Changes in students' moral development during medical school: a cohort study

To the Editor CMAJ

In reading the article by Patenaude et al. regarding the lack of advancement on Kohlberg’s moral development scale through medical school, I was disappointed, but not surprised.

Like Dr. Peter Singer , I have observed very high levels of ethical behaviour in students and residents at times. I have also witnessed from staff, and no doubt modelled myself, less than ideal professional ethical behaviour at times.

While “admitting students who have high levels of ethics and professionalism in the first place” 1 is desireable, I wonder if it will not be a strategy that comes too late. Competition to get into medical school is great. With the stakes so high, we hear about unethical behaviour in the premedical programs. Ideals of cooperation, mutual respect and interdependence that we encourage in the graduate physician may not be highly evident in traditional premedical classes. Are our selection processes biased against those who would rank higher on Kohlberg’s stages, in favour of those who are more likely to put themselves first?

In medical shool, the collegial atmosphere of cooperation and support nurtured in the first two years of medical training seems to diminish in the face of senior year competition for preferred residencies. Might this have an impact on the moral development of a cohort as well?

Although teaching and modelling ethical behaviour is essential, a further challenge will be how to practically integrate this ethical teaching, and its evaluation, into assessments that will have a tangible impact on selection to medical school, matching to postgraduate training programs, and eventually to physician performance. A further question might be whether these changes in ethical development are similar in other competetive professional programs such as law.