For the past few years I have taught an undergraduate course in bioethics. The cou rse is introductory in na ture. Its purpose is to acquaint the undergraduate with some of the more important bioethical issues confronting medicine and society today, and to provide the student with some skills in the area of analysis and decision making. I have found that the use of case studies in this course is very beneficial. Students often remark that the examination of various cases is a significant factor in heightening their interest in bioethics and encouraging them to pursue their studies with a more serious disposition.
The purpose of this article is to discuss some of the benefits which result from the utilization of case studies in similarcourses. I will preface my remarks with a brief description of the course content, structure, goals and a description of the role of the course instructor. Although introductory in nature, the course is designed to invite students to enter into a more thorough and systematic study of bioethics. Furthermore, it provides some immediate and practical dividends to nursing students, pre-med majors and other undergraduates who are pursuing careers in the health care professions.
I begin the course with an overview of the various issues to be studied. They include human experimentation, abortion, issues in death and dying, care of the handicapped, behavior modification, allocation of health resources and others. I highlight the contemporary significance of these issues by sharing recent newspaper reports and journal articles which draw attention to the practical moral dilemmas they pose in society. My aim is to show that these issues, regardless of how novel they may seem to the student, are the frequent concerns of people in their daily lives.
My second concern is to outline the various philosophical and theological methodologies which are employed in the decision-making process. I examine various classical ethical theories, as well as those reflecting the moral sensitivities of the 20th century. I point out that these different approaches have continued usefulness today, even though the layman may not be conscious of their application. In the particular cases we examine I try to show how different theoretical models are utilized to yield practical results in the decision-making process. This increases the student's ability to discern the relationship between practical moral dilemmas and theoretical constructs for problem solving.
Now a brief word about the format of the course. After my introductory lectures, we proceed with an analysis of the specific issues I have indicated. We examine one issue per week through a series of scholarly articles. These resources include contributions by theologians, philosophers, bioethicists, health care professionals and others. I advocate this interdisciplinary approach to issue analysis because it provides the student an opportunity to explore the moral significance of specific bioethical issues from different perspectives. This method is beneficial because it does not foster or recommend a rigid approach to analysis or problem solving. My goal throughout the course is to enable the student to utilize these various perspectives and methods in their own analyses of specific issues.
After studying each issue, the students analyze specific cases which disclose the moral dilemmas confronting the decision maker. Before discussing the particular benefits of the case study approach, I want to describe briefly the role of the instructor in the course. At the outset of the course I assume the posture of lecturer. This enables me to outline a variety of concerns. They include: (l) an identification of the issues to be examined, (2) an analysis of some of the more pertinent literature in the field, (3) an overview of the contributions of bioethicists, and (4) a description of the various methodologies and schools of thought that can be employed in the process of analysis and decision making.
Following these initial lectures I consciously alter my role in the class. One way I do this is by abandoning the lectern and physically rearranging the class in a seminar format. I have had interesting reactions to this change. One student remarked that it pointed out to her that she now had to assume a significant degree of responsibility in the decision-making process. In addition to the physical change in my posture, I adopt the role of listener and questioner as my primary relationship to the class. My purpose is threefold: (1) to challenge the students to scrutinize the moral/ethical implications of the scholarly articles they have studied, (2) to oblige each student to analyze carefully the dilemmas raised by the cases they have studied, and (3) to encourage the students to apply their own insights in the decision-making process. My intent is to draw the student into an analysis of the moral dilemmas as thoroughly as possible. I try to show them that in the process of case study they are developing, however unconsciously at first', skills in analysis, methodology and decision making. My role as instructor is important throughout the case study process. I will make additional comments about this role as I turn to a description of some of the significant benefits of acasestudyapproach in bioethics courses. 1 have identified nine specific benefits.
First, the case study approach is beneficial in sensitizing the student to the importance of ascertaining and analyzing the data in each case. It demonstrates the obligation toca refullyconsider the physical, medical, emotional, psychological, family and social facts that constitute the reality fabric of each situation. Students come to understand that the moral quality of a decision often rests upon how well the facts are recognized and interpreted. I recall one class when we were discussing "the patient's right to know." The wife of a terminally ill cancer patient had requested the doctor to withhold his diagnosis from her husband. While most students in the class argued in support of "the patient's right to know," a clearer focus was brought to this decision when a student in the class pointed out that the facts in the case indicated that it would be virtually impossible for the doctor to withhold his diagnosis from the patient while proceeding with drug and radiation therapy. An understanding of the facts in this case reinforced the student's conviction in "the patient's right to know."
