도덕지향에 따른 의과대학생 선발(Medical Education, 2005)

도덕지향에 따른 의과대학생 선발(Medical Education, 2005)

Selection of medical students according to their moral orientation

Miles Bore,1,2 Don Munro,2 Ian Kerridge3 & David Powis1

INTRODUCTION:

Consideration has been given to the use of tests of moral reasoning in the selection procedure for medical students. We argue thatmoral orientation, rather than moral reasoning, might be more efficacious in minimising the likelihood of inappropriate ethical behaviour in medicine. A conceptualisation and measure of moral orientation are presented, together with findings from 11 samples of medical school applicants and students.

AIM:

To provide empirical evidence for the reliability and validity of a measure of moral orientation and to explore gender, age, cultural and educational influences on moral orientation.

METHODS:

A questionnaire designed to measure a libertarian-dual-communitarian dimension of moral orientation was completed by 7864 medicalschool applicants and students in Australia, Israel, Fiji, New Zealand, Scotland and England and by 84 Australian psychology students between 1997 and 2001.

RESULTS:

Older respondents produced marginally higher (more communitarian) moral orientation scores, as did women compared to men. Minor but significant (P <0.05) cultural differences were found. The Israeli samples produced higher mean moral orientation scores, while the Australian psychology student sample produced a lower (more libertarian) mean score relative to all other samples. No significant change in moral orientationscore was observed after 1 year in a sample of Australian medical school students (n=59), although some differences observed between 5 cohorts of Australian medical students (Years 1-5; n=234) did reach significance. Moral orientation scores were found to be significantly correlated with a number of personality measures, providing evidence of construct validity. In all samples moral orientation significantly predicted the moral decisions made in response to the hypothetical dilemmas embedded in the measurement instrument. Discussion The results provide support for the conceptualisation of a libertarian-dual-communitarian dimension of moral orientation and demonstrate the psychometric properties of the measurement instrument. A number of questions concerning the use of such tests in selection procedures are considered.

---

Introduction

최근 CMA Journal에 의과대학생이 학년이 올라감에 따라 도덕적 추론의 단계가 하강하는 것 같다는 연구결과에 대하여 commentary를 하면서 Singer는 윤리적인 의사를 선발하고 교육하는 것의 복잡함을 지적한 바 있다. 특히 Singer는 의과대학생을 논리적추론능력에 기반하여 선발해야한다고 주장하였다. 이러한 주장이 일견 타당해보이지만, 우리는 도덕적추론에 대한 시험을 선발도구로 사용하는 것이 부적절하며, 그보다는 도덕지향(moral orientation)을 사용하는 것이 더 좋음을 주장하고자 한다.

In a recent commentary in the Canadian Medical Association journal, written in response to findings that students' stages of moral reasoning appeared to decline over the course of medical education,1 Singer2 addressed some of the complexities of selecting and training ethical practitioners. In particular, Singer suggested the need for the selection of medical students to be based on level of moral reasoning. While this seems reasonable, we would argue that tests of moral reasoning are inappropriate for use as selection instruments and that it may be more valuable to consider individual differences in ‘moral orientation’.

Moral reasoning

도덕 심리학과 도덕적 추론과 관련한 기존의 연구는 콜버그의 이론을 기반으로 하고 있다. 콜버그는 도덕성 발달의 인지적 발달이론을 주창한 사람으로서, 6단계의 도덕적 정의추론 단계를 구성하였다. 이러한 단계는 개개인이 추상적인 윤리적 이론을 실제 윤리적 문제에 적용하여 활용하는 인지적 발달단계이며, 콜버그의 도덕적 추론에 대한 이론은 MJI, SROM, DIT 등 다양한 검사의 근간을 이루고 있다.

Much of the literature relating to moral reasoning and moral psychology is based upon the work of Lawrence Kohlberg,3,4 who outlined a cognitive developmental theory of moral development constructed upon 6 stages of moral justice reasoning (Table 1). These stages reflect an individual's progressive cognitive developmental ability to utilise abstract ethical principles in addressing ethical issues. Kohlberg's theory of moral reasoning forms the basis of a number of tests of morality, including the Moral Judgement Interview (MJI),5 the Sociomoral Reflective Objective Measure (SROM)6 and the Defining Issues Test (DIT).7

