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Volume 20, Number 3 1993

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Further Exploration of the Relationship between Veterinary Medical Education and Moral Development

D. J. Self
Departments of Humanities in Medicine, Philosophy and Pediatrics, College of Medicine
Texas A&M University, College Station, TX 77843-1114

D. C. Baldwin, Jr.
The American Medical Association, Chicago, IL 60610

F. D. Wolinsky
Department of Medicine
University of Indiana School of Medicine, Indianapolis, IN 46101


Introduction

A recent pilot study has indicated that the experience of veterinary medical education appears to inhibit moral development among veterinary medical students (1). As a result, increased attention needs to be given to the structure of veterinary medical education and the influence it has on veterinary students. Interest in ethics and moral reasoning has become widespread in many aspects of professional and public life. Generally, however, society has exhibited very little interest in the ethical issues confronting veterinarians. Although veterinary medicine involves many serious ethical dilemmas, they are not widely known to the public and have attracted little attention except for the issues of animal rights, animal welfare and the role of animals in medical research. It is rare for the mass media to mention the many other ethical dilemmas of veterinarians such as euthanasia of healthy pets, insurance conflicts of interest, grief management of clients over pet loss, truth-telling, confidentiality, dealing with impaired colleagues, and so forth.

The curriculum of veterinary medical education has paralleled and reflected this general societal lack of interest in veterinary ethics. While most schools of human medicine offer and frequently require course work in ethics (2, 3), fewer veterinary medical schools offer such courses, much less require them. This situation may partly account for the previous finding that the experience of veterinary medical education appears to inhibit moral development (4). The previous study, which was a pilot study with a small sample size of only 20 students, requires further substantiation. Clearly further research is needed to characterize and understand better the relationship of veterinary medical education to moral development.

Methods

The study consisted of comparisons of the levels of moral reasoning of entering first-year veterinary medical students with the levels of moral reasoning of these same students four years later, just before graduation at the end of their formal undergraduate veterinary medical curriculum. The students were recruited as volunteers with a minimal monetary incentive and appropriate informed consent. The project was approved by the Institutional Review Board. Since it was not a random sample of veterinary medical students, there is a potential bias of data being collected only from those students interested enough to be participants. However, the sample represented 47.5% of the students in that class and there is no reason to believe that they were not comparable to the other veterinary medical students.

The instrument used for both pre- and posttest measurement of moral reasoning was the Socio-moral Reflection Measure (SRM) of Gibbs (17). It is a paper and pencil written version of the original Moral Judgement Interview (MJI) of Kohlberg (18). The MJI consists of a 45-minute semistructured oral tape recorded interview in which subjects are asked to resolve a series of three moral dilemmas. Each dilemma is followed by a systematic set of open-ended probe questions designed to enable the subject to reveal the structure of logic of his or her moral reasoning. It was felt that using the MJI was not feasible due to the significantly larger amount of time and expense involved in administering and scoring it. Being group administrable and relatively inexpensive to score, the SRM enabled the study to incorporate a considerably larger group sample size than would otherwise have been the case. Furthermore, the SRM, like the MJI, still addresses the spontaneous generation of moral reasoning and justification rather than merely the recognition or preference of given moral reasons, such as is accomplished with the use of the Defining Issues Test (DIT) of Rest (19). Scores on the SRM range from a low of 100 to a high of 400 and are highly correlated to the 6 stages of moral reasoning found in Kohlberg's cognitive moral development theory.

Kohlberg's theory, which provides the theoretical basis for this study, has been described in summary and in detail elsewhere (20, 21). The following is a sketch of the theory. Kohlberg's theory posits six stages in the development of moral reasoning. Stage 1 defines right in terms of obedience to authority and avoiding punishment. Stage 2 presents right as serving one's own interests and allowing others to serve theirs. These first two stages form the preconventional level of moral reasoning. Stage 3 defines right action in terms of interpersonal relationships, involving concern for shared feelings and expectations, while Stage 4 sees right in terms of maintaining the social order by obeying the law and doing one's social duty. These middle two stages form the conventional level of moral reasoning. Stage 5 presents right in terms of basic rights and rules freely agreed upon by individuals and, finally, State 6 defines right in terms of self-chosen, abstract, universal ethical principles. These last two stages comprise the post-conventional or principled level of moral reasoning.

