Professional Values and Ethics in Medical Education

Abstract

Medical ethics, professionalism and values have been commonly attached to medicine since its ancient era. These terms, although they differ, have been used in medical literature to refer to the right way to do the right thing by medical professionals. Professionalism was and still is one of the major aims of medical education. It refers to a complex process by which medical professionals acquire and apply the essential knowledge and skills together with acceptable values and ethics to serve society. However, teaching and assessing professionalism is not a straightforward mission. The complexity of it comes from its real nature being affected by many factors in multiple dimensions, including individual, interindividual and the larger societal or institutional levels. In this chapter, I describe the interaction between these factors after shedding light on the different interrelated terms. I also highlighted the advances and recommendations regarding teaching and assessment of professional values in the field of medicine.

1. Introduction

Ethical principles have long framed medicine. The Hippocratic Oath, 400 BC, reflected the constant goal of medicine ‘I will use treatment to help the sick according to my ability and judgment; I will keep them from harm and injustice’. This oath is based on beneficence, non-maleficence, justice and respect for the patient’s autonomy with its two rules of confidentiality and veracity. Looking at this, medicine is commonly perceived as a respectable profession that best serves society. Doctors are expected to perform procedures and take decisions based on their professional education and training. They are usually assumed to do all that is right in the right manner. Therefore, certain values characterise medical professionals and even medical students as they collectively form a special society with specific characteristics. When we look at this society one would assume that they attain sophisticated knowledge and they have special skills that an ordinary individual would not easily acquire or apply. The white coats usually symbolise highly respected professionals. These professionals besides their knowledge and skills are commonly perceived as being wise and strive to do the right things. It is not uncommon for patients seeking treatment to trust their physicians and let them decide on and carry out the best options in the right manner based on their experience. The physicians’ presented behaviour and ethical values are affected by multiple factors. Understanding the dynamic nature of professionalism would aid its teaching and assessment and therefore, its acquisition by medical professionals.

In this chapter, I describe ethics, morality and professionalism based on medical literature. In depth contemporary categorisation of medical values is discussed. I also highlighted the advances in teaching and assessing professional values.

2. What are the differences between ethics, morality and professionalism?

Ethics, morality and professionalism are frequently encountered terms when discussing what is right and wrong. Although sometimes these terms were used synonymously, there are some differences between them. I will describe these differences in a simple way. Members of a particular profession are governed by a set of values or principles, duties and obligations based upon standards of right and wrong. These sets of standards are known as ethics, and they are formulated by the governing council of a professional group. All professions have a known Code of Ethics that characterises professions and reflects a high level of trust between professionals and their clients [1]. Morality on the other hand reflects the individual values and conduct that people believe in when deciding good and bad behaviours. Morality is deeply rooted within the individuals themselves rather than being proposed by governing bodies [1]. The last term proposed here is professionalism. This term has a wider aspect when compared to ethics and morality. It includes both mastering biomedical aspects (knowledge and its proper application), psychometric aspects (mastering of specific skills) and humanistic aspects (attitude, behaviour, virtues and characteristics), desirable among professionals. The usual definition of a profession is that it is a vocational occupation characterised by specific knowledge and skills specially devoted to this specific field, which comprises autonomy and self-regulated bodies. All this knowledge and skills are serving the good of the public [2].

Medicine is a speciality which has long been known to focus on professionalism, representing a trustworthy relationship between physicians and their patients. Acceptable conduct or traits constituting professionalism were imperative to health professions. However, professionalism, per se, was not the focus of medical education 30 years ago. This state remained until the American Board of Internal Medicine (ABIM) started its humanism project in the early 1980s, which led to Project Professionalism in the mid-1990s [3]. Although professionalism is actually one of the 11 values encountered in healthcare professions literature [4], the term professionalism was also used synonymously in medical literature to refer to sets of values that are collectively acceptable by medical professionals. I suggest that using the term professionalism to refer to multiple professional values might reflect that medicine is an autonomous profession that is characterised by its ethics and values.

