Reflection and self-evaluation
In medical training, students often feel worried by how well they can perform in front of their seniors and teachers and often feel distressed when receiving negative feedback (Good 1998). However, we found that students can also feel disturbed and distressed when they feel that their work or performance was not as well as they themselves expected in regard to patient care. They believe that they might have caused harm and contributed to poor outcomes of patients (Monrouxe 2012). This is also part of an ethical reflection related to one’s responsibility to others, in this case the patients and their families (Burns 2017). We believe it is important to give some space and opportunity for students to share such problems, in which they feel they might have been ethically responsible for the patient’s wellbeing (Gillam et al. 2014, Guillemin and Gillam 2015, de Zulueta 2015). Although it is not always easy to share feelings about such problems in a group, we think it is important for students to learn that having negative emotions of oneself, such as guilt and regret, is normal and can be a good sign of self-reflection and self-evaluation, which is part of the broad view in ethics education (Branch 2005). Moreover, other students might have similar experience and can support each other and learn from the experience as well.
In this first category, we found similarities between the two countries. During the group discussions, students in both settings rarely shared cases in which they felt they have not performed well enough. We suggest that there might be two reasons for this. First, students often feel uncomfortable admitting that they made mistakes or did something unethical in front of their peers and teachers (Good 1998). While during the interviews, students had more freedom and time to express their thoughts and emotions in a relaxed atmosphere to the interviewer, who is not part of the training system. Second, some students may have a higher sense of responsibility for patients than others, considering that as clerkship students, they are not yet responsible for patients. Results of our study also show that in both settings, reflection and self-evaluation have not yet been incorporated much into the learning activities of the ethics clerkship curriculum. Moreover, the group discussion is the only form of ethics teaching during clerkship in both schools, although it is conducted slightly more frequently in the Dutch setting.
Discussing unethical behavior of others
Previous studies have shown that at least 50% of medical students have witnessed unethical behavior from their seniors and teachers during clinical training (Imran et al. 2014, Kovatz and Shenkman 2008, Okoye, Nwachukwu, and Maduka-Okafor 2017). Unfortunately, we have not found any literature on experiences from Indonesian or Dutch medical students regarding this topic, although this does not mean that acts of unethical behavior do not occur or are more prevalent in either setting. Despite the large number of publications, there is limited discussion within those studies on what students thought and felt about their experience. It is clear however, from our study, that many Indonesian students shared negative feelings such as anger, disappointment, frustration, regret, and resentment due to their experiences of witnessing unethical behavior from their colleagues, seniors and teachers in their daily work. Our concern is that these negative emotions may lead to long term consequences such as emotional exhaustion and decreasing moral sensitivity (Monrouxe et al. 2015, Rushton 2017).
Cases of unethical behavior, in our study, were more often brought up by Indonesian students, both in interviews and group discussions. There are perhaps two reasons for this. First, there is a huge difference in terms of the health care system as well as the education system between the two countries, characterized by a more paternalistic system in Indonesia. This may lead to students feeling disturbed by healthcare workers perceived as behaving unethically, while patients, on the other hand, might feel that they are just being treated normally like other patients. Second, there is a difference in the organization of the group discussions between the Dutch and Indonesian setting. In the Dutch setting, students are given a set of criteria for the cases which leads to an ethical dilemma; while in the Indonesian setting, students were free to share any cases which they felt problematic, without any certain criteria. Cases of unethical behavior are often considered an ethical issue but not an ethical dilemma. Moreover, Dutch students have a mentor outside of their ethics education program, whom they can share their problems and concerns with, including problems about unethical behaviors of seniors. This might explain why there were less cases about this topic reported by Dutch students during the group discussions.
Working in a difficult/intrusive environment
In many countries, poverty and scarcity still provide the most difficult ethical challenges for health practitioners in their daily work (Olweny 1994) and “justice” is a difficult topic for ethics teachers to discuss with students. Today, medical students perhaps see this problem in a different perspective than their seniors. Since the emergence of bioethics education in medical schools worldwide, medical students are now “well equipped” with ethical principles and values. However, in situations where health care access and resources are one of the major issues, ethical principles such as autonomy and justice often become surreal and unrealistic for students, as described in our study. A number of Indonesian students expressed their concerns, that ethics teaching somehow becomes nonsense and useless (Bahasa Indonesia: “percuma” or “sia-sia”) in such an environment, referring to the fact that students can hardly do anything in such situations. Respecting patient’s autonomy become somewhat vague when patients actually do not have any, or limited, choices due to financial reasons and scarcity. At the same time, Dutch students hardly shared any emotional experiences on the topic of health care access and lack of resources. Hence, our study can perhaps contribute to the limited studies about students’ experiences in working in a rather intrusive system and difficult environment with limited resources.