콜버그의 이론과 척도가 널리 받아들여지고 있지만 여러가지 의문도 제기된 바 있어서, 문화적, 특히 서구문화의 bias가 작용할 수 있다는 점, 6단계와 일부 5단계에 대한 근거가 부족하다는 점, 성별에 따른 bias가 존재할 수 있다는 점, MJI의 점수산출방법, 도덕추론단계가 실제 행동을 예측하는 능력 등등이 지적되어왔다. 그러나 도덕추론에 대한 척도(MJI, DIT, SROM등)를 개발하는데 있어서 보다 근본적인 문제가 있다. 응답자는 가상의 딜레마 상황을 제시받게 되고, 도덕적 판단을 내린 뒤 응답자가 그렇게 응답한 근거를 선택하게 되어있다. 이 때 근거로 제시한 이유에 따라서 도덕적 추론능력 점수가 매겨지는데, 따라서 이러한 검사가 보여주는 것은 의사결정을 내린 후 사후에 그것을 정당화하는 능력이다. 콜버그의 이론이 한 개인의 도덕적 가치관이나 신념에 대해서 다뤘다기보다는 추상적인 윤리적 원칙을 활용하는 능력에 대한 발달단계를 다루고 있다는 점에서 위 척도들의 설계는 적절하며 논리적인 것으로 보인다. 한 개인이 교육을 받고 성숙해감에 따라서 추상적 이론을 실제 도덕적 의사결정에 활용하여 타당성을 입증할 수 있다.

While Kohlberg's theory and measure are highly regarded, questions have been raised about cultural or Western liberal bias,8–11 a lack of evidence for stage 6 and to some extent stage 5,12 a possible gender bias,13 the scoring method of the MJI,14,15 and the ability of moral reasoning stages to predict behaviour.14,16,17 There is, however, a further, more fundamental problem with the design of major measures of moral reasoning (e.g. the MJI, DIT and SROM). In each of these instruments, respondents are presented with a hypothetical dilemma and asked to make a moral decision concerning the dilemma and to give reasons for their decision. Moral reasoning stage scores are determined from the reasons they provide. Thus, these tests appear to provide a measure of the ability to produce post-decisional justifications. Given that Kohlberg was not concerned with a person's moral values and beliefs (cognitive content), but with the development of the capacity to utilise abstract ethical principles (cognitive structure), the measurement design is appropriate and logical. As individuals mature and gain greater levels of education,18 they become increasingly able to utilise abstract principles to justify their moral decisions.

그러나 자신의 결정이 도덕적으로 옳음을 보여주는 능력은 실제로 그 행동이 도덕적인가와는 다를 수 있다. 역사적으로 이것을 보여주는 무수한 사례가 있으며, 최근 이라크 침공에 대한 보도도 그것이 정당하다는 기사와 정당하지 않다는 기사가 모두 존재한다. Bandura는 '비인간적인 행동의 도덕적 정당성을 입증하는 것은 어렵지 않다'라고 했다.

The ability to justify a decision, however, may have little to do with whether that decision or subsequent behaviour was actually ‘moral’. History is replete with examples of individuals who committed atrocities but were quite able to justify their actions by reference to normative ethical theories or to ethical principles. More recently, the media has reported principled justifications for invading Iraq and principled justifications for not invading Iraq. As Bandura19 notes, ‘It is not uncommon for sophisticated moral justifications to subserve inhumane endeavours.’

도덕적 의사결정이 이미 내려진 의사결정의 정당성을 입증하는 것과 무관하다는 것은 비인간적인 행동에만 국한된 것은 아니다. 콜버그의 이론에서 최상위 단계의 근간인 칸트의 윤리원칙을 사용해서 인공호흡기를 유지할 것이라는 결정 뿐 아니라 유지하지 않을 것이라는 결정도 정당화할 수 있다.

The independence of a moral decision and the ability to justify the decision are not limited to inhumane endeavours. For example, the decisions to discontinue or to continue mechanical ventilation can both be justified using the abstract Kantian ethical principles that underpin Kohlberg's highest stage of moral reasoning ability.

의사결정을 내리고 거기에 대해서 타당한 근거를 제시하는 것에 초점을 두기보다는, 개개인이 의사결정을 내릴 때 어디에 근거해서 그러한 결정을 내리는가에 초점을 맞추는 관점이 필요하다. 말하자면 '어떤 심리학적 변인이 윤리적 민감성, 도덕적 의사결정에 대한 개인간 차이를 만들어내는가?' 우리는 세 가지를 주장하고자 한다.

