임상실습 전 의과대학 교육을 받으며 도덕지향이 변하게 될까? (Journal of Medical Ethics, 2012)

임상실습 전 의과대학 교육을 받으며 도덕지향이 변하게 될까? (Journal of Medical Ethics, 2012)

Is medical students’ moral orientation changeable after preclinical medical education?

Chaou-Shune Lin,1,2 Kuo-Inn Tsou,1,3 Shu-Ling Cho,1 Ming-Shium Hsieh,4 Hsi-Chin Wu,5 Chyi-Her Lin6

PURPOSE:

도덕지향은 윤리적 의사결정에도 영향을 줄 수 있다. 의학교육을 통해서 도덕지향을 바꿀 수 있는가에 대한 연구는 매우 적다. 본 연구는 의과대학생들의 도덕지향을 분류하고, 전임상실습 교육 이후에 바뀌는지를 보았다.

Moral orientation can affect ethical decision-making. Very few studies have focused on whether medical education can change the moralorientation of the students. The purpose of the present study was to document the types of moral orientation exhibited by medical students, and to study if their moral orientation was changed after preclinical education.

METHODS:

2007년부터 2009년까지 Mojac scale을 활용하여 대만 의과대학생의 도덕지향을 측정하였다. 271명의 1학년과 109명의 3학년을 대상으로 하였다. 사회주의지향-중도지향-자유주의지향으로 구분하였으며 2년 후 변화를 살펴보았다.

From 2007 to 2009, the Mojac scale was used to measure the moral orientation of Taiwan medical students. The students included 271 first-year and 109 third-year students. They were rated as a communitarian, dual, or libertarian group and followed for 2 years to monitor the changes in their Mojac scores.

RESULTS:

1학년과 3학년에서 중도지향 학생은 2년간의 전임상실습 교육 이후에 변화가 없었다. 자유주의지향 그룹은 1학년도 ㅏ3학년 모두 99.4점에서 101.3점으로, 103.0점에서 105.7점으로 높아졌으며, 사회주의지향 그룹은 1학년과 3학년 모두 낮아졌다.

In both first and third-year students, the dual group after 2 years of preclinical medical education did not show any significant change. In the libertarian group, first and third-year students showed a statistically significant increase from a score of 99.4 and 101.3 to 103.0 and 105.7, respectively. In the communitarian group, first and third-year students showed a significant decline from 122.8 and 126.1 to 116.0 and 121.5, respectively.

CONCLUSION:

전임상실습 교육을 겪으며 사회주의지향과 자유주의지향 그룹은 모두 중도쪽으로 가까워졌다. 이러한 결과는 의과대학의 생명윤리 교육과 학생선발을 담당하는 사람들에게 중요한 힌트를 준다.

During the preclinical medical education years, students with communitarian orientation and libertarian orientation had changed in their moral orientation to become closer to dual orientation. These findings provide valuable hints to medical educators regarding bioethics educationand the selection criteria of medical students for admission.

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일부 연구에서 도덕적추론능력이 교육으로 향상된다는 것을 보여준 바 있다. 그러나 Evans 등은 belief-bias dual effect를 언급하며, 이상적 추론과 실제 결정이 차이가 있음을 지적한 바 있다. 즉 아는 것과 행하는 것 사이에 차이가 있다는 것이다. 

Some studies have shown that medical education may enhance the moral reasoning skills of the students.2 However, Evans3 proposed the ‘belief-bias dual effect’ of reasoning to highlight the discrepancies between optimal reasoning and actual moral decision. There is a gap between ‘knowing’ and ‘doing’. For example, when a physician is faced with a patient with terminal cancer, intellectually the physician knows he/she must tell the patient the truth, but under the influence of family members or other factors, a physician may decide not to tell the patient the truth.

Tsai와 Harasym은 의사들의 도덕적 의사결정을 연구하여 도덕적 의사결정은 세 가지 요소(지식, 도덕적 추론능력, 태도) 에 의한 복합적 과정임을 밝혔다. '태도'라는 용어는 도덕적합리화시스템을 관장하는 도덕적 가치나 신념에 대한 것으로서 이를 통해 윤리적 이슈의 옳고 그름에 관한 결정하게 된다. 도덕적 가치관의 발달은 어떤 교육을 받았는지, 어떤 경험을 했는지, 사회문화적 배경이 어떠한지와 밀접한 연관이 있다. 서로 다른 도덕적 가치관을 가진 사람들은 서로 다른 의사결정양상을 보인다. Gilligan이 제안한 도덕지향의 개념에 따르면 어떤 사람들은 사회적정의의 원칙을 중시하며, 다른 사람들은 개인적 안위를 가장 중요한 요소로 본다. 일부 이론가들은 도덕적 추론능력이 아니라 도덕지향이 윤리적의사결정에 더 중요하다고 주장하기도 한다.

