Ethics and education
====================

* Guy LeBlanc

**The moral development of health care professionals** Bertram Bandman Westport (CT): Praeger; 2003 US$69.95 pp. 208 ISBN 0-86569-259-9

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[Figure1](http://www.cmaj.ca/content/171/5/485/F1)

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Most if not all medical schools offer at least some introduction to the ethics of health care delivery. But there are skeptics who maintain that medical ethics courses are a waste of time, money and effort. One of the most well known articles on this subject was written by Michael Levin and appeared in 1989 in the *New York Times*. The article's title succinctly summarized the author's point of view: “Ethics Course — Useless.” Simply, Levin postulated that “moral behavior is the product of training, not reflection.” Although Levin was not the first to express this opinion, his argument was well articulated and compelling.

Since this idea was first proposed, bioethicists, philosophers and other proponents of ethics courses have had to answer the skeptics' questions. A recent attempt, *The Moral Development of Health Care Professionals*, seeks to make a case for the teaching of health care ethics and to show that this teaching will lead to moral development. Bandman begins by looking at Levin's main argument, pointing out that training and reflection are not mutually exclusive. Citing many examples in support of this view, Bandman reasons that medical students can learn health care ethics through the two-pronged approach of practical experience and didactic instruction.

Bandman poses several basic questions: Is there such a thing as moral development in health care? How does a professional develop morally? What are the factors that influence moral development? What is the role of rights and virtues in health care ethics? In seeking answers, he makes use of a number of interrelated methodologies, most notably “counterfactual conditional judgements.” A counterfactual conditional judgement takes the form of an “if–then” statement — that is, an antecedent “if clause” and a consequent “then clause.” Bandman supports that controversial view that if the antecedent is to be considered to be true even when it is known to be false, then one can then attribute a value of true or false to the consequent to determine the overall validity of the statement. By relying mainly on this kind of reasoning, Bandman analyzes and presents an argument for each of the basic questions he has posed. However, the arguments he makes within this framework are not always well elucidated.

Bandman describes a range of hypotheses on moral development. These range from Lawrence Kohlberg's six stages of development to Gilbert Ryle's argument that the terms “moral” and “development” cannot coexist in the same context. Ryle believed that mental processes (including morality) cannot be reduced to the level of physical reality (stage-based development). He considered this to be a “category mistake,” meaning that he did not believe that the mind developed in the same straightforward way as the body, through linear growth in stages. Bandman assumes otherwise, and argues that moral development is possible — but only when it is “justifiable.” This notion of “justifiable” development, however, asks more questions than it answers.

Bandman describes several factors affecting moral development, including the concept of teaching and learning of values, the role of knowledge and the place for beliefs in health care, as well as the interplay between determinism and free will. These factors influence the different aspects or gears that make the health care system work in unison, from deliberation to justification to intervention, in a way that is accepted but hardly ever reflected on. As illustration, Bandman uses easy-to-understand examples taught in most medical ethics courses, such as Nazi practices and the infamous Tuskegee experiment in which 399 black American men suffering from syphilis were, without their knowledge, denied treatment so that the progress of their disease could be studied.

Bandman appeals to John Rawls' *A Theory of Justice* to justify the function and role of rights in health care ethics. By applying counterfactual conditional judgements, Bandman further explores three fundamental rights: the right to initiate life, the right to sustain life, and the right to end life. Medical students are taught about these rights as a means of attaining moral development. It follows, then, that to appreciate the role of rights in health care ethics, health care professionals should be taught the least rationally contestable and most justifiable of possible views. Bandman's quintessential example of this is that “if a woman were to carry a fetus after stage L and if the fetus after L were judged to be a person, then abortion after L would be murder, but not before L.”

A weakness of this book is that it at times loses focus and jumps to conclusions. Although each chapter makes several valid points, the overall argument is not laid out in a logical manner and is therefore difficult to follow. For example, Bandman analyzes the role of “if” in the arts and shows how it is necessary to immerse ourselves in the imaginative world of a play, painting or piece of music to truly appreciate it. From this, Bandman draws a tenuous connection to the role that imagination must play in the moral development of health care professionals. In the very next paragraph, however, he invites us to consider Descartes' teachings more carefully, to doubt everything and to accept only ideas that are “clear and distinct.” He concludes that a moral view is justified only if its values are grounded in fact and science.

Although this book in general would not serve as appropriate reading material for an undergraduate medical ethics course, its second chapter is an exception and would provide any physician or medical student with a concise history of virtue ethics and justifiable health care values. It eloquently summarizes the views of classical and modern philosophers ranging from Plato and Aristotle to Kant and Adam Smith. Overall, the book's heavy philosophical content and rich theories should at least provide several issues for debate among those interested in the ethical education of health care providers.

**Guy LeBlanc** Medical Student Dalhousie University Halifax, NS