 Dr. John Yuen. Dr. Yuen is an assistant professor of medicine here at the University of Chicago and a faculty member in the McLean Center for Clinical Medical Ethics. Dr. Yuen received his MD from the University of Texas Southwestern Medical School. He then completed residency in internal medicine and fellowship training at the University of Chicago. Dr. Yuen's research focuses on the field of virtue ethics, moral psychology, and moral and professional formation in medical education. He is currently co-investigator on the project on the good physician, a longitudinal study of medical students funded by the New Science of Virtues Project at the University of Chicago. He's also interested in the role of burnout and a sense of calling in physicians' work, motivation, and career retention. Let's welcome Dr. Yuen. Okay. Despite widespread efforts in medical schools to form good physicians through courses in ethics and professionalism, a recurring question arises, and I believe our previous speaker, Dr. Lycombe, brought it up very nicely. This question, what are the primary goals of this education? The responses to this question tend to reflect two prevailing perspectives that dominate the medical education literature. These two perspectives constitute what is sometimes referred to as the virtue-skill dichotomy. In this paper, I argue that medical ethics and professionalism education may be enriched by insights from the rationalist intuitions debate in contemporary moral psychology. After outlining this debate, I'll then briefly discuss the implications that this debate has in teaching ethics and professionalism for medical education. And I should note that this talk is a summary of a paper that we recently published last month under the same title in the Journal of Advances in Health Sciences Education. I turned it off. Okay. What are the central goals of a medical ethics and professionalism education? Opinions vary on this subject, but in our review, two perspectives dominate the literature. As I said, the first argues that teaching ethics is a means of providing physicians with a skill set for analyzing and resolving ethical dilemmas. This perspective relies on the teaching of analytical skills related to the learning of explicit ethical rules or principles in the clinical context, traditionally based on a rules and results based approach, deontological and consequentialist ethics. The second perspective suggests that teaching ethics is a means of creating virtuous physicians. This relies on creating relationship centered mentoring training experiences through a character oriented virtues focused approach. The dichotomy constituted by these two perspectives, again referred to as a virtue skilled economy appears to be firmly entrenched in the medical education literature. And despite attempts to bridge the two perspectives, I argue that medical ethics and professions education in many ways mirrors aspects of the rationalist intuitions to be in moral psychology. In moral psychology today, approaches to moral development and education are divided into two opposing camps that are rooted in different philosophical paradigms. The rationalist camp conceptualizes moral development in a similar way as skill-based theories of ethical training in the medical literature. Both focus on the deliberate use of rationally acquired moral and ethical systems with the rationalist camp of moral psychology focused emphasizing the centrality of conscious moral values driven by moral willpower producing moral action. In general, the rationalist approach follows the Kantian-Colbergian assumption that good moral judgment and behavior are achieved primarily through the process of conscious language-based reasoning and reflection. Most famously, Kolberg emphasized language-based deliberative moral reasoning and its advancement through discussion of moral dilemmas. This approach to moral education is generally referred to as moral reasoning education that intentionally target in psychological terms the use of cold cognitive processes. According to this approach, morality is about resolving dilemmas involving competing interests of people. And the moral philosopher Edmund Pincoffs has ruthfully called this modern approach to moral education quandary ethics. The rationalist paradigm with his emphasis on moral reasoning has undergirded the traditional educational approach toward the teaching of ethics in medical schools which seek to equip physicians in training with an ethical skill set for analyzing and resolving ethical dilemmas. In contrast, the recent intuitionist paradigm, like the Aristotelian virtual approach in the medical literature, posits a different kind of moral competence, one in which moral motivation, not moral reasoning, as the central focus of character posits it to be the central focus of character education. In this approach, reasoning and deliberation remain important. Part of being a virtuous person is being able to reason in the right way about difficult and problematic situations. But intuitionist virtue theory is nevertheless a departure from quandary-based ethics, which considers moral reasoning the central psychological mechanism of moral action. Rather, intuitionist models highlight the centrality of rapid, implicit, habituated moral actions that are activated more by innate moral intuitions, emotions, and virtues than by rational deliberation. According to this paradigm, moral development is primarily about the cultivation of virtue, and this approach to moral education is generally referred to as character education, one that in psychological terms intentionally targets the hot, affective processes. In this approach, it is understood that different models of character education reflect divergent, cultural, philosophical, and or religious preferences for those virtues held to be most important. In effect, what I've introduced to you in a small nutshell is a great debate of moral psychology, namely what really motivates moral action, the head or the heart. Cold cognitions are hot, affective processes. Indeed, should medical educators be signing books more along the lines of Jerome Grootman's book, How Doctors Think, or more along the lines of Danielle Ofri's book, What Doctors Feel. To put it another way, I'll frame for you two predominant answers that have been given by moral psychologists. The first, the rationalist model. Most contemporary moral psychologists agree that any good moral psychological theory should be able to answer the question of moral motivation. In other words, it should be able to predict when a particular person in a particular situation will behave morally or prosocially. The rationalist model drawing on the philosophical heritage of Immanuel Kant would suggest that a person must first assess