2007; 29: 431–436

How can we know that ethics education

produces ethical doctors?
ALASTAIR V. CAMPBELL, JACQUELINE CHIN & TECK-CHUAN VOO
Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Abstract
This article examines the challenges that medical ethics education faces, given its aim of producing ethical doctors. Starting with an
account of the ethical doctor, it then inquires into the key areas of medical students’ ethical development, viz. knowledge,
habituation and action, and describes more specific outcomes in these areas. Methods of teaching aimed at achieving specific
outcomes are also discussed. The authors then turn to some difficulties that stand in the way of achieving the desired outcomes
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of medical ethics education, and survey what has been achieved so far, by considering a number of studies that have evaluated the
efficacy of a range of medical ethics courses. The article concludes by suggesting that medical ethics education should give
attention to the problems of evaluation of ethics curricula as the discipline comes of age.

Introduction Practice points

How can we know that ethics education produces ethical
. The aim of medical education is to develop doctors who
doctors? The question presses upon us as medical ethics,
are reflective, empathetic, trustworthy, committed to
reportedly, has come of age (Miles et al. 1989; Goldie et al.
patient welfare and able to deal with complexity and
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2000). Or, if it has not come of age, it is at least in late

adolescence and moving on towards the age of full
competence. In the last three decades a remarkable develop-
ment of medical ethics has taken place everywhere in the
world, perhaps mostly in the United Kingdom, Europe and
the United States, but more widely also. Sometimes we forget
what a dramatic change it is. Consider the following remark by
the Chair of the British Medical Association Ethics Committee
some 60 years ago:
While certain established customs and even rules are
written and must be written, the principal influence
to be cultivated is that of good fellowship. Most men
know what is meant by ‘cricket’ and the spirit of the
game. Difficulties and differences will arise but most
of them can be successfully met by mutual goodwill
and recognition of the other fellow’s point of view.1
Setting aside the special puzzle of the connection in the
English mind between cricket and ethics, medical ethics has
changed dramatically over the period. To mention some
differences: firstly, there is now a wide acceptance that
medical ethics has to be multi-disciplinary and multi-profes-
sional. It cannot be the business of one particular academic
discipline or the concern of any single profession. Secondly,
it should be academically rigorous, and taught in a manner that
is clearly related to research, as the other academic subjects in
the medical curriculum must be. Thirdly, it ought to be fully
integrated into the medical curriculum both horizontally and
vertically so that there is a seamless transition between
whatever is being taught at that time and the ethical issues.
uncertainty.
. Medical ethics should be multidisciplinary and multi-
professional, academically rigorous, grounded in
research, and fully integrated into the medical
curriculum.
. Attention to evaluating ethics education is increasing,
but there is a paucity of evidence regarding the
effectiveness of medical ethics courses, and there are
numerous problems in assessment design.
. The challenge of training ethical doctors lies in a
rigorous evaluation of medical ethics teaching based
on clearly defined outcomes and valid assessment
methods.
Ethics should not be regarded as an add-on or after-thought to
the main business of medical education. A number of bodies
have recognized this, including the General Medical Council
in the UK which in its 1993 report on Tomorrow’s Doctors and
its subsequent reports has emphasized the importance of
including ethics in the curriculum (GMC 1993).
A recent survey of medical schools in the UK received
replies from 22/28 medical schools. All of the respondents did
teach ethics to some extent but, notably, there was a broad
range in terms of how it was taught, who taught it and how
frequently it was taught. Despite the fact that there is now in
Britain a core curriculum in medical ethics (Consensus
Statement by Teachers of Medical Ethics and Law in UK
Medical Schools 1998), there is quite a huge diversity in

Correspondence: Alastair Campbell, Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
Email: medavc@nus.edu.sg
ISSN 0142–159X print/ISSN 1466–187X online/07/050431–6 ß 2007 Informa UK Ltd. 431
DOI: 10.1080/01421590701504077
 A. V. Campbell et al.
Assessment Method
Action
• OSCE
• 360 Feedback
• Case Reports
• Portfolios
Habituation
• Vignettes
• Essays
• MCQs,
Knowledge
etc.
Figure 1. Learning outcomes and matching methods of assessment in key areas of medical ethics education.
