Bioethical Inquiry DOI 10.1007/s11673-014-9605-5
CRITICAL PERSPECTIVES
Teaching Corner: The Prospective Case Study A Pedagogical Innovation for Teaching Global Health Ethics Kearsley A. Stewart
Received: 3 August 2014 / Accepted: 9 September 2014 # Journal of Bioethical Inquiry Pty Ltd. 2015
Abstract Over the past decade, global health has emerged as one of the fastest growing academic programs in the United States. Ethics training is cited widely as an essential feature of U.S. global health programs, but generally it is not deeply integrated into the global health teaching and training curricula. A discussion about the pedagogy of teaching global health ethics is long overdue; to date, only a few papers specifically engage with pedagogy rather than competencies or content. This paper explores the value of case study pedagogy for a full-semester graduate course in global health ethics at an American university. I address some of the pedagogical challenges of teaching global health ethics through my innovative use of case study methodology—the Bprospective case study^ (PSC). Keywords Global health ethics . Pedagogy . Teaching . Prospective case study
Introduction Over the past decade, global health has emerged as one of the fastest growing academic programs in the United States (Merson and Chapman 2009). At all educational levels, from undergraduate liberal arts (Hill, Ainsworth, K. A. Stewart (*) Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, North Carolina 27708, USA e-mail:
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and Partap 2012) to postgraduate medical residency (Kerry et al. 2013; Khan et al. 2013) and increasingly in interdisciplinary classroom settings (Wipfli, Press, and Kuhn 2013), U.S. universities continue to build, and benefit from, their global health programming (Merson 2014). The bulk of published literature on teaching global health ethics focuses on establishing competencies for overseas short-term training for medical students (Crump, Sugarman, and WEIGHT 2010), developing online self-directed modules (DeCamp et al. 2013), and facilitating the institutional review board (IRB) process in the context of international, collaborative research between high-income countries (HIC) and low- and middle-income countries (LMIC) (although Yassi et al. 2013 is an excellent example of a new framework for global health IRBs). Ethics training is cited widely as an essential feature of U.S. global health programming, but generally it is not integrated deeply into global health teaching and training curricula (Cole et al. 2013). A discussion about the pedagogy of teaching global health ethics is long overdue; to date, only a few papers specifically engage with pedagogy rather than competencies or content (Hanson 2010; Dwyer 2011; Jackie et al. 2012; Cole et al. 2013). In a 2010 report, Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World, the Commission on Education of Health Professionals for the 21st century observed that the field of public health offered little consideration about why and how to teach public health (Frenk et al. 2010). The same lament is true for global health ethics (Stewart, Keusch, and Kleinman 2010).
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A graduate course in global health ethics shares one of the central objectives of most graduate courses in bioand medical ethics: Guide students to gain confidence applying their classroom study of a range of ethical values, principles, and theories to their future practices confronting the complex, iterative, and uncertain ethical challenges of improving human health. However, unlike biomedicine, the core skills for global and public health practitioners do not focus on the doctor–patient dyad but rather on understanding that the health of a single patient is enmeshed in a complex system of individual behaviors, family and community relationships, environmental surroundings, and economic limitations (Stewart 2008). Global health reaches beyond even public health to examine the deleterious effects of structural injustices on both individual and population health and to seek ways to change, or at least challenge, those injustices (see Battams and Matlin 2013 for a current and concise summary of the ongoing debate to define global health). In addition, graduate students in global health programs reflect the intellectual and career diversity that is a hallmark of the field: Some are practicing medicine, others are returning Peace Corps volunteers, a few want to train for a career in health policy or diplomacy. Rather than attempt another definition of the emerging field of global health ethics (see Stapleton et al. 2014 for a current perspective; see also two excellent textbooks by Benatar and Brock 2011 and Pinto and Upshur 2013), this paper will focus briefly on pedagogy specific to teaching global health ethics. My discussion reflects the context of a two-credit semester core course in global health ethics, required for all students enrolled in a two-year Master of Science in Global Health (MScGH) degree program at Duke University in preparation for a 10-week summer research experience. I outline the value of teaching global health ethics through case studies and, in particular, introduce my innovation in case study methodology—the Bprospective case study^ (PSC).
