Teaching and Learning > DISCOURSE

Ethical Dilemmas in Practice: Development of an Ethical Reasoning Assessment Tool for Veterinary Undergraduates

Author: M. Lesley Wiseman-Orr, Susan A. J. Stuart and D.E.F. McKeegan

Journal Title: Discourse: Learning and Teaching in Philosophical and Religious Studies

ISSN: 2040-3674

ISSN-L: 1741-4164

Volume: 8

Number: 2

Start page: 187

End page: 196

Return to vol. 8 no. 2 index page

This paper is a collaboration between the Pain and Welfare Research Group, Department of Statistics, the Humanities Advanced Technology and Information Institute, Faculty of Arts, and the Division of Animal Production and Public Health, Faculty of Veterinary Medicine, University of Glasgow.

A recent, brief survey of UK veterinary professionals has revealed that they experience difficult ethical dilemmas regularly and often up to five times per week, that some situations with which they are confronted are more stressful and/or common than others, and that years of experience do not necessarily make these situations any easier to handle (McKeegan et al., 2007). Repeated exposure to challenging ethical conflicts may cause an erosion of emotional well-being and even a state of 'moral distress', a phenomenon which has been the subject of extensive investigation in medical ethics (see, for example, Kaylemark et al., 2004). Although not formally presented and described in the literature, there can be little doubt that moral distress exists in veterinary clinical environments. The moral distress associated with euthanasia has been particularly highlighted by Rollin (1990), who states that 'Moral stress...arises out of a fundamental conflict between one's reasons for going into animal work and what one is in fact doing, or being asked to do'. Such moral distress can only add to other causes of emotional distress in veterinary practice, such as those associated with clinical mistakes (Mellanby & Herrtage, 2004) and may contribute to the relatively high suicide rate amongst veterinary graduates (Mellanby, 2005).

Studies in Britain and Australia have found that many veterinary students view their education as a rite of passage from 'tender minded' pet owner to 'tough minded' clinician. In particular, students appear to reduce their beliefs about the sentience of animals, and their empathic reactions to animals in distress (Paul & Podberscek, 2000). Although this process of hardening one's attitudes towards animals may help some students cope with the emotional and ethical challenges of veterinary work, it may also threaten the welfare of animals in their care. Consequently, education programmes fostering reflective thinking about ethical issues are increasingly included in the veterinary undergraduate curricula in a number of European countries. However, the scope and extent of inclusion varies widely and the effectiveness of this teaching is currently not assessable.

The need for ethical tuition and assessment in other ethically challenging professions has been recognised (Corley et al., 2005; Redman & Fry, 2000) and existing measurement tools are available in nursing, dentistry and midwifery. More generally, tests such as the self-administered Defining Issues Test (DIT) have been developed and applied to measure moral reasoning capacity in various (mostly undergraduate) contexts (King & Mayhew, 2002). The challenge of developing a tool for assessing the capacity for moral reasoning in the veterinary community is currently being undertaken by a small, interdisciplinary group with expertise in animal welfare and veterinary ethics, philosophy, statistics, and the development of psychometric instruments.

What do we want to teach? What do we want to assess?

It is essential, when developing an instrument of any kind, to define at the outset what it is that you intend to assess. Competence in making decisions when faced with ethical dilemmas, reflecting upon one's thinking, and engaging in debate which will shape the professional codes of conduct of the future are important components of the veterinary professional role that can be developed through a programme of veterinary ethics teaching at undergraduate level (and beyond). The first of these may be regarded as a 'Day 1' competency¹ on a par with reading a radiograph, making a differential diagnosis, or communicating bad news to a client; all of which are currently rigorously tested at the end of the undergraduate course. Those students who do not meet the standards required in all such areas are not considered ready to join the profession. Given the complex demands of dealing on an almost daily basis with challenging decision-making and with having to produce a competent defence of such decisions, it seems essential that a means of determining such competence be added to our armoury of assessment practices.

Equipping the veterinary professionals of the future to be reflective practitioners, and to provide them with sufficient knowledge and understanding to discuss relevant issues within and beyond the profession, requires a pluralistic approach to ethics teaching—one where the intended pedagogical outcome is that students understand that there are different ethical perspectives, that they can identify and discuss these perspectives, and that they do not simply take refuge in either the assumption of a professional moral absolutism or a risky and impotent moral relativism. These outcomes are largely concerned with acquiring knowledge and understanding of various ethical perspectives and an appreciation of the complexity of such varied perspectives. Assessment of such knowledge and understanding can most readily be carried out by means of an essay or examination process. Building on this knowledge and understanding is a crucial further requirement if we are to equip students with Day 1 competency in decision-making when confronted with a situation that presents an ethical conflict.

