Teaching and Learning > DISCOURSE
Why Shouldn't Philosophers Teach Medical Ethics?
Author: Andrew Fisher
Journal Title: Discourse
ISSN: 2040-3674
ISSN-L: 1741-4164
Volume: 6
Number: 2
Start page: 227
End page: 236
Return to vol. 6 no. 2 index page
In a recent article Christopher Cowley argues that medical ethics should not be taught by philosophers.1 I disagree with just about everything that Cowley writes. In fact I suggest that the transferable skills that the philosopher can teach are precisely the ones that will best equip the medic in their ethically overwhelming workplace. Cowley's arguments are often unclear, ambiguous and self-contradictory. However, rather than getting bogged down in all the problems, let's look at what I take to be his central argument.
The central argument
1) Ethics has a double-aspect: a legislative process and a dramatic process
(52).
2) The legislative involves 'discussion' about ethical issues (52).
3) The dramatic involves the 'cultivation of appropriate behavioural dispositions'
(53).
4) The philosopher teaches the legislative (52).
5) The dramatic aspect is of primary importance over the legislative aspect
in medical ethics (53).
6) If the philosopher teaches students medical ethics she will be teaching
them something of secondary importance (from (4) and (5)).
How good is this argument? Well, it is valid. However, the premises are all false or trivial and the argument isn't justified.
Before proceeding I want to 'lay my cards on the table'. I think that medical ethics should be taught with both the traditional didactic style and interactively - by using Problem Based Learning, case studies, role plays etc. Moreover, given the amount and variety of medical ethical decisions students will have to face, I suspect that it may even be true that in medical ethics rather than say, business ethics or engineering ethics, there should be a greater emphasis on such interactive teaching methods. I myself have found that case study is often the best way to get the students thinking about how various ethical issues 'play out' in the real world.
However, the observation that it is beneficial to teach ethics in interactive ways seems like an overstated and obvious point. So, if this is Cowley's claim then his position would be true but uninteresting. But it isn't; he is claiming that 'philosophers qua philosophers should not teach medical ethics'. And I for one see absolutely no reason why this should be the case. We had better consider Cowley's justification.
Premises 1-3: Does ethics have a double-aspect?
It just isn't clear what Cowley means when he says that there is a 'double-aspect nature of ethics'. He says that one aspect is legislative - which is about thinking and discussion; the other aspect is dramatic - which is about action, about 'cultivating the right dispositions'. But this then looks true but uncontroversial - ethics not only includes thinking about stuff, it includes doing stuff as well, and this is a two way interactive process. Does Cowley move beyond this empirical claim? Well, the article reads as if he means something more substantive. But what?
Maybe we can glean more by considering some quotations? Discussing the dramatic Cowley states it involves:
...the cultivation of appropriate behavioural dispositions (52).
And that the:
...successful cultivation of such dispositions and sensitivities will result in the adult knowing what to do in many situations without experiencing ethical perplexity (ibid).
Of course, this begs some important questions: 'What does 'appropriate' mean? 'How do we gauge 'success'? etc.' However, leaving this aside, does it help us to grasp the more substantive claim that Cowley is alluding to? Not really, it merely takes us to another seemingly uninteresting empirical claim.
For, given that Cowley talks in terms of 'cultivation' then it seems that what he means is that you can teach ethics either by cultivating a disposition in people or by getting them to think clearly in the classroom. This is surely true. We can either teach people by encouraging student-centered learning and the development of skills, or on the other hand just tell them stuff. But again, if this is the case then I don't see why ethics turns out to be 'unique' in the way described. Presumably we can teach engineering by either teaching students in the traditional lecture style, or by cultivating dispositions about how to approach problems etc.
So, after considering premise one, we have it that either Cowley means that ethics is both about thinking and action which is trivial, or that ethics can be taught in two distinct ways which is also trivial. However, let's be charitable and interpret Cowley as meaning latter as this fits better with the emphasis of the article (it does appear in a learning and teaching journal after all).
Premise 4:The philosopher deals with the legislative.
So, we are now dealing with how ethics can be taught. However, even with the clarification above, this claim - that the philosopher deals with the legislative (52) - is ambiguous. It can either be read that philosophers as a matter of fact teach via the legislative process, or that philosophers qua philosophers have to teach via the legislative process. The former seems like an uncontroversial claim. The latter is the more interesting and the one I will ascribe to Cowley. But what justification is there for this? Well, Cowley doesn't give any explicit reasons and it is very hard to find anything that supports his claim. However, we can perhaps get some justification by considering the other premises.
Premises 5 & 6: The dramatic aspect should dominate over the legislative.The philosopher will teach something of secondary importance.
Let's grant that Cowley has shown that ethics can be taught in a both a legislative and dramatic fashion, and that he has shown that philosophers qua philosophers have to teach via the legislative process, why does he think that the dramatic aspect should predominate over the legislative? Again, he doesn't say explicitly but I think there are two related things he might be saying in support of this.
