Development of Moral Reasoning during Medical Education

1
Development of Moral Reasoningduring Medical
Education
Darko Hren, PhD Croatian Medical Journal and
University of Split Croatia
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Moral reasoning(Neo-Kohlbergiann approach)

• 3 developmental schemae

P
MN
PI
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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 studiesRest Deemer (1986)
  attending college explained 38 of variance in
  scores
• Educational orientationDeemer (1987)
  educational orientation explained 13 of variance
  in scores
• Review articlesKing i Mayhew (2002) more than
  500 studies which addressed the issue of
  relationship between education and moral
  reasoning

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MORAL REASONING AND MEDICAL EDUCATION

• No gains in moral reasoning scoresSelf et
  al,1993 Self Baldwin, 1994Morton, 1996
  Self, Olivarez Baldwin, 1998
• Decline in scoresPatenaude et al, 2003

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AIM

• Investigate the relationship between moral
  reasoning and medical education

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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)

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RESEARCH DESIGN
Times of measurement
Year ofenrolment
2004
2003
2002
1st yr.n131
2004
2nd yr.n139

• Controlsn298
• Same age span(18-27)
• Never studied

2003
3rd yr.n153
2nd yr.n207
Matchedn61
2002
4th yr.n101
2nd yr.n192
Matchedn75
2001
5th yr.n85
2000
6th yr.n77
1999
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RESULTS AGE AND DIT2 SCORES

• Zero correlations between all DIT2 scores and age
  for both, medical students and controls

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RESULTS SEX AND DIT2 SCORES (M0, F1)
SEX (M0, F1)
DIT2Scores P MN PI
Med. Students 0.20 -0.12 -0.14
Controls 0.12 -0.04 -0.12
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RESULTSScores of different generations of
students at the same time point of their study

• no stat. sig. differences

P
MN
PI
Generations of students
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RESULTSDifferencef between medical students on
different study years

• stat.sig. difference between groups of students
  (F5,6793.67, p0.003, ?20.03)
• stat. sig. quadratic trend (p0.035)

P

• no stat. sig. differences (F5,6790.83, p0.527)

MN

• stat.sig. difference between groups of students
  (F5,6793.38, p0.005, ?20.03)
• stat. sig. reverse quadratic trend (plt0.001)

PI
Year of study
12
RESULTSChanges in scores over time

• stat. sig. interaction between repeated
  measurements and developmental profiles at the
  first measurement (F1,1298,25, plt0,001,
  ?20,11)

P

• stat. sig. interaction between repeated
  measurements and developmental profiles at the
  first measurement (F1,12912,58, plt0,001,
  ?20,16)

MN

• stat. sig. interaction between repeated
  measurements and developmental profiles at the
  first measurement (F1,12914,87, plt0,001,
  ?20,19)

PI
GenerationIn75
Generation IIn61
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CONCLUSIONS

• Medical students moral reasoning scores increase
  during preclinical years, but...

• ...they decrease when students enter clinical
  rotations, but...

• ...they do not decrease below Maintaining Norms
  schema.

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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
• ...

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WHAT CAN BE DONE?

• Small group case discussions
• specific issues
• as early as possible
• at least 20 hours (Self et al, 1998)
• vertical approach
• related to students experiences (critical
  incidents discussions)

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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