Amy Caruso Brown, Assistant Professor of Pediatrics at SUNY Upstate Medical University, and our 2017 Andrew Markus visiting scholar
Two years ago, SUNY Upstate Medical University, an American medical school located in Upstate New York, underwent an intensive curricular reform. Previous required coursework in bioethics and in public health was reorganised and integrated into a new longitudinal course, spanning the first two years of the four-year curriculum. Within the course, students meet in small groups approximately once a week for three hours of discussion; each session includes two cases with a shared theme. For example, one such session focused on trauma and violence: the first case involved an adolescent who had attempted suicide, using a parent’s handgun, and the second involved a woman who survived sexual violence as a refugee and presented with chronic abdominal pain. Pairs of faculty with expertise in bioethics and public health guide students to consider not only what to do medically for the hypothetical patient but also how to navigate social, cultural, legal, and economic concerns. Working outward from the level of the interaction between the individual physician and patient, students are eventually asked to consider their obligations to advocate for individual patients, for their local communities, and for policies at regional, state, national and international levels, in order to promote human health.
Although the course is designed to be unbiased politically, the faculty do take the position that ‘medicine abstracted from the political realities of health is impotent, since the greatest determinants of health are social, economic, and political.’  Unsurprisingly, then, this approach is not without tensions and challenges. First, medical students are not blank slates: they bring a wealth of previous life experiences, including moral, cultural, and spiritual beliefs and values, to medical education and to the development of professional identity. While students’ own racial, ethnic, and national backgrounds are increasingly diverse and many students cite advocacy and community engagement as reasons for choosing health careers, others have little exposure to discussions of race, ethnicity, inequity, and social justice and more traditional expectations of a physician’s professional obligations. Second, while the worldview that informs this course increasingly permeates American medical education – manifested in a host of statements naming health equity as major ethical issue or an ethical imperative in medicine – the fragmented U.S. healthcare system is ill-equipped to support young physicians and other healthcare professionals in achieving these goals.  Furthermore, recent political events and policy changes have created a climate in which it cannot be assumed that all or most American citizens share these goals for the healthcare system.
During the first two years of the course, student and faculty feedback were generally positive, yet we puzzled over a few comments to the contrary, particularly those that indicated some content was perceived as biased. An experienced qualitative researcher, blind to the question, was tapped to observe and take field notes on several sessions; however, this approach did not yield any answers. We did note that the reactions were unpredictable. A case exploring the epidemic of lead poisoning in Flint, Michigan – intended to engage students in a debate regarding physicians’ obligations to go beyond the care of the individual patient, as well as to raise questions regarding research ethics and the public’s “right to know” – turned out to be powerfully emotional when held the day after the U.S. presidential election. Another case, involving a conflict between parents regarding whether their transgender son should receive the hormone blocking agent leuprolide to delay puberty, stimulated little debate, as nearly all students agreed that the child should decide. The penultimate case, a discussion of ‘voluntourism’ and the ethics of short-term medical mission work in low-income countries, was expected to hinge on the most fundamental of ethical principles – first, do no harm – and yet provoked the most impassioned arguments of the year, laying bare divisions between equally idealistic students, half of whom saw the sins of paternalism and imperialism in this approach to global health and half of whom saw the virtue of charity.
Recently, I turned to moral foundation theory to better understand what might be happening. [3,4] Briefly, moral foundation theory, based on the social intuitionist model of morality, suggests that everyone – including our medical students – has a set of moral foundations, or intuitions, rooted in moral emotions. Proposed foundations include care for others (or relief of suffering), fairness, loyalty, purity (or sanctity), respect for authority, and liberty. Classical Western bioethics education has a great to deal to say about three of these, particularly care and fairness, and the contemporary prioritization of autonomy can be seen tracing back to liberty. However, in many respects, we not only de-emphasise but actively undermine the others, foundations which underpin a more conservative ‘social order’-based worldview. For example, when we teach students to ‘speak up’ in the face of a potential medical error and protect patients, we teach them that caring for the patient is a greater virtue than loyalty to a peer or respect for the authority of a supervising physician.
This hypothesis is not an argument for changing the content of bioethics education but, rather, for changing our approach and acknowledging the importance of students’ experiences before medical school, in order to help them become physicians who can capably navigate the realities of pursuing health equity after medical school.
- Barr D, Fenton L, Edwards D. Politics and health. QJM: Int J Med 2004;97(2):61-62.
- American Association of Medical Colleges. Achieving health equity: How academic medicine is addressing the social determinants of health. 2016.
- Haidt J. The righteous mind: Why good people are divided by politics and religion. Vintage, 2012.
- Blum L. Political identity and moral education: A response to Jonathan Haidt’s The Righteous Mind. Journal of Moral Education 2013;42(3):298-315.