character "with the intellectual tools and interactional skills to give that character its best behavioral expression." Michels and Kelly (20) caution against confusing ethics and personal morals when teaching psychiatric ethics, but believe character traits "may be enhanced, developed, or refined through education." Pellegrino’s (19) more activist view holds that didactic instruction alone cannot close the gap between "knowing what is good and doing good." He believes virtue is acquired by "the repeated performance of right and good acts," and that it is the responsibility of medical faculty to convey that practical knowledge by serving as "models of ethical behavior." A common theme of these positions is the importance of fostering professionalism; in conjunction with didactic knowledge it forms the basis of development of moral agency.
The traditional medical ethics curriculum involves didactic instruction in substantive and process issues, the latter addressing communication and behavioral interactions with patients, their families, and professional colleagues. Teaching psychiatric ethics must be viewed as a longitudinal task that builds on general medical ethics education, because students incorporate different types of knowledge during different educational stages. Broad ethical issues should be addressed in the undergraduate medical school curriculum, with the introduction of basic concepts during the preclinical years, and application of that material, as well as development of appropriate interpersonal skills, during the clinical years. Residency programs are venues for further intensive training in understanding and managing ethical issues that often arise in a given specialty (4, 18, 21). Academic psychiatrists have a responsibility to participate in each of these educational stages in order to emphasize to students that ethical concerns should be as much a part of psychiatric treatment as consideration of general medical issues, to support interdisciplinary ethics teaching whose importance has often been stressed (18, 22), and to allow themselves opportunity for ongoing study of psychiatric ethics.
The goals of preclinical teaching are primarily those outlined by Culver et al. (18)—emphasizing the presence and importance of medical ethics by focusing on basic issues, concepts, and moral theory. The undergraduate clinical years provide opportunity to expand this knowledge base through application to real life situations. Some clinical issues are obviously generic (e.g., confidentiality), while others are more common to a given specialty (e.g., competency determinations in psychiatry). The other important educational goal of the clinical years is to teach basic communication skills, as didactic knowledge is of little use if students fail to relate adequately and empathically to patients. Culver et al. believe that by the end of medical school students should have "the conceptual moral-reasoning, and interpersonal abilities to deal successfully with most of the moral issues they confront in their daily practice."
Forrow et al. (21) state that "it is primarily during residency that an individual incorporates the ethics and clinical skills of the specialty into a working persona." Postgraduate trainees increasingly take on the full measure of responsibility for patient care, including making decisions about ethical issues or implementing decisions made by others. Moreover, the frequent occurrence of ethical issues common to a specialty offers the opportunity for intensive study—for example, ongoing consideration of how to manage transference and countertransference in ways that preserve ethical therapeutic boundaries—contributing to the "lasting impact" provided by ethics education during residency (23). Common goals for teaching ethics to residents include learning to recognize ethical issues arising in the clinical setting, identifying hidden values, understanding the importance of individual values when two or more come into conflict, and honing ethical sensitivity, humanism, and moral integrity (21, 23, 24). Forrow et al. list "core maxims" that residents should learn in order to deliver ethical care, while acknowledging that some ethical issues confronting residents can be specialty-specific and require distinct conceptual and practical skills. Michels and Kelly (20) offer a detailed ethics curriculum for psychiatry residents.
The traditional teaching model for ethics education during preclinical and clinical years of education has been extensively described (1, 15, 18, 22, 25). Predominantly an analytic, cognitive-based approach, it employs lectures, small group discussions, and required readings covering both general topics (e.g., moral theory, bioethical principles, and codes of medical ethics) and specific issues (e.g., treatment refusal). Alternative teaching models have been proposed (7, 22, 24), in an effort to focus more attention on values and the moral development of clinicians. Fox et al. (22) suggest greater emphasis on promoting humanistic qualities and behavior skills and advocate adult-learning principles that favor active over passive learning with greater reliance on small group discussions, a case-based approach, the use of videotaped interviews, and role playing. Engagement with curricula material in this manner is better suited to acquisition of new skills, attitudes and behaviors than the large lecture format and facilitates application of theoretical knowledge acquired in the preclinical years to clinical experiences because of a greater attention to interactions with patients and families. Fox et al. also believe it enhances appreciation of issues of macroethics, as patient-centered discussion heightens awareness of the impact on clinical care of institutional policies, hierarchical relationships, financial issues, and methods of resource distribution.
