AMA Journal of Ethics^®

Lowe M, Kerridge I, Bore M, Munro D, Powis D. Is it possible to assess the "ethics" of medical school applicant? J Med Ethics. 2001;27(6):404-408.

Grades, summer jobs, MCAT scores, applications, interviews, and a little luck. All steps on the way to admission to medical school. In theory, jumping through these hoops suggests that the applicant is prepared to learn how to be a physician. Success attests to perseverance, interest, and ability to learn the prerequisites for the scientific side of medicine. But is there something else we should be measuring in applicants? Ethical behavior is essential to the daily practice of medicine, so should we assess student readiness to learn the specifics of medical ethics? Should we deny medical training to applicants who hold opinions that are incompatible with the core values of medicine in order to keep those students from doing harm as doctors?

Michael Lowe and co-authors ask this question in a recent article "Is it Possible to Assess the 'Ethics' of Medical School Applicants"?¹ The authors react to the recent conviction of a British physician for the murder of 15 of his patients by asking whether there is a way that medical schools could have identified him as morally unfit to become a physician prior to medical school. In this way, certain people could be excluded from the profession "before they cause harm." The authors systematically address different possibilities for measuring student ethics. They reject assessing ethical reasoning, moral reasoning, individual opinions on specific issues, and the use of vignettes. The authors suggest that screening for character traits consistent with certain personality disorders is a reasonable step to take in medical school admissions. They conclude that ethics should be measured in aspiring students, but that instruments need to be better defined and carefully validated before being employed in the application process.

Lowe et al begin their discussion with two premises. First, they claim that "ethics is the study of what we ought to do." Next, they assert that there are 2 types of factors that contribute to ethical behavior: those that can be taught and those that are innate. The authors decide that only innate factors should be tested before medical school. Other factors such as knowledge base, communication skills, and professional competence skills can all be taught in medical school, and, thus, it is unfair to require that premedical students already possess them. The authors then turn to how innate factors can be defined and measured.

Reasoning is a factor that contributes to ethical behavior. Ethical reasoning is dismissed by the authors as a logic game. Testing it will not yield useful information because students who are good at logic can also score well on this test. Kohlberg laid out a concept of moral reasoning in his theory of moral development, and others have elaborated on the concept in the form of validated tests. It has also been found that moral development can be improved by instruction as evidenced by increased reasoning scores. An important tenet of Kohlberg's theory is that moral reasoning is independent of the moral decisions that are made as a result. Since reasoning is detached from action in this way, the authors assert that it is neither fair nor informative to test aspiring students on their moral reasoning skills.

Next, the authors address asking students about their individual beliefs on specific topics. Although the authors do not acknowledge this, it is a common practice of medical school interviewers to ask students about their opinions on certain topics in ethics. The authors do not think that applicants should be rejected because of their individual beliefs. Furthermore, they point out that unsophisticated beliefs should be expected from students who have not yet developed them through instruction and experience. Similarly, the authors reject testing students using a vignette because it tests a single issue and asks for post-hoc reasoning, which is not the same as making a decision in real time.

Finally, the authors address character traits as indicators of the virtues associated with medicine. They cite a list of descriptors used by physicians to describe inappropriate behavior and attitudes observed in medical students, which includes "selfish," "amoral," "rude," "aggressive," "rigid," and "judgmental." The authors draw a link between these descriptors and traits listed in the psychiatric diagnosis of personality disorders. Since there is an overlap between DSM-IV criteria and moral judgments, the authors reject the movement to keep the two separate and conclude, ". . . we believe it is entirely appropriate to use some of the tools of psychiatry to investigate morality. A logical place to start is to screen applicants with standard questionnaires for the diagnosis of personality disorders."

A closer look at the personalities involved in unethical behavior reveals narcissistic traits, general disinterest in ethical behavior that could be akin to antisocial personality disorder, and uncritical following of instructions from superiors. This final trait is not linked to a recognized personality disorder, but is described as problematic nonetheless. The authors admit that screening for antisocial traits among highly intelligent applicants could be difficult and low-yield. They also admit that some degree of narcissism is beneficial in some branches of medicine. They say that what they are really looking for is some sort of tendency toward exploitiveness and shamelessness that turns self-confidence into a dangerous pathology.

The authors believe there is a moral imperative to screen for potential serial killers among medical school applicants in order to keep them out of the profession. They demand that any selection measure used for applicants be empirically validated and stick to testing sensitivity to moral issues (not competency in teachable skills). They concede that there are difficulties in defining unethical behavior in a testable manner, but remain convinced that this is a necessary exercise for the profession.

While this article raises important concerns about the character and judgment of people admitted to medical school, it leaves us with some unsupported claims and no particular direction for resolving the challenges presented. The premise that some components of ethical behavior are innate is a strong claim to make if the authors cannot identify any descriptive or measurable factors that fit in this category other than personality disorders. The potential for a discrimination or disability lawsuit is high with this sort of categorization, and the authors offer us little reason for accepting it. While a link between unethical behavior and personality traits is interesting, the authors back away from a convincing connection between traits and psychiatric disorders. Furthermore, blurring the distinction between "mad" and "bad" is something that should not be done lightly; nor should it be characterized as an area of agreement within psychiatric circles.

The intent of the authors is noble and well-founded. The profession does have a responsibility to ensure that its trainees are the best suited for the job, and medicine should take action to avoid as much unethical behavior as possible. Perhaps an ethics entrance exam is not the best way to accomplish these goals.

Questions for Discussion

1. Should we measure the character or ethical aptitude of medical school applicants? Does the profession have a responsibility to screen for "unethicalness?" Would the data tell us anything?
2. The authors claim that certain components of ethical or unethical behavior are innate; that is, inborn. If this is true, would it be discriminatory to reject someone on the basis of "innate" qualities? Is unethical behavior a disability?
3. Why shouldn't applicants be rejected on the basis of their individual beliefs? If someone is unwilling to change a strongly held belief that is at odds with the core values of medicine, why shouldn't he or she be barred from entry to medical school? (Examples: doctors shouldn't prescribe medication to people in pain; certain ethnic, socioeconomic, or gender groups don't deserve medical care.)
4. Medical school interviewers often assess individual ethical or moral beliefs informally and unsystematically. Is this a sufficient way to screen for potentially unethical physicians?