Ethical awareness among first year medical, dental and nursing students

Inr. J. Nun. Stud.. Vol. 32, No. 5, pp. 506-517, 1995 Copyright Q 1995 Elsener Science Ltd Prmted an Great Britain. All rights reserved 002&7489/95 $9.50+0.00

Pergamon 0020-7489(95)00012-7

Ethical awareness amongJirst year medical, dental and nursing students PETER W. NOLAN, R.G.N., D.N.(Lond), Department

of’ Nursing

JANE SMITH, The Medical

School,

Studies,

Ph.D., M.Ed., B.A.(Hons), B.Ed.(Hons), R.M.N., R.N.T. The University

of Birmingham,

Birmingham,

U.K.

Ph.D. The Uniwrsity

of Birmingham,

Birmingham,

U.K

is increasingly being included in the training curriculum for health-care professionals. However, debate continues around the appropriate content of ethics courses for such students and the most relevant teaching approaches which will enable students to apply their ethical knowledge in clinical settings. At a time when health-care professionals are starting to collaborate more closely in multidisciplinary teams, it is appropriate to explore the ethical values held by different groups of heath professionals. This study sought to ascertain the ethical views and knowledge which medical, dental and nursing students have at the commencement of their training, to establish their opinions on the most important areas of ethical debate in contemporary health care and to examine their ethical reasoning in response to a series of vignettes. Students gave detailed answers to the questionnaire and the data they provided furnishes useful material for those designing and teaching ethics courses. Abstract-Ethics

Introduction

Despite the growing interest of health professionals in ethical issues relating to health care, there is still much uncertainty about the ideal conditions under which students acquire the skills of ethical reasoning. Although there is some literature indicating that ethics can be 506

ETHICAL

AWARENESS

AMONG

FIRST

YEAR

MEDICAL,

DENTAL

AND

NURSING

STUDENTS

507

taught, there is little research supporting the notion that teaching strategies actually increase student sensitivity to and response towards ethical dilemmas (Hebert et al., 1990). That they should acquire such skills is essential as they face the many challenges posed by a resource-limited health service and daily advances in medical technology. Only limited reference to health-care ethics has been made in the many policy documents which have been issued in Britain during the last 10 years and there appears to be an unspoken assumption that individual health professionals will be able to resolve the ethical dilemmas they encounter. All the professional bodies responsible for the content of various health-care courses recommend that an ethics component be included, but are rarely explicit about what should be taught. The General Medical Council, for example, has recently decreed that ethics should form a central part of the medical curriculum; however, it leaves it to the discretion of those who draw up courses for medical students to decide what should be taught, how, the amount of time to be devoted to ethics courses and whether or not they should be formally examined (Tomorrow’s Doctors, 1993). It would appear that the situation is similar in other professional groups allied to medicine (PAMS). Although attempts to improve the teaching of ethics have been reported, they remain idiosyncratic and uncoordinated. Some courses have been developed without the expertise of staff with appropriate philosophical training. Others have been allocated insufficient time to permit ethical analyses of issues (Grant, 1989; Osborne and Makin, 1989) reflecting the reluctance of those who teach the traditional medical disciplines to create space for the inclusion of ethics. Any subject which is taught by people with no in-depth knowledge of it, and which is not examined is inevitably devalued in the eyes of those studying it. Seedhouse (1991) noted that those medical schools which taught ethics allocated only a few hours for the course which generally comprised less than 0.1% of the undergraduate programme. Attendance at the course was usually not compulsory, nor was it examined either formally or informally (Seedhouse, 1991). Traditionalists have argued that the value of introducing moral philosophy into the curriculum is questionable and deprives the ‘essential’ scientific subjects of the time they require. Young professionals are increasingly aware that health care is not a value-free activity, but is delivered according to the political, social and moral values and beliefs of the institution or person providing it. The recognition that the delivery of health care involves many inequalities, such as ease of access to services and ability to obtain a quality service, is now motivating professionals to reconsider the importance of education in ethical reasoning to assist them in their daily practice. As the influence of consumer organisations has grown stronger, health professionals have had to hear the message that clinical well-being is only part of the general well-being that patients seek and expect from health services. Three problems confronted the authors when charged with the responsibility of designing courses in ethics for medical, dental and nursing students during the early 1990s. The first was to find sufficient time in an already overloaded curriculum to allow students to reflect seriously upon ethical issues and relate them to their professional practice. The second was to decide whether ethics should have the status of an optional or a core subject in the curriculum, and whether it should be taught as a discrete subject or introduced into every aspect of the curriculum including clinical practice. The third was to consider the content of the ethics course and the process by which it should be taught. Although these areas have been touched upon in the literature to varying degrees, few studies have examined the expectations and experiences of those at the centre of the educational enterprise, namely