According to the theory, people proceed through these stages as they mature. The sequence is invariant, although the rate and end stage reached vary with the individual (22). The content of a moral position is irrelevant to the stage structure; that is, only the type of justification provided is used in assigning a stage score. It does not matter what position one holds on any given issue. Rather, what is important is why one holds it or how one supports it and with which reasons. Kohlberg's theory is not without its problems. It has been criticized and defended in the literature extensively, including from the feminist perspective by Gilligan and Noddings (23-27).

Results

A total of 68 students, 55.7% of the students of that class, were initially enrolled in the study. Complete moral reasoning data pre- and postveterinary medical education were obtained on 57 of the original 68 students representing a 16.2% sample loss. The analyses were limited to only the 57 students, representing 47.5% of the students of that class, for whom complete data were available. The moral reasoning SRM scores ranged between 250 and 400. Table 1 shows that the mean increase from first-year to fourth-year of 17.54 points was statistically significant at the p_.05 level for the SRM score (p_.01), the Global Stage Score (p_.01) and Modal Stage Score (p_.02). Analysis of this data seems to disconfirm the earlier finding that the experience of veterinary medical education appears to inhibit the increase in moral reasoning of veterinary medical students which would be expected in young adults of this age and education level.

Table 1. Statistics on SRM Moral Reasoning Data of Veterinary Medical Students.

  1st Year 4th Year Mean  
(N=57) Range Mean Range Mean Change t-value*
SRM Score 250-394 340.86 270-400 358.40 17.54 3.29
p_.0l
Global Stage Score 2.75-4.00 3.44 2.75-4.00 3.66 0.22 3.28
p_.01
Modal Stage Score 2.5-4.0 3.50 3.0-4.0 3.71 0.21 2.51
p_.02
*t-value computed using pooled estimate of common variance.

Discussion

The findings of this study are both interesting and disturbing. It is encouraging to find that after many years of considering moral reasoning and the development of values in veterinary medicine to be an intangible and unmeasurable part of the veterinary curriculum, it now appears that moral reasoning and development of values are objectively assessable like other parts of veterinary medical education. Also, if the findings of this study are accurate, it is encouraging to find that the experience of veterinary medical education is not necessarily accompanied by an arrest in the moral development of students as previously indicated by the pilot study. However, it is disturbing that the results of the 2 studies which were very similar in many ways have yielded such contradictory findings.

Several explanations might be given for why the findings here were so different from those of the previous pilot study. First, there is the difference in the sample size. This study (N=57) with a sample size roughly three times that of the pilot study (N=20) had a much better chance of detecting changes that occurred. In the pilot study with only 20 subjects in the sample, there was a relatively small chance of detecting a significant difference in the scores even if a difference were present.

Second, in this study a different instrument was used to assess the moral reasoning of the students. Although the SRM used in this study was derived from the MJI used in the previous study, there may be subtle differences that are not well understood or recognized between the two instruments even though they are both products of Kohlberg's cognitive moral development theory. The fact that the SRM is a written instrument may for practical reasons inhibit or limit the spontaneous generation of moral reasoning and justification. Clearly it is easier and faster to verbalize ideas than it is to write them down. This limitation may produce lesser quality data which could give inaccurate assessments. In the moral development research community it is widely believed that the original MJI gives the most accurate assessment of moral reasoning of any of the instruments currently available.