Rather than focussing on the justifications that an individual might give for their decisions, an alternative view is to consider what it is about an individual that determines their opinions, their decisions and their actions. To put this in question form: what psychological variables lead to individual difference in ethical sensitivity (the recognition of an ethical situation), moral decision making, the decisions made, and the interpersonal behaviours displayed in making and enacting the moral decision? We would argue that 3 factors are highly relevant:

1. 개개인의 도덕적 지향

2. 도덕적 행동과 관련한 인적 특성

3. 도덕적 규준/정책/전문원칙에 대한 개인의 지식과 경험 

1. an individual's moral orientation;

2. personality traits that may influence moral decision making and the performance of moral behaviour, and

3. an individual's knowledge and experience of moral norms, laws, policies, professional principles and the professional culture in which the person is operating.

도덕지향 Moral orientation

도덕지향에 대한 개념은 Gilligan에 의해서 처음 제시되었는데, 그는 여성이 보다 care-oriented되어있고, 남성은 justice-oriented 되어있다고 주장하엿다. 연구를 바탕으로 한 명확한 근거가 존재하지는 않지만, 도덕지향에 관한 개개인의 차이가 도덕적 행동에 영향을 줄 수 있다는 주장은 눈여겨볼 만 하다.

The concept of moral orientation was proposed by Gilligan,13 who suggested that women are more care oriented while men are justice oriented. While this hypothesis has not been clearly supported by empirical studies,20,21 the contention that individual differences in moral orientation might be influential in moral behaviour is noteworthy.

우리는 도덕적 의사결정을 내리기 전에 가지고 있던 도덕지향을 측정하기 위해 만들어진 설문지를 활용한 연구에 근거하여,도덕지향에 관한 또 다른 개념을 개발하고자 했다. 본 연구는 개개인의 도덕지향의 차이가 정규분포를 이루며, 한 극단에는 libertarian이, 다른 극단에는 communitarian이 있음을 보여준다. 대부분의 응답자는 그 중간 어디에 위치하며, 대체적으로 개인적 요구와 사회의 요구를 균등하게 고려한 의사결정을 내린다.

We have developed an alternative conceptualisation of moral orientation based on insights arising from empirical studies using a questionnaire designed to measure moral orientation prior to the making of a moral decision.22 This research indicated that individual differences in moral orientation formed a normally distributed trait-like dimension with, 

• at one extreme, respondents consistently placing greater importance on the needs, rights and well-being of individuals and relatively less importance on the rights, needs, norms and well-being of society and referent groups within society. We labelled this a ‘libertarian’ moral orientation. 
• The opposite was apparent at the other extreme of the dimension, with respondents consistently placing greater importance on group/society needs and relatively less importance to the needs of individuals: a ‘communitarian’ orientation. 
• A majority of respondents, occupying the central area of the score distribution, appeared to give approximately equal importance to individual needs and group/societal needs, indicating a ‘dual’ moral orientation.

도덕지향에 대한 이러한 관점에 따르면, 도덕적 딜레마 상황에서, 도덕지향은 맥락을 이해하고 처리하는데 관여하며 가능한 선택사항과 개인과 집단에 미치는 영향을 평가하여 의사결정을 내리게 된다. 

The articulation of this view of moral orientation is that, when presented with a moral dilemma, the moral orientation of the respondent mediates the perception and processing of the context, the evaluation of potential options and consequences for individuals and groups and determines/predicts the moral decisions the respondent makes. In short, when confronted by a moral dilemma, 

• libertarians will ‘see’ and place greater value on the needs of and potential consequences for the individual/s in the context, 
• communitarians will ‘see’ and place greater value on the needs of and potential consequences for society and important referent groups within that society, and 
• the dual-oriented will ‘see’ and approximately equally value the needs of and consequences for both the individual/s and society.

The above conceptualisation emerged in concert with the development of a questionnaire-based measure of libertarian−communitarian moral orientations that we called the Mojac Scale.

Mojac Scale의 점수가 관련되어있는 가치들을 살펴보면 construct validity의 근거도 어느 정도 있는 것으로 보인다. 또한 이 점수는 도덕추론 단계와는 상관이 없는 것으로 나타난다.