508

P. W. NOLAN

and .I. SMITH

the students themselves. This study aimed to address the third question posed above, and was based on the premise that to consult those who are receiving education about their educational needs is an essential prerequisite when designing courses for adults. Its contribution to the debate on ethical education is, therefore, via an exploration of the ethical values which students bring to their professional studies and their expectations of an ethics course. Little is known about the values which students hold prior to training as health professionals. In the absence of such information, it is impossible to assess whether a change has occurred in students’ ethical thinking by the time they have completed their studies, Before attempting to design an ethics course, the authors needed to know more about the students than could be gleaned from their UCAS (Universities and Colleges Admission Service) forms. For example, who had most influenced their moral development? what did they consider to be the major ethical dilemmas in health care today? what expectations would they have of an ethics course and what would they hope to derive from it? The literature

Self (1988) suggeststhat many teachers of ethics tend to focus exclusively on curriculum

content and teaching methods, and to disregard the considerable contribution that students themselves can make to such courses. Self argues that students come to their courses already primed with ethical values and often with a very clear idea as to the place ethics should have in the curriculum. The study concludes that some students are resistant to ethical education, fearing perhaps that lecturers will attempt to indoctrinate them into their own views, and believing that, in a multi-ethical society, each individual’s value system deserves equal respect. Grundstein-Amando (1992) found that not only were there differences between students taking different health-care courses, but also differences between members of the same groups. Nursing students varied greatly as to how they defined an ethical problem, why it was seen as an ethical problem and what would be considered a satisfactory resolution. She concluded that much that passes for poor communication amongst professionals should more properly be attributed to their acting out of different values and motivation: Nurses arc motivated in their ethical behaviour responsiveness and sensitivity to the patient’s

by the fundamental value of caring which wishes. Doctors, in contrast, value above

entails all the

patient’srightsandthescientificapproachthat impliesa majorconcernwith disease andits cure (Grundstein-Amando,

1992).

Gilligan (1982) went some way towards explaining why there might be differences within groups. Women, she observed, tended to see morality in the context of particular relationships which she described as the ethic of care, while men subsume it into their view of justice and impartiality with its attendant obligations and rights. Kolhberg (1971) argued

that a personal morality has little to do with gender differences between people but is largely dependent on the individual’s stage of intellectual development and on the contemporary social and educational climate in which they were reared. He claimed that those capable of processing information at the level of formal operations will be more advanced in their moral development than those operating at the concrete level of thought. Environments providing opportunities for group participation, shared decision making and assumption of responsibility for the consequences of actions stimulated the development of higher levels of moral judgement. Acquiring ethical reasoning skills argued Grant (1989) is best done in

ETHICAL

AWARENESS

AMONG

FIRST

YEAR MEDICAL,

DENTAL

AND

NURSING

STUDENTS

509

small group settings where philosophers and clinicians listen sensitively to their experiences and questions and allow ample time for inter-student discussion while emphasising that even the most experienced clinicians face ethical dilemmas. The same point was made 30 years earlier by Welbourn (1958) who decried the idea that ‘ethicists’ should undertake the teaching of ethics to health professionals. Welbourn considered that those in direct contact with the sick and the dying were best placed to teach the subject and to enable students to see that ethics is a practical subject to be applied in every day practice. A considerable body of knowledge has been generated as a result of the publication of the Pond Report (1987) which represented the first systematic survey of the teaching of medical ethics in the United Kingdom. The Report observed that good clinical practice was often hampered by ethical conflict between health-care disciplines and also amongst members of the same discipline, especially in medicine. It had no doubts about the centrality of health-care ethics in medical education, especially at a time of radical change in both the health and social services, and of considerable advances in all aspects of medicine. Pond noted that when ethics did not form part of the curriculum, students acquired ethical values which conformed to those of their peers or senior role models. Recent studies have supported this observation that students who are poorly grounded in general ethical theory, and who do not understand the formulation of ethical ideas reflect the values of others rather than developing their own (Irwin et al., 1988). Since the Pond Report, there has been a proliferation of courses on ethics which have attempted to meet health professionals’ increasing awareness of their needs to be informed in this area. Aims

