의과대학기간의 의대생의 도덕성 발달(CMAJ, 2003)

의과대학기간의 의대생의 도덕성 발달(CMAJ, 2003)

Changes in students’ moral development during medical school: a cohort study

Johane Patenaude, Theophile Niyonsenga, Diane Fafard

프로페셔널리즘에 대한 요구와 의료진에 대해 기대하는 퀄리티(도덕성 등)은 각 관련기관으로 하여금 의과대학생이 의학교육기간동안 윤리적 성장에 관해 관심을 가질 동기를 부여하였다. 윤리는 과학과 기술적 지식을 습득하는 것과 관련하여 의사에게 기대되는 여러 스킬 중 하나이다.

The requirements of professionalism and the ex- pected qualities of medical staff, including high moral character, motivate institutions to care about the ethical development of students during their medical education.1,2 Ethics is thus one of several expected physician skills related to the acquisition of scientific and technical knowledge.3–6

미국이나 다른 곳에서 진행된 연구의 결과는 의과대학기간동안 윤리적 스킬이 점진적으로 하락한다는 것을 보여준다. 이들 연구는 세 가지 다른 도구를 사용하였고, 서로 다른 결과를 보여주었는데, 때로는 윤리적 민감성이 감소하였고, 때로는 도덕적 추론능력의 발전이 억제되었다. 일부 결과는 낮은 도덕적 추론 수준과 의료과오로 인한 법적 문제의 숫자가 상관관계가 있다는 것을 보여주기도 했다. 한 설문으로부터 거의 절반의 학생이 비윤리적으로 행동해야 할 것 같은 압박을 느낀대고 응답했고, 또 다른 설문에서 3, 4학년의 62%가 그들의 윤리적 원칙이 점차 부식되어가거나 사라지는 것처럼 느낀다고 했다. 이러한 상황은 의학교육이 종료된 이후에도 나아지는 것 같지 않다.

The results of studies performed in the United States and elsewhere suggest a negative trend in the progress of ethical skills during medical training.7–10 These studies, which used 3 different instruments, yielded divergent re- sults, showing sometimes decreased ethical sensitivity11 and sometimes inhibited development in moral reasoning.12–15 Some of the results demonstrated a strong correlation be- tween low levels of moral reasoning and the number of le- gal proceedings for malpractice (unpublished data). In one survey, nearly half of the students reported that they felt pressure to act unethically,16 and in another survey of 665 third- and fourth-year medical students, 62% of them felt that their ethical principles had been seriously eroded or had disappeared.17 The situation does not appear to im- prove once medical education is completed.18

의료행위에 있어서 윤리의 중요성에 대한 관심이 늘어남에 따라, 성숙에 따른 도덕적 추론의 자연적 성장과 교육에 의한 성장 사이의 차이에 대한 이해가 더 필요해졌으며, 여기에는 윤리적 기술을 향상시키기 위한 교육법, 의과대학기간의 윤리성 저하 등이 포함된다. 의학교육 기간에 더 나은 개입법을 만들기 위해서 많은 사람이 이러한 차이를 설명하고자 했다. 미국 의대생들의 도덕 발달에 대한 연구를 보면 단 하나만이 장기적 자료를 사용하고 있다. 그 연구에서 도덕적 추론 점수의 상승은 4년에 기간동안 이뤄지지 않았으며, 이는 핛생들의 교육경험이 도덕추론의 발달을 촉진한다기보다는 억제함을 시사한다.

In light of growing concern about ethics in medical practice, it is important to have a better understanding of the divergence between the natural progression of moral reasoning that comes with maturity19 and education,20 in- cluding pedagogical measures taken to promote ethical skills, and the degradation observed during medical educa- tion. Many have attempted to explain this divergence in or- der to better intervene during medical education.21–23 Stud- ies have been published on the moral development of American medical students,12–15 but only one used longitudi- nal data.13 In that study, the expected increase in scores for moral reasoning did not occur over the 4 years of medical education, which suggests that the students’ education ex- perience somehow inhibited rather than facilitated the de- velopment of their moral reasoning.

