The Health Professional Ethics Rubric: Practical
The Health Professional Ethics Rubric:Practical Assessment in Ethics Educationfor Health Professional SchoolsNathan Carlin, Cathy Rozmus, JeffreySpike, Irmgard Willcockson, WilliamSeifert, Cynthia Chappell, Pei-HsuanHsieh, Thomas Cole, et al.Journal of Academic EthicsISSN 1570-1727Volume 9Number 4J Acad Ethics (2011) 9:277-290DOI 10.1007/s10805-011-9146-z1 23
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Author's personal copyJ Acad Ethics (2011) 9:277–290DOI 10.1007/s10805-011-9146-zThe Health Professional Ethics Rubric: PracticalAssessment in Ethics Education for HealthProfessional SchoolsNathan Carlin & Cathy Rozmus & Jeffrey Spike & Irmgard Willcockson &William Seifert Jr & Cynthia Chappell & Pei-Hsuan Hsieh & Thomas Cole &Catherine Flaitz & Joan Engebretson & Rebecca Lunstroth & Charles Amos Jr &Bryant BoutwellPublished online: 26 August 2011# Springer Science Business Media B.V. 2011Abstract A barrier to the development and refinement of ethics education in and acrosshealth professional schools is that there is not an agreed upon instrument or method forassessment in ethics education. The most widely used ethics education assessmentinstrument is the Defining Issues Test (DIT) I & II. This instrument is not specific to thehealth professions. But it has been modified for use in, and influenced the development ofN. Carlin (*)Assistant Professor of Medical Humanities, McGovern Center for Humanities and Ethics,University of Texas Medical School at Houston, 6431 Fannin, Jesse Jones Library, Room 410, Houston,TX 77030, USAe-mail: Nathan.Carlin@uth.tmc.eduC. Rozmus : J. EngebretsonSchool of Nursing, UTHealth, Houston, TX, USAJ. Spike : T. Cole : B. BoutwellMcGovern Center for Humanities and Ethics, UTHealth, Houston, TX, USAI. WillcocksonSchool of Biomedical Informatics, UTHealth, Houston, TX, USAW. Seifert JrThe Graduate School of Biomedical Sciences, UTHealth, Houston, TX, USAC. ChappellSchool of Public Health, UTHealth, Houston, TX, USAP.-H. Hsieh : R. LunstrothMedical School, UTHealth, Houston, TX, USAC. FlaitzSchool of Dentistry, UTHealth, Houston, TX, USAC. Amos JrOffice of Institutional Quality Assurance, UTHealth, Houston, TX, USA
Author's personal copy278N. Carlin et al.other instruments in, the health professions. The DIT contains certain philosophicalassumptions (“Kohlbergian” or “neo-Kohlbergian”) that have been criticized in recentyears. It is also expensive for large institutions to use. The purpose of this article is to offera rubric—which the authors have named the Health Professional Ethics Rubric—for theassessment of several learning outcomes related to ethics education in health sciencecenters. This rubric is not open to the same philosophical critiques as the DIT and othersuch instruments. This rubric is also practical to use. This article includes the rubric beingadvocated, which was developed by faculty and administrators at a large academic healthscience center as a part of a campus-wide ethics education initiative. The process ofdeveloping the rubric is described, as well as certain limitations and plans for revision.Keywords Ethics . Ethics Education . Assessment . Rubric . Interprofessional . HealthProfessionalBackgroundThere is widespread agreement that ethics education is important in all of the healthprofessions (Stern 2006; Yarborough et al. 2000). There is less agreement, however,concerning the outcomes of ethics education in the health professions. Broadly speaking,the literature supports two alternative views on the goal of ethics education in the healthprofessions: 1) to create virtuous health care professionals in terms of behavior andintention; or 2) to equip health care professionals with a set of cognitive skills foranalyzing and resolving ethical dilemmas (Eckles et al. 2005). This article is concernedwith the latter.Many health professional schools provide formal ethics education to their students. Thistraining occurs in both didactic settings and clinical settings, sometimes as an individualcourse, or other times as a part of a larger course, such as an introduction to clinicalmedicine course. Because the field of bioethics only emerged in the 1970s, ethics coursesare often taught by faculty with a variety of backgrounds, many without degrees orsubstantial training in ethics, though there is no agreement on what this training shouldentail (Chambers 2006). Indeed, at the national meeting of the American Society forBioethics and Humanities in 2009, a panel was convened to address this very topic. In anycase, common methods for teaching ethics include requiring students to listen to lectures, toread relevant literature, to present cases with ethical dilemmas in small groups, or to roleplay in patient simulations (see, e.g., Fox et al. 1995). One way this training can beevaluated is by using instructor-created exams which include multiple choice questions