Finally, the difference in the findings of the two studies could simply reflect the fact that this second study was done on a different groups of students who come from a slightly different period of history Although there was only a few years difference in the time of the studies, recent years have been a time of rapid changes in public concerns about ethics and moral issues with much more public discussion about them. Perhaps these latter students and their faculty had simply become more aware of and sensitive to ethical issues which in turn influenced their moral reasoning scores. Certainly recent years have increasingly brought to public attention moral concerns over discrimination and prejudice.

It might also be worth noting that, like the previous study, this study found a narrowing of the range of moral reasoning scores as students go from the first year to the fourth year of their education. This tends to suggest that there is a powerful socializing influence which results in a homogenizing effect on the wider diversity that is seen at the beginning of veterinary medical education. This narrowing of the range of moral reasoning scores reflects a regression to the mean with higher scores coming down and lower scores coming up which suggests a squelching of uniqueness, creativity and individuality. This is not necessarily bad but should at least give one pause to reflect in light of the recent popular and widespread emphasis on multicultural diversity. Certainly additional work on the moral reasoning of veterinary medical students needs to be done using larger samples, students from different schools, and schools in different parts of the country.

Conclusion

This study describes an appropriate method for assessing the influence of veterinary medical education on the moral reasoning and development of veterinary students. It disconfirms the earlier findings of a similar pilot study which found that moral growth and development appeared to be inhibited in veterinary students during their experience of veterinary medical education. However, although the sample size in this study was larger than that of the pilot study, further investigation is still needed. Both the pilot study and the current study were done at the same institution which raises concern about the generalizability of the findings to other areas of the country. These findings need to be replicated by other studies in different settings using larger sample sizes, perhaps with a consortium of several schools. If they are confirmed, then their persuasiveness would be greatly strengthened. Also it would be gratifying to have these findings reinforced, since a similar study in human medicine has found that the experience of education in human medicine inhibits moral reasoning growth and development (28, 29).

Summary

In light of a recent pilot study which indicated that the experience of veterinary medical education appears to inhibit moral development, a study was undertaken to confirm or disconfirm that earlier finding. Using the Socio-moral Reflection Measure (SRM) of Gibbs, this study assessed the moral reasoning of 57 veterinary medical students (47.5% of the students in that class) at the beginning and again at the end of their veterinary medical education to determine if their moral reasoning scores would reflect the expected maturity-related increases usually found at this age range and educational level. The SRM scores ranged between 250 and 400. The mean increase from first-year to fourth-year of 17.54 points was statistically significant (p_.01). This study appeared to disconfirm the earlier finding that the experience of veterinary medical education may inhibit the increase in moral reasoning of veterinary medical students. Both the earlier pilot study and this current study were done at the same institution. Although this study represented nearly half of the students of that particular class, these findings indicated the need for other studies in different settings using larger sample sizes.

References and Endnotes

1. Self DJ, Schrader DE, Baldwin DC Jr, Root SK, Wolinsky FD, Shadduck JA: Study of the influence of veterinary medical education on the moral development of veterinary students. JAVMA 198:782-787, 1991.

2. Pellegrino ED and McElhinney TK: Teaching Ethics, the Humanities, and Human Values in Medical Schools: A Ten-year Overview. Washington, DC: Society of Health and Human Values. 1982.

3. Bickel J: Integrating Human Values Teaching Programs into Medical Students' Clinical Education. Washington, DC: Association of American Medical Colleges. 1986.

4. Self DJ, Schrader DE, Baldwin DC Jr, Root SK, Wolinsky FD, Shadduck JA: Study of the influence of veterinary medical education on the moral development of veterinary students. JAVMA 198:782-787, 1991.

5. Tannenbaum J: Veterinary Ethics. Baltimore: Williams & Wilkins. 1989.

6. Miller HB, Williams WH, (Eds): Ethics and Animals. Clifton, NJ: Human Press. 1983.

7. Rollin B: Animal Rights and Human Morality. Buffalo, NY: Prometheus Books. 1981.

8. Wilson JF, Rollins BE, Garbe JL: Law and Ethics of the Veterinary Profession. Yardley, PA: Priority Press. 1988.

9. Self DJ, Safford SK, Shelton GC: Comparison of the general moral reasoning of small animal veterinarians vs. large animal veterinarians. JAVMA 193:1509-1512, 1988.

