Measuring Moral Courage

Intersecting Highways With Overpasses

By: William Martinez, MD, MS, assistant professor of medicine, Division of General Medicine and Public Health, Vanderbilt University Medical Center

An intern has scrubbed in for surgery for the first time since starting her residency. The surgeon she is working with is a nationally recognized expert in the treatment of breast cancer. The intern dutifully read about the operation and the patient’s condition the night before and introduced herself to the patient in the pre-operative area. As the first incision is being made, it appears to the intern that the surgeon is planning to perform a total mastectomy. However, from her reading of the chart and discussion with the patient, the intern was expecting a lumpectomy. The intern feels she should say something but does not want to embarrass the surgeon or herself (if she is wrong) and make a poor first impression, particularly because she is hoping to become a breast surgeon herself and is hoping for a good evaluation and recommendation from the surgeon.

All physicians face situations like this one that call for moral courage (i.e., the willingness to stand up for and act upon one’s moral convictions despite potential barriers or threats). Addressing an incompetent or impaired colleague, disclosing a medical error, and raising concerns about unethical or unsafe practices may challenge physicians to weigh what is right for patients and families against their own self-interest.

Medical educators have long recognized the need to produce physicians capable of facing these challenges and to cultivate moral courage among medical students and residents. Despite the importance of moral courage to medical practice, our ability to assess this essential virtue and to determine the impact of curricular interventions aimed at teaching moral courage have been limited, in part, by the lack of a valid and efficient tool for measuring moral courage among physicians.

In the hope of filling this void, my coauthors and I sought to develop a short, psychometrically sound, self-administered survey instrument to measure moral courage for physicians in the context of patient care (described in our recent Academic Medicine article). We believe our Moral Courage Scale for Physicians represents an important first step in measuring moral courage for physicians and will begin to allow researchers and educators to identify deficits, assess curricular interventions, and better understand the foundations of physician behavior.

In the end, we all want to ensure that the intern in this case speaks up about her concern and the patient receives the appropriate care. Our scale is an initial step toward ensuring that physicians are well equipped to meet the ethical challenges they face and are prepared to put virtue into action by acting in the best interest of their patients.

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