of the study:

The aims of the study were: 1. To identify the values that students hold at the commencement of their professional studies; 2. To establish the differences, if any, in ethical thinking between different groups of health-care students at the commencement of their courses; 3. To identify those ethical issues about which students’ thinking is unclear. Methodology A 29-item questionnaire, consisting of both open and closed questions, was designed and piloted. The items were classified into three sections to elicit (a) biographical data about the students, (b) their perceptions of ethical dilemmas in health care, and (c) their moral reasoning around a variety of ethical problems presented to them through vignettes. Vignettes have been advocated as an economical means of discovering how people might behave in situations which would be difficult to observe in daily life (Polit and Hungler, 1989; Hebert et al., 1990). They also provide an inexpensive means of data collection. At the commencement of the academic year 91/92, questionnaires were distributed to all medical, nursing and dental students studying at one particular University in the West Midlands. A cohort of accountancy students, selected randomly from the first year intake, was also included in the study to act as a comparison. The accountancy students shared a variety of characteristics with the student health professionals; they had achieved a similar standard of academic attainment in order to enter the University; they were also similar in age range and socio-economic backgrounds. It was assumed by the authors that these students would not be exposed to and hence influenced by health-care ethics teaching during

510

P. W. NOLAN Table

1. Sample

Group

and J. SMITH

sizes for each group

Distributed

Accountants Dentists Medics Nurses

of students

Returned

% Response

24 63 53 34

30 72 170 34

80% 88% 31% 100%

their course. A modified version of the questionnaire was prepared for them. All students were informed about the project and invited to participate. In recognition of students’ vulnerability at the start of their courses, every effort was made to ensure that students did not feel under pressure to participate. A total of 306 questionnaires was distributed and 174 were returned, giving an overall response rate of 57%. Table 1 shows the sample sizes for each group of students in the study. The response from the medical students was noticeably poor, with more than two-thirds of the students failing to return their questionnaires. Such a response rate is slightly less then what might be expected from a postal questionnaire. It might be speculated that such is their pressure of work, medical students are unwilling to participate in academic activities not directly relevant to their studies. Many of those who did return questionnaires only partly completed them, suggesting perhaps that they found the questions difficult to answer or too lengthy and hence abandoned the task or felt that the questions were intrusive. Nurses, on the other hand, appear from the earliest stages of their training to be either a very compliant group or not afraid of revealing their ethical values. The nursing cohort consisted entirely of females and the return rate was a 100%. The return rate for dental and accountancy students was lower compared with that of the nurses, but both were high in comparison to the medical students. Results

The mean ages of the members of each group on entry to their courses were: accountants 19.16 years, dentists 19.52 years, medical students 18.76 yrs, and nurses 18.51 years. Four of the dentists were mature students, i.e. over the age of 25 years, and one was in his early thirties. The gender mix of the samples is shown in Table 2. Surprisingly low numbers answered “yes” to the question: “Have you ever attended a course about ethical issues or on moral philosophy?’ 4.2% of accountancy students had attended such a course; 6.3% of dentists; 17% of medical students, and 14.7% of nurses. The courses which the students had taken were, for the most part, components of the GCSE in Religious Studies and, in the case of six students, were courses followed at Sunday Schools attached to their local churches. One medical student had covered some health-care ethics during earlier training as a dentist, and another when completing the requirements for Table Gender Female Male

Accountants 33.3 66.7

2. Gender

mix of groups

(%)

