Development of Moral Reasoningduring Medical Education

Darko Hren, PhDCroatian Medical Journal and University of Split

Croatia

Moral reasoning(Neo-Kohlbergiann approach)

• 3 developmental schemae

P

PI

MN

PERSONAL INTERESTWhat each protagonist of a moral dilemma (or their significant other) has to gain or lose?

• Personal gain is the main issue• Includes only immediate surrounding

MAINTAINING NORMSTaking a broader societal perspective through adherence to norms, regulations and laws.

• Need for norms• Broader societal viewpoint• Uniform and categorical application of norms

POSTCONVENTIONALAdministration of moral ideals in a fully reciprocal way so that each member of society has an equal status

• Adhering to ideals• Generalizable ideals• Primacy of moral ideals

DEVELOPMENT OF MORAL REASONING DURING HIGHER EDUCATION

• Cross sectional studies: Rest (1979) – formal education explained 50% of variance in scores on a test of moral reasoning

• Longitudinal studies:Rest & Deemer (1986) – attending college explained 38% of variance in scores

• Educational orientation:Deemer (1987) – educational orientation explained 13% of variance in scores

• Review articles:King i Mayhew (2002) – more than 500 studies which addressed the issue of relationship between education and moral reasoning

MORAL REASONING AND MEDICAL EDUCATION

• No gains in moral reasoning scores:Self et al,1993; Self & Baldwin, 1994;Morton, 1996; Self, Olivarez & Baldwin, 1998

• Decline in scores:Patenaude et al, 2003

AIM

• Investigate the relationship between moral reasoning and medical education

INSTRUMENT

• DIT2 – Defining Issues Test (Rest et al, 1999)

• 5 short stories presenting a moral dilemma• After deciding, participants rate 12 questions for

importance in making a decision

• Scores for each schema (P, MN and PI)• Developmental profiles (predominant schema)

RESEARCH DESIGN

Year ofenrolment

2004

2003

2002

2001

2000

Times of measurement

200420032002

2nd yr.n=192

2nd yr.n=207

2nd yr.n=139

1st yr.n=131

3rd yr.n=153

4th yr.n=101

1999

5th yr.n=85

6th yr.n=77

Controlsn=298

• Same age span(18-27)• Never studied

Matchedn=75

Matchedn=61

RESULTS – AGE AND DIT2 SCORES

• Zero correlations between all DIT2 scores and age for both, medical students and controls

RESULTS – SEX AND DIT2 SCORES(M=0, F=1)

DIT2Scores

PMNPI

Med. Students

0.20*-0.12*-0.14*

Controls

0.12*-0.04-0.12*

SEX(M=0, F=1)

RESULTSScores of different generations of students at the same time point of their study

• no stat. sig. differencesP

MN

PI

Generations of students

RESULTSDifferencef between medical students on different study years

• stat.sig. difference between groups of students (F5,679=3.67, p=0.003, η2=0.03)

• stat. sig. quadratic trend (p=0.035)

• no stat. sig. differences (F5,679=0.83, p=0.527)

• stat.sig. difference between groups of students (F5,679=3.38, p=0.005, η2=0.03)

• stat. sig. reverse quadratic trend (p<0.001)

P

MN

PI

Year of study

RESULTSChanges in scores over time

• stat. sig. interaction between repeated measurements and developmental profiles at the first measurement (F1,129=14,87, p<0,001, η2=0,19)

• stat. sig. interaction between repeated measurements and developmental profiles at the first measurement (F1,129=12,58, p<0,001, η2=0,16)

• stat. sig. interaction between repeated measurements and developmental profiles at the first measurement (F1,129=8,25, p<0,001, η2=0,11)

P

MN

PI

GenerationI

n=75

Generation II

n=61

CONCLUSIONS

• ...they decrease when students enter clinical rotations, but...

• Medical students’ moral reasoning scores increase during preclinical years, but...

• ...they do not decrease below Maintaining Norms schema.

WHY?(a few speculations...)

• Clinical hierarchy

• Specific dilemmas which are not addressed• Feudtner & Christiakis (1993):

• LEARNING vs. PATIENT CARE• TEAM PLAYER vs. PERSONAL PRINCIPLES• QUESTIONING ROUTINES vs. ABSOLUTE IGNORANCE• PERSONAL KNOWLEDGE OF THE PATIENT vs. MEDICAL

KNOWLEDGE

• Hidden curriculum

• ...

WHAT CAN BE DONE?

• Small group case discussionso specific issueso as early as possible o at least 20 hours (Self et al, 1998)o vertical approacho related to students’ experiences

(critical incidents discussions)

WHAT ELSE?

• Social learning – teachers, mentors, elders, superiors...

• Hidden curriculum – research, awareness, direction

• Investigate all components which lead to moral behavior (moral sensitivity, moral reasoning, moral motivation, moral character), develop and evaluate interventions