The Cambridge Consortium for Bioethics Education took place at the Cambridge University Press offices in New York this April. Hosted and sponsored by the Press, with cosponsors, CQ and the Program in Medicine & Human Values at California Pacific Medical Center in San Francisco, the Consortium brought together representative leaders in bioethics to discuss some of the unsolved issues in the field: goals, curriculum, methods, and assessment. For three days participants shared their own programs, research, and current projects as well as ideas on where bioethics education needs to go in the future. Beginning with this special section, and in CQ’s Bioethics Education section in subsequent volumes, we will be bringing you what is happening as bioethicists everywhere take a more focused approach to the field.

Biomedical ethics is an essential part of the medical curriculum because it is thought to enrich moral reflection and conduce to ethical decisionmaking and ethical behavior. In recent years, however, the received idea that competency in moral reasoning leads to moral responsibility “in the field” has been the subject of sustained attention. Today, moral education and development research widely recognize moral reasoning as being but one among at least four distinguishable dimensions of psychological moral functioning alongside moral motivation, moral character, and moral sensitivity. In a reflection of this framework, medical educators and curriculum planners repeatedly advance the idea that educators should be concerned with supporting empathy, and this, very often, as a means of improving on and broadening medical ethics education’s traditional focus on moral reasoning.

The importance of humanities in the medical curriculum is increasingly recognized. For example, in the United Kingdom, The General Medical Council (GMC), which is an independent body established under the Medical Act 1858 and responsible, among other things, for fostering good medical practice and promoting high standards of medical education, in its publication Tomorrow’s Doctors, encouraged inclusion of humanities in the medical curriculum. Literature, arts, poetry, and philosophy are thought to foster the doctors’ ability to “communicate with patients, to penetrate more deeply into the patient’s wider narrative, and to seek more diverse ways of promoting well being and reducing the impact of illness or disability.”

Military medical ethics is garnering growing attention today among medical personal in the American and other armies. Short courses or workshops in “battlefield ethics” for military physicians, nurses, medics, social workers, and psychologists address the nature of patient rights in the military, care for detainees, enemy soldiers and local civilians, problems posed by limited resources, ethical questions arising in humanitarian missions, as well as end-of-life issues, ethics consultations, care for veterans, advance directives, and assisted suicide. Although many of these issues are the core subjects of any bioethics curriculum, military medical ethics presents unique challenges to bioethics educators.

Readers’ Theater (RT) is a unique vehicle for introducing ethical, cultural, and social issues in medicine to academic, professional, and community audiences. It brings alive the characters in a story in a way that silent reading or reading a story aloud cannot. Audience members experience what is, in essence, a case report acted out “on stage” rather than reading or hearing someone report on a situation second hand. RT has an immediacy about it, a compelling aspect, that makes listeners pay attention and mentally participate in the action. It draws people into the story, engages them. The oral reading and subsequent open discussion combine to educate audience members about the topic of the story and the variety of ways one can interpret the story’s message. This article describes the long-standing RT program at the Brody School of Medicine (BSOM) at East Carolina University (ECU) and some of variations on RT that people have developed around the country.

Ethics education is recognized as an integral component of health professionals’ education and has been occurring in various guises in the curricula of health professional training in many countries since at least the 1970s. However, there are a number of different aims and approaches adopted by individual educators, programs, and, importantly, different health professions that may be characterized according to strands or trends in ethics education.

Formal teaching of ethics in health science programs at the entry level and postprofessional level in the United States and Canada has been documented in the professional literature for more than 30 years, yet there are significant differences in the way it is taught and how much time is devoted to the subject. Numerous teaching and evaluation methods have been used in ethics education, such as lectures, written examinations, debates, role-playing, small group discussion, and case study analysis. Most instruction in ethics in the health sciences has been geared toward ethical analysis of case studies, that is, the student is asked to read a case or discuss a case with others, identify the ethical issues verbally or in writing, propose different resolutions supported by principles and theory, and select the best course of action. Yet, analysis of a case is an unlikely route to develop skills in coping with the uncertainty and emotional nature of ethical issues commonly encountered in clinical practice, nor does it give us an indication of what students would “really do” when they encounter an actual ethical problem.

