SPECIAL ARTICLES FREDERIC W. HAFFERTY, PhD, and RONALD FRANKS, MD. The Hidden Curriculum, Ethics Teaching, and the Structure of Medical Education Abstract—The authors raise questions regarding the wide- spread calls emanating from lay and medical audiences alike to intensify the formal teaching of ethics within the medical school curriculum. In particular, they challenge a prevailing be- lief within the culture of medicine that while it may be possible to teach information about ethics (e.g, skills in recognizing the presence of common ethical problems, skills in ethical reason- ing, or improved understanding of the language and concepts of cthies), course material or even an entire curriculum can in no way decisively influence a student's personality or ensure et cal conduct. To this end, several issues are explored, including ‘whether medical ethics is best framed as a body of knowledge and skills or as part of one’s professional identity. The authors ‘argue that most of the critical determinants of physician iden- tity operate not within the formal curriculum but in a more subtle, less officially recognized “hidden curriculum.” The over- all process of medical education is presented as a form of morat training of which formal instruction in ethics constitutes only one small picce. Finally, the authors maintain that any attempt to develop a comprehensive ethies curriculum must acknowl- edge the broader euitural milieu within which that curriculum ‘must funtion. In conclusion, they offer recommendations on hhow an ethies curriculum might be more fruitfully structured to become a seamless part of the training process. Acad, Med. 69(1994):861-871 The teaching of ethics has become medicine's “magic bullet” for the 1990s. Problems ranging from the breakdown of the physician-patient relationship to medicine's loss of advo- cacy, the emergence of the patient- as-consumer, and the moral complexi- ties of technological medicine have prompted calls for a greater emphasis, on the formal teaching of ethies in medical schools. In this article we explore the rela- tionship between the formal and the informal teaching of medical ethics during medical training. We also ex- amine—albeit more indirectly—how three beliefs, described below, serve to marginalize ‘ethics in the culture of medicine. We argue that although matters of technical information and the transmission of technical skills De. Hafferty is professor, Department of Behavioral Sciences University of Minnesota, Duluth Sehool of Medicine, and Dr. Franks is the dean ofthat school. ‘Correspondence and requests for roprints should be. addressed. to Dr. Halferty, Department of Behavioral Sciences, Univer: sity of Minnesota, Duluth School of Medicine, 410 University Drive, Duluth, MN 55812-2187. ‘Other artiles about the teaching of ethics ‘appear on pages 872 and 807. VOLUME 69 + NUMBER II * NOVEMBER 1994 traditionally have been thought to lie at the heart of the medical educational system, medical training at root is 1 process of moral enculturation, and ‘that in transmitting normative rules regarding behavior and emotions to its trainees, the medical school func- tions as a moral community, We ex- plain how formal instruction in ethies makes only a small contribution iat, community, since most of the critical determinants of physicians’ identities lie not within the formal curriculum but in a more subtle “hid- den curriculum,” which we describe Finally, we argue that any attempt to develop a comprehensive ethies cur- riculum must acknowledge the hidden curriculum and the broader cultural milieu within which ethics teaching must funetion, We close with recom- mendations on how an ethies eurricu- lum might be more fruitfully struc- tured to become a seamless part of the training process. BACKGROUND This paper had its origins in several events. The first_was a conference, “The Meaning of the Holocaust for Bioethics,” hosted by the University of Minnesota's Center for Biomedical Ethies, May 17-19, 1989. The confer- ence focused on the gathering of “sc entific” data from concentration camp inmates during World War Il It raised broad questions about the nature of ethics, science, medicine, and society, and painted a shocking picture of how the work of science and medicine can become distorted and ultimately im- ‘moral, A prominent solution offered by several of the presenters was that fu- ture ethical atrocities of this kind might be prevented if greater empha- sis were given to the inclusion of ethi- cal principles and precepts in the med- ical school curriculum. In December of the same year, a special issue of Academic Medicine, “Teaching Medical Ethics,” appeared. Coming, as it were, on the heels of this conference, this special issue could be viewed as a blueprint for the develop- ment. and delivery of such a curricu- lum, With its two overview chapters, extensive review of the literature on medical ethics education, two research reports, and descriptions of the his- tory, goals, and content of ethics cur- ricula at nine medical schools, this is- sue provides readers with an excellent, opportunity to explore a number of 861(Gometimes differing) views of the na- ture of medical ethics and its purpose as an object of pedagogy. In December 1993, and January 1994, a shocked American public found itself battered by a whirlpool of unsavory revelations about the unwit- ting involvement of fellow citizens, in- cluding infants and children, in radia- tion experiments during the 1950s."* Prominent among the questions raised has been how scientists, including physicians, could have allowed them- selves to participate in these under- takings. Once again, suggestions for remediation have featured the need for greater formal ethics instruction in graduate and medical training pro- grams. A few months earlier, in October 1993, the Association of American Medical Colleges (AAMC) published Promoting Medical Students’ Ethical Development: A Resource Guide. Based on survey data and related ma- terials, this publication focuses on the ethical dilemmas experienced by med- fcal students during their training. Although structured differently from the earlier Academic Medicine special issue, this publication also advances ‘numerous recommendations about the form and content of ethies instruction during undergraduate medical train- ing, In the following pages we offer a set of observations regarding the presence and role of medical ethics in the med- ical school curriculum that is some- what different from what has ap- peared in these two publications and in the public debates about the ethical sensitivities of physicians and scien- tists. Our discussion centers around three themes or beliefs evident either within medicine or in the broader cul- ture when matters of ethics and ethies instruction are raised. The first belief, ‘mentioned above, is that past ills in the practice of medicine and the con- duct of science ean be corrected and fu- ture ills avoided only if ethics instruc- tion is accorded a greater formal presence in the medical school eurricu- lum" ‘The second belief, well en- trenched in the culture of medicine and somewhat antithetical to the first, is that while it may be possible to teach the knowledge base of, or infor- mation about, ethics (eg., skills in recognizing the presence of common ethical problems, skills in ethical rea- soning, or improved