Scores from this scale have been found to be empirically related to the values of hedonism and social power (favoured by libertarians), beneficence and tradition (favoured by communitarians), thus providing some evidence of construct validity. Furthermore, the scores were found to be unrelated to moral reasoning stage.22,23

The study reported below aimed to examine the influence of education, age, gender and culture and the relationship of the libertarian−communitarian dimension to particular personality traits and the prediction of moral decisions.

Methods

Participants

연구참여자 

From 1997 to 2001 data were collected from 11 samples of applicants to medical schools and medical school students in Australia, England, Scotland, New Zealand, Fiji and Israel. The samples were chosen for the purpose of determining test norms and examining the variables of education, age, gender and culture in conjunction with a broader research project reported elsewhere.24 Sample description, size, age and gender details are shown in Table 2.

Instruments

두 가지 버전의 Mojac Scale 사용. 24문항의 짧은 버전과 45문항의 긴 버전.

All participants completed either the short (24 items) or long (45 items) measure of the Mojac Scale.22,23 The short measure (Mojac-24) consists of 3 hypothetical dilemmas (vignettes); Mojac-45 contains an additional dilemma. Respondents read each dilemma and then respond to a series of statements relevant to the needs of individuals or to the needs and moral expectations/norms of society using a 4-point Likert scale (strongly agree to strongly disagree). Respondents were also asked to make a forced choice 2-option ‘final decision’ for each dilemma. Responses to the 24 (or 45) statement items were used to derive a libertarian (low score) to communitarian (high score) moral orientation score (LibCom score). An example of the Mojac protocol, using a dilemma based on the ‘Heinz’ dilemma used in the MJI, the DIT and SROM is given in the Appendix.

Dilemma example

Mr D's wife is dying from cancer. A new but expensive treatment for this type of cancer is available. However, all of Mr D's savings and assets have been spent on previous treatments and hospitalisation. The only way to obtain the treatment for his wife is to embezzle a large amount of money from the bank where Mr D has worked as a valued and trustworthy employee for 28 years.

What is your opinion? How do you feel about each of the following statements?

There is never any excuse for theft (group item)

(a)Strongly agree

(b)Agree

(c)Disagree

(d)Strongly disagree

A husband should try to save his wife's life (individual item)

(a)Strongly agree

(b)Agree

(c)Disagree

(d)Strongly disagree

Even in this situation stealing is wrong (group item)

(a)Strongly agree

(b)Agree

(c)Disagree

(d)Strongly disagree

Mr D should maintain his trustworthy reputation (group item)

(a)Strongly agree

(b)Agree

(c)Disagree

(d)Strongly disagree

Saving a person's life is more important than upholding the law (individual item)

(a)Strongly agree

(b)Agree

(c)Disagree

(d)Strongly disagree

Final decision question example

You now have to make a decision about what Mr D should do. For the next question select either (a) or (b)

(a)Mr D should steal the money

(b)Mr D should not steal the money

H그룹과 I그룹은 다른 인성검사도 시행했음. J그룹도 다른 검사 시행. 

Samples H and I also completed the following personality tests: Right-wing Authoritarianism,25 Social Desirability,26 the International Personality Item Pool (IPIP) measure of the Big 5 Factors of Personality27 (extroversion, neuroticism, openness, agreeableness and conscientiousness), the NACE Scale24 (a measure of narcissism, aloofness, confidence and empathy), and the 16 Personality Factors28 (16PF) scale. Sample J completed the Sensitivity to Punishment and Sensitivity to Reward Scale29 (SPSRS), the IPIP and the Eysenck Personality Questionnaire30 (EPQ: Extroversion, Neuroticism and Psychoticism). These tests were chosen as the traits they measure (or specific traits within multi-trait scales) were expected to provide further evidence of the construct validity of the Mojac Scale. In samples A and G, participants also completed a battery of tests for the purpose of selection to medical schools; however, scores from the selection tests were not included in this study.

Procedure

절차

For all samples, the tests were administered under supervision in pen and paper format, using either optical mark reading (OMR) response forms or hand-marked forms, to participants in either a large hall or room. The response sheets were then collected and the data either scanned or hand-entered into spreadsheets for statistical analysis.

Results

Reliability

신뢰도

Cronbach's α reliability coefficients of 0.82−0.87 for the 24-item short form and 0.83−0.92 for the 45-item version were found (Table 2), indicating a high and stable internal consistency for the measure.