orshort-answer questions. Another way is by tracking scores on national licensing exams inrelevant categories, such as ethics and professionalism. The purpose of this article is to offera practical means of assessment of ethics education in health professional education.Assessment of ethics education in the health professions is difficult, and relatively new, butif ethics education is not evaluated and shown to be effective, it can lose space in thecurriculum in favor of other clinical topics (Bertolami 2004).Literature on Evaluation Instruments in Ethics EducationWhile ethics education can be evaluated by examining cognitive or behavioral outcomes(Stern 2006), this article, as noted, focuses specifically on cognitive outcomes. Although a
Author's personal copyThe Health Professional Ethics Rubric: Practical Assessment279large number of instruments to evaluate ethics education exist, there are significantdifferences in technical design, target audience, goals, and instrument standardization andevaluation. Lynch et al. (2004) list forty-nine different instruments, of which nine wereassessed with respect to validity and reliability. However, only three have been widely usedin the health sciences. Four instruments have been created for and used within singlestudies, all of which were specific to medical students or physicians. Table 1 summarizesthe characteristics of five of these instruments, along with two used in generalundergraduate and graduate education as well as two other influential assessments.The most widely used instrument is the Defining Issues Test (DIT I and II), originallydeveloped by Rest (1979). Along with the Moral Judgment Interview (MJI) (Kohlberg1984; cf. Kohlberg 1981; Baldwin and Self 2006) and the Sociomoral Reflection Measure(SRM) (Gibbs and Widaman 1982), the DIT is situated in a particular philosophicaltradition, which might be called “Kohlbergian” or “neo-Kohlbergian” (Rest et al. 1999).This tradition has received a great deal of criticism, particularly from feminists (Gilligan1982), because some believe it inappropriately favors abstract impartial reasoning as thehighest form of moral reasoning as opposed to thinking about ethics as rooted in particularrelationships (MacDonald 2007). In other words, a particular way of thinking about ethicsis assumed, and perhaps unjustifiably so, and this way of thinking about ethics is embeddedin the DIT. Another critique of the DIT is that it is expensive for large institutions to use.For example, to use the DIT for 5,000 students the cost would be nearly 4,500 (see et/DIT%20price%20sheet.htm).In addition to philosophical assumptions about ethics, instruments also differ intheir design. Only one of the ten assessment methods listed in Table 1 is designed tobe an oral interview: The Moral Judgment Interview (MJI). All of the others are writtenevaluations. Written evaluation instruments use multiple choice questions, rankings, orrubrics to evaluate short-answer or essay responses. And all of these instruments usepre-determined case studies or vignettes to present ethical dilemmas to the students(see Table 1).Using rubrics has advantages that other assessment methods do not. Specifically, rubrics,unlike the DIT, do not necessarily privilege a particular way of thinking about ethics, butinstead evaluate the quality of a student’s response based on concrete criteria. Because, theAssociation of American Colleges and Universities (AACU) (2010) notes, “there are nostandardized tests for many of the essential outcomes of an undergraduate education,” theydeveloped fifteen rubrics to assess these outcomes. One of these rubrics is for ethicseducation assessment: the Ethical Reasoning VALUE Rubric. The AACU notes that it isdifficult, if not impossible, to assess whether or not students, after taking a given course orprogram, actually behave more ethically. But what can be assessed is whether or not theyhave the intellectual tools to think about ethical issues.The Ethical Reasoning VALUE Rubric evaluates five areas of ethical reasoning:&&&&&Ethical Self-Awareness,Ethical Issue Recognition,Understanding Different Ethical Perspective/Concepts,Application of Ethical Principles, andEvaluation of Different Ethical Perspectives/Concepts.In each of these areas, learning activities can be scored on a continuum of 1–4, 1 beingthe lowest (benchmark) and 4 being the highest (capstone). Scores of 2 or 3 are milestones.In each of the cells of the rubric, the authors of the rubric explain what would constitutesuch a score. (For details on this rubric, see http://www.aacu.org/value/rubrics/pdf/
