Increasing Bioethics Education in Preclinical Medical Curricula: What Ethical Dilemmas Do Clinical Clerks Experience?

Abstract

The increase in bioethics education in preclinical curricula enables medical students to recognize ethical issues and determine right action. The authors sought to explore the ethical dilemmas medical students experience during clinical clerkships. Following an e-mail invitation, 100 of 104 graduating medical students allowed their final ethics assignment, a written description of an ethical dilemma experienced during clinical clerkship, to be analyzed. After all identifiers were removed, the narratives underwent qualitative analysis and were then reanalyzed using Jameton's determinants of moral action. Four themes emerged: the clinical service rotation, target, source, and nature of the ethical dilemma. For many clinical clerks, the ethical dilemma arose because they recognized an ethical issue but neither brought it to their supervisors nor resolved it themselves for fear of incurring disfavor. The source of the ethical dilemma was most frequently the student's supervisor (46%), which may explain why, although all narratives demonstrated the Jameton criteria of "moral sensitivity" and 76% demonstrated "moral judgment," only 24% indicated "moral motivation" and only 4% suggested "moral courage." Patients were the most frequent target (76%), followed by students (14%). Students reported informed consent (18%) and inadequate care (17%) as the most common types of dilemmas under the nature theme. Clinical clerks' experiences of ethical dilemmas might be mitigated if residency education and professional development mirrored the increase in preclinical ethics education, if ethics training included encouraging students to discuss ethical issues as they arise, and if educators developed innovative models of student evaluation.