Bioethics and the hidden curriculum

The inherent significance of bioethics and social science in medicine is now widely accepted… at least on the surface. Despite an assortment of practical problems—limited curricular time compounded by increased concern for “whitespace”—few today deny outright that ethical practice and humanistic patient engagement are important and need to be taught. But public acknowledgements all too often are undercut by a different reality, a form of hidden curriculum that overpowers institutional rhetoric and the best-laid syllabi. Most medical schools now make an effort to acknowledge that ethics and humanities training is part of their mission and we have seen growing inclusion of bioethics and medical humanities in medical curricula. However, more curricular time, in and of itself, is not enough.

Even with increases in contact hours, the value of medical ethics and humanities can be undercut by problems of frequency and duration. Many schools have dedicated significant time to bioethics when measured in contact hours, but in the form of intensive seminars that are effectively quarantined from the rest of the curriculum. While this is a challenge for modular curricula in general, it can be harder for students to integrate ethics and humanities content into biomedical contexts. Irrespective of the number of contact hours, placing bioethics in a curricular ghetto risks sending a message that it is simply is a hoop to jump through, something to eventually be set aside as one returns to the real curriculum.

While partitioning ethics and humanities content presents problems, the integration of ethics into systems-based curricula poses different challenges. While, case-based formats make integration easier, they limit the extent to which one can teach core concepts themselves. For organ systems curricula, where ethics lectures often are “sprinkled in,” the linkages with the biomedical components of the course are underspecified or inherently weak. Medical ethics and humanities are diffused in actual practice such that attempts at thematic alignment with organ systems curricula often are noticeably artificial. In turn, there is an unintentional but palpable message that ethics is an interruption to medical learning. Anyone who has delivered an ethics lecture, sandwiched between two pathology lectures in a GI course knows this feeling only too well.

Finally, there is a misalignment of goals and assessment in bioethics that remains a significant challenge. Certainly, one goal of ethics and humanities education in medical curricula is to provide concrete information about legal directives and consensus opinions. Most of us, however, want to go beyond a purely instrumental approach to ethics and promote the ability to empathize with patients and think critically about ethical and humanistic features of patient care. These issues are much more important than an instrumental approach. While there are a variety of ways to assess these higher-order capacities within a course, board exams loom large in the medical student consciousness (and rightfully so). On a multiple choice exam, being reflexive about one’s ethical framework and exploring the large supply of contingencies surrounding a particular case is a recipe for disaster. In turn, I often find myself encouraging students to pursue interesting and creative lines of thought or to challenge consensus statements from professional bodies, only to end the discussion by warning that they should abandon all such efforts on board exams. Most would agree that ethics is a dialogical activity, yet the examinations with the highest stakes send hidden messages that it is formulaic and instrumental. When “assessment drives learning,” it is difficult for students to set aside concerns about gateway exams and engage the genuine complexity of ethics.

While these challenges are curricular, pedagogical, and even cultural, I think there are practical ways that medical schools, and even individual instructors, can destabilize the messages of this hidden curriculum. First, with regard to assessment, we can teach both complex and instrumental ethical methodologies. While this may appear a rather dismal prospect, it can be made respectable by explicating the conditions under which each way of thinking is useful (e.g. the former in real life, the latter on exams). Students then learn not only to turn on and off particular test taking strategies, but this also bolsters their ability to be critical and reflexive—in this case about a instrumental processes of ethical decision-making that are problematic, but nonetheless widespread, even in practice.

Second, we need to move beyond simply including more bioethics education and toward addressing its rhythms within our curricula. I have been fortunate enough to recently join a new medical school unencumbered by a historical (read: petrified) curriculum. In addition to an institutional culture genuinely amenable to ethics and humanities, our curriculum utilizes longitudinal courses that run in parallel to the biomedical systems courses. Instructors therefore have the ability to build the sort of conceptual complexity that truly attends ethics and students have the spaced practice that is key to their development. This structure therefore avoids the problems both of quarantining and random inclusion.

Finally, bioethics curricula need to develop less emphasis on information and a greater utilization of “threshold concepts”. No medical curriculum affords enough time to exhaust the terrain of bioethics and medical humanities. Certainly we need to accept the reality that we typically are not training ethics and humanities scholars, but, at a minimum, physicians with those competencies and even more ideal, physicians who embody those values. However, where the idea of delivering ethics at an appropriate level for physicians often serves as a call for simplicity, I believe it supplies a warrant for focus on our most complex concepts, which also are the most generative and useful. When training practitioners, epistemological concepts—for example, integrative and differentiating ways of thinking—often are eschewed in favor of simpler kinds of information that promote instrumental applications to situations, and a limited ability engage the messy nuances of real world situations. Richer, more complex threshold concepts—like the sociological imagination (the ability to see the interweaving of macro and micro level phenomena)—are broadly relevant and transposable to any number of complex situations.

In the contemporary landscape, few deny outright the significance of ethics and humanities in medicine. But the explicit messaging about their importance remains outmatched by implicit messages hidden in curricula. Having just returned from the annual meeting of the American Society for Bioethics and Humanities, I cannot help but feel that we are spending too much time fighting old battles by repetitiously announcing the relevance of bioethics and too little time confronting the more insidious, hidden messages nestled deeper in the trenches of curriculum and pedagogy. This is a critical challenge.