articles about ethics in education

A Critical Evaluation of Educational Ethics

• Posted February 9, 2023
• By Ryan Nagelhout
• Moral, Civic, and Ethical Education
• Teachers and Teaching

Education is a field full of choices, and not just for students. Teachers, administrators, and parents are also faced with an endless array of decisions to weigh among an ever-changing educational landscape.

Navigating that landscape requires an understanding of the impact of those choices. Professor Meira Levinson knows that moral quandary well, both as an educator and researcher. Through the development of case studies, Levinson and her peers in the field of educational ethics have developed methods to evaluate situations where educators grapple with issues of inequality, morality, and uncertainty.

In recent years, Levinson has spearheaded EdEthics at HGSE, developing projects with the help of a number of collaborators. The latest is an online class launching this spring, Promoting Powerful Ethical Engagement with Normative Case Studies , co-taught by Levinson and doctoral student Ellis Reid , and co-designed by Sara O’Brien, Ed.M.'19; Ariana Zetlin, Ed.M.'20; and HGSE's Teaching and Learning Lab (TLL). EdEthics is also hosting a field-launching conference  at HGSE in May, designed to help build the field in a model similar to bioethics.

Below, Levinson discusses the growing field of educational ethics and how the new class and other projects will help expand the impact ethical thinking has in the classroom and beyond.

What is the goal of your new course, Promoting Powerful Ethical Engagement with Normative Case Studies?

I was most interested in creating opportunities for people to have complex conversations about the ethical dilemmas we faced in policy and practice. And yes, it is explicitly focused in areas of ongoing uncertainty where I don’t think there is a single, right answer. I think there may be wrong answers. And there are worse answers and better answers, so it’s not as if this is a stance that’s all about being relative, or everybody’s entitled to their own opinion. That’s not what’s going on here. And I think it can be useful to collectively discover or identify or explain wrong answers, right? But even once we say “oh well these are worse answers,” we still have a constellation of better answers.

We create solely around hard ethical choices where we ourselves do not know what the right answer is. And if we think that there is an answer, or the right way to see the problem, then we’ll write an article about it. And so that's actually been very useful as well. We don’t only write cases, we also write philosophical articles.

With EdEthics, part of what you are doing is framing long-standing educational issues within an ethical lens. How did you start approaching things in this way?

When I was an eighth-grade teacher, I faced lots of ethical questions in my work. Really, on a pretty daily basis trying to figure out what was the just thing to do. What was the right thing to do? What was the ethical thing to do? I was thinking about really basic questions like, I have kids with lots of different needs in front of me and I can’t fulfill all of them simultaneously, so how do I figure out whom to prioritize? And how? And why?

"I wanted to make it possible for HGSE students but also others out in the field, to have complex conversations about the ethical dimensions of our work in education and to recognize that ethics is central to what we do."

If I have a disruptive student in my room and it’s really annoying, in some ways, yes, they’re choosing to be disruptive. But they’re 13, they’re 14, right? We don’t want any of these choices that they’re making right now to have any impact on the shape of their lives. … But you also want to teach them a sense of responsibility, you want to teach them actions have consequences. You want to teach the other kids that actions have consequences. What they’re doing is disrupting the learning for the other kids. And so, you owe the other kids the opportunity to learn.

Answering those questions requires an understanding of a variety of issues and balancing the impact of multiple outcomes. How do educators gain the tools to help tackle these big questions in a productive way?

These really, really concrete questions were ones that I thought, well if anyone should have an answer to these from an ethical perspective, I should. I have a DPhil in political theory from Oxford. I wrote a dissertation about what the aims of education should be in a liberal democratic society and how we should achieve those. And I was just stuck.

I looked around and I could not find stuff that would answer my question. A lot of things had been written about what do you do when you have someone trying to pull out of a particular lesson. There’s lots of stuff about some very specific questions. But the day-to-day quotidian stuff of teaching? There just wasn’t much there except stuff that was really, really rule-bound. Stuff like, don’t steal the copy paper. Don’t sexually harass kids. And that’s true: don’t steal the copy paper, don’t harass kids. But that doesn’t help you figure out other stuff. The very concrete but also really big ethical questions. That was part of why I started the site Justice in Schools .

A lot of the case studies you’ve written seem to be about big problems that don’t really have clear solutions with lots of opinions on both sides. Why is it important to evaluate these issues critically?

When I finally came to the Ed School as a faculty member in 2007, I had a whole series of students come through my office and say, “Professor Levinson, we are so glad that you’re here. I believe in educating for social justice.” And I would say “Great!” And then they would think it was clear that by telling me they cared about social justice that they had also told me what their stance was on charter schools, on high-stakes standardized testing, on teacher accountability measures or value-added measures for teachers, on project-based learning — on lots of stuff that was being debated in 2007.

And I have no idea what they thought about those things, right? They could be a total advocate for charter schools because they believed in autonomy and in some kind of greater measures of local control. You could believe that these districts are failing kids and that these charters might be great. Or you could be totally against charters because you thought that schooling should be directed in a public and democratic way and you were worried about issues of equity. Students would come in with all kinds of these different views but it never occurs to them that the opposite view might also be an ethically held one that was actually driven by values. Or even by some of the same values.

Seeking answers to those questions, then, was one part of your goal at HGSE in developing EdEthics?

I wanted to make it possible for HGSE students but also others out in the field, to have complex conversations about the ethical dimensions of our work in education and to recognize that ethics is central to what we do.

Our work always has ethical balance, and also at the same time helps us understand that people whose policy prescriptions we might disagree with often are driven by values. It’s not that they are totally unethical, it’s not that they hate kids or are captured by the teachers’ unions or textbook lobby. They’re not rapacious, racist, or are necessarily defenders of the status quo. Sometimes that’s what’s going on, but oftentimes what’s going on is that people really care, deeply, about the values that they’re trying to live out in their daily life and they’re trying to put into practice.

HGSE has a very strong leadership focus and policy focus. Over time I became interested not only in the kind of quotidian, ethical dilemmas we face in the classroom as teachers but also the ethical dilemmas as you go up the scale — questions about what principals face, what do school boards face? What do curriculum developers and designers face? What do we think about the state legislature, things like that. So my interest in ethical question about education expanded that way too.

I’m curious how you select topics for case studies. Is the goal to find something universal to talk about with a wide variety of students? Is it more about recency and what’s newsworthy, or maybe just what you think could bring about the best discussion?

The Promoting Powerful Ethical Engagement course is focused on helping people learn how to write normative case studies for their own context. So in that respect, we don’t have any preconditions about what they write about. We want them to write about whatever dilemma feels most salient and important to them to address in their context. We do have a lot of guidance in the course about how to identify and evaluate dilemmas, so, what’s in the news can actually be really important. This online course actually comes out of a workshop that we held in the summer of 2021 with about 15 people from around the world who had used our normative case studies in their own work but they wanted to develop normative case studies that were more targeted to their own context thanks to support from Radcliffe through one of their accelerator workshops.

Being COVID times, we did this online. But it meant we had participants from Kenya, mainland China, Hong Kong, Australia, Germany, the United Kingdom, Canada. Mexico. All over. Many of these cases were very real-time dilemmas. For example, one team in Germany wrote about a social studies teacher trying to figure out how to deal with a student who’s been captivated by the German equivalent of QAnon. And who’s very smart and very passionate, and very well-spoken, and he can get on a roll in class and start spewing this stuff and the other kids are like “Oh, yeah, that makes sense. You’re right.” And she’s like, “No!.” So that’s a very of-the-moment case.

There’s another case in Kenya about a fairly recent requirement that students who graduate from primary school automatically get to go to secondary school, which is clearly really important for improving access and equity. But many kids board at these secondary schools because they’re too far away from their homes to be able to go on a daily basis. And these schools just don’t have the space, they don’t have the dorms. They don’t have the teachers, they don’t have the physical plan. And so she wrote a beautiful case about questions of access and opportunity and quality in trying to implement Kenya’s secondary school access curriculum. Other people who participated wrote about things that were somewhat more evergreen.

You’re written a lot about schooling amid the COVID-19 pandemic, which has had a huge impact on education. As an ethicist, is there anything to be learned when public consensus moves clearly away from ethical thinking?

COVID revealed to many people what experts in the field already knew, which is that our social safety net for children is very thin and full of gaping holes. And we just apparently aren’t willing to support kids in terms of their health, their nutrition, their mental health, their dental care, their learning, their housing. There are all sorts of ways where we don’t help as much as we should. And so in lots of ways, we just don’t value children, and that came out during COVID and has come out many times before and unfortunately will continue to come out.

But what about educational ethics? Well, given the lousy choices that we did make and have made and, unfortunately, look as though we’re going to continue to make, I think that is a reason to have ed ethics as a field that can speak up and have a broad array of people who have done the kind of thinking we need ahead of time so that when questions of public policy and practice come up and we have concerns we can have the tools to hand immediately to speak out about these things. So that’s one reason that it’s important to me to start a field of educational ethics so we have that kind of broad base of expertise and range of experts — this is not just about philosophers, it’s not just about historians, it’s not just legal experts, not just academics. It’s not just in the United States, it’s all over. We want people in all sorts of fields, in all sorts of positionalities who are able to talk about the ethical dimensions of the work and offer guidance about it in real time.

As we are able to develop educational ethics as a field, we will engage in more ethical behavior. It’s not only about hard problems. It’s also, in fact, about being able to say “This is an ongoing question. Let’s figure out what the best answer is to that question,” and have that at hand.

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(Disclosure: The author spoke at the conference described in this story as an invited panelist whose travel expenses were paid by Harvard University. The panel he served on is not featured in this story.)

From responding to public pressure over school mascots to navigating parent complaints about LGBTQ-themed library books, the staff of the 3,200-student Guilford, Conn., school district must confront a steady stream of ethical quandaries.

So, Superintendent Paul Freeman decided to call in the experts.

“It doesn’t matter if you’re an elementary teacher supervising indoor recess or a physics teacher at the high school, things will come up,” Freeman said earlier this month at a Harvard University conference intended to spur the formal establishment of a new field of educational ethics. “We were looking for somebody who could help teachers feel competent and confident in having these conversations.”

That person turned out to be Harvard political philosopher Meira Levinson , the driving force behind the effort to help schools better manage vexing situations in which it’s impossible to satisfy everyone’s wishes without compromising someone’s core values. The goal is less about giving recommendations than encouraging thoughtful deliberation around general principles that can be applied to real-life situations as they arise.

Professionals in numerous other fields work with ethics experts in such a manner. During the height of the COVID-19 pandemic, for example, hospitals and public health agencies had bioethicists on call as they worked through wrenching decisions about allocating ventilators and distributing finite supplies of vaccines. In the K-12 world, however, school boards, superintendents, and state education leaders were often on their own when making similarly tough calls about reopening schools and requiring masks—not to mention confronting a raft of other concerns around everything from bathroom access to artificial intelligence.

The barriers to Levinson’s vision are numerous. At the Harvard conference, for example, historian Jarvis Givens questioned whether any widely agreed-upon ethical principles are possible in a nation where many states criminalized teaching and learning in Black communities for decades, resulting in alternate visions of what’s right and just that are sometimes at odds with the priorities of existing school systems. The leadership of the nonprofit American Principles Project, meanwhile, told Education Week that any effort toward a field of educational ethics would need to prioritize parental perspectives and respect conservative moral values in order to gain widespread support.

With public education now such a hot-button political issue, many key stakeholders are also more interested in imposing their own preferred solutions than in seeking consensus. And Superintendent Freeman, Boston Teachers Union President Jessica Tang, and New York City special education student support lead Khalya Hopkins were among the K-12 practitioners at the Harvard conference who raised practical questions around everything from staffing to funding.

Still, Levinson is convinced that an ethical lens can be a powerful tool for educators in the hot seat.

“We need to be honest about the complexity of these decisions,” she said.

The value of studying realistic ethical dilemmas

The most important tools used by educational ethicists are called “normative case studies.”

These short write-ups describe realistic situations in which relatable protagonists must navigate moral gray areas. Trained facilitators then lead discussions designed to help participants consider the situation from every angle. So far, Levinson and her team have developed roughly four dozen such case studies. Many are available online .

One scenario featured at the conference is called “Talking Out of Turn.” It explores the complexities of political speech in schools through the stories of real-life educators including David Roberts, a substitute teacher in California who was banned from subbing at Clovis West High School after wearing a Black Lives Matter pin at school, and Tim Latham, a history and government teacher in Lawrence, Kan., who claimed his contract was not renewed because he’d criticized presidential candidate Barack Obama in class and because he maintained a website containing patriotic and military material.

Inside a Harvard classroom, a mix of college professors and K-12 educators drew easy connections between the details of the case study and their own fraught experiences planning social studies curricula and responding to colleagues who refuse to use students’ chosen pronouns.

Much of their dialogue focused on identifying underlying themes, such as the tensions inherent in protecting rights of teachers who are politically out of step with the communities in which they work.

That’s what educational ethics aims for, Levinson told the conference attendees, saying that educators need to be prepared in advance with an “ethical repertoire” they can lean on in the heat of the moment.

“The same way you might say, ‘This calls for a turn-and-talk, but that calls for a small-group discussion,’ teachers should have a set of ethical options already in mind,” she said.

‘We found ourselves at the center of a maelstrom’

During the fall of 2022, Levinson’s team walked Superintendent Freeman and more than 300 Guilford educators through Talking Out of Turn and another ethical case study during a series of professional development days.

The district’s troubles began with a school-mascot renaming controversy , then intensified with fights over social-emotional learning and a graphic novel in the school library that featured a gay character. Things boiled over when Freeman started referencing the work of such left-leaning antiracist figures as Ibram X. Kendi in his public remarks. Last September, with help from a conservative Idaho-based advocacy group called We the Patriots USA, a group of local parents filed a lawsuit accusing the Guilford district of pushing a “radical racist agenda.”

“Somehow, we found ourselves at the center of a maelstrom,” Freeman said. “I didn’t even know what critical race theory was until I was accused of teaching it.”

Dedicating a day to discussing case studies didn’t solve the Guilford district’s problems. But the superintendent said teachers appreciated the chance to think through options for balancing their sometimes-competing desires to teach social justice-themed material, ensure that conservative students still feel free to speak in class, and avoid being targeted on social media.

“The feedback was, ‘We feel seen and heard today,’” Freeman said.

But while the ethical case study model has promise, K-12 education has been slower than many other fields to integrate the principles and processes employed by professional ethicists.

Khalya Hopkins, the administrator who works with special education teachers in New York City, highlighted some of the day-to-day challenges. The reality is that her district creates many of the ethical dilemmas she and her colleagues must face daily, Hopkins said, citing as an example difficult decisions about whether to compromise one’s personal integrity by signing documents promising services that are unlikely to get delivered effectively.

That’s why the details of any formal push to bring education ethicists into schools matter greatly, Hopkins argued.

“The biggest issue is who’s going to be doing this,” she said. “I don’t want only older white men making decisions or determining what is ethical for poor Black and brown people.”

Establishing a more formal academic field of educational ethics

Though dozens if not hundreds of professors from disciplines as diverse as philosophy and public policy are interested in issues related to educational ethics, Levinson said they currently lack many of the key facets of a formal academic field, such as dedicated tenure lines and journals.

There are, however, recent signs of movement. The Spencer Foundation, a major education-philanthropy, provided financial support for the Harvard conference. (The Spencer Foundation helps support Education Week’s coverage of educational research.) Harvard Graduate School of Education Dean Bridget Terry Long has also thrown her support behind the effort.

Still, given the contemporary political climate, the K-12 sector isn’t exactly flush with faith that even the most well-intentioned outsider can play the role of honest broker in heated debates about issues such as schools’ treatment of transgender students.

“We do what’s right for children,” said Freeman, who described his district as committed to supporting and celebrating trans kids. “That doesn’t mean we have a political agenda.”

“How I see it is that I’m also working to protect kids who identify as transgender from being exploited through expensive medical treatments,” said Terry Schilling, the president of the American Principles Project, who describes the push to recognize non-traditional gender identities as undermining a shared sense of reality and thus “inherently divisive.”

For Levinson and her team, however, such diverging views are precisely why ethicists are needed throughout the K-12 world.

“By 2050, I hope that teachers and professors, school principals and university provosts, PTA presidents, central office administrators, school boards, Head Start directors, charter network CEOs, learning technology providers, after-school partners, and even students think it is totally natural that they can call on education ethicists whenever they face an ethical dilemma or conflict they feel ill-equipped to resolve on their own,” she said.

