INTRODUCTION: Medical ethicists have pointed out that a gap exists between classroom teaching of bioethical theory and the ethics of clinical reality. Studies recommend that the teaching of bioethics should focus on everyday dilemmas in the clinical setting instead of only dramatic dilemmas and have expressed the need for more studies of how medical students perceive ethical problems in the clinical setting. This study explored themes in and types of ethical dilemmas in medical students’ reflective writing in their clinical rotations.
METHODS: The study was a qualitative explorative analysis of group reflection texts from fourth-year medical students at Aarhus University, Denmark.
RESULTS: The thematic analysis of 51 group reflection texts (n = 396) revealed four key themes in the material: 1) confidentiality issues, 2) treatment options and side effects, 3) the students' role and responsibility and 4) information-giving and communication. The majority of the ethical dilemmas that the students identified were everyday dilemmas. Dramatic dilemmas were represented to a limited degree.
CONCLUSIONS: Students’ perspectives on ethical dilemmas in the clinical setting provide a unique opportunity to integrate a variety of ethical dimensions into bioethical education and draw attention to overlooked everyday ethical dilemmas. Thus, involving the students’ perspectives may be a way to bridge the gap between bioethical theory and the ethics of clinical reality.
TRIAL REGISTRATION: not relevant.
During the past four decades, medical ethics has received increasing attention in medical education and is now an integral part of medical school curricula around the world . There are several reasons for this development. First, it is widely recognised that medicine is a moral practice . Second, studies show that medical students lose their ability to recognise ethical dilemmas and to approach such situations with empathy and moral reasoning during medical training [3, 4]. Thus, there is agreement that ethics needs to be taught. There is, however, no consensus on what the exact purpose of the teaching should be – let alone what to teach and how . Some advocate that the aim is to create virtuousdoctors, others that the purpose is to provide doctors with a set of skills for ethical reasoning [1, 5] or to develop a ”moral compass” .
Several medical ethicists point out that there is a gap between bioethical theory as typically taught in formal university teaching, and the ethics of clinical reality [5, 7]. However, how this gap may be bridged seems to cause disagreement. Finnerty et al  claim that the four principles (autonomy, beneficence, non-maleficence and justice) described in Beachamp and Childress’ classic text  should be combined with an introduction to ethical theoretical traditions.Others emphasise clinical cases and ‘tool kits’  as the best way. It has also been suggested to develop models for ethical reasoning that are structured within the frame of clinical reasoning  or to implement ward-round ethics . Some make a more general critique of the bioethics movement as a whole and claim that bioethics teaching should focus on the narrative practice of everyday actions in clinical practice instead of on bioethical theory [11, 12]. In line herewith, Zizzo et al  distinguish between dramatic ethics and everyday ethics. They emphasise how a more balanced perspective also encompassing everyday ethics (e.g., regular practical clinical ethical issues and real-life problems of patients and healthcare providers) should replace the current dominant focus on dramatic ethics (e.g., emergency care, high technology and invasive or life-threatening interventions).
The need for qualitative research exploring how medical students perceive ethical problems has been addressed . Studies have contributed with insight into what students identify as ethical dilemmas [14, 15], and projects have enabled students to share stories and notice the otherwise “hidden curriculum”, i.e., the lessons, norms, and values that are learned, but not openly intended [10, 15-17].
Our study adds to this picture with the aim of exploring 1) which themes and types of ethical dilemmas are captured in students’ written reflections in the clinical setting? and 2) how students’ perspectives may inform the organisation of biomedical ethics training and curriculum development?
Our study used a qualitative exploratory design including an analysis of students’ reflectie texts.
At Aarhus University, Denmark, medical students receive training in biomedical ethics both at the bachelor’s (BA) (pre-clinical) and the master’s (MA) level. At the MA level, students receive short seminars in bioethics during every semester that relate directly to the clinical practice they are about to experience during rotations (see Table 1).
Data collection and participants
We collected portfolio texts, i.e., already existing material, from fourth-year medical students (MA) at Aarhus University (n = 396). The collection took place in the course of two semesters (12 months). The texts were reflection exercises written in the students’ clinical rotation groups. The groups were instructed to choose an ethical dilemma encountered during their eight-week clinical stays at various hospital departments in Denmark (see Table 2). After discussing these dilemmas in the groups, students wrote a 4-5-page text conveying the reflections of the group. All 53 groups were presented with written information about the project, also stating that their texts would be anonymised. Written informed consent was obtained from 51 groups. Two groups did not wish to participate, and their texts were therefore not included in the analysis. The study was exempted from ethics approval according to the Danish Act on Research Ethics Review of Health Research Projects.
We used thematic analysis  to identify key themes in the material. In addition, we employed the theoretical framework from Zizzo et al and their distinction between dramatic ethics and everyday ethics to establish what types of ethical dilemmas the students identified. First, the two principal investigators (first and last author) read all of the material and made an initial thematic categorisation. Then, we invited a group of five assistants (authors 2-6) to each read half of the material and conduct a thematic analysis of its contents. Subsequently, we exchanged material and repeated the process. In the final validation, all authors met to compare themes. All inconsistencies were resolved by re-reading the material and reaching a consensus.