Professionalism is demonstrated through attitudes and behaviors. Medical education is concerned with teaching and evaluating it among students. It is often bioethicists who teach professionalism to medical students. Most bioethics curricula use lectures and group discussions to introduce principles and theories, but there is variation in number of credit and contact hours, placement in the curriculum (which year(s) and alongside which courses bioethics is placed), the extent of individual mentoring, and the emphasis placed on any particular philosophical approach. Bioethics curricula also vary in whether and how explicitly and extensively they address topics, including professionalism, cultural competence, medical humanities, spirituality, death and dying, and community service, and in the number and topics of vignettes, controversies, assignments, and course activities.

The predominant influences on health are social or upstream factors. Poverty, inadequate education, insecure and toxic environments, and inferior opportunities for jobs and positions are inequitable disadvantages that adversely affect health across the globe. Many causal pathways are yet to be understood. However, elimination of these social inequalities is a moral imperative of the first order. Some physicians by word and deed argue that medical doctors should oppose the “structural violence” of social inequalities that greatly shorten lives and wreak so much suffering.

The rural health context in the United States presents unique ethical challenges to its approximately 60 million residents, who represent about one quarter of the overall population and are distributed over three-quarters of the country’s land mass. The rural context is not only identified by the small population density and distance to an urban setting but also by a combination of social, religious, geographical, and cultural factors. Living in a rural setting fosters a sense of shared values and beliefs, a strong work ethic, self-reliance, and a tendency for close-knit extended social structures where overlapping relationships are commonplace.

Let’s face it, the humanities are in trouble. Last year, in The Chronicle of Higher Education, Thomas H. Benton warned prospective graduate students to avoid doctoral studies in the humanities. His rationale: a job market down 40%, the improbability of tenure, the more certain prospect of life as an adjunct, and eventual outright exile from one’s chosen field. Benton, the pen name of William Pannapacker, an associate professor of English at Hope College in Holland, Michigan, pulled no punches. His piece was entitled, “Graduate School in the Humanities: Just Don’t Go.”

Medical training is intense by design. Starting with medical school, for 4 years most of the time in the formal curriculum is filled with numerous essential topics, and, as scientific and medical knowledge increases, it is increasingly difficult to “triage” what must be learned. Efforts to insert new topics are often fraught with obstacles and resistance. Thus, it is problematic to suggest that even more be taught in those finite years of formal medical education. However, that is exactly what we propose to do here.

Mrs. J was a 66-year-old Muslima who was brought to the hospital from the subacute unit where she had been living for the past 2 years because of intense pain caused by keratitis, an inflamed cornea of a nonfunctioning eye. In addition to her severe eye pain, Mrs. J suffered with a number of other difficult medical conditions, including amyotrophic lateral sclerosis. She was both gastric tube and ventilator dependent and had a history of multiple myleoma, chronic obstructive pulmonary disease, and congestive heart failure. Mrs. J came from a large and traditional Muslim family with 6 children and 17 grandchildren. Although she had full decisionmaking capacity, she designated one of her sons to make her medical decisions for her.

Although this case raises what are commonly called “cultural issues,” it does so in two rather different ways: first, an explicit question of what Shari’a, or Islamic law, teaches regarding bodily mutilation and, second, the most appropriate manner of conveying information in the idiom of the culture. It is necessary for an ethics committee or consultant who is dealing with such a case to obtain accurate information and, if possible, to ascertain how best to communicate that information.

The case of Mrs. J is interesting not only because of the difficult questions that the clinical ethicist must confront but also because of the intriguing way in which such cases make Western clinicians and ethicists confront their own oft-unspoken cultural ethical norms and presuppositions.

As is often the case with healthcare treatment dilemmas, it matters in what “voice” an ethical difficulty is related. In this instance, the voice of the healthcare team is clearly heard as the patient’s medical condition is described. The voice of the patient is heard as she cries out in pain. The patient’s son’s voice is heard as he identifies the religious guidelines that must be observed in his mother’s care. Finally, it is the voice of the Hospital Ethics Committee that is heard as it deliberates the questions brought to it.

The heart-rending story of Mrs. J raises many complex ethical issues. Key elements include suffering, disagreement, culture, religion, perspective, and facts. Overarching concerns include whose voices and stories should count, the connection of pain with suffering, and how healthcare ethics committees should respond.

Through one of their members, the ethics committee was fortunate to have access to a prominent Muslim scholar, Abdulaziz Sachedina, and asked for clarification regarding Islamic beliefs regarding eye removal.