Professional Character Formation

1. Professional Character Formation Dr. Shahram Yazdani

2. Virtue Ethics • What today is called ‘‘virtue ethics,’’ or virtue-based ethics is the oldest philosophical foundation for moral conduct. Its origins are firmly rooted in the philosophies of Plato, and Aristotle.

3. Natural & Superanatural Virtues • Aristotle’s ethics is an outcome oriented ethics. The ‘‘end’’ aimed at is the good for man, a life lived in conformity with reason whose end is happiness. • Aristotle grouped these end-oriented character traits in two classes: • The moral virtues: Justice, fortitude and temperance • Intellectual virtues: philosophic wisdom, understanding and practical wisdom

4. Aristotle’s ethics • In Section 6 of Book II of the Nichomachean Ethics, Aristotle puts it this way: • “We may remark then that every excellence both brings into good condition the thing of which it is the excellence and makes the work of that thing done well” • Thus the virtues (the excellences) make the physician a good man or woman, and make them do their work of medicine well.

5. Aristotle’s Ethics And The Medical Virtues • The virtue of fidelity to the promise to put the primacy of the patient’s well-being at the center of the relationship. • Honesty and truth-telling • Compassion, the ability to enter into the predicament of each patient’s illness in all its social, personal and spiritual uniqueness. • Effacement of self interest, i.e. doing what is in the patient’s best interests even when it involves loss of time, money or extra effort on the physician’s part. • Courage, the willingness to defend the morally right decision and action even when it means loss of social esteem. • Justice, to render to others what is owed to them

6. Virtue Ethics in Middle Ages • Virtue ethics was enriched in the Middle Ages by the infusion of moral teachings of the Christianity and Islam. • Thomas Aquinas, added three ‘‘supernatural’’ virtues of faith, hope and charity • Its aim was not the formulation of rules, or guides for action. It enunciated few principles, or obligations directly mostly dealing with things which ought never be done. • Rather, moral guidance was provided by the model behavior of good, or virtuous persons, those paradigm persons each era respected.

7. Virtue Ethics after Enlightenment • All of this dramatically changed in the Enlightenment and Post-Enlightenment periods in Europe. • The Enlightenment ideal of a religion-free, metaphysics-free ethic (i.e. free autonomous rationality) turned the emphasis to principles, duties, obligations and consequences as the criteria for right and wrong, good and bad human acts.

8. Virtue Ethics after Enlightenment • While the reality of the moral agent could not be totally eradicated from ethics, the virtues were overshadowed by rights, duties, rules and principles. • Virtues were pushed further to the back- ground of the moral life as ethics became progressively secularized and the good was defined in human rather than theistic terms.

9. There is a problem! • Many patients, physicians and medical educators are alarmed by the perception that medicine is fast becoming ‘‘deprofessionalized,’’ with damaging results to patient welfare and physician morale. • By ‘‘deprofessionalization’’ they imply a loss of certain attitudes, values and character traits usually associated with the traditional idea of a profession.

10. Arguments in the 1970s and 1980s • Values were well established by the time students reached professional school (thus little could be accomplished) • Teaching ethics was simply moralizing (which had no place in a public institution) • Even if something could be accomplished, faculty were ill equipped to teach

11. The Ethics Movement 1970s – 1980s • In the early days of the movement, ethicists had to argue for the importance of instruction that focused on ethical reasoning. • Some argued that ethics instruction needed to attend to moral perception and moral aspirations in addition to reasoning.

12. The Ethics Movement and Principalism • In the early days, the predominant method for resolving moral issues was the application of principles (autonomy, nonmaleficence, beneficence, and distributive justice) to the resolution of dilemmas presented in condensed case descriptions. • It was not until the early 1990s that challenges to principlism resulted in a rethinking of principled approaches to resolving moral issues.

13. The Ethics Movement and Ethics of New Technologies • The ethics movement in medicine was precipitated by technological advances that posed difficult moral questions for patients and families. • Thus, the resurgence of ethics education in medicine originated with challenging moral problems in health care, rather than concerns about the development of moral character.

15. Defining Character from the Psychologist’s Perspective • Webster’s New World Dictionary describes character as • ‘‘the pattern of behavior or personality found in an individual or group; moral constitution … moral strength; self-discipline, fortitude, etc.’’

16. The Components of Morality • Beginning with the question ‘‘How does moral behavior come about?’’ Rest (1982, 1983) described four internal processes, each of which must be activated for moral behavior to occur: • Sensitivity • Reasoning • Motivation and commitment • Moral character and competence.

17. Ethical Sensitivity • Moral sensitivity focuses on the interpretation of a situation, the various actions that are available, and how each action might affect the self and others. • It involves imaginatively constructing possible scenarios, knowing cause–consequence chains of events in the real world, and having empathy and role-taking skills. • It includes knowing the regulations, codes and norms of one’s profession, and recognizing when they apply.

18. Ethical Sensitivity Measurement • Methods for assessing ethical sensitivity, were first developed in dentistry • Dental Ethical Sensitivity Test (DEST, Forms A and B), • Geriatric Dental Ethical Sensitivity Test (GDEST) • Racial Ethical Sensitivity Test (REST) • In measures where the construct is well-elicited, a drama is presented consisting of an interaction between two or more persons. The drama includes many clues to a moral or ethical problem, but never offers any interpretation of the clues. • The challenge for the observer is to recognize that what is exhibited is a significant problem, and that the professional has a responsibility to do something aside from the normal routine.

