Use of casuistry in the process of teaching-learning of bioethics in health

Abstract

There are several bioethical models capable of contributing to decision making in health. The casuistic model works with the analysis of real cases for decision making regarding bioethical problems. It is conducted with 16 academic scholars from the health field with the objective of identifying academic experiences in the teaching-learning process of bioethics. It uses the case method, based on the casuistic model. It is a descriptive, qualitative study using thematic analysis, where two categories emerged: “the difficulty of practical application of paradigms and analogies in the casuistic model’’ and ‘’how the casuistic model facilitates the formation of ethical positioning and the decision making process’’. From the reported experiences, it is concluded that the casuistic model significantly contributes to decision making in bioethical issues and assists in the teaching- -learning process of bioethics during undergraduate study in the health field.

Bioethics; Health sciences; Decision making; Teaching; Teaching materials

Resumo

Existem vários modelos em bioética capazes de contribuir para tomada de decisão em saúde. O modelo da casuística trabalha com análise de casos reais para se tomar decisões diante de problemas bioéticos. Trata-se de estudo descritivo, qualitativo, a partir de análise temática, realizado com 16 acadêmicos da área de saúde com o objetivo de identificar suas experiências no processo de ensino-aprendizagem em bioética a partir do método de casos, fundamentado no modelo da casuística. Emergiram duas categorias: “o modelo da casuística como facilitador da formação do posicionamento ético e do processo de tomada de decisão” e “a dificuldade da aplicação prática dos paradigmas e analogias no modelo da casuística”. A partir das experiências relatadas, conclui-se que o modelo da casuística contribui significativamente para a tomada de decisão em problemas bioéticos, bem como auxilia o processo de ensino-aprendizagem de bioética durante a graduação na área da saúde.

Bioética; Ciências da saúde; Tomada de decisões; Ensino; Materiais de ensino

Resumen

Hay numerosos modelos de bioética capaces de contribuir a la toma de decisiones en salud. El modelo de la casuística trabaja con el análisis de casos reales para la toma de decisiones frente a las cuestiones de bioética. Este estudio tiene como objetivo identificar las experiencias académicas en el proceso de enseñanza-aprendizaje de bioética a partir del método de casos, con base en el modelo de la casuística. Se trata de estudio descriptivo y cualitativo, a partir del análisis temático, realizado con 16 académicos de la salud. Surgieron dos categorías: “el modelo de la casuística como un facilitador en la formación de la posición ética y el proceso de toma de decisiones’’ y “la dificultad de la aplicación práctica de los paradigmas y analogías en el modelo de la casuística”. A partir de los experimentos relatados, se concluye que el modelo de la muestra contribuye significativamente a la toma de decisiones en cuestiones de bioética y ayuda positivamente en el proceso de la enseñanza-aprendizaje de bioética durante la graduación en salud.

Bioética; Ciencias de la salud; Toma de decisiones; Enseñanza; Materiales de enseñanza

The growing variety of ethical and bioethical problems present in the health field intensifies the need to teach bioethics in college courses, especially those focused on this area. Future professionals must be able to link theoretical concepts learned in the classroom to professional practice in the field. Bioethics offers tools for this link, since the early study of bioethical problems helps students form ethical stances and consequently helps make decisions in real-life situations.

When faced with ethical problems commonly found in health services, the capability to make decisions collaborates for quality health care provision. Innumerous teaching models and methods contribute to the bioethics teaching-learning process and as a result, to the students forming their own ethical stances. However, since the area in question demands greater reflection and autonomy on the student’s part, the use of active methodologies in the teaching-learning process is gaining force.

In bioethics, the scholar’s teaching-learning process includes everything involved in thinking, acting and reacting to different professional situations with which he might be faced ¹. Present discussions consider the need to widen the teaching focus by expanding questions like “what I should and should not do” to the areas of moral reflections, formation of self-criticism and conscientious decisions, based on the value and dignity of the human being ². For this purpose, the teaching bodies must appropriate and search for more interactive educational tendencies, which take advantage of innovative teaching methodologies and resources ³. That is, the teaching of ethics needs to motivate reflections on values, culture and decision making in real context, from practical field experience ⁴.

