Abstract
Bioethics has increasingly become a standard part of medical school education and the training of healthcare professionals more generally. This is a promising development, as it has the potential to help future practitioners become more attentive to moral concerns and, perhaps, better moral reasoners. At the same time, there is growing recognition within bioethics that nonideal theory can play an important role in formulating normative recommendations. In this chapter we discuss what this shift toward nonideal theory means for ethical curricula within healthcare education. In particular, we contend that more attention to the particularities of historical and social context needs to be incorporated into bioethics training. To make this argument, we focus on two examples: teaching units on race and medicine and those that focus on stigma and coercion in mental health. For both, we show how a pedagogical approach in which educators focus on social injustice could influence how practitioners engage in ethics in the clinic. This chapter, then, demonstrates what a commitment to nonideal theory can mean practically when it comes to bioethics education.
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Notes
- 1.
The literature on bioethics education tends to focus on clinical ethics training in medical schools, and this chapter largely follows suit. But this discussion also has potential implications for research ethics, as well as ethics education in all of the allied health professions.
- 2.
To be clear, our primary interest here is in a particular application of principlism that does not allow for nuanced analysis. More recent versions of principlism that emphasize the method of “specification” are not necessarily vulnerable to this charge, in our view.
- 3.
Fiester’s argument is supported by the fact that the Accreditation Council for Graduate Medical Education (ACGME) outlines ethics standards that include a focus on exhibiting adherence to ethical principles: “Residence must demonstrate…an adherence to ethical principles” (ACGME 2017).
- 4.
There is some empirical support for the type of concern developed by Fiester. For example, focus groups of medical students reveal a general familiarity with ethical theory, although they also report difficulties putting such ideas into practice and request more training in practical ethics (Stites et al. 2018).
- 5.
A further consideration is the question of how exactly a robust and nuanced version of priniciplism should incorporate nonideal commitments. We do not pursue this broader theoretical project.
- 6.
More precisely: “…(1) everyone accepts and knows that the others accept the same principles of justice, and (2) the basic social institutions generally satisfy and are generally known to satisfy these principles” (Rawls 1971, 4).
- 7.
In principle, this allows for the reversal of ideal theory’s priority, given the possibility that starting from nonideal theory can help identify courses of action before an ideal conception is available and complete. For discussion of one such “anticipatory” approach to nonideal theory, see Sreenivasan (2012).
- 8.
Our usage of the term corresponds with contemporary trends and the literature on critical race theory (Hatch 2007).
- 9.
For further discussion of the ongoing debates surrounding these issues, see Glasgow et al. (2019).
- 10.
The presence of implicit biases in physicians and healthcare professionals is well-established (FitzGerald and Hurst 2017), although evidence of the influence of such biases on actual clinical decision-making and treatment recommendations remains equivocal (e.g. Oliver et al. 2014; Dehon et al. 2017).
- 11.
- 12.
Mental health stigma is a rapidly developing area of research, with a great deal of newly emerging evidence. For example, recent studies have shown that anti-stigma social marketing campaigns appear to increase the use of mental health services (Collins et al. 2019). In addition, anti-stigma initiatives for healthcare practitioners in low- and middle-income countries appear to benefit from strategies that emphasize social contact (Heim et al. 2020).
- 13.
This does not hold for outpatients subject to community mandated treatment (Molodynski et al. 2016).
- 14.
When involuntary patients are asked which values they prioritize, they tend to mention the following: freedom of choice, personal safety, and respect from staff (Valenti et al. 2014).
- 15.
More research is needed on advance statements and advance directives in psychiatry, especially given the challenges of implementation (Thornicroft and Henderson 2016).
- 16.
This includes the use of involuntary psychiatric treatment to suppress political mobilization in African American communities (Metzl 2010).
- 17.
There is also evidence suggesting that mental health practitioners’ perceptions of need for psychiatric treatment vary according to the race and ethnicity of patients (Breslau et al. 2017).
- 18.
It’s worth noting that others have also signaled the need for a similar form of progress in bioethics education. Perhaps the initiative with the clearest affinities places emphasis on building “structural competency” in healthcare practitioners, with the goal of improving clinical medicine through increased recognition of—and action on—social and economic conditions (Metzl and Hansen 2014). This has included innovative work on pre-health curricula in universities (Metzl and Petty 2017), as well as proposals aimed at training physicians (Hansen and Metzl 2017). There have also been calls for a similar approach in medical schools, including the recent development of a teaching guide that uses case-based analysis of structural inequalities and health disparities (Krishnan et al. 2019). All of this is part of a broader shift to expand training on the social determinants of health. Given that this shift is already underway, it could be a natural entrypoint for the incorporation of nonideal theory into bioethics education.
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We would like to thank Autumn Fiester and the editors, Elizabeth Victor and Laura K. Guidry-Grimes, for helpful comments on earlier versions of this chapter.
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Liebow, N., Cratsley, K. (2021). Bioethics Education and Nonideal Theory. In: Victor, E., Guidry-Grimes, L.K. (eds) Applying Nonideal Theory to Bioethics. Philosophy and Medicine, vol 139. Springer, Cham. https://doi.org/10.1007/978-3-030-72503-7_6
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