Changes in students' moral development during medical school: a cohort study

Abstract

Introduction: The requirements of professionalism and the expected qualities of medical staff, including high moral character, motivate institutions to care about the ethical development of students during their medical education. We assessed progress in moral reasoning in a cohort of medical students over the first 3 years of their education.

Methods: We invited all 92 medical students enrolled at the University of Sherbrooke, Que., to complete a questionnaire on moral reasoning at the start of their first year of medical school and at the end of their third year. We used the French version of Kohlberg's Moral Judgment Interview. Responses to the questionnaire were coded by stage of moral development, and weighted average scores were assigned according to frequency of use of each stage.

Results: Of the 92 medical students, 54 completed the questionnaire in the fall of the first year and again at the end of their third year. The average age of the students at the end of the third year was 21 years, and 79% of the students included in the study were women. Over the 3-year period, the stage of moral development did not change substantially (i.e., by more than half a stage) for 39 (72%) of the students, shifted to a lower stage for 7 (13%) and shifted to a higher stage for 8 (15%). The overall mean change in stage was not significant (from mean 3.46 in year 1 to 3.48 in year 3, p = 0.86); however, the overall mean change in weighted average scores showed a significant decline in moral development (p = 0.028).

Interpretation: Temporal variations in students' scores show a levelling process of their moral reasoning. This finding prompts us to ask whether a hidden curriculum exists in the structure of medical education that inhibits rather than facilitates the development of moral reasoning.

Fig. 1: Mean stage of moral development (top panel) and weighted average scores assigned to stages (bottom panel) in year 1 and year 3 of medical school among students at the University of Sherbrooke. Group 1 = students who had no substantial change in stage or weighted average score by year 3; group 2 = students who had an increase in stage or weighted average score by year 3; group 3 = students who had a decrease in stage or weighted average score by year 3.

Fig 2: Correlation between weighted average scores for stages of moral development at year 3 and weighted average scores at year 1 (r = –0.07).