Educational approaches and methodologies tailored to developing moral and ethical competency involve the scholar in an active manner, encouraging and allowing him to confront ideas and opinions, while also relating to real-life questions and problems. This type of organization seems more effective in moral formation than traditional lecture classes ⁵. Active methodology is an educational concept that looks to encourage critical-reflexive teaching-learning processes, wherein the scholar participates and become directly involved in his own learning. It is a method that creates teaching situations to establish critical approximation of the scholar to reality and reflection on challenging problems, in addition to providing assets to research problems and solutions, identifying and organizing hypothetical solutions more appropriate for the situation and ensuring the practical application of these solutions ⁶.

These methodologies also allow the scholar to be an agent of his own transformation, while capacitating him to detect ethical problems that come about in his day-to-day routine and to look for original, creative, responsible and prudent solutions. As such, small, interactive and participative groups are recommended, with approaches that are more practical than theoretical ⁷. It is known that reflection in groups, as well as dialogue and context recognition, contributes to building new paths, directed to integrating the theory with practice and teaching with learning, for example. It is also stressed that reflexive, critical and committed practice stimulate autonomy, freedom and dialogue, in addition to facing resistance and conflict ⁸.

The case method is an example of active methodology. Initially, it is important to note that the proximity existing between the terms “case method” and “case study” conceptually confuse those that are beginning their academic formation process. As such, we must clarify that the case method is an educational tool used, for example, to teach lawyers, jurists and business managers and likewise is not a research methodology, as seen in case study ⁹.

The casuistic ethical model may be used to apply the case method to teach undergraduate bioethics in the health field. This model analyzes real cases to make decisions in situations with ethical dilemmas. The casuistic model validated by Jonsen and Toulmin in 1988 analyzes ethical problems using equational procedures that are based on paradigmatic cases, analogies and opinions from those trained in the existence and severity of moral obligations in private situations. As a result, this model is characterized by ordering cases by paradigm and analogy, calling for maxims, analyzing circumstances, qualifying opinions, accumulating arguments and concluding with the ethical problem’s resolution.

Jonsen and Toulmin’s casuistic model embodies an appropriate method for hospital committees that must resolve matters of clinical ethics. In addition, it also contributes to teaching bioethics in health. The method presents itself as case taxonomy, that is, the case to be solved must be compared to paradigmatic cases already resolved to finally arrive at a probably resolution ¹⁰. Casuistry orders cases into topics by paradigm and analogy, wherein each topic must make reference to a principal. The topics arise from the definition of the key words and proceed with examples of cases, whose description includes the following questions: who, what, where, when, why, how and by what means. The topic’s first case works with the most obvious challenges, those that exemplify extreme violation of the principle. This emblematic case is the “paradigm”. The others, through analogy, retreat from the paradigm and introduce combinations of circumstances that make the affront less disagreeable ¹⁰.

To use the casuistic method, one must analyze the clinical case discovered as an ethical problem according to the following topics: medical indications, ill person’s preferences, quality of life and conjunctural aspects. Due to analyzing four topics, this procedure is also known as the four-box method ¹¹. It is important to stress that even though this study adopted the casuistic model as a reference, another model widely used is the principlist model by Beauchamp and Childress, which proposes the prima facie application of the principles of beneficence, nonmaleficence, autonomy and justice. The essential difference between the two models is found in the fact that in principlism, decisions are formed using pre-established principles, while decisions in casuistry stem from analyzing the case and the individuals involved.

The casuistic criticism of principlism stems from the fact that it rests on an elevated level of security, based on universal judgements, such that, from the casuistic point of view, the judgments should consider the sociocultural context of those involved, i.e. the individuality of the cases. Principlism is a popular approach because it is simple and viable, and its simplicity resides in the application of a stable set of ethical themes and concepts. However, this simplicity constitutes the principle limitation to the approach, since it does not consider the risk of leaving out a series of values and perspectives ¹².