A wide spectrum of teaching methods is suggested for postgraduate training, including case conferences, didactic seminars and lectures. However, as Forrow et al. (21) discuss, the day-to-day clinical routine is likely the most effective venue for education of house officers. They endorse a case-based methodology for clinical ethics, "an orderly approach to identify and characterize the different values in each case, as well as any nonmoral facts which affect decision-making" (e.g., information about available treatments or prognosis). Their perspective de-emphasizes the place of moral theory, which they feel is needed only to the extent necessary for "reaching ethically defensible clinical decisions," just as medicine is predominantly guided by practical information, such as an electrocardiogram (ECG), as opposed to its justifying electrophysiological theory. As for communication skills, the authors believe they are best taught via supervisory input and role modeling, though they note the value of role playing and specialized instruction.
Trainees are constantly exposed to an informal education falling outside the formal curriculum. As described by Hundert et al. (26), "small day-to-day dramas of medical students’ and residents’ lives…about what is right, fair, skillful and good" construct "an influence of process" at least as relevant to the moral and professional development of students as formal curricula. Because negative ethical consequences of this "hidden curriculum" are widespread and often considerable (5, 7, 9, 14, 17, 27), promoting professionalism among trainees (and practitioners) must be a priority goal for academic psychiatrists.
Varied definitions of medical professionalism convey a common theme. Stephenson et al. (14) discuss the classic triad of "a high level of intellectual and technical expertise, autonomy in the practice and regulating of the discipline, and a commitment to public service," while Reynolds (28) discusses "a set of values, attitudes, and behaviors that results in serving the interests of patients and society before one’s own," including honesty, integrity, humility and accountability to patients, colleagues and society. These same sentiments are reflected in health policy and statements by different medical organizations (29, 30).
There has been a recent interest in promoting professionalism through educational activities both in the U.S. and U.K. (14, 31, 32). However, there remains a question of how to teach it, given the varied ways it is currently addressed in medical school curricula (33). Reynolds (28) argues that the key to securing professionalism among trainees is by building an "educational community" that places priority on "assimilation of knowledge, skills, and values, and the development of individuals personally and professionally." Specific proposals for reforming residency training accordingly include close mentoring of trainees, didactic instruction focused on professionalism, and routine evaluation of trainees’ professional conduct. He offers an excellent curriculum guide for teaching professionalism to physicians-in-training but stresses the necessity of a "process matrix" to complement didactic learning that employs a core teaching faculty and programs for role modeling, an approach also favored by Markakis et al. (34).
Empirical evidence supports the value of programs that help trainees internalize the positive behaviors of mentors through a socialization process. Brownell and Cote’s (35) study of senior residents revealed that a majority listed contact with positive role models as their preferred method of learning about professionalism. Stephenson et al. (14) also discuss the importance of role modeling in medical school, urging educators "to embody the values and behaviors that are desired of students and new doctors" to help offset such negative influences as "competition, economic concerns, and the misuse of authority." Wright et al. (36) report on attributes shared by faculty recognized as good role models, such as spending 25% of one’ time teaching, stressing the importance of the doctor-patient relationship, and including psychosocial aspects of medicine in didactic instruction.
Academic faculty must provide formal and informal instruction about professionalism and the substance and process of ethical care in order to meet a focal commitment of helping trainees develop moral agency. I offer the following suggestions for realizing that goal.
First, academic departments must support a core faculty trained in ethics and primarily responsible for developing and organizing curricula, meeting varied teaching responsibilities (e.g., classroom, clinical and consultative work), and pursuing research activities. Secondary responsibilities would include participation in medical center activities, such as service on the hospital ethics committee. The faculty should be involved in a longitudinal ethics curriculum that spans all medical school and postgraduate training years. I generally concur with the curriculum recommendations and teaching methodology previously referenced.