Dentists

Medics

Nurses

39.7 60.3

47.2 49.1

100 -

ETHICAL

AWARENESS

AMONG Table

FIRST

YEAR

3. Work-experience

Experience

MEDICAL, prior

to commencing Dentists

Accnts

Hospital Nursing Home GP Surgery Dental Surgery St. John’s Ambulance

DENTAL

33 6

10 0.25

46

AND

NURSING

5I 1

STUDENTS

course (%) Medics 64 19 9 9 9

Nurses 41 59

9

with the Pharmaceutical Society. Students who had read around ethical issues in health care prior to starting their University courses amounted to 12.5% of accountancy students; 11% of dentists; 30.2% of medical students, and 23.5% of nurses. A considerable number of the students in all four groups had had work experience in health care prior to starting their training: 16.7% of accountants; 68.3% of dentists; 81% of medical students, and 79.4% of nurses. The authors had not foreseen that so many accountancy students would have had health-care experience prior to starting their course. This was a gross miscalculation because some accountants on qualifying seek to establish a career for themselves in health care. Table 3 shows the type of health-care work which the students had undertaken. When asked to list the major ethical debates in health care in Britain today (Table 4) students most frequently referred to abortion, issues around prolonging life and assisting death (including euthanasia), resource allocation (both of time and money), health services management, and research using animal and human subjects. The lists of issues raised by the nursing and medical students were very similar although worries about remuneration and career prospects were mentioned by some medical and dental students but not by nursing students who focused more on the adequate provision of health-care services for marginalised groups, e.g. the elderly, the mentally ill and those suffering from AIDS. Other responses less frequently given by the four groups concerned IVF, genetic engineering, private practice, prescription charges, junior doctors’ working hours and low levels of remuneration for some health-care workers. Some accountancy students expressed concern that badly needed services were not getting to those who most needed them, while dental students, many of whom expected to be working privately in the future, were unhappy about asking clients to pay for services. All four groups were in agreement that the most important influences on the development registration

Table 4. Current

ethical

health

care issues (% responses)

Issues

Act.

Dent.

Med.

Nur

Prolonging life/Assisting death Abortion Concern over the current position Resource allocation Animal experiments Genetic engineering Research on human subjects AIDS IVF Transplants

33 2s 50 25 4 4 0 8 4 0

40 38 44 24 19 14 14 10 11 5

15 68 55 23 13 19 0 9 9 I1

82 65 21 15 12 15 15 12 6 15

of the NHS

512

P. W. NOLAN Table Political

5. Political

ideology

Conservative Socialist Liberal None

and J. SMITH

leanings

of respondents

(% responses)

Accnts

Dents

Medics

Nurses

62.5 8.3 12.5 16.7

27 7.9 9.5 46

28.3 13.2 24.5 26.4

23.5 14.7 26.5 32.4

of their ethical awareness were firstly parents followed by teachers, friends, religion and the media. Preliminary data derived from the pilot study had suggested that some students consider political beliefs influence the individual’s ethical values. Table 5 shows the political leanings of the students. Apart from a large group of accountancy students who adhered to the Conservative party, the majority of the other students were largely either Liberals or undecided in their political affiliation. In response to the question: “Do you hold a religious belief?“, 50% of accountancy students said they did; 66.7% of dental students; 71% of medical students and 64.7% of nurses. Fewer, however, engaged in religious practice: 41.7% of accountants; 38% of dentists; 52.8% of medical students, and 44% of nurses. The students were asked to consider whether they could foresee occasions when their own ethical values might come into conflict with their professional codes of conduct. Table 6 summarises the responses. Less than half of medical and nursing students foresaw situations in which their own ethical beliefs could conflict with their professional duties. The majority of students either felt that there would never be any conflict or were uncertain about the question. None of the dental students expected to encounter any ethical conflict. When asked to rate the importance of including an ethics component in their professional courses (see Table 7) the majority of students responded either that this would be ‘imporTable

6. Could

Response Yes No Don’t

Table

know

personal

ethics conflict (% responses)? Dentists 0 52 47

with professional

Medics

Nurses

45 13 42

44 6 50

7. (% Responses) How important do you consider ing of health care ethics?