The first step in such decision-making is to be able to recognise an ethical conflict when you are faced with one. So, let's start with a sufficiently vague and, let us hope, non-controversial definition of an ethical conflict: an occasion on which it is not clear which is the right course of action to take. Ethical conflicts occur frequently in veterinary practice and generally include patient-centred considerations about the quantity and/or quality of the animal's life, the negative and the positive effects of different treatment options, the divergence between the duty of care for an animal and other duties to the owner (both enshrined in legislation and in professional codes of conduct), to other animals, to members of the veterinary team, and so on. The net result of such dilemmas may be a compromise of either professional responsibilities or of the animal's interests in terms of welfare or continuation of life. Rest (1997) has proposed that such decision-making requires 'moral judgement', which involves defining what the moral issues are, how conflicts among parties are to be settled, and the rationale for deciding on which course of action should be adopted. It is these which we deem to be the ethical reasoning skills necessary for Day 1 competency in veterinary practice, that is, those with which a new veterinarian will be deemed to be competent enough to join the profession.

A number of existing tools provide a starting point for the development of a veterinary-specific instrument, providing possible formats and scoring mechanisms; examples include Self et al. (1988), Self et al. (1991), and Self et al. (1995) who have used Sociomoral Reflection Measures (SRM), Moral Judgement Interviews (MJI) and Defining Issues Test (DIT) in veterinary medicine contexts; Clarkeburn et al. (2003) who used a Meta-ethical Questionnaire (MEQ) to measure ethical development in Life Sciences students; and Eckles et al (2005) who used a Problem Identification Test (PIT) to measure medical students' and professionals ethical sensitivity. Some tests are 'open ended', where the subject is provided with a scenario and simply asked for their responses. Others are self-administered and provide a scenario followed by a series of pre-determined statements which the subject must rank in order of importance, that is, how much they should or should not influence their decision-making process. This approach provides a number of perspectives that the subject might not otherwise have considered, and time-consuming individual marking of tests is avoided by a system of automatic scoring from ranked values previously assigned to the statements. With the inclusion of an 'Other' option the assessors also allow for the possibility that students might come up with another significant influencing factor that the assessors had not. All assessment requires that statements or scores be ranked in some way. We do not seek to minimize the difficulty of this task and propose at this stage just one possible approach that has been taken in the assessment of ethical reasoning skills in other contexts (McAlpine et al., 1997). This approach implements levels of attainment which are broadly similar to the 'pre-conventional', 'conventional' and 'postconventional' stages of moral reasoning defined by Kohlberg (1973), with the expectation that students would progress towards higher levels in the course of their training:

Level 1 (Traditional response): Reasoning is based on self interest and practical considerations; the aim is to win rewards and avoid punishment; it utilizes 'gut level' responses; there is non- or low recognition of the ethical issues involved and a fundamental belief in decisions being classifiable as either right or wrong.

Level 2 (Conventional response): Reasoning is based on conformity to social norms and expectations; some relevant ethical issues are recognised; and although they may raise questions they will tend to act within traditional boundaries.

Level 3 (Post-conventional/reflective response): Reasoning is based on universal ethical principles; centred on the notion of justice; there is critical thinking about relevant ethical issues, and use of an ethical framework within which to clarify, evaluate and justify various viewpoints; there will also be a willingness to challenge unethical practices, and a recognition of personal accountability and responsibility for choices.

Assessment of learning

So, now our question must be, how can we assess the progress that students are making towards the goal of Day 1 competency and whether or not Day 1 competency has been achieved by the end of a course of veterinary training? Our first step towards answering this question is to generate a suitable assessment tool using established approaches to the development of psychometric instruments. It is an approach with which we have considerable experience (Wiseman-Orr et al., 2004, 2006) and is one which will reflect, with a high degree of accuracy, the kinds of ethical dilemmas that are faced routinely by vets in practice and for which the application of Day 1 competency skills will be required.