understanding of the language and concepts of ethics), one’s moral character basically is es- tablished prior to entry into medical school and that course materials or even an entire curriculum will not de- cisively reshape a student's personal- ity or ensure ethical conduct in the fu- ture A corollary to this set of beliefs is that principles of moral behavior are familiar and obvious to all who seek to ‘become physicians and that since ‘those who enter medical sehool do so with high moral dispositions, specifie instruction in this area is not neces- sary, The third belief is that while one’s ethical posture is most deeply shaped by long-standing personal and family values and beliefs, if it is to bbe influenced by current work and training environments the most influ- ential "vehicle involves _ informal processes such as “general clinical ex- perience,” peer interactions, “ward rounds,” and “role models” rather than formal coursework in ethics or related topies:* TYPES OF MEDICAL ETHICS TEACHING ‘The assumption that “flaws,” “lapses,” or “perversions” in ethical behavior in medicine can be satisfactorily ad- dressed by a concerted dose of wellin- tentioned and formally structured course work rests on two (often unex- amined) assumptions. First, that the evils, faults, or flaws under considera- tion would probably not have occurred had the “proper” ethical instruction or foundations been present originally. Second, that in liew of such a precondi- tion, an increased commitment to the teaching of ethical precepts and princi- ples represents an effective remedial (as opposed to prophylactic) tool. In turn, both of these assumptions are underscored by an even more primor- dial and flawed conjecture: that med- ical ethics can be approached and taught like other basic _ science courses—a conjecture that, if not ac- Iknowledged, can lead to a distorted view of the nature of ethics in medi- Ethics as Identity We begin our discussion of the differ- cent types of othies teaching with the proposition that ethies occupies a cen- tral place in clinical decision making As such, its presence is critical to th professional development of the physi- cian, Similarly, we concur with those who argue for a highly visible and in- deed seminal role for ethies in medical training. Nonetheless, we also believe that there is a fundamental distinction between a pedagogical approach that highlights ethical principles as resid- ing squarely within the physician's professional identity and a view of ethies that frames ethical principles as tools to be employed in the course of clinical work. In the latter case, ethi- cal principles may be framed as some- thing that can be picked up or put down, used or discarded, depending upon ‘the situation or circumstances involved. As such, ethies becomes cast, as an entity whose locus of control is external both to the situation and to the actors involved—an instrument for manipulation much like any of the more technological tools medicine has at its disposal. It is an organizing promise of this essay that only when ethical principles have been fully inte- grated into the practitioner's profes- sional identity can medicine begin to resist future excursions into the dia- bolical, and not incidentally, to ade- quately justify its long-standing claim for autonomy based on an effective system of peer review grounded in eth- ical principles.* Culture, Medicine, and Ethics Within the culture of medicine, the de- lineation between ethies-as-tools and ethics-asidentity, although certainly not alien to discussions about teaching and medical ethics, often is relegated to cursory comments about differences between’ “skills” and “orientations,” distinctions between “training” (the transmission of specific skills for the predictable solution of specific prob- Jems) and “education” (more the realm ACADEMIC MEDICINEof “inguiry, adaptability, and flexibil- ity’)? or the need for medical students to “be” (the verb “become” is used much less frequently) compassionate and caring physicians and not simply exhibit an ability to dominate facts.” ‘Traditionally, medical culture has sub- sumed these dichotomies under the general rubric of medicine-as-art and thus something that operates along a dimension different: from that of medi- cine-as-science, In turn, legions of studies, commissions, and medical educators have advocated “infusing” (the term is important—implying “coming from without’) both the struc ture and the content of medical eduea- tion with materials and experiences designed to blunt the negative impact of a fact-based and punishing eurrieu- lum, ‘A somewhat different, orientation exists in the field of education. Professional edueators are less in- ined to draw critical lines between cts” and their setting or ap- plication." There is widespread recog- nition that all educational strategies (however targeted, task-specific, or “factually” based) involve the presence and transmission of cultural values and therefore the prospect of value change. Similarly, educators routinely acknowledge that the overall process of education is a form of socialization and that. all socialization involves a ‘moral dimension, In this sense, minds are being shaped—young and old, teacher and student—within a frame- work that transmits notions of right- ness and wrongness, appropriateness and inappropriateness. ‘The basic is- sue is not one of ridding the environ- ‘ment of “contaminating” values or ele- ments but rather one of recognizing their presence and working with them—including taking steps to counter whatever elements are deemed (at the time) to be unwar- ranted or undesirable." ‘Traditionally, such a paradigm has found little receptivity among medical school faculty, particularly those who view the knowledge base and applica- tion of science as value-neutral, “objec- tive” and therefore transcultural. They are not inclined to acknowledge the ‘social and cultural matter—the ‘VOLUME 69 » NUMBER 11» NOVEMBER 1994 world view—embedded in the sci- ences they teach.S2-1¢ Administrators can add to this cul- tural myopia in terms of the bene- fits they attribute to certain teaching vehicles. For example, in a recent na- tional study, medical school deans cited “role models” (by 82% of the re- sponding deans), coursework (66%), and freshman orientation (59%) as the three major influences on their stu- dents’ development of high profes- sional standards. In short—and here we are being deliberately provoca- tive—administrators are saying that they expect a great deal from (1) largely unobserved, unmonitored, and highly idiosyneratic interactions, (2) formal instruction that occupies a marginal presence in the training structure (see below), and (8) a set of brief and often ritual experiences cen- tered around salutations and cere- monies of greeting. Medical ethies, as a focus of peda ‘ogy, appears similarly encumbered, ‘During the 1960s, the field of philoso- phy—along with the newly emerging social and behavioral sciences—ven- tured into medical schools, a domain that had been largely dominated by medicine as taught. by physicians.” These “outsider” disciplines often sought legitimacy within the medical culture by embracing many of medi- cine's beliefs and rationales, including the methodologies and values of ratio- nal positivism.!