Response Vitally important Important Indifferent No response

Dentists 32 52 11 5

ethics

the teach-

Medics

Nurses

36 60 0 4

32 59 6 0

ETHICAL

AWARENESS

AMONG Table

FIRST 8. Priorities

YEAR MEDICAL,

DENTAL

in an ethics course Dentists

Response Acquiring rules Understanding Hearing other people’s Awareness Self development The law

Table

9. Preferred

orientation

Medics

Moral Philosophy Practical Ethics Health Care Law

STUDENTS

5 13

Nurses

25 30 30 34 28 II

24 29 29 23 12 6

in an ethics course (% responses)

Dentists

Response

NURSING

(% responses)

11 30 16 16 17 3

views

AND

Medics

Nurses

0 89 9

3 85 9

2 65 30

tant’ or ‘vitally important’ despite the fact that many of these same students apparently foresaw no ethical conflicts ahead of them during their careers. The students were next asked to consider what they would hope to gain from the study of ethics. Table 8 lists what they felt important in an ethics course. Table 9 shows the orientation which students would prefer an ethics course to take. The majority sought to develop their understanding of ethics by increasing their awareness of ethical issues and by hearing other people’s views on issues. The vignettes

The students were presented with a series of vignettes detailing contemporary ethical dilemmas and asked to consider how they would advise or manage people involved in these situations. Vignette 1 A 24-year-old woman lives by herself and is dependent on social security. She suffers from bouts of deep depression and occasional violent outbursts. Her family and friends in recent years have found her increasingly difficult to cope with and now have little contact with her. Recently she has had a brief relationship with a married man and finds herself pregnant. She is now desperately seeking advice about what to do. What course of action would you suggest,giving reasons?(seeTable 10). Table

10. Suggested

Response Abortion Adoption Allow informed Keep the child

courses of action Accts

choice

21 8 67 21

for vignette Dentists 10 5 26 I1

1 (% responses) Medics

Nurses

11 2 38 17

9 0 33 24

514

P. W. NOLAN Table Reasons

11. Factors

for responses

und J. SMITH motivating

Accts

Consequences for mother Consequences for child Against abortion Woman’s right to choose

responses

Dentists

50 42 4 17

Medic

43 19 10 41

Nurses

42 25 17 40

19 29 12 21

The accountancy students were most inclined to allow the mother a free choice in her decision regarding her pregnancy. The medical and nursing students were far more likely to want to advise her in a particular way. There was considerable controversy around the abortion issue with health-care students in particular likely to make such comments as: “I don’t believe in abortion”; “I don’t want to abort”; “The fetus is innocent”. There was no difference between the sexes in the health-care groups regarding their antipathy towards abortion. In justifying their responses to the vignette, the students claimed to have been motivated by a variety of factors, as summarised in Table 11. The nursing students, who were all women, were likely to justify their advice to the fictitious mother on the grounds of deciding what would be in her best interests, but were also much less likely than the medical and dental students to allow that she had the right to choose. It may be that female health professionals and especially nurses feel more confident to know what is best for their own sex than other professional groups -an interesting reflection on concepts of informed choice. Vignette 2

A S-year-old boy has terminal cancer. His parents have been told that he is going to die and are adamant that he should not be told the truth. One day, you are alone with him during a period of intense pain when he says: “I’m going to die, aren’t I?” What would you say to him, giving your reasons? (see Table 12). The medical and nursing students were less prepared to “tell a lie” than the other groups, but more prepared to be evasive, offering the child such responses as: “We all have to die some time”, or “What do you think?” The majority in each group did not consider the child as capable of having a proper understanding of the question he was asking and did not think he should receive a straight answer. As a whole, female students were more inclined to view the child as an autonomous individual than male students, (x2 = P < 0.001) but not female nurses which may well tie in with the female nurses’ responses to the previous vignette when they were less inclined than other groups to allow the woman the right to choose. Table 13 shows the justification given by the students for their decisions. Student nurses were also very inclined to respect the parents’ wishes regarding the Table Response Tell the truth Tell a lie Be evasive

