D evelopment of Moral Reasoning during Medical Education
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Transcript of D evelopment of Moral Reasoning during Medical Education
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