There is a large amount of literature on professionalism in medicine as old as 1890. However, these were mainly common advice to doctors and medical students towards doing what was socially acceptable and what was the right thing to do such as being honest and maintaining the patient’s dignity as Cathell reported over a 100 years ago [5]. Professionalism was, and still is, generally perceived as a developmental value that medical students informally and passively catch from their educators [6]. Despite the increasing interest in professionalism, a consensus about the proper definition is still lacking in medical literature [3]. There are more than 20 different definitions for professionalism in medical literature reflecting the different aspects of it [3, 7]. Some of these definitions simply refer to the constitution of the contract between the profession and the society [8, 9]. Burak et al. [6] found 90 constituent elements of professionalism in their review of medical literature. Altruism, accountability, respect and integrity were among the most common elements. They identified three types of professionalism based on the nature of interaction. Interpersonal professionalism reflects meeting the demands for adequate contact with patients and other healthcare professionals. Elements such as altruism, respect, integrity, service, honour, honesty and compassion were related to this type. The other type is the public professionalism, which is expressed by meeting the demands society places on the medical profession. Elements related to this type include accountability, submission to an ethical code/moral commitment, excellence and self-regulation. The last type is intrapersonal professionalism perceived as meeting the demands to function in the medical profession as an individual including lifelong learning, maturity, morality, value of medical work intrinsically, humility and critique as common elements. The discipline that deals with the practical application of professional ethics is known as clinical medical ethics. Its main aim is always to ensure that the right and good decisions are taken for individual patients’ cases, which in turn improve the quality of the healthcare provided [10].

3. What values are encountered in medical professions?

It is a common practice to refer to lists of values, traits and behaviours when discussing professionalism in medical education. This practice has its advantages and limitations. On one hand, analysis of the data having these lists of measurable behaviours that reflect certain values would formulate the basis for teaching and assessing medical professionalism for certification. However, there is a need to implement the internationally accepted and agreed-upon list of values to aid in teaching professionalism in medical curricula [11, 12]. On the other hand, it would be unwise to limit the definition of professionalism in such a manner. Focusing on these lists would mask the interactive and developmental process of professionalism.

Is attaining the listed behaviours enough to reflect the level of professionalism? To answer this question, we must immerse ourselves in professionalism and its sociological perspectives. Martimianakis [5] argued that there are competing and unstable factors affecting professionalism. These factors are related to the individual traits of the professional, the available facilities of the healthcare organisation and the power of assessing individuals related to race, gender and class.

As discussed earlier, a long time ago central values were attached to doctors such as beneficence, benevolence, respect and concern for patients, truthfulness, friendliness and justice when treating their patients [13]. Technical, interpersonal and humanistic values are all required to ensure the best care delivery to society [7]. To start discussing the professional values related to healthcare, we should highlight the definition of values. Values usually refer to the right and acceptable thing to do with a consensus in society. Values are prominent in everyday activities. They guide the evaluation of people, choices and actions and influence their behaviours [14].

The nature of the doctor-patient relationship was categorised by Drane [13] into 6 dimensions: medical, which represents diagnostic and therapeutic acts; spiritual, the verbal communication between the two; volitional, the decision of the doctor and the patient; affective, reflecting the feeling associated; social, the broader aspect of medicine towards the society; and lastly a religious role that sometimes played by doctors in some cases. We should also differentiate between personal values, which guide an individual’s behaviour and personal choices [14], from professional values, which govern their behaviour as members of a profession [15]. Both types of values affect the decision-making process taken by clinicians. Therefore, personal and professional values are equally important to be clearly understood and assessed in medical education. Healthcare specialties share relatively similar professional values with some differences in prioritising them and focusing on specific profession-related ones. Common principles such as putting the patients’ interests above self-interests, avoiding harm to patients and equitable access to healthcare, are shared and applied to all healthcare professions [16].

