Medical ethics and law: a practicalguide to the assessment of the corecontent of learningVal Wass

‘What is important is to keep learning,to enjoy challenge, and to tolerate ambi-guity. In the end there are no certainanswers.’1

Martina HornerRadcliffe College, Cambridge Massachusetts

Assessing students’ learning on medicalethics to fully understand how they inter-pret, react and behave when faced withthe uncertain, often ambiguous, chal-lenges of real clinical encounters remainsan educational conundrum. The authorsof this guide are to be congratulated ontheir comprehensive summary of currentpractice. They provide an excellent plat-form from which to reflect and thinkforward. Are our assessment practices fitfor purpose? Do they effectively relay theappropriate and necessary educationalmessages to our future doctors? I believe,although the range of assessment tools wehave to date are welcome, there are pit-falls that remain unresolved.

A strong foundation knowledge ofethical principles and law is important. Arobust moral framework is essential. TheGuide confirms that we have the tools toassess students’ learning at the ‘knowshow’ and ‘shows how’ level of Miller’spyramid.2 The context in which thisknowledge is integrated into actual ethicalpractice, that is, ‘the does’, still presentsmany challenges perhaps more pertinentto ethics and professionalism than to othercurriculum themes. We should acknow-ledge that, for a future clinician, we assessat a level distant from the ideal educationalendpoint for graduation. Pelligrino3 high-lights that, in the clinical encounter, thereis ‘a peculiar constellation of urgency,intimacy, unavoidability, unpredictability,and extraordinary vulnerability’. Therecent Francis report4 emphasises this ‘vul-nerability’ only too well. Assessing stu-dents on how they ‘should’ apply ethicalframeworks to clinical scenarios cannotvalidly address the realities of medicalpractice. We know that transition into theFoundation years remains difficult as stu-dents meet the clinical intensity of the

workplace.5 Herein lies a genuine danger.We ‘train’ students for a theoretical‘medical school world’ that students inter-pret as ‘what they should do’; a view rein-forced by our assessments. They thendivorce this from the reality of the clinicalworld and ‘what they would do’: a dividewe are increasingly aware of.6

The clinical environment does not alwaysmirror what students are taught andassessed on.7 The authors of the Guideacknowledge the forceful, as yet poorlyexplored, ‘hidden curriculum’. They arguethere is evidence that teaching and assessingethics can help overcome these forces. Thismay be true. I suspect the evidence tosupport this claim remains weak. The dif-ferent and conflicting role models and inter-actions students experience in theworkplace cannot be ignored.8 Our assess-ments risk confusing students if theyencourage responses that support attitu-dinal behaviours that fail to connect withthe uncertainty and ambiguity of the realworld. Unfortunately health professionalsdo not always work within the frameworkof their theoretical learning. Educationalresearchers exploring the hidden curricu-lum are increasingly demonstrating this.7 9

Professional behaviours that are embedded,as Pelligrino states, in the complexity of theclinical encounter may fail to match the the-oretical frameworks students hold. In thepresence of significant external constraints,attitudes and behaviour are not necessarilystrongly related.10 We do not know theextent to which inner virtues and outerconduct differ.11 This leads to the possibleconclusion that ethical understanding canbe stage-managed; students demonstratethe professional behaviour required tograduate but hold within themselves unpro-fessional attitudes. In addition, there is agenuine fear that the current focus on ‘com-petency’ encourages a tick box ‘can do’culture that detracts from a desire to con-tinue to understand, improve and strive forexcellence.12

Should we accept this? I believe not. Tothis end the Guide might have taken astep further and explored the direction oftravel postulated by van der Vleuten andSchuwirth.13 They argue cogently forassessment programmes that intertwine

with the curriculum, sample widely acrossauthentic contexts and address ‘complexcompetencies that cannot be broken downinto simple parts’.13 Much of the ethicalframework as outlined in the Guiderequires Tomorrow’s Doctors’ competen-cies14 that centre on professional valuessuch as honesty integrity confidentialityand trust. A recent international reviewon the assessment of professionalism15

concludes that not only is professionalismcontextually bound it should be assessedat three levels of interaction: individual,inter-personal (team) and societal–institu-tional. We need a multidimensional, mul-tiparadigmatic approach to assessingethical behaviours at these different levels.More attention to enabling students todevelop and understand their personalidentity and their interpersonal interac-tions is essential. To achieve this, weshould encourage more formative assess-ments designed to enable students toaddress the significance of their internalcultural values and prejudices. Theyshould understand how these impact ontheir decision making when faced withdifficult clinical challenges. We areincreasingly aware of how difficult sharingthese thoughts can be.16 The competencybased culture must not be allowed tofoster complacency. The Francis report4

has highlighted the need to build ourmedical training to enable doctors todemonstrate ethical behaviour embeddedin the complexity of the clinical work-place. In the end there are no certainanswers and our future doctors need tocome to terms with this. Our assessmentscan change to ensure we enable studentsto keep learning, enjoy challenge and tol-erate ambiguity. This Guide provides auseful platform to this next step.

Competing interests None.

Provenance and peer review Commissioned;internally peer reviewed.

To cite Wass V. J Med Ethics 2014;40:721–722.

Received 22 April 2013Accepted 30 April 2014Published Online First 26 May 2014

▸ http://dx.doi.org/10.1136/medethics-2013-101329▸ http://dx.doi.org/10.1136/medethics-2013-101331

J Med Ethics 2014;40:721–722.doi:10.1136/medethics-2013-101330

Correspondence to Prof Val Wass, School ofMedicine, Keele University, Keele ST5 5BG, UK;v.j.wass@keele.ac.uk

Wass V. J Med Ethics October 2014 Vol 40 No 10 721

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722 Wass V. J Med Ethics 2014;40:721–722. doi:10.1136/medethics-2013-101330

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learningthe assessment of the core content of Medical ethics and law: a practical guide to

Val Wass

doi: 10.1136/medethics-2013-1013302014 40: 721-722 originally published online May 26, 2014J Med Ethics 

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