Antecedents and Consequences of Medical Students' Moral Decision Making during Professionalism Dilemmas

Abstract

Medical students often experience professionalism dilemmas (which differ from ethical dilemmas) wherein students sometimes witness and/or participate in patient safety, dignity, and consent lapses. When faced with such dilemmas, students make moral decisions. If students' action (or inaction) runs counter to their perceived moral values-often due to organizational constraints or power hierarchies-they can suffer moral distress, burnout, or a desire to leave the profession. If moral transgressions are rationalized as being for the greater good, moral distress can decrease as dilemmas are experienced more frequently (habituation); if no learner benefit is seen, distress can increase with greater exposure to dilemmas (disturbance). We suggest how medical educators can support students' understandings of ethical dilemmas and facilitate their habits of enacting professionalism: by modeling appropriate resistance behaviors. IntroductionFor many, medical school is a time of great stress. Indeed, a systematic review of research examining psychological distress in medical students suggests they suffer a high degree of depression and anxiety and greater psychological distress than the general population [1]. In this article, we consider medical students' distress, focusing on moral distress, i.e., emotional distress arising from the dissonance between one's ethical/moral beliefs and one's behavior, which occurs when one's actions are perceived as being limited by institutional constraints or unequal power relations [2][3][4]. By highlighting the concepts of professionalism dilemmas and moral decision making, we examine various types of dilemmas encountered by students, how they respond to those dilemmas, and any resultant moral distress they experience. Finally, we offer suggestions for how medical educators, working at the student, faculty, and organizational levels, can reduce or prevent students' professionalism lapses in the face of ethical dilemmas, thereby reducing their moral distress.

A multi-method exploratory study of health professional students’ experiences with compliance behaviours

“…Most participants indicated Displacement of Responsibility was a factor in obedience, having acted on the instructions of an authority because they did not believe that they would be held personally responsible, aligning with the findings of other research [ 8 , 25 , 50 ]. Though displacement of responsibility can be legally exonerating [ 73 , 74 ] there is an additional moral responsibility beyond the legal one for people to engage in positive deviance when it is believed something inappropriate is occurring [ 63 ]. Further, when students displace responsibility and are obedient it can have a negative personal impact, namely Moral Distress, with its attendant negative outcomes.…”

“The Water in Which We Swim:” A Unique, Post-Clerkship Multidisciplinary Course

“… 25 – 29 , 56 Medical educators and bioethicists theorize that these changes are by-products of the moral dilemmas and contradictions that students experience during their clinical years, especially as the students feel inexperienced and powerless. 57 – 62 One antidote is to provide an introduction to concepts of CEPH, HP, MEP, and SM prior to students’ core clinical experiences (ie, to prime the students), followed by consolidation and advancement of these concepts, along with the addition of HCDL, after core clinical experiences. If students’ humanism waned during clerkships, EOP2 offers an opportunity to re-ignite and enhance humanism and activism, remind students why they chose the medical profession, prepare them to overcome challenges, and devise solutions applicable to their future training and ongoing practice of medicine.…”

A Multi-Method Exploratory Study of Health Professional Students’ Experiences with Compliance Behaviours

“…Moral Distress can arise in healthcare due to con ict that occurs between the maintenance of a person's moral integrity, the internal consistency of a set of personal standards, and behaviour constrained by external factors (de Raeve, 1998); or more simply the experiencing of a moral event and the resultant psychological distress (Morley, Ives, Bradbury-Jones, & Irvine, 2019). Institutional, environmental or system factors can create moral distress through challenges imposed to the maintenance of moral integrity creating a sense of futility and can lead to negative psychological and physical outcomes including burnout, fatigue, disengagement and increased susceptibility to negative compliance (Atabay, Çangarli, & Penbek, 2015;McAndrew, Leske, & Schroeter, 2018;Monrouxe, Shaw, & Rees, 2017;Schwenzer & Wang, 2006;Wiggleton et al, 2010).…”

“…Most participants indicated Displacement of Responsibility was a factor in obedience, having acted on the instructions of an authority because they did not believe that they would be held personally responsible, aligning with the ndings of other research (Bould et al, 2015;Delaloye, 2017;Sur et al, 2016). Though displacement of responsibility can be legally exonerating (Darley, 1995;Hamilton & Sanders, 1995) there is an additional moral responsibility beyond the legal one for people to engage in positive deviance when it is believed something inappropriate is occurring (Monrouxe et al, 2017). Further, when students displace responsibility and are obedient it can have a negative personal impact, namely Moral Distress, with its attendant negative outcomes.…”