Trial registration: not relevant
The data material consisted of 51 group reflection texts, a total of 252 pages. The thematic analysis revealed four key themes in the material, distributed into 62 subthemes: 1) confidentiality issues, 2) treatment options and side effects, 3) the students' role and responsibility and 4) information-giving and communication. These themes were analytical categories in the sense that one case narrative could involve several ethical themes.
Types of dilemmas
As seen in Table 3, we found that students identified both dramatic and everyday ethical problems. However, the majority of the dilemmas they identified and reflected upon were everyday problems (a total of 49). Furthermore, our analysis showed two different types of dramatic dilemmas: 1) classic dilemmas that were somehow detached from a specific context and 2) extreme dilemmas that were rarer and bound to a particular and complex situation.
As seen in Table 4, the main part of the dilemmas concerned confidentiality issues and issues related to professional secrecy. This theme was identified both as classic, extreme and everyday dilemmas. An example of the classic dramatic issue was the issue of breaking confidentiality when a patient exposed others to an infectious disease (e.g., hepatitis or HIV).
However, the majority of the dilemmas were categorised as everyday dilemmas, e.g., cases involving a “minor” breach of confidentiality – for example when doctors and nurses “dictated with the door to their office left open”, thus violating confidentiality. This attention to the everyday ethical dimension of confidentiality was also witnessed in cases where information was sought or provided by the doctor in a multi-bed room (e.g., during ward rounds). Often, fellow patients and their relatives were present during rounds, which meant that it became difficult to maintain confidentiality (see Table 4, Quote 1).
The students repeatedly stressed that it was important that such conversations took place with the individual patient in a conversation room. However, their cases also bore witness that far from all departments have the capacity to do so due to overcrowding. Several groups identified how the cause of these problems with keeping confidentiality in a busy clinical hospital practice was not as much a matter of ill intention from healthcare providers as it was a problem intrinsic to the system itself and due to scarcity of resources (see Table 4, Quotes 2 + 3).
Treatment options and side effects
Classic themes related to questions about treatment effect versus side effects following different treatments, e.g. chemotherapy. Here, the students pointed to dilemmas where dignity and quality of life were at stake. Few extreme dilemmas were observed and these concerned issues such as foreign patients who were caught in between countries and hence did not have the right to free treatment in the Danish healthcare system.
A dominant everyday theme that students identified was the limited resources of the healthcare system. This working condition created dilemmas for doctors about using resources on one individual patient, knowing that other patients could not be offered the same treatment.
The students described how doctors often debated the level of treatment for patients and decisions concerning resuscitation of seriously ill and mentally despaired patients. Reflections showed how all these were embedded in ethical dilemmas (see Table 4, Quote 4).
Information giving and communication
Classic examples were rare in this theme. Those witnessed regarded information-giving and how doctors balance the patients' right to information on the one hand while respecting the patients' right to not wanting to know on the other.
Everyday ethical dilemmas were more prevalent and among others related to the style of communication of health professionals, both when communicating with patients and when communicating about patients with colleagues. From time to time, a harsh or sarcastic tone was seen as ethically problematic. The students identified this type of jargon in the presence of other patients as morally questionable and discussed how collegial ways of talking about patients sometimes created a culture or communication style that was disrespectful to patients and maybe led to a lack of trust (see Table 4, Quote 5).
A recurring everyday theme was how the presence of other patients and relatives led to patients evading to answer certain questions from healthcare workers, for example, concerning alcohol habits, sexual habits, etc. This theme related to communication skills of doctors and nurses, for example that although patients non-verbally signalled that a topic of conversation was uncomfortable for them, the doctors did not adjust their communication but kept asking questions. This entailed two problems: First, the doctor - maybe unintentionally - showed a lack of respect for the patient. Second, they faced the risk of not getting the information they needed to treat and help the patient in the best possible way.
The role and responsibility of the student
A minor theme in the material was the role and responsibility of the students. These were all everyday dilemmas where students reflected on issues such as whether they should interfere if they witnessed morally undesirable situations. For example, if a doctor did not inform a patient the way he or she ought to, the students reflected on whether they could and/or should interfere and how (see Table 4, Quote 6).
Our findings showed that groups of students were able to recognise and reflect on ethical dilemmas in the clinic. The reported clash between the principles of confidentiality and the busy clinical reality led to in-depth reflections about the challenge of acting as morally correct as one would wish. Furthermore, the students identified core ethical questions concerning ”the good life” of the patient as something that should not only to be determined from a medical perspective, but needs to involve the perspective of each individual patient. Raising such awareness at this time in their medical career is important for them to understand the everyday challenges of what may seem to be abstract ethical principles in the classroom.
There is some resonance between our findings and those of previous studies exploring students reflective writing. Like our study, Karnieli-Miller et al  found that key themes were clinical interactions, especially role models interacting with patients, and students’ experiences as learners. While their material showed more embodiment of professional values, we identified dilemmas. Kaldjian et al  found themes similar to ours, although with more thematic variation. However, as both studies asked the students to reflect not only on ethical but also professional issues, the scope of the assignments differed slightly from ours.
