As a former medical student – but not a doctor – studying the field of care ethics, I was always interested in bringing these two worlds together. Whereas the dominant (bio)medical ethics in healthcare revolves around four principles – beneficence, non-maleficence, respect for autonomy, and justice – care ethics questions whether morality can be derived from abstract principles and suggests it rather emerges from relational practices. As a medical student I wasn’t even aware of an, or any, alternative brand of ethics. Was it just me or was my lack of knowledge a consequence of medical education and the profession I was briefly acquainted with?
My years as a medical student had left me with a negative stance towards medical education and health care practice in general, without actually being able to explain why. My negative feelings were corroborated by several (non-)scientific sources describing harm in the medical encounter. In 2011, Elin Martinsen ((Martinsen, E. (2011). Harm in the absence of care: Towards a medical ethics that cares. Nursing Ethics, 18(2), pp.174-183.)) attributed this harm to the dominant ethics in healthcare.
She pleads to include “care as a core concept in medical ethical terminology” because of “the harm to which patients may be exposed owing to a lack of care in the clinical encounter,” specifically between doctors and patients. She leaves the didactical challenges arising from such a venture open for further enquiry. This left me with a chance to tackle both my personal questions and fill a scientific gap.
The informal and hidden curriculum of medical education
In this paper, medical education in the Netherlands is investigated through a “care-ethical lens”. This means exploring the possibility of enriching medical education with care-ethical insights, while at the same time discovering possible challenges emerging from such an undertaking. We present an overview of what is written on medical education, we describe care-ethical theories and what implementing these theories into medical education would imply, and we consider the accounts of several authors on the subject of care ethics and medical education.[pullquote]Master Care Ethics and Policy, University of Humanistic Studies.[/pullquote]
Personally, I have learnt most from further investigating medical education. Several authors offer alarming insights into its unintended, educational effects. Besides a formal curriculum or the explicated learning objectives, an informal and a hidden curriculum are also described. The informal curriculum is about the interpersonal level of teaching and learning between teacher and student. The hidden curriculum is also about learning objectives, but, as its name suggests, hidden, unintentional, and implicit.
What is so alarming about this, is that these curricula can lead to the erosion of expectations, ideals, and personal traits in students. Several examples of erosion have been described, such as the loss of idealism, adopting a ritualized professional identity, emotional neutralization, change of ethical integrity, tolerance of abuse, and acceptance of hierarchy. Students become hidebound, focused on facts, emotionally detached, cynical, arrogant, and irritable. Important to note here is that erosion doesn’t occur in every medical student nor does it always happen to the same extent.
Enriching medical education
What do these hidden, unintentional, and implicit effects of medical education imply for the possibility of enriching medical education with care-ethical insights? By connecting the collected bodies of knowledge on both medical education and care ethics, possible challenges are identified which can be narrowed down to two: didactical and non-didactical. These challenges might be overcome through focusing more deeply on the clinical phases of training and creating awareness of the medical morality and all that is implicit among healthcare practitioners.
With care ethics, we are dealing with a different way of thinking, one that deviates from what is currently dominant within the medical field, as I quickly realized leaving that field. We should not underestimate the possible resistance to a paradigm shift.
Eva van Reenen, MA Care Ethics
Van Reenen, E. & Van Nistelrooij, A.A.M. (2017). A spoonful of care ethics: the challenges of enriching medical education. Nursing Ethics. doi: 10.1177/0969733017747956