Understanding professional values is important to medical educators so that they can teach and ensure the development of these values in their students, which in turn guides them through their profession and highlights the importance of a patient-centred approach in healthcare [17]. Since 1985, Braithwaite and Law [18] identified ten broad values, or value types, which describe motivational goals responsible for the decision-making process in all cultures. Moyo et al. [4] proposed a theoretical framework of values applicable to health professions based on Schwartz’s values model, which describes these values after adding an eleventh value type ‘spirituality’ to the list. However, this value type was not consistently perceived across cultures [19]. Moyo et al.’s Healthcare Practioner Values Framework aimed at implementing a universal and sharable framework through health professions, which can facilitate the delivery of integrated healthcare [4] and interprofessional practice [20]. This framework categorises certain values common in healthcare professions. Figure 1 illustrates these healthcare practitioner values and their aligned values in the Schwartz model. The relations between these values were also described in the framework, adapted from the Schwartz model. Four motivational goals, each comprising a group of values, were described and their positions in the sphere reflect their relation. Adjacent goals show greater compatibility and their values related to each other, whereas, opposing goals in the sphere contain values with greater conflicting relations e.g. openness to change opposes conservation and self-enhancement opposes self-transcendence. The different values are categorised into four main groups of conflicting pairs as follows:

• Values that serve individual interests, which are known as self-enhancement conflict with values that serve collective interests referred to as self-transcendence values.

• Values that highlight independent thoughts and flexibility to change, which are known as openness to change values oppose values that emphasise self-restriction, order and resistance to change representing conservation.

Figure 1.

The healthcare practitioner values framework. Adapted from Moyo et al. [4]. Motivational goals are present in frames at each quadrant of the sphere. Each goal comprises number of values. Values between brackets are special for the healthcare practitioner. They are written below their corresponding values commonly found in individuals derived from Schwartz’s structure of value relations [19]. Adjacent values show greater compatibility. However, competing values are located opposite to each other. The projected behaviour of an individual is a result of the interaction between these values.

Within these groups, there are 11 values derived from values presented by healthcare practitioners. These value types are namely: authority, capability, pleasure, intellectual stimulation, critical-thinking, equality, altruism, morality, professionalism, safety and spirituality [4].

In the proposed framework these values were structured as follows:

• Authority, capability and pleasure into the group of self-enhancement values as they emphasise advancing self-interests

• Equality and altruism into self-transcendence values as they emphasise concern for the welfare and interests of others

• Critical-thinking, intellectual stimulation and pleasure are grouped into openness-to-change values as they emphasise independent action, thought

• New experiences; and spirituality, morality, professionalism and safety are grouped into conservation values as they emphasise order and preservation of traditions.

• Pleasure is placed in both self-enhancement and openness-to change groups, as it shares emphases with both groups

From the previous discussion of human values, we understand that the nature of the presented behaviour or action is based on the conflict or enhancement interaction between the different values. Therefore, applying clinical ethics is not a direct process. Rather, the interaction between many factors plays important roles in this process. Clinicians try to make their decisions based on medical and scientific facts. Moreover, the preferences, values and their nature discussed earlier, and the goals of both the physician and the patient are important. Their decision is also affected by external constraints, such as cost, limited resources and legal duties, that may shape or limit choices [10, 21].

4. Teaching medical ethics

Nowadays, the focus has been given to the humanistic values in medical literature and little to the technical ones, because the latter were kind of normally expected by patients when they seek medical treatments by healthcare services [22, 23]. With the changing goals of medicine towards a more patient-based approach, professional ethics should be applied besides clinical competency and dictate the physician-patient relationship [24]. As old as the 1970s medical educators reinforced the importance of teaching ethics. In the late 1980s and early 1990s, there were repeated calls for the formal education of medical ethics in medical schools [25]. Gazibara [26] described the need for a holistic approach in contemporary education. In this approach, certain important qualities were compared to the active components of human presence: the heart (values), head (knowledge) and hands (skills). All of these contribute to the values necessary for the development of professionalism.

Nevertheless, dilemmas and conflicting views are present as to whether ethics can be effectively taught or not. Can we anticipate that when medical ethics are taught, medical students will have ethical values when practising medicine? Is there a difference between good doctors and doctors who perform well? Is it a skill that can be taught and applied later in training or values that characterise the identity of medical professionals? These questions will lead us to think about the nature of ethical value education. The focus here would be the effect of individual values and personality. It was found that medical students caught for unprofessional behaviours during their undergraduate study were more inclined to do the same after they graduated [27]. This argument further stresses the effect of individual values that tend to be stable. Another issue surrounding the teaching of medical ethics is, if we can formally teach and assess ethics as tools present in the curriculum, are we neglecting socialisation in the development of these values? The complex and multidimensional nature of professionalism together with the present lack of consensus about what constitutes professionalism adds more difficulties to teaching it. In addition to all these factors, it would be unwise to underestimate the effect of hidden curriculum. A hidden curriculum can adversely affect the acquiring of ethical values in medical students when the teaching faculties do not appreciate the role of the hidden curriculum, which should be aligned with the formal instructions [25].

