Both of New Zealand’s medical schools have well-developed and long-standing programs in medical ethics. These were developed, in part, as responses to a recommendation made by the Cartwright Report (a royal commission of inquiry into standards at National Women’s Hospital) in 1988 that the medical degree program needed to improve its teaching of ethical principles and communications skills,Footnote 1 although their development is also consistent with the relatively early interest in bioethics and ethics teaching at medical schools in Australasia. In 2001, a consensus statement on the core curriculum for medical ethics teaching was published by academics teaching ethics at Australasian medical schools.Footnote 2 This statement is reflected in the ethics curricula in Auckland and Otago. The two medical schools also draw on international statements about the medial ethics curriculum.Footnote 3
University of Otago
The Bioethics Centre of the University of Otago celebrated its 25th anniversary in 2013. Over that time, its size and remit have developed such that it now teaches in most of the health care training programs at the University of Otago (including pharmacy, dentistry, oral health, and physiotherapy) and provides a number of postgraduate courses.
In 2013, the Centre began an internal review of all its teaching in the medical program. This review was guided by the conviction that medical ethics teaching should prepare students for the ethical challenges that are encountered by physicians in the clinic and by the profession as a whole. It was recognized that in order to do this well, the teaching needed to be structured around a coherent set of course aims and learning outcomes, and appropriately integrated with the rest of the medical curriculum.
At the University of Otago, the medical students are a single cohort for the second and third years of their training, and they are taught primarily through lectures and small group tutorials. Following the review, the ethics teaching in these years has been reconceived as aiming to train students in the use of certain ethical concepts that are relevant to current medical practice, or to provide them with an “ethical toolkit.” So, although there is discussion of ideas such as autonomy, beneficence, and nonmaleficence, these are presented as concepts that are necessary for ethical understanding and good decisionmaking, rather than as principles (as traditionally described). This means that the range of ideas that are discussed can be easily broadened to include whatever concepts might be relevant to a given problem (e.g., sanctity of life, paternalism, and coercion), and, therefore, allow for the provision of a more sophisticated set of ethical tools with which to work. Moreover, it circumvents the need to explain the technical sense that “principles” have in bioethical literature, and avoids certain common confusions associated with the traditional “four” principles of biomedical ethics (such as the idea that the four principles are meant to capture everything that is ethically significant, or that ordinary ethical terms should be answerable to these principles, or that when properly applied they resolve ethical difficulties).
In the fourth and fifth years of the program, the learning shifts to a range of clinical environments, as the students are separated across three different “schools” (based around teaching hospitals) and then rotated through a series of rounds. Here, the ethics teaching focuses more on the application of ethical concepts to the sorts of ethical problems encountered in each run, and on extending the students’ ability to analyze such problems alongside their growing awareness of clinical realities. To this end, final year students are assigned the task of identifying a case from their clinical attachments that in some way prompted ethical reflection, and to analyze this case using the concepts that have been covered in their ethics teaching. This mode of assessment reinforces the need for students to personalize their ethical reasoning, and to review and apply prior learning to what they are experiencing. The assignment also provides a list of headings around which students are required to structure their analysis, and by which the grading criteria are set. This structure is intended to model good clinical ethical reasoning, and to help both students and examiners to clearly identify the different aspects of the reasoning process.
University of Auckland
The ethics teaching within the undergraduate medical program at the University of Auckland is well established, and practical in its focus. It aims to promote and encourage good ethical practice as well as to positively influence the moral behaviors and attitudes of future physicians.Footnote 4 Within years 2 and 3 (the pre-clinical years) the ethics teaching is situated within the domain of personal and professional skills. Within this domain, student learning also encompasses professional and reflective practice, health and well-being, cultural competence, and the physician as educator, as well as integrating clinical and communication skills. The ethics teaching is framed and guided by a number of important nationalFootnote 5 and internationalFootnote 6 documents.
Similarly to the University of Otago, the emphasis on ethical learning in the pre-clinical years focuses on providing medical students with a sound understanding of ethical concepts and principles, while situating them within an applied medical context. For example, the ethical basis of the duties and limits of confidentiality is discussed with students in year 2, as well as the weighing of private and public interests in the context of a given case. There is a strong focus on learning through cases, on ethical reasoning as a collective activity, and on developing the ability to explain and justify ethical decisions. Formal teaching via lectures and small group work in years 2 and 3 equips students with the content knowledge, ethical concepts, and reasoning skills needed to identify and reason through ethical dimensions of clinical practice. A range of professionals are involved in teaching, and provide different dimensions of ethical import.
As students progress into the clinical years (4 and 5), the teaching and learning focus shifts toward the clinical environment as students move among six cohort sites across the greater Auckland region, the mid-North Island, and Northland. The clinical environment provides students with a wealth of opportunities to experience the “real” world of medicine with ethical challenges routinely encountered. Therefore, the teaching and learning must reflect the actual realities facing students. The ethical framework developed in years 2 and 3 provides students with skills to recognize, address, and critically analyze ethical tensions and problems.
As they move into the clinical years, a health information management symposium in year 4 explores the safe use of patient medical information. District health board privacy officers, lawyers, and medical ethicists lead the discussions around practical cases experienced in the clinical environment. Students are encouraged to explore and discuss their responses to a number of case studies and report back to the class. “Ethics lab” sessions provide the opportunity to discuss cases that students have submitted, based on their experiences in clinical placements, in a facilitated and safe small-group environment.
In year 5, the ethics teaching focuses attention on the ethics of speaking up,Footnote 7 with a number of practical issues being addressed (boundary violations within the doctor–patient relationship, consent issues, and challenges with the hidden curriculumFootnote 8). Many cases are discussed that come directly from students or from publically available cases on the Health and Disability Commissioner website.Footnote 9 Guest lecturers are also instrumental in guiding and challenging student participation in ethical and legal discussion. Assessment of ethics in year 5 is by way of the ethics report.Footnote 10 The purpose of the report is for students to critically reflect on the ethical dimension of a clinical case or situation they have been involved in over the previous 2 years. It is an opportunity for them to demonstrate their ethical sensitivity in the practice of medicine by utilizing the ethical skills they have developed over their medical education thus far.
Whereas the discussion so far has focused primarily on the ethics teaching undertaken by ethicists within the medical program, ethical concepts and principles are also taught by clinicians within many clinical placements. For example, students within obstetrics and gynecology discuss the importance of informed consent within the context of sensitive examinations performed or observed by students. Within the psychiatry attachment, students may discuss practical issues around confidentiality, coercion, and justice within the context of mental health. Thus the ethical dimension of the medical endeavor is woven throughout most aspects of a medical student’s education.
Concluding Thoughts
The Australian and New Zealand consensus statement was published 13 years ago, and since that time, medical and ethics education have developed and matured. There is an increased awareness of the importance of “professionalism” or “professional development,” and this is reflected in more recent curriculum statements such as the revised British core curriculum.Footnote 11 The timing seems right for something similar to happen within Australasia and for the work to begin toward a revised curriculum statement.