From our study, we learned that clerkship students in the Indonesian setting had numerous tasks, such as performing routine follow-ups, monitoring patients and night shifts duty, to support the overload work of their supervisors. This is very different from the Dutch training system, where clerkship students only encounter a limited number of patients in their daily work, far less than the Indonesian. With the relatively small number of patients and clinical tasks, Dutch students have more time to discuss clinical cases thoroughly with their supervisors and also have more free time outside of their clinical clerkship. Moreover, students in the Indonesian setting shared feelings of exhaustion, of being overwhelmed and of powerlessness (Bahasa Indonesia: ‘pasrah’) concerning their workload in the hospital. During one of the interviews, an Indonesian student admitted that he is actually often unaware of ethical problems going on in the hospital due to his workload, both academic and clinical. Therefore, although he appreciated and enjoyed learning ethics during the bachelor phase, he had doubts if it had any benefit for their clerkship phase, not because it was irrelevant, but due to the fact that there is hardly any time and space for ethical reflection. Insights from our study suggests that assigning clerkship students with too many clinical tasks might cause harm, even if it can benefit students in enhancing their clinical skills and is needed for the sake of patients. Teachers and physicians working in academic hospitals should be aware of this problem and try to balance the risks and benefits for both students and patients.
It is also interesting to learn from our study that students have sometimes taken actions based on their own initiatives and moral values for the patient’s sake, despite their limited level of responsibility and the potential risks they bear as students towards their senior/superior. Whether or not students have taken any actions, such as not following orders or “bending the rules”, students in the Indonesian setting shared mixed feelings of doubts and uncertainties, worries and guilt, in regard to their own decisions. In many cases, students expressed feelings of relief after the group discussions, hearing similar experiences from their peers and receiving support from both peers and teachers for their efforts and courageous actions. Even though many students felt overwhelmed and simply accept the fact that they work in a hospital with limited resources, we believe that willingness from students to take such actions is a positive sign of moral resilience (Rushton 2017, Young and Rushton 2017). Although Rushton suggests that moral resilience is unlikely to flourish in environments that lack a culture of ethical practice, we suggest in contrary, that being in a rather intrusive environment and experiencing ethical challenges may trigger one’s need for moral resilience, as opposed to being in a rather ideal or non-intrusive environment where everything is ethically and systematically well organized.
Questioning and educating emotions
Students may have diverse opinions and emotions in dealing with disturbing cases, as shown in our study. Some might have negative emotions, while others can be indifferent or uncertain on how to respond. However, some students might also have positive emotions while the majority find it disturbing, such as the two cases in our study where one of the students was not disturbed by the doctor’s unprofessional behavior of being rude to patients, and another student feeling fine with doctors having special privilege in the hospital while it was unjust for other patients. In such cases, teachers might feel uncertain on how to respond to these situations, as they fear that their honest opinions may stop students from being open and willing to share their thoughts and emotions. At the same time, teachers might have the feeling that such positive emotions in disturbing cases might be “not right” and worrying, in regard to students’ sensitivity and moral development. Our question is whether we are allowed to question one’s emotion and if emotions can be educated. Cates, in reviewing Martha Nussbaum’s “Upheavals of Thoughts”, stated that “emotions have some relationship to thoughts, especially to beliefs and evaluative judgments, and they are appropriately subject to critical reflection and moral evaluation”. She also argues that some beliefs, which influence one’s emotions, are sometimes false, and that it is good to correct false beliefs (Cates 2003). Therefore, we suggest that teachers can indeed question students’ emotions and that it is possible to educate emotions. We believe that questioning one’s emotion is needed to clarify one’s beliefs and values, which is also an important step in the process of ethical deliberation.
In our study, there is a slight difference between the two settings with regard to how teachers facilitate the group discussions. Teachers in the Dutch setting used a more structured method compared to the Indonesian, which was more flexible and less structured. Therefore, teachers in the Indonesian setting had more opportunity to ask students how they felt after dealing with their ethical problems. However, students’ reasonings were often not explored or discussed further, and teachers sometimes seemed uncertain on how to respond to students’ emotional reactions. Gracia suggests that the role of teachers in this case should be neither “imperative” (indoctrinating values) nor purely “neutral” (value free). Rather, he proposes the so called “Socratic” or “deliberative” method, which emphasizes the practice of reasoning (Gracia 2016). Teachers should not judge the way students feel or think, but rather pose questions until the students themselves realize that what they feel, or think, is false. Differences in knowledge, experiences, and beliefs, indeed may cause different emotions among individuals. By guiding them through their reasonings, teachers can understand where the emotions are coming from and students can understand their own emotions as well as reflect on their own knowledge, beliefs and values. One might say that this brings ethics discussion or moral case deliberation too close to psychological guidance or even psychotherapy. However, we believe that the difference between the two lies on the main goal or purpose. In ethics teaching, the main goal should be the practice of moral reasoning while also dealing with emotions, and not to enhance or improve one’s mental health as in psychotherapy.