* In many cases what, emerged was an ethics curriculum grounded in logic and rationality, prin- ciple-based, and “as positivistie and reductionistic as the theoretical per spective and research strategy of mol- ecular biology:"” One consequence was the evolution of course work that stressed individualism while it de-em- phasized the relevance of ethics to such macro entities as communities, organizations, and. institutions."® Similarly downplayed have been val- vues such as “decency, kindness, sym- pathy, empathy, caring, devotion, ser- vice, generosity, altruism, sacrifice, and love." Lest we forget sociology in this list of transgressors, major sociologie stud- ies of ethies in medicine!™-"" tended to ignore critical aspects of medical culture, sometimes to the point of mistakenly concluding that physicians receive virtually no ethical instruction during their training. Equally limiting, social scientists have been slow to recognize the ethical dilemmas created by the structure of the educational experience itself, in- cluding its highly stratified system of power and authority relationships and the requirement that. students func- tion in multiple—and often conflict- ing—roles (eg, students simultane- ously functioning as learners and as providers of care)® Challenged by studies such as Bosk’s analysis of post- graduate surgical training,” sociolo- sists are beginning to recognize that medical training above all else in- volves the transmission of a distinctive medical morality. As we note below, outsiders, particularly the lay public, may take issue with the promulgation of notions of good and bad, right and ‘wrong, but this is a different issue from the position that the practice of ‘medicine is a value-neutral enterprise. Ethics Education versus Ethical Conduct ‘A central ingredient in the marginal status of ethics in the culture of m cine is the caveat that it is impossible to clearly establish a connection be- tween “ethics education” and “ethical conduct.” A typical caution is that ethics should not be viewed as a vehi cle for creating sound moral character or as a counter to the dehumanization wrought by medical training™ When curriculum goals are specified, the em- phasis is on the teaching of skills thought to enable students to identify, analyze, and resolve ethical problems in patient care situations and thus on what might be termed “ethies- as-technique.” in contrast to a skill-based ap- proach, issues of identity, identifica- tion, and affectivity receive a more limited (and sometimes ambivalent) billing. For example, Pellegrino dis- cusses. seven challenges or criticisms applied to the teaching of ethics, be- ginning with the question of whether teaching ethics can change physicians’ behaviors. His equivocal response is eelthat there has been no proven correla- tion between the teaching of other ba- sic science courses and clinical compe- tence and therefore ethies should not be singled out. ‘To the question “Can ethies be taught?” Pellegrino asserts that ethics, as a distinct subject mat- ter with its own body of literature and methodology, is as teachable as any ‘other discipline. Nonetheless, he does assert that the knowledge of ethics cannot be expected to guarantee virtue. He also comments here (and elsewhere!) that students arrive at medical school with their own val uues—values that are not changed much by a course in ethies, a view point, widely held in clinical medici and frequently endorsed by bi cence faculty. Although Pellegrino's se- lection of “course” as his unit of analy- sis (as opposed to “curriculum” renders this last. assertion virtually unassailable, his overall response to this list of seven basic criticisms ap- pears to affirm the existence of an im- mutable value system residing within ‘one's personality. In sum, when dis- tinetions are drawn between know! ‘edge or skills and their application, an implicit message is that there is a valid and operationally viable distine- tion between “good doctors” and doc- tors who “do good,” between ethical physicians and physicians who act ethically; and ultimately between an ethics that exists independent of its practitioners and external to the prob- Jem at hand (and thus can be charac- terized as something that can be ap- plied) and an ethics that functions as an integral part of the physician's identity Distinctions between —_knowl- edge-skill and identity are also evi- dent (albeit once again indirectly) in discussions about the domain of ethics. Many articles urge faculty to make ethies “clinically relevant,” most often by structuring teaching around vehicles such as ambulatory care ethics conferences, inpatient ethies rounds, weekly ethies journal clubs, and ethies rotations Those contem- plating developing, renovating, or ex: panding their ethics curricula are urged to use the case-study approach, preferably using “real-life” examples ao selected by clinical students in order to enhance relevancy, authenticity, and thus student interest.*?2" But while critics may be hard pressed to find fault with “relevance” either as a pedagogical tool or as an ‘educational goal, the use of case exam- ples, however contextually focused, is not without important drawbacks. One danger is that case-oriented ma- terials traditionally have framed the domain of ethies almost entirely within the physician-patient relation- ship.® What becomes lost is a view of how medicine in general or medical schools in particular might be eonsid- ered as moral agents or moral entities. Jn turn, this pedagogical strategy builds upon and reinforces the already pervasive value complex of individual- ism present in the subject matter itself and thus further dissuades students from developing either the inclination or the ability to raise broader ques- tions about the nature of ethics and its domains. Important issues such as whether a medical school curriculum can be thought of as immoral, whether medicine (as a corporate entity) has a fiduciary responsibility to society (par- alleling the responsibility that physi- cians supposedly have toward their patients), or whether professional organizations (eg, the American Medical Association) have obligations that transcend their status as a trade group, remain unaddressed by suc- ceeding classes of students. ‘Asecond and potentially more insid- ious shortcoming is that when calls are made for the use of contextually based case studies, they frequently are accompanied by the recommendation that these materials be grounded in the ethical quandaries directly experi- enced by students.’ While we would agree with the general principle of contextually based materials, the ele- vation of experience to the status of ex- istence ignores the fact that one of the functions of professional training, par- ticularly as it relates to the internal- ization of feeling rules and the general process of emotional socialization, isto transform that which is startling, dis- quieting, and/or morally unsettling into something that is routine, accept able, or perhaps even to be preferred.” In short, any approach to the construe- tion of case studies that exclusively re- lies on trainees to identify the pres- ence of ethical quandaries runs the risk of “underreporting” or otherwise distorting the nature of the educa- tional experience, given that the trainees themselves are undergoing a process of socialization that is de- signed in part to alter their perception of what is going on around them. In short, what we have is the social sci- ence ‘equivalent of the Heisenberg, Uncertainty Principle. Finally, calls to apply the logic and methodology of outcomes analysis to ‘medical school training also slight the presence of moral development in the ‘medical educational milieu by choos- ing to subsume entities such as “pro- fessional attitudes” within a longer list of skills, knowledge, and technique- based criteria” One result is that en- tities that once formed the ideologic cornerstone of what it means to be a ‘good physician, such as “good charac- ter,” “the whole personality,” and “ac- tual knowledge,” have become incon- spicuously absent in these later formulations.