Since the 1970s, courses in medical ethics have become an integral part of medical education in Europe and the United States (1, 2). Medical educators now agree that medical students should develop a foundation of knowledge in medical ethics (2, 3), with specific aspects emphasized as demonstrating professional competence (4). The growing interest in medical ethics education is rooted in the understanding that clinical practice presents ethical challenges, and educators need to measure trainees’ abilities to recognize and deal with the ethical aspects of their work.
Despite the acknowledged importance of ethics education, little empirical work has assessed its effectiveness and value (or lack of it). One way to gather such evidence is to directly survey medical students about their needs and preferences for training in ethics and professionalism. However, only a handful of such studies have been conducted. Notable among them was Shelp et al.’s (5) 1981 survey of 106 Texas medical students, which demonstrated that 64% believed ethics was highly or critically important to medical care and 66% wanted to learn more. A similar study (6) of 101 Nigerian medical students found that 88% of the students believed medical ethics should be part of the curriculum and 84% felt medical ethics was of high to critical importance in providing medical care. The great majority (95%) of those surveyed indicated they were interested in learning more about medical ethics.
Two decades later, Roberts et al. (4) compared the perspectives of 200 medical students and 136 residents at the University of New Mexico regarding ethics education and found that most students believed ethics could be taught and learned and was an appropriate curricular topic. Medical students valued diverse learning approaches for ethics (e.g., clinically oriented, multidisciplinary-expertise oriented, and nontraditional formats) (4). The students also reported a strong preference for assessment using direct observation of their knowledge and skills in a clinical setting rather than through a structured assessment such as a standardized patient exercise or written examination (4).
More data are clearly needed to help medical educators make thoughtful decisions about the ethics curricula that are grounded in empirical data. Studies that examine different needs and preferences among specific students, such as clinical versus preclinical, are also required. The current study extends prior work at the University of New Mexico by surveying medical students regarding their interest in learning about ethics and specific ethics topics, endorsement of specific goals for ethics training, attitudes toward ethics as part of medical school curricula, and preferred ethics teaching methods.
The work reported here was part of a larger NIH-funded study on clinical research ethics that included a randomized, controlled experiment to assess the effects of two different types of research ethics training on medical students’ attitudes. After a 30-minute ethics training event or comparison event, all participants were asked to complete a written survey of 185 rating-scaled questions, open-ended questions, and demographic items. The survey focused on expressions of opinion, and each item could be answered relatively quickly. Participants required 20 to 62 minutes to complete the survey (modal time 40 minutes). Results of the research ethics training intervention protocol have been reported elsewhere (7, 8).
Here we describe participants’ postintervention survey responses to the 41 questions related to medical education in ethics and professionalism. The content of the interventions and comparison group activities will not be described here, because assignment to the intervention group or comparison group did not influence responses to any of these 41 questions.
All 300 medical students at the University of New Mexico in January 2001 were invited via e-mail to participate in a research project involving a single evening educational session on research ethics for which they would receive $50 compensation and pizza. Ethics instruction at the University of New Mexico in 2001 involved small group, loosely structured instruction in medical ethics during the first 2 years and an extensive performance-based examination with ethics and professionalism evaluated as a core competency. Potential research participants received an informed-consent briefing, and a total of 83 students volunteered to participate (overall participation rate 28%). The survey of one participant was dropped from this analysis because of substantial missing responses for the items reported here. The study was deemed exempt by the Human Research Review Committee (IRB) at the University of New Mexico School of Medicine because of its educational intent, minimal risk status, and the anonymity of data collected from student participants.
Responses to attitude items were rated on a 9-point scale and subjected to repeated measures item (within-subjects repeated measure) × intervention group (intervention 1 with intervention 2 with comparison, between-subjects) × training level (preclinical with clinical phase medical students, between-subjects) × gender multivariate analysis of variance (MANOVA). We also examined correlations among attitude measures and of attitude measures with reported amount of previous ethics training and frequency of encountering ethical problems in medical training or research.
Among the 82 participants, the majority were women (60%), white (60%), and in the preclinical phase of medical school (66%) (Table 1). By comparison, the total student body was 50% female, 62% white, and 50% were in the preclinical phase of medical school. Half the survey respondents anticipated entering primary care residency training, 33% specialty training, and 17% did not specify postgraduate training plans. No effects of assignment to one of the three intervention groups were found for attitudes toward education in ethics and professionalism (p range=0.07 to 0.96). Thus group assignments are not mentioned in the results or tables.