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Ethics education to support ethical competence learning in healthcare: an integrative systematic review

Henrik andersson.

1 Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden

2 Centre of Interprofessional Collaboration within Emergency Care (CICE), Linnaeus University, Växjö, Sweden

3 Faculty of Caring Science, Work Life, and Social Welfare, University of Borås, 50190 Borås, Sweden

Anders Svensson

4 Department of Ambulance Service, Region Kronoberg, Växjö, Sweden

Catharina Frank

Andreas rantala.

5 Department of Health Sciences, Lund University, Lund, Sweden

6 Emergency Department, Helsingborg General Hospital, Helsingborg, Sweden

Mats Holmberg

7 Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden

8 Department of Ambulance Service, Region Sörmland, Katrineholm, Sweden

Anders Bremer

9 Department of Ambulance Service, Region Kalmar County, Kalmar, Sweden

Associated Data

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Ethical problems in everyday healthcare work emerge for many reasons and constitute threats to ethical values. If these threats are not managed appropriately, there is a risk that the patient may be inflicted with moral harm or injury, while healthcare professionals are at risk of feeling moral distress. Therefore, it is essential to support the learning and development of ethical competencies among healthcare professionals and students. The aim of this study was to explore the available literature regarding ethics education that promotes ethical competence learning for healthcare professionals and students undergoing training in healthcare professions.

In this integrative systematic review, literature was searched within the PubMed, CINAHL, and PsycInfo databases using the search terms ‘health personnel’, ‘students’, ‘ethics’, ‘moral’, ‘simulation’, and ‘teaching’. In total, 40 articles were selected for review. These articles included professionals from various healthcare professions and students who trained in these professions as subjects. The articles described participation in various forms of ethics education. Data were extracted and synthesised using thematic analysis.

The review identified the need for support to make ethical competence learning possible, which in the long run was considered to promote the ability to manage ethical problems. Ethical competence learning was found to be helpful to healthcare professionals and students in drawing attention to ethical problems that they were not previously aware of. Dealing with ethical problems is primarily about reasoning about what is right and in the patient’s best interests, along with making decisions about what needs to be done in a specific situation.

Conclusions

The review identified different designs and course content for ethics education to support ethical competence learning. The findings could be used to develop healthcare professionals’ and students’ readiness and capabilities to recognise as well as to respond appropriately to ethically problematic work situations.

Introduction

Healthcare professionals and students undergoing training in healthcare professions are confronted with a variety of ethical problems in their clinical practice. These ethical problems appear as ethical challenges, conflicts, or dilemmas that influence the daily provision of care and treatment for patients [ 1 , 2 ]. Addressing these problems requires ethical competencies that involve the ethical dimensions of sensitivity, knowledge, reflection, decision making, action, and behaviour [ 3 ]. As the future workforce, students need training to effectively deal with ethically problematic situations [ 4 ], and experienced professionals need to develop ways to manage ethical problems [ 5 ]. Therefore, it is essential for ethics education to support the learning and development of ethical competencies among healthcare professionals and students undergoing training to work in healthcare. In this study, ethics education is referred to educational components with a content of support and learning activities that promote understanding and management of ethical problems. The focus is on ethics education that is carried out at universities and in clinical practice. In conclusion, it would be valuable to first compile the existing knowledge about designs and course content that support ethical competence learning.

The provision of care is based on patients’ care needs and the complexity of their health conditions; this process is further complicated by the nature of the care environment, which is frequently chaotic and/or unpredictable, with care often being provided under stressful working conditions [ 6 – 10 ]. Healthcare professionals and students in clinical practice are confronted daily with difficult choices and must cope with questions of ‘rightness’ or ‘wrongness’ that influence their decision-making and the quality of the care provided [ 11 , 12 ]. The underlying reasons for the emergence of ethical problems in everyday healthcare work are multifaceted, unfold over time, and are caused by factors such as a lack of resources, insufficient leadership, hierarchical organisational structures, chaotic work environments, or a lack of competencies [ 13 ]. Ethical problems and value conflicts are inherent in clinical practice and do not necessarily mean that healthcare professionals or students have done anything inappropriate or that structures are inadequate. Whatever the cause, ethical problems can lead to conflicts between principles, values, and ways of acting [ 14 ]. This, in turn, might lead to compromised moral integrity and generate moral distress [ 11 , 15 , 16 ], as these reactions result from acting or not acting on the basis of one's own sense of right and wrong [ 17 ]. At worst, moral distress can lead to moral injury, which occurs as a result of witnessing human suffering or failing to prevent outcomes that transgress deeply held beliefs [ 18 ]. Therefore, healthcare professionals and students in clinical practice need to develop their ethical competencies to be prepared for their responsibility and commitment to caring for patients.

The concept of competence is multifaceted and include many things. In this study, competence is viewed as entailing knowledge, skills, and attitudes that are essential when healthcare professionals and students are carrying out their work in clinical practice [ 19 ]. Ethical competence contain components such as the capability to identify ethical problems, knowledge about the ethical and moral aspects of care, reflection on one’s own knowledge and actions, and the ability to make wise choices and carefully manage ethically challenging work situations [ 3 ]. Ethical competence is essential for the ability to respect the patient’s rights and the quality of care [ 20 , 21 ]. This means that ethical competence includes not only knowledge of the ethical and moral aspects of care, but it also includes moral aspects of thinking and decision-making. Furthermore, ethical competence is important since it may prevent or reduce moral distress [ 22 ].

Healthcare professionals and students in clinical practice need a solid foundation that supports when they are confronted with ethically problematic situations. Care and treatment depend not only on knowledge and skills or acting according to guidelines; they also depend on personal values, beliefs, and ethical orientations [ 23 ]. There are various strategies to support and develop the capability to identify and solve ethical problems. [ 24 ]. Ethics education is one such way to develop ethical competencies [ 20 ]. Simultaneously, ethics education raises questions about the content and teaching methods relevant for clinical practice [ 25 ]. While theoretical education via small-group discussions, lectures, and seminars in which ethical principles are applied is quite common [ 26 ], an alternative educational method is simulation-based learning [ 27 ]. However, there is no evidence to support the determination of the most effective strategy to promote the application of ethics in care. There are also challenges to teaching and assessing ethics education. For example, ethics education does not always occur contextually or in a realistic situation, and theoretical knowledge of ethics does not necessarily lead to improved ethical practice [ 28 ]. Teaching ethical principles and maintaining codes of ethics without contextualising them risks forcing healthcare professionals and students in clinical practice to adapt to ethical practice without questioning their own beliefs. Thus, ethical competence risks being hampered by limited reflection and moral reasoning about the situation as a whole [ 29 ].

In summary, ethical problems in everyday healthcare work arise for many reasons, and sometimes themselves constitute threats to ethical values. Hence, healthcare professionals and students in clinical practice require readiness and the capability to recognise and respond appropriately to ethically problematic work situations. Therefore, the aim of this integrative review was to explore the available literature on ethics education that promotes ethical competency learning for healthcare professionals and students undergoing training in healthcare professions.

This integrative review followed the method described by Whittemore and Knafl and was used to summarise and synthesise the current state of research on a particular area of interest [ 30 ], which in this study was the area of ethics education in healthcare.

According to Whittemore and Knafl [ 30 ], the review process is composed of the following stages, which were applied in this study:

Stage 1: problem identification

Two questions were addressed in this review to explore the available literature regarding ethics education: (1) How can ethics education support the understanding and management of ethical problems in clinical practice? (2) What kind of design and course content can support ethical competence learning?

Stage 2: literature search

Prior to the literature search, a study protocol was submitted to the PROSPERO database with the ID number CRD42019123055. In collaboration with three experienced information specialists at a university library, guidance and support were provided in the creation of a search strategy. A systematic and comprehensive data search was conducted using the standards of the PRISMA guidelines [ 31 ]. To enhance the breadth and depth of the database searches, the main search strategy was based on three themes; study population, exposure/intervention and outcomes. The following search and/or Medical Subject Heading’s (MeSH) terms were used: ‘health personnel’, ‘students’, ‘ethics’, ‘moral’, ‘simulation’ and ‘teaching’. The search strategy was different between the databases as the construction of search and MeSH terms differs between the selected databases, see Table ​ Table1. 1 . The main search was carried out between 22 and 23 June 2020 in three scientific publication databases and indexing services: PubMed, CINAHL, and PsycINFO. A supplementary search was carried out 10 January 2022.The searches was limited to (a) articles in English, (b) peer-reviewed articles, (c) theoretical articles as well as qualitative and quantitative empirical research articles, and d) articles published in the last 12 years (January 1, 2010–December 31, 2021). Articles were included if published after 2010, and they (a) described the design and content of ethics education for healthcare professionals or students in, or preparing for, clinical practice, and/or (b) described ethics education supportive of understanding and/or managing ethical problems in clinical practice. Articles were excluded if they focused on research ethics, ethical problems in a military context and ethical consultation with the primary and main goal of supporting ethical decision-making for an individual patient and the healthcare team. In the literature search, the search for “grey literature” such as dissertations, conference papers, reports, etc. was excluded since this was too resource and time consuming. The article searches resulted in 5953 articles, including 1559 in PubMed, 529 in CINAHL, and 3865 in PsycINFO. For a detailed description of the search results, see Fig.  1 . After the search process was completed, all the articles were uploaded onto Endnote X9 (Clarivate Analytics, Philadelphia, PA), and duplicates were then excluded (n = 860). A total of 5093 articles were then imported into the Rayyan QCRI, a web-based sorting tool for systematic literature reviews [ 32 ].

Description of the search strategy with three themes and the search results

Flow diagram of the data selection and quality assessment process based on the PRISMA statement

Four of the authors (HA, AB, AS, and MH) independently screened all titles and abstracts, with the support of Rayyan QCRI, against the inclusion/exclusion criteria. The screening process consisted of two steps: (1) screening of articles identified in the main search and (2) screening of articles identified in the supplementary search. In the screening of articles identified in the main search, the blinded article selection in Rayyan QCRI indicated a 93% consensus between the authors with respect to the articles to exclude (n = 3811). After this, those articles for which there was no consensus regarding their inclusion (n = 287) were screened. Through discussions between the authors (HA, AB, AS, and MH), consensus was reached on which articles should then be excluded (n = 235). In the screening of articles identified in the supplementary search, the blinded article selection in Rayyan QCRI indicated a 95% consensus between the authors with respect to the articles to exclude (n = 953). After this, those articles for which there was no consensus regarding their inclusion (n = 42) were screened. Through discussions between the authors (HA, AB, AS, and MH), consensus was reached on which articles should then be excluded (n = 33). In total, 61 articles were selected for an additional full-text review. The articles were independently read in full by five of the authors (HA, AB, AS, MH, and AR) and then discussed, leading to an agreement to exclude 21 articles that did not meet the inclusion criteria. This led to 40 articles remaining for the quality assessment (see Fig.  1 ).

Stage 3: data evaluation

The quality assessment of the 40 articles was independently performed by two of the authors (HA and AB). A critical appraisal tool was used to score the articles on a four-graded scale (i.e., good, fair, poor, and very poor) [ 33 ]. The quality assessment consisted of two steps: (1) quality assessment of articles identified in the main search and (2) quality assessment of articles identified in the supplementary search. In the quality assessment of articles identified in the main search, there was consensus on the quality of 17 of the reviewed articles. However, there were different views on the quality assessment of 14 articles. Any discrepancies regarding authenticity, methodological quality, information value, and representativeness were considered, discussed, and resolved in the data evaluation process [ 34 ], leading to consensus between the authors regarding 11 articles pending between two adjacent grades: good–fair (n = 6), fair–poor (n = 3), and poor–very poor (n = 2). The authors’ quality assessment differed by more than one grade regarding three articles. However, even in these cases, the disagreement could be resolved through discussions between the two authors, after which a consensus was reached. In the quality assessment of articles identified in the supplementary search, there was consensus on the quality of 7 of the reviewed articles. However, there were different views on the quality assessment of 2 articles. Any discrepancies regarding authenticity, methodological quality, information value, and representativeness were considered, discussed, and resolved in the data evaluation process [ 34 ], leading to consensus between the authors regarding 2 articles pending between two adjacent grades good–fair. No articles were excluded due to a low-quality score. The characteristics of the included articles, as well as the quality scores, are presented in Table ​ Table2 2 .

Characteristics of the included articles

Stage 4: data analysis

The data analysis was conducted by the first author. The findings were summarised and synthesised using a thematic analysis method [ 35 ] to identify the key themes that describe ethics education for healthcare professionals and students in clinical practice. This inductive approach also allowed us to answer the question regarding the design and content of ethics education and how ethics education could support the understanding and/or management of ethical problems in clinical practice, based on the available literature.

The analysis was conducted in the following six phases [ 35 ]: (1) reading and re-reading the included articles closely to become familiar with the data, (2) generating initial codes (228 codes in the present study) based on the information obtained from the included articles, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing a report where the findings are presented in terms of broad themes. The interpretation of the themes was discussed, and disagreement was resolved through discussion between the authors (HA, CF, AB, and AR) until a common understanding was reached.

Forty articles were included for review to explore the available literature regarding ethics education for healthcare professionals and students in clinical practice. The results showed a widespread international distribution of studies. Most of the studies were conducted in the United States (n = 5) and Taiwan (n = 5). When dividing the articles into continents, 17 were from Asia, 14 from Europe, six from North America, and three from Australia. Table ​ Table3 3 shows the key themes and sub-themes identified through the thematic analysis.

Sub-themes and key themes identified in the review

Making ethical competence learning possible

Making ethical competence learning possible for managing ethical problems in clinical practice requires support. However, this support entails those certain conditions be met for learning in the organisation in which ethics education is conducted, including opportunities to plan the education. The design and content of education are governed by external structures and the way in which the learning objectives have been specified. To support learning, it is also important that education is designed to facilitate opportunities to receive and create meaning with respect to the information received, change one’s own values and attitudes, and determine the consequences of one’s own actions. Interaction with others is important since it can constitute a valuable source of knowledge, especially with respect to determining whether the individual healthcare professional or student has understood or done something correctly. Simultaneously, ethics education is influenced by both the healthcare professionals and the students who have different qualifications, expectations, and strategies for their learning.

The factors influencing the planning and organization of ethical education were discussed in 32 articles. Three sub-themes were identified: (1) creating conditions for learning, (2) designing strategies for learning, and (3) interacting with others.

Creating conditions for learning

A starting point for making ethical competence learning possible is to identify and shed light on the kinds of ethical problems that healthcare professionals and students in clinical practice are expected to be able to manage and to create conditions for this learning. Therefore, it is important that ethics education reflect the relevant conditions for ethical competence learning by using real work situations [ 36 ]. One way to create such conditions is to construct appropriate learning objectives that clearly describe what should be achieved in terms of knowledge, skills, approaches, and values to effectively manage ethical problems [ 37 , 38 ]. However, the perception of what is relevant is influenced by healthcare professionals’ and students’ previous experiences of ethical problems in their everyday healthcare work. Limited experience entails a risk that the education will not be perceived as relevant, and that the educational content may be difficult to absorb [ 39 ].

Another condition that influences ethics education is the time available. Developing an ethical identity and creating meaning in discussions about ethical problems in everyday healthcare work takes time [ 37 , 40 ]. Simultaneously, it might be difficult to predict how long, for example, group discussions may take to shed light on the various aspects of ethical problems [ 39 ]. There is thus a risk that the time will be too short and insufficient to finish the discussion, or that there may be too much time, thus causing the discussions to be perceived as less engaged [ 37 ]. Therefore, it is important that the time aspect be considered in the design of education.

Finally, it is essential to create conditions for psychological safety and confidence in ethics education, or, in other words, to enable opportunities to express opinions or make blunders without this leading to consequences for the participants [ 41 ]. Instead, trust between the participants should be emphasised and acknowledged in discussions about ethical problems in clinical practice [ 40 , 42 , 43 ]. Simultaneously, there is a risk that high staff turnover and frequent changes in management may limit opportunities for building trust through conversation [ 44 ]. Passive or absent healthcare professionals and students might also limit opportunities for establishing such trust, for example, in group discussions [ 45 ].