12. Responses Accts 30 39 26

to vignette

Dentists 16 32 38

2 Medics

Nurses

30 15 51

24 9 56

ETHICAL

AWARENESS

AMONG

FIRST Table

YEAR MEDICAL,

13. Justification

Response

of responses

48 39 39 17 13

NURSING

STUDENTS

Medics

Nurses

55 40 40 27 9

15 56 56 38 12

24 48 48 9 19

child, perhaps pointing to a respect for and subservience traditionally, been associated with nursing. Vignette

AND

515

given

Dentists

Accts

Consequences for child Respect parents wishes Child not autonomous Respect child’s autonomy It is wrong to lie

DENTAL

to authority

which

has, at least

3

A multi-national pharmaceutical company is developing a new drug which it is believed will prove effective in the treatment of a frequently fatal form of adult leukaemia. In order to test the efficacy of the drug, the company’s research team proposes to conduct experiments involving mice. If theseexperiments show the drug to be efficacious, extensive safety testing will then have to be carried out on rodents and on dogs, in order to examine the possible toxic effects of the drug. All of these tests are likely to cause some pain and distress to a proportion of the animals involved, and, at the end of the tests, all of the animals will be killed to provide material for necropsy and histology. However, if the results of the animal studies are favourable, clinical trials will proceed immediately, and many human lives could be saved. Are the animal testsjustified? Pleasegive reasons(seeTable 14). The majority of students from all disciplines were in favour of the experimentation, with lessthan a quarter of health-care professionals against it. Judging from the relatively low percentage of students who did not know how they felt on this issueor did not reply to the question, it would appear that animal experimentation is an area in which students have clearly formulated ideas and convictions. It is interesting to note that twice asmany nursing students were against vivisection as medical students. Discussion

The present study clearly demonstrates that students do not embark on health-care studies, without some knowledge of ethical issues.This confirms the findings of Self (1988). The majority of the respondents had either read about ethical issues, or had followed courses at school or in church. A large number were religious believers and a significant number practised their religion. Many students had had previous experience of working in Table Response Yes No Don’t know No reply

14. Are the tests in vignette

3 justified?

Accts

Medics

Nurses

87 6 2 6

59 21 12 9

75 25 0 0

Dentists 78 11 2 10

516

P. W. NOLAN

and J. SMITH

health-care settings which might have encouraged them to think about ethical issues in relation to the health services. Students, therefore, bring with them at the commencement of their studies much valuable, first hand material which lecturers in ethics can work with when designing and teaching a course appropriate to students’ needs. Some interesting differences emerged between the four groups of students, although in many cases, there was a homogeneity about the responses given which may be a reflection of the students’ youth and social backgrounds. It may be easier for students to answer questions about ethics in a ‘politically correct’ way whilst still untested by the realities of health-care practice than later on in their careers when dilemmas such as illustrated in the vignettes have been confronted in reality. No correlation was found between the political affiliation of students and the ethical views they held. Issues around abortion aroused both the strongest feelings and the most diverse. The conflict between students’ convictions that abortion is wrong and their desire to accord the mother in the first vignette a free choice was evident from their answers and would provide excellent material for analysis during an ethics course. There would appear to be no doubt that the sex of the students played a part in their responses with the nursing group who were all female most keen to make decisions on behalf of the woman in vignette 1, perhaps in the subconscious belief that, as women, they know best for other women. Equally interesting is that the nursing students were very inclined to be evasive when answering the child in vignette 3, justifying their decision on the grounds of respect for the parents’ wish that he should not be told he was dying. Concepts of authority and the interface between the patient’s needs and the judgment of those caring for him (parents/health professionals) would appear to be an area in which nursing students bring with them strong ideas which would be worthy of exploration. In general, students would find it difficult to answer a question from a child about death in a direct way. This probably reflects the anxiety and uncertainty felt by young health professionals and adults (and many older ones) in dealing with terminally ill children. Probably one of the most stressful areas of care, students need help to understand the needs of children and to separate their own adult perceptions of illness and death from those of a child. The rights of children would be an excellent topic for discussion during an ethics course. It would seem to be far easier for students to make decisions on behalf of animals than on behalf of people, with the majority of the students being quite clear in their thinking about the justification for animal experiments. The nurses who appeared fairly sure about their own authority to make decisions for the pregnant woman in vignette 1 and to support the parents’ authority in vignette 3 were the group which was least certain about taking the authority to carry out experiments on animals. Again, this may reflect a bias related to sex since many groups which are active in such areas as animal experiments and abuse of human rights are largely female in membership. Conclusion

