November 27, 2013

Cognitive-Moral Development in Pharmacy School

by Stephanie M. Callinan, Pharm.D., PGY1 Pharmacy Practice Resident, VA Maryland Health Care System

"I promise to devote myself to a lifetime of service to others through the profession of pharmacy. In fulfilling this vow:
  • I will consider the welfare of humanity and relief of suffering my primary concerns.
  • I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for my patients.
  • I will respect and protect all personal and health information entrusted to me.
  • I will accept the lifelong obligation to improve my professional knowledge and competence.
  • I will hold myself and my colleagues to the highest principles of our profession’s moral, ethical and legal conduct.
  • I will embrace and advocate changes that improve patient care.
  • I will utilize my knowledge, skills, experiences, and values to prepare the next generation of pharmacists.

I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.
-       American Pharmacists Association, “Oath of a Pharmacist”

During the commencement ceremony, the pharmacy school class in all their pride and joy recites the “Oath of a Pharmacist” as an affirmation of their dedication to serving others through the profession of pharmacy.  One of the key precepts of this oath is to uphold the highest “moral, ethical, and legal conduct.” Although appropriate ethical and legal principles can be taught in a classroom setting, what can we do as educators to “teach” moral behaviors? How can we insure that every student in that graduating class meets this requirement?

Cognitive-moral development is the process of developing one’s self-awareness regarding ethical and professional behaviors. The process of cognitive-moral development was first described by the great constructivist, Jean Piaget, who observed that children develop and enhance their knowledge through their personal and environmental interactions.1  The moral development process was further described by American psychologist Lawrence Kohlberg as six stages grouped into three levels: pre-conventional, conventional, and post-conventional morality.

Kohlberg’s Stages of Moral Development2
1. Pre-Conventional (Individual)
Person sees only right or wrong and is driven to complete tasks based upon rewards or avoiding punishments.

1. Obedience and punishment
2. Instrumental purpose and exchange
2. Conventional (Group)
Persons conform to social expectations/roles and respect authority as part of a team.

3. Interpersonal relationships
4. Maintenance of Social Order
3. Post-Conventional (Professional/ Institutional)
Persons adhere to institutional rules, however recognize that personal morals may conflict with these regulations.
5. Social contract and individual rights
6. Universal ethical principles

Kohlberg’s stages of moral development can be seen in the educational setting through these examples:
  • Individual: Bob always interrupts class to inject his own opinions. He is frequently seen arguing grades with the professor stating, “You didn’t tell us to study this for the exam!” He often competes with classmates to enhance his self-image.
  • Group: Susie is a listener; she respects the leader(s) in her group project and reflects on their suggestions to create her own recommendation(s). She actively implements changes based on feedback from her teachers.
  • Professional: Joe is a “B” student, involved in several committees, and volunteers his time in the community. He is able to prioritize his responsibilities, while also maintaining his grades.  Joe asks for feedback as he recognizes that he is not “perfect” and sets goals to improve.
As healthcare shifts to a team-based, patient-centered approach, techniques to mold “individual” students into “professional” students are crucial within pharmacy school curricula. A 1999 study that compared the moral reasoning skills of pharmacy students, pharmacy practitioners, and other professions (i.e. medicine, nursing, and law) found that pharmacy students and practitioners had a lower level of moral reasoning when compared to staff nurses, medical students, and law students.4 Although this data is somewhat dated, this is an alarming finding.  Are we, as educators, doing enough in pharmacy schools to promote high-level, post-conventional cognitive-moral reasoning?

A recent review suggests that cognitive-moral development in the classroom can be facilitated by problem-based learning, team (or group)-based learning, in-class discussion, and discussion of topics regarding moral or ethical decisions.5  By using these strategies, the educator adopts the role of a facilitator, instead of a lecturer or “expert.” Students are required to collaborate with peers, defend their recommendation(s) based on their own knowledge, and “experience” difficult ethical scenarios that occur in practice, but are rarely discussed within the pages of a book.  By having students develop and defend their decisions, they can improve individual-level moral reasoning skills by recognizing the “rules,” (group level) and begin to identify and plan for the exceptions to the rules (professional level).

Although cognitive-moral reasoning can be cultivated in the classroom, there is no substitute for practice and experience. As described by Piaget, moral reasoning is chiefly promoted through interactions with other people and the environment.  As pharmacists in a teaching environment, we must act as role models for pharmacy students — leading by example and holding students accountable, not only for patient care duties but other responsibilities too. Although literature in this area is sparse, some studies suggest the teacher-prompted personal reflection exercises can encourage moral growth.6,7 In my own experience, personal reflection encouraged me to ask for feedback on characteristics/skills which I would like to improve.

We can unknowingly impede our student’s cognitive-moral development by modeling “individual” level behaviors such as self-centeredness and black and white thinking (i.e. refusal to accept the validity of multiple answers). The ideal pharmacy preceptor should reflect on his/her own personal behaviors in order to model high moral character and assess their students’ level of moral reasoning.  Moreover, the ideal preceptor should implement practices that help student become true professionals, aware of the “rules” that should govern our conduct but also able to identify and sort through conflicts between the “rules” and what’s “the right thing to do” for patients and the society in which we live.

Think back on the students you have educated and precepted. What have you done to develop their moral reasoning? Have you inadvertently, at times, sent the wrong messages? What can you do to prevent this in the future? Addressing these questions is essential because you have an important role to play in your students’ cognitive moral development.  When you look at that graduating class each year, do you think we have prepared students to uphold the highest standards of “moral, ethical, and legal conduct?”  I’ll leave that question for you to answer.

1. Piaget, J. The moral judgment of the child. New York: The Free Press; 1965.
2. Moral development and moral education. In: Kohlberg, L. & Turiel, editors. Psychology and education practice. Upper Saddle River, NJ: E. Scott Foresman; 1971.
3. Duncan WC. Strategies for incorporating cognitive & moral development. PowerPoint presented at: 2013 AACP Teacher’s Seminar: Strategies for Effective Teaching and Learning. American Association of Colleges of Pharmacy Annual Meeting; 2013 July 13; Chicago, IL.
4. Latif DA and Berger BA. Cognitive moral development and clinical performance: implications for pharmacy education. Am J Pharm Educ. 1999;63(1):20-27.
5. Schuitema J, Ten Dam G, Veugelers W. Teaching strategies for moral education: a review. J Curric Stud 2007;40(1):69-89.
6. Vertress SM, Shuman AF, Fins JJ. Learning by doing: effectively incorporating ethics education into residency training. J Gen Intern Med 2013;28(4):578-82.
7. Daboval T, Moore GP, Ferretti E. How we teaching ethics and communication during a Canadian neonatal perinatal medicine residency: an interactive experience. Med Teach 2013;35(3):194-200.

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