The development of such an instrument will begin with the creation of appropriate scenarios representing ethical dilemmas or conflicts in veterinary practice. These will be sourced from the literature (Rollin 1990) and from interviews with veterinary practitioners. The scenarios will reflect those that are commonly encountered and have the potential to cause moral distress to either the veterinarian or the owner and which will have a significant animal welfare impact. The range of scenarios will also address the main types of veterinary practice in the UK: companion, equine and farm. Once potential scenarios have been identified, key informants will be asked to identify issues that they would consider relevant to the decision-making process in each scenario. Key informants will include experienced vets, veterinary undergraduates, those with expert knowledge of veterinary ethics, and members of the public, to ensure that associated statements are generated which represent the widest possible range of views and include those commonly held by the target respondent (the veterinary student). Thereafter, an expert panel, consisting of philosophers and veterinary experts, including those with detailed knowledge of relevant legislation and codes of conduct, will rank these statements according to the response levels described above or, possibly, according to other criteria which will be established by the expert group prior to exposure to the generated statements, and subject to refinement through exploration of the statements. This statement ranking will allow a scoring method to be devised that will accurately reflect a range of skill levels, including those required for Day 1 professional competency. It is envisaged that the finished prototype instrument will consist of a number of scenarios, each one associated with 12-15 statements. Respondents will be required to indicate the relative importance of each of these statements, and the extent of their agreement with expert ranking will be considered to provide evidence for the respondent's level of ethical reasoning and their attainment of certain Day 1 competencies.

The content validity of the instrument—the extent to which a measure represents all facets of a given ethical or social concept—will be assessed by independent experts in veterinary ethics and by fieldtesting of the instrument using naturally-occurring known groups (construct validity) which would be expected to differ in terms of moral judgment, for example, members of the public, those completing the Royal College of Veterinary Science Certificate in Animal Welfare, Ethics and Law, and moral philosophers. This form of 'field-testing' or construct validity differs from content validity in that it tests whether, and to what extent, a scale correlates with the theorized professional construct.

Following validation of the instrument and its process of development, it is envisaged that an online, self-administered, that is, selfassessment format will be devised. This format, with the addition of a substantial database of further scenarios, their associated statements and rankings, and with appropriate formative feedback would provide an invaluable educational tool offering the student the opportunity to self-assess and to practice the relevant skills. The addition of other scenarios will make it possible to avoid the student learning what might be considered to be a set of rote responses to a limited number of cases, whilst also broadening their horizon of possible real life experiences. In their final examinations, this tool could form part of a composite assessment consisting of traditional forms of assessment and understanding of ethics and of veterinary ethics involving: (1) assessment of their ability to recognise scenarios that present ethical dilemmas from among a selection of scenarios that represent difficult decisions of various other kinds, and (2) measurement of ethical reasoning using the tool developed as described above.

Assessment of teaching

Because it would assess that which we want students to learn, the same instrument could be used to assess the effectiveness of both the teaching practice and what is being taught to the extent that it enhances or diminishes the students' knowledge, understanding and skills. The validated method and online self-assessment tool could be used in veterinary schools throughout the UK—and, if appropriate, further abroad—to examine the effects of a range of educational interventions. The instrument could also provide a mechanism for examining ethical abilities in related disciplines, for example, in veterinary nursing, and the effectiveness of continuing professional development.

Conclusion

We do not seek to unduly simplify the challenging complexity of ethical decision-making or the intricacies involved in ethical theory and theorizing. Nevertheless, we maintain that, just as it is possible to assess all other aspects of professional competence, it should be possible to assess the professional competence in veterinary ethics of veterinary students. We have outlined a process for the development of a specialized tool for the assessment of such competence as part of the assessment of outcomes for a comprehensive approach to the teaching of professional ethics to undergraduate veterinary students. The validation of such an approach opens the way to the development of an online self-assessment tool to raise students' awareness of, and create familiarity with, the sorts of ethical dilemmas with which they are only too likely to find themselves confronted in their professional lives. It also opens up the possibility of devising appropriate instruments for use in other parts of the world where professional codes of conduct may vary from those employed in the UK and Ireland.²

Used as a teaching tool incorporating formative feedback, this instrument will enhance veterinary education and training. It will benefit the profession as a whole by encouraging the development of reflective ethical thinking in veterinary students and professionals and, perhaps most importantly, it has the potential to reduce moral distress and its negative consequences for individuals and for the profession as a whole. As an assessment instrument it will provide a means of gauging both individual student competencies and overall teaching effectiveness, and it will serve to guide the development of teaching approaches and materials in this vital area of professional development. We consider that valid and reliable assessment of the kind we describe will encourage rigorous thinking about the aims and intended learning outcomes of ethics teaching in vet schools, and will allow future developments in this field to be evidence-based which will be to the benefit of teachers, their students, and the animals in their future care.

Endnotes

'"Day 1" competency' refers to the competencies that the veterinary practitioner must have on their first day on the job, not on the first day of their training.
For more on the professional codes of conduct in the UK, Ireland and abroad see Hewson, 2006.

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