Design strategies for learning

Different design strategies make ethical competence learning possible, through which the healthcare professionals and students can be brought to ask questions, make comments, and talk about their previous knowledge or own experiences. Knowledge of, for example, ethical values can be gained through theoretical lectures and the reading of appropriate literature [ 46 – 48 ]. Simultaneously, it is valuable to design ethics education so that theoretical learning activities are integrated with practical ones and thereby provide an experience of real-life situations [ 46 ]. Skills can be practiced through workshops [ 49 ], case studies and problem-solving sessions [ 37 , 43 , 47 , 48 , 50 – 53 ]. Understanding one’s own values and attitudes can be facilitated through, for example, role-play or simulation activities [ 54 – 56 ], narratives [ 40 , 57 , 58 ], storytelling [ 42 ] and discussions in small groups [ 38 , 43 – 45 , 47 , 59 – 62 ]. Small group discussions are appropriate when healthcare professionals or students are unwilling to stand out by asking questions or giving individual opinions in learning situations in which many people participate [ 63 ].

There are also different educational technologies to consider in the design of strategies for ethical competence learning. For example, the internet makes it easier to deliver lectures and carry out exercises [ 64 ], as well as to discuss issues in groups with digital aids [ 59 ]. This means that ethics education can take place in the form of internet-based education where video conferencing technique is used. This technique is valuable when using external educators in a rural setting for example in rural-based hospitals [ 59 ]. This technique is also useful to stimulate discussions with other healthcare professionals or students who are outside their regular workplaces [ 59 ]. However, a prerequisite for internet-based education is that the workplace has the required learning resources such as reliable internet connection and video equipment [ 64 ].

Ethics education needs to be built on strategies that optimise the ability to achieve the desired learning objectives [ 48 ]. To achieve these objectives, it may be necessary to choose different design strategies [ 36 ]. However, the strategy that best supports the development of a “professional self” is difficult to determine, for example, in terms of its ability to influence healthcare professionals’ and students’ capabilities for moral sensitivity [ 47 , 65 , 66 ] and critical thinking [ 47 ]. Nevertheless, support and learning activities do not necessarily promote ethical competence learning. Instead, these activities can also lead to stagnation in the development of ethical competence [ 67 , 68 ].

Interacting with others

An open atmosphere and interaction between participants are important in ethics education when sensitive issues are discussed [ 69 ]. Sometimes, it is difficult to express one’s critical thoughts about ethical problems in everyday healthcare work, since relationships with others and cohesion between individuals can be affected and compromised [ 45 , 57 ]. Simultaneously, there is a need for healthcare professionals and students to formulate their thoughts, feelings, and intentions about the ethical problems that they have observed themselves or heard about through colleagues [ 37 , 38 , 41 , 43 , 45 ]. Making ethical competence learning possible based on problem solving, interaction, and discussion of ethical problems in clinical practice can therefore be a support mechanism for healthcare professionals and students [ 37 ]. Learning together about issues that are perceived as ethically problematic can strengthen both the individual and their relationships with their colleagues [ 44 , 52 ].

Simulation is a way of highlighting ethical problems that exist in interactions with other individuals, such as patients or family members [ 54 ]. Narrative groupwork is another way of highlighting and processing ethical problems [ 57 ]. Through a narrative, different perspectives can be made visible and lead to in-depth learning about ethically challenging work situations [ 58 ]. With group discussions, ethical problems can be viewed in different ways [ 59 ], which in turn can lead to improvements in dealing with such problems [ 44 ]. However, if group discussions are to lead to improvements, it is necessary that there be a willingness to discuss what is perceived as ethically problematic in everyday healthcare work [ 38 , 45 ], as well as an interest in learning new approaches [ 37 ]. There is also a need for a welcoming climate in which the contradictions between different perceptions and attitudes can be balanced in a constructive way [ 43 , 51 ].

Having awareness of one’s own thoughts and perceptions

Ethical competence learning can help healthcare professionals and students in clinical practice direct their attention to ethical problems that they were not previously aware of. Such learning can involve unconscious attitudes, approaches, or emotions. These aspects influence how healthcare professionals and students react to ethical problems in everyday healthcare work.

The aspects that influence awareness of one’s own thoughts and perceptions were discussed in 22 articles in terms of both educational design and the content of ethics education. Two sub-themes were identified: (1) visualising attitudes and approaches, and (2) experiencing emotional conditions.

Visualising attitudes and approaches

Being aware of one’s own thoughts and perceptions in one’s attitudes and approaches to circumstances such as a certain illness, patient, or event influence what is perceived as an ethical problem in clinical practice [ 41 , 70 ]. One way of designing ethics education that facilitates the visualisation of ethical problems is to use a narrative approach [ 40 , 57 , 58 ]. Using narrative writing, one’s own or others’ attitudes and approaches to everyday healthcare work situations where ethical problems occur can be made visible [ 57 ]. Examples of such ethical problems are when honesty and respect for the patient are not demonstrated, or when the establishment of trust in the care encounter is lacking [ 57 ].

Another way to visualise one’s own or others’ attitudes and approaches when designing ethics education is to use learning activities based on problems or scenarios [ 48 , 51 , 52 , 54 – 56 , 64 ]. This ethical competence learning focuses on challenging and realistic situations, such as conflicts regarding informed consent or cases where tensions arise between the patient’s wishes and needs in relation to professional norms [ 36 ]. Problem- or scenario-based learning stimulates healthcare professionals and students to learn and develop new understandings that allow them to manage ethical problems in their clinical practice [ 36 ]. Such learning could also create a means of engagement to discuss how ethical problems should be managed [ 64 ]. The visibility can also emerge by reserving time for ethical reflection and, in systematic forms, discussing ethical problems in everyday healthcare work [ 38 , 43 – 45 , 59 , 70 ]. Attitudes towards a particular illness or patient, for example, govern our way of justifying the approaches used [ 70 ]. By highlighting how healthcare professionals and students think about and analyse their attitudes and approaches when designing ethics education, previous habits can be made visible and critically examined [ 44 ]. The visibility of attitudes and approaches promotes a process of change in one’s own thoughts and perceptions [ 43 , 45 ]. However, it is essential to consider that attitudes and approaches are complex, developed over time, and strongly influenced by the perceptions of individuals who are close to the healthcare professionals and students undergoing training in healthcare professions [ 36 , 48 ]. Accordingly, ethics education to support ethical competence learning does not always lead to a change in how ethical problems are managed in everyday clinical practice [ 71 ].

Experiencing emotional conditions

Awareness of one’s own or others’ emotions influences what is perceived as an ethical problem in everyday healthcare work. Healthcare professionals and students in clinical practice encounter a variety of ethical problems in which they are either actors or observers. Depending on the prevailing circumstances on site and at a given time, ethical problems, and their significance, as well as their relevance, can be experienced differently. When designing ethics education, real experiences, such as incidents that are ethically challenging and witnessed by healthcare professionals or students, can be used in ethical competence learning [ 58 ]. Group discussions make it possible for all participants to hear different interpretations and reflections on the same situation [ 38 , 45 ]. Furthermore, such discussions can draw attention to situations where care and treatment have been experienced as unethical, such as when the patients’ concerns are not heard, or their needs are not met [ 61 ].

By imitating a realistic situation through simulation, healthcare professionals and students are given the opportunity to learn about real-life situations, apply ethical content in the situation, and experience different emotional states [ 56 ]. Educational content that highlights emotions, such as feelings of dependence, vulnerability, fear of abandonment, and a lack of control, gives healthcare professionals and students an opportunity to change their perspectives on factors such as caregiving and care-recipients [ 55 ]. Simulation can also be a way to raise awareness of other people’s ways of feeling and experiencing specific work situations, regardless of whether they play the role of professional, patient, or family member [ 56 ].

Doing right by the patient’s best interests

Healthcare professionals and students in clinical practice are constantly faced with ethical problems related to patients, their significant others, colleagues, and the work organization. Dealing with such problems primarily involves reasoning about what is right and good to make decisions about what needs to be done in a specific situation. However, doing right based on the patient’s best interests can sometimes jeopardize the management of ethical problems since it could conflict with other patients’ interest, which may not be ethically acceptable or legally permitted.

Those aspects influencing healthcare professionals’ and students’ capabilities to do right by the patient’s best interests were discussed in 19 articles. Two sub-themes were identified: (1) managing emotions and tensions, and (2) managing different perspectives in the situation.

Managing emotions and tensions

Ethical problems can provoke strong emotions, such as anger, disapproval, and frustration [ 40 ]. These emotions, in turn, generate tensions, such as those between ethical values and legal principles in relation to how healthcare professionals and students in clinical practice perceive a particular situation [ 40 , 51 ]. Therefore, it is essential that ethics education be designed to provide time and space for reflection. By reflecting together with others, thoughts and perceptions about these emotions and tensions can be verbalised [ 43 , 72 ]. Ethics education should provide the opportunity to learn how to deal with emotions [ 40 ] and foster understanding of what is ethically ‘right’ or ‘wrong’ for the patient [ 45 ], which in turn influences the decisions made by healthcare professionals and students in clinical practice [ 51 , 70 ]. Group discussion, for example in ethics seminar, is a way to reduce unethical behaviour [ 73 ]. There is, however, a difference between learning how to manage ethical problems in everyday healthcare work and how these problems are actually managed, since one’s own inabilities or limitations may influence the outcome [ 62 ].

Managing different perspectives on the situation

In everyday healthcare work, healthcare professionals and students face several challenges in determining how to ‘do the right thing’ in situations that arise in their contact with patients and their significant others. Ethical problems can arise when two perspectives, such as an ethical and a legal perspective, collide, as would be the case when there is conflict between what is perceived to be best for the patient and the patient’s right to self-determination [ 37 ]. There may also be a feeling of inadequacy in managing ethical problems in care situations [ 38 ] since there is rarely only one way to cope with the situation [ 51 ]. Therefore, ethics education needs to be designed in such a way that the content includes both medical and ethical reasoning when the care situation is to be resolved [ 70 , 74 ].

The design of such training could consist of lectures that are combined with watching movies, playing games, and performing case analyses and group discussions [ 37 , 47 , 60 , 65 ]. Through such training, an increased understanding of ethical problems can be gained [ 54 , 72 ], for example, regarding the ways in which certain patients, events, and situations are to be viewed [ 37 , 57 , 65 ]. Ethical competence learning with a focus on ‘thinking ethics’ and problematising one’s own capabilities to judge and act can be an eye-opener for healthcare professionals and students [ 72 , 75 ]. This can strengthen the capability to identify certain situations and provide examples of instances where ethical values and norms have been violated [ 66 ].

Even if the design and content of ethics education focus on thinking about critical ethics, this does not necessarily mean that the degree of critical ethics thinking is influenced [ 47 ]. Prerequisites for ethical competence learning of how to manage different perspectives and do right by the patient’s best interests are, among other things, that there is time for discussion, and that the educational content is perceived as useful [ 37 ]. It is also crucial that such learning be based on consideration and respect for different beliefs, so that ethical problems can be managed effectively in everyday healthcare work [ 43 – 45 , 54 ].

Making ethical competence learning possible, having awareness of one’s own thoughts and perceptions, and doing right by the patient’s best interests are important aspects when seeking to increase the understanding and management of ethical problems in everyday healthcare work.

An important aspect emphasised in the present study is the need to create a psychosocial climate that allows healthcare professionals and students to feel safe. Previous knowledge reveals that feeling psychologically safe is important for engagement in educational activities, regardless of the context in which they are implemented [ 76 ]. Hence, it is important that educators use an approach that clarifies what psychological security in feedback conversations can look like [ 77 ]. To promote effective learning conditions in which healthcare professionals and students feel safe, educators need to encourage an open dialogue aimed at enhancing the implementation of the intended learning activity [ 76 , 77 ].

The results present different designs and educational strategies for making ethical competence learning possible. In general, it is essential that educators develop course content that supports healthcare professionals and students in developing ethical competence in terms of their ethical decision-making ability and the moral courage to confront ethical dilemmas [ 78 ]. However, although ethical education might increase ethical sensitivity and the ability to detect an ethical problem, it is not obvious that education influences the development of ethical behaviour [ 79 ].

The results show how interaction with others is important since it constitutes a valuable source of knowledge; it also allows for the determination of whether the individual healthcare professional or student has understood or done something in an ethically defensible manner. Relationships between people constitute the foundation of ethics, and ethics is essential to the maintenance of relationships between two or more people [ 80 ].

Another critical aspect is the value of clinical experience. According to the results, limited experience poses a potential risk of not enabling healthcare professionals and students to absorb and contextually relate to the content of ethical education. However, previous research indicates that those with less clinical experience are more perceptive of ethical issues than more experienced colleagues, possibly counteracting the potential lack of experience [ 11 ].

The results underline the significance of attending to ethical problems that individual participants in ethics education may not already be aware of. This might be related to the fact that the patients, healthcare professionals, and students each have different and unique perspectives in caring encounters. To provide care based on the preferences of a specific patient, one needs insight into the patient’s lifeworld [ 81 ]. This might pose some challenges in designing and developing course content for ethics education.

Further, based on the present results, narrative approaches and realistic simulation are considered components that could influence ethical competence learning. Such learning should be based on the patient’s perspective to transform healthcare professionals’ and students’ tacit knowledge into explicit knowledge with support from reflective practice [ 82 ]. According to this, reflection with some theoretical depth grounded in caring science can contribute to a deeper understanding beyond that which is common in the clinical practice [ 83 ]. However, being aware of ethical problems—earlier not being aware of—raises new moral concerns among healthcare professionals and students. Thus, ethical education needs to be dynamically designed to capture different aspects of ethical problems.

The result highlights the importance of doing right by the patient’s best interests. Besides clinical competence, decisions regarding care and treatment also require ethical competence [ 3 ]. To do the right and good thing, an educational design that emphasises the healthcare professionals’ and students’ personal experiences, understanding, and views is required; such a skill can be cultivated, for example, through reflection [ 84 ]. Approaches such as moral case deliberation, ethics rounds, or discussion groups can be advantageously used to support ethical reflection [ 85 ]. At the same time, there are challenges regarding how ethical problems can be handled in clinical practice. Each problem and situation is unique, complex, and uncertain, since it can never be completely predicted. Therefore, doing right by the patient’s best interests may not necessarily only be about what to do in a specific situation; it can also be about scrutinising, interpreting, and processing other healthcare professionals’ and students’ knowledge, skills, and attitudes to ethical problems in clinical practice.

Doing right by the patient’s best interests also requires an educational design that provides space and time for reflection. Research indicates that the opportunity to share thoughts and obtain support from others, as well as from the organization, when ethical problems occur is considered helpful [ 86 ]. However, there are other factors that are essential for reflection. Space for reflection, for example, to create psychological safety is crucial for healthcare professionals and students to express themselves or make blunders without this leading to consequences. A hierarchical organizational climate influences sensitivity to ethical concerns, and a conformist work attitude could lead to an unwillingness to challenge routines in everyday clinical practice [ 86 ]. Time is also required to ensure that there is an opportunity for reflection. Without time, there is a risk that decision-making regarding ethical problems may become inconsistent [ 87 ].

Methodological strengths and limitations

This study followed the recommendations for conducting and reporting the results of an integrative systematic review, and the researchers have strived to make the research process as transparent as possible, which is considered to have strengthened its reliability.

In this study, a broad literature search strategy was used to find as many articles as possible to answer the study aim and research questions. However, some issues may be encountered when conducting broad literature searches. One is that such a literature search likely leads to a greater number of irrelevant articles that match the search criteria. Another weakness is that it is time consuming to review a great number of articles. Accordingly, there is a risk that relevant articles may have been accidentally deleted, thereby weakening the validity of the study. However, this risk was partly managed by involving four of the authors in the screening process against the inclusion/exclusion criteria. The decision not to include “grey literature” can be considered a limitation as this may have affected the validity of the results.

Three available databases at a university in western Sweden were used. Since universities have different levels of licenses to access the contents of the databases, there is a risk that the search terms and search strings used in this study have failed to identify all articles on ethics education due to limited license agreements. Thus, there is a risk that some articles that are available in more extensive license agreements are not included in this literature review, which should be considered a limitation.

The decision not to include the perspective of those who supervise, and mediate ethics education could be seen as a weakness. However, it was a deliberate choice not to include the search term ‘educators’ based on the study aim and research questions. The requirements for educators can be different depending on whether the participants are students at a university or if they are healthcare professionals and are taught at their workplace. However, continued research on what competencies these educators should have in relation to supporting the learning and development of ethical competencies is important, and possibly points to a need for a systematic literature review that describes the educators’ competencies.