Based on actual problems seen byCanadian family doctors,international panel of ethicists andfamily physicians validated scoring;Scenarios specific to clinicalspecialty; ethical reasoningNo6 cases with a selection of fivecourses of action and ranking ofreasonsPatient autonomy and patientwelfareFamily Doctors in Canada andUS, General Practitioners inEngland and WalesChristie Ethical DecisionMaking Questionnaire(Hoffmaster et al. 1991)Ethical reasoning style neutral, broad,not health professional specificYesAny work produced by studentsEthical awareness,organizational ethics,research ethics,Undergraduate and GraduateStudentsRubric for Ethics Audit /rubricethics.htmlEthical reasoning style neutral, nothealth professional specific, theorydrivenPrescribes ethical reasoning style, notuniversally accepted, mostfrequently used, potentiallyexpensive to usePrescribes ethical reasoning style, notuniversally accepted, not healthprofessional specificYesEthical Self-Awareness, Understanding different ethicalperspectives and concepts,Ethical issue recognition,Application of ethical perspectives and concepts,Evaluation of different ethical perspectives andconceptsUndergraduatesEthical Reasoning ValueRubric, AACU, AACUWebsiteNoPrescribes ethical reasoning style, notuniversally accepted, expensive toadminister and requires training toscore, not health professionalspecificCommentsAny work produced by studentsMoral development stageAdultsDefining Issues Test (DIT Iand II) (Rest 1979)Written version of MJI, free textresponsesNoRubric (Yes/No)NoMoral development stageAdultsSociomoral ReflectionMeasure (Gibbs andWidaman 1982)3 hypothetical moral dilemmaswith probing questions, oralAssessment Types6 moral dilemmas with 12 choicesfor action and justificationMoral development stageAdultsMoral judgment interview(Kohlberg 1984)TopicsAudienceName of Instrument (if any)and ReferenceTable 1 A comparison of ethics education evaluation methodsAuthor's personal copy280N. Carlin et al.
Ethical reasoningEthics and law knowledge,ethics self-efficacy, attitudetoward ethics educationMedical students rotating throughinternal medicine serviceFaculty and House OfficersHealth Professionals and HealthProfessional StudentsSiegler Assessment (Siegleret al. 1982)Sulmasy Questionnaire forHouse Officers (Sulmasy etal. 1995)Health Professional EthicsRubric (this paper)Critical thinking in ethicsEthical awareness and ethicalreasoningMedical StudentsSavulescu Ethics CompetenceTool (Savulescu et al. 1999)TopicsAudienceName of Instrument (if any)and ReferenceTable 1 (continued)YesNo21 MCQAny work produced byrespondentUnsureYesRubric (Yes/No)Several simulated cases, free textresponse to question6 vignettes, open-ended responseto question, scored using rubricAssessment TypesIterative by committee, inter- andintra-rater reliability; Ethicalreasoning style neutral, applicable toall health professionsReliability assessed, face validitythrough consultation with 2ethicists; Legal questions specific tolocationCases developed by faculty, scoringcreated post hoc; Scoringindependent of ethical reasoningstyle, not efficientVignettes, scoring criteria refinedthrough inter-rater reliability,content validity and test-retestreliability; Scoring partly prescribesethical reasoningprescribedCommentsAuthor's personal copyThe Health Professional Ethics Rubric: Practical Assessment281
Author's personal copy282N. Carlin et al.ethicalreasoning.pdf.) While the Ethical Reasoning VALUE Rubric was developed forgeneral undergraduate education, we developed a rubric more appropriate for healthprofessional education: The Health Professional Ethics Rubric. We began by identifyingwhat would be the ideal characteristics for a rubric for ethics education assessment in ourparticular context at an academic health science center.Characteristics of an Ideal Rubric for Ethics Education AssessmentIn order for an evaluation rubric to be adopted widely in health professional ethicseducation, we suggest that the rubric should have the following characteristics:1) while the rubric should be specific to the health sciences, it also should beapplicable to multiple health professions; 2) the rubric should not assume a particularstyle of ethical reasoning; 3) while ethical reflection necessarily has an essentialsubjective component, the rubric should introduce some measure of objectivity to theevaluation; 4) the rubric should be reliable and valid; 5) from a practical standpoint,the rubric should be short and easy to use—faculty should be able to use it withminimal training, and it should be easy to explain to students; 6) the implementation ofthe rubric should not place a heavy financial burden on institutions; and 7) the rubricshould be adaptable so it can be used for evaluating a variety of different studentproducts or activities. We believe that these characteristics should hold for othermethods of health professional ethics education evaluation as well, such as interviewsand checklists. The DIT, for example, does not fulfill several of these criteria, such ascriterion 2 and possibly criterion 6.The Health Professional Ethics RubricThe Health Professional Ethics Rubric (Table 2) is similar to the AACU EthicalReasoning VALUE Rubric. The Health Professional