19. Ethical Sensitivity Measurement • Ethical sensitivity measures classified as well-developed and validated demonstrate the following psychometric properties: good interrater reliability, acceptable internal consistency, and test retest reliability, and good Convergent and Divergent Validity

20. Ethical Reasoning and Judgment • Once a person is aware that various lines of action are possible, one must ask which line of action is more morally justified.

21. Ethical Reasoning and JudgmentMeasurement • The dilemma discussion technique and the assessment of written essays • The most familiar approach to assessing reasoning in professional ethics courses is the analysis of written arguments, typically conducted by faculty with a background in philosophy

22. Ethical Reasoning and JudgmentMeasurement • Researchers demonstrated that essays can be reliably assessed and that instruction is effective in promoting the ability to develop well-reasoned essays, assuming that criteria for judging the essays are specified in advance of instruction and there are frequent opportunities for practice with feedback.

23. Ethical Reasoning and JudgmentLife-Span Developmental Measures. • Several measures of moral reasoning and judgment have been devised: • The Moral Judgment Interview, • Gibb’s Socio-Moral Reflection, • The Defining Issues Test • Lind’s Moral Judgment Test. • They vary in terms of the • target populations for whom they are designed (children vs. adolescents vs. adults)

24. Ethical Reasoning and Judgment Measurement • The most widely used test for assessing adult development is the Defining Issues Test (DIT) • Similar to the Kohlberg interview, the DIT begins by presenting the respondent with stories that highlight a moral dilemma. But unlike the Kohlberg interview, in which the respondent must produce a response, the task on the DIT is to rate and then rank 12 short issue statements. • In Action Choice, the respondent decides, on a 3-point scale, what the protagonist ought to do. • Then 12 items are presented and rated on a 5-point scale (very important to not at all important) in which the respondent is asked to rank the four items that best reflect their Thinking About what the protagonist action

25. Ethical Reasoning and JudgmentMeasurement • Profession-Specific Measures of Ethical Reasoning and Judgment. • Dental Ethical Reasoning and Judgment Test (DERJT) • Medical Ethical Reasoning and Judgment Test • The DERJT presents five common ethical problems in dentistry. Respondents rate a list of possible action choices and justifications and then are asked to rank order the two best and the two worst actions and the three best and the two worst justifications.

26. Ethical Reasoning and JudgmentMaturation • Research using the DIT supported Kohlberg’s claim that moral judgment developed rapidly over the high school and college years • A meta-analysis of studies of moral judgment development in schools of medicine, dentistry, and veterinary medicine (Bebeau, 2002) shows such growth does not continue in the absence of a well-validated ethics curriculum.

27. Moral Motivation and Identity Formation • Moral motivation and commitment involves prioritizing moral values over other personal values. • People have many values. • Whether the individual gives priority to moral concerns seems to be a function of how deeply moral notions penetrate self-understanding, • For behavior to occur, the moral agents must first decide on a morally correct action when faced with a dilemma, and then conclude that the self is responsible for that action.

28. Moral Motivation and Identity Formation • Individuals move from self-centered conceptions of identity through a number of transitions, to a moral identity characterized by the expectations of a ‘‘profession’’ – to put the interests of others before the self, or to subvert one’s own ambitions to the service of society or to the nation.

29. Moral Motivation and Identity Formation: Evolution • The fully integrated moral self (one whose personal and professional values are fully integrated and consistently applied) tends not to develop until midlife – if it develops at all

30. Moral Motivation and Identity Formation: Measurement • Interviews: Developmental assessments involve semistructured interviews using the method detailed by Lahey et al. (1988). • A trained interviewer prompts respondents to recall recent experiences in response to stimulus words printed on an index card. • The interviewer asks a series of follow-up questions to elicit the respondents’ underlying understandings. • Interviews are audiotaped and transcribed for scoring. • As with conducting the interview, training is required to score the interview and achieve interrater agreement.

31. Moral Character and Competence • Moral character and competence is having the strength of your convictions, having courage, persisting, overcoming distractions and obstacles, having implementing skills, and having ego strength.

32. Moral Character and Competence • A person may be sensitive to moral issues, have good judgment, and prioritize moral values; but if he or she is lacking in moral character and competence, he or she may wilt under pressure or fatigue, may not follow through, may be distracted or discouraged, and moral behavior will fail.

33. Moral Character and CompetenceMeasurement • Performance-based assessments are typically used to assess the integrated abilities required for effective, responsible professional practice. • Certainly objective tests of personal styles or personality traits can sometimes provide insight about dimensions of character that the individual needs to address to increase personal effectiveness, but such measures lack fidelity to professional practice.

34. Moral Character and Competence • Objective Structured Clinical Examinations (OSCEs) have been designed for ethics instruction that approximate the kind of integrated performance required for assessing ‘‘character and competence.’ • Communicating with a parent whose child’s health care is being neglected, speaking to a patient about an adverse outcome, confronting a peer or superior about substandard performance, responding to a complaint about your performance, achieving consent for treatment from a patient with dementia, etc.

35. Moral Character and Competence • Using real-life enactments of situations that are likely to occur in practice, students are required to plan strategies for handling the case, try out dialog on a peer, then submit a case write-up that includes (1) key facts and their interpretation that influenced their plan of action case; (2) an action plan; and (3) verbatim dialog to illustrate how the action plan can be implemented.

36. Thank You ! Any Question ?