Teaching Doctors Virtue
The following interview is part of a Philanthropy Roundtable series highlighting how philanthropy can improve America’s health-care system by investing in medical education to achieve transformational results.
Interview with Dr. Lauris Kaldjian on Why the Four Principles of Bioethics Are Not Enough
Lauris Kaldjian is a doctor of internal medicine and a leading voice in the discipline of bioethics. He holds the Richard M. Caplan Chair in Biomedical Ethics and Medical Humanities at the University of Iowa’s Carver College of Medicine, runs a four-year bioethics program there, and speaks and consults widely on ethics in medicine. He spoke in early December about the varieties of doctor burnout, the need for more virtue education in medical schools, and how to develop educational curriculum that gets at future medical professionals’ “deepest motivation.” This interview has been edited for length and clarity.
Lott: You direct the program of BioEthics and Humanities in the College of Medicine at the University of Iowa. What do you teach your students?
Kaldjian: We advance a rigorous understanding of human health and health care through the kind of knowledge we can gain from bioethics, the medical humanities, and related disciplines.
The first principal is that medicine is an ethical endeavor. There's no way to think of it just as science, even though often medicine and medical science is seen as just that. There's this need to integrate ethics and science in the practice of medicine because the practice of medicine is dealing with people.
Lott: What comes next in the teaching process?
Kaldjian: Then we focus on and define and demonstrate how ethical principles are used and do the same regarding ethical virtues. It would be interesting if you were to review the curricula of medical ethics in medical schools across North America. How many of them would immediately pair principles and virtues?
The predominance of ethics education in North America tends to be the so-called four principles of biomedical ethics. The medical students who have memorized it will be able to almost rotely list those off: beneficence, non-maleficence, respect for autonomy, and justice. Sometimes people will think so long as you can name those four principles, you somehow have done ethics; you've arrived. But of course, so much more needs to be said and there is much more to the ethical life than those principles, but especially the question of what is the difference between a principle and a virtue.
Lott: You talk about ethics and virtues. What's the relationship of one to the other?
Kaldjian: Certain things at the molecular level get integrated into the genome of a cell, but other things, like proteins, could stay separate from that genome. If a principle becomes also a virtue, it's as if it's getting integrated into the moral DNA of the person.
If you recognize a principle like beneficence—which just means “do good”—that doesn't necessarily mean that when you're in an actual real-life situation, you will do good. This goes back to Plato and Aristotle: To know the good is not the same as to do the good. When it becomes part of who one is, that means you now also have the motivation to act accordingly.
Lott: Health care is a huge pressure cooker for the people involved, leading to burnout. There are long hours involved, and life and death decisions. Do you think virtue and bioethics can help people to get through that?
Kaldjian: Burnout has three aspects to it. The first is emotional exhaustion. The second is called either depersonalization or cynicism. The third is a lack of personal effectiveness. It's important to know which of those aspects are being referred to.
That second one is called depersonalization in the sense of meaning that you're no longer relating to your patient as a person. You’re really treating them now more as a body. There's another topic called “moral distress” that came out of the nursing literature. If one's integrity or conscience is being compromised, that leads to a form of horror. You're really at war with yourself.
Lott: And the virtues offer a way out?
Kaldjian: One of the key virtues is integrity. Let's say a resident asks a student to get on the phone and order a test. Because the resident wants the test right away, instead of having to wait in line to get it done for a patient, he says to the student, "Well, just make up a different story for our patient so we can get it expedited." Which is to say, lie to the person you're getting the test order through.
Now the student’s integrity is being compromised. Will the student have the courage to say, “No, whatever the right answer is here, I'm not going to go along with this. I need to express certain key virtues and resist what I'm being asked to do,” and then hopefully have the practical wisdom to know how, carefully, to respond to that resident in that situation?
Lott: You need both courage and prudence in that case, is what I’m hearing.
Kaldjian: Yes, with a real drive to sustain, to preserve one's own integrity. In terms of the emotional exhaustion, I think that there are plenty of people who have very difficult lives. But if they have sufficient meaning in their lives, they have the resources and motivation to persevere and endure.
Lott: How important is mentorship in a good virtue ethics education?
Kaldjian: Mentorship allows students to see in real time what virtue looks like. You need so many things like honesty, compassion, humility, courage, integrity. A student is going to be so much better off if they can see what this looks like, so that in the future they can mimic what they have seen.
Lott: You're in charge of the curriculum and so have more hands-on experience than most to answer this next question: How should philanthropists encourage the development of new curriculum in a way that will improve medical education?
Kaldjian: Students learn about motivational interviewing, tapping into a patient's desire to be healthy. Likewise, you could say, “What are the deepest motivations that students bring to medicine that can be tapped into?”
Another area would be the use of personal and literary narratives, the right kind of storytelling. Do it in such a way that doesn't strike students as being fluffy and just this extra icing on the cake. You have to find ways to make it credible so that even students who are skeptical about some things can start to see the meaning in those things.
The best way to do it is to give students opportunities to reflect on and write about their own experiences, and then engage those experiences with the students. Now it's real for them. Even if they're not as into it as they might be into molecular biology, at least they will say, “OK, well, this person wants to talk to me about what I experienced last week. So let's talk about that.”
We've already talked about role modeling and mentorship. That is time consuming. If people are short of anything in medicine and life, it's time. So what new curricular opportunities might there be that [philanthropists] could actually help support with funding—opportunities for students to have longitudinal mentoring over time?
Jeremy Lott is a writer who lives in Lynden, Washington. He conducted this interview on behalf of The Philanthropy Roundtable. To read the rest of this series, click below.