Pedagogies of Teaching and Learning Global Health Ethics More than the Bart,^ Bscience,^ or even Bcraft^ of teaching, pedagogy also can refer to learning: learning theories, learning styles, learning tools, etc. Cole et al. (2013) reviewed three pedagogical approaches that show promise for fostering good practice in global
health: transformative education, experiential learning, and critical pedagogy. Transformative education (Arnold et al. 1991) begins with an initial student experience, then moves to reflection, discovery, analysis, generalization, and future action based on the previous experience. Experiential learning is similar to transformative education but with a stronger emphasis on reflection about self and service to a community. Finally, Freire’s (1970) critical pedagogy emphasizes student reflection before beginning an academic or field experience in an effort to unmask and critique the assumptions, privilege, and power dynamics that enable student participation in such an experience. Neither transformative education nor experiential learning seem well suited to a graduate seminar on global health ethics whose main objective is to prepare students for summer field research. While Freire’s message is certainly central to teaching global health ethics, the prose can be offputting to some students. In developing my pedagogical approach to teaching global health ethics for graduate students, I focus instead on metacognition and fostering student ability to confront moral ambiguity in the context of ethical decision-making. In its 2000 landmark study, How People Learn: Brain, Mind, Experience, and School, the National Research Council synthesized decades of research into three key findings about learners and learning. The third key finding addressed metacognition (National Research Council 2000, 18), defined variously as the ability to think about one’s own thinking, to conduct selfassessment through self-reflection, to discover what you do not know while simultaneously recognizing when you are learning and deepening your own conceptual frameworks, or to adapt previous knowledge to new circumstances among other definitions (see Chick 2013 for an overview of the scholarship on metacognition). The bioethicist Dwyer, after many years of teaching bioethical principles and theories of justice, no longer leads students to parse the differences between Rawls, Singer, and Pogge. Instead, he focuses student learning on Bresponsibility and responsiveness^ to bring them closer to wrestling with Bthe breadth and depth of moral concern in the realm of global health^ (Dwyer 2011, 324). Dwyer’s approach spoke directly to the many conundrums I faced in my graduate classroom: Students attend my global health ethics course because they must, not because they freely choose to; most students do not know how, or have the patience, to read philosophy or ethical theory; and in most students’
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minds, ethics means studying medical error, egregious breeches of clinical trial protocols, and infamous cases such as the Tuskegee syphilis or Willowbrook hepatitis experiments. Finally, but perhaps most distressing of all, for the students, ethics education primarily signifies the fear and loathing of seeking IRB approval for their master’s projects. The challenge was evident immediately: How could I transform Dwyer’s Bresponsibility and responsiveness^ insights into a class that engaged some of the self-reflection central to all three of Cole et al.’s recommended pedagogies, was rooted in a metacognitive perspective rather than a selfimprovement approach, and emphasized global health ethics as an emerging field students actively defined through their innovative fieldwork? Equally important, the course needed to feature a productive assignment that genuinely and concretely strengthened each student’s project and advanced everyone toward IRB approval. I wanted to achieve all this without ceding one minute of my class to standardized, didactic research ethics and responsible conduct of research training materials. My solution was to rework the classic of medical ethics instruction—the case study.
The Prospective Case Study Assignment Teaching and learning with case studies is a fundamental feature of bioethics education. It also is a standard pedagogical tool for business, management, policy, and law programs. Case studies illustrate a specific issue and test students’ analysis skills. They are usually based on recent Breal-life^ examples or historical events with a focus on what not to do, rather than what to do. Cases for teaching also can be assembled to better illustrate a specific learning objective; the Christensen Center at the Harvard Business School is a pioneer in the case writing method for teaching. Currently, case study research is enjoying a renaissance. Recent, well-received papers have debunked some of the perceived weaknesses of case studies and case study research. Flyvberg (2006), Bitekine (2008), Tsang (2014), and Ketokivi and Choi (2014) all note that case study research can generate hypotheses, test and elaborate theories, and compensate for some of the shortcomings of general theoretical, context-independent (deductive) knowledge. Global health pedagogy reflects this revival of interest in case studies. Global health is frequently taught through case studies; one of the most popular global health textbooks in the United States is