* In spite of the wide- spread attention accorded matters of ethics and medicine in recent calls for ‘educational reform,” the prevailing sentiment, at least within the basic science faculty of medical schools, is a rather limited and task-oriented view of ethies, a view in which ethies exists as a tool and therefore as something ‘external to the core of medical practice and the physician's identity. MEDICAL TRAINING AS SOCIALIZATION: THE HIDDEN CURRICULUM Formal instruction in medical ethics does not take place within a cultural vacuum. This seemingly obvious fact, however, remains critically under-ac- Iknowledged in discussions about how the teaching of ethics might best be ac- complished during medical training. Only a fraction of medical eulture is to be found or can be conveyed within those curriculum-based hours formally allocated to medical students’ instruc- tion, Most of what the initiates will in- ternalize in terms of the values, atti- ACADEMIC MEDICINEtudes, beliefs, and related behaviors deemed important, within medicine takes place not within the formal cur- ricalum but via a more latent one, a “hidden curriculum,” with the latter being more concerned with replicating the culture of medicine than with the teaching of knowledge and tech- niques." In fact, what is “taught” in this hidden curriculum often can be antithetical to the goals and content of those courses that are formally of fored.!” The result can be a progres- sive decline of moral reasoning during undergraduate medical school train- ing By definition, socialization is the “processes by which people acquire the values and attitudes, the interests, skills, and knowledge—in short, the culture—current in the groups of which they are, or seek to become, a member. Sociologically, medical training is the pathway by which lay persons. are transformed into some- thing other than lay persons—in this case, physicians. Neophyte students are taught what is valued by this new culture, along with strategies and techniques to organize these values. ‘They also are provided with opportu- nities for internalizing these values ‘Via the socialization process, initiates are prepared for a type of work that unfolds in a landscape populated by both miracles and the macabre." Both society at large and the culture of medicine expect that. as physicians they will think about and react to things differently than will lay people. As such, medical training involves considerably more than the acquisi- tion of a new knowledge base. It also involves learning new rules about feel- ings® and about mistakes and the ‘management of failure.”** ‘The process of socialization and ex- posure to medicine's hidden curricu- jum begin well in advance of formal entry into medical school. Applicants craft. an admission biography that in- cludes appropriate justifications for their decision to enter medicine and an acceptable vocabulary of mo- tives. Acceptees arrive for their first classes with rather well-defined ideas about what constitutes meaning- fal medical intervention ("treatment") VOLUME 69 + NUMBER 11 * NOVEMBER 1994 and what clinical activities (‘mainte- nance”) are less highly valued within the culture of medicine® Once in school, they learn to value detach- ment, cope with uncertainty, develop strategies and rationales for amelio- rating ambiguity, and structure issues of clinical responsibility." Karly in their training, initiates are called ‘upon to function as both students and future colleagues. Later, as residents, they occupy conjoint roles as students and practicing physicians. Patients, in turn, are cast concurrently as victims of disease, objects for learning, and subjects for research. Combined with the pressures of a burdensome, stress- ful, and (for some) abusive® training environment, patients may not be held as objects of fiduciary responsibility. Instead, they can be transformed into objects of work and sources of frustra- tion and antagonism—evocatively re- cast as *hits,” “gomers,” “geeks,” and “dirtballs.™®""® They become “the en- emy.™" with students feeling justified in their use of negative labels and cor- responding behaviors. In sum, (1) students encounter an endless barrage of often conflicting messages about the nature of medical work and their place in it; (2) students internalize an appreciable number of clinically relevant values well before they formally embark on their clinieal training’; and (3) the overall process of medical training helps establish and reinforce a value climate that explic- itly identifies matters of rightness and wrongness within the overall culture of medicine. From these perspectives, a significant component of medical training involves the development of a ‘medical morality and supporting ratio- nales within its initiates. ‘The hidden curriculum itself oper- ates along several different but re- inforeing dimensions. Within the classroom, a hidden curriculum ac- companies formal instruction in a va- riety of ways. Instructors in biochem- istry, immunology, and pharmacology transmit not only information about metabolism, cytomogaloviruses, and drug biotransformation but also mes- sages about the nature of science, in- cluding the presence (or more correctly the absence) of uncertainty and ambi- guity in scientific work. Unwittingly, case reports may convey images that perpetuate gender, racial, ethnic, cule tural, or disability —stereotypes.** Stories, jokes, and personal anecdotes, ‘whether told by faculty or fellow stu: dents, all function as a part of the oral culture of medical training and thus as an influential part of the educa- tional process.* But a hidden curriculum need not depend upon social actors to convey its messages.