Survey Says – You Know Less Than You Think You Do

Phillip Fernbach and his colleagues at the University of Colorado’s Leed’s School of Business conducted a study with interesting implications that may also be relevant to teaching medical ethics. In Fernbach’s study, people were asked to rate their positions on a scale of 1 to 7 (1 = strongly in favor to 7 = strongly opposed) to complex issues such as unilateral sanctions on Iran for its nuclear program, a cap-and-trade system for carbon emissions, and raising the retirement age for social security. Participants also rated their knowledge of each issue on a scale of 1 to 7. Next, they were asked to "describe all the details you know” on two randomly selected issues. Finally, participants were asked to rerate their knowledge on the same seven-point scale. The study showed that most people are unable to rationalize extreme political opinions, which, according to Fernbach, made them lower the ratings of their understanding and take less extreme positions.1

If the illusion of understanding can support extreme political positions, can an illusion of understanding support extreme moral positions? Even more important for teaching ethics and rational approaches for resolving medical dilemmas, can requiring students to explain their opinions result in lowering the ratings of their own understanding and taking less extreme positions on controversial bioethical issues? This is the question I explored, surveying the views and opinions of doctoral level students in a recent class on medical ethics and professionalism.

The first part of my survey required students to rate their own personal views on a seven-point Likert scale (1 = strongly in favor to 7 = strongly opposed) to each of the following complex issues in bioethics: 1) Abortion should remain legal, 2) Socialized medicine should be instituted in the U.S.A., 3) Doctors should be permitted to help terminally ill patients commit suicide, and 4) New drugs should be given to patients outside of clinical trials. Students also rated their knowledge of each of these issues on a scale of 1 to 7 (1 = very knowledgeable to 7 = very unknowledgeable). The next part of the survey required each student to elaborate on one randomly selected bioethical issue. After they finished writing, they were asked to re-rate their own understanding as well as their position on the issue.

Before reporting any earth-shattering revelations, I must stress that only 19 students participated in this very informal survey. Notwithstanding, statistical analysis of the responses from this small group agrees with Fernbach’s hypothesis. After explaining their positions, the group re-rated their knowledge an average of 0.90 points lower that what they initially thought it was. However, unlike the results of Fernbach’s study, my ethics students did not budge on their extreme positions. That is, they rated their positions the same after writing the explanations as they did before writing the explanations. Instead of spending the rest of this commentary defending the validity or reliability of the survey and any conclusions that might be made about ethics students in general, I want to focus on the insight I gained from the ratings and responses of individual students. These insights may help others who teach ethics to do the impossible – really teach ethics.

Just because a teacher might encourage self-reflection does not mean that the act of self-reflection will automatically lead to growth and development. Apparently, blind faith in extreme moral positions (e.g., rating yourself a 1 = strongly in favor or a 7 = strongly opposed) is stronger than blind faith in extreme political positions. Whereas political beliefs such as raising the retirement age for social security may change with self-reflection (and age!), morals form the very foundation of who we think we are. That is why you cannot change yourself just by wishing to change. You really need to allow yourself to become vulnerable in order to challenge your own beliefs. I once had a student post, "My beliefs are who I am. If I give them up, then what do I have left?” What you have left is an open mind to growth and development. You should only give up what you realize was misunderstood or unsubstantiated. Unquestioned values might make you feel safe, but you can make better choices based on truth. Without the ability to question and surrender misperceptions and unfounded biases, life becomes a string of knee-jerk reactions.

Our morals are influenced by the knowledge in our heads, and change or growth requires more than self-reflection – change requires vulnerability and the courage to put your own misconceptions on the chopping block. Self-reflection is the first step; next, you have to be willing to admit that your knowledge may be biased, insufficient, or incomplete – a work in progress.

An ethics class is a safe environment that can offer the perfect opportunity for students to practice vulnerability and learn how to separate the wheat from the chaff in their own minds. When you question and release opinions that are based on unsubstantiated beliefs, you are truly free to make decisions that are in your patient’s best interest. The methodology requires freeing your own mind of moral and cultural biases while trying to understand patient beliefs and behaviors in their local context. The denial of extremist positions may seem like a threat to religious and cultural beliefs that some say don’t need to be rationalized or explained. When one student explained her extreme position against physician assisted suicide, writing, "I am strongly opposed to permitting physician assisted suicide (PAS) because it is playing God. Only God can give and take a life,” she is suggesting that no more justification is necessary to support her position. To suggest that she needs to take a more moderate view may be misunderstood as a challenge to her religious beliefs, when in fact, it is an invitation to become vulnerable. Moral, religious, and cultural beliefs that are true will stand the test of scrutiny, but to refuse vulnerability is to limit your patient interactions to unsubstantiated, knee-jerk responses. There is more to each of the four issues on my impromptu survey than any single individual can possibly know. And even an expert, if she did some self-reflection, would realize that her explanation cannot cover all situations under all medical, personal, and contextual features. This realization provides the opportunity to admit that if I do not know as much as I thought, perhaps I should take a less extreme position.

It is possible to really teach ethics, but first you have to get students to free their minds and welcome vulnerability, which is just accepting the possibility that you may be wrong or simply not as informed as you think you are. My impromptu survey suggests that self-reflection may help us realize that we do not know as much as we thought, but it also suggests that self-reflection by itself is not enough to motivate growth and development - implying that it is much more difficult to free our minds of extreme moralism. In order to really teach ethics, we need to ask future health professionals, "Do you want to cling to unsubstantiated beliefs and dogmatic fanaticism and knee-jerk responses to your patient’s problems and concerns?” Taking students to this place, this realization through self-reflection, vulnerability, and surrender of unsubstantiated bias, is where teaching - really teaching ethics begins.

1. Mikulak, A. Extreme political attitudes may stem from an illusion of understanding. April 29, 2013 Press Release from the Association for Psychological Science. Available from http://www.psychologicalscience.org. Accessed June 19, 2013.


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