This study is limited to and focused on providing answers to questions regarding ethics education in various healthcare contexts in different countries. This is considered, on the one hand, to strengthen the validity and transferability of the results and, on the other hand, to limit the transferability of the results to contexts with similar cultural, economic, and social conditions, which are reflected in the included articles.

This integrative systematic review provides insights into ethics education for healthcare professionals, students, and educators. The results show that ethical competence learning is essential when seeking to draw attention to and deal effectively with ethical problems. Healthcare professionals and students in clinical practice need a supportive learning environment in which they can experience a permissive climate for reflection on ethical challenges, conflicts, or dilemmas that influence everyday healthcare work. The design and course content of ethics education meant to increase the understanding and management of ethical problems in clinical practice may vary. However, regardless of the design or course content, educators need supportive conditions both on campus and in clinical practice to maximise opportunities to generate a high level of learning in ethics education.

Further studies on ethics education should be carried out. Comparative research, through which different educational designs can illuminate what provides the best possible learning process for managing ethical problems, would be valuable. Intervention studies aiming to maintain and protect the autonomy of patients with impaired decision-making capabilities may also be warranted. Another interesting area for further studies is about the educators’ and their competencies in ethics education with a special focus on the requirements if the participants are students at a university or if they are healthcare personnel and are taught at their workplace. Further studies could be used to develop healthcare professionals’ and students’ readiness and capabilities to recognise and respond appropriately when they encounter ethically problematic situations. This would, in turn, give healthcare professionals and students a sense of self-confidence and faith in their everyday clinical practice.

Acknowledgements

We would like to thank the librarians Anna Wolke, Ida Henriksson, and Lynn Rudholm at Linnaeus University for their valuable assistance with the systematic literature search process.

Authors' contributions

All the authors contributed to the study design. The review design and literature search were performed by HA and AB. Data extraction was done by HA, AB, AS, MH, and AR. The data analysis was conducted by HA, CF, AB, and AR. All authors made substantial contributions to the study and have read and approved the final version of the submitted manuscript. All authors read and approved the final manuscript.

Open access funding provided by University of Boras. The authors received the following financial support for the research, authorship, and/or publication of this article: This work was funded by the Kamprad Family Foundation for Entrepreneurship, Research & Charity (Ref. No. 20180157).

Availability of data and materials

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The authors declare that they have no competing interests.

Publisher's Note

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The Right Has an Opportunity to Rethink Education in America

T he casual observer can be forgiven if it looks like both the left and the right are doing their best to lose the debate over the future of American education.

On the left, public officials and self-righteous advocates practically fall over themselves working to subsidize and supersize bloated bureaucracies, hollowed-out urban school systems, and campus craziness. They’ve mutely watched teacher strikes shutter schools and insisted that “true history” requires the U.S. to be depicted as a cesspool of racism and villainy .

Meanwhile, on the right, bleating outrage impresarios have done their best to undercut the easy-to-make case for educational choice by weaving it into angry tirades against well-liked local schools. They’ve taken Taylor Swift, a strait-laced pop star beloved by middle school and high school girls, and imagined her as part of some bizarre Biden Administration PSYOP. Heck, they’ve even decided to try to “ take down ” Martin Luther King, Jr., a Civil Rights icon honored for his legacy of justice, equality, and nonviolence.

What gives?

The left has a problem. Democrats have long benefited from alliances with teacher unions, campus radicals, and the bureaucrats who run the college cartel. This played well with a public that tended to  like  its teachers, schools, and colleges. But  pandemic school closures ,  plunging trust in colleges , and  open antisemitism  have upended the status quo.

This has created an extraordinary opportunity for the right—free of ties with unions, public bureaucracies, and academe—to defend shared values, empower students and families, and rethink outdated arrangements. The right is uniquely positioned to lead on education because it’s not hindered by the left’s entanglements, and is thus much freer to rethink the way that early childhood, K-12, and higher education are organized and delivered.

The right also needs to demonstrate that it cares as much (or more) about the kitchen table issues that affect American families as the culture war issues that animate social media. Affordability, access, rigor, convenience, appropriateness, are the things that parents care about, and the right needs something to offer them.

The question is whether the right will choose to meet the moment at a time when too many public officials seem more interested in social media exposure than solving problems.

We’re optimists. We think the right can rise to the challenge.

It starts with a commitment to principle, shared values, and real world solutions. This is easier than it sounds. After all, the public  sides  with conservatives on hot-button disputes around race, gender, and American history by lopsided margins. Americans broadly  agree  that students should learn both the good and bad about American history,  reject  race-based college admissions,  believe  that student-athletes should play on teams that match their biological sex, and  don’t think  teachers should be discussing gender in K–3 classrooms.

And, while some thoughtful conservatives recoil from accusations of wading into “culture wars,” it’s vital for to talk forthrightly about shared values. Wall Street Journal-NORC  polling , for instance, reports that, when asked to identify values important to them, 94 percent of Americans identified hard work, 90 percent said tolerance for others, 80 percent said community involvement, 73 percent said patriotism, 65 percent said belief in God, and 65 percent said having children. Schools should valorize hard work, teach tolerance, connect students to their community, promote patriotism, and be open minded towards faith and family.

At the same time, of course, educational outcomes matter mightily, for students and the nation . A commitment to rigor, excellence, and merit is a value that conservatives should unabashedly champion. And talk about an easy sell! More than 80 percent of Americans say standardized tests like the SAT should matter for college admissions . Meanwhile, California’s Democratic officials recently approved new math standards that would end advanced math in elementary and middle school and Oregon’s have abolished the requirement that high school graduates be literate and numerate. The right should both point out the absurdity of such policies and carry the banner for high expectations, advanced instruction, gifted programs, and the importance of earned success.

When it comes to kitchen table issues, conservatives can do much more to support parents. That means putting an end to chaotic classrooms. It means using the tax code to provide more financial assistance. It means making it easier and more appealing for employers to offer on-site daycare facilities. It means creating flexible-use spending accounts for both early childhood and K–12 students to support a wide range of educational options. It means pushing colleges to cut bloat and find ways to offer less costly credentials. This means offering meaningful career and technical options so that a college degree feels like a choice rather than a requirement, making it easier for new postsecondary options to emerge, and requiring colleges to have skin in the game when students take out loans (putting the schools on the hook if their students aren’t repaying taxpayers).

Then there’s the need to address the right’s frosty relationship with educators. It’s remarkable, if you think about it, that conservatives—who energetically support cops and have a natural antipathy for bureaucrats and red tape—have so much trouble connecting with teachers. Like police, teachers are  well-liked  local public servants frustrated by bureaucracy and paperwork. It should be easy to embrace discipline policies that keep teachers safe and classrooms manageable, downsize bloated bureaucracy and shift those dollars into classrooms, and tend to parental responsibilities as well as parental rights.  

There’s an enormous opportunity for the right to lead on education today. The question is whether we’re ready to rise to the challenge.

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Fundraising Ethics In Higher Education

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Every profession likes to claim ethics are essential to its success. But you can make an especially robust case that this is indeed the case in fundraising.

What does it take to be successful in fundraising? Strengths like persuasion, problem solving, and persistence come to mind quickly. But integrity is squarely at the top .

Fundraising is a profession directed at nurturing friendships that culminate in gifts of time, talent, and treasure. There’s no way this is possible without earning and maintaining trust. I love the expression that fundraising occurs at the speed of trust.

Fundraising ethics isn’t an option but a necessity. We simply aren’t going to be successful if donors don’t have faith in us. They must have full confidence that we and the organizations we serve are going to do what we say we’re going to do and fulfill their philanthropic intent.

I think the best way to illuminate the day-to-day application of ethics in fundraising is to examine actual examples that arise among fundraisers, management, and donors. A day doesn’t go by in which nonprofit leaders have to wrestle with complex situations which put institutional success in the short run in competition with doing the right thing. I don’t pretend to have led a life of perfection, but experience is a great teacher.

Here are 10 issues around fundraising ethics from my time leading advancement programs for higher learning institutions.

• Selection of scholarship recipients : The majority of funds raised during my higher education career were to provide much-needed financial assistance to students in need. Though the rules have been changing, an essential constant has been that donors should not have a dominant voice in the process. Rather they can shape selection criteria such as majors, GPA, financial need, geography and extra-curricular activities. Race and ethnicity are forbidden, but specific school districts are permissible in which minorities are populous. Donors can serve on committees, but I always contended that contributed to awkward situations in which they would have varying opinions that might intimidate faculty and staff serving on the same committee.
• Hiring decisions : I’ve been asked by donors to make sure their favorites were being considered in searches. They certainly could serve as references and write letters of recommendation, but candidates receiving extra points is avoided. To be candid, as a candidate for positions myself, as a courtesy, I’ve drafted letters of recommendation for mentors who would submit them.
• Personal gifts : We often work with donors of substantial wealth. “De Minimis” guidelines apply in both directions, limiting the value of meals, gifts, and mementos to a modest level. For example, donors can only deduct the amount of support for a special event to the value above tangible benefits received. From the other side of the coin, I found it awkward and to be avoided to benefit from too much generosity from donors.
• Poaching: It is the nature of the nonprofit environment for development officers to change employers. In fact, keeping high-performing staff is one of the more serious challenges facing nonprofits . While it is blatantly wrong to take databases and donor records, it is common for employees assuming new positions to reach out to former donors. Remember, most donors support multiple causes; this is especially true in the education sector. My personal standard was never to speak poorly about former employers or even compare and contrast them to new organizations. I wanted their support based on passion and respect for the new organization, not because of discontent with others.
• Naming rights : Typically, it’s family, friends, and other loved ones who push more for naming recognition more than donors themselves. Many institutions go by the guideline that the gift must represent at least half of construction costs. I always made it a point to forcefully resist “honorific” naming because it is imprecise and it reduces the inventory of buildings and facilities to be named for financial gifts in the future
• New technology: What you do when you receive information that can benefit you and your organization through email or other transmissions not intended for you. While you haven’t broken any rules, taking the high road and informing the intended recipients of what happened typically strengthens your long-term standing.
• Gossip : It’s common for colleagues to gather after work for social purposes. There is clearly an upside as working relationships can be strengthened. But when these get-togethers result in innuendos, backstabbing, or spreading rumors, it unfairly and inappropriately creates innocent victims. For that reason, as a supervisor I never welcomed gossip and challenged why such negative information was being brought to me.
• Abhorring anything resembling commissions : As both employer and consultant, I have run at the very mention of them. They are wrong for several reasons. Bottom line: There is no one-size-fits-all formula to trace the continuum that culminates in gifts.
• Taking credit for work that isn’t your own : This is another slippery slope, especially with more and more work being performed in teams. The mark of a true leader is giving credit to those who report to him or her for their contributions in moving the organization forward.
• Going beyond compliance and what is legal : Ethics at its highest level is consistently doing the right thing, for the right reason, and at the right time because it reflects the character of employees and the culture of the nonprofit.

It can take large measures of both character and courage to be ethical, even standing up to the desires of CEOs, executive directors, and board chairs. Fortunately, fundraisers are not without strong resources and guidance. Drafting a code of ethics for professional fundraisers was the first order of business for founders of the Association of Fundraising Professionals (AFP) in 1960. Ethics remains a top priority for AFP, serving as a guide and major asset to the 25,00+ members in some 240 chapters that have generated more than $1 trillion. Every member must sign and abide by the AFP Code of Ethical Principles and Standards . This is the strictest and only enforced code in the profession.

But even more impactful are the righteous examples set by our leaders and practitioners. Over several decades, and especially now as a fundraising trainer/consultant to a wide range of nonprofits from all across the country, I am proud of the state of our profession and the men and women who live and practice the ideals of honesty, integrity, and excellence in advancing their noble missions and causes.

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Guest Essay

The Troubling Trend in Teenage Sex

By Peggy Orenstein

Ms. Orenstein is the author of “Boys & Sex: Young Men on Hookups, Love, Porn, Consent and Navigating the New Masculinity” and “Girls & Sex: Navigating the Complicated New Landscape.”

Debby Herbenick is one of the foremost researchers on American sexual behavior. The director of the Center for Sexual Health Promotion at Indiana University and the author of the pointedly titled book “Yes, Your Kid,” she usually shares her data, no matter how explicit, without judgment. So I was surprised by how concerned she seemed when we checked in on Zoom recently: “I haven’t often felt so strongly about getting research out there,” she told me. “But this is lifesaving.”

For the past four years, Dr. Herbenick has been tracking the rapid rise of “rough sex” among college students, particularly sexual strangulation, or what is colloquially referred to as choking. Nearly two-thirds of women in her most recent campus-representative survey of 5,000 students at an anonymized “major Midwestern university” said a partner had choked them during sex (one-third in their most recent encounter). The rate of those women who said they were between the ages 12 and 17 the first time that happened had shot up to 40 percent from one in four.

As someone who’s been writing for well over a decade about young people’s attitudes and early experience with sex in all its forms, I’d also begun clocking this phenomenon. I was initially startled in early 2020 when, during a post-talk Q. and A. at an independent high school, a 16-year-old girl asked, “How come boys all want to choke you?” In a different class, a 15-year-old boy wanted to know, “Why do girls all want to be choked?” They do? Not long after, a college sophomore (and longtime interview subject) contacted me after her roommate came home in tears because a hookup partner, without warning, had put both hands on her throat and squeezed.

I started to ask more, and the stories piled up. Another sophomore confided that she enjoyed being choked by her boyfriend, though it was important for a partner to be “properly educated” — pressing on the sides of the neck, for example, rather than the trachea. (Note: There is no safe way to strangle someone.) A male freshman said “girls expected” to be choked and, even though he didn’t want to do it, refusing would make him seem like a “simp.” And a senior in high school was angry that her friends called her “vanilla” when she complained that her boyfriend had choked her.

Sexual strangulation, nearly always of women in heterosexual pornography, has long been a staple on free sites, those default sources of sex ed for teens . As with anything else, repeat exposure can render the once appalling appealing. It’s not uncommon for behaviors to be normalized in porn, move within a few years to mainstream media, then, in what may become a feedback loop, be adopted in the bedroom or the dorm room.

Choking, Dr. Herbenick said, seems to have made that first leap in a 2008 episode of Showtime’s “Californication,” where it was still depicted as outré, then accelerated after the success of “Fifty Shades of Grey.” By 2019, when a high school girl was choked in the pilot of HBO’s “Euphoria,” it was standard fare. A young woman was choked in the opener of “The Idol” (again on HBO and also, like “Euphoria,” created by Sam Levinson; what’s with him ?). Ali Wong plays the proclivity for laughs in a Netflix special, and it’s a punchline in Tina Fey’s new “Mean Girls.” The chorus of Jack Harlow’s “Lovin On Me,” which topped Billboard’s Hot 100 chart for six nonconsecutive weeks this winter and has been viewed over 99 million times on YouTube, starts with, “I’m vanilla, baby, I’ll choke you, but I ain’t no killer, baby.” How-to articles abound on the internet, and social media algorithms feed young people (but typically not their unsuspecting parents) hundreds of #chokemedaddy memes along with memes that mock — even celebrate — the potential for hurting or killing female partners.

I’m not here to kink-shame (or anything-shame). And, anyway, many experienced BDSM practitioners discourage choking, believing it to be too dangerous. There are still relatively few studies on the subject, and most have been done by Dr. Herbenick and her colleagues. Reports among adolescents are now trickling out from the United Kingdom , Australia , Iceland , New Zealand and Italy .

Twenty years ago, sexual asphyxiation appears to have been unusual among any demographic, let alone young people who were new to sex and iffy at communication. That’s changed radically in a short time, with health consequences that parents, educators, medical professionals, sexual consent advocates and teens themselves urgently need to understand.

Sexual trends can spread quickly on campus and, to an extent, in every direction. But, at least among straight kids, I’ve sometimes noticed a pattern: Those that involve basic physical gratification — like receiving oral sex in hookups — tend to favor men. Those that might entail pain or submission, like choking, are generally more for women.

So, while undergrads of all genders and sexualities in Dr. Herbenick’s surveys report both choking and being choked, straight and bisexual young women are far more likely to have been the subjects of the behavior; the gap widens with greater occurrences. (In a separate study , Dr. Herbenick and her colleagues found the behavior repeated across the United States, particularly for adults under 40, and not just among college students.) Alcohol may well be involved, and while the act is often engaged in with a steady partner, a quarter of young women said partners they’d had sex with on the day they’d met also choked them.

