Development of Moral Reasoning during Medical Education Darko Hren, PhD Croatian Medical Journal and University of Split Croatia

Moral reasoning (Neo-Kohlbergiann approach) 3 developmental schemae P PI MN PERSONAL INTEREST What 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 NORMS Taking a broader societal perspective through adherence to norms, regulations and laws. Need for norms Broader societal viewpoint Uniform and categorical application of norms POSTCONVENTIONAL Administration 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 of enrolment Times of measurement nd yr. n=192 2nd yr. n=207 2nd yr. n=139 1st yr. n=131 3rd yr. n=153 4th yr. n= th yr. n=85 6th yr. n=77 Controls n=298 Same age span (18-27) Never studied Matched n=75 Matched n=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) DIT2 Scores P MN PI Med. Students 0.20* -0.12* -0.14* Controls 0.12* * SEX (M=0, F=1)

RESULTS Scores of different generations of students at the same time point of their study no stat. sig. differences P MN PI Generations of students

RESULTS Differencef between medical students on different study years stat.sig. difference between groups of students (F 5,679 =3.67, p=0.003, η 2 =0.03) stat. sig. quadratic trend (p=0.035) no stat. sig. differences (F 5,679 =0.83, p=0.527) stat.sig. difference between groups of students (F 5,679 =3.38, p=0.005, η 2 =0.03) stat. sig. reverse quadratic trend (p<0.001) P MN PI Year of study

RESULTS Changes in scores over time stat. sig. interaction between repeated measurements and developmental profiles at the first measurement (F 1,129 =14,87, p<0,001, η 2 =0,19) stat. sig. interaction between repeated measurements and developmental profiles at the first measurement (F 1,129 =12,58, p<0,001, η 2 =0,16) stat. sig. interaction between repeated measurements and developmental profiles at the first measurement (F 1,129 =8,25, p<0,001, η 2 =0,11) P MN PI Generation I 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 discussions o specific issues o as early as possible o at least 20 hours (Self et al, 1998) o vertical approach o 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