® Appreciable information about the “nature of things,” including messages about rightness and wrong- ness, is imbedded in the very structure of medical work and the learning envi- ronment. One example is the afore- mentioned conflict between the role of student-as-student and that of stue dont-as-provider of medical services. Another is the demands of work plans ‘and. schedules versus the clinical needs of patients. Other “message sites” include the dynamics of author ity and the structure of inter-term re- lationships. Driven by a fear of failure ‘nd the threat of uncertainty, students often will translate a perception of themselves as. technically ignorant into a belief that they are ethically ig- norant as well’ As a consequence, they have a tendency to elevate what is normative (expected) into that which is morally preferable. ‘The point is not to paint a dismal or nefarious picture of medicine and ‘medical training. Rather, itis to stress that medical education does not take place in a cultural vacuum, within a value-neutral environment’ or in a place in which medical morality sim- ply replicates lay values. Medical training is not just learning about be- coming a physician, it involves learn- ing how to “cease” to be a lay person. ‘Medical training is not just about the acquisition of new knowledge and skills, it is about the acquisition of a physician identity and character. Initiates arrive at the gates of medical school with established values. They do not, however, leave medical train- ing with those values intact or unmod- ified, More to the point, they are not supposed to exit from’ the training process unaltered—at least as far as the culture of medicine is concerned 565‘Tp claim otherwise is to deny that pro- fessional enculturation is a fundamen- tal part of the educational process. Perhaps most germane to our ar- guments is the point that the social- ization process itself is directly in- volved in moving students toward the belief that matters of values and attitudes remain fundamen- tally untouched by the medical train- ing process. Students hear routinely that “good"/sensitivelearing physicians ‘come to medical school as “good” appli- cants. Conversely, “bad’insensitive students, they are told, are destined to become insensitive physicians. In e- ther ease, and with exquisite irony, students are expected to internalize the “fact” that their “fundamental” character will remain uninfluenced by the training process, even as the edi cational system uses this “fact” to pro- mote the internalization of desired changes in attitudes, values, and ac- companying rationales. If surrounded by a medical culture that discourages certain feelings, introspection, or per- sonal refleetion, and buffeted by a ba- ce curriculum that empha- sizes rote memorization, medical students may come to embrace such & reflexive myopia quite early in the training process. If ethical principles are to be faith- fully woven into the professional iden- tity of the physician, then medical ed- ucators must acknowledge not only the existence of a distinctive medical culture but also the presence of a deci- sively influential hidden curriculum, Tt makes little sense to insert addi- tional educational requirements (an- other ethies class, for example) into an already overburdened and disjointed curriculum when the overall structure of the educational process and the commonly stated goals of medical training (‘the preparation of knowl- edgeable and compassionate physi- cians”) seem to be at rational and ethi- cal loggerheads. In lion of such acknowledgements, ethies becomes ‘just another course,” usually offered for the wrong reasons and usually at a time when itis least likely to interfore with other, “more important” subjects. If left to this fate, ethies becomes a peripheral curiosity, Even worse, it 866 comes to be seen by students as a bar- rier to the “true” and unimpeded prac- tice of medicine, Human subjects com- ‘mittees and hospital ethics boards can become east as bureaucracies whose principal redeeming value lies in their ability to avoid lawsuits. Rather than guiding the study and practice of med- icine, ethics can become a tool for the fartherance of goals and policies that ultimately are structured without ref erence to ethical precepts. The very notion of ethics can become alien to the people it is supposed to serve. ‘The Ethic Taught in the Hidden Curriculum We are currently witnessing a signifi- cant metamorphosis in medical ethies.® A number of competing per- spectives based on the Hippocratic tra- dition, on principle-based moral theo- ries, and/or on virtue-based theories, ‘among others, are jockeying for legiti- ‘macy within the medical ethical mar- etplace. The validity of these differ- ent approaches aside, the fact remains that notions of nonmaleficence, benefi- cence, autonomy, and justice’ (prima facie principles), and these of charac- ter, goodness of intent, duty, compas- sion or love (virtue), are being taught, ‘on a daily basis during medical train- ing. One might argue that, what is be- ing “taught” is misinformed, mis- guided, or a distortion of some fundamental principle such as auton- omy, but this does not alter the fact that students are continuously and re- Tentlessly exposed to messages about such entities, as well as to notions about what makes for a good (or bad) physician, and that all ofthis is taking place outside the formal curriculum— but not necessarily outside the class- ‘To recognize medical training as 1a process of moral socialization is to acknowledge medicine's cultural dis- tinetion between attitudes and behav- ior for what. it is—something much ‘more ideological than rational. While associations between specific educa- tional experiences, particular atti- tudes or values, and concrete behav- iors will always be elusive, medical education—at root—involves the in- ternalization of new values, attitudes, and rationales, and much of what stu- dents learn involves matters of a moral nature. Tt is during medical training (which itself operates under the influence of a broader medieal cul- ture) that students learn to establish the primacy of individual experience along with the “dangers” of becoming “too” involved, “too” reflective, or “too” introspective. Other examples of lessons learned include the preemp- tive dominance of clinical experience over scientific knowledge and a rea- soning process that emphasizes induc- tion over deduction. In short, many of the “messages” transmitted via the hidden curriculum may be in direct conflict with what is being touted in formal courses on medical ethics or with what are for- mally heralded by the institution as desirable standards of ethical conduct. One consequence is that students ex- perience the educational process as something struetured around ineonsis- tencies, contradictions, and “double- messages.” The result is feelings of moral relativism and cynicism regard- ing the sanctity of the standards that are supposed to govern their profes- sional lives.® Unless medical educators recognize that the broader context of ethics training involves both a formal and a hidden system, and that this hidden system operates within the classroom, in the “hallways,” and within the very structure of training institutions themselves, then efforts to enhance ethies instruction solely on a formal level will continue to be mired in an overall milieu in which higher- order principles become buried be- neath the normative structure and the daily exigencies of life on the ward or in the classroom. Consequences ‘The marginalized place of medical ethics in the curriculum, combined with the belief that one’s inclination to act ethically or unethically resides rather immutably in one’s personality, have insidious consequences. Even though medical students can readily ‘expound on the importance of medical ethics as well as on their own abilities ACADEMIC MEDICINEto analyze ethical issues, most will graduate with at best a minimum of skills or resources (i.e., familiarity with specific ethical principles, litera- ture sourees, etc.) that will allow them to do so in a scholarly or rigorous fash- ion. It is likely that the same incon- sistency between beliefs and perfor- mance holds true for medical school faculty. ‘Training in ethies at the postgradu- ate level appears equally encumbered. Although formal instruction in