the eliciting situation, reason through a variety of values at stake, and then make a conscious judgment as to the correct course of behavior. Once they recognize this course and acknowledge their duty to behave morally, they draw upon an act of the will to carry out the behavior. Overall, the process is believed to draw heavily upon cold, calculated reasoning. Indeed, to the extent that affect is seen to be part of moral motivation at all, it is merely as one of the inputs into the reasoning process and it remains the job of conscious reasoning to objectively weigh its merits against other considerations. It is this model of moral decision making that serves as the basis for many professionalism and ethics courses traditionally. Learn the codes, ponder the ethical dilemmas to which they apply, deliberate over the prioritization of one or more values, make a judgment, and do the right thing. However, this theory has now received three decades of critique largely due to its inability to reliably predict actual moral behaviors and judgments. In contrast to this theory is the intuitionist model. In this model, the first step of moral decision making is not reasoning, but it is instead the triggering of a moral intuition. Moral psychologist Jonathan Haig defines a moral intuition as, quote, the sudden appearance in consciousness of an evaluative feeling, like or dislike, good, bad, disgust, admiration, about the character of or actions of a person without any conscious awareness of having gone through the steps of a search, weighing evidence, or inferring a conclusion, end quote. Such intuitions can be thought of as sort of a moral radar which scans the environment for a morally relevant stimuli and which typically bypass systems of higher level thinking. These intuitions then typically give rise to more robust moral emotions, the affect, which in turn provide the motivational force in triggering moral behaviors. Furthermore, intuitionists suggest that these moral behaviors are less like the duty bound, willed behavior of Immanuel Kant, and are more like the reflexive habituated virtues discussed by Aristotle in the virtue ethicists. In contrast to rationalist models, intuitionists suggest that it is these non-conscious moral intuitions and not reasoning that go on to trigger more judgments and further behaviors. And indeed, if reasoning is involved at all, it is usually after the fact to provide a post-talk explanation for one's moral decision making. Intuitionists would admit that while private reasoning can influence judgment under circumstances, such circumstances are both unusual and infrequent in their view. Perhaps one exception from the medical field might be the thoughtfully deliberative and reflective debates that occur on the ethics case conferences here at the University of Chicago. And yet in contrast, most of the daily decisions of the medical practitioner are of an entirely different nature, how to respond to a patient in crisis, when to slow down and spend time with the patient, when to speed up to manage the next crisis. These are fast, intuitive, relationship centered responses to patients and co-workers that occur rapidly and often without significant deliberate thought, at least on our words. Over the past 15 years, there has been a growing body of evidence to suggest that this intuitionist model explains a great deal of our moral decision making in practice. In the context of this rationalist intuitions debate, our colleague Michael Leffold has developed a moral intuitionist model for medical education. In this model, he suggests several practical implications, specifically for the teaching of medical ethics and professionalism. And this approach proposes that character development is best accomplished not so much by learning explicit rules and principles in the formal curricula. Rather, he argues that character development is best accomplished by tuning up moral intuitions, amplifying moral emotions, and strengthening moral virtues. And moral development of this sort calls for the immersion of persons in environments rich in exemplars and in narratives that embody the intuitions that persons wish to habituate. Applied to medical ethics and professionalism education, this would suggest that training programs might consider designing curricula and training experiences that intentionally target the activation and repetition of moral intuitions. This would likewise suggest that programs pay particular attention to the institutional culture in order to mitigate the insidious and often negative emotional experiences in the training environment, otherwise known as the hidden curriculum. The hidden curriculum is often perpetuated by negative role models that inhibit the experiences of positive moral emotions at work in their trainees. This would suggest that programs should consider designing practices and experiences that intentionally expose trainees to exemplars in an attempt to facilitate virtue mimesis. For example, some have argued for an educational model formation in which lives of service are created and sustained in intentional learning communities that link the lived experiences of mentors and learners with an interdisciplinary set of didactic materials. Schools which have adopted a similar model of moral formation tend to emphasize the use of narrative, the creation of a rich community of learners, both with faculty and students, and intentional reflective processes in a longitudinal curricula that foster an apprenticeship model of medical education, perhaps something similar to what's going on in Nepal. Having sketched the relevance of the rationalist intuitions debate for medical education, I therefore make the argument that this education could be enriched by the incorporation of theoretical insights and empirical findings from contemporary moral psychology. Future studies should establish the validity of this virtue-centered approach to ethics and professionals in education, and this research should explore whether character formation is indeed best accomplished by tuning up moral intuitions, amplifying moral emotions, and strengthening moral virtues. Such an approach posits that intuitions, emotions, and virtues, and not necessarily ethical principles and moral reasoning, are the central mechanisms of moral action, and therefore perhaps it could be the focus of education in medical ethics and professionalism in medical schools in the years to come. Thank you. Hi, Mary Mahowald. I guess I don't see your presentation, which I thank you for. It was very thorough and helpful, but I don't see it as an either or. Yes, I would agree. Neither do I see even both of those orientations as adequate to link between thinking and feeling, which I don't think are really separable in human beings, and