By focusing the attention of the student on the necessity of understanding and analyzing the importance of facts in a specific case, the student can better appreciate the interdisciplinary character of decision-making in bioethics. Understanding the facts in a case will often necessitate a reliance on the wisdom and insights of a variety of disciplines. The obligation to know the facts introduces an obvious sense of caution and humility into the decisionmaking process.
A second major benefit of using case studies is their ability to alert the student to the value of developing and utilizing a carefully constructed methodology and applying it to a particular case. In a recent class, I examined with the students the methodology which Daniel Maguire outlined in his recent book The Moral Choice. In the chapter entitled "Routes to Realism," Maguire discusses the moral obligation of the potential decision maker to ask the "reality revealing" questions to each moral dilemma. These questions include: what, why, how, who, when, where, the consequences of actions and creative alternatives. In each of the cases we examine/ I ask the students to identify how the "how" or the "why" in the case affects the moral quality of action. At the outset, the application of Maguire 's method (or other similar methods) seems artificial and rigid, but after examining a number of cases students begin to raise the "reality revealing" questions almost routinely. I remember a discussion when one student disagreed with the entire class about a decision in a particular case. He argued that they had failed to recognize a creative alternative to the courses of action proposed. Interestingly enough, the class agreed after some debate and clarification. The student had recognized a possibility the others had not considered. His alternative had enriched the moral quality of the eventual decision.
A third beneficial consequence of utilizing case studies is that the various points of view aired in the discussions afford the students an opportunity to discern the merits of different philosophical and theological perspectives. My intention is not to confirm the students in a belief that one particular system is superior to others (although arguments may be made for this) but to enable the students to see that differing perspectives do shape the way individuals interpret the moral content of particular situations. I remember one instance when a student admitted (much to her surprise) that her approach to many ethical issues was deeply influenced by definite religious convictions. She confessed to the class that at the outset of the course she was not aware that these convictions were so operative in her life. She went further to suggest that prior to the experience of the course she would have denied that she held these beliefs so strongly.
Throughout the course I make an attempt to have the students recognize how philosophical and/or religious beliefs influence their thought. This diversity of perspective in the class represents a microcosm of the pluralism which exists in society. By being exposed to this the students in the class are in a better position to become sensitive to the diverse moral perspectives in the community which contributes to many of the dilemmas in the decision-making process.
A fourth beneficial effect of the case study approach is that it places students in a position (however artificially constructed) to test out different theoretical approaches utilized in the decision-making process. I remember a case involving a newborn child, who was a victim of Downs Syndrome. In this well-known case the mother insisted that the child not be operated on for an intestinal blockage. The baby was placed in a side room and died of starvation eleven days later. One student disagreed vehemently with her decision. Indiscussing his feelings he admitted he felt this way because he knew two teen-agers, victims of Downs Syndrome, who were very happy. I asked him what his decision would have been if he hadn't known these youngsters. After a reflective pause he indicated that he would have agreed with the decision of the mother. In a f urtherdiscussion Iquestioned him about these conflicting judgments. He confessed to the class that it was disturbing to him that his initial feeling was based solely on his experience. This pointed out to him the need to develop a more adequate framework for decision making than simply experiential knowledge. I thought at this point the student had understood one of the primary goals of the class.
In relating this incident I do not mean to suggest that the object of the course is to "trip up" the students, or convert them to a particular point of view. Nonetheless, it is very interesting to observe what happens when students are obliged to recognize through case studies the practical consequences of the theoretical convictions they hold.