방법

Methods

Uni- versity of Sherbrooke에 입학한 모든 92명의 학생을 대상으로 MJI설문을 함. 참여는 자율적이었으며, 비밀이 지켜질 것을 확실히 했음. 같은 학생을 3학년 말에 다시 설문함.

We invited all 92 students entering medical school at the Uni- versity of Sherbrooke, Que., to complete the Moral Judgment In- terview (MJI) questionnaire upon registration. Participation was voluntary, and we assured respondents of confidentiality. We in- vited the same individuals to complete the questionnaire again at the end of their third year of medical studies.

MJI scale은 Lawrence Kohlberg 에 의해서 1958년 개발되었고, 원래는 도덕적 추론의 로직에 따라 변화를 측정하려는 것이었다. Kohlberg의 이론에 따르면 다음의 단계에 따라 성숙한다.

The MJI scale, developed by Lawrence Kohlberg in 1958,24,25 was designed to measure changes in the logic of moral reasoning that usually occur over years. According to Kohlberg’s theory, people proceed through stages of reasoning as they mature (Table 1).

 

참가자의 도덕추론에 대해서 검사한 것은 그 사람의 도덕신념이나 가치에 대한 것이 아니었다. 예컨대 4단계의 사람도 보수적이거나 진보적일 수 있으며, 실제로 어떤 사람이 보수적이거나 진보적이라는 것은 도덕적 추론 능력과는 아무런 관계가 없다.

What is being tested is the participant’s capacity for moral reasoning and not the person’s particular set of moral be- liefs and values. For example, a person could be at stage 4 and have either conservative or liberal values; indeed, whether a per- son holds conservative or liberal values has no bearing on the rea- soning capacities for supporting whatever values are held.

Colby and Kohlberg가 정의한 매개변수에 따라서 코딩하고, 각 학생별로 발달의 단계를 평가하였다. 이 단계는 학생의 응답에서 가장 많이 등장하는 것으로 하였고, 두 개가 같은 빈도일 경우 두 단계 사이의 중간이라고 하였다.

We coded responses according to parameters defined by Colby and Kohlberg.19 A stage of development was first attributed to each response. The stage attributed most frequently in a stu- dent’s questionnaire constituted the individual’s dominant stage. When students invoked 2 stages with equal frequency, an inter- mediate category falling halfway between the 2 stages was created (e.g., intermediate stage 3–4).

 

세 번째 단계에서 각 단계의 빈도에 가중치를 둔 단계를 산출함

In a third step, we converted recorded stages to numeri- cal scores (weighted average scores) according to the frequency of use of each stage.

해석

Interpretation

미국에서의 종단연구와 마찬가지로 우리는 maturation에 따라 동반될 것으로 기대된 도덕 추론능력의 향상을 관찰하지 못했다. 우리는 가중-평균점수에서 유의미한 감소를 확인하였다. 그러나 우리의 관찰결과는 이러한 도덕발달의 저하와 의학교육 사이의 인과관계를 보여주는 것은 아니다. 그러나 명백한 것은 해당 연령대에서 기대되는 발달의 하한선 정도밖에 미치지 못한다는 점이다. Colby와 Kohlberg는 도덕적 추론의 conventional 수준(3~4단계, 4단계)이 청년과 성인에서 가장 흔하게 나타나는 것이라고 했다. 이와는 대조적으로 어린이나 유년기에는 preconventional level (1~3단계)가 가장 흔하다. 이 단계에서 부모의 권외와 벌을 회피하고자 하는 성향이 두드러진다. postconventional level (4~5단계, 5단계)는 사회적 관점을 받아들이는 것이며 성인의 소수에서만 발견된다.

