One way to teach Medical Ethics courses is to start with theory and then work through a series of pro/con pieces on abortion, euthanasia, using non-human animals in research, organ markets, etc. It’s a standard approach and for good reason: it introduces students to the moral aspects of these debates and helps them critically assess a position that they may not have thought about before. I thought about taking this approach when I was designing my first Medical Ethics class six years ago but decided against it. When I started talking to friends and family who worked in healthcare about starting my job and building the course, they offered case studies or anecdotes to help fill in between those “big debates.” But the more we talked, the more I realized that these issues were a whole other course in themselves.
So, instead of the “standard approach” I asked more questions and reached out to more friends and family in healthcare to build the course entirely around the problems that they encountered on the job and wished that they would have known about ahead of time. It turned out that these more ordinary issues were just as morally fraught as all the other high-profile ones, and did just as good a job illustrating conflicts and applications of moral theories.
While a lot of the conversations were very uncomfortable, students appreciated the fact that they were learning about situations they might encounter when they went on to practice medicine. Because they were already invested in learning about these topics and questions, they wanted to know what other people had done, both when they had made mistakes and done the right thing. So, while some of the topics were emotionally grueling, I didn’t have to convince them that philosophy was important because ethical theory came with built-in tools to help them navigate problems they already cared about.
When we covered virtue ethics, for example, we started looking at what kind of healthcare professional students wanted to be. Students readily reached for virtue-language: compassionate, caring, helpful, or brave and recognized that they needed mentors and role models to learn how to exemplify those virtues in medical practice. But we also talked about how race complicated that learning process—say, when a doctor of color encounters a racist patient, colleague, or higher-up. It very much matters if the mentor is aware of or has experienced micro-aggressions in medical education (e.g., mistaking a student for a custodian) or in professional responses (e.g., just let it go, making a joke of it).
We worked through a few provider narratives that talked about what it means to be a “difficult patient.” It’s not a clinically precise term, but it’s easy enough to apply: the patients you don’t feel compassionate towards; the ones who aren’t grateful or who are pushy, aggressive, or second-guessing everything. Difficult patients are close relatives to “non-compliant” patients, the ones who miss appointments, don’t take their medications, disobey medical advice, the ones that make you groan when they walk through the door. The providers’ narratives talked about how challenging it was to treat these patients and be the doctor they aspired to be when they started medicine, but they also talked about the real harms of writing “difficult” or “non-compliant” in a patient’s chart: every future provider will see that label and apply it to everything the patient does. It’s no mystery as to why patients who are so labeled gradually stop coming for care.
Understandably, students are also concerned about how the law shapes ethical debates. While I don’t encourage them to break the law, I do try to show them cases where it will not give them an immediately obvious answer. There were a few different versions of it, but several people told me about a pretty common case of lying on paperwork or committing insurance fraud. A patient, for instance, is undergoing physical therapy and insurance will cover at-home care if the patient cannot walk X feet. On the last day of her therapy, the patient can walk with a walker just a foot or so past X but is clearly physically tired and worn out for the rest of the day. While she was rightly proud of her progress, she says that she wouldn’t feel confident doing the exercises by herself at home. Because her progress is borderline, the provider marks her down as not being able to walk the X feet. Strictly speaking, it’s insurance fraud, but students really took to Principlism to work out the different moral elements at stake. As we dove deeper into possible courses of action (I conceal what I think they should or should not do with the cases), they started to appreciate that balancing the Principles was not just a “give me your opinion,” because it really would matter what they chose to do and why they thought that was (not) justified. To their immense credit, they also recognized that while they might disagree with another student’s answer, they still understood why someone would (not) judge the risk appropriately.
None of these examples are to say that the “standard approach” is insufficient, lackluster, or needs to be discarded. It is, after all, standard because it successfully gets students to think about issues in a way that they may have never known existed. But working through these more ordinary problems that often fall by the wayside in the “big issue” discussions helps students accomplish those same goals.
Like most other Medical Ethics courses, we talk about reproductive ethics and we did spend time working through both the legal and moral issues around abortion access and prenatal screening. But I also build that class around what options counseling is to emphasize that no matter what kind of medicine they end up going into, a patient may trust them enough to talk about an unplanned pregnancy or they may just happen to be the person the patient tells while going for physical therapy. Obviously, one class isn’t enough to prepare them for that conversation, but it does help them workshop questions and reflect on presuppositions they may not have been aware of.
I also direct the discussions around infertility and pregnancy loss, both topics which are common, but lack a well-developed and socially widespread vocabulary. Here too, it’s less about making sure they leave the class with the right answer about any of these issues and more about helping them prepare for how to be present with the real people they will be with when they start practicing. In some cases, that means knowing what not to say. A common theme in the pregnancy loss narratives we read is that however well-intentioned “you can always try again” is, it just makes people feel worse. So, we also cover knowing when to say you don’t know what to say while adding that you want to know what would help that person in that moment. On occasion, a student will stay after or send me an email talking about how they recognized themselves in the readings about pregnancy loss. After reading Tressie Cottom’s experience with perinatal grief, one student mentioned that she cried all the way through it because it was close to being her when she was in high school and she was grateful (not the right word, but here too we don’t have a good moral vocabulary) to know it wasn’t just her.
It’s not, of course, all success. As I said above, some of the conversations are emotionally challenging not just because of the content, but also because students start discovering implicit biases they may have had about topics—treating the patient who was housing insecure, gossiping about and googling the patient’s criminal background records, or which patients “just waste resources.” They feel safe enough to be honest enough with those beliefs and it’s not about making them ashamed or embarrassed, but it does take patience and a lot of classroom management to make sure discussions don’t go off the rails. That being said, even getting them to pause on those beliefs and critically reconsider them (with me or on their own) is a resounding philosophical win.
Many of my students will learn about these problems on the job. And by no means do I think my course is a substitute for any of these experiences. While I do include formal moral theories in the course and I would be thrilled if they could remember what “justice as fairness” means ten years (or six months) after the course is over, I am far happier when students email me to tell me that they remember one of our case studies, examples, or discussions because it helped them make a patient feel less afraid and more like a person.
Kurt Blankschaen
Kurt Blankschaen is an Assistant Professor at Daemen University. He primarily teaches classes on ethical issues in medicine and medical humanities. He has overlapping research interests in how marginalized communities access healthcare, how gender and sexuality affect participation in religious communities, and the extent to which categories or identities in healthcare (e.g., mass shooters, innocent victims) are socially constructed.
