The Clinic Effect: Ethical Formation in Law Students

1. THE CLINIC EFFECT:Ethical Professional Identity Formation in Law Students Donald Nicolson, Director, University of Strathclyde Law Clinic JoNel Newman, Director, University of Miami Health Rights Clinic Melissa Swain, Assoc. Director, University of Miami Health Rights Clinic

2. Miami’s Health Rights Clinic • Schools of Medicine and Law MLP Clinic Since 2005 • HIV/AIDS Clinics, Community Health Center, Pediatric Mobile Clinic • 1000s of low-income patients helped with: • Public Benefits • Health insurance • Housingandimmigration cases • Advance directives • Recovered >$1M for patients in benefits

3. What is a Medical Legal Partnership? • Integrates legal assistance as a vital component of patient care because medicine alone cannot solve the health problems of vulnerable populations • Doctors learn to screen for legal issues and refer a patient to an on-site attorney when an underlying social circumstance impairing a patient’s health is detected • MDs and JDswork together to remove legal and social barriers that prevent vulnerable populations from getting needed care and improve health outcomes • Legal professionals become members of the healthcare team to assist patients with legal issues, such as disability, public benefits, advance directives, immigration, and unhealthy housing conditions

4. Client Demographics – Assistingthe Most Vulnerable Race Language

5. 2013-2014 Academic Year: 174 Cases

6. Working Hypothesis • Uses “teaching hospital” model • High Volume • High Stress • Repetitive Practice – Creates Habits • Utilizes Routinized System • Cross-disciplinary leads to • Development of professional role and voice • Enhances team-delivered care • Responsiveness to community & public need

7. Ethics Teaching in Health Rights Clinic • Begin with 16 Learning Goals • 14 2L and 3L students enrolled for an academic year • 10 to 12 cases, usually 6 to 8 cases at a time • High level of responsibility – students primary case handlers • Series of disorienting moments • Weekly individual meetings with supervising faculty • Weekly class includes • Guidance on self reflection • Ethics instruction • Substantive law • Skills training

8. Written Self-Reflective Materials • Respond to series of prompts matched to Learning Goals (guided) • Mid-point of each semester • Suggested 3 page limit • Half hour individual meeting with faculty to discuss • Self-reflection on significant clinical event • Also responds to prompts • Students do in class

10. Ethics Teaching at Strathclyde • Only for (200) clinic students at UG level, compulsory for all on Diploma • Optional Ethics and Justice (Clinical Legal Practice/CLP) • Legal ethics and issues of justice illuminated and illustrated through • Seminars on • Introduction to ethical theory • professionalism and sociological context; • client autonomy; • conflicts and confidentiality; • immoral means and ends; • ethical education and regulation). • the profession’s response to access to justice • Reflection on cases in surgeries, diary dialogue and essays • Induction Training • Clinical LLB – degree topped and tailed by ethics teaching, allowing for repeated revolutions of Kolb’s learning cycle

11. Strathclyde Reflective Diaries • 500 words, with 200 words in response to comments • Submitted 2x per semester for responses • Written weekly by Ethics and Justice students on relevant issues raised by cases, class (or other classes) and other clinic activity • Written fortnightly throughout second and third year of degree by Clinical LLB students on any issue relating to their classes, cases, other clinical work and indeed that impacts on their university or clinic experiences • 9 students’ diaries analysed: 7 graduate entrants with two years of clinic experience; 2 and school leavers with 3 years experience • Undertaken an average of just over 9.5 cases each

12. The Project Two Clinics, Similar Missions, Two Sets of Student Narrative Data …

13. Clinics’ Aims • Social justice orientation • Access to justice for underserved communities • Inculcate ethical professional identity • Skills and values – beyond minimum (code-based) • Expose students to theories about ethics and altruism • Repeated opportunities to make ethical judgments and responses in role • Opportunites for reflection

14. Educational and Ethical Theory:Four necessary psychological components • Ethical Sensitivity • Ethical Reasoning and Judgment • Ethical Identity/Commitment • Ethical Implementation/Moral Courage • (D. Narvaez and J. Rest ‘The Four Components of Acting Morally’ in Kurtines and Gewirtz (eds), Moral Development: An Introduction)

15. Theory:Moral Character and Ethical Behaviour • Moral character develops through actual engagement and experimentation with ethical issues, and particularly from feelings of satisfaction and regret, and from learning from moral exemplars • Law school cannot radically alter character, but it can at least help resist the hidden curriculum, confirm existing altru-ethical traits, and translate them into professional moral character and, and might even develop altru-ethical traits in some • (Bebeau, Promoting Ethical Development and Professionalism, 5 U. St. Thomas L.J. 366 (2008))

