Health ethics education - From principle to practice

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When people seek advice, diagnosis or treatment from health professionals, they are typically vulnerable because of their condition or ill-health and their relative lack of knowledge. When health professionals provide that advice, diagnosis or treatment, doing so with skill and in an ethical manner is essential for beneficial outcomes and for the community to retain confidence in their professions.   Ethical practice is indispensable for health care.

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The evolution of ethical training  and education
Before educational institutions provided training for heath care professionals, it was largely based on an apprenticeship model in which trainees learned skills and ethics by example.
Although this remains an important part of professional education, it can be inconsistent and it lacks an objective measure of quality.
Early in the last century, one response to inconsistency was the development of codes of ethics as a means of defining, by a prescription of ethical conduct, who was and who was not eligible for professional membership. These codes, and the history of their origin and use, were a source for the development of curricula in professional ethics.  However, early codes of ethics tended to be concise and prescriptive, offered inadequate guidance for multiple contexts and lacked a conceptual foundation.

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“Contemporary curricula recognise that experiential learning is essential in order to test and refine ethical knowledge and skills so that the conduct characteristic of the professional becomes part of the day-to-day practice.”
COLIN THOMSON

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Revisions in more recent decades, of which the Australian “Good Medical Practice” is a clear example, have corrected these deficiencies and inform contemporary curricula which now commonly include ethics in teaching professionalism.
Curricula have, however, retained both instructional and experiential forms of education of health professionals.  It is widely accepted that the institutional stage should include formal instruction on the principles of professionalism.  This builds on the conceptual foundations of contemporary codes of ethics and introduces, by hypothetical or real examples, the complex intellectual and moral task of applying principles to practice. An important aim of this phase of education is to equip students with abilities, first, to identify ethical questions that clinical contexts present and, second, to deploy the ethical principles relevant to those questions in developing and justifying their answers.  It might be called learning the principles of professional practice.
Assessment and experience
A critical test of success of such education will be whether the essential features of these conceptual frameworks can withstand either the influence of role models that students encounter among their instructors or clinicians in early short-term clinical experience or the emotional pressures of personal responsibility in later, longer term, clinical placements. These influences can help students to refine and modify conceptual frameworks to be more realistic. However, the primary goal of the instructional phase is to establish a robust and resilient approach to ethical challenges so that one difficulty facing institutions is how to assess professionalism before students have been subjected to those influences and pressures.
Contemporary curricula recognise that experiential learning is essential in order to test and refine ethical knowledge and skills so that the conduct characteristic of the professional becomes part of the day-to-day practice. Accordingly, curricula include multiple periods of clinical experience, with gradually increasing responsibility, and also foster self-reflection. Completion of these phases might be called learning the practice of professional principles.
Continuity
An effective program of training in professionalism requires a continuous and co-ordinated program throughout the instructional and experiential phases so that knowledge at the level of framework formulation is reinforced and refined through reflection on the fit between principle and practice.  Learning needs to be consistently supported through the curriculum in two important ways. First, there need to be discussions, seminars, reflective journals and instruction.  Second, and of more importance, students need to see that the subject of professionalism is consistently recognised and practised by training staff at all levels. Accordingly, establishing effective teaching programs in professionalism requires careful long-range planning and persistent attention to its delivery.
Professionalism is sometimes described as the foundation of the contract between health professions and society – the contract that grants to those professions a monopoly in providing health care in return for a commitment to the welfare of patients. Professionalism is the basis for the expectations of patients, the obligations of health professionals and the trust of society in the professions.  The final outcome of a program of training in professionalism might be called the principled practice of professionals.

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Colin Thomson
BA, LLB, LLM (Sydney)
www.ehealthinfo.gov.au
Colin Thomson, BA, LLM (Sydney) is Professor of Law at the University of Wollongong and Academic Leader for Health Law and Ethics in the Graduate School of Medicine.  He also works as a consultant.
He was a member of the Medical Research Ethics Committee (1988-91) of the National Health and Medical Research Council and, from 1998-2002 a member, and from 2006-2009, chair of the Australian Health Ethics Committee.  As a consultant, he has advised NHMRC, FaHCSIA, Health Departments of NSW, Qld and Vic and several universities. He is a Senior Consultant with Australasian Human Research Ethics Consultancy Services  (www.ahrecs.com).
Colin has provided training to human research ethics committees, chairs the CSIRO Social Science HREC and is a member of HRECs at Department of Health and Ageing and University of Wollongong/Illawarra Shoalhaven LHD.
He is a joint author of Good Medical Practice: professionalism, ethics and law, 2010, Cambridge University Press.