Enlightening medical students
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* Jonathan Pulman

The recent report by Johane Patenaude and associates1 about the levelling of moral reasoning among medical students during their years in medical school does not surprise me. The environment to which students are exposed in teaching hospitals might be one aspect of their training that inhibits the development of moral reasoning.

I work in the inpatient psychiatry unit of a teaching hospital. Every few months, all staff psychiatrists receive a compilation of length-of-stay statistics, “savable days” and other related data, listed by individual staff member. I believe that this practice is common in other departments and hospitals as well. Through this process, staff are openly ranked according to the speed with which they discharge their patients, the worst offenders (those who keep their patients in hospital the longest) appearing at the top of the list. These reports, masquerading as “information,” represent an example of public shaming, a descendent of tarring and feathering, head shaving and public hanging. This practice encourages staff to regress in their moral development to Kohlberg's stage 3,2,3 interpersonal conformity, the stage to which the students in Patenaude and associates' study tended to move (from lower or higher stages).

I wait in vain for rankings of humanistic parameters such as compassion, empathy and supportiveness toward patients, or even simpler measures such as providing good treatment or treating other staff well.

Is it any surprise that our students do not progress to higher moral levels?

**Jonathan Pulman** Staff Psychiatrist The Ottawa Hospital Ottawa, Ont.

## References

1.  1. Patenaude J, Niyonsenga T, Fafard D. Changes in students' moral development during medical school: a cohort study. CMAJ 2003;168(7):840-4.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNjgvNy84NDAiO3M6NDoiYXRvbSI7czoyNDoiL2NtYWovMTY4LzExLzEzOTAuMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  2. Kohlberg L. *The development of modes of moral thinking and choice in the years ten to sixteen* [dissertation]. Chicago: University of Chicago; 1958.
    
    

3.  3. Kohlberg L. The psychology of moral development: moral stages, their nature and validity. Vol 2 of *Essays in moral development*. San Francisco: Harper & Row; 1984.