Now is the time to take a more imaginative approach to curricular development so as to incorporate ethics courses into the training of health professionals. Whilst it is generally agreed that ethics courses should include a brief study of Logic combined with a consideration of what is involved in responding sensitively to the needs of others, there remains a large element of uncertainty about the construction and integration into the overall syllabus of an ethics course and as to how the course should be examined. The present

ETHICAL

AWARENESS

AMONG

FIRST

YEAR

MEDICAL,

DENTAL

AND

NURSING

STUDENTS

5 17

study suggests that students have much directly relevant reading, learning and work experience which could be used as the basis for ethics courses, and that there are a variety of issues which they find both challenging and confusing. The study also suggests that further research into the differences in ethical thinking between male and female student health professionals would be fruitful and likely to yield valuable information in terms of designing appropriate health ethics courses. The study reveals areas of conflict between students’ desire to respect the autonomy of their patients and clients, and a sense, perhaps born out of their concept of the role of health professionals, that they should be telling people what to do. Some students expected that a course in ethics would tell them what to do in a variety of difficult circumstances; such a misconception should be addressed at the beginning of any ethics course. Ethics is not the study of “a set of rules for how to behave”; rather it is about developing powers of moral reasoning and applying them appropriately. The majority of students consider the teaching of ethics important and want a course which is practically based and will help them to cope with situations they are likely to encounter in their professional practice, rather than a course centring on intellectual debate about definitions and concepts of morality. It would be helpful, as a follow-on from this study if research were carried out into how students learn to apply ethical knowledge in practice. Such research would facilitate the designing of the type of ‘practical’ course in ethics which the students who responded to this study clearly want. Aclino~~~ledgements-The authors would from the Scientific Research Committee

like gratefully of the Medical

to acknowledge the financial support which School at The University of Birmingham.

they received

References Gilligan, C. (1982). In a Diff erent Voice Cambridge. Harvard University Press, Cambridge, Mass. Grant, V.J. (1989). Advanced medical ethics for fifth year students. J. Med. Ethics 15, 2OC202. Grundstein-Amando, R. (1992). Differences in ethical decision making processes among nurses and doctors. J. Adr. Nurs. 17, 129-137. Irwin, W. G., McClelland, R. J., Stout, R. W. and Stchedroff, M. (1988). Multidisciplinary teaching in a formal ethics course for clinical students. J. Med. Ethics 14, 1255128. Hebert, H., Meslin, E. M., Dunn, E. V., Byrne, N. and Reid S. R. (1990). Evaluating ethical sensitivity in medical students: using vignettes as an instrument. J. Med. Ethics 16, 141-145. Kolhberg, L. (1971). From is to ought. In Cognitive Development and Epistemology (Mitchel, T., Ed.). Academic Press, New York. Osborne, L. W. and Makin, C. M. (1989). The importance of listening to medical students’ experiences when teaching them medical ethics. J. Med. Ethics 15, 35-38. Polit, D. F. and Hungler, B. P. (1989). Essentials ofNursing Research. J. B. Lippincott Co., Philadelphia. Pond Report. (1987). Institute of Medical Ethics. Report of a working party on the teaching of medical ethics, Chairman: Sir Desmond Pond. IME Publ. Ltd, London. Seedhouse, D. (1991). Health care ethics teaching for medical students. Med. Educ. 25, 230-237. Self, D. J. (1988). The pedagogy of two different approaches to humanistic medical education; cognitive vs. affective. Theorer. Med. 9, 2277236. Tomorrow’s Doctors (1993). Recommendations on Undergraduate Medical Education. General Medical Council. London, Welbourn, R. B. (1958). A model for teaching medical ethics. J. Med. Ethics 11, 29-31. (Received

17 October

1994; accepted

in revisrd,form

9 January

1995)