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Professional Character Formation
Dr. Shahram Yazdani
Virtue Ethics
• What today is called ‘‘virtue ethics,’’ or virtuebased ethics is the oldest philosophical
foundation for moral conduct. Its origins are
firmly rooted in the philosophies of Plato, and
Natural & Superanatural Virtues
• Aristotle’s ethics is an outcome oriented ethics.
The ‘‘end’’ aimed at is the good for man, a life
lived in conformity with reason whose end is
• Aristotle grouped these end-oriented character
traits in two classes:
– The moral virtues: Justice, fortitude and
– Intellectual virtues: philosophic wisdom,
understanding and practical wisdom
Aristotle’s ethics
• In Section 6 of Book II of the Nichomachean
Ethics, Aristotle puts it this way:
• “We may remark then that every excellence
both brings into good condition the thing of
which it is the excellence and makes the work
of that thing done well”
• Thus the virtues (the excellences) make the
physician a good man or woman, and make
them do their work of medicine well.
Aristotle’s Ethics And The Medical
1. The virtue of fidelity to the promise to put the primacy of
the patient’s well-being at the center of the relationship.
2. Honesty and truth-telling
3. Compassion, the ability to enter into the predicament of
each patient’s illness in all its social, personal and spiritual
4. Effacement of self interest, i.e. doing what is in the
patient’s best interests even when it involves loss of time,
money or extra effort on the physician’s part.
5. Courage, the willingness to defend the morally right
decision and action even when it means loss of social
6. Justice, to render to others what is owed to them
Virtue Ethics in Middle Ages
• Virtue ethics was enriched in the Middle Ages by the
infusion of moral teachings of the Christianity and
• Thomas Aquinas, added three ‘‘supernatural’’ virtues
of faith, hope and charity
• Its aim was not the formulation of rules, or guides for
action. It enunciated few principles, or obligations
directly mostly dealing with things which ought never
be done.
• Rather, moral guidance was provided by the model
behavior of good, or virtuous persons, those paradigm
persons each era respected.
Virtue Ethics after Enlightenment
• All of this dramatically changed in the
Enlightenment and Post-Enlightenment
periods in Europe.
• The Enlightenment ideal of a religion-free,
metaphysics-free ethic (i.e. free autonomous
rationality) turned the emphasis to principles,
duties, obligations and consequences as the
criteria for right and wrong, good and bad
human acts.
Virtue Ethics after Enlightenment
• While the reality of the moral agent could not
be totally eradicated from ethics, the virtues
were overshadowed by rights, duties, rules
and principles.
• Virtues were pushed further to the background of the moral life as ethics became
progressively secularized and the good was
defined in human rather than theistic terms.
There is a problem!
• Many patients, physicians and medical
educators are alarmed by the perception that
medicine is fast becoming
‘‘deprofessionalized,’’ with damaging results
to patient welfare and physician morale.
• By ‘‘deprofessionalization’’ they imply a loss of
certain attitudes, values and character traits
usually associated with the traditional idea of
a profession.
Arguments in the 1970s and 1980s
1. Values were well established by the time
students reached professional school (thus
little could be accomplished)
2. Teaching ethics was simply moralizing (which
had no place in a public institution)
3. Even if something could be accomplished,
faculty were ill equipped to teach
The Ethics Movement 1970s – 1980s
• In the early days of the movement, ethicists
had to argue for the importance of instruction
that focused on ethical reasoning.
• Some argued that ethics instruction needed to
attend to moral perception and moral
aspirations in addition to reasoning.
The Ethics Movement and Principalism
• In the early days, the predominant method for
resolving moral issues was the application of
principles (autonomy, nonmaleficence,
beneficence, and distributive justice) to the
resolution of dilemmas presented in condensed
case descriptions.
• It was not until the early 1990s that challenges to
principlism resulted in a rethinking of principled
approaches to resolving moral issues.
The Ethics Movement and Ethics of
New Technologies
• The ethics movement in medicine was
precipitated by technological advances that
posed difficult moral questions for patients
and families.
• Thus, the resurgence of ethics education in
medicine originated with challenging moral
problems in health care, rather than concerns
about the development of moral character.
Defining Character from the
Psychologist’s Perspective
• Webster’s New World Dictionary describes
character as
– ‘‘the pattern of behavior or personality
found in an individual or group; moral
constitution … moral strength; selfdiscipline, fortitude, etc.’’
The Components of Morality
• Beginning with the question ‘‘How does moral
behavior come about?’’ Rest (1982, 1983)
described four internal processes, each of
which must be activated for moral behavior to
1. Sensitivity
2. Reasoning
3. Motivation and commitment
4. Moral character and competence.
Ethical Sensitivity
• Moral sensitivity focuses on the interpretation of
a situation, the various actions that are available,
and how each action might affect the self and
• It involves imaginatively constructing possible
scenarios, knowing cause–consequence chains of
events in the real world, and having empathy and
role-taking skills.
• It includes knowing the regulations, codes and
norms of one’s profession, and recognizing when
they apply.
Ethical Sensitivity
• Methods for assessing ethical sensitivity, were first
developed in dentistry
– Dental Ethical Sensitivity Test (DEST, Forms A and B),
– Geriatric Dental Ethical Sensitivity Test (GDEST)
– Racial Ethical Sensitivity Test (REST)
• In measures where the construct is well-elicited, a drama is
presented consisting of an interaction between two or
more persons. The drama includes many clues to a moral or
ethical problem, but never offers any interpretation of the
• The challenge for the observer is to recognize that what is
exhibited is a significant problem, and that the professional
has a responsibility to do something aside from the normal
Ethical Sensitivity
• Ethical sensitivity measures classified as welldeveloped and validated demonstrate the
following psychometric properties: good
interrater reliability, acceptable internal
consistency, and test retest reliability, and
good Convergent and Divergent Validity
Ethical Reasoning and Judgment
• Once a person is aware that various lines of
action are possible, one must ask which line of
action is more morally justified.