It is recommended that teaching medical ethics should start early in medical schools and continue throughout undergraduate and postgraduate study and training [1]. Instead of having lists of theoretical medical values, teaching ethical values should focus on applying them in clinical situations where they are practically applied in the real world [28]. Another recommendation in teaching medical ethics is giving full attention to hidden curriculum, by playing not only role models by the faculty but also by engaging all educators and students in making up a culture of medicine representing ethical values. Teaching ethical values is an integrative and comprehensive process. It should be directed towards raising sensitivity, providing knowledge, facilitating reflection, decision-making and improving action and behaviours [29]. This teaching still needs support from educational organisations. It could be facilitated by directing the learning towards relevant ethical problems regularly encountered in clinical settings and including modalities that encourage knowledge and skill development [30]. However, studies have indicated that there is low consensus among doctors in solving a wide range of ethical dilemmas encountered daily. This further indicates the need to address more ethical dilemmas, other than the classical dilemmas dealing with death and life, when teaching medical ethics [31].

There are different designs and course contents applied in medical schools regarding teaching medical ethics [30]. The different modalities involved, regular instructions and knowledge of the ethical values by lecturing and seminars, whether in person or online, the use of simulation and the presenting of real-life scenarios that involve students’ discussions and reflection, with the latter proved to be more effective in developing the students’ ethical behaviours [29, 30]. Problem-based learning and narrative reflections were also effective modalities that could be used to teach medical ethics [30, 32, 33]. Programs for teaching professional medical ethics have involved teams of faculty, residents and students in a longitudinal curriculum, focusing on the shared real experience of the members and the associated reflection by the students. This was thought to be effective in creating a medical school environment around professionalism [34]. Small group discussion is another modality that is thought to facilitate the discussion and reflection by students, especially for sensitive ethical issues that one would avoid discussing on a large scale [35]. Some innovative strategies, such as team-based learning were used to teach medical professionalism and found to be effective [36].

Searching the literature on medical education over the last five years led to some insights into how to develop ethical values in medical students. Some teaching experiences were found to enhance the appreciation of medical ethics by students, such as patient-led educational sessions. It also was found to aid the development of professional identity by role-playing [37]. Interventional workshops designed for fostering the development of professional values in medical students were also found to be effective in raising the students’ positive attitudes, subjective norms, perceived behavioural control and intentions [38]. Measures to teach professional values may require adjustment of the medical curriculum to integrate more professional values of social accountability such as relevance, quality, equity and cost-effectiveness in the regular curriculum. These measures were found to be effective when they were applied to a problem based learning (PBL) curriculum [39]. In including the socialisation aspect of professionalism, I found a single study in medical education literature. This study used an innovative especially designed co-curriculum program with experiential learning opportunities in social settings during summer time. This was found to be effective in enhancing medical students’ socialisation skills and teamwork, all of which contributed to their professional development and aided hominisation of medical curricula [40].

In conclusion, despite the serious attempts regarding the teaching of medical ethics, this practice is still not precise and not officially included in medical curricula [1]. Lastly, although one can assume that ethical education increases ethical sensitivity and the ability to detect an ethical problem, it is not obvious that education influences the development of ethical behaviour in medical students [41]. Therefore, the International Ottawa Conference Working Group on the Assessment of Professionalism recommended that research should be directed towards distinguishing what values are amenable and therefore can be taught from those which are deeply rooted in individuals and unable to amend. In this case, they should be included in the selection criteria during admission [42].

5. Assessing professionalism

As Arnold [3] stated ‘Without solid assessment tools, questions about the efficacy of approaches to educating learners about professional behavior will not be effectively answered’. Assessment of professional values is important to guide medical educators during the teaching of these values. It also helps to discover the level of professionalism in practitioners and facilitates the development of problem-solving skills [4]. Furthermore, research in the assessment of professionalism highlighted that high levels of professionalism were associated with better clinical performance by medical students [3, 4]. It is also highly recommended to implement formative assessment because medical students can benefit from the feedback that they receive during this process in managing their behaviours [42].