16. Ethics and Educational Theory • Four aims of ethical education: • Inspire an interest in ethics • Illuminate the general and professional ethical tools available to resolve issues of professional ethics, and factors which affect resolution • Illustrate these tools and issues through exposure to situations involving moral dilemmas • Inculcate the habit of identifying, evaluating and caring about ethical issues so that this becomes a more or less spontaneous response in practice

17. Advantages of Teaching Ethics Experentially • Learning experiences are realistic, involve future social roles, more profound than abstract learning • Adult learning theory: • See themselves as self-directing • Have a good deal of experience to draw upon as a learning resource • Gear their educational development towards future social roles rather than just learning from learning’s sake or to develop basic cognitive skills • Adults seek to apply knowledge immediately, • The ‘disorienting moments’/ ‘moral crises’ which occur when prior assumptions and settled values jar with experiences stimulate an ‘engaged moral faculty’ and is more memorable • Repetition is key

18. Educational Theory - Adults Kolb’s learning cycle

19. The Clinic Effect:Evidence of Impact on Ethical Development • Qualitative Research Methodologies Used • Began with Grounded Theory (Nicolson) • First read diaries without analysis, then read for ethical themes, evidence of moral development and its influences, new themes emerged, etc. • Narrative Inquiry (Newman) • Thematic analysis of personal accounts of experiences, interviews, identity approach, how students construct their identity within institutional context.  • Some control for qualitative weaknesses • Blind reading of each other’s materials • Tested against actual experience in Clinics

20. The Clinic Effect:Evidence of Impact on Ethical Development • Ethical Sensitivity (Micro) • Moral Reasoning and Judgment • Understanding of Professional Role (Meso) • Understanding of Law and Justice (Macro) • Learned through supported case work, role modeling and mentorship

21. Ethical Sensitivity Through case work I am now more prepared to deal with lawyer-client relations, empathy, listening to the client, maintaining communication to build rapport and also ensure that the client feels confident in my ability and the way their case will be handled. I have found that my clients are looking for an individual that they can trust that will express real concern for them as individuals. Checking up with clients to see how they are feeling or if they need something goes a long way. Asking them about their life and interests, not only about the specific events that led up to their case, generate the rapport crucial to creating a long-lasting and trusting relationship with the client. Showing empathy to my clients definitely helped.

22. Sensitivity / Empathy She seemed really happy when we told her that we would work hard to get her statement of facts sent out to her as soon as possible, it made me realize that clients really want to feel that someone actually cares about the their issue and want to help them. Whilst I did not get an opportunity to improve on the issues I think I had during my ethics and justice classes - I do feel that I have learnt that one of the most important ways to help and work with clients is to make them feel that they have someone who is attentive and eager to help them. I have learned that it is not about me “winning.” The clinic has taught me that some clients just need to feel like someone is advocating on their behalf. Z, for example, is so grateful to us even though we are still appealing her case.

23. Sensitivity Reasoning and Judgment Given that the client may be suffering from depression is also on my mind when dealing with the case as I would not want to pester the client too much for a reply and end up stressing him out too much or putting too much pressure that he is sort of turned off from our service. Lawyers will regularly deal with aggrieved individuals and I would imagine there is a some sort of balance of counseling being provided and also legal expertise being given due to the client reliance on the lawyer to sort out their problems. My goal was to not only to develop a case theory, but also to get to know the needs of my client as much as possible. I knew that he suffered from anxiety so I tried to make our time at the Social Security office as stress free as possible. I asked him questions, but mostly listened to his story and got to know him better. I have built I very good relationship with this client and he trusts me.

24. In-Role Judgment and Reasoning Once again, working in the clinic has taught me how to be more patient with people who ask for help but do not want to help himself or herself. I have a few clients who are unresponsive or straight up rude; but I keep telling myself that there are societal and health pressures that have made them the way they are and that I must continue to persevere in trying to get them help. Regardless of their attitude it is my job to help them become healthier in any way that I can. In general I’m not very tolerant of people being late or forgetting to be somewhere…. Clearly in law-clinic I need to be more understanding as there are often many factors which affect our client’s ability to attend meetings or arrive on time. It would be entirely unprofessional to allow this to have an effect on how I interact or treat the client, and I would like to think this is not something I would ever do.