Age and gender

연령과 성별 - 약하지만 유의한 상관관계

Although the age distribution was greatly skewed in all samples, weak but significant (P < 0.05) positive correlations were found between age and combined Mojac-24 samples LibCom scores (r = 0.19) and combined Mojac-45 samples (r = 0.18). Weak but significant gender differences were also found. In the Mojac-24 samples the mean LibCom score for women (66.4, SD = 9.7) was significantly higher than the mean LibCom score for men (65.0, SD = 9.1; t = − 4.88, P < 0.001). This difference was also observed in the Mojac-45 samples (women 114.9, SD = 14.3; men 110.7, SD = 15.4; t = 8.51, P < 0.001).

Differences between samples

표집간 차이 - 거의 비슷했으나 일부 차이 있는 집단 존재

Generally, differences in the mean LibCom scores, standard deviation and range across samples (Table 2) were not large and a similar near-normal distribution was evident in all samples. Some differences did reach statistical significance as indicated by a 1-way analysis of variance (anova) and Tukey's post hoc pairwise comparisons with a family error rate of P = 0.05. For the Mojac-24 samples, the means from both Israeli samples were significantly higher than all other Mojac-24 samples, while the mean for the psychology students was significantly lower than all other Mojac-24 samples [F(5, 4227) = 30.1, P < 0.001]. A 1-way anova of the Mojac-45 samples also reached statistical significance [F(4, 3714) = 3.54, P = 0.007]; however, no significant difference between any pair of means was found.

Influence of medical education

교육의 효과: C그룹에서 1년 차이를 보았을 때는 거의 차이 없음. 

A subsample of sample C completed the Mojac-24 again 12 months after the initial testing in 1999. If medical education does influence moral orientation, then a significant difference in the 1999 and 2000 sample mean scores would be expected. For this subsample of 59 students, the 2000 LibCom mean of 64.0 (SD = 7.6) was not significantly different from the 1999 mean of 62.9 (SD = 7.3). The correlation between scores produced in 1999 and 2000 was r = 0.77, indicating only minor changes in moral orientation after 1 year. While this finding also suggests acceptable test-retest reliability, a study with a more typical period of 3−4 weeks between test and retest has not yet been undertaken.

C그룹에서 1,2,3,4,5학년을 비교했을 때 3학년과 5학년이 1학년보다 높음.

Sample C was of sufficient size to allow cross-sectional comparison of LibCom means between students from Years 1, 2, 3, 4 and 5 of the medicine programme, with 65, 43, 59, 30 and 37 students in each year cohort, respectively. anova indicated that there were significant differences between the year groups [F(4, 229) = 4.72, P = 0.001]. A Tukey's pairwise comparison of the means with a family error rate of P = 0.05 indicated that Year 1 participants had significantly lower scores than Year 3 and Year 5 participants. This is also indicated in the plot of the means and 95% confidence intervals shown in Fig. 1. No other significant differences between year levels were found.

학년은 LibCom score의 유의한 예측인자이나, 나이는 그렇지 않음.

A tendency for later-year students to produce higher LibCom scores (more communitarian) is apparent in Fig. 1. A regression analysis found that year of study was a significant predictor of LibCom scores (t = 2.85, P = 0.005), while age was not (P > 0.05). However, the variance of LibCom scores accounted for by the predictors was minimal (R-Sq = 4.2%; t = 3.18, P = 0.002). These findings indicate modest differences between the year cohorts tested. Observation of any change in moral orientation requires a longitudinal design and such a study is yet to be completed.

Construct validity

세 표집에서 construct validity를 확인해보았음. marker test와 비교했을 때 유의한 상관관계를 보임

The conceptualisation of Mojac scores as indicative of a continuum of libertarian to communitarian moral orientation was tested against several well validated personality measures in 3 samples: 508 Scottish medical school applicants (sample J) and 2 samples of New Zealand medical school students (samples H and I in which a total of 204 participants completed the same test battery). Table 3 shows highly significant (P < 0.001) correlations between Mojac-45 LibCom scores and scores from the ‘marker’ tests.

Predictive validity

예측타당도: Mojac Scale의 마지막 문항인 최종결정에 대한 점수와 LibCom score 비교하였을 때, 30%~40%의 변동을 설명할 수 있다.

The relationship between the libertarian−communitarian dimension and the moral decisions individuals make was examined using the final decision items embedded in the Mojac Scale. Final decision scores for each respondent were determined by coding the response options for each of the 3 (Mojac-24) or 4 (Mojac-45) final decision items as 1 for a decision that favoured the individual in the dilemma and 2 for a decision that favoured the group. The final decision items were then summed to produce an overall final decision score.