Either way, most say that their partners never or only sometimes asked before grabbing their necks. For many, there had been moments when they couldn’t breathe or speak, compromising the ability to withdraw consent, if they’d given it. No wonder that, in a separate study by Dr. Herbenick, choking was among the most frequently listed sex acts young women said had scared them, reporting that it sometimes made them worry whether they’d survive.

Among girls and women I’ve spoken with, many did not want or like to be sexually strangled, though in an otherwise desired encounter they didn’t name it as assault . Still, a sizable number were enthusiastic; they requested it. It is exciting to feel so vulnerable, a college junior explained. The power dynamic turns her on; oxygen deprivation to the brain can trigger euphoria.

That same young woman, incidentally, had never climaxed with a partner: While the prevalence of choking has skyrocketed, rates of orgasm among young women have not increased, nor has the “orgasm gap” disappeared among heterosexual couples. “It indicates they’re not doing other things to enhance female arousal or pleasure,” Dr. Herbenick said.

When, for instance, she asked one male student who said he choked his partner whether he’d ever tried using a vibrator instead, he recoiled. “Why would I do that?” he asked.

Perhaps, she responded, because it would be more likely to produce orgasm without risking, you know, death.

In my interviews, college students have seen male orgasm as a given; women’s is nice if it happens, but certainly not expected or necessarily prioritized (by either partner). It makes sense, then, that fulfillment would be less the motivator for choking than appearing adventurous or kinky. Such performances don’t always feel good.

“Personally, my hypothesis is that this is one of the reasons young people are delaying or having less sex,” Dr. Herbenick said. “Because it’s uncomfortable and weird and scary. At times some of them literally think someone is assaulting them but they don’t know. Those are the only sexual experiences for some people. And it’s not just once they’ve gotten naked. They’ll say things like, ‘I’ve only tried to make out with someone once because he started choking and hitting me.’”

Keisuke Kawata, a neuroscientist at Indiana University’s School of Public Health, was one of the first researchers to sound the alarm on how the cumulative, seemingly inconsequential, sub-concussive hits football players sustain (as opposed to the occasional hard blow) were key to triggering C.T.E., the degenerative brain disease. He’s a good judge of serious threats to the brain. In response to Dr. Herbenick’s work, he’s turning his attention to sexual strangulation. “I see a similarity” to C.T.E., he told me, “though the mechanism of injury is very different.” In this case, it is oxygen-blocking pressure to the throat, frequently in light, repeated bursts of a few seconds each.

Strangulation — sexual or otherwise — often leaves few visible marks and can be easily overlooked as a cause of death. Those whose experiences are nonlethal rarely seek medical attention, because any injuries seem minor: Young women Dr. Herbenick studied mostly reported lightheadedness, headaches, neck pain, temporary loss of coordination and ear ringing. The symptoms resolve, and all seems well. But, as with those N.F.L. players, the true effects are silent, potentially not showing up for days, weeks, even years.

According to the American Academy of Neurology, restricting blood flow to the brain, even briefly, can cause permanent injury, including stroke and cognitive impairment. In M.R.I.s conducted by Dr. Kawata and his colleagues (including Dr. Herbenick, who is a co-author of his papers on strangulation), undergraduate women who have been repeatedly choked show a reduction in cortical folding in the brain compared with a never-choked control group. They also showed widespread cortical thickening, an inflammation response that is associated with elevated risk of later-onset mental illness. In completing simple memory tasks, their brains had to work far harder than the control group, recruiting from more regions to achieve the same level of accuracy.

The hemispheres in the choked group’s brains, too, were badly skewed, with the right side hyperactive and the left underperforming. A similar imbalance is associated with mood disorders — and indeed in Dr. Herbenick’s surveys girls and women who had been choked were more likely than others (or choked men) to have experienced overwhelming anxiety, as well as sadness and loneliness, with the effect more pronounced as the incidence rose: Women who had experienced more than five instances of choking were two and a half times as likely as those who had never been choked to say they had been so depressed within the previous 30 days they couldn’t function. Whether girls and women with mental health challenges are more likely to seek out (or be subjected to) choking, choking causes mood disorders, or some combination of the two is still unclear. But hypoxia, or oxygen deprivation — judging by what research has shown about other types of traumatic brain injury — could be a contributing factor. Given the soaring rates of depression and anxiety among young women, that warrants concern.

Now consider that every year Dr. Herbenick has done her survey, the number of females reporting extreme effects from strangulation (neck swelling, loss of consciousness, losing control of urinary function) has crept up. Among those who’ve been choked, the rate of becoming what students call “cloudy” — close to passing out, but not crossing the line — is now one in five, a huge proportion. All of this indicates partners are pressing on necks longer and harder.

The physical, cognitive and psychological impacts of sexual choking are disturbing. So is the idea that at a time when women’s social, economic, educational and political power are in ascent (even if some of those rights may be in jeopardy), when #MeToo has made progress against harassment and assault, there has been the popularization of a sex act that can damage our brains, impair intellectual functioning, undermine mental health, even kill us. Nonfatal strangulation, one of the most significant indicators that a man will murder his female partner (strangulation is also one of the most common methods used for doing so), has somehow been eroticized and made consensual, at least consensual enough. Yet, the outcomes are largely the same: Women’s brains and bodies don’t distinguish whether they are being harmed out of hate or out of love.

By now I’m guessing that parents are curled under their chairs in a fetal position. Or perhaps thinking, “No, not my kid!” (see: title of Dr. Herbenick’s book above, which, by the way, contains an entire chapter on how to talk to your teen about “rough sex”).

I get it. It’s scary stuff. Dr. Herbenick is worried; I am, too. And we are hardly some anti-sex, wait-till-marriage crusaders. But I don’t think our only option is to wring our hands over what young people are doing.

Parents should take a beat and consider how they might give their children relevant information in a way that they can hear it. Maybe reiterate that they want them to have a pleasurable sex life — you have already said that, right? — and also want them to be safe. Tell them that misinformation about certain practices, including choking, is rampant, that in reality it has grave health consequences. Plus, whether or not a partner initially requested it, if things go wrong, you’re generally criminally on the hook.

Dr. Herbenick suggests reminding them that there are other, lower-risk ways to be exploratory or adventurous if that is what they are after, but it would be wisest to delay any “rough sex” until they are older and more skilled at communicating. She offers language when negotiating with a new partner, such as, “By the way, I’m not comfortable with” — choking, or other escalating behaviors such as name-calling, spitting and genital slapping — “so please don’t do it/don’t ask me to do it to you.” They could also add what they are into and want to do together.

I’d like to point high school health teachers to evidence-based porn literacy curricula, but I realize that incorporating such lessons into their classrooms could cost them their jobs. Shafia Zaloom, a lecturer at the Harvard Graduate School of Education, recommends, if that’s the case, grounding discussions in mainstream and social media. There are plenty of opportunities. “You can use it to deconstruct gender norms, power dynamics in relationships, ‘performative’ trends that don’t represent most people’s healthy behaviors,” she said, “especially depictions of people putting pressure on someone’s neck or chest.”

I also know that pediatricians, like other adults, struggle when talking to adolescents about sex (the typical conversation, if it happens, lasts 40 seconds). Then again, they already caution younger children to use a helmet when they ride a bike (because heads and necks are delicate!); they can mention that teens might hear about things people do in sexual situations, including choking, then explain the impact on brain health and why such behavior is best avoided. They should emphasize that if, for any reason — a fall, a sports mishap or anything else — a young person develops symptoms of head trauma, they should come in immediately, no judgment, for help in healing.

The role and responsibility of the entertainment industry is a tangled knot: Media reflects behavior but also drives it, either expanding possibilities or increasing risks. There is precedent for accountability. The European Union now requires age verification on the world’s largest porn sites (in ways that preserve user privacy, whatever that means on the internet); that discussion, unsurprisingly, had been politicized here. Social media platforms have already been pushed to ban content promoting eating disorders, self-harm and suicide — they should likewise be pressured to ban content promoting choking. Traditional formats can stop glamorizing strangulation, making light of it, spreading false information, using it to signal female characters’ complexity or sexual awakening. Young people’s sexual scripts are shaped by what they watch, scroll by and listen to — unprecedentedly so. They deserve, and desperately need, models of interactions that are respectful, communicative, mutual and, at the very least, safe.

Peggy Orenstein is the author of “Boys & Sex: Young Men on Hookups, Love, Porn, Consent and Navigating the New Masculinity” and “Girls & Sex: Navigating the Complicated New Landscape.”

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An earlier version of this article misstated the network on which “Californication” first appeared. It is Showtime, not HBO. The article also misspelled a book and film title. It is “Fifty Shades of Grey,” not “Fifty Shades of Gray.”

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Ethics of AI in Education: Towards a Community-Wide Framework

• Open access
• Published: 09 April 2021
• Volume 32 , pages 504–526, ( 2022 )

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• Wayne Holmes   ORCID: orcid.org/0000-0002-8352-1594 1 ,
• Kaska Porayska-Pomsta   ORCID: orcid.org/0000-0002-9433-4022 1 ,
• Ken Holstein 2 ,
• Emma Sutherland 3 ,
• Toby Baker 3 ,
• Simon Buckingham Shum   ORCID: orcid.org/0000-0002-6334-7429 4 ,
• Olga C. Santos   ORCID: orcid.org/0000-0002-9281-4209 5 ,
• Mercedes T. Rodrigo   ORCID: orcid.org/0000-0001-7881-7756 6 ,
• Mutlu Cukurova   ORCID: orcid.org/0000-0001-5843-4854 1 ,
• Ig Ibert Bittencourt   ORCID: orcid.org/0000-0001-5676-2280 7 &
• Kenneth R. Koedinger 2  

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While Artificial Intelligence in Education (AIED) research has at its core the desire to support student learning, experience from other AI domains suggest that such ethical intentions are not by themselves sufficient. There is also the need to consider explicitly issues such as fairness, accountability, transparency, bias, autonomy, agency, and inclusion. At a more general level, there is also a need to differentiate between doing ethical things and doing things ethically , to understand and to make pedagogical choices that are ethical, and to account for the ever-present possibility of unintended consequences. However, addressing these and related questions is far from trivial. As a first step towards addressing this critical gap, we invited 60 of the AIED community’s leading researchers to respond to a survey of questions about ethics and the application of AI in educational contexts. In this paper, we first introduce issues around the ethics of AI in education. Next, we summarise the contributions of the 17 respondents, and discuss the complex issues that they raised. Specific outcomes include the recognition that most AIED researchers are not trained to tackle the emerging ethical questions. A well-designed framework for engaging with ethics of AIED that combined a multidisciplinary approach and a set of robust guidelines seems vital in this context.

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Introduction

It is almost certainly the case that all members of the Artificial Intelligence in Education (AIED) research community are motivated by ethical concerns, such as improving students’ learning outcomes and their lifelong opportunities. However, as has been seen in other domains of AI application, ethical intentions are not by themselves sufficient, as good intentions do not always result in ethical designs or ethical deployments (e.g., Dastin 2018 ; Reich and Ito 2017 ; Whittaker et al. 2018 ). Significant attention is required to understand what it means to be ethical specifically in the context of AIED . The educational contexts which AIED technologies aspire to enhance highlight the need to differentiate between doing ethical things and doing things ethically , to understand and to make pedagogical choices that are ethical, to account for the ever-present possibility of unintended consequences, along with many other considerations. However, addressing these and related questions is far from trivial, not least because it remains true that “ no framework has been devised, no guidelines have been agreed, no policies have been developed, and no regulations have been enacted to address the specific ethical issues raised by the use of AI in education” (Holmes et al. 2018 , p. 552).

As a first step towards addressing this critical gap, we invited 60 of the AIED community’s leading researchers (operationalised mainly by citations and/or reputation) to respond to a survey of questions about ethics and the application of AI in educational contexts.

The 17 respondents (in alphabetical order by surname) were: Vincent Aleven (CMU, USA), Ig Ibert Bittencourt (UFAL, Brazil), Jesus Boticario (UNED, Spain), Simon Buckingham Shum (UTS, Australia), Mutlu Cukurova (UCL, UK), Ben du Boulay (University of Sussex, UK), Janice Gobert (Rutgers, USA), Ken Holstein (CMU, USA), Judy Kay (University of Sydney, Australia), Ken Koedinger (CMU, USA), Bruce McLaren (CMU, USA), Ma. Mercedes T. Rodrigo (Ateneo de Manila University, Philippines), Olga C. Santos (UNED, Spain), Eileen Scanlon (OU, UK), Mike Sharples (OU, UK), Erin Walker (University of Pittsburgh, USA), and Beverly Woolf (UMASS, USA).

In this paper, we first summarise the background (including the ethics of AI in general, and the ethics of educational data) and introduce the ethics of AI in education. Next, we outline the methods used in this project, before going on to summarise the survey responses (NB all responses quoted in this paper are verbatim, with any words that have been added or deleted for clarity marked by square parentheses or ellipses as appropriate). We finish with a discussion of the issues raised by the survey, and a suggestion for next steps.

The AIED conferences in 2018 and 2019 hosted a workshop called “Ethics of AIED. Who Cares?” (Holmes et al. 2019a ; Holmes et al. 2018 ). Although the workshop discussions were engaging and productive, the small number of attendees suggested a disappointingly low level of interest in the topic from the broader AIED community. While other AI communities are increasingly attending to ethical considerations around the design and deployment of AI-based technologies, ethical dimensions of AIED do not yet appear to be a central area of focus for many in the AIED community. Since Aiken and Epstein published their ethical guidelines two decades ago to begin a conversation around the ethics of AIED (Aiken and Epstein 2000 ), there has been a striking paucity of published work in the AIED community that explicitly focuses on ethics. In any case, the potential impact of AIED designs and methods of deployment on students, teachers and wider society appears yet to be fully worked out.

Nonetheless, it is generally accepted within the community that AIED raises far-reaching questions with important ethical implications for students, educators, parents, policymakers, and other stakeholders. Ethical concerns permeate many of the community’s core interests, including but not limited to: accuracy of diagnoses of learners interacting with AIED systems; choices of pedagogies employed by AIED systems; predictions of learning outcomes made by those systems; issues of fairness, accountability, and transparency; and questions related to the influence of AI and learning analytics on teachers’ decision making.

In many ways, AIED is itself a response to each of those issues and more – with most being addressed, one way or another, in work conducted in the varied research subdomains of AIED. For example, questions around data ownership and control over their interpretations have long been recognised as critical in AIED (e.g., in the context of open learner modelling: Bull and Kay 2016 ; Conati et al. 2018 ). However, what is currently missing is a basis for the meaningful ethical reflection necessary for innovation in AIED, to help researchers determine how they might best contribute towards addressing those challenges explicitly. This requires a deep engagement both with recent ethics related debates and frameworks in other AI research subdomains, and with ethical questions specific to the AIED subdomain itself (e.g., issues around pedagogy), many of which remain unasked and unanswered (although there are some exceptions - e.g., Aiken and Epstein 2000 ; Friedman and Kahn 1992 ; Holmes et al. 2019b ; Sharkey 2016 ).

The Ethics of AI in General

As with any transformative technology, some AI applications may raise new ethical and legal questions, for example related to liability or potentially biased decision-making. The ethics of artificial intelligence in general has received a great deal of attention, by researchers (e.g., Boddington 2017 ; Floridi 2019 ; Jobin et al. 2019 ; Whittaker et al. 2018 ; Winfield and Jirotka 2018 ) and more widely (e.g., the European Union 2019 ; the UK’s House of Lords 2018 ; UNESCO 2019 ; and the World Economic Forum 2019 ), with numerous other AI ethics initiatives emerging in recent years (e.g., Ada Lovelace Institute 2019 ; AI Ethics Initiative 2017 ; AI Now Institute 2017 ; DeepMind Ethics & Society 2017 ; Future of Life Institute 2013 ; The Institute for Ethical AI & Machine Learning 2018 ).

All of these efforts principally focus on data (involving issues such as informed consent, data privacy, and biased data sets) and how that data is analysed (involving issues such as biased assumptions, transparency and statistical apophenia – finding patterns where no meaningful, causal patterns are present). The Montréal Declaration for Responsible Development of Artificial Intelligence ( 2018 ), for example, offers a comprehensive approach involving ten human-centred principles, encompassing: well-being, respect for autonomy, protection of privacy, solidarity, democratic participation, equity, diversity, prudence, responsibility, and sustainable development. No such declaration currently exists for the specific issues raised by AIED.