ethical principles can be found in virtually all specialty and subspecialty areas,"*~® as noted above, most efforts appear to be constrained by the demands of “tight schedules” and “Limited time.” Whether such time shortages are due to a low priority’s being assigned to matters of ethics or to an unfamiliar- ity with how to effectively integrate ethical considerations into clinical do- cision making, it is widely acknowl edged that ethics teaching in clinical settings is lacking. Although the virtue of imparting ethical principles at the bedside and via role models is almost universally acclaimed, most advocates direct only a passing glance at the issue of how “objectively busy” clinicians can be counted on to ade- quately cover the important moral is- sues that appear omnipresent in clini- cal settings. All of this stands in some conflict with calls for educational reforms to include the teaching of ethies and ethi- cal principles as educational corner- stones. The GPEP Report, for exam- ple, identifies the teaching of medical ethics as an integral component in any overall effort to help students acquire the skills, values, and attitudes that reside at the foundation of the physi- cian's identity and practice. The Liaison Committee on Medical Eduea- tion (CME) of the AAMC has revised its standards of accreditation to ree- ommend the inclusion of ethical, be- hhavioral, and socioeconomic. subjects relevant’ to medicine? While many appear to recognize (although perhaps only rhetorically so) that moral consid- erations are as much a part of medical decisions as technical considerations, most medical schools (and faculty) appear satisfied to locate the content, VOLUME 69 « NUMBER 11 * NOVEMBER 1994 and teaching of medical ethics as a second-order priority relegated to odd hours in the formal curriculum. It therefore should not be surprising to encounter both medical students and faculty who come to view ethics as a “clinical too!” composed largely of dis- crete pieces of technical information and/or skills. A PROPOSED CURRICULUM ENVIRONMENT If the arguments advanced above have ‘merit, then it follows that the teaching of ethical principles in the medical school curriculum should be ap- proached and framed quite differently from the teaching of other basic sci- fence subjects such as biochemistry, anatomy, and physiology. Principles of Ddiochemistry (e.g., the Krebs cycle) and physiology (e., temperature reg- ulation) are usually'not thought to be part of one's identity. Although such processes do represent fundamental components of what we are, they are not generally thought to be germane to the issue of who we are. Moreover, these processes are considered to exist and function independent of their teaching or even of our awareness of their existence. Ethies, however, com- bines elements of knowledge with ele- ents of identity. As such, the estab- lishment of an overall value climate, along with a curriculum within that climate that will integrate ethical principles into the student's profes- sional identity, represents a dual chal- lenge to medical educators and faculty. Failure in this task may result in physicians who are armed with know! edge and techniques but have little awareness of the meaning and place of those tools. It follows, then, that efforts to reme- diate the problems associated with a “lack” of an ethics curriculum must take place at the level of medicine-as- culture and therefore must address, as an integral matter, the presence and influence of the hidden curriculum. The process of rendering manifest those latent messages embedded in the culture of medicine has analogies in programs currently operating within private and public sectors de- signed to combat the institutional re- production of cultural values asso- ciated with sexism, racism, and dis- crimination against people with disabilities. We will not review such efforts here; let us simply note that successful efforts require acknowledg- ing the presence of a hidden value sys- tem lying outside official company policies or business practices, along with the recognition that changes (1) will take time, (2) will require partici patory support from leadership and ‘management, and (3) must focus not just on individual attitudes and re- lated behaviors but on identifying how the structure and overall milieu of the setting in question may foster such undesirable values, attitudes, and/or behaviors. Presupposing that such acknowl edgement and support are forthcom- ing (both highly problematic assump- tions), we propose that the teaching of ethies should parallel ethical issues as they arise during the training experi- ence, beginning in the basic science years and continuing into clinical training. Although most case examples outline a fall four-year ethies curricu- lum, what is described usually falls short of our proposed goal in three critical respects. First, most efforts do not include the basic scientist and the full range of basic science courses in their proposals. Second, the curricu- lum described’ most often stresses ethics at the level of the individual physician—patient relationship, with relatively little attention to medicine ‘as an institutional and organizational entity. Third, although we heartily en- dorse the goal of making formal ethics instruction more contextually rele- vant, we do not view the self-perceived experiences of students as a necessary crux upon which case studies should be built. While neophyte medical stu- dents—particularly those from di- verse backgrounds—are more sensi- tive to the proseneo of a hidden curriculum than are their more “ad- vanced,” “seasoned,” or otherwise cul- turally embrued classmates (as well as faculty in general) —given their status as cultural neophytes (who therefore are more lay-like in their perceptions) the acculturation process is both rapidand desensitizing, thus rendering them more insider-like with each pass- ing week. Recommendations Within this framework, we have four recommendations. First, those who teach students, (including faculty, staff, other professionals, and more advanced students) need to become ‘more aware of the perceptions of initi- ates, particularly those from diverse backgrounds and those at the earliest, stages of their training and/or at the earliest stages of certain types of training experiences (e.., preceptor- ship or clerkship experiences). Within the culture of medicine, these individ- uals are the most lay-like in their per- ceptions of and reactions to the taken- for-granted “realities” of the training experience. As such, they serve as an important barometer of the presence and content of a hidden curriculum. In the same vein, those who teach stu- dents must abandon their traditional posture that all initiates need is “time” to “adjust to” or “get over” their “hy- persensitivities.” ‘Second, the content and possible im- pact of a’ hidden curriculum are best identified and addressed within a eon- sortium of faculty, students, and ex- pert outside observers (such’as social scientists), whose goal it is to address the training process in its broadest sense. “Insiders” cannot do it alone. Third, all faculty (not just clinical faculty or specifically identified ethies, faculty) who have contact with stu- dents must be both willing and able to identify the ethical issues they en- counter, whether in the laboratory or at the