Regression analysis was used to examine the relationship between LibCom scores and final decision scores. Across all samples, LibCom scores were found to account for approximately 30% (Mojac-24) to 40% (Mojac-45) of the variance in final decision scores. R-Sq values for all samples are given in Table 4. Additionally, in the sample of 2906 Australian medical school applicants, 3 moral orientation groups were created using a tri-median split of LibCom scores. Figure 2 indicates that libertarian-oriented respondents showed a strong tendency to make decisions that favoured the outcome for individuals in each of the Mojac dilemmas, while communitarians made decisions that favoured the maintenance of group norms, values and laws. Dual-oriented respondents sometimes favoured the individuals and sometimes favoured the group in their final decisions. Analysis by anova found the differences between each group to be highly significant [F (2, 2901) = 897.39, P < 0.001].

Discussion

도덕지향은 최종 의사결정 문항을 유의미하게 예측했다.

This study has provided empirical evidence of the validity of the Mojac measure of moral orientation. In addition, the results of our research support the hypothesis that an individual's libertarian−communitarian moral orientation is a determinant of their moral decision making. In each of the samples tested, a person's moral orientation was found to be a significant predictor of their responses to the final moral decision questions embedded in the Mojac Scale.

연령, 성별, 문화에 따른 차이는 크지는 않았지만 유의했음. 나이를 들수록 communitarian이나 표집의 연령 폭 자체가 좁음.

Age, gender and cultural differences, although not large, were significant. Older respondents tended to be more communitarian; however, the distribution of respondents' ages in the samples is not representative of the general population. Some differences in LibCom scores were observed across 5 year-of-study student cohorts and were found to be weakly predicted by exposure to medical education rather than by age. However, the cross-sectional design of the study does not allow any inference concerning change in moral orientation. Longitudinal research exploring moral orientation change is required.

남성이 보다 libertarian, 여성이 보다 communitarian. 

Men generally were more libertarian and women more communitarian, although a notable exception was the predominantly female psychology student sample, which produced a significantly lower mean LibCom score (more libertarian) compared to the medical school samples. Respondents from the Israeli samples, coming from a somewhat more collectivistic culture, were generally more communitarian. While a near normal distribution of scores was observed within each group (men versus women and within each cultural group), indicating that the differences within groups were much greater than the differences between groups, further research regarding the influence of age, gender and culture is required. If differences are consistently found then the establishment of separate norms might be warranted.

도덕지향이 기존의 인성검사에서 확인되는 scale과 잘 일치하는 양상을 보임

Importantly, libertarian−communitarian moral orientation scores were found to be related to well validated personality scales in a conceptually coherent patterning. 

• High Mojac scorers (indicating an extreme communitarian moral orientation) had tendencies (as identified by parallel test instruments) to be authoritarian, conscientious, perfectionistic and self-controlled, while 
• low scorers (indicating an extreme libertarian orientation) tended to be disorderly, narcissistic, abstracted and unrestrained. 

Thus, when presented with an ethical dilemma in a medical situation, extreme communitarians might tend to be inflexible, reliant on procedures, rules and their perception of the ‘authority’ of medicine at the expense of the unique needs, rights and autonomy of their patients. Conversely, extreme libertarians might be overly flexible and ignore or bend the usual rules of procedure while being disproportionately concerned for the rights, well-being and liberty of patients and themselves as doctors.

Mojac Scale이 의료와 관계없는 딜레마 상황을 사용하여 이뤄졌지만, 다양한 맥락에 대한 일반화가 가능하다는 가정을 지지하는 많은 연구가 있음.

An important point concerns the use of non-medical dilemmas in the Mojac Scale (which is also the case with the well known tests of moral reasoning). The aim of such tests, and many others, is to measure individual differences in a particular psychological construct: in this case, moral orientation. The assumption is that these individual psychological differences influence a person's behaviour across situations. While this is arguable, the extensive literature on personality traits generally supports the assumption that traits generalise across different contexts. The correlations found between the Mojac moral orientation scores and the personality trait scores noted above empirically support the notion that, regardless of the stimulus used, the scale is measuring a psychological trait or tendency.