The Ethics of Educational Data

Similarly, the ethics of educational data and learning analytics has also been the focus of much research (e.g., Ferguson et al. 2016 ; Slade and Prinsloo 2013 ; Potgieter 2020 ). This work is extensive, far too wide to summarise here; however, some key issues can be noted. First, because the field is still emerging, exactly what an ethics of learning analytics should include remains the subject of debate: ‘the ethical and privacy aspects of learning analytics are varied, and they shift as the use of data reveals information that could not be accessed in the past’ (Ferguson et al. 2016 , p. 5). Second, the ethics of learning analytics involves several types of questions, including but not limited to: informed consent and privacy, the interpretation of data, the management of data, and perspectives on data (e.g., institutional versus individual); as well as on much broader issues such as power relations, surveillance, and the purpose of education (Slade and Prinsloo 2013 ). Third, it has been argued that ‘educational data mining [...] is not the superconductor of truth that some of its proponents believe [...] and the transformative impact that it will have on the autonomy of learners is cause for concern’ (Potgieter 2020 , pp. 3, 6) .

The learning analytics community have endeavoured to agree principles against which learning analytics research and practice can judge itself and be judged. The DELICATE checklist, for example, comprises guidance centred on determining added value and the rights of participants, being open about intentions and objectives, legitimising the collection of data, involving all stakeholders including the data subjects, ensuring consent is genuinely informed and freely given, ensuring that data is truly anonymised, establishing and implementing procedures to guarantee individual privacy, and adopting clear and transparent obligations with any external agencies that might be involved with the data (Drachsler and Greller 2016 ). In fact, the clear overlaps between learning analytics and AIED, that are centred on educational data, suggest that an ethics of AIED might usefully draw on approaches such as the DELICATE checklist. However, there are also clear differences between the two fields, “with an emphasis on agents and tutors for AIED, [...] and visualization for LA” (Labarthe et al. 2018 , p. 70). This active engagement/passive representation distinction, although radically oversimplified, suggests that a comprehensive ethics of AIED is likely to have additional requirements.

The Ethics of Other Related Research Areas

Ethics have also received attention in related research areas such as user modeling, e-learning environments, and intelligent agents. For example, in the user modeling community, issues centred on security and privacy (e.g., Schreck 2003 ), inspectability (e.g., Zapata-Rivera and Greer 2004 ), and privacy (e.g., Kobsa 2007 ) have long been considered. Most recently, dedicated workshops have been held at leading conferences (e.g., FairUMAP, Mobasher et al. 2020 ), with contributions exploring issues such as fairness (Sacharidis et al. 2020 ), transparency (Schelenz et al. 2020 ), and biases (Deshpande et al. 2020 ). Researchers in e-learning are also interested in ethical issues raised by the systems that they build; issues such as equity and diversity, surveillance and consent, identity and confidentiality (e.g., Anderson and Simpson 2007 ), and student privacy: “when an observer [which could be an automated system] monitors someone’s behavior with full knowledge of their identity, the person being monitored does not enjoy any privacy” (Anwar and Greer 2012 , p. 63). However, it is notable that other researchers in e-learning appear more interested in the ethical practices of the students, such as cheating and fraud (e.g., Gearhart 2012 ). Finally, researchers and developers of intelligent agents such as chatbots are also increasingly focusing on the ethical issues raised by their work (e.g., Murtarelli et al. 2020 ; Richards and Dignum 2019 ). Most recently, the World Economic Forum has launched ‘RESET’, a framework and set of principles for governing responsible use of conversational AI (WEF 2020 ) – which, although focused on healthcare, have self-evident potential for the ethics of intelligent agents in education. The RESET principles focus on safety/non-maleficence, efficacy, data protection, human agency, accountability, transparency, fairness, explainability, integrity and inclusiveness.

The Ethics of AIED in Particular

As with AI in general, concerns exist about the large volumes of data collected to support AIED (such as the recording of student competencies, inferred emotional states, strategies and misconceptions). Who owns and who is able to access these data, what are the privacy concerns, and who should be considered responsible if something goes wrong?

Other major AIED ethical concerns, again as with AI in general, centre on the computational approaches. How should the data be analysed, interpreted, shared and acted upon? How should the biases (conscious or unconscious), that might impact negatively on the civil rights of individual students, be prevented or ameliorated – especially given that the scale of AIED in the coming years is likely to amplify any design biases (e.g., about gender, age, race, social status, income inequality…)? Finally, as the Facebook and Cambridge Analytica data scandal showed, data is vulnerable to hacking and manipulation: ‘it’s impossible to have personal privacy and control at scale, so it is critical that the uses to which data will be put are ethical – and that the ethical guidelines are clearly understood’ (Tarran 2018 , pp. 4–5).

However, the ethics of AIED cannot be reduced to questions about data or computational approaches alone (Holmes et al. 2019b ). AIED research also needs to account for the ethics of education , which, although the subject of decades of research, is all too often overlooked. For example, AIED research needs to address explicitly issues such as (1) the purpose of the learning (e.g., to prepare students to pass exams or to help them self-actualise), (2) the choice of pedagogy (with a common approach, instructionism, being contested by the learning sciences community), (3) the role of the technology with respect to teachers (to replace or augment human functions), and (4) access to education (often seen by the community through the ethical dimension of fairness and equity). In addition, there remains limited research into what teachers and students actually want from AIED systems - such as requirements around student agency and privacy about which teachers and students might not agree (Holstein et al. 2019 ). Furthermore, where AIED interventions target behavioural change (such as by ‘nudging’ individuals towards a particular course of action), the entire sequence of AIED enhanced pedagogical activity needs to be ethically warranted in the context of the broader activities within which AIED systems are being deployed.

To highlight just some of the potential breadth of issues, AIED ethical questions include:

How does the transient nature of student goals, interests and emotions impact on the ethics of AIED?

How can K12 students give genuinely informed consent for their involvement with AIED tools?

What are the AIED ethical obligations of private organisations (developers of AIED products) and public authorities (schools and universities involved in AIED research)?

How might schools, students and teachers opt out from, or challenge, how they are represented in large datasets?

What are the ethical implications of not being able to easily interrogate how some AIED deep decisions (e.g., those using multi-level neural networks) are made?

What are the ethical consequences of encouraging students to work independently with AI-supported software (rather than with teachers or in collaborative groups)?

Notably, as mentioned above, some guidelines were proposed almost 20 years ago (Aiken and Epstein 2000 ), but have not been widely adopted by the AIED community. Aiken and Epstein start with a negative and a positive meta-principle related to the impact of AIED on ‘dimensions of human being’; with the dimensions ethical, aesthetic, social, intellectual, and physical, together with psychological traits such as ‘the individual’s ability to lead a happy and fulfilling life’. Aiken and Epstein’s negative meta-principle is that ‘(AIED) technology should not diminish the student along any of the fundamental dimensions of human being .’ The positive meta-principle is that ‘ AIED technology should augment the student along at least one of the fundamental dimensions of human being .’ They go on to provide and discuss ten ‘fundamental principles’ for educational technologies that incorporate AI methods. Some of these (such as ‘avoid information overload’) are essential tenets of good user experience and effective pedagogy for most educational technologies. The principles that are most specific to the application of AI in education are: ‘ 7. Develop systems that give teachers new and creative roles that might not have been possible before the use of technology. Systems should not attempt to replace the teacher. ’ and ‘ 10. Avoid glorifying the use of computer systems, thereby diminishing the human role and the human potential for learning and growth. ’

Broadly, the aim of this work is to galvanise the AIED research community’s engagement with the ethics of its domain. Accordingly, it was first important to establish community members’ existing beliefs and understandings of the ethics of AI applied in educational contexts, to which end a survey of AIED researchers was developed and conducted. The survey questionnaire comprised 10 substantive open questions (Appendix 1), which covered the following themes: (i) what it means for AIED researchers to consider the ethics of their work, (ii) pertinent AI and education ethical issues, and (iii) what distinguishes the ethics of AIED from the ethics of other AI domains. The research was approved by the Open University’s Human Research Ethics Committee (HREC/3339/Holmes: 02/08/2019).

Potential invitees for the survey were identified by reviewing contributions to the International Journal of Artificial Intelligence in Education and the proceedings of the International Conference on Artificial Intelligence in Education , both from the last 10 years. The names of researchers with the most citations, together with those researchers otherwise known by reputation (e.g., they hold or have held a central role in the International Artificial Intelligence in Education Society ), were collated. To this list were added some mid- and early-career researchers who had already made a noteworthy impact in the community (e.g., they had received a Best Paper award at an AIED conference). In total, the list comprised 60 candidate survey invitees, all of whom were invited to participate in the survey. An invitation email and up to three reminder emails were sent to each invitee, 17 of whom completed the questionnaire.

At the beginning of the questionnaire, respondents were asked to give explicit permission for their names to be given in the proposed paper, and for any of their responses included in the paper to be attributed to them (this approach draws on Guideline 41 of the British Educational Research Association’s Ethical Guidelines for Educational Research 2018). This was both to ensure transparency and to maximise impact on early- and mid-career AIED researchers. All respondents gave their permission. In addition, before the paper was submitted for publication, the respondents were given the opportunity to check, amend, agree, and/or delete any quote that was attributed to them. No respondent requested any substantive change. Finally, to further acknowledge their contribution, the respondents were given the opportunity to be named as a co-author of the paper. Six respondents took this up (Holstein and Buckingham Shum also made substantial contributions to the writing of the paper).

Paying Attention to Ethics in AIED

Survey respondents were first asked to reflect upon whether and why they agree or disagree with the statement, “AIED researchers do not pay sufficient attention to the ethics of AIED.” All 17 respondents answered this question, revealing overall agreement that there is room for improvement. For instance, Buckingham Shum noted that while “there are vibrant communities and journals” focusing on the ethics of technology, these exist as “a ‘parallel universe’ separate from the AIED circuit.” Similarly, Holstein observed that when the topic of AIED comes up in communities other than AIED itself, “ethical considerations tend to be the first topics raised by those outside the community,” but that “within AIED [...] this is not so.” Several respondents noted that the field lacks shared frameworks for thinking through ethical issues in AIED. As Walker noted, “collectively we lack the training in frameworks and principles that would allow us to grapple with major ethical questions of AIED research.”

However, five out of 17 respondents reported that they perceive growing urgency and attention to ethical issues within the AIED research community. For example, Scanlon noted that “there is much discussion now of ethics because of high profile examples in AI which are hitting the media [...] ethical consideration [s] are becoming not just part of the academic community’s discourse but part of wider public discussion.” Similarly, Bittencourt suggested that “since [there is so much] news and arguments about the implications of AI, researchers are starting to think about ethics in AIED.” Buckingham Shum framed growing concerns around the ethics of AIED as a consequence of the field’s growth in real-world applications: “It is only relatively recently with ‘adaptive products’ hitting the mainstream that AIED has found itself being touched by the broader public spotlight. Until then, it was an academic community, with such a small user base that nobody was asking ethics questions.”

Only one participant out of 17 outright disagreed that AIED researchers pay insufficient attention to ethics. However, this participant’s response focused exclusively on AIED research ethics , noting that institutional ethics boards in university settings ensure that researchers consider certain ethical dimensions of their research practice. Four of 17 respondents described themselves as “on the fence,” or stated that they agreed only “to an extent.” Koedinger noted that “many of us got into AIED because we wanted to improve education, and especially for students who most need the help of free public education,” characterizing the pursuit of this goal as “doing ethics, which goes beyond research about [ethics] .” Aleven similarly said that “one suspects that many AIED researchers are fundamentally motivated by ethical concerns,” while acknowledging that “so far the field has not often addressed [ethics] explicitly or discussed it publicly.” Other respondents pointed out that “this is a problem inherent to many fields of technology research and not solely AIED” (Walker). In line with this view, Sharples characterized the practice of AIED as being “primarily led by technology,” noting that “its impacts on stakeholders, including direct users, those indirectly affected and society at large has been largely ignored.” Finally, some respondents commented that this is a complex question to answer. McLaren noted that it may be difficult to make generalizations across the whole of the AIED community, as “some researchers are very cognizant and sensitive to ethical issues [...] others, not as much.” Other respondents emphasised that the AIED community has attended to certain aspects of ethics (e.g., data privacy and research ethics), although historically it has attended less to others (Rodrigo).

In a follow-up question, survey respondents were asked to reflect upon why it is important for AIED researchers to pay careful consideration to the ethics of their work. Respondents highlighted the role AIED research may play in shaping what education looks like for the next generation of students. For example, Cukurova emphasised the potential for “long term adoption of technology.” McLaren noted that AIED research “could have an impact on students, their education, and thus the future of mankind.” Walker, Rodrigo, and Holstein emphasised the moral responsibilities that come with AIED being a design discipline, not solely an empirical science. As Walker put it, “we are shaping a future where technology can personalize instruction to learners’ unique needs, and should be more involved in ensuring that future is a positive one.” Similarly, Rodrigo highlighted that AIED researchers are engaged in “trying to create systems that can assist in the formation of the next generation. These students have to be treated fairly, with respect, with consideration, and their needs as individuals have to be attended to, to the extent possible.”

A number of respondents emphasised that AIED researchers have a responsibility to make their “research more accessible, and more transparent” (Buckingham Shum), and to “be particularly mindful of the ways that people interpret our results” (Kay). As Gobert noted, “generalizing results beyond the demographics for whom the study was designed could mean that students might get interventions that are not suitable for them.” du Boulay distinguished between “two main areas of concern” for AIED research: “the danger of harm to participants,” including (1) “harm arising from decisions that the AIED system might make,” and (2) “the careful curation of data derived from the research,” including the related issue of “the models of individuals that the AIED system might build.” Other responses focused specifically on the unique sensitivity of the data collected and used by AIED systems. For example, Boticario said “Data are no longer data because there is so much information available on anyone. Data are people themselves and should be treated as such [...] we are [providing] personalised support to our students based on [an] increasing body of data, which is starting to include personal and affective information. This information is by its nature sensitive and demands a careful consideration and management.” Finally, one respondent noted that the need for AIED researchers to attend to the ethics of their work had been “argued in a journal article [in] IJAIED back in 2000,” (Aiken and Epstein 2000 ) and asked, “how has it changed?”

Most Important Ethical Issues for AIED

When asked ‘ What are the most important ethical issues for AIED? ’, nine respondents directly referenced ‘data’, with several more identifying issues overlapping with the governance of data. Many of the issues cited are not specific to education settings. These included: (1) Data ownership and control, both within and outside the context of research: “ In a research context, the data normally “belongs“ to the researcher. Once a system is deployed in normal teaching, the issue of the ownership of this data is much more problematic ” (du Boulay). (2) Expectations of privacy, while recognising that “ privacy is more than a binary value, it has many nuances and shades ” (Boticario). (3) Limitations of data, bias and representation, “ where information is inferred without noticing the existing limitations or the actual evidence behind results ” (Boticario). (4) Consequently, “ the management of the data collection, where users need to be properly informed ” (Santos). (5) The transparency and intelligibility of decisions: “ user agency, and user awareness of how the technology functions are important issues” (Walker). Emerging technologies can bring new dimensions to these issues, with one respondent asking “ How to treat facial recognition technology?” (Scanlon).

In addition, several respondents identified properties of AI in education which, in combination together, make education distinct to other sectors: “ All the generic concerns around big data and algorithms apply to education. What’s more interesting are the features that make the formal education system, and learning as a phenomenon, distinctive from the other sectors of society being impacted by data science” (Buckingham Shum). These issues relate not just to the ethics of the development of AIED tools in and of themselves, but to their educational context – when, how, and to what end, an AIED tool is being used.

Unsurprisingly, the implications of AIED for teaching and learning was central to many of the respondents’ concerns. The “ quality of education ” (Aleven) enabled by AIED tools was highlighted. There was a recognition of the pedagogical choices inherent within the design of AIED tools, with one respondent emphasising a desire for “ designing a pedagogy that empowers learners and teachers ” (Sharples), while another arguing that the scope of many AIED tools remains narrow and therefore there may be elements of education that are better off without AIED, asking: “ What do we risk losing through automation, and are we prepared to preserve those aspects that should be preserved (e.g., intentionally ‘not’ automated)? Are we diminishing the quality of education, overall, by conveying that we have reached human parity in AI-based teaching systems (but failing to emphasise that we have done so on a very narrow set of teaching tasks, whereas good education involves much more than this)? ” (Holstein).

