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This work is protected by copyright and other intellectual property rights and duplication or sale of all or part is not permitted, except that material may be duplicated by you for research, private study, criticism/review or educational purposes. Electronic or print copies are for your own personal, non- commercial use and shall not be passed to any other individual. No quotation may be published without proper acknowledgement. For any other use, or to quote extensively from the work, permission must be obtained from the copyright holder/s. Medical schools and the virtuous physician: how to ensure that physicians will do the right thing. Thalia Arawi Doctorate in Medical Ethics June, 2014 Keele University Abstract: The focus of this thesis is moral education. This study is important as it aims at solving a prevailing and increasing problem that is harming the medical profession of our times, namely, the fact that physicians are losing touch with the nature of their profession as a moral venture. This is evident from the numerous surveys done which report complaints from patients regarding physicians’ interpersonal and ethical skills. I argue in this thesis that modern day physicians experience moral erosion and that medicine is falling prey to deprofessionalization. This thesis focuses on the case of medicine in US-style universities in general and Lebanon in particular. Starting from the assumption of the ends of medicine as elaborated by Edmund Pellegrino, it asks what are the means that are most conducive to the attainment of these ends (or some of these ends)? The main conclusions are that curricular reforms must be made to ensure appropriate training of students of medicine and that the hidden curriculum is far too important to be ignored if changes are to take place and if moral erosion of physicians is to be avoided. In addition to curricular reforms, there is a need to work with veteran physicians who should serve as role models and mentors in an appropriate institutional culture, hence, there is a need for what I term a “post-flexnerian revolution”. In addition to teaching students the basic sciences and skills necessary for the making of a successful physician, medical schools ought to concentrate on attempting to produce graduates that are virtuous physicians, who will do the right thing even when no one is looking. If adequate training in virtue and goodness takes place, doing the right thing will become a second nature and the moral ends of medicine will be met. Key words: medicine, physician, student of medicine, role model, mentor, VE, virtuous physician, Pellegrino, Aristotle, ends of medicine, moral education, hidden curriculum, formal curriculum. i CONTENTS INTRODUCTION .................................................................................................. 1 1. MEDICINE AS A MORAL ENDEAVOUR ...................................................... 4 1.1. Why Edmund Pellegrino? ................................................................... 5 1.2. Medicine as a moral enterprise ........................................................... 6 1.3 Edmund Pellegrino and the Ends of Medicine .................................... 13 1.3.1. The Ends of Clinical Medicine ........................................... 21 1.4. Towards a Combined View of the Ends of Medicine ........................ 26 1.5. Needs, Perceptions, and the Ends of Medicine .............................................. 33 1.6. Performing Abortion as an Example of Ends External to the Profession of Medicine............................................................ 38 1.7. Moral Absolutes ............................................................................................. 41 1.8. The Importance of Trust in the Physician-Patient Relationship ........ 47 2. ARISTOTLE’S VE AND THE PROFESSION OF MEDICINE ..................................................................................................... 55 2.1. Virtuous Activity and the Acquisition of Virtues .............................. 57 2.2.Aristotelian Ethics and the Medical School ........................................ 61 2.3. VE and the Good Physician ............................................................... 63 2.4. Can We Teach Virtue? ....................................................................... 85 2.4.1. Role Models ........................................................................ 87 2.4.2. Organizational Structures and Culture ................................ 90 3. THE MORAL DEVELOPMENT OF THE MEDICAL STUDENT AND THE CURRICULUM .......................................................... 94 3.1. The Curriculum .................................................................................. 96 3.1.1. The Formal Curriculum and the Making of a Good Physician ........................................................................... 100 3.1.1.1. Medical School and Moral Erosion.................... 106 3.1.2. The Clandestine Curricula................................................. 109 3.1.3. The Hidden Curriculum ................................................................ 110 3.1.4. Curriculum Development, the Hidden Curriculum, and Organizational Culture ...................................................... 111 3.1.4.1. White Coat Ceremonies ................................................. 114 3.1.5. The Informal Curriculum .............................................................. 120 3.1.5.1 Role Models in the Informal and Hidden Curricula ...................................................................................... 121 3.1.6. The Phantom Curriculum .............................................................. 129 3.2. Where Do We Go From Here?......................................................... 132 ii 4. TOWARDSA POST-FLEXNARIAN REVOLUTION IN MEDICAL EDUCATION ............................................................................... 135 4.1. The Flexnerian Revolution ............................................................... 138 4.1.1. Medicine Was Basically Directed by the Laws of General Biology ............................................................ 140 4.1.2. Medical Colleges Must Put Into Effect Some Entrance Requirements..................................................................... 141 4.1.3. Learning by Doing ............................................................ 142 4.1.4. Engaging in Original Research ......................................... 143 4.2. Medical Education and the Physician of the 21 st Century ............... 145 4.2.1. Admission Policies ............................................................ 150 4.2.2. Not Everyone Should Graduate ................................................................ 157 4.2.3. The Curriculum and the Professional Physician ............... 160 4.2.4. Medical Curricula, Medical Professionalism, and the Making of the Virtuous Physician............................................... 161 4.3. Obstacles Awaiting the Post-Flexnerian Revolution ................................... 167 4.4. A Return to VE ............................................................................................ 169 4.5. Conclusion and suggestions for further research ......................................... 171 iii Acknowledgements: First and foremost, I would like to thank Dr. Angus Dawson and Dr. Stephen Wilkinson for their guidance throughout the writing of this thesis and of course Dr. Anthony Wrigley for his candid advice and patience. Most importantly, I would like to thank my mother Dalal, my sister Mimoza and my friend Wadad for their support and encouragement all through. I am forever grateful for their help and support. I would not have made it without them. They are significant others who do the right thing even when no one is looking. iv INTRODUCTION: In the Republic , Glaucon resorts to a thought experiment and introduces the legend of the ring of Gyges: A shepherd becomes in possession of a ring that makes him invisible. Armed with this power, he starts acting unjustly: seduces the queen, murders the king and occupies his kingdom (1947, pp. 43-44). He was fearless of reprisals demonstrating that even the just man would behave unjustly if this can go unseen and unpunished. Plato wanted this myth to illustrate an important and eternal truth around which this thesis revolves: the good person is the person who will do the right thing regardless of punishment or rewards. Applied to the practice of medicine, one can argue that the same pertains to the fine physician. She will be the kind of physician who will do what is right even when there is no one to judge her. Several forces make this ideal difficult to reach. Such forces are the same ones that are attacking what came to be known as medical professionalism: market forces, personal corruption, the economic situation, to mention but a few. Nonetheless, it is my contention that although this ideal is difficult to achieve, it is not an impossibility. One way to achieve this ideal is by nurturing good and virtuous physicians. This thesis offers an attempt at addressing this issue. The main question that this thesis deals with is what can medical schools do in order to graduate students of medicine who will possess a fine character? Put differently, what can medical schools do to graduate physicians who will serve the ends of medicine as a profession not a trade and who will do the right thing even when no one is looking? Although this thesis stresses the importance of virtues and their