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Holland Kaplan, MD, is an assistant professor in the Center for Medical Ethics and Health Policy and the Section of General Internal Medicine at Baylor College of Medicine in Houston. In this Q&A with Medscape Medical News, Kaplan discussed critical gaps in medical ethics education, challenges in teaching ethical reasoning, and how the field has evolved in response to recent developments in healthcare. The interview has been edited for length and clarity.

In your experience, what is the most important ethical issue that often gets overlooked in medical school curricula — and why does it matter in practice?

I think the most important ethical skill that is underemphasized or inadequately taught in medical school is being able to conduct thorough assessments of patients’ decision-making capacity. When physicians lack this ability, they are dependent on other physicians to make this assessment and may over- or under-involve patients in their own decision-making.

What’s one ethical gray area that students are often surprised by in clinical training? How do you guide them through it?

A topic that students find consistently challenging is the concept that it is often ethically appropriate and in line with principles of shared decision-making for a physician to make a medical recommendation to a patient. Our culture of clinical practice has become focused on respecting autonomy sometimes to a fault.

I have observed medical students and residents presenting patients with complex clinical options for advanced conditions without providing any guidance to the patient on how to choose between these options — the “menu” approach. While patients sometimes do want and need to make completely independent medical decisions without physician guidance, more often than not it is appropriate for a physician to guide a patient through the decision-making process and make a medical recommendation based on the patient’s values and the clinical situation.

What role should ethics play in preparing future physicians to address health disparities and systemic injustice?

Ethics education plays a central role in enabling future physicians to address health disparities and systemic injustice. A critical concept taught in medical school and in ethics courses is the importance of patient-centered care — care that respects the rights and preferences of patients to the extent possible. Often, one of the first hints that care is unjust or unequal is when individual patients’ rights and preferences are not being fully respected. Ethics education provides a framework and language for articulating how these injustices and inequities take place at a systemic level and how they can be addressed.

How do you evaluate whether a student has developed good ethical reasoning — not just memorized principles?

Assessing whether a student has developed sound ethical reasoning is quite challenging. I find that the best way to assess students’ ethical reasoning is through a dialogue in the clinical setting when they are taking care of patients. This can be done by asking questions about rote ethics knowledge, then asking the student to apply that knowledge to their patient’s case, and then asking probing questions about contingency scenarios. It can also be helpful to ask students how they would navigate specific aspects of challenging conversations with patients or families, as this often involves demonstrating the ability to elicit values.

How has the teaching of medical ethics changed in recent years?

The main way we’ve seen ethics education change is that the pass or fail grading and optional lectures have decreased student accountability to learn the material. While most students still engage meaningfully with the material, it has become more challenging to ensure that every student has achieved a bare minimum degree of competence in ethics during their medical education. Artificial intelligence has also made it more difficult to assess ethical reasoning via assigned essays.

If you could add one ethical topic to every med school curriculum that’s currently underrepresented, what would it be and why?

It would be education on the concept of “dual loyalties.” Physicians experience dual loyalties when their allegiance is strongly pulled toward something or someone other than their patient. There are settings where this is more likely to occur, such as when physicians practice in prisons or in the military. However, physicians’ loyalty in day-to-day practice can be pulled toward institutional policies, length-of-stay metrics, managed care organizations, and so forth. Medical students are not typically taught about this concept or how to navigate it.