A fifth beneficial consequence of the case study approach, relating to the very heart of so many ethical dilemmas, is that it directs the attention of the student to the multiple and conflicting rights in specific cases. This recognition is an important corrective to a more simplistic mindset which suggests that the objective of the ethical choice is to recognize the right involved in a specific case and serve in support of it. I recall a class when we were discussing a case involving human experimentation. One student felt he had made an acceptable decision in deciding against a research project involving a group of army recruits. In discussing the case, a number of other students pointed out the potential social benefits of the experiment. The student was now perplexed. At first he only had paid attention to the need to protect the rights of the potential subjects. Now he recognized that the society also had some rights that had to be taken into consideration. This incident pointed out how case studies can be instructive in demonstrating the complexities that are often involved in the moral choice. When the instructor can bring the student to see the dilemmas posed by conflicting rights situations, the need for a systematic ethical analysis in the area of medicine and health care is clearly demonstrated.
A sixth benefit of the case study approach is that it points out the need for different parties to participate in the decisionmaking process. This may include not only the patient but the family, physician, hospital administration, etc. I remember a case when the ethical quality of a decision was judged harshly because the participants in the final decision had failed to involve a particular individual who had information very pertinent to the case. This incident revealed that broad consultation in some cases is more than simply a matter of formality or courtesy. It reveals that the manner in which the decision-making process is structured can have a direct bearing on the moral quality of decisions and actions.
A seventh beneficial consequence of case studies is that they reveal the role of creative imagination in the decision-making process. Daniel Maguire addresses this aspect of ethical reflection at length in The Moral Choice. The role of the imagination in moral choices directs itself to the ability of individuals to discern creative alternatives to the courses of action proposed. Such alternatives can enrich the moral character of actions. Often this aspect of the moral choice is met with both surprise and interest by the student. Too often ethical reflection is construed as a rigid process void of the qualities of crea tivity and vision. By stressing the role of the creative imagination, students develop a deeper appreciation of the fact that the moral quality of action often is related directly to the ability of individuals to broaden their own horizons and imaginative powers.
I recall one class when we were discussing a case involving the allocation of health resources. It was obvious to the class that the strategies proposed were not likely to deal adequately with the needs of the community in question. One student then suggested a new formula for distribution based on an inventive idea. His plan received immediate acceptance not only because of the imagination it revealed, but because the plan would meet human needs more directly and comprehensively. Utilizing case studies to disclose the role of the creative imaginationin the decision-making process is important because it demonstrates that the best course of action often resides somewhere beyond the conventional options. It reveals that ethical reflection must strain to incorporate not only new insights in the community, but that it must provide a vision powerful enough to attract the attention and commitment of others.
An eighth beneficial effect of the case studies in bioethics is that it demonstrates to students that they must invest significant energies, both intellectual and personal, in the decision-making process. Struggling with moral dilemmas in medicine and health care is not for the weak of heart. It demands that the student be willing to invest significant energies in the struggle to reach a decision which adequately attends to all of the moral concerns which constitute the contours of a given situation.
I remember a class when a student indicated that she could not make a decision in a particular case. Prior to the class she had discussed it with her family, some friends and her fiance in medical school. After all these consultations she was still perplexed. This often happens in cases involving rights in conflict. The student expressed exasperation because after all the work she had done she was still in a quandary; still unable to say "this is what must be done".
This dimension of the case study process is directly related to the ninth and final benefit I want to discuss. There is no doubt that long after the decision-making process is completed, and a decision reached, moral ambiguity at times remains. The students in the class are introduced to this element of the moral choice. Absolute confidence in one's decision in cases in medicine and health care is rarely a sure dividend. Students come to an appreciation of the fact that moral decisions demand a maturity which accepts the implications and consequences of decisions once they are made. This does not mean that moral ambiguity and unce rtaintycompletely vanish. However, it does mean that the participants are capable of moving forward to confront the other difficult choices demanded by life's reality.
In the preceding I have tried to identify some of the benefits which result from utilizing case studies in undergraduate courses in bioethics. Although I have placed particular emphasis on the case study approach, I do not intend to minimize the importance of a serious concern for the methodological tools which are essential in the decision-making process. Case studies alone are not adequate for maturing the mind of an ethicist. However, when case studies are analyzed in concert with va rious methodological tools the results can be most rewarding.
In conclusion I want to point out that this course represents one of the most rewarding experiences I have had in my career as a teacher. A great deal of satisfaction is derived from observing students developing the ability to move from the point where they are totally perplexed by a situation toa point, whereby using their intelligence and imagination they can confidently make moral choices in the field of medicine and health care.
- 1. Maguire D: The Moral Choice. New York, Doubleday, 1978.