A further set of concerns for several respondents centered on the experience of users. These included reflections on agency, transparency and intelligibility in education contexts. For example, “ making the teaching and learning actions transparent to learners and teachers ” (Sharples), or “ avoiding alienation on the part of teachers, students, and other stakeholders ” (Aleven). These also included reference to equity and fairness. For example, “s ome students may need to work longer than others; ideally, every student should reach the same level of mastery of the content they need to learn ” (Woolf), or “ are we diminishing the quality of education for ‘certain groups of students’, in cases where ‘business as usual’ would have worked better for these groups?” (Holstein). That respondent also identified a risk at a societal level that users of AIED could be subjected to “ cultural imperialism as we scale up AIED systems to a diverse range of contexts ” (Holstein).

A final group of concerns related to the ethics of AIED research , rather than its applications and uses. These covered the need to treat research subjects – particularly children – ethically and fairly (McLaren), reporting results while respecting confidentiality and anonymity, particularly given potential to re-identify data (Santos, Boticario), and data collection (Gobert). In addition, the potential for AIED research to be (mis)used by companies was identified: ‘ How will our outputs be used (or misused) by more profit-driven entities? How do we manage misuses of our outputs? ’ (Holstein).

Most Ignored Yet Critical Ethical Issues for AIED

When asked what were the most ignored ethical issues for AIED, several of the respondents (Bittencourt, Boticario, du Boulay, Santos, Scanlon, Sharples) again emphasised issues centred on data, for example: (1) The problems of data collection: “What I think it is […] critical is how to approach the need to collect data in a real world scenario when you need to compare proposals and you think one of them might be bad for the students, or give them less opportunities for learning” (Santos). (2) “The lack of clarity of what happens to the data collected by AIED systems” (du Boulay). (3) Data ownership and control: “The student is providing data for their benefit, and thereof they should have to control what data and what usage of that data is to be allowed. No one but them must have the control or right to manipulate those data for anything else but to support their learning” (Boticario). (4) Data anonymity: “In many journal papers, the reporting of the data is anonymized, yet participants are able to recognize themselves in the reporting because there is only one woman who is 26 years old and has 3 years of experience as [a] teacher” (Santos). In a similar vein, other researchers mentioned issues around transparency: “How to make the teaching decisions and the system’s model of the learner visible and inspectable” (Sharples).

Many respondents (including Aleven, Holstein, Koedinger, Rodrigo, Walker and Woolf) raised issues around representativeness and equity: are we diminishing quality education for certain groups, are AIED systems biased against some groups, and are some other groups being ignored? The many complementary comments are worth quoting: “I think because it is so difficult to collect representative data sets and because funding is structured so as not to reach out to a multitude of populations, it is accepted that data sets will always be limited” (Rodrigo). “The challenge of designing equitable AIED technologies that do not show bias against a particular group is not discussed much in the community, and probably should be engaged with” (Walker). “Are we diminishing the quality of education for ‘certain groups of students’, in cases where ‘business as usual’ would have worked better for these groups?” (Holstein). “The degree of personalisation for some students might be less than that for others, which could lead to inequitable outcomes. Personalised instructional strategies could ignore under-served/ underrepresented/minority students and fall short of providing fair learning opportunities to each student” (Woolf). “It seems inevitable that giving the same instruction to students who are well prepared for that instruction versus students who are not well prepared for it will lead to different results. [...] Should we now conclude that this instructional intervention is unethical, as it seems to be increasing inequality?” (Aleven). “There could be more projects that have direct impact on disadvantaged learners” (Koedinger).

Finally, issues were raised over AIED systems and human agency, for example “How to embed pedagogies of learner and teacher empowerment into AIED systems” (Sharples). Areas that need specific attention are: “The ongoing misplaced belief that AIED systems can wholly replace human teachers and still enable effective and socially responsible learning.” (du Boulay), “The lack of human agency in fully autonomous AI in Education systems” (Cukurova), and “What […] we risk losing through automation, […] are we prepared to preserve those aspects that should be preserved (e.g., intentionally ‘not’ automated)?” (Holstein).

What Distinguishes the Ethics of AIED from Other AI Applications?

Survey respondents were asked to reflect on what distinguishes the ethics of AIED from other AI applications/domains and to identify the most important ‘educational’ ethical issues for AIED. The majority of responses identified how issues common to the ‘ethics of AI’ manifest in educational contexts - particularly issues of consent, transparency, control over data and algorithmic bias. In particular, the application of AI to children and young people was noted as a distinguishing feature of AIED (e.g., McLaren). This was not only associated with issues of consent, but also the longer-term individual and social impacts of engaging with young people during a formative period: “We are influencing impressionable young people, and that comes with a moral obligation to be as correct and proper as possible” (Rodrigo). Despite a general recognition of the potential long-term impacts of AIED, two respondents (du Boulay, Santos) also noted that AIED systems do not make the same ‘life and death’ decisions typical of other AI applications, such as autonomous vehicles or medicine: “a bad treatment in learning might imply more effort from the student or more time, but it does not seem as critical as a bad treatment in medicine or a bad decision in an autonomous car, which can cause death” (Santos). This reveals a tension between how researchers frame the ethical issues and potential ‘harms’ associated with AIED.

Another issue noted by the respondents was the value of transparency in AIED systems, with one respondent suggesting that teachers might prefer an AI system that is less accurate but offers more transparency around decision-making “ over an AI system that is perfectly accurate but not transparent” (Cukurova). Others referred to the importance of giving learners agency and control over their data, and the potential impact of algorithmic bias on different sub-populations and demographics of learners. There was particular concern that biased data sets have the potential to benefit more advantaged groups of learners: “Instructional strategies that aim to benefit all learners might disproportionately benefit more advantaged groups of learners. Our community needs to learn to integrate fairness-promoting algorithms into the system and deploy them for real students” (Woolf).

Markedly less common were responses that identified issues specific to the ethics of education, and how these intersect with the ethics of AI more generally. Choice of pedagogy was mentioned by a few respondents, who acknowledged that AIED embodies assumptions about which instructional strategies are ‘best’ for learners. For example, “pedagogy driven AI in Education is often considered as good regardless of [whether] the pedagogy chosen to drive AI is an appropriate one or not in the first place” (Cukurova). One respondent also referred to issues relating to the accuracy and validity of learning assessments more generally: “classifying students in terms of educational tests has to consider the inherent ambiguity and variability in the measure, but for computer scientists we usually consider them as rigid labels” (Santos). Brief reference was also made to the particular responsibilities of educators and the dependent relationship between learners and educators/teaching systems.

Advice for Teachers, Faculty Members and Professors about Teaching the Ethics of AIED

When asked for their advice on how best to teach AIED students to properly address the ethics of AIED, some respondents acknowledged that they did not feel sufficiently qualified: “To be quite honest, I do not know.... I would like to note that very few of us are trained in ethics!” (Aleven). “I feel like I need to better educate myself about this (and in fact, I joined a committee to introduce an ethics curriculum in my department in part to try to better inform myself)” (Walker). One suggestion for how this might be addressed was to: “bring together voices from academics who study ethics, those who build systems and those who will use them.” (Scanlon). Aleven broadly agreed: “ To properly address ethical issues, we probably need to look at a bigger picture than we are used to doing as AIED researchers. And [...] , we should avoid armchair ethics and work with experts in ethics”. Nonetheless, a starting point might be for academics to ‘practise what they preach’: “Ethics need to be modeled in order to be taught. We academics have to conduct ourselves and our research practices as ethically as we know how” (Rodrigo).

Other respondents suggested that academics “ should start with the philosophy of technology use and adoption in general” (Cukurova), and should “learn from the history of AIED, to understand how AIED implements an explicit or implicit theory of teaching and learning, to understand how that affects the learning outcomes and life opportunities of learners, and to explore how this relates to [the] ethics of research in education” (Sharples). Starting with the wider context and previous literature is important perhaps because “we need better guidance than we currently have. A checklist, with items linked to the relevant foundation documents” (Kay). “Maybe a good starting point is to collect some interesting examples of how research can help with ethical issues in AIED” (Aleven).

A common thought was that students would learn best through direct experience: “Don’t just ‘build ethics into the curriculum’. Have students learn by doing. Make ethical considerations a core part of the evaluation criteria (e.g., for student deliverables in project-based courses). Make class discussions around ethics part of the actual formative evaluation / feedback process for student projects” (Holstein). “I would also suggest that they should give actual hands-on experience with AI systems, let their students build, test, play with AI tools in controlled conditions to understand potential ethical issues through experience” (Cukurova). “Introduce them to accessible frameworks (such as those beginning to emerge in AI FATE [e.g., https://facctconference.org ] work) and develop exercises that help people to apply them. This will in turn refine them” (Buckingham Shum) .

Other respondents took this approach an intriguing step further: students might benefit from experience of AIED tools that have been developed without addressing any ethics: “I think it could be an interesting approach to ask them [to] be part of a study where ethics are not considered, so they can perceive the need to take care of it” (Santos). “Mak [e] them investigate a scenario where those principles are not followed and have them research all possible consequences. This way they could figure out not just the basic principles involved but also possible flaws or missing considerations” (Boticario).

Advice for Early- and Mid-career Researchers About the Ethics of AIED

Survey respondents were asked what advice they would give to early- and mid-career researchers about the ethics of AIED. The 16 responses to this question encouraged early- to mid-career researchers to take ethics seriously (Bittencourt, Boticario, du Boulay, Gobert, Holstein, Koedinger, Rodrigo, Sharples, Woolf), to actively participate in discussions about what ethical practice in AIED should look like (Aleven, Kay, Scanlon, Sharples), to critically reflect upon and question their own research practices (Boticario, Cukurova, Holstein, Walker), and to engage with relevant expertise outside of the AIED community (Buckingham Shum, Cukurova, Santos).

Sharples encouraged early- to mid-career researchers to actively contribute to the “development of a code of ethical practice in AIED,” and to abide by this code. A number of respondents urged researchers towards more critical reflection around their own research practice. Walker advised researchers to “think about the implications of what you’re doing and be able to critically engage with them.” Similarly, Boticario said, “we have the *responsibility* to keep our eyes open and respond to what is happening in the world around us. As AIED researchers we are constantly changing the trajectories of others’ lives. [...] If we cannot take responsibility for our actions, we do not deserve to remain in this field.” Holstein advised that “we are a generation [of researchers] that cannot afford to ignore the ethics of AIED,” noting that “generations that are trying to push an innovative technology into the world have the luxury of thinking primarily about hypotheticals,” whereas “the generation that carries forward this work once the systems are already being [used] and impacting lives at scale” must reckon with more immediate ethical concerns.

Finally, several respondents urged early- to mid-career AIED researchers to expand beyond the AIED literature, and to engage with the broader research community outside of AIED. For example, Buckingham Shum encouraged AIED researchers to “consider engaging with academics in critical data studies and tech-ethics.” Similarly, Cukurova encouraged researchers to “read fundamental philosophy as most ethical questions come down to philosophical discussions and frameworks that are driven by certain values.”

Should the IJAIED Require an Ethics Statement for all Articles?

Respondents were asked whether they agreed with the suggestion that all articles published in this journal should be accompanied by a statement explaining how the authors have fully accounted for the ethics of their AIED work. Of the 16 respondents to this question, only two disagreed, but mainly because “the ethics of AIED are not yet defined sufficiently to make this useful or viable” (du Boulay). This was echoed by many of the respondents who did agree (Bittencourt, Boticario, Buckingham Shum, Gobert, Kay, Sharples, Walker), who for example pointed out that “we need much more nuanced conceptions of what ‘ethical’ means” (Buckingham Shum), and that the journal would first need “to indicate clearly what is meant by ‘fully accounted for the ethics’” (Sharples).

Nonetheless, the respondents were broadly in favour. Santos, for example, noted “I think it would help to get more awareness and try to do things right. Maybe it can be asked to have a short section at the end of the paper that the authors explain in their own words how they have covered the ethics in the research reported. It would be something similar to the bios some journals have, or the highlights section .” Other tangible suggestions included: “Perhaps the Journal can ask authors to upload a copy of their ethics clearance” (Rodrigo), and “Authors should be required to provide statements of both positive and negative broader impacts, along with a discussion of trade-offs. Reviewers should then be specifically asked to evaluate these statements, and should be incentivized not to let shallow, ‘ticking the box’-style slide.” (Holstein).

Woolf brought the discussion back to AIED specifics: “Researchers should determine whether the current adaptive tutor is biased in every applied paper published. For [example,] examine the algorithm or the model or knowledge tracing used to track student progress. Does an algorithm select problems that allow students to demonstrate skill mastery before moving on to new content? All authors should evaluate whether their teaching system learned on training data that introduced bias along certain socio-demographic categories.”

Another challenge noted by respondents was how to ensure that such a policy was meaningful: “I do think this is a good idea. As to how it won’t become a tick box, I am totally unsure” (Gobert). In any case, Walker noted, “in practice I do think it is difficult to enforce” . O thers proposed ways in which the spirit of the statement might more effectively be addressed: “My suggestion is to change that statement into a clear and easily affordable questionnaire, where the most basic issues can be specified” (Boticario); “Publishing a more specific list of ethical principles you expect people to engage with and affirm may be an intermediate step” (Walker); “I think it would be very useful to create such a check list of issues to consider” (Kay).

The survey results presented in this paper indicate that AIED researchers recognise the importance and value of engaging with the ethics of their work (e.g., “We need to be sure that our work is of both the highest standards of research and the highest standards of ethics.” McLaren). Nonetheless, there are nuances of opinion with respect to what this might include and how it might be best achieved. With this in mind, in this section, we first summarise key emergent themes and identify some issues that we believe are missing from the discussion; then we propose a draft of an initial AIED ethics framework to help galvanise further debate.

As noted previously, there is no doubt that all respondents do wish to explore, better understand and engage with the ethics of the design and application of AI in educational contexts. However, some respondents appear to believe that we, as a community, are already ‘doing ethics’ by virtue of operating with best intentions in the educational domain, which is in and of itself ethical (e.g., “Many of us got into AIED because we wanted to improve education [...]. Pursuing that goal is doing ethics [...]. Yet, definitely, we could do more .” Koedinger). However, the reality is that “no ethical oversight is required to deploy an elearning system or an AIED system as part of the normal teaching process” (du Boulay).

Clearly, good intentions are not by themselves sufficient. As was acknowledged by several respondents, we need to understand more precisely the ethical risks and to be always on the lookout for unintended consequences that relate specifically to the pedagogical designs (including their readiness for real-world use) that are encapsulated in the AI systems we develop and deploy (e.g., “One could envisage a time when judgements about progress through educational stages might be taken by AIED systems and these might be seriously damaging to individuals’ progress and well-being if they were wrong.” du Boulay).

The precision of such an understanding needs to be expressed in an actionable code of best practice that the community can rely on in designing and deploying AIED technologies in diverse educational contexts. However, although there appears to be a clear appetite for some kind of ethics of AIED framework that would build upon university research ethics, the community also recognises that such a framework also needs to be distinct from the generally established research ethics approvals and procedures. In particular, such a framework would need to incorporate guidance addressing the many issues raised by respondents (including fairness, accountability, transparency, bias, autonomy, agency, and inclusion) specifically at the intersection of AI and the learning sciences, and ensure that AIED is ethical by design and not just by intention.

In this context, the respondents were also cognizant of the problems that such a framework might itself inadvertently entail. In particular, in line with Bietti ( 2020 ), having such a framework might both stifle innovation and lead to accusations of, or actual, in-house “ethics washing” . So, while the community recognises the critical importance of AIED’s specific code of ethical practice, what is meant by ethical AIED remains an open question (e.g., “There is no agreement on the guiding principles.” Boticario). Thus, establishing a useful framework for the ethics of AI in education, although desirable and potentially useful, is likely to be a challenging and long-term task. Specifically, given the diversity of interpretations within the community, as indicated in the survey, it is likely that as well as incorporating presently known ethics-related issues and challenges, any ethics framework developed for the AIED context will need to allow for a degree of flexibility to incorporate new knowledge, new understandings and new ways of supporting learning and teaching, as our science, socio-cultural norms, values, and educational systems change over time (e.g., Porayska-Pomsta and Rajendran 2019 ).