Tsai and Harasym4 studied the moral decision- making process of clinicians and found that the moral decision is a complex process composed of three components: the doctor’s knowledge (clinical and ethical); moral reasoning skills and attitudes. The term ‘attitude’ refers to the moral value or belief governing the moral justification system that determines the ethical issues of right and wrong.4 The development of moral value is closely tied to a person’s education process, personal experience, culture and socioeconomic background. Persons with different moral values when making moral decisions show different tendencies: some relied on the social justice principle while others used personal care as the most important factor, a concept of moral orientation pointed out by Gilligan.5 6 Some theorists argue that moral orientation, rather than moral reasoning, might be more important in ethical decision-making in medicine.7

Bore 등은 Gilligan의 원칙에 따라 의과대학생의 도덕지향을 측정하는 도구를 개발하였다(Mojac) 다양한 나라에서 여러 학년의 학생을 대상으로 Mojac을 활용해보고 나서 Bore는 libertarian-dual-communitarian의 개념을 개발하였다. 도덕적 딜레마 상황에서 자유주의자는 개인의 요구에, 사회주의자는 사회적 요구에, 중도주의자는 두 가지에 모두 중점을 둔다는 것이다. 또한 그는 극단적인 사회주의자나 극단적인 자유주의자는 입학평가과정에서 배제해야 한다고 주장하였다. 왜냐하면 이러한 학생들의 도덕적 지향은 의료 맥락의 윤리적 기준이나 요구조건과 잘 맞지 않기 때문이다.

Bore et al,8 following Gilligan’s theory, had developed a tool to measure the moral orientation of medical students, known as the moral orientation of justice and care (Mojac) scale. After using Mojac to measure medical students at different levels from different countries, Bore developed a conceptualisation of a libertarianedualecommunitarian dimension of moral orientation. When confronted by a moral dilemma, libertarians will place greater value on the needs of the individuals, communitarians will place greater value on the needs of society and important reference groups, and the dualoriented will equally value the needs of both the individuals and society. He argued that extreme communitarians and extreme libertarians could be considered for exclusion from the process of selecting medical students on the grounds that that their moral orientation is likely to be incongruent with the ethical standards and requirements of the medical context.7

임상실습전 교육은, 대부분 18~22세에 속하는 이 시기에서 학생들의 학습능력에 유연성이 가장 뛰어나기에 학생들의 도덕지향을 형성하는데 중요한 시기이다. 

The preclinical medical education stage is especially important for moulding the moral orientation of students because students at this age (18e22 years) exhibit the most flexibility in their learning ability.9 10 A proper medical education at this stage will prepare them for the complex clinical situations they will encounter

METHODS

Background

Medical education in Taiwan is a 7-year undergraduate programme, which offer courses in liberal arts, general education and general science in the first 2 years, problem-based learning courses in basic sciences and some clinical sciences in the third and fourth years, clerkship in the fifth and sixth years and internship in the seventh year.

We focused our study on the preclinical period of year 1 to year 4. 

• During years 1 and 2, there were courses on introduction to medical ethics and law that included topics on ethical theory, patient autonomy, clinical dilemmas, professional ethos and social issues.
• During years 3 and 4, healthcare problems in the problem-based learning curriculum are used as the focus on the teaching of medical ethics.

Instrument

The instrument used at each point to measure students’ moral orientation was the Chinese version of the Mojac scale, which consists of three hypothetical situations (dilemmas) with 45 statement items. Respondents read each dilemma and were then asked to choose the answer that most closely reflects their value system and what they believe is appropriate for the statement using a four-point Likert scale (strongly agree to strongly disagree). The tests were administered in pen and paper format, using the optical mark reading answer sheets.

The Mojac scale has demonstrated high internal consistency (Cronbach a coefficient of above 0.80) and construct validity among medical school applicants and students in Australia, Israel, Fiji, New Zealand, Scotland and England.7 8

영문도구를 번역하여 활용하는 방법

The original English version of the Mojac scale was translated into Chinese, then back translated into English by bilingual persons. Three authors (CSL, KIT and SLC) examined each translated version. Any inconsistencies were resolved by discussion among the three authors.

DISCUSSION

도덕지향은 교육을 통해 쉽사리 변하지 않는 인적특성이다.

Moral orientation is considered to be a personal trait that is not easy to change with education.7

본 연구에서 학생들은 교육과정을 거치며 보다 중도쪽으로 수렴하는 경향을 보였다. 중도적 도덕지향이 도덕적 의사결정시에 다양한 측면을 동시에 고려해야 하는 임상 환경에 보다 적합한 형태라 할 수 있다. 어느 한 쪽에 치우친 의사는 도덕적 의사결정시에 중요한 이슈를 놓칠 수도 있다.