Students reported having had a moderate amount of previous ethics coursework or other training (mean=4.74, scaled from 1=none to 9=great amount) and encountering ethical problems in medical training moderately often (mean=5.35, scaled from 1=not at all to 9=all the time) and during research experiences somewhat less often (mean=3.72, p<0.01). Experiences with ethics training or ethical problems were not consistently related to attitudes toward education in ethics and professionalism.
Personal Interest in Ethics Education
Respondents agreed that they were personally interested in learning more about ethics in clinical medicine (mean=7.16, 1=strongly disagree, 9=strongly agree) (Table 2) and agreed somewhat less that they were interested in learning more about ethics in clinical research (mean=6.65; item main effect F=5.54, df=1, 70, p<0.03, Cohen’s d=0.21). Women were more interested than men in learning more about ethics in clinical medicine and research (respective means=7.46 versus 6.35, gender main effect F=5.12, df=1, 70, p<0.03, d=0.50).
Students rated agreement (1=strongly disagree, 9=strongly agree) with seven goals for ethics education in medical training (Table 3). They most strongly agreed that the goal of ethics education in medical training is to help professionals “better recognize ethical issues and clarify values-laden choices,” “improve patient care and clinical decision making,” and “improve ethical practices in clinical research” (means=7.74 to 8.08). Preclinical students expressed greater overall agreement with the listed goals of ethics education than clinical students (means=7.18 and 6.47, respectively; training level main effect F=4.81, df=1, 70, p<0.04, d=0.52).
Attitudes Concerning Education in Ethics and Professionalism
Respondents rated agreement (1=strongly disagree, 9=strongly agree) with eight statements about education in ethics and professionalism (Table 4). They most strongly agreed that “professional attitudes and values are an appropriate focus for medical education” (mean=7.76). Greater agreement with all statements on education in ethics and professionalism was associated with students’ greater personal interest in ethics in clinical medicine (r=0.33 to 0.64, mean r=0.41, p<0.01 in all cases) and ethics in clinical research (r=0.24 to 0.59, mean r=0.36, p<0.03 in all cases).
Respondents also rated agreement (1=strongly disagree, 9=strongly agree) with two statements on the need for ethics training for researchers in medicine. Compared with men, women more strongly agreed that researchers in medicine need more ethics training and are not usually well prepared to deal with ethical problems than did men (means=6.33 and 5.46, respectively; gender main effect F=5.87, df=1, 70, p<0.02, d=0.53).
Preferences for Topics in Ethics Education in Research and Clinical Medicine
Students agreed that they would like more training on all of 15 topics about ethics in clinical research and medicine (means=5.42 to 6.76, 1=strongly disagree, 9=strongly agree) (Table 5). Preclinical students expressed a greater desire for additional training on all ethics topics than clinical students (means=6.73 versus 5.77, training level main effect F=5.34, df=1, 70, p<0.03, d=0.55), as did women compared with men (means=6.81 and 5.69, respectively; gender main effect F=7.33, df=1, 70, p<0.01, d=0.60).
Students were asked to rate agreement (1=strongly disagree, 9=strongly agree) that medical training in ethics should include specific methods of training (Table 6). They most strongly agreed that methods should include group discussion, consultation and guidance on the ethical and scientific designs of specific protocols, and interactions with institutional review board leadership (means=6.84 to 7.39).
Although the percentage of U.S. medical schools providing formal ethics instruction has dramatically increased during the past 35 years (2, 3), there remains a dearth of empirical evidence on how students view ethics-related curricular topics and teaching methods. Detailed information is needed to guide attempts to refine ethics curricula so that it is aligned more closely with the needs and preferences of students and subsequently leads to measurable changes in attitudes and behaviors. The current study suggests that medical students view numerous curricular topics in ethics and professionalism in a positive light, and that they have clear preferences for both the content and process of learning. Students consistently expressed a strong interest in learning more about clinical and research ethics. In their strong agreement that “professional attitudes and values are an appropriate focus for medical education,” participants clearly affirmed including medical ethics training in medical school curricula.
This study suggests that students are most keenly interested in learning about specific topics in medical ethics with relevance to clinical work. Because this survey was given in part to assess the efficacy of an intervention related to research ethics education, most of the item choices in the list of 15 topics were research-ethics related. Although respondents expressed interest in additional teaching on all the topics, they demonstrated strongest interest in learning more about three topics also directly pertinent to clinical care—informed consent, decisional capacity, and surrogate decision makers. Of least interest were authorship and publication issues, professional activities that may be perceived as far removed from direct patient care.