First, he says that the philosopher will be ethically overwhelmed in specific medical situations, in particular in a hospital. What does this mean? I think the general idea is that in a hospital there are just too many ethical problems and situations. So whereas, for instance, the flight deck of a MIG fighter will be overwhelming psychologically to the philosopher (unless they have been in the Russian Airforce), the hospital will present the philosopher with so many ethical problems that they are ethically overwhelmed.
Second, Cowley attempts to show that there are limits to legislative discussion. For he claims that if a student has been taught by a philosopher then they will be more likely to be ethically overwhelmed. And being ethically overwhelmed is a disadvantage. What does Cowley say to back this up? Well it seems he thinks that teaching in a legislative way just won't help when overwhelmed with the real issues.
Until the student encounters a dying patient, until he really listens to the dying patient, all discussion of euthanasia are little more than shrill posturing stirred up by facile journalistic accounts. Whatever conclusions the students may reach in the debating club will have little effect on what he feels and does during this critical first encounter. (57. Emphasis mine)
There seems to be some obvious problems with this quotation. First, there seems to be an assumption that by 'dramatic' Cowley means 'real'. But this seems wrong, presumably one can teach dramatically and develop the correct dispositions, via case studies, role play without actually being faced with real patients.
Second, it isn't the case that the underlying principle here is obviously generally true and as such claiming its truth in this case seems arguably ad hoc. For example, it certainly isn't true that what the doctor learns in the classroom has little effect in practice. Nor, is it true that what the fighter pilot learns doesn't help him when faced with a ground-to-surface missile attack. Nor, what the vet learns about lambing doesn't help him in a field in the middle of the night. So why think that the ethical is any different? Cowley offers no reasons, and as such the suggestion seems like stipulation.
Third, Cowley is running two different things together: feeling and thinking. It is, as Cowley states, most probably true that what the student learns in the classroom will have little or no effect on what the student feels when faced with real world examples. Obviously how they feel will be dependent on a whole host of things, e.g. history, culture, the actual situation, what they had for breakfast etc. However - and this is the key point - one would hope that what the student feels doesn't directly tie into what he does. After all, if what we feel is somehow hardwired into what we do then we've lost thinking and reflection altogether. Surely a bad thing.
As such, following on from this third point, the fact that the classroom doesn't directly impact on feeling seems irrelevant. Moreover - and contrary to what Cowley seems to be saying - it seems that it is teaching via the legislative process that is important in cases where we are ethically overwhelmed. Imagine a student entering a hospital and facing countless issues. What the classroom learning, in terms of the legislative, gives students is the critical thinking skills to know how to proceed. How to isolate what is and what is not important, whether to trust one's feelings, to judge what weight to give one's moral intuitions and dispositions, to 'stand back' from the situation etc. This suggests then that it is just false that the legislative teaching is limited in a way that makes it of secondary importance.
Fourth, to try and defend further the claim that the legislative is somehow restrictive, Cowley asserts an even more implausible view. He writes:
[The medic taught by the philosopher] will probably adopt words...without really understanding what they mean...'quality of life' only means something when it is used in the context of a discussion with a real patient making terrible decisions that will affect his quality of life. (58-9. Emphasis mine)
This seems very strange. Just think about what account of meaning Cowley must need for this to be true. What he seems to be saying is that unless you experience what you are talking about then you can never really understand the words you use.
Does Cowley seriously think that because the philosopher hasn't experienced, say, euthanasia first hand, he doesn't know what 'euthanasia' means? Well it seems that is exactly what Cowley does mean:
There is a very real sense in which [the philosopher] does not know what he is talking about. (Ibid)
This is wrong. Again, to think otherwise is to be committed to it either being the case that we need to give a unique account of meaning and knowledge concerning ethics or claim that there is a unified account of meaning and knowledge and accept the consequences that this brings. The first just seems ad hoc and completely unmotivated. The second just seems like a reductio ad absurdum of Cowley's position. For it would mean that claims about history, the majority of cosmology, the future, and lots and lots and lots of claims are literally meaningless. Consider one basic example: imagine a cosmologist's claim that 'at the beginning of the universe there was a big bang'. Presumably the cosmologist hasn't experienced this and as such Cowley is committed to saying that there is a 'very real sense in which he doesn't know what he is talking about'. Or more radically consider claims about other minds, presumably we can't experience them in the way that Cowley would require, but we don't want to reduce the ascription of mental states to others to meaningless talk. Anyway the basic point is that surely we don't want to accept this account of meaning and as such we should resist this defense of premises 5&6.
It is worth noting, to avoid any confusion, that there is of course a trivial and uninteresting claim lurking around here. Namely, that experience is often far richer than description. However many words we write we cannot capture what it is actually like to, say, fall in love, to face the cancer patient eye to eye etc. The phenomenology outstrips the description. However, this is one thing. But to assert, as Cowley seems to, that there is some link from this to meaning is another.
So let's recap. I have suggested that the truth in what Cowley has said amounts to this: ethics can be taught in a dramatic or a legislative way and that sometimes - perhaps more often than not - the philosopher teaches ethics in a legislative way.