Ethical Reasoning and Judgment
• The dilemma discussion technique and the
assessment of written essays
• The most familiar approach to assessing
reasoning in professional ethics courses is the
analysis of written arguments, typically
conducted by faculty with a background in
Ethical Reasoning and Judgment
• Researchers demonstrated that essays can be
reliably assessed and that instruction is
effective in promoting the ability to develop
well-reasoned essays, assuming that criteria
for judging the essays are specified in advance
of instruction and there are frequent
opportunities for practice with feedback.
Ethical Reasoning and Judgment
Life-Span Developmental Measures.
• Several measures of moral reasoning and
judgment have been devised:
– The Moral Judgment Interview,
– Gibb’s Socio-Moral Reflection,
– The Defining Issues Test
– Lind’s Moral Judgment Test.
– They vary in terms of the
• target populations for whom they are
designed (children vs. adolescents vs. adults)
Ethical Reasoning and Judgment
• The most widely used test for assessing adult development
is the Defining Issues Test (DIT)
• Similar to the Kohlberg interview, the DIT begins by
presenting the respondent with stories that highlight a
moral dilemma. But unlike the Kohlberg interview, in which
the respondent must produce a response, the task on the
DIT is to rate and then rank 12 short issue statements.
• In Action Choice, the respondent decides, on a 3-point
scale, what the protagonist ought to do.
• Then 12 items are presented and rated on a 5-point scale
(very important to not at all important) in which the
respondent is asked to rank the four items that best reflect
their Thinking About what the protagonist action
Ethical Reasoning and Judgment
• Profession-Specific Measures of Ethical Reasoning
and Judgment.
– Dental Ethical Reasoning and Judgment Test (DERJT)
– Medical Ethical Reasoning and Judgment Test
• The DERJT presents five common ethical
problems in dentistry. Respondents rate a list of
possible action choices and justifications and
then are asked to rank order the two best and the
two worst actions and the three best and the two
worst justifications.
Ethical Reasoning and Judgment
• Research using the DIT supported Kohlberg’s
claim that moral judgment developed rapidly
over the high school and college years
• A meta-analysis of studies of moral judgment
development in schools of medicine, dentistry,
and veterinary medicine (Bebeau, 2002)
shows such growth does not continue in the
absence of a well-validated ethics curriculum.
Moral Motivation and Identity
• Moral motivation and commitment involves
prioritizing moral values over other personal
• People have many values.
• Whether the individual gives priority to moral
concerns seems to be a function of how deeply
moral notions penetrate self-understanding,
• For behavior to occur, the moral agents must first
decide on a morally correct action when faced
with a dilemma, and then conclude that the self
is responsible for that action.
Moral Motivation and Identity
• Individuals move from self-centered
conceptions of identity through a number of
transitions, to a moral identity characterized
by the expectations of a ‘‘profession’’ – to put
the interests of others before the self, or to
subvert one’s own ambitions to the service of
society or to the nation.
Moral Motivation and Identity
Formation: Evolution
• The fully integrated moral self (one whose
personal and professional values are fully
integrated and consistently applied) tends not
to develop until midlife – if it develops at all
Moral Motivation and Identity
Formation: Measurement
• Interviews: Developmental assessments involve
semistructured interviews using the method detailed
by Lahey et al. (1988).
• A trained interviewer prompts respondents to recall
recent experiences in response to stimulus words
printed on an index card.
• The interviewer asks a series of follow-up questions to
elicit the respondents’ underlying understandings.
• Interviews are audiotaped and transcribed for scoring.
• As with conducting the interview, training is required to
score the interview and achieve interrater agreement.
Moral Character and Competence
• Moral character and competence is having the
strength of your convictions, having courage,
persisting, overcoming distractions and
obstacles, having implementing skills, and
having ego strength.
Moral Character and Competence
• A person may be sensitive to moral issues,
have good judgment, and prioritize moral
values; but if he or she is lacking in moral
character and competence, he or she may wilt
under pressure or fatigue, may not follow
through, may be distracted or discouraged,
and moral behavior will fail.
Moral Character and Competence
• Performance-based assessments are typically
used to assess the integrated abilities required
for effective, responsible professional practice.
• Certainly objective tests of personal styles or
personality traits can sometimes provide
insight about dimensions of character that the
individual needs to address to increase
personal effectiveness, but such measures lack
fidelity to professional practice.
Moral Character and Competence
• Objective Structured Clinical Examinations (OSCEs)
have been designed for ethics instruction that
approximate the kind of integrated performance
required for assessing ‘‘character and competence.’
• Communicating with a parent whose child’s health care
is being neglected, speaking to a patient about an
adverse outcome, confronting a peer or superior about
substandard performance, responding to a complaint
about your performance, achieving consent for
treatment from a patient with dementia, etc.
Moral Character and Competence
• Using real-life enactments of situations that
are likely to occur in practice, students are
required to plan strategies for handling the
case, try out dialog on a peer, then submit a
case write-up that includes (1) key facts and
their interpretation that influenced their plan
of action case; (2) an action plan; and (3)
verbatim dialog to illustrate how the action
plan can be implemented.
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