A related important point that emerged from the survey is the observation that AIED is not merely an empirical science but also a design science (Holstein). We understand this to mean that AIED operates in both the theoretical and practical spheres of AI and the learning sciences, and further that as a design science it aims to create educational tools and interventions that are adapted to the demands of different specific users and contexts of use. Highlighting the practical and human-centric orientation of AIED brings into focus the fact that AIED is explicitly concerned with designing interventions which by definition aim to foster positive behaviour change in the users. This is especially important given that many of the intended users of AIED are at pivotal points in their intellectual development.

Adopting a design science orientation also points to another practical outworking of ethical principles – namely, the use of human-centred design methods that give stakeholders genuine agency in shaping digital tools, thus increasing the chances of producing tools that are usable, effective, organisationally acceptable, and ethically sound. However, the AIED community also has to be aware that, despite the best of intentions, human-centred design may itself, in some senses, be sometimes harmful to some users (Norman 2019 ). Nonetheless, a community is emerging around the critical adoption of human-centred design methods and tools for educational technologies powered by analytics and AI (e.g., Buckingham Shum et al. 2019 ). In common with the survey reported in this paper, they ask what makes the specific stakeholders and contexts of teaching and learning distinctive from other domains, that raise specific challenges for human-centred design.

All of these considerations further highlight related ethical implications for AIED. For example, “The system forms an explicit or implicit model of the learner’s knowledge and skills that it uses to make teaching interventions. That model may embody assumptions by the AIED designer as to appropriate methods of teaching and the abilities of the learner.” (Sharples). Thus, AIED’s explicit aim to foster behaviour change in its users, adds additional pressure on the community, to embrace ethics and the related dimensions both as a necessity and as a moral obligation for the community. The flip side of this is that the field (alongside related fields such educational data mining, learning analytics, and user modelling) has a real potential to influence the educational systems at the frontline, precisely because it designs for and deploys in real-world contexts, and to contribute to broader approaches of designing for and deploying AI in other than educational human contexts.

In particular, it might be useful to consider how AIED research may contribute to broader debates about the ways in which AI might impact human cognition, decision-making and functioning. Given AIED’s focus on human learning and development, it is at least worth considering its potential role in informing those broader debates from its unique perspective of designing AI specifically for the purpose of influencing human cognition. AIED’s ambition to support human learning and the field’s proximity to the learning sciences, educational neuroscience and educational practice, likely affords a very human-centric, human-developmental understanding of ethics and related dimensions of fairness, transparency, accountability etc., than is afforded by the more general socio-political and legal considerations in the context of other AI subfields.

Furthermore, as well as contributing to the broader ethics of AI debates, there is a more specific question related to whether or not AIED as community might serve as a guiding discipline with respect to ethics best practices in non-academic areas such as the educational technology industry – something that Blikstein touched upon during his AIED 2018 conference keynote speech. Deciding how this might work best is non-trivial. To begin with, it might be worth considering a distinction between “the ethics of AIED research” (which should be informed by standards such as APA 2014 and BERA 2004), “the ethics of AIED tools and practices in and outside of classrooms” (for which, as we have noted, little has been published), and “the ethics of commercial AIED products” (for which nothing has so far been seen). For each of these, the community might benefit from drawing on the experience of other communities in related areas. In web accessibility research, for example, researchers have critiqued approaches that appear reasonable but that embody counterproductive assumptions that need to be problematised (e.g., Lewthwaite 2014 ).

The various stakeholders (developers, educators, policymakers) all need to be provided key information about the pros and cons of specific AIED technologies – perhaps something in the style of the list of ingredients and allergy warnings on food, or side-effects on medicines. Such key information could include both the known limitations (e.g. in terms of pedagogies, biases of interpretation, privacy etc.), as well as benefits that are likely to emerge from the use of specific AIED systems. Can such an open approach serve to better inform the users’ choices and transparency of what we create? Would it allow the community to become more accountable, more in touch with the broader developments and debates in AI as well as educational practice? The idea is certainly worth exploring as it carries a potential for both making AIED more influential with respect to AI in Education policy and practice, and for informing AIED’s future innovations and its standing in the broader scientific, educational practice and AI contexts.

First Steps towards a Framework

As noted above, the ethics of AI raises a variety of complex issues centred on data (e.g., consent and data privacy) and how that data is analysed (e.g., transparency and trust). However, it is also clear that the ethics of AIED cannot be reduced to questions about data and computational approaches alone. In other words, investigating the ethics of AIED data and computations is necessary but not sufficient . Given that, by definition, AIED is the application of AI techniques and processes in education, the ethics of AIED also as noted earlier needs to account for the ethics of education (Holmes et al. 2019b ). Yet, while the ethics of education has been the focus of debate and research for more than 2000 years (e.g., Aristotle 2009 ; Macfarlane 2003 ; Peters 1970 ), it is mostly unacknowledged and unaccounted for by the wider AIED community.

Because of the rich history, there is inevitably insufficient space here to provide a comprehensive account of the ethics of education. Instead, we will simply identify some pertinent issues, each of which continues to be the subject of debate: the ethics of teacher expectations, of resource allocations (including teacher expertise), of gender and ethnic biases, of behaviour and discipline, of the accuracy and validity of assessments, of what constitutes useful knowledge, of teacher roles, of power relations between teachers and their students, and of particular approaches to pedagogy (teaching and learning, such as instructionism and constructivism).

The three foci identified – the ethics of data, computational approaches and education – together constitute the foundational level for a hypothesised comprehensive ethics of AIED framework (see Fig.  1 ). There is, however, a second level, which is concerned with the overlaps between the three foci (as illustrated in Fig. 1 ): the ethics of data in AI in general (which is, as discussed, an ongoing focus of much research; e.g., Boddington 2017 ), the ethics of data in education (also an ongoing focus; e.g., Ferguson et al. 2016 ), and the ethics of algorithms applied in educational contexts. This third overlap remains the least developed area of research.

A ‘strawman’ draft framework for the ethics of AIED

However, a serious effort to develop a full ethics of AIED cannot be limited even to these six areas (data, computational approaches, education, and the overlaps between them). These constitute the ‘known unknowns’ of AIED ethics, but what about the ‘unknown unknowns’, the ethical issues raised by AIED that have yet to be even identified (i.e., those issues at the central intersection of data, computation and education, and the specific interaction between AI systems use and human cognition at the individual level, indicated by the question mark in Fig.  1 )? Any sufficient ethics of AIED needs to involve horizon scanning, interdisciplinary conversations, explicitly taking into account insights from the learning sciences, cognitive and educational neuroscience, and philosophical introspection. All of these are necessary to help us identify and explore the unknown unknowns, in order to establish a comprehensive framework for the ethics of AIED. In fact, establishing such a framework is only the first step in the process. If our efforts in this area are to have genuine and future use value for the AIED community, teachers, students, policymakers and other stakeholders, considerable effort then needs to be focused on how that framework might be best implemented in practice.

Finally, but no less importantly, we should recognise another perspective on AIED ethical questions: ethics is not just about stopping ‘unethical’ activities. Instead, the ethical cost of inaction and failure to innovate must be balanced against the potential for AIED innovation to result in real benefits for learners, educators, educational institutions and broader society. In other words, the ethics of AIED cannot just be preventative – it cannot just be about stopping researchers and developers from ‘doing harm’. Instead, it needs to provide a proactive set of foundational guidance, within which to ground AIED research and development, which is both protective and facilitative, to help ensure the best outcomes for all stakeholders from the inevitable push of AI into educational contexts.

While the low numbers of researchers attending the Ethics of AIED workshops and responding to the survey reported in this paper suggest that the AIED community have a low level of interest in the ethics of AIED, the responses to this survey and the other papers in this SI indicate otherwise. Clearly, many AIED researchers do recognise the importance and value of engaging with the ethics of their work (indeed, there is no evidence of AIED work that is deliberately unethical). However, as the responses reported here have demonstrated, this engagement now needs to be surfaced, the nuances of opinion need to be discussed in depth, and issues around data, human cognition, and choices of pedagogy need to be investigated, challenged and resolved. In particular, the AIED community needs to debate the value and usefulness of developing an ethical framework and practical guidelines, to inform our ongoing research, and to ensure that the AIED tools that we develop and the approaches that we take are, in the widest sense, ethical by design. It is also clear that without a more targeted approach to the ethics of AIED, the work conducted by the community may remain largely invisible to the rest of the AI subfields and related policies, also potentially stifling the impact of the AIED research on the increasingly human-oriented, real-world applications of AI. With its deep understanding of the human users of AI and the AI’s potential to support human learning and behaviour change, AIED offers critical perspective on the way that people interact with and change due to the interaction with AI systems, and on the potential benefits and pitfalls of such an engagement. The time is ripe to bring this perspective into the open and to allow for cross-fertilisation of AI science and approaches with the benefits for human learning and development as investigated for decades within the AIED field as the guiding principles for AIED and beyond.

Data Availability

The full survey responses will be made available on request. The respondents all gave consent for this to happen.

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APPENDIX 1: Survey questions

“AIED researchers do not pay sufficient attention to the ethics of AIED.” Explain why you agree or disagree with this statement. Where appropriate, please give illustrative examples.

Why is it important for AIED researchers to pay careful consideration to the ethics of their work?

What are the most important ethical issues for AIED?

What are most often ignored yet critical ethical issues for AIED?

What distinguishes the ethics of AIED from the ethics of other AI applications/domains?

The ethics of AIED is often reduced to the ethics of AI (mainly the ethics of data and algorithms), while the ethics of education are often ignored. What are the most important education ethical issues for AIED?

“All articles published in The International Journal of Artificial Intelligence in Education (IJAIED) should be accompanied by a statement explaining how the authors have fully accounted for the ethics of their AIED work.” Please explain why you agree or disagree with this statement. If you agree with the statement, please explain how the journal can ensure that this requirement does not become a worthless tick-box exercise.

What advice would you give to teachers/faculty members/professors about how best to teach/encourage their AIED students to properly address the ethics of AIED?

What advice would you give to early- and mid-career researchers about the ethics of AIED?

Please use the following box to give any other comments that you would like to make about the ethics of AIED.

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Holmes, W., Porayska-Pomsta, K., Holstein, K. et al. Ethics of AI in Education: Towards a Community-Wide Framework. Int J Artif Intell Educ 32 , 504–526 (2022). https://doi.org/10.1007/s40593-021-00239-1

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A q&a with gerald shulman, gerald i. shulman, md, phd.

Gerald I. Shulman, MD, PhD , George R. Cowgill Professor of Medicine (Endocrinology) and Cellular and Molecular Physiology, Investigator Emeritus of the Howard Hughes Medical Institute, and co-director of the Yale Diabetes Research Center, studies the molecular basis for insulin resistance, a condition found in approximately forty percent of U.S. adults.

“One of the major threats to global health in the 21st century, insulin resistance is a key factor in the development of type 2 diabetes, cardiovascular disease, fatty liver disease, neurogenerative disease, and obesity-associated cancers,” Shulman said. “Understanding the molecular basis for insulin resistance can lead to novel therapies that help prevent these diseases.”

Shulman is the recipient of numerous awards, including the American Diabetes Association’s Banting Medal for Scientific Achievement, the European Association for the Study of Diabetes-Lilly Centennial Anniversary Prize, the American Society of Clinical Investigation’s Stanley J. Korsmeyer Award, and the Endocrine Society’s Outstanding Clinical Investigator Award. Most recently, he was selected for the Bodil M. Schmidt-Nielsen Distinguished Mentor and Scientist Award, which recognizes a member of the American Physiological Society who has made outstanding contributions to research and to training the next generation of physiologists.

In a Q&A, Shulman discusses the basics of insulin resistance, how the condition impacts our health, and the steps we can take to reverse it.

What is insulin resistance?

The hormone insulin, which is produced by the pancreas, regulates blood glucose, or sugar from the food we eat, by allowing it to enter the body’s cells, where it is used for energy. Insulin resistance—found in both lean and overweight individuals—is when the body’s cells don’t effectively respond to insulin and take in glucose, leading to high blood sugar levels.

What causes it?

My lab has found that insulin resistance in liver and skeletal muscle, the organs where insulin normally promotes glucose storage as glycogen, is linked to increased ectopic lipid accumulation, or fat accumulation inside the liver and muscle cells.

Why has evolution preserved insulin resistance, something we think of as a deleterious process? It turns out insulin resistance is activated during starvation. During starvation, your body breaks down stored lipid in the white adipose tissue, which becomes mobilized and leads to fat accumulation in liver and muscle cells. These organs become insulin-resistant, which in turn preserves glucose in the bloodstream to fuel brain metabolism and other obligatory glucose-requiring cells in the body (e.g., red blood cells). In this way, insulin resistance is a normal physiological process that has promoted survival from starvation in mammals throughout evolution.

But now, insulin resistance is activated by overnutrition in our toxic food environment.

How does being insulin-resistant impact our health?

Insulin resistance is the major reason people go on to develop type 2 diabetes. The condition also results in metabolic dysfunction-associated steatotic liver disease, in which the body stores excess fat in the liver, and steatohepatitis, which can progress to end-stage liver disease and liver cancer. Muscle insulin resistance also leads to increased plasma triglycerides and LDL, the bad cholesterol, which are major contributors to heart disease.

Insulin resistance is also associated with obesity-related cancers. When you’re insulin resistant, your pancreas produces more insulin, which promotes tissue growth. In preclinical studies, my collaborators and I have shown that insulin resistance promotes the growth of breast and colon cancers.

Finally, insulin resistance is likely a major driver of Alzheimer’s disease.

How can we reduce or reverse insulin resistance?

Our research has shown that modest weight reduction due to caloric restriction to about 1,200 calories a day leads to a reduction of liver fat and reversal of liver insulin resistance and type 2 diabetes. You don’t have to get down to the weight you were in high school—a 10% weight reduction can make a big difference. This is also likely the major mechanism by which the new GLP-1 agonist medications are working to reverse type 2 diabetes.

We have also learned that exercise opens the door for glucose transport into the muscle cell, bypassing the block in insulin action. If you have muscle insulin resistance, you can normalize the storage of ingested carbohydrate into the muscle as glycogen, decreasing the conversion of carbohydrate to fat in the liver. This, in turn, leads to protection from the development of fatty liver disease and improvement in the plasma lipid profile, which will protect against the development of atherosclerosis.

I encourage my patients with diabetes or prediabetes to find a physical activity they like to do every day and stick with it.

As we deepen our understanding of the molecular basis of insulin resistance and develop new drugs to target this mechanism, I’m optimistic about the future of treating insulin resistance and improving cardiometabolic health.

Yale School of Medicine’s Section of Endocrinology and Metabolism works to improve the health of individuals with endocrine and metabolic diseases by advancing scientific knowledge, applying new information to patient care, and training the next generation of physicians and scientists to become leaders in the field. To learn more, visit Endocrinology & Metabolism .

• Endocrinology

Featured in this article

• Gerald I Shulman, MD, PhD, MACP, MACE, FRCP George R. Cowgill Professor of Medicine (Endocrinology) and Professor of Cellular And Molecular Physiology; Co-Director, Yale Diabetes Research Center, Internal Medicine; Director, Internal Medicine

US Senate Panel Chair Issues Subpoena in Supreme Court Ethics Probe

FILE PHOTO: U.S. Senate Judiciary Committee Chairman Dick Durbin (D-IL) speaks to reporters outside a hearing on federal judge nominations on Capitol Hill in Washington, U.S. October 4, 2023. REUTERS/Jonathan Ernst/File Photo

By Kanishka Singh and Nate Raymond

WASHINGTON (Reuters) - The chair of the Democratic-led U.S. Senate Judiciary Committee issued a subpoena on Thursday to influential conservative legal figure Leonard Leo as part of an ethics inquiry spurred by reports of undisclosed largesse directed to some conservative Supreme Court justices.

WHY IT'S IMPORTANT

The Supreme Court in late 2023 announced its first formal code of conduct governing the ethical behavior of its justices, following months of outside pressure over revelations of their undisclosed luxury trips and hobnobbing with wealthy benefactors.

The Judiciary Committee in November voted to authorize subpoenas for Leo, a legal activist and co-chair of the Federalist Society who was instrumental in compiling Republican former President Donald Trump's list of potential Supreme Court nominees, and for Harlan Crow, a billionaire Republican donor and benefactor of conservative Justice Clarence Thomas.

Republican senators walked out of that contentious committee meeting in protest while Democrats cast votes. Some Republicans also questioned the vote's legitimacy, accusing Democrats of violating procedural rules.

"Since July 2023, Leonard Leo has responded to the legitimate oversight requests of the