This study also suggests that students prefer interactive methods of learning about ethics and professionalism, such as group discussion, consultation, interaction with institutional review board leaders, and web-based learning. Our findings that students believe curricula should be diverse and integrated throughout the training process are consistent with the findings of prior surveys of medical students in New Mexico and Texas (4, 5).
Also consistent with findings from prior surveys of medical students (9, 10) were significant gender differences in our respondents’ attitudes and preferences for ethics education. Women medical students more strongly endorsed interest in additional ethics education in clinical research and medicine and expressed stronger preferences for specific topics in ethics education in clinical research and medicine than did men. Women also more strongly endorsed the desire for more ethics education for each of the 15 curricular topics assessed. The cause of these gender differences is unknown, though one could hypothesize, as did Price and colleagues (9), that it may be due to earlier socialization of women. Our sample size was not large enough to demonstrate whether the gender difference was more pronounced preclinically than clinically. The consistent finding of gender differences in attitudes and preferences toward ethics education invites future studies using qualitative methods to uncover the meaning of these differences.
Finally, our survey also demonstrates differences between the attitudes of preclinical and clinical students. Preclinical students were significantly more likely to agree strongly with specific goals of ethics education than were clinical students. Preclinical students also demonstrated significantly stronger preferences for more education about specific topics in ethics education in clinical research and medicine than clinical students. These findings may be related to the particular curriculum at the University of New Mexico, which emphasizes ethics during the preclinical years and thus may cause the preclinical students to be more aware of and/or interested in ethics instruction. Another possibility is that as students progress through medical training and gain more knowledge about medical ethics, their desire for additional ethics training diminishes accordingly. Students’ personal goals for ethics education may also change because of their increasing experience in working with patients (10). A fourth possibility is that with increased training, students become more cynical about their profession, and this growing cynicism is reflected in a diminished interest in ethics education (6, 9, 11, 12). Further study utilizing qualitative methods is necessary to explore these issues more deeply and to learn precisely how moral development is affected by the student’s journey through the medical education system (13).
This study has several important limitations, which may affect its generalizability. First, our sample size was relatively small, and our participation rate among medical students was only 28%. Respondents were ethnically similar to the entire student body, but were more likely to be female and in the preclinical years. The response rate should be considered in light of the time commitment required to participate in the evening session, which was not feasible for students on clinical rotations requiring work during the early evening or overnight. It is not unexpected that most of our respondents were in the preclinical years, a time of relative flexibility in scheduling. It is also possible that our sample was biased toward those with a favorable attitude toward ethics instruction or research, who may have been more likely to respond to recruitment materials mentioning the topic of the study. If such selection bias exists, we would expect it to lead to more positive attitudes toward ethics instruction and learning about research ethics topics.
Another important limitation is that this study assessed students’ views at a single point in time and at one medical school. Because the University of New Mexico has a relatively robust ethics curriculum, the students in our sample may have been more knowledgeable about ethics and professionalism than the norm. In addition, University of New Mexico students are exposed to ethics through small group instruction; familiarity with this method may have influenced responses to items about preferred teaching methods.
The study’s strength derives from bringing student perspectives to the discussion about incorporating ethics and professionalism in undergraduate medical training. Participants clearly endorsed including medical ethics in the curriculum and learning more about several topics.
Future work is needed to determine whether this study’s affirmation of ethics education is generalizable across medical schools and if and how ethics training in medical school affects professionalism, interpersonal skills, communication, practice-based learning, and patient care during residency. Longitudinal studies are also needed as student perspectives may change significantly over time and as changes occur in social mores, the practice of medicine, and the sociodemographic composition of medical school classes.
The authors wish to thank Ann Tennier, ELS, for her assistance in the preparation of this manuscript. This study was funded by the National Institute of Mental Health and the National Institute on Drug Abuse. Drs. Hoop, Roberts, and Ms. Tennier are also funded through the Research for a Healthier Tomorrow-Program Development Fund, a component of the Advancing a Healthier Wisconsin endowment at the Medical College of Wisconsin.
At the time of submission, Drs. Lehrmann, Hoop, and Green Hammond declared no competing interests. Disclosures of Academic Psychiatry editors are published in each January issue. Manuscripts authored by an editor of Academic Psychiatry or by a member of its editorial board undergo the same editorial review process, including blinded peer review, applied to all manuscripts. Additionally, the Editor is recused from any editorial decision making.