The Significance of the Hidden Curriculum in Medical Ethics: Literature Review with Focus on Students' Experiences

Introduction

According to Melinkoff “ The goal of medical education is to produce the physician we would like to see if we are sick ” (Melinkoff, 2000) The attributes which are essential for the practice of medicine in order to fulfil the clinical needs and interpersonal needs of the patients are knowledge, skills and humanism. (Kumar, 2001) But, as remarked by Samuel Le Baron (2004), “ W (w)e have lost a healthy and necessary balance in the learning and professing of medicine between knowledge (science) and wisdom (humanism).”(662). Humanism in medicine is the main premise for rethinking medical ethics education.

Expertise, ethics and service are the three pillars of medical professionalism (Irvine, 1997). In recent decades, increase in knowledge in health sciences has been exponential and technological developments unprecedented, leading to marked changes in health care and the traditional doctor- patient relationship. The health care professionals are empowered to achieve high standards of diagnosis and therapy, but at the same time have to face ethical, legal, social and human rights issues. The medical students of today will become the practitioners and researchers of tomorrow and it is the responsibility of the educators of medical professionals to sensitise the students to these issues, provide the knowledge needed to analyse the ethical issues, help the students develop analytical skills in moral reasoning and inculcate in them the habit of applying the skills to clinical situations(Miles,1989). At the same time the teachers have the onerous duty of making the students assimilate the values of the medical profession and understand the nature of medicine as a moral profession.

Traditionally the ‘art’ of medicine, namely the virtues which mark a medical professional, was learnt by observing the teachers, the apprenticeship model. In the second half of the twentieth century efforts were initiated to teach the cognitive basis for ethical analysis, mostly by philosophers using didactic teaching methods. (Arnold & Forrow, 2003, p.293) The focus of ethics education was only on the dilemmas arising because of advancements in science and technology. From late 1990s the need to concentrate on the day- to-day issues in physician- patient relationship has been realised. Public health ethics too is coming into prominence in bio ethics education. In spite of the wide variations in the practice of medicine in different parts of the globe, the basic principles of medical profession are the same - the principles of primacy of patient welfare, patient autonomy and social justice (Annals of Internal Medicine, 2002) It is acknowledged by medical educators all over the world that professionalism, especially its essential component of ethics, must be taught explicitly.

Some medical educators are of the opinion that the incorporation of ethics in clinical teaching is more valuable than imparting theoretical knowledge. (Arnold, 1998) The influence of positive role modeling, the ‘hidden curriculum’ in ethics education has been emphasised by many authors, who feel that “the fundamental character of medicine’s culture is best reflected not in the curriculum- formal, but in the curriculum- hidden”. (Hafferty, 1994, p.869) Hidden curriculum is the unwritten, informal learning that occurs through interpersonal interactions during the training. It refers to the tacit influences outside the formal course work which shape the knowledge and behavior of students. (Wear, 1998) Atmosphere in the academic institutions too has an important role in the moral development of trainees. It may be rightly pointed out here that both formal and hidden curricula are essential facets of medical ethics education- the knowledge of theories and principles of ethics will equip the students with the necessary tools for the argumentation of bio ethical judgment, and the hidden curriculum helps them to develop the moral perception.

According to Vetlesen (1994), moral perception is the first step in moral performance and it is an essential precondition for moral judgment and moral action. Moral judgment is located predominantly in the cognitive domain as it is concerned with the knowledge of norms and principles for guidance in ethical deliberations. The moral agent’s perception of a particular situation as a morally relevant one is provided by the emotion of empathy which belongs to the affective domain and, without which the sequence of moral performance cannot be set in motion.