25. In-Role Judgment and Reasoning I have learned that even with clients who seem to be forthcoming, you always need to ask certain questions, even if you think you know the answer. My experience has been that I often don’t have the full story. I have also learned that as a lawyer, my responsibility in acquiring facts is not only crucial and a fundamental part of being ethical, but often times a gateway to information that I never would have thought was important until it came to light. Alternatively and more plausibly the client attempted to manipulate and underestimated our competence. She may represent the ‘manipulative’ client that Ellmann refers to in his article. This is clearly disappointing and has now made me alert to situations where the client may attempt to mislead the legal representative. However, it proves that one should not merely accept that which you are told by your client, you must always carry out extensive research

26. Law and Justice - Access The client came to clinic really as a last chance saloon after being through solicitors working pro-bono and also the CAB. When I found out that the client had already been through so much it did hit me personally and I felt sad for the client knowing that she had been through so many different loops trying to seek justice. If my client did not have representation she would probably never have the opportunity to have her case heard.… If it was not for the clinic they would not have access to the legal system at all. Even I get frustrated at how hard it is to navigate the system. The frustration has made me a better advocate because I know how much this population needs our help.

27. Access to Justice – Professional Identity The clinic has had a tremendous impact on my professional identity as a lawyer. I have a much better understanding of the underserved and how people’s rights are ignored and how they are denied benefits they should be entitled to. It has taught me that we are all created equal, but it sometimes take someone with special skills and training (a lawyer) to help the layman navigate a system that is sometimes pitched against them. Law Clinic experience …has allowed me to see that the law has not been as helpful to many of my clients as it could have and in my opinion should have. It has been a rather sobering thought process but I now feel I have a better appreciation of the actual inner working of the legal system and how they affect different sectors of society. I am now more determined than ever to try and use the Law to get satisfactory result for my client despite knowing this could be an incredibly difficult task.

28. Access to Justice – Moral Commitment The clinic has really taught me a lot about myself and made me think about what it is I want to do with my degree. Representing people who would otherwise not have access to an attorney or “the system” has been eye-opening. I would like to continue to work with poor communities and do whatever I can to remedy some of the inadequacies that currently exist. It is truly satisfying to work with people who have nothing, and are so grateful for all the help we offer them. Since losing his appeal, everywhere he has turned, the door has been closed. CAB refused to assist; firms of solicitors were also ignorant of the law, and also declined. Such ignorance deprives those most in need of access to justice, and a fair outcome. I am also frustrated that he may be left to seek an outcome on his own. Surely it is essential that justice is accessible to all, regardless of who they are? That is the overriding reason why I want to work in the legal profession. So that I can be of assistance others when they need it.

29. Professionalism- Mentors, Role Models, Ethos and Teamwork The ten year event was really good for morale in the Clinic because it highlighted, and reminded us all, of the bigger picture: where the Clinic came from, its ethos, how many people it has helped already, and where it is going in the future. It made me feel proud to be part of the Clinic, and lucky to be part of such a great team of people with the same ideas about access to justice as I have. Definitely one of the greatest things about my clinical experience is just how great everyone in our clinic is and what a large team effort everyone puts in. Because of the randomization of each student’s case load, some of us become “experts” in different areas before some others. This actually helps create a more team-centered clinic because when you ask there are usually at least two people ready and willing to help you with whatever problem you have. And the same works both ways; it is a pleasure to return a favor for a student that has helped you by imparting some of the things you’ve learned earlier on.

30. Professionalism- Mentors, Role Models, Ethos and Teamwork Our peers in the clinic are our greatest resource. The help that Albert, Vanessa, and Julia have provided on a day-to-day basis is invaluable. And while I may spend a few hours trying to solve a problem by myself, looking through the internet or our course handbook, usually the best help will come from one of the members of our faculty, staff, or fellows. My motivation to return to study was a desire for a change in career. I had little knowledge, or interest, in the field of social justice. The law clinic, and in particular the guidance and direction of its director has changed this for me. Social justice is an important field, and one that all too often is overlooked, and regarded as not being particularly ‘sexy’. Do I see the legal profession as a means to make lots of money? Not anymore, I see it as a way to help others, and by doing so enrich their lives for the better.

31. Next Steps • Evidence suggests transformative effect of working in social justice clinics   • Newman – Consider more frequent memorialized reflections • Nicolson – Consider requesting reflections on specific learning • Both – Interest in surveying Clinical alumni