Since casuistry first considers the cases and later the principles to make clinical bioethical decisions, the main method used in this study was the case method, more precisely the study of bioethical cases. First of all, this study justifies itself by the fact that it shows the contributions that the casuistic model may offer to scholars in the health field to make their decisions in situations involving bioethical problems. Furthermore, it is known that few studies in Brazil have assessed the use of active methodologies, like the case method, for teaching bioethics in undergraduate courses. Therefore, the objective of this study was to identify the experiences of scholars in the health field in the teaching-learning process in bioethics using the case method, based on the casuistic model.

Method

It is a descriptive study of a qualitative nature, developed on the campus of the Federal University of São João Del Rei. Through a qualitative approach, it is possible to extensively and deeply understand human behavior and its relationship to values, attitudes, feeling and beliefs ¹³. The study consisted of 16 scholars in the nursing, pharmacy and biochemistry courses, participants of the third cycle of activities of the campus’s Bioethics Teaching and Research Nucleus (NIBio). The nucleus’s meeting adopted the case methodology to teach and discuss bioethical problems, with the premise for decision making based on Jonsen and Toulmin’s casuistic model ¹¹.

The nucleus’s scholars participated in training on bioethics and the casuistic model during the initial meetings. In later meetings, they were divided into four groups, and each group received two different, real cases. One of the cases was the paradigmatic case, the one that presented the most obvious deviation from the principal, and the other, characterized as the case itself, was the one that still required a decision to be made. These cases approached the bioethical problem to be worked that day: for example, allocation of health resources, abortion, considerations about Jehovah’s witnesses, among others. The cases discussed were taken from a case book developed by the Regional Medical Council of São Paulo (Cremesp) ¹⁴.

The selection criteria for the participants were: 18 years of age or older, registered in the nucleus’s activities, have participated in the nucleus’s meetings from April to July of 2014 and give written consent to participate in the study. For transcription purposes, the interviewees were identified by the letter “A” (scholars) and the numbers 1 to 10, looking to ensure the confidentiality of the responses.

The data was collected using semi-structured interviews containing the following guidance questions: “what is your perception about the casuistic model for decision making?”; “what are the difficulties and facilities in using the case method for teaching?”. The reports were recorded and later transcribed in their entirety for analysis. The transcribed material was submitted to content analysis, under the topic analysis modality. For the analysis, the three steps proposed by Bardin were adopted in this study ¹⁵: 1) pre-analysis (scanned reading, corpus constitution, hypotheses formation); 2) exploration of the material; and 3) treatment and interpretation of the obtained results.

Results and discussion

Of the 16 scholars participating in the NIBIo activities, ten responded to the interview, and six did not meet the selection criteria. The average age was 22 years old, with a minimum age of 18 and a maximum of 31. There were eight females (80%) and two males (20%). With regard to the courses, five (50%) were in the nursing program, three (30%) the biochemistry program, one (10%) in the pharmacy program and one (10%) in the nursing masters’ program. During the analysis of the interviews, two topic categories arose: 1) the casuistic model as a facilitator in the formation of ethical stances and in the decision-making process; and 2) the difficulty in practical application of the paradigms and analogies in the casuistic model.

The casuistic model as a facilitator in the formation of ethical stances and for the decision-making process

This topic shows the importance of the joint assessment of the method and its contributions to the practice of teaching, in addition to its case-problem use. The dominance position of the interviewees as to the comprehension facilities that the method provides makes it clear that the use of casuistry is very relevant for better perception of the principles and values of each situation. The interviews include terms like humanization, care, valorization and solution, as follows:

“My perception is that this casuistic model is very important, because it allows us to see the situation from all angles, both from a judicial point of view, and the patient’s bioethical point of view, a form of humanization in patient care” (A3);

“Yes, I think it has a good base, which serves as an example for decision making and really helps because when faced with a problem, it helps build a solution, so that new errors are not repeated” (A10).

Note that the participants considered it important to have practical cases to compare to the situation that needed to be resolved. In this manner, the casuistic model facilitates the formation of ethical stances, since it stimulates the perception of principles and personal values in the decision making process:

“I found it different from what I am used to using, because I normally use the principlist model that is autonomy, beneficence, nonmaleficence and justice, and the casuistic model promotes the case more, because when you use a more principlistic model, you begin reading already thinking about what is there in those principles, you already read considering the principles” (A2);

“Casuistry promotes the situation more, so even though it is a problematic situation, in casuistry I found that each individual involved is important. You use the principles, but give more importance to the case, the stance of each individual within that situation” (A2).