We add to these studies by showing that the student perspective on the clinical setting provides an opportunity to pay give attention to the otherwise overlooked everyday ethics , thus modifyingthe “dominance of dramatic ethics” [11-13].Encouraging students to reflect on ethical dilemmas during clinical rotations may serve as a window of opportunity and help bridging the gap between classroom teaching and the reality of clinical ethics . Other studies demonstrate that students’ written reflections are a rich source of information about the lived clinical experience of not only biomedical ethics, but also of the“hidden curriculum”  and the concept of “the good doctor” .
Our findings have implications for how the education in biomedical ethics should be organised: Firstly, education should provide students with theories allowing them to grasp the everyday ethical problems experienced in the clinic  as a supplement to more traditional biomedical ethics curriculum. Secondly, more ethics teaching should take place in clinical practice, for example as “ward round ethics” sessions . By this we do not suggest replacing more traditional bioethical theoretical teaching with teaching of everyday ethics but rather to consider it a necessary supplement.
Our study has limitations. As our material was produced as part of a portfolio exam and not directly for the research project, this may have shaped the students’ reflections. Furthermore, the use of written material prevented us from asking follow-up questions and thus from achieving a more in-depth qualitative perspective. Even so, the large sample of statements from a well-definedgroup of students is a strength, and we find that the richness of our many texts provided us with valuable insight into the, often overlooked, student perspectives about ethical dilemmas in the clinical setting.
CORRESPONDENCE: Jane Ege Møller. E-mail: firstname.lastname@example.org
ACCEPTED: 31 January 2020
CONFLICTS OF INTEREST: none. Disclosure forms provided by the authors are available with the full text of this article at Ugeskriftet.dk/dmj
Eckles RE, Meslin EM, Gaffney M et al. Medical ethics education: Where are we? Where should we be going? A review. Acad Med J Assoc Am Med Coll 2005;80:1143-52.
Zeiler K. Bringing the lived body to medical ethics education: learning to see the suffering other. In: Cowley C, ed. Reconceiving medical ethics. London & New York Continuum International Publishing Group, 2012:44-55
Goldie J, Schwartz L, McConnachie A et al. The impact of a modern medical curriculum on students’ proposed behaviour on meeting ethical dilemmas. Med Educ 2004;38:942-9.
Hébert PC, Meslin EM, Dunn EV. Measuring the ethical sensitivity of medical students: a study at the University of Toronto. J Med Ethics 1992;18:142-7.
Kaldjian LC, Weir RF, Duffy TP. A clinician’s approach to clinical ethical reasoning. J Gen Intern Med 2005;20:306-11.
Roff S, Preece P. Helping medical students to find their moral compasses: ethics teaching for second and third year undergraduates. J Med Ethics 2004;30:487-9.
Finnerty JJ, Pinkerton JV, Moreno J et al. Ethical theory and principles: Do they have any relevance to problems arising in everyday practice? Am J Obstet Gynecol 2000;183:301-8.
Beauchamp TL, Childress JF. Principles of biomedical ethics. 7th ed. New York Oxford University Press, 2012.
Jonsen AR, Siegler M, Windslade WJ. Clinical ethics: a practical approach to ethical decisions in clinical medicine. 7th ed. Copenhagen: McGraw-Hill, 2010.
Fryer-Edwards K, Wilkins MD, Baernstein A et al. Bringing ethics education to the clinical years: ward ethics sessions at the University of Washington. Acad Med J Assoc Am Med Coll 2006;81:626-31.
Kass LR. Practicing ethics: Where’s the action? Hastings Cent Rep 1990;20:5-12.
Lantos JD. Reconsidering action: day-to-day ethics in the work of medicine. In: Charon R, Montello MM, eds. Stories matter: the role of narrative in medical ethics. New York Routledge, 2002:154-59.
Zizzo N, Bell E, Racine E. What is everyday ethics? a review and a proposal for an integrative concept. J Clin Ethics 2016;27:117-28.
Kaldjian LC, Rosenbaum ME, Shinkunas LA et al. Through students’ eyes: ethical and professional issues identified by third-year medical students during clerkships. J Med Ethics 2012;38:130-2.
Karnieli-Miller O, Vu TR, Holtman MC et al. Medical students’ professionalism narratives: a window on the informal and hidden curriculum. Acad Med J Assoc Am Med Coll 2010;85:124-33.
Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med J Assoc Am Med Coll 1994;69:861-71.
Belling C, Coulehan J. A window of opportunity: ethics and professionalism in the obstetrics and gynecology clerkship. Teach Learn Med 2006;18:326-9.
Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:83.
Rutberg PC, King B, Gaufberg E et al. Do medical students’ narrative representations of “the good doctor” change over time? Acad Med J Assoc Am Med Coll 2017;92:537-43.
Gaufberg EH, Batalden M, Sands R et al. The hidden curriculum: What can we learn from third-year medical student narrative reflections? Acad Med J Assoc Am Med Coll 2010;85:1709-16.