10. Self DJ, Jecker NS, Baldwin DC Jr, Shadduck JA: Moral orientations of justice and care among veterinarians entering veterinary practice. JAVMA 199:569-573, 1991.

11. Self DJ, Wolinsky FD, Baldwin DC Jr: The effect of teaching medical ethics on medical students' moral reasoning. Acad Med 64(12):755-759, 1989.

12. Self DJ, Baldwin DC Jr, Wolinsky FD: Evaluation of teaching medical ethics by an assessment of moral reasoning. Med Educ 26:178-184, 1992.

13. Baldwin DC Jr, Daugherty SF, Self DJ: Changes in moral reasoning during medical school. Acad Med 66(9) supp:1-3, 1991.

14. Self DJ, Schrader DE, Baldwin DC Jr, Wolinsky FD: A pilot study of the relationship of medical education and moral development. Acad Med 66:629, 1991.

15. Sheehan J, Husted S, Candee D, Cook CD, Bargen M: Moral judgment as a predictor of clinical performance. Evaluation and the Health Professions 3:393-404, 1980.

16. Sheehan J, Candee D, Willms J, Donnelly J, Husted S: Structural equation models of moral reasoning and physician performance. Evaluation and the Health Professions 8:379-400, 1985.

17. Gibbs JC and Widaman KF: Social Intelligence: Measuring the Development of Sociomoral Reflection. Englewood Cliffs, NJ: Prentice-Hall Inc. 1982, pp 1-271.

18. Kohlberg L: Essays on Moral Development Vol II. The Psychology of Moral Development. San Francisco: Harper & Row, Publishers. 1984, pp 640-651.

19. Rest JR: Development in Judging Moral Issues. Minneapolis: University of Minnesota Press. 1979, pp 289-296.

20. Kohlberg L: Moral stages and moralization: the cognitive-developmental approach. In Lickona T (Ed): Moral Development and Behavior. New York: Holt and Rinehart and Winston. 1976, pp 31-53.

21. Kohlberg L: Stage and sequence: the cognitive-developmental approach to socialization. In Goslin D (Ed): Handbook of Socialization Theory and Research. Chicago: Rand McNally. 1969, pp 347-480.

22. Colby A and Kohlberg L: The Measurement of Moral Judgment Vol I. Theoretical Foundations and Research Validation. New York: Cambridge University Press. 1987. pp 77-117.

23. Modgil S and Modgil C (Eds): Lawrence Kohlberg: Consensus and Controversy. Philadelphia: The Falmer Press. 1985.

24. Reed TM: Developmental moral theory. Ethics 97:441-456, 1987.

25. Kurtines W and Grief EB: The development of moral thought: review and evaluation of Kohlberg's approach. Psychological Bulletin 81:453-470, 1974.

26. Gilligan C: In a Different Voice: Psychological Theory and Women's Development. Cambridge, MA: Harvard University Press. 1982.

27. Noddings N: Caring: A Feminine Approach to Ethics and Moral Education. Los Angeles: University of California Press. 1984.

28. Self DJ, Schrader DE, Baldwin DC Jr, Wolinsky FD: A pilot study of the relationship of medical education and moral development of medical students. Acad Med 66:629, 1991.

29. Self DJ, Schrader DE, Baldwin DC Jr, Wolinsky FD: Further evidence of the relationship between medical education and moral development. Social Science in Medicine. (Submitted to the editor.)

This project was funded in part by a grant from the American Medical Association whose generous support is gratefully acknowledged.

The scoring of the SRM protocols was expertly done by Mary Lou Arnold whose contribution is gratefully acknowledged and appreciated.


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