In this topic, the reports are grouped together that remit to the comprehension of the casuistic model. This fact is due to the facility to visualize the ethical problem involved and the possible multi-disciplinary stances in the casuistic model, since it requires thorough assessment of the clinical case to make a better decision. The affirmation that the casuistic model is an important method for decision making is the predominant statement in the responses by the interviewees. As a result, we can consider the idea acceptable that the method reinforces moral-practical reasoning, comprehension of the relevance of the cases during each analysis and the attainment of a critical eye to arrive at the priority of the particularities of each one. From there, it is possible to respect the wishes and autonomy of the individuals, adjusting the patient care to the circumstances until arriving at the excellence of a solution ¹⁶.

As such, the teaching of bioethics in undergraduate courses is extremely relevant, since it lends theoretical basis and contact of the scholars with the reality of bioethical problems. It is also necessary to have professors with knowledge of bioethics, capable of contributing to the teaching-learning process of the scholars, and consequently for their maturing with respect to ethical competency. In a study ¹⁷ intended to assess existing methodologies for decision making in the clinical ethics realm, it became clear that each problem has a rational solution even if the process to reach it has many uncertainties. The complexity of the ethical decisions is in the fact that people may have different opinions, since each individual has his own perception about any ethical dilemma ¹⁷, even if we consider the conditioning influence of culture, social and physiological factors (gender, age, level of instruction, life circumstances and situation, health, etc.).

It is also appropriate to say that if human sickness and health and life in general of live beings are essentially complex realities and depend on inter-relationships, they shouldn’t be comprehended only using theories on technical objects. It then becomes necessary to stimulate and develop attitudes of ethical wisdom and insight, characteristic to casuistry. As such, the casuistic model reveals a method appropriate both to resolve ethical dilemmas implied in sickness, in health and in life in general ¹⁸, and to promote ethical reflection, as a process to become aware of the values that are involved in mere existence.

Observe that applying the casuistic model to the teaching-learning process in bioethics contributed to establishing ethical stances and making decisions when faced with bioethical problems in health care, according to analyses of the participants’ interviews. To that respect, it is important to note that the objective to integrate science and ethics in an educational configuration, through the adoption of active methodologies, allows scholars to begin to develop abilities for critical thinking and the necessary knowledge to identify and face the challenges of their professions ¹⁹.

This type of methodology may also contribute to the scholar’s own assessment system, who may measure his learning, recognizing it as knowledge constructed and incorporate it more easily, since it deals with a model that stimulates scholars and attitudes focused on the search for their own ethical responses ²⁰. To apply the causistic model in the teaching-learning process allows assessment of the abilities of the scholars in the decision-making process, in the development of their critical reasoning and in the application of moral and ethical precepts.

Just as it is important to assess the scholar’s performance, it is relevant that the teaching allow for reflection about various questions of professional practice, by showing values and principles that serve as “instruments” for critical thinking, for comprehension and decision-making when facing ethical challenges.

If educational strategies are restricted to the transmission of information and training abilities, critical thinking will not be thoroughly develope ⁴. The relevance for the use of the casuistic model in teaching bioethics is included in this context, and the scholars’ reasoning may be stimulated through this active methodology to facilitate decision-making.

The difficulty in practical application of the paradigms and analogies of the casuistic model

This topic presents accounts that refer to the fragilities of the practical application of the casuistic model. Most importantly, the main difficulty indicated by the participants relates to the selected paradigmatic cases. It is known, for example, that there are cases of different nationalities, which provoke conflict even from a judicial standpoint; that is, the legislation of each country influences decision making. The main difficulties faced by the participants in the use of the casuistic model are shown as follows:

“The difficulties are that you cannot always follow set parameters, since each case is different from the next” (A9);

“As to the difficulties, maybe there is a certain peculiar case where it may be difficult to compare to the paradigmatic cases, but I consider this very rare, and we always manage to use a method and reach the main objective, which is decision-making” (A6).