As in the US longitudinal study,13 we did not observe the increase in the development of moral reasoning that was expected with maturation and involvement in university studies. We found a significant decrease in weighted aver-age scores after 3 years of medical education. Our findings do not, however, establish a direct causal relation between the observed decrease in moral development and medical education. Yet they do clearly indicate the occurrence overtime of a levelling to a lower threshold of development than that expected for this age group. Colby and Kohl-berg19 stated that the conventional level of moral reasoning(represented by intermediate stage 3–4 and stage 4) is the one most commonly found in the adolescent and adult population. In contrast, among children and young adoles-cents, the preconventional level (represented by stages 1 to3) prevails; at this level parental authority and the desire to avoid punishment are determinative. The postconventional level (represented by intermediate stage 4–5 and stage 5) is characterized by the adoption of a societal perspective and is found only in a minority of adults. 

우리의 결과는 의과대학이 강력한 사회화 경험을 구성한다는 가설을 확인시켜주었다. 높은 단계에 있는 학생들은 반 단계 이상 단계가 감소하는 경향이 있었으며, 이들 중 단 한 명만이 3년이 지난 후 원래 단계를 유지하고 있었다. 이들학생에서 가중 평균점수가 감소할 가능성은 100%였다. 반대로, 낮은 단계에서 시작했던 학생들은 반 단계 이상 단계가 높아지는 경향을 보였다. 이는 이러한 레벨링 효과가 의과대학 3년의 기간동안 도덕적 추론에 대해서 발생함을 보여준다.

Our findings appear to confirm the hypothesis that medical school constitutes a strong socializing experience. There was a strong likelihood of a decrease in stage of moral development by more than half a stage among the students rated as having a high stage (stage 4 or intermedi- ate stage 4–5) upon entering medical school. Among these students, only 1 stayed at his or her initial stage after 3 years. The probability of a decrease in weighted average scores among these students was 100%. Inversely, the like- lihood of an increase by more than half a stage among the students who were initially rated at lower stages (interme- diate stage 2–3 and stage 3) was high. It seems reasonable to infer that a levelling effect occurred in moral reasoning over the 3 years of medical education.

 

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CMAJ. 2003 Apr 1;168(7):840-4.

Changes in students' moral development during medical school: a cohort study.

Patenaude J1, Niyonsenga T, Fafard D.

Author information

• 1Department of Surgery, Faculty of Medicine, University of Sherbrooke and the Centre for Clinical Research, Centre hospitalier universitaire de Sherbrooke, QC. johane.patenaude@usherbrooke.ca

Abstract

INTRODUCTION:

The requirements of professionalism and the expected qualities of medical staff, including high moral character, motivate institutions to care about the ethical development of students during their medical education. We assessed progress in moral reasoning in a cohort ofmedical students over the first 3 years of their education.

METHODS:

We invited all 92 medical students enrolled at the University of Sherbrooke, Que., to complete a questionnaire on moral reasoning at the start of their first year of medical school and at the end of their third year. We used the French version of Kohlberg's Moral Judgment Interview. Responses to the questionnaire were coded by stage of moral development, and weighted average scores were assigned according to frequency of use of each stage.

RESULTS:

Of the 92 medical students, 54 completed the questionnaire in the fall of the first year and again at the end of their third year. The average age of the students at the end of the third year was 21 years, and 79% of the students included in the study were women. Over the 3-year period, the stage of moral development did not change substantially (i.e., by more than half a stage) for 39 (72%) of the students, shifted to a lower stage for 7 (13%) and shifted to a higher stage for 8 (15%). The overall mean change in stage was not significant (from mean 3.46 in year 1 to 3.48 in year 3, p = 0.86); however, the overall mean change in weighted average scores showed a significant decline in moral development (p = 0.028).

INTERPRETATION:

Temporal variations in students' scores show a levelling process of their moral reasoning. This finding prompts us to ask whether a hidden curriculum exists in the structure of medical education that inhibits rather than facilitates the development of moral reasoning.

Comment in

• Pilot study of the defining issues test. [CMAJ. 2003]
• Strengthening the role of ethics in medical education. [CMAJ. 2003]
• The moral of the study. [CMAJ. 2003]
• Enlightening medical students. [CMAJ. 2003]
• Enlightening medical students. [CMAJ. 2003]

PMID:

 

12668541

 

[PubMed - indexed for MEDLINE] 

PMCID:

 

PMC151989

 

Free PMC Article