However, it is very difficult to agree upon the best practices to assess professionalism. The difficulty reflects the complex nature of this phenomenon. Professionalism encompasses a wide range of aspects, starting from the individual level, which includes attributes, capacities and behaviours. It extends to the interpersonal domain, involving interactions with other individuals and various contexts. Finally, it reaches the macro-societal level, where concepts like social responsibility, morality, political agendas and economic imperatives come into play. Additionally, these domains interact with each other. For instance, an individual’s professional behaviour can be influenced by the context they are in, and similarly, the individuals within an institution can impact its collective professional values [42]. In order to assess this phenomenon, it would be beneficial to have lists of measurable behavioural expectations that are derived from each proposed value [43].

Regarding the available assessment tools for professionalism, a variety of them are developed and used for three specific intentions. Some of these tools were directed towards measuring professional behaviour as a component of clinical performance. The other type focuses on assessing professional behaviour, as a comprehensive entity in itself. The last type aimed to assess only single components of professionalism [3].

Professionalism was used to be assessed as a stable characteristic of an individual rather than assessing the professional behaviour of the individual [44]. Educators who support this view focus on assessing professionalism as a stable trait that is inherently present or sometimes developed in individuals. Therefore, they stress the importance of assessing professionalism for applicants in medical schools before their admission. For this group, who believe in the individualist approach, many tools are used, up to 88 scales and ratings [45]. Recent research showed that very short answer questions can also be used to assess ethical reasoning in medical students [36]. Most of the available assessment tools are criticised for their validity, reliability and their theoretical basis [46]. We now understand that professionalism is a complex construct that involves knowledge, values, attitudes and the ability to employ professional behaviours in real practice settings. Assessing professionalism as an individual construct by focusing on behaviour alone misses the complexity and multidimensional nature of it. In reality, the expressed behaviour resulted from conflicts between values, and for this specific reason, the assessment of professionalism should focus on the interaction and the conflicts between values and emotions that lead to specific professional or unprofessional behaviour, by medical students [47].

In contrast to the rigid assumption of individualist approach, a more fluid approach considers the interactions between individuals as an important factor responsible for the projected behaviours. In this view, professionalism is seen as an interpersonal process. Context is given more attention. Moreover, for the assessment tool to be reliable it also should consider the task-dependence nature of professionalism and its environmental factors [3]. Professionalism is perceived as being entirely created in interpersonal interactions. Assessment should take into account assessing students’ cognitive problem-solving processes, monitoring learning environments as well as teacher-student relationships for interpersonal characteristics that could lead to unprofessional behaviours [45]. Therefore, educators who support this view argue that professionalism should not be assessed by scales at all [48]. This view suggests assessing professionalism by using data from multiple methods such as observation, conversations about behaviour and behavioural explanations, through narrative and text assessment besides using multi-source feedback [49].

The last view in the assessment of professionalism perceives it as a societal/institutional phenomenon. In this view assessment of professionalism should be directed towards fulfilling the expectations of the society or organisation. For that reason, values that constitute professionalism and their targeted assessment process may vary from one culture to another reflecting the different beliefs and interests [50]. In this view, professionalism should be assessed at a macro-level in terms of the function of groups, settings and institutions more than the micro-level of the individuals [5]. In 2011, the International Ottawa Conference Working Group on Professionalism concluded that assessing professionalism should be directed towards a multi-dimensional, multi-paradigmatic approach at different levels: individual, interpersonal and societal/institutional [42].

6. Conclusion

Medical professional values have been commonly discussed in medical literature. Medicine is well known for its ethics and values. However, we lack a consensus regarding the definition of professionalism and how it would ideally be taught and assessed. Listing medical professional values without deeply understanding their interaction and the multiple factors involved would mask the richness of professionalism phenomenon. Implementing the different perceptions of medical professionalism reflects its multidimensional nature and facilitates its teaching and assessment. In this chapter, I shed light on the contemporary view of medical values and the advances in teaching and assessing professionalism.

Conflict of interest

The authors declare no conflict of interest.