These results showed that education channels the students more towards dual orientation. This type of moral orientation (dual orientation) is more suitable for clinical situations because a clinician has to consider a situation from many aspects when making a moral decision. For example, factors such as equality of healthcare resources distribution, severity of a patient’s medical condition, a patient’s wish (or decision), and possible benefits and harms, are important issues for a clinician to consider when making a moral decision.4 Consideration of these factors will undoubtedly lead to conflicts, and only after careful weighing of the pros and cons can a clinician arrive at a logical moral decision. Clinicians with moral orientation leaning more towards libertarian or communitarian when faced with moral dilemmas often cannot balance different issues, thus missing some important moral issues in their decisionmaking process.7 13

Libcom점수는 문화적 배경에 의해 영향을 받을 수 있다.

Libcom scores may be influenced by the cultural background of the students.7

의과대학생의 도덕지향의 유형과 분포에 대한 이해를 통해서 생명윤리 교육과정 계획에 활용할 수 있다. 

An understanding of the distribution and types of moral orientation of medical students is important for teachers who are planning the curriculum on bioethics. This is because students with different moral orientations when faced with moral dilemmas may arrive at different interpretations and decisions, and the way to change their value system is to consider things from their point of view.14

도덕성 발달에 영향을 주는 두 요인은 성별/연령/교육수준과 같은 개인적 특성과, 부모의 교육수준, 사회경제적 수준, 문화와 같은 환경적/사회적 요인이다.

There are two factors that influence the moral development of a person: personal characteristics such as gender, age and level of education; and familial and societal factors such as educational level and income of the parents, and cultural background.15

Jaffee와 Hyde의 메타분석연구를 보면 성별은 도덕지향에 큰 영향을 주지 못한다.

A meta-analysis by Jaffee and Hyde16 on the influence of gender differences on moral orientation found that small differences in care orientation favour women and small differences in justice orientation favour men.

본 연구에서도 성별은 도덕지향 차이에 있어서 큰 역할을 하지 않았으며, 가정환경의 영향력을 고려할 때 일부 사람들은 중국인에게 있어서 가족구성원의 영향이 클 것이라고 주장하는 사람도 있다.

These results are similar to those reported by others, ie, gender plays a minor role in the change in moral orientation.16 Concerning the influence of family background on moral orientation, some have suggested that the moral development of Chinese individuals is greatly influenced by family members, because traditional thinking is that children strive to be obedient and to satisfy the wishes of their parents.17

본 연구는 대만에서 진행되었으며 문화적 맥락 차이에 의해서 다른 지역에서는 적용가능하지 않을 수도 있다. 대부분의 아시아 의과대학은 시험결과를 바탕으로 학생을 선발하고 18~19세에 입학하게 된다. 반면 영미권에서는 면접이 입학절차에서 한 부분으로 활용되고 있기 때문에 더 적합한 학생을 선발할 수 있을지도 모른다.

Finally, our study was carried out in Taiwan, which may not be applicable to other regions with different cultural backgrounds. Most Asian medical schools choose their students based on examination results and their average age is between 18 and 19 years. In contrast, personal interview is part of the admission process in medical schools in Europe and North America, so that students more suitable for medicine are probably selected through this process. Some of these students already have college degrees, and the age of these students is also older than Asian students.

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J Med Ethics. 2012 Mar;38(3):168-73. doi: 10.1136/medethics-2011-100092. Epub 2011 Sep 24.

Is medical students' moral orientation changeable after preclinical medical education?

Lin CS1, Tsou KI, Cho SL, Hsieh MS, Wu HC, Lin CH.

Author information

• 1College of Medicine, Fu-Jen Catholic University, No. 510 Chung-Cheng Road, Hsin-Chuang District, New Taipei City, Taiwan, ROC. 049687@mail.fju.edu.tw

Abstract

PURPOSE:

Moral orientation can affect ethical decision-making. Very few studies have focused on whether medical education can change the moralorientation of the students. The purpose of the present study was to document the types of moral orientation exhibited by medical students, and to study if their moral orientation was changed after preclinical education.

METHODS:

From 2007 to 2009, the Mojac scale was used to measure the moral orientation of Taiwan medical students. The students included 271 first-year and 109 third-year students. They were rated as a communitarian, dual, or libertarian group and followed for 2 years to monitor the changes in their Mojac scores.

RESULTS:

In both first and third-year students, the dual group after 2 years of preclinical medical education did not show any significant change. In the libertarian group, first and third-year students showed a statistically significant increase from a score of 99.4 and 101.3 to 103.0 and 105.7, respectively. In the communitarian group, first and third-year students showed a significant decline from 122.8 and 126.1 to 116.0 and 121.5, respectively.

CONCLUSION:

During the preclinical medical education years, students with communitarian orientation and libertarian orientation had changed in their moral orientation to become closer to dual orientation. These findings provide valuable hints to medical educators regarding bioethics educationand the selection criteria of medical students for admission.

PMID:

 

21947804

 

[PubMed - indexed for MEDLINE]