bedside, and to pass on these experiences and this knowledge to their students. Not only by their words but by their behavior, faculty should demonstrate the integration of ethical principles into the everyday work of both science and medicine. By sharing their recognition of ethical problems, the decisions reached, and more im: portant, the reasoning that, led to these decisions, faculty will have drawn their students into a mutually beneficial dialogue about the vital role of ethics in medicine. This recommen- 868 dation goes beyond calling for geneti cists to mention ethical issues under- seoring the human genome project in their lectures or for immunologists to mention the ethical aspects of HIV sereening in the classroom. Rather it calls upon faculty, irrespective of disci pline, to routinely provide students with insights into scientifie and clini- cal work as a fundamentally value- laden enterprise. Fourth, and at the other end of the spectrum, students need to be given “real-life” opportunities to ap- preciate the relevancy of ethics to medicine at, the organizational level. This remedial ethic may well be the ‘most difficult of our four recommenda- tions. Organizations such as medical schools, hospitals, and clinics are not often thought of as ethical entities. This benign neglect is compounded by the fact that within medicine, mat- ters of ethics are framed most often at the individual level and not at the or- ganizational level. Even when topics such as the allocation of scarce re- sourees are discussed, the frame of ref- ‘erence is more often at the level of the physician-patient rather than that of the organization. Similarly, “broad? is- sues such as abortion, reproductive technologies, and genetic manipula- tion are often discussed with little at- tention paid to what steps organized ‘medicine as a legally enfranchised and protected profession might take in ad- dressing and remedying any ethical is- sues in these areas. Although orga- nized medicine may occasionally take a stand on matters of public policy and bioethics, such positions are often weakened by medicine's long-standing position that individual physicians camnot be expected to act contrary to their own moral belief. ‘An acknowledgment by organiza tions that they are ethical entities is particularly problematic because such a confession may call for a degree of insight that has been precluded by medicine’s almost exclusive focus on ethics at the individual level. What is to be done if, for example, a basic sci- cence curriculum, burdensomely rich in lecture hours, is persuasively deemed unethical (as opposed to being, for ex- ample, pedagogically unsound}? Does the medical school face a moral obliga- tion to change? If so, would this obliga- tion be seen by administrators as tran- sending the interests of powerful basic science or clinical departments? Medical schools have long been known for their resistance to curricular change. This historical inertia repre- sents 2 significant challenge for indi- vidual school leaders who wish faculty to view their teaching as con- taining a dimension and messages that transcend the particular subject matters described in the course cata- logue. ‘Addressing issues of ethics at the or- ganizational level calls for steps to be taken across many areas. Agents of change must be identified, particularly within the administrative ranks. Curriculum committees must become involved. The traditional concept, of academic departments as curricular fiefdoms must be rethought. As an ex- ample of how one medical school unit, it respond, admission materials and advertising brochures can high- light medicine and medical education ‘as ethical entities. Admission inte views can profile medicine from this vantage point, thus beginning an en- culturation process at the point of in- stitutional first contact. Admission committees themselves can begin to view their deliberations as grounded in an overall ethic of societal obliga- tion. Orientation programs and even financial aid conferences can under- score issues such as the fundamen- tally moral and fiduciary nature of medicine at both the organizational and the practice levels ‘Who Shall Teach the Teachers? The above recommendations presup- pose that basic science and clinical fac- ulty are willing and able to function as, positive ethical agents and role mod- els, This is frequently not the case, and sometimes just the opposite may be true. Basic science faculty may ar- gue that ethics has no place in the teaching of biochemical pathways or anatomic function. Clinical faculty may criticize materials that are thought to emanate from those unfa- miliar with the “realities” of clinical ACADEMIC MEDICINEpractice. In fact, as we have argued throughout this’ essay, the relatively invisible profile of the topic of medical ethics in medical schools constitutes a curriculum in absentia, with its invisi- ble “content” reinforcing the message that ethics most appropriately resides as an adjunct to, or on the periphery of, scientific and medical work. ‘As such, any integrated medical school curriculum must begin with the instruction of the instructors ‘Training programs for physician—ethi- cists have been developed at. several institutions.%**°- Nonetheless, such programs represent the exception rather than the rule, The fact that ‘most: basie science and clinical faculty are familiar with the demands of human subject review committees or hospital ethics committees should not be taken as proof that these individu- als have any fundamental under- standing of, or commitment to, the ba- sic ethical principles that guide such ‘work. Similarly, a long record of scien- tists’ constructing elegant human sub- ject consent forms or the fact that par- ticular clinicians enjoy a vaunted reputation for their interpersonal skills provides no assurance that these individuals can function as effective teachers of ethical principles and pre- cepts. It is within this realm of the teaching of teachers that a most im- portant role for the professional ethi- cist lies. Although the particulars will have to differ by school, we once again rec- ominend that the existence of a morally oriented hidden curriculum be acknowledged within the medical school community “from the top down” and that appropriate changes in that, curriculum be made. Deans must make a commitment to broker support for a de-curricularized form of ethics instruction, to decrease the distance between basic science and clinical medicine, and to blur traditional dis- tinctions between what is character- ized as the “art” and the “science” of medicine, From dean to department head, from clinical chief to individual faculty, from one segment of the health care team to others, there must exist a belief within the culture of medicine that in health care, issues of VOLUME 69 # NUMBER 11 # NOVEMBER 1994 morality and ethics are ubiquitous to the organization and practice of medi- How might such a belief be fostered and put into practice? One step would be to reexamine mission statements, both long- and short-range, with an eye towards whether or not they in- clude some statement relating ethics to the practice of medicine and the work of science. Faculty development plans need to be re-examined to see how they might facilitate faculty awareness of how ethics relates to ‘medicine and science on a macro level Faculty