의과대학 학생선발에서의 활용. 인지적 척도에 대해서는 일정 점수 이상, 혹은 일정 석차 이상의 학생을 선발하게 된다. 그러나 도덕지향에 대해서는 극단의 성향을 보이는 지원자를 배제하는 것이 보다 합당하다. 2SD정도를 제안한다.

The use of tests in medical school selection procedures, be they tests of academic ability, cognitive skills, personality traits or moral orientation, requires that each test reliably measures the trait or ability it purports to. For ethical reasons, those charged with the responsibility for assessing and selecting medical school students clearly would need to consider the properties of any measure used. Additionally, considerable care needs to be taken in establishing how scores determine selection. Typically, as is the case with cognitive measures, test scores are ranked from highest to lowest and a ‘cut-point’ determined, above which applicants are retained in the selection pool. However, this might be an inappropriate procedure with tests that indicate individual differences in moral orientation, moral reasoning or moral values. To admit only high scoring applicants on such tests would require a test to produce a range of scores from the ‘most likely to be moral’ to the ‘least likely to be moral’ and the validity of such a test would be highly questionable. In view of the correlations found in the present study, an argument can be made that extreme high and low scorers, in this case extreme communitarians and extreme libertarians (perhaps defined by cut-points of + 2 SD and − 2 SD from the mean, respectively), could be considered for exclusion from the applicant pool on the grounds that their moral orientation is likely to be vocationally incongruent with the ethical standards and requirements of the medical context. The substantial majority who remain in the applicant pool would approximately equally value the needs, rights and well-being of individual patients and the needs, rights and well-being of others, the profession and society as a whole and so might be more likely to behave in an ethically appropriate way in the practice of medicine.

Screening out extreme scorers assumes, by definition, that a majority of applicants have the qualities to practise medicine ethically, particularly, as noted by Singer,2 if the medical education undertaken by successful applicants includes ethics training, evaluation of ethics in performance, and an ethical learning environment. Rather than select on the basis of high moral reasoning scores, it would seem more realistic and appropriate to screen out those few who indicate an extreme moral orientation. This would allow for moral development with time, education and experience and acknowledgement of the fact that most health professionals behave ethically. Most people are able to consider the needs and perspectives of both the individual and the group in their daily lives. If most did not, it is unlikely we humans would have survived and thrived as we have.

---

Med Educ. 2005 Mar;39(3):266-75.

Selection of medical students according to their moral orientation.

Bore M1, Munro D, Kerridge I, Powis D.

Author information

• 1Faculty of Health, University of Newcastle, Callaghan, New South Wales, Australia. Miles.Bore@newcastle.edu.au

Abstract

INTRODUCTION:

Consideration has been given to the use of tests of moral reasoning in the selection procedure for medical students. We argue thatmoral orientation, rather than moral reasoning, might be more efficacious in minimising the likelihood of inappropriate ethical behaviour in medicine. A conceptualisation and measure of moral orientation are presented, together with findings from 11 samples of medical school applicants and students.

AIM:

To provide empirical evidence for the reliability and validity of a measure of moral orientation and to explore gender, age, cultural and educational influences on moral orientation.

METHODS:

A questionnaire designed to measure a libertarian-dual-communitarian dimension of moral orientation was completed by 7864 medicalschool applicants and students in Australia, Israel, Fiji, New Zealand, Scotland and England and by 84 Australian psychology students between 1997 and 2001.

RESULTS:

Older respondents produced marginally higher (more communitarian) moral orientation scores, as did women compared to men. Minor but significant (P <0.05) cultural differences were found. The Israeli samples produced higher mean moral orientation scores, while the Australian psychology student sample produced a lower (more libertarian) mean score relative to all other samples. No significant change in moral orientationscore was observed after 1 year in a sample of Australian medical school students (n=59), although some differences observed between 5 cohorts of Australian medical students (Years 1-5; n=234) did reach significance. Moral orientation scores were found to be significantly correlated with a number of personality measures, providing evidence of construct validity. In all samples moral orientation significantly predicted the moral decisions made in response to the hypothetical dilemmas embedded in the measurement instrument. Discussion The results provide support for the conceptualisation of a libertarian-dual-communitarian dimension of moral orientation and demonstrate the psychometric properties of the measurement instrument. A number of questions concerning the use of such tests in selection procedures are considered.

Comment in

• How to choose tomorrow's doctors. [Med Educ. 2005]

PMID:

 

15733162

 

[PubMed - indexed for MEDLINE]