Cowley's suggestions
There are a number of issues that I want to highlight before concluding. If Cowley is right then how should the dramatic process be implemented? And who should facilitate this process? Addressing the latter question Cowley states:
Ideally the facilitators [of the dramatic aspect of ethics] will have clinical experience, of course, but there may not be enough available, and notoriously, some who do volunteer may have strong didactic impulses. But the best facilitators might well be those with theatrical experience. (60)
Let's then see how Cowley address the former question; how do these theatrically experienced facilitators implement the dramatic process?
Cowley has a number of suggestions and I won't look at them all. His first suggestion runs as follows:
'A professional actor would play the patient, students would rotate playing the doctors, and the other students would observe and take notes, and then feed back. The ensuing discussion would cover not only communication skills but also ethics. (60. Emphasis mine)
Why can't the philosopher facilitate this? It's not clear to me that a philosopher qua philosopher is ruled out of this method.2 Moreover, what is clear from this quotation is the central role of discussion. Now, it seems to me that this must be guided by the legislative.
Cowley's second suggestion is where:
...students could bring 'baggage' to unload in confidence among a small group of their peers, in the presence of two clinicians.The clinicians would not be there to teach at all, merely to help the students articulate their concerns....(61. Emphasis mine)
First, as Cowley says, this isn't about teaching, so it seems out of place in an article about teaching medical ethics. Second, again it is unclear what is stopping the philosopher qua philosopher being involved in this? Third, presumably when Cowley talks about 'articulating their concerns' this would be about finding the appropriate language, the right focus, and the right emphasis. Sounds like the legislative process is required.
It is worth picking up on one more of the suggestions. Under the title 'A central place for theology' Cowley writes:
....the most sophisticated account of the meaning of suffering and death have been offered by the major world religions. At the very least, medical students should know something of these accounts in order to understand something of their patients religious beliefs. (61)
Why can't the philosopher teach this? Why is it relevant in medical ethics? Moreover, what Cowley is saying is that to understand the patient as a religious being we need to think in the classroom about the meaning of death presented by the world religions. This is, of course, legislative. Moreover, it seems like a good case where the students could come to understand what they are learning without actually being faced with issues.
The point I want to end with is rather more positive. After reading Cowley's analysis of the philosopher's disadvantage in teaching ethics, we may be left wondering what the philosopher actually teaches in terms of skills. What are the primary skills the philosopher teaches? Well strangely one of the most helpful accounts I've read about this comes from Cowley himself in an online article 'Cultivating transferable skills in philosophy undergraduates.'3 He says that what a student learns from studying philosophy include: problem solving, analysis of problems, justification of arguments, communication, practical judgements and wisdom.4 I think this is spot on. So the philosopher teaching medical ethics would presumably be a very good starting point for any medic wanting to be able to problem solve, analyze, justify arguments, communicate and make practical wise decisions. The transferable skills the philosopher can teach are essential for ethics in practice. In his online article Cowley says it best:
In smaller doses, however, I believe a philosophical training can provide the best sort of education and the best package of transferable skills a state's money can buy. True, a philosopher might not be able to follow the intricacies of international politics or of the dot.com revolution like her more learned fellow-graduates in politics, finance and computer science. But, once the details of this or that problem are acquired independently of any systematic training, it will be the philosophically-developed skills that allow her best to deal with such a problem - to her own and to society's overall benefit.5
It seems then that the suggestions that Cowley present are methods that are perfectly open to the philosopher to teach, and moreover with the skills highlighted, something that the philosopher probably should be encouraged to teach.
Conclusion
Christopher Cowley claims that 'Philosophers Should Not Teach Medical Ethics'. I have argued that Cowley is mistaken. It seems that on the most charitable interpretation, what Cowley wants to maintain is that philosophers qua philosophers are forced to teach in a traditional didactic style, a style that is ill equipped to train medical students for the ethically overwhelming jobs they will have to do. It seems to me that that the traditional style is a necessary but not sufficient method of teaching in medical ethics. I disagree that there is something about the discipline of philosophy which restricts it to the traditional style. In fact, using Cowley's own research, I suggest that the transferable skills that the philosopher can impart are taught via both the 'passive' and 'interactive' form of learning. Cowley is wrong. Philosophers should teach medical ethics, they are better equipped than most - they just need to do a good job of it.
Endnotes
1 'Why Medical Ethics Should Not be Taught by Philosophers', Discourse (2006),
vol. 5, no.1. All references are to this article unless stated otherwise.
2 Oddly enough Cowley does state that the philosopher may be able to teach
ethics via the dramatic process (60). But then if this is the case I am at
even more of a loss as to what point Cowley is trying to make.
3 http://www.prs-ltsn.ac.uk/philosophy/articles/cowley/index.html (accessed
28/11/06).
4 Ibid. pg. 2.
5 Ibid.
Return to vol. 6 no. 2 index page
This page was originally on the website of The Subject Centre for Philosophical and Religious Studies. It was transfered here following the closure of the Subject Centre at the end of 2011.