organized around case studies (Skolnik 2012). Teaching global health research ethics is often case-focused as well (Cash et al. 2009). In addition, several alliances and organizations have developed significant web-based collections of global health cases for teaching (see, for example, the Center for Global Development,1 the Harvard Global Health Delivery Project,2 and Unite for Sight3). Despite this plethora of case study resources for teaching global health, few of these case studies engage ethics sufficiently to satisfy an ethicist. Of those that do raise ethical issues related to the case, it is generally around research ethics or challenges of international collaboration. Most importantly, they are nearly all retrospective; they look backward at what went wrong, not forward at what ethically needs to be done to make it right. They ask: What would you have done in this situation? I wanted to ask my students: Imagine all the possible ethical situations you may face, what will you do in each of these situations? The prospective case study (PCS) assignment (a 2,000-word analysis of anticipated ethical dilemmas for the summer master’s research projects) accounts for half of the course grade; the other half is based on weekly reflection papers about the assigned readings and on discussion participation. The PCS is composed of two distinct parts: (a) the 2,000-word written product and (b) a 20-minute NIH-style peer review panel of the PCS assignment. During the first third of the course, students read basic background materials defining bioethics, public health ethics, global health ethics, moral duties of researchers and participants, etc. The next third is devoted to reading global health case studies that I choose ad hoc to ensure that the entire class reads a case study that is related in some way to every project in the class. For example, in one recent cohort I needed to find case studies that were related to: the ethics of consenting children for HIV/AIDS research in Haiti; training rural Indian health care providers in an experimental medical device to detect cervical cancer; introducing a validated but novel and resource-intensive mental health intervention in Nepal; interviewing patients about neurosurgical outcomes in a public hospital in east Africa; interviewing noncitizen patients in the emergency department of a large public hospital in Qatar; taking blood samples to study interspecies disease transmission at a bonobo sanctuary in the 1
http://www.cgdev.org/page/case-studies. http://www.globalhealthdelivery.org/case-studies/. 3 http://www.uniteforsight.org/global-health-university/courses. 2
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Democratic Republic of the Congo; observing Egyptian health care workers who simultaneously work in the public and private sectors; and observing men who have sex with men cruising for partners in west-central China! During the final weeks of the course, each project is presented and discussed by a two- or three-student panel, in the style of an NIH peer-review panel (National Institutes of Health 2011). The panel review is the highlight of the class: Students are amazed to discover the range of topics and methods their peers are pursuing, plus they see the strengths and weaknesses of their own project in a fresh light by sitting and listening to a panel of their peers present their PCS to the class for a discussion. Each alternate week for two months, students submit one section of the five total sections in the PCS, thereby slowly developing a first draft: Week 1 Introduction: Describe your study. Week 3 General ethics background: Literature review of other similar cases that may apply to your specific case and which are critical for you to know. Week 5 Your case study: Identify potential problems and clearly discuss relevant issues. A decision tree might be helpful in exploring all possible options and outcomes. Plus, be sure to clearly distinguish and engage both themes: a) Your specific (potential) research ethics problems: What specific Responsible Conduct of Research (RCR) or research ethics guidelines are relevant? Are these issues rooted in your research design? Methods? Sampling strategy? Specimen collection? Intervention? Budget? History of previous work in the area? b) Broader, more general ethical and moral problems that you may encounter in the process of conducting your research. What are the (1) facts, (2) values, (3) principles, and (4) loyalties that describe your case? Do they come into conflict with each other? Week 7 Judgment/action plan/conclusion: Engage ethical theories, moral concepts, and principles to discuss all possible solutions, then defend your solution against obvious rebuttals and clarify your logic in choosing it Week 9 References; Appendix A: IRB; Appendix B … (if necessary): Maps, abbreviations, tables, figures, etc.
Students then submit a complete draft of their PCS to their peer-review panel. The panel has one week to analyze, critique, and improve the PCS. The peerreview panel works together to develop a critical but supportive and constructive analysis of the draft. The class presentation is about 15 minutes, plus five minutes for audience questions and panel and author responses. Panel members can consult directly with the author at any time to clarify information in the draft case study. During the panel presentation, the rest of the class is expected to pay close attention to the presentation and to write down a few comments and questions on paper. I instruct the audience to focus their questions and comments on clarifying points, omitted information, and suggestions for improvements to the case, not improvements to the presentation. All handwritten audience questions are submitted to the author at the end of the presentation.
Summary This paper briefly describes the rationale for, and the implementation of, the prospective case study assignment as a first step toward developing pedagogical innovations appropriate for teaching global health ethics at the master’s level in the United States. As developed here, in addition to standard didactic approaches to ethics education, the PCS introduces active learning, group work, peer instruction, and multiple opportunities for students to engage in self-reflection and become aware of their own learning (metacognition). Students leave the seminar with the sense that they not only spent an entire course strengthening their own projects but also did so in collaboration with their colleagues, the professor, and a body of ethics readings that now makes perfect sense to them and will serve as a confidencebuilding tool as they embark on their projects.
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