Medical Educators Aren’t Just Whistling Ethics

Some people think it is impossible to teach ethics. “Either you are born ethical, or you are not,” they say. “Even if it could be taught,” others add, “distance education is not up to the rigors of mentoring and evaluating a student’s ethical development. The Internet is no replacement for face-to-face interaction.”

My doctoral thesis challenged these naysayers, showing how medical educators can teach ethics. The dissertation, “The Influence of Narrative in Fostering Affective Development of Medical Professionalism in an Online Class,” describes how Krathwohl’s 5-step taxonomy for affective development (Receiving, Responding, Valuing, Organizing, and Internalizing) can be used to foster emotional as well as cognitive intelligence.1

Whether in a traditional face-to-face classroom or in an online learning environment, the cognitive approach has been the predominant method for teaching ethics: “Define beneficence and use it in a sentence.” But the cognitive approach does not encourage students to question personal values that influence their own attitudes and behaviors. The goal of my doctoral study was to explore the impact of patient narratives (video, audio, and text-based stories of dealing with illness) on affective development, personal attitudes, and behavior. The results of the study, measured in terms of the Jefferson Scale of Physician Empathy (JSPE), suggest that ethics can be taught, and that it can be taught from a distance.2 And yet, when I say I teach ethics to online students, the running joke is still something like, “Yeah, and I can teach a dog to whistle – that doesn’t mean he’ll learn how to do it.”

According to Krathwohl’s taxonomy and the theory of “internalization” upon which it is based, affective development occurs when old values that fail to resolve a problem are replaced by new values that do. Teaching ethics and measuring affective development requires a safe learning environment with multiple opportunities for students to question and appraise personal beliefs and attitudes. This opens the door for internalizing new and improved values, effective tools that the student can use to resolve medical dilemmas, improve patient care, and live a meaningful life.

Patient narratives foster affective development and the internalization of ethical values because they create opportunities for empathy, compassion, self-reflection, and characterization of new values – in order to feel what it is like to “stand in the patient’s shoes.”

It is impossible to teach a dog to whistle (believe me, I googled it, and if anyone out there has taught a dog to whistle, it would be on Youtube). But teaching ethics is not like teaching a dog to whistle, nor is it simply whistling in the dark. Krathwohl’s taxonomy is one way to organize narratives and discussion forums, initiate online case study forums, and share patient narratives that catch the student’s attention (Receiving), promote discussion (Responding), identify options and alternate responses (Valuing), compare old with new values (Organization), and then, finally, adopt and demonstrate these new values (Internalization).

The use of multimedia narratives, organized to address each level of Krathwohl’s taxonomy is one way to teach ethics to online students. As for whistling, “You know how to whistle, don’t you? You just put your lips together and…blow.”3


  1. Krathwohl, DR, Bloom, BS, & Masia, BB. Taxonomy of educational objectives, the classification of educational goals. Handbook II: Affective domain. NY, NY: McKay; 1996.
  2. Hojat, M. Empathy in patient care: Antecedents, development, measurement, and outcomes. NY, NY: Springer; 2006.
  3. To have and have not. Warner Bros. 1944


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