Narrative Approach to Ethics Education for Students without
Clinical Experience
M. Miyasaka, H. Yamanouchi, K. Dewa, and K. Sakurai
Department of Legal Medicine, Niigata University School of Medicine
The College of Biomedical Technology of Niigata University
1. Introduction
Medical ethics (ME) education is becoming one of the common features of medical
curricula in Japan.1 However, Japanese medical schools do not seem to share a generalempirical understanding about how ME should be taught. Case-based learning of ME isbecoming accepted by world-wide medical schools, but it is not clear how students shouldanalyze a case and reach to a judgment. This paper reports an application of narrative
approach to case-based ME education for Japanese students.
2. ME courses and learning strategies
・ME courses and students
Students of Niigata University School of Medicine are provided three courses in which ME
is instructed. In the first year, an elective course, “Iryou Rinri Gaku (Health Care Ethics),” isopened to both medical and non-medical students. “Houigaku (Legal Medicine)” in the
fourth year, and “Seimeirinri (Bioethics)” in the fifth year are compulsory courses formedical students. Clinical education at the medical school includes early medical exposure in
the first year, but the core clinical teachings are given in the fifth and sixth years, therefore,
most students who take part in the ME courses have little or no clinical experience.
・Learning strategies
One of the major goals of our ME education is to prepare students for ethical dilemmas,that can be met in daily clinical practice, therefore the case-based learning is thought to be
most desirable. However, the lack of clinical experience sometimes makes students feel acase as if “a play with cardboard characters,” in which they see no medical or psycho-socialreality. To evoke student’s imagination, we have developed what we call a “narrativeapproach” to learn ME. Fig 1 shows the general flow chart of this strategy. Prior to a caseanalysis, students are required to exchange their own life history regarding the core issues in
the case, such as “death and dying.” A case is presented not only in the form of vignette,
which has traditionally been used in textbooks2 and casebooks3 of bio-medical ethics, but also1

in the form of narrative. In the vignette, a case is briefly summarized as a factual report andwritten with objective sentences (Fig 2 a), but in the narrative, a case is a story composed of
personal narratives, collected and edited from diaries, letters, interviews of persons involvedin the case (Fig 2 b).
3. Performance of Students1 ） Principle-based analysis of cases in vignette
When cases are presented as a vignette, students showed relatively poor performance in thefollowing points.
Some students misunderstood medical or psycho-social facts involved in the case.

Many students could not attribute problems to conflicts between two or more ethicalprinciples.

Many students judged the case, not by logical reasoning based on the facts written in
the vignette, but from what he or she arbitrarily imagined (i.e. patient’s mental state).

2 ） Aid by narrative description
Narrative description of cases verified student’s performance in the following points.
Precise understanding of medical and psycho-social situation of the caseStudents rarely misunderstood the factual (medical, and psycho-social) situation
involved in the case. Patient’s condition was viewed not only from physician’sstandpoint, but also from patient’s and his or her family’s standpoints. Many students
reported that they could know how condition changed, and how each person perceivedit.

Imagination
Emotional response (i.e. “I was impressed very much,” “I almost shed a tear”) wasoften observed ---- this was not the case with vignettes. Students typically expressedcompassion for patient’s psychology, importance of family’s role, criticism onrelationship between doctor and patient or patient’s family,Relativization of his or her moral standpoint
Many students intentionally compared the viewpoint of their own and that of each
person involved in the case. Some students expressed psychological tension between
them. Some students felt uneasy when they have ambivalent standpoints, andcomplained about they could not reach a clear-cut solution. However, much more
students expressed thatthey should not impose their own standpoints to patients, and that the process ofdecision-making should be shared among medical staff and patients or their families.
2

“Heuristic” reasoning
Some students reported original frameworks or concepts which had not been instructedor suggested in the lecture. For example, a student analyzed who should tell the true
diagnosis about incurable cancer to patients using an original concept of “kodoku(solitude).”4. Discussion
The narrative approach to biomedical ethics presupposes that personal narrative iscentral to detailed case analysis in which ethical issues are embedded in the personal,historical, and social context. We have used this approach supplementing theprinciple-based approach, which is popular in bio-medical ethics, in teachingbioethics to students without clinical experience. Our experience suggests that theprinciple-based reasoning using simple vignettes is often hardly accomplished bystudents. However, the narrative approach was found to be useful since students can:1) gain more accurate and wider comprehension of medical and psycho-social aspectsof the case, 2) grasp the nature and the history of the conflicting views among persons
in the case, 3) find more easily any method for dealing with and settling problems,and 4) exchange viewpoints with patients and their family.
NoteThe term “narrative approach” is used here to designate learning strategies ofcase-based ME education, which focus on life history expressed by some forms of
personal narrative2-4.
References1.

Mlyasaka, M., Akabayashi, A., Kai, I., Ohi G. “An International Survey of Medical Ethics
Curricula in Asia ” Journal of Medical Ethics, 1999, in press.

2.

Brody, H. The four principles and narrative ethics. In. Gillon, R. ed.

Principles of healthcare ethics. Chichester: John Wiley and Sons Ltd. 1994; 207-215.
3.

Ellos, W.J. Some narrative methodologies for clinical ethics. Cambridge Quarterly ofHealthcare Ethics.

4.

7(3):315-22, 1998.

Tovey, P. Narrative and knowledge development in medical ethics. Journal ofMedical Ethics.

24(3):176-81, 1998.

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