The moral of the study

The methods described and the interpretation presented in Johane Patenaude and associates'1 thought-provoking study on medical students' moral development call for some clarification.

First, it is unclear why the authors calculated a weighted score based on the students' responses. The most substantial evidence presented for the assertion that moral reasoning declined over the study period was the small but “statistically significant” changes in weighted scores, but the change for the total group was only 17.98 points (out of a possible 450). Does this small change really represent a significant difference in students' moral reasoning abilities?

Second, the authors argue that a lack of improvement in moral reasoning is of concern, and their concluding paragraph indicates a belief that ideally students' moral reasoning skills should increase through their medical education experience. However, many students come to medical school with significant life experience and have already completed advanced degrees. At what point can they be expected to attain the highest stage of moral reasoning that they will achieve?

Finally, although the moral reasoning of students who started at a higher stage declined, that of students starting at a lower stage improved. This finding could be interpreted positively: those who needed improvement most did improve. It also seems odd that the students who were the most morally mature would be most adversely affected by the medical school experience.

Merril Pauls Assistant Professor Departments of Emergency Medicine and Bioethics Dalhousie University and Queen Elizabeth II Health Sciences Centre Halifax, NS