Ethics Rubric, however, wasdesigned specifically to fulfill the seven characteristics of an ideal rubric for ethicseducation assessment. While the two rubrics are similar, the Health Professional EthicsRubric was not derived from the AACU Ethical Reasoning VALUE Rubric and,moreover, was developed prior to the publication of the VALUE Rubric. The AACUEthical Reasoning VALUE Rubric is not suitable for our purposes because it seems to betheory-driven, as reflected in the order of areas to be evaluated in the AACU EthicalReasoning VALUE Rubric. A common difference between the teaching of ethics at theundergraduate level and the teaching of ethics in health professional schools is that ethicseducation in health professional schools tends to be cased-based rather than theory-driven(Carson 1986; Fox et al. 1995). The major difference between the Health ProfessionalEthics Rubric and that of the AACU is that the Health Professional Ethics Rubric learningoutcomes were derived from health professional literature (Beemsterboer 2010, pp. 88–89; Fletcher et al. 1997, p. 22 ff.; Shamoo and Resnik 2009, p. 34; Israel and Hay 2006,p. 132; Jennings et al. 2003), while the AACU Ethical Reasoning VALUE Rubric isrooted in committee work involving educators and administrators from undergraduateinstitutions.The Health Professional Ethics Rubric is being used as an assessment method in acampus-wide ethics program at our institution. We will describe its development and its
Author's personal copyThe Health Professional Ethics Rubric: Practical Assessment283application so that other institutions might be able to modify and to implement this rubric asa practical means of assessment.MethodThe Health Professional Ethics Rubric was developed by a committee comprised of facultyand administrators from all six schools of our academic health science center. To maintaingood inter-rater reliability (or consistent consensus), we decided to have three possiblescores (1 insufficient, 2 acceptable, and 3 proficient) for each learning outcome area:&&&&Identifies an Ethical Issue,Outlines Options for Addressing the Issue,Selects a Personal Action Plan, andIdentifies Professional Values Relevant to the Ethical Situation and Articulates theirRelevance.In each category, we list criteria for each possible score (see Table 2). The areas ofevaluation were derived from ethical reasoning models that are widely used among thehealth professions (Beemsterboer 2010, pp. 88–89; Fletcher et al. 1997, p. 22 ff.; Shamooand Resnik 2009, p. 34; Israel and Hay 2006, p. 132; Jennings et al. 2003) so as to establishTable 2 The health professional ethics rubric 2011 UTHealthOutcomeInsufficient (1)Acceptable (2)Proficient (3)Identifies anethical issueIdentification ofethical concernsis sparse ormissing.Identifies 2 of theethical concerns in acomplex situation.Fully describes multipleethical concerns in acomplex situation.Outlines optionsof addressingthe issueIdentification ofoptions is sparseor missing.Identifies 2 optionsfor addressing theissue.Fully describes multipleoptions for addressingthe issue.Personal actionDescription ofpersonal actionis sparse ormissing.Developed a realisticapproach/plan aboutaction in a complexsituation, missedsome minorconsiderations.Developed a realisticapproach/plan aboutaction in a complexsituation. Takesownership for action/decision.Able to identifyprofessionalvalues relevantto the ethicalsituation andable to articulaterelevanceIdentification ofprofessionalvalues is sparseor missing.The relevance ofthese values isnot articulated.Incorporatesprofessionalguidelines andapplies ethicalmodels or valuesto consideration ofalternative options.Recognizes thatalternate ethicalperspective resultsin differing options.Fully incorporatesprofessional guidelinesand applies ethicalmodels or values toconsideration ofalternative options.In choosing one option,recognizes that alternateethical perspectivesresult in differingoptions and is able toevaluate the merits ofthese differing options.Score
Author's personal copy284N. Carlin et al.face validity. Faculty with expert knowledge of health professional ethics also reviewed therubric to confirm face validity.The first use of the Health Professional Ethics Rubric involved a large survey that askedstudents to identify an ethical dilemma that they had encountered during their educationalprogram, how the issue could have been or was dealt with, which professional valuesinfluenced their thinking, and what the ideal course of action would have been in thatspecific situation. This survey entailed obtaining and using the rubric t
a practical means of assessment of ethics education in health professional education. Assessment of ethics education in the health professions is difficult, and relatively new, but if ethics education is not evaluated and shown to be effective, it can lose space in the curri
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