Note that interpretation, knowledge, comprehension and thorough analysis of analogies between the cases are precautions that should be taken in order to obtain the best ethical decision, taking into consideration mainly the patient’s quality of life and the context of the entire situation. Furthermore, many difficulties in the application of the method may be linked to the fact that the cases, despite being real, do not present all the information necessary to bring real-life situations to the classroom. This is because they only simulate fragmented contexts, allowing for several interpretations of the same problem. This may be overcome using cases that approach the scholars’ own experiences during their curricular activities.

In the teaching institution where this study was performed, this fact may still be easily overcome, since the students are inserted in the professional practice from the first periods of the course. It is important to also indicate that, through the participants’ reports, it was possible to note the existence of certain comparison between the principlist bioethical model and the casuistic model, as shown in the following excerpt:

“I thought using the casuistic model was more difficult than the principlist model that I was already used to using, and because you see the case is more complicated, you see who has more importance there, and in the principlist case you don’t. Like I said, you go to the principle and its already there, right? You already start to resolve it… but I found the casuistic model more difficult to understand, to search for a bioethical solution, but it is much more interesting because the situations are not all alike, right? The cases vary, so the casuistic model provides this independent of the situation, I manage to resolve the problem while promoting each individual” (A2).

The idea became evident that the study participants have more ability to apply the principlist model than the casuistic model. The claim to use principlism in an instinctive manner, while the casuistic model is still more challenging, especially since it’s a model that values reflection, to the contrary of the principlistic checklist. This facility to work with principlism may be related to the fact that many modifications were made to resolve criticism beginning with the first editions of the work “Biomedical ethics principles”, which is the fundamental basis of the principlistic model.

This criticism refers to the model as purely deductive and containing obligations, indicating the necessity to respect the proposed principles ²¹. However, it is believed that the weak points in general of the principlistic paradigm are the strong points of the casuistic model, and the strong points of considering principles are the negative aspects of case analysis ¹⁸.

In a study ²¹ whose objective was to explain the main similarities and differences between the principlistic and casualistic bioethical models, note that one of the characteristics of the casuistic model includes the difficulties themselves arising from existing paradigmatic cases not applying to the case under discussion. This fact should be resolved by choosing the paradigmatic case closest to the case under consideration. In other words, once there is no analogous case that clearly applies to the present case, one must rely on his own capability to choose the best option among those available. It is important to consider that, when dealing with the inexistence of paradigmatic cases for comparison, the decision making then becomes reference for future discussions ²¹.

The process of discussing and analyzing different principles and values of the cases and studying their intricacies and the reality of each one results in the emergence of multi-disciplinary stances, which will be responsible for indicating the best paths to choose and arguments to use in a determined situation. It is important to have a wider vision of the cases, from different points of view, since as soon as the different implications that may be caused by a certain decision are known, it is possible to reflect with more ownership the choices to be made.

Final considerations

Considering the main discussions raised in this study, it is believed that the casuistic model significantly and positively contributes to the teaching-learning process of bioethics during undergraduate courses in the health field, enabling future professionals to make decisions when faced with ethical problems. Note that some of the criticism cited by the scholars is relative to the method, requiring better comprehension and utilization to improve its use and avoid abuse. The use of the qualitative approach through semi-structured interviews allowed the scholars to clearly express their experiences with the casuistic model. This model contributes to discussion in the realm of teaching-learning of bioethics and makes the scholars take an active part in their learning.

Considering the importance of the scholar’s participation in the process of knowledge construction, especially bioethics, with the results of the study, the importance of using active methodologies in the teaching-learning process become very clear. That is, methodologies that present educational strategies which cause the students to reflect on real issues and cases during the student’s practical period and future professional practice.

However, especially with respect to the use of the casuistic method as active methodology, it is worth noting that there is a certain difficulty in finding paradigmatic cases. As such, it is suggested that, before using the casuistic model for teaching, a vast research and case selection be performed that better adapts to each context. In addition, it is important to offer the students study time intended for the conceptualization of the model.

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Publication Dates

• Publication in this collection
  Jan-Apr 2017

History

• Received
  7 Dec 2015
• Reviewed
  22 Sept 2016
• Accepted
  24 Nov 2016