seminars, journal clubs, “brown bags,” and other forums ean ali provide opportunities to highlight. the ethical aspects of what might other- wise be thought of as “pure” or “basic” activities. Although many of these sug- gestions can be found elsewhere, our proposal differs in that it calls for such efforts to be extended in an integrated fashion throughout the medical teach- ing community. Offices of grants and contracts can sponsor seminars on the role of ethics in scientific and medical work. Whatever the setting, the goal is a “routine” and “everyday” place for ethics within the scientific and med- ical communities. CONCLUSIONS Our argument may appear self-evi- dent: training in medical ethics should be started arly and continued throughout all of the basic and clinical sciences. Faculty committed to identi- fying the ethical problems they face and their limitations in resolving them will immeasurably enrich the profes- sional development of their students as ethically sensitive and socially re- flexive physicians. Faculty, students, administrators, and interested others need to establish working partner- ships with the goals of identifying the hidden curriculum that permeates their institution and, in turn, imple- menting remedial solutions best suited for their situation, As faculty strive to both impart and impress, they, too, will find their perspectives ‘on the nature of science and medical work pushed, prodded, and provoked. In these and related ways, faculty and students thus become symbiotically linked in an effort to ensure the pro- fessional development of both. Of course, all of this is much easier said than done. Nonetheless, our call is not to render medicine moral, to re- structure formal ethics courses, or to develop a multi-departmental, multi tiered ethics curriculum. Rather we are calling for the transformation and reorientation of a professional culture that has become ethically compro- mised in some important ways. ‘Medicine does not lack formal ethical codes, a culturally rooted sense of what. is right or wrong, or morally well-intentioned practitioners and teachers. But what dominates the cul- ture of medicine, along with the hid- den curriculum that supports it, is not ‘good intentions but rather a’ struc- turally ambiguous training process that too often is characterized by the existence of double-messages. What needs to be remembered, first and foremost, is that the fundamental character of medicine's culture is best reflected not in the curriculum-formal but in the curriculum-hidden. What students learn about the core values of medicine and medical work takes place not so much in the content of for- mal lectures but rather between the blackboard and the pen, not so much at the bedside (medicine’s preeminent metaphor) but via its more insidious and evil twin, “the corridor.” It is time medicine started claiming ownership of both realms. There is no quick fix. Stacking the deck with more pedagogically sophisti- cated course offerings is not the an- swer. Even the development of an ex- quisite, multidisciplinary, four-year, formal ethies curriculum, staffed by the best role models dollars and com- mitment can ensure, will afford stu- dents little more than a temporary haven in what amounts to a stormy ethical sea. The hidden curriculum is not something that can be supplanted or replaced by dedicated pedagogy or “new and improved” learning experi- ences. Itis not something that will dis- appear in the face of more course hours. ‘Medical education (and thus med- ical educators) must adopt a new and‘more activist role within the culture of medicine. Too long a simple conduit for values honed within the fire fights of ‘medical practice, the training years— ineluding preclinical, clinical-clerk- ship, and residency (although this latter period of training is decidedly more problematic given the dual provider-student role occupied by jdents)—should reflect a new com- mitment to the highly idealistic yet necessary role of transforming the cul- ture of clinical practice and the subcul- ture of basic science training. If orga- nized medicine cannot “marshal the charge” then the baton needs to be picked up by the education system itself. Leaders in the field must define a new medical morality grounded in the distinction between ethics and morals, with educators viewing their ‘own domain as an ethical territory. Particulars offered earlier include ba- sic science faculty's taking on a broader responsibility for the training of medical students and the existence of a greater partnership between stu- dents and faculty in making explicit aspects of the hidden curriculum that at the same time operate to shape them both. Eighty years ago the combined ener- gies, enthusiasm, and financial re- sources of a few individuals and foun- dations revolutionized the nature of medical education. In some respects, the success of these efforts has resulted in the dilemma facing us today. Perhaps what we need is the endorsement and legitimacy af- forded by a Robert Wood Johnson “Bthical Scholars Program,” a Kellogg Foundation “Ethical Leaders Initia tive,” or a National Science Founda- tion or National Institute of Health initiative to understand the nature of medicine as a moral enterprise and medical education as a process of moral enculturation, Whatever the cease, it will not happen without vision and the commitment of institutional resources, including money. In sum, we are calling for a more virtue-based medicine and a com- mitment of medical schools to the placement of character at the hub of physicians’ identity and practice orientation. While we recognize that 510 there exists considerable debate within academic circles about the ad- vsability of a virtue-centered ethic,**® we also feel that medicine's social le- gitimacy—including the ability of physicians to “act rightly” —will suffor if medicine identifies itself as unwill- ing or unable to acknowledge that virtue resides at the core of its profes- sional identity. We believe that, at minimum, institutions of medieal edu- cation have a responsibility to facil tate students’ development not just of, critical thinking skills but of an ability and normative expectation to be self reflecting, to be aware of the distine- tions between the self and the roles one occupies, and to be sensitive to how structural factors, social situa tions, and cultural contexts influence the work of medicine. More important, medicine has the obligation to identify these skills as éraits of a good physi- cian and thus as entities to be inter- nalized and made part of one's charac- ter, ‘The fundamental question is whether virtue is to be considered a necessary or sufficient condition for the practice of an ethical medicine, ‘Those who argue for efforts seated within the formal curriculum, and particularly those who emphasize the teaching of rules, principles, or con- cepts, advance a sufficiency argument, ‘contending (usually indirectly) that re- gardless of character, proper training in ethical precepts and their applica tion will suffice—or at leastis the best. medical education can hope for. Conversely, we argue that while virtue is not a sufficient condition, it is neces- sary for the practice of ethical medi- cine and it is something that can be taught (given our broadened definition of teaching). 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