action. Morality is action. Ethics is intellectual or cognitive. Teaching is a cognitive enterprise, and what really dawned on me as absent in both models is what we keep emphasizing as a community, autonomy. When I used to teach ethics even to undergraduates, sometimes I used to say, now look, you can ace this course and go out and be more of a moral scrounge than you used to be, because now you've thought about what you're doing and you choose to not do it or do it. So it seems to me either model. I guess maybe what I'm saying is maybe we can teach ethics, but we can't just teach morality or autonomy is the crucial link between what we think and feel and what we choose to do. Right. I would say I fully agree with you. I guess in some ways, when a dominant paradigm is sort of occupied by the educational curricula for many years, sometimes the other paradigm that tries to also offer critique tends to be overshadowing. But in any case, I would agree with you. In some ways, there are folks who are trying to bridge the two perspectives together rather than see it as either or, but at both end. I'm just curious about whether educators in their particular medical schools feel that a particular paradigm is sort of shaping their curricula. That would be interesting to know. I would guess that perhaps the rationalist paradigm tends to be at least historically shaping the curricula. But I would agree with you. I think in my clinical ethics training here, I felt like I was getting both perspectives. So that's just sort of something that I've been noticing. But I appreciate that observation. Yeah. Excuse me. Thanks for the clear articulation of the position. And I'm going to leave aside concerns I have about the idea that character is something stable people have because that's just assumed for the talks. I'll let it go. But my concern is actually about sort of even if we adopt the sort of Aristotelian character perspective, Aristotle is very clear about how moral education is important, which I think you're emphasizing. But he wants, he argues that it has to start at a young age, which is something I think we have lots of evidence for, is that in order for this character to develop, the moral education starts with the community at a very young age. And since we're talking about people who are in their 20s typically, by the time they're there, is there a question of, is it too late? That is, if the character hasn't been developed by then, is there even really an opportunity to develop character in this time span given where it sits in the life plan? And so, you know, I don't know, I guess I wonder how you'd respond to that. Well, you highlighted the, I guess the key holy grail question in medical education like this, you know, can character change in medical school? My reading of the literature is that there's sort of a general assumption that it doesn't change. So all we can do is sort of change professional behaviors, alter attitudes a bit, but not necessarily get at character. I don't, I'm curious to hear what other people think. Can adults change? I mean, is that an ethical question or is that from a different period of discipline that we should be talking about this, but. Hi, Dan Broadney, University of Chicago. John, thanks for a lovely talk. I think what puzzled me about it, and I just hoped you'd say more, is that I would have thought both Kant and Aristotle would be on the character side of the dichotomy, but they would have different visions of what a person of good character would be like. And this may have relevance to the previous question. For Kant, it would not, good character, although there's currently debate in the literature about this, but it was standardly thought that a Kantian person of good character doesn't require a set of affective characteristics, but does require a settled commitment of the reason to act out of respect for the moral law. And this is something that presumably could be done lightning fast. They don't need to go through each time a long bit of celebration. And what would count as a good character is someone whose will is of a certain kind and reliably always of a certain kind. Whereas Aristotle does demand something more robust in terms of having certain kinds of feelings, certain kinds of responses, and so forth. And so that's for him the difference between someone who is merely, as he puts it, continent and someone who's really virtuous. But each thinker is, in their different ways, focusing on the thought that what's crucial is to be a person of good character. And so I would sort of think that those who want to develop physicians of good character need to try to specify as the content of a good character what they mean by that. And that would go to the issue of whether what counts on this view of a good character is the sort of thing that can still be taught to 20-somethings. Well, since I would say everything that I know about Kant and Aristotle came from you, since you're my teacher, I'll just defer to that and appreciate that observation. Just to say that if I were to summarize maybe how I feel about the whole moral psychology literature, it seems to me that people are more likely to say that moral psychology, I mean, more reasoning can be taught to a certain extent, but more intuitions are more caught than taught. So I have like a hundred questions buzzing around in my head. I'm wondering about the role of larger narratives rather than the case studies in the kind of education you're talking about. And if I don't think Aristotle was this pessimistic about adults being changed, and that's probably the reason he spent so much time talking about friendship and things like that. But I wonder about things like not just mentors, but narrative display and how that would work out. And I'm also wondering about some of the thinking and virtue that emotions are actually themselves judgments of fact, or at least partially that that's partially what they are, it's their judgments of fact. And so that emotions are changeable, educational, educatable, because they are at least in part judgments about what's happening. And so that would at least suggest that adult education is possible, even if it's slower than childhood education. So I wonder about all that stuff, but I also would just wonder, does some of this then suggest that these criteria should be part of the mission process? That is that we're looking more seriously at the character of people who are admitting and the formability of their character. Those are good points. In terms of the admissions process, I don't think I would qualify to say whether emotional intelligence should be part of the admissions criteria, but I appreciate your thoughts. I'll probably have to talk to you afterwards in the conversation. Thank you very much.