AMA Journal of Ethics^®

Abstract

The AMA Code of Medical Ethics offers ample guidance regarding professionalism, communication, and education in medicine. This article highlights opinions in the Code that exemplify obligations to promote social justice and equity in health care pedagogy and training.

Professionalism Qualities

Medical education is a critical component of training competent clinicians and necessitates going beyond teaching scientific and procedure-based preparation for health care practice. Critical pedagogy, as put forth by Paulo Freire’s Pedagogy of the Oppressed, is “problem-posing education” in which students explore conditions of inequity and challenge the status quo through collaborative dialogue and a shared praxis of justice and liberation.^1,2,3 The need for critical pedagogy and health justice studies in medical education has been recognized in the literature as important to supporting trainees’ capacities to respond with care to structural biases in the health sector.^2,3,4,5,6 Critical pedagogy in medical education requires teaching and learning about social, political, cultural, and environmental determinants of human health.³

Although there are examples of academic boundaries of medical education being pushed to provide more comprehensive and justice-driven service-learning experiences for medical trainees,^7,8 this approach is certainly not standard in training programs. The American Medical Association (AMA) Code of Medical Ethics provides guidance on physicians’ ethical obligations to be socially responsible and to advocate for health equity, thereby supporting the need for prioritizing critical pedagogy and social justice learning in medical education.

Professional Identity Formation

Opinion 8.13, “Physician Competence, Self-Assessment and Self-Awareness,” stipulates that education and training programs must teach and assess technical knowledge and skills and promotes a broad view of what it means to be competent. That is, competence “is fluid and dependent on context”⁹ and requires “habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served.”¹⁰ Being a competent physician, according to the AMA Code, means expressing one’s commitment to ongoing self-reflection, receptiveness to critical feedback, self-care, and attentiveness to factors—including nonclinical factors—that could compromise a patient’s best interest.⁹ Critical pedagogy nurtures students’ and trainees’ deep reflection about biases, for example, thereby facilitating their moral formation and preparation to consider social and structural causes of patients’ illness experiences.

Skill Development, Communication, and Team-Based Care

Problem-posing critical pedagogical models restructure physicians’ roles from “‘most responsible problem-solver’ to one [in which physicians are one] of multiple situated actors with insight and agency.”³ This approach and commitment to social justice and shared responsibility in health care is consistent with Opinion 10.8, “Collaborative Care,”¹¹ which encourages “open discussion of ethical and clinical concerns and foster[ing] a team culture in which each member’s opinion is heard and considered and team members share accountability for decisions and outcomes.”¹¹ Dialogue is essential to critical pedagogy, so uplifting all clinical team members is imperative. Opinion 10.8 also encourages physicians to challenge their institutions to address barriers to effective collaboration and to facilitate effective teamwork.¹¹

Cultural Humility and Health Equity

Advancement of equity in health care is an ethical imperative to be undertaken by all health care professionals. As stipulated in Opinion 8.5, “Disparities in Health Care,” physicians have responsibilities to mitigate inequity by serving disadvantaged populations and, in particular, by promoting “effective communication and trust by seeking to better understand factors that can influence patients’ health care decisions, such as cultural traditions, health beliefs and health literacy, language or other barriers to communication and fears or misperceptions about the health care system.”¹² Cultural humility and equity, as outlined in Opinion 8.5, mutually support compassionate, competent practice.

Physicians’ obligations to advance health equity and social justice are also articulated in the AMA’s Principles of Medical Ethics. Principle I describes the obligation to provide competent care “with compassion and respect for human dignity and rights,” which complements Principle VII’s description of an obligation to “participate in activities contributing to the improvement of the community and the betterment of public health.”¹³ Relatedly, Principle IX describes physicians’ duties to “support access to medical care for all people.”¹³ These principles inform and support critical pedagogical approaches to all health professions education.

Conclusion

Centering obligations to promote equity, critical dialogue, and cultural humility helps nourish social and clinical competency and patient-centered practice.^4,14 The AMA Code’s opinions support critical pedagogical approaches grounded in justice and equity that facilitate introspective professional formation, team collaboration, equity-based structural change in the health sector, and, ultimately, improved outcomes for patients and communities.