Professor Kristján Kristjánsson is professor of Character Education and Virtue Ethics at the University of Birmingham, and Deputy Director of the Jubilee Centre for Character and Virtues. Together with five other academics he recently published a major research report on the role of the character and virtues in the medical profession in Britain.
The paper was based on research involving four medical schools in the UK, and medical practices in roughly the same geographical areas as those schools. A survey was answered by 549 1st year undergraduates, final-year students and experienced professionals. 85 of those were subsequently interviewed. 66% of the experienced doctors were GPs.
Professor Kristjánsson recently spoke with BioEdge about the broader implications of his research.
Xavier Symons: Based on your research, do you believe there is there a problem with cognitive and/or deontological approaches to teaching medical ethics?
Kristján Kristjánsson: I did consider this a problem – for purely philosophical reasons – before we started the research project, and the findings provided empirical backbone to those concerns. They revealed a strange mismatch in the UK between general medical ethics (bioethics), where virtue ethics has become the theory of choice, and professional medical ethics which is still focused almost entirely on formal rules, regulations and codes of conduct, or highly abstract deontological principles (such as respect for patient autonomy).
<span style="font-family: 'trebuchet ms', geneva; font-size: medium;">"medical <em>phronesis</em> is not inborn – it requires attention and training, both in medical education and further in the workplace." </span><br />
The doctors – especially the more experienced ones – complained that the rules they had learned were too general, with no attention to particularities such as special circumstances and special personal characteristics of individual patients. They also complained about the over-estimation of compliance and the under-estimation of professional judgement. Some attention seems to be paid in medical ethics education to what used to be called “bedside manners” (dress code, manner of speaking, demeanour, politeness, etiquette, cultural sensitivity). However, between the codes and the manners the “moral middle” gets squeezed out: moral character as learning to perceive moral salience, responding emotionally in the right way and making practically wise decisions based on the most virtuous course of action. As many doctors correctly pointed out, medical phronesis is not inborn – it requires attention and training, both in medical education and further in the workplace.
In ‘Virtuous Medical Practice’ you asked doctors what they thought were the most important virtues for a medical practitioner to acquire. Was there a general consensus?
The consensus was astounding across the three cohorts, much more so than in our two parallel projects into virtues in teachers and lawyers. Fairness, honesty, judgement, kindness, leadership and teamwork scored highest as the virtues of the ideal practitioner. The respondents attributed the same strengths to themselves, except for judgement and leadership, and those also fed into the way they responded to the moral dilemmas in the survey. Some gender differences were noticed (with kindness scoring higher for women).
"Most of the conflicts that the doctors mentioned did not involve a choice between virtue and vice, but rather hard choices between two or more competing virtues."
What do you think their answers show?
They seem to show that students enter medical studies with a fairly mature and robust view of the kind of doctor they want to be, and this view does not change much during the course of their study or work experience. An anecdotal explanation could be that quite a few students enter medicine from families where a parent or a grandparent is also a doctor. Thus, professional virtues and values may filter through down the generations. On a more negative note, the most disconcerting finding of the study, in my view, was that more than 20% of experienced doctors say they (“sometimes” or “often”) experience difficulties in living out their characters, that is they fail to live up to their own ideals and moral expectations of themselves. The reasons they give are not surprising, however: too little time (to consult, discuss, treat), unrealistic targets and shrinking budgets.
Do you yourself share these doctors’ view of important virtues? (i.e. would you have selected other virtues)?
I find the above list reasonable as such. However, lists of this kind are less important than the capacity to develop the meta-virtue of phronesis for adjudicating virtue conflicts. Most of the conflicts that the doctors mentioned did not involve a choice between virtue and vice, but rather hard choices between two or more competing virtues.
"Consultation cannot be learnt from rule books, either about abstract principles or earthbound mannerisms."
Based on your research, what do you think are the most important changes that need to be made to medico-ethical education models?
The main message I take from this research is the time-honoured one that the core currency in medicine is consultation. Consultation cannot be learnt from rule books, either about abstract principles or earthbound mannerisms. It involves trustworthiness which is a moral virtue, not a rule or a codifiable behavioural procedure. At present, medical ethics education in the UK does not aid aspiring doctors in developing such virtues. In the Report, we conclude that medical ethics education needs to be more virtue based, focusing on a) virtue literacy, b) virtue responsiveness (recognising virtue-relevant situations) and c) the development of practical moral wisdom (phronesis), for example by providing time and space for medical students to discuss and reflect upon the moral dilemmas that all doctors will meet with in their practice.
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