Second, psychiatry departments must support a program of educational activities occurring at least on a monthly basis. These can include grand rounds, a lecture series addressing different aspects of psychiatric ethics, a regularly scheduled case conference, informal lunchtime meetings to review clinical material or research in progress, or presentations by nonpsychiatrists (e.g., a hospital attorney). The journal club can regularly review published articles or standard works from the literature, such as those listed in an annotated bibliography for consultation-liaison psychiatry (37). The importance of each activity should not preclude grounding residents’ ethics education in the day-to-day routine of clinical rounds, supervision and informal discussion with faculty. This approach of focusing on "everyday ethics," which is widely supported (1, 18, 19, 22, 23, 38), both hones trainees’ moral agency while communicating to them how integral it is to psychiatric care. Daily instruction of residents can be supplemented by educational activities, such as seminars specific to their interests and needs (4). Senior residents can also work with mentors in independent courses of study that culminate in a research paper and/or presentation to colleagues.
Third, departments of psychiatry must support interdisciplinary collaboration within the medical center. Physicians generally lack sufficient training in ethics, and ethicists generally are too naive clinically. Therefore, neither group can teach clinical ethics in an effective manner (22). Expertise external to the department can be quite useful, and all activities that broadly promote ethics training should be encouraged.
Finally, psychiatry departments must evaluate trainees for their professionalism and ability to provide ethical care, an important endeavor for several reasons: 1) It communicates to them that each is as integral to becoming a physician as learning basic science and clinical medicine. 2) It provides a measure of effectiveness of teaching, both in terms of subject matter and methods (1, 19, 39, 40), and helps determine what trainees want to learn about (4). 3) Regular evaluation emphasizes that medical ethics is as important an area of study as other required courses. Evaluation can be complicated by the difficulty of establishing precise objectives for assessment, given different emphasis on the importance of didactic knowledge, communication and behavioral skills, and the degree to which trainees’ character is a focus of ethics education. Emphasis on different educational goals is reflected in the different methods of evaluation, which include standardized instruments (e.g., self-administered questionnaires) (12, 13, 41), staff observation, objective structured clinical examinations with simulated patients or videotaped interviews, self-reports and writing exercises, required case reports and research papers. A combined system of evaluation seems most logical given reported shortcomings associated with individual methods (42).
Epstein’s (43) discussion of "mindful" practice largely captures how clinicians develop and exercise moral agency. He emphasizes the importance of reflection and self-awareness as a way of helping physicians examine their belief systems and values in order to "listen attentively to patients’ distress, recognize their own errors, refine their technical skills, make evidence-based decisions, and clarify their values so that they can act with compassion, technical competence, presence, and insight." Mindfulness consists of explicit and tacit knowledge; the former is readily taught, and the latter is learned via self-observation and cultivated through practice. It involves linking evidence-based and relationship-centered care; Bloch and Green suggest a similar approach specific to the ethical practice of psychiatry (44). I have attempted to describe the responsibilities of academic psychiatrists that promote such mindfulness in order to help trainees develop moral agency and, in the words of Christakis and Feudtner (45), reach the point where "ethics ceases to be only a theoretical discipline and begins to become a professional code of conduct." Before closing, I alert the reader to several obstacles impeding that goal.
First, Ludmerer (32) discusses how institutional culture can shape attitudes, values and behavior in a way that undermines ethics education and professionalism—as Michels and Kelly (20) note, training sometimes occurs in "monstrously immoral social institutions." Academic psychiatrics must enlist administrative support, such as the authority of the medical dean, to help transform these environments.
Second, lack of adequate teaching time has been a chronic impediment to ethics training. Largely integrating ethics education into clinical activities, as opposed to the crowded medical school curriculum, is one means of limiting the problem (15), but taxing demands on house officers and logistical problems associated with teaching in the clinical setting diminish the effectiveness of this approach (46).
Third, insufficient numbers of trained faculty to comprise an effective core teaching group, coupled with inadequate commitment to faculty development in ethics training, undermine educational efforts at all levels within an academic department (1, 15, 24, 46).
Finally, the subject matter of psychiatric education raises particular difficulties for ethics education. As Michels and Kelley discuss (20), residents often struggle to reconcile the new paradigm of biopsychosocially driven behavior with a preexisting framework that includes a considerable degree of moral judgment when assessing behavior. This can prompt trainees to conflate incorrectly ethical and clinical issues in the same way physicians do when requesting psychiatric consultations to resolve moral dilemmas (47—49).