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its teaching. One of the most interesting findings of the survey
was the response to the question, ‘Is it possible for a student to
graduate if they fail their ethics assessment?’ Fifteen schools
replied that they would be allowed to graduate (Mattick &
Bligh 2006). In other words, the question of whether ethics
assessment would make a difference to final graduation and
subsequent registration as a medical practitioner is still a very
open and live question. What, then, are we trying to do in
medical ethics education? To what extent can we assess
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whether or not it is doing what it ought to be doing? It may be
appropriate at this juncture to revisit the aims of ethics
education, reflect on some problems, take stock of what has
been achieved, and then attempt to paint a picture of the
future.
Aims of ethics education
Consider an ideal of the ethical doctor. Such a person would
have a commitment to patient welfare. He or she would have
an ability to deal with complexity and uncertainty. In addition,
he or she would be reflective, empathetic and trustworthy, a
description of an ideal that places emphasis on the qualities
patients look for in a practitioner. How can this be achieved?
What might be the key areas in medical ethics education, and
how might we seek to achieve outcomes in these areas? At a
conference organized jointly by the Institute of Medical Ethics,
the British Medical Association, and the Higher Education
Academy Subject Centre for Medicine, Dentistry and
Veterinary Medicine in 2006 on learning, teaching and
assessing medical ethics, three broad areas were identified,
as illustrated by an ascending pyramid (Figure 1)2 with three
levels: knowledge, habituation and action. All three of these
levels are what we need to be aiming for. At times, we can see
the impact of the irresponsible behavior of medical students
on their careers later on. From that point of view, clearly,
knowledge is not enough. Knowledge is needed for habitua-
tion, to shape the mould within which a student behaves so
that there emerges action of a kind that is clinically appropriate
and effective.
Along these lines, we can include on the bottom right-hand
side of the pyramid knowledge and understanding of ethical
principles, medical guidelines as well as historical precedents.
432
Outcomes
• Clinical ethical
competency
• Critical thinking
• Ethical awareness
• Empathy
• Knowledge and
understanding of
ethical principles,
medical guidelines
and historical
precedents
If medical ethics and law are taught together (and there is
much to recommend it), then naturally it would encompass
knowledge of the relevant legal requirements. The next level
comprises in fact three areas—the ability to empathise with
patients, ethical awareness or sensitivity, where the student
learns to spot the ethical dimensions of clinical situations, and
a habit of constructive analysis. One of the problems in much
of the ethics literature and in ethics teaching has been its
tendency to highlight dramatic situations—sometimes called
the ‘quandary ethics’ approach. Presenting cases involving
major life and death decision making enables one to get across
the ethical issues in a vivid way. But it is a fundamental point
in medical ethics that there are ethical dimensions in all
medical encounters, the non-dramatic as much as the
dramatic. Thinking of medical ethics as a subject concerned
about only critical decisions is a mistake. Habituation must also
include becoming a reflective practitioner, that is, one who has
the capacity for analysis and constructive criticism by force of
habit, as a routine aspect of medical practice.
At the top region of the pyramid is an attempt to specify
more clearly the outcome expected at this level. Here, we have
identified clinical ethical competency as a desired outcome.
This notion expresses a hope (or belief) that medical students,
once they are out into clinical practice, will practice in an
ethical manner and be able to handle the complexity of the
problems that they encounter. It is often observed that
medicine has changed so rapidly over the last few decades
that it is almost inevitable that medical ethics came to the
forefront (Cruess & Cruess 2006). Accustomed ways of making
decisions in the past relied on a relatively stable situation in
terms of the limited range of therapeutic options available to
the practitioner, and on the fairly paternalistic relationship
between the practitioner and the patient. Now both of these
dimensions have changed dramatically. The possibilities that
have opened up for medical interventions of all kinds seem to
be increasing by the day, and at the same time, an assumption
about how a patient will view a doctor and their relationship,
based on past experience, simply will not fit the present, far
less the future. It is often remarked that many patients now are
very literate and highly knowledgeable at certain levels, so that
the questions they pose to their doctors will be based on a
certain amount of medical knowledge, and certainly a very

different attitude from that of the past. Thus, clinical ethical
competency is increasingly important for preparing students
for future practice.
If the above list of outcomes is aimed at, what methods
might be used to assess them? We offer a few suggestions on
the left-hand side of the diagram. At the level of knowledge,
the essay-style question may be the best for testing an
understanding of theoretical concepts, although one can use
various structured adaptations for ease of marking. The
MCQ—so beloved of medical examiners because once you
have designed the test, you can run it through the system
without too much labour—is a very difficult measure for most
of ethics teaching, although other versions may be possible to
develop and certainly some of the core knowledge that one
would want the person to have in relation to laws and
guidelines can be tested by MCQs. At the level of habits or
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habituation, the methods of training might include case reports
by the student reflecting on ethical circumstances encountered
in clinical postings, the portfolio method that develops and
observes the student’s development over the course of the
medical training, and the writing of case vignettes which can
be used in numerous ways to test whether or not the student
actually can perceive the range of ethical questions arising
in given situations. At the top of the pyramid, that is, at the
level of action, an ethics OSCE method, despite some of its
psychometric limitations, may be one of the better ways of
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assessing competence. In addition to the ethics OSCE, the
360-degree feedback from a good range of sources may be
used to provide the student with a sense of how he or she
actually is performing in a clinical setting, as part of formative
training in this area.
Some problems in medical
ethics education
These, then, are the ways we might begin to try to answer the
question of whether or not we are achieving anything in
medical ethics education. It would be wrong, however, to
suggest that this is straightforward. Indeed, there are a number
of fairly large problems in ethics education that have to be
addressed. The first is the ‘too little, too late’ issue. As it is not
only knowledge but also habits and attitudes that are in
question, many people have suggested that we really may as
well give up, because many of these would have been so
heavily formed that by the time our students start the course,
they are not likely to change by any methods that we employ.
This may be true to an extent, but it also suggests that more
attention needs to be directed at the selection and admission of
students into medical schools. It may be that some people are
simply not suited to the kinds of demands of character that are
involved in practising medicine. Related to that is the ‘too little’
question. If we are really seriously wanting to change people’s
habitual ways of acting towards other people in a professional
context, how much time in the medical curriculum would that
realistically take? Complicating this is the large increase in the
numbers coming into medical schools. While one might work
in a more personal and focused manner with 50 or 70 students
coming in per year, the problem of ‘too little, too late’ is
Ethics education and ethical doctors
magnified (to possibly an unmanageable scale) when the
numbers rise to 250 or 300.
Secondly, the ‘hidden curriculum’ may well be more
important than anything formal that is offered (Hafferty &
Franks 1994). In the area of attitudes and habits of consultation
with patients, one can be sure that role models are going to be
widely important for students, both positive and negative ones.
It is a commonplace that when medical students are asked
identify examples of good practice in their clinical postings,
they find it quite difficult to identify even a few examples, but
when asked to identify examples of bad practice, it is often
necessary to shut them up! Perhaps this merely suggests that it
is easier to see what is wrong than to see what is right in most
settings. Undoubtedly, though, bad role models have sig-
nificant influence in the clinical years and onwards. Moreover,
peer culture is very powerful. A number of studies have
suggested that instead of talking about pre-clinical and clinical
years we should talk about pre-cynical and cynical years!
As the students go further up the course, some seem to lose
ethical sensitivity rather than gain more of it (Goldie 2004;
Akabayashi et al. 2004). This phenomenon may be due to a
number of factors but, if clinical medical students enter into a
culture that actually devalues ethics, then whatever is said in
the ethics course will make little difference.
The next problem may be termed the lack of institutional
support. Any new discipline in the medical curriculum is going
to have to fight for space and for adequate teaching resource.
The ethics curriculum may be quite resource-expensive, if it
needs to do small group teaching, especially when all other
disciplines are seeking to do the same.
Cultural issues are also an area in which much discussion
will be needed in order to ensure that what we identify as
basic principles or values genuinely reflect similarities and
differences between cultures. There is a real danger of
exporting wholesale a set of values and assumptions about
medical conduct from one culture, instead of asking how these
values might fit a particular setting, and how they would be
interpreted in that setting.
What has been achieved?
To the extent that we can overcome such problems, at least in
part, can we be confident that we have measures in place that
can genuinely assess the effects of ethics education? The
problem of the objectivity of such measures will occupy the
rest of our discussion. There is clearly an impetus for change,
with increasing attention to measuring what ethics education
is, or is not, achieving. Nevertheless, as we understand the
literature, there is a paucity of good evidence about the effect
of medical ethics courses, and there are also conflicting
findings. Some studies seem to imply that there can be a
progression; others seem to imply that in the later years (as
mentioned above), less and less effect is seen on the attitudes
and actions of students.
There are also numerous problems in design. A few
examples illustrate this. The first is a preliminary study by
Hébert et al. (1992) which tried to measure the ability to
identify ethical issues using an instrument that presented four
clinical vignettes to respondents. Sensitivity to ethical values
433
 A. V. Campbell et al.
implicit in the vignettes seemed to increase between the first
and second year, and then decrease throughout the rest of
undergraduate medical training. This study thus seemed to
suggest that in the later years, instead of getting better at
ethical sensitivity, students’ ability in this area actually declined
(possibly due to a lack of reinforcement). While this is an
important finding, Hébert et al. caution that a test of ability to
recognise an ethical issue touches on only a portion of the
cognitive aspects of ethics. There are unanswered questions
about how an attribute such as ethical sensitivity is to be
properly measured and, further, whether ability to analyse
cases corelates to acting ethically in practice.
Self and colleagues in a seminal study (Self et al. 1992)
argued that those who say that the teaching of medical ethics
cannot be objectively assessed, measured or evaluated, fail to
distinguish between teaching moral values and teaching moral
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reasoning. Self claimed that it is possible to assess the extent to
which students have developed awareness of ethical issues
and are able to apply principles to cases (the lower two section
of our pyramid). She saw a significant increase in the level of
moral reasoning of students exposed to an introductory
medical ethics course, by administering Rest’s Defining
Issues Test.3 This study assumed that reasoning ability is the
key to achieving the desired outcomes of ethics education,
but no obvious connection has been shown between helping
students to reason things out and defend their point of view on
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the one hand, and on the other hand, acting in an ethically
acceptable manner in the future. Indeed, increase in reasoning
ability seems a minimal criterion for measuring success in
ethics education–necessary, no doubt, but is it sufficient?4
A paper by Goldie et al. (2001), which looks at the effect of
a change in curriculum in the Glasgow University Medical
School, seems richer in its measurement of outcomes. Since
the whole curriculum was changed, the authors were able to
use a control group consisting of second-year students who
had not undergone ethics training in their first year, and the
new first-years who were trained by the new methods. They
assessed the effect of teaching in ethics using an instrument
that they called ‘consensus professional judgement’. This was a
set of vignettes in which there was a consensus on the best
way of resolving a given dilemma, both from the literature and
from experts who were consulted about the issues in the
vignette. The paper showed fairly conclusively that the
teaching given to the first-year group did improve their
capacity to make judgements that were consistent with what
would be the judgement of the experts. This does take
demonstration of the efficacy of ethics education a little
further, but it still leaves us with the question of whether these
students, who are now able to make convincing decisions,
would follow this through in clinical practice.
Turning to studies that are much more action-centred,
Cushing & Jones (1995) reported that pre- and post- tests that
were used to measure the effectiveness of a course on
breaking bad news showed a marked increase in confidence
and interpersonal communication in fourth and fifth year
medical students. Another action-evaluating study by Roberts
et al. (2003) assessed medical students’ ability to obtain
consent for HIV-testing using an OSCE style examination. The
investigators used a checklist based on criteria culled from
434
expert medical opinion on important considerations in
obtaining consent. It was found that students were able to
deal with a range of demands in getting consent for
HIV-testing, and had themselves given high ratings to this
training process (Roberts et al. 2003). Despite these optimistic
findings, there remains the vexing question of how well we
can know that in the actual clinical situation students will act
in the same way. Perhaps it is more than mere cynicism that
causes us to worry about the unfortunate case of Harold
Shipman.5 If one asked, ‘Would he have passed his ethics
exam?’, the answer may well be ‘Yes’! It is exceedingly difficult
to predict with any certainty how a person will act in the
future, however hard we may try to influence them during
training. Aware of this difficulty, Roberts et al. (2003).6
The future
Our very brief survey of the literature on evaluating ethics
education provides a glimpse of the issues that have been
faced by others who have grappled with this challenge.
Unfortunately, we do not have a consistent and clear picture in
the current literature of the efficacy of existing forms of ethics
education. Perhaps the situation is not entirely without hope,
but it does not hold out a great deal of promise! The weakness
in the literature described by Self et al. (1992) is still largely
present:
Both the content and process of teaching medical
ethics are now well-documented . . . . Nevertheless
there has been recurring concern over the evaluation
and the effectiveness of teaching medical ethics.
Unfortunately those responsible for medical ethics
courses . . . often . . . have simply said that medical
ethics deals with intangibles such as values and
attitudes, thereby excusing themselves from
evaluation.
What then might be hoped for, if medical education
continues to come of age? We would hope for an increasing
consensus on a core curriculum, so that we can see the subject
taught consistently across medical schools. In the UK, this has
been achieved quite well with a statement published in the
Journal of Medical Ethics in 1998. This specifies 12 core areas,
and (whether or not the details of this proposal could be
revised and updated) the idea of there being an agreed core
curriculum is an important first step.7 Secondly, there has to be
an enrichment of teaching methods. If the broad educational
aims suggested in this paper are widely agreed, then they must
be matched with a range of methods that would be
appropriate to what we are trying to achieve. Thirdly, there
has to be a continued search for valid assessment methods.
The 2006 survey conducted in the UK (Mattick and Bligh 2006)
showed a huge variation not just in what was taught, but on
how it was assessed, on whether or not that assessment
counted in any way, and on whether assessment aimed to be
formative or summative. Indeed in some cases, it did not seem
to be regarded as necessary to assess the students at all! Surely,
without valid and consistently applied assessment tools, the
evaluation of ethics education becomes impossible.

In the future, then, lies the challenge of a rigorous
evaluation of the teaching of medical ethics, based on clearly
defined outcomes and properly validated assessment methods.
Nothing less than this will do, if we are ever to answer the
question of whether ethics education can help to produce
ethical doctors.
Notes
[1] Dr Hawthorn was Chair of the Medical Ethics
Committee of the British Medical Association between
the world wars.
[2] Miller (1990) first proposed a pyramid of learning
focused on increasing professional authenticity. See
also Shumway & Harden (2003) for a detailed
representation of assessment of learning outcomes for
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physicians.
[3] Rest’s defining issues test (DIT) is a self-administered
test in which subjects are presented with short vignettes
or dilemmas and asked to select their answers on a
multiple-choice basis. For a discussion of the DIT and its
application, see Rest et al. (1999).
[4] Self et al. (1992) remarked that the appropriateness of
the evaluation approach that had been used in
assessing the teaching of medical ethics hinged upon
two premises: the first is a distinction between teaching
moral values and teaching moral reasoning about
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values; the second ‘involves accepting the. . . claim
that the appropriate function of teaching medical ethics
in our modern pluralistic society is to improve students’
moral reasoning about value issues regardless of what
their particular set of moral values happens to be. . . .
Accepting these premises is to hold that ethics is
basically a principled or rule-governed approach to
rational decision-making about value issues. Not every-
one accepts this position’. However, it is unclear that an
acceptance of the two premises requires accepting the
idea of principlism, or the claim made by Self and her
colleagues that ‘(m)edical ethics is a principle-based
approach to rational decision-making’. But, ending on
a judicious note, Self et al. advocate that ‘alternative
methods of teaching medical ethics need to be
compared and contrasted in order to identify the most
effective and efficient approaches.’ In our opinion, the
study does indeed make ‘an important beginning in
demonstrating that sound empirical assessment can be
carried out on the effectiveness of teaching medical
ethics’.
[5] Harold Fredrick Shipman was convicted and sentenced
to life imprisonment in the UK, on 31 January 2000, for
the murder of 15 of his patients while he was a general
practitioner at Market Street, Hyde, near Manchester,
and for one count of forging a will. Police also
investigated allegations that he may have murdered
many more patients while he was a GP in Hyde and
Todmorden. The Shipman Inquiry, led by Dame Janet
Smith, subsequently produced six reports published
between 2002 and 2005 that indicated that Shipman
may have been responsible for the deaths of some 200
of his patients.
[6] In a report on the literature and a prospective study of
the use of standardized patients to measure outpatient
Ethics education and ethical doctors
clinical practice, Glassman et al. evaluated the quality of
20 consenting physicians at two outpatient settings
using 27 trained standardized patients. The study, which
developed a method of measuring the quality of
outpatient care, was also designed to evaluate, vis-
à-vis the ‘‘gold standard’’ of reports by standardized
patients, the validity of other methods of assessing the
quality of care, such as abstraction of medical
records from standardized patient visits and
physicians’ responses to clinical vignettes correspond-
ing to the SPs’ presentations (see Peabody et al. 2000,
2004).
[7] A similar statement has been produced for Australasian
medical schools (Association of Teachers of Ethics and
Law in Australian and New Zealand Medical Schools
Working Group 2001).
Notes on contributors
ALASTAIR V. CAMPBELL is the inaugural Chen Su Lan Centennial Professor
of Medical Ethics at the Yong Loo Lin School of Medicine, National
University of Singapore (NUS), and director of the Centre for Biomedical
Ethics. He has published extensively in both medical ethics and pastoral
theology.
DR JACQUELINE CHIN is a research fellow at the NUS Centre for
Biomedical Ethics. She is also an adjunct lecturer in the NUS Department of
Philosophy.
MR VOO TECK CHUAN is a research assistant at the NUS Centre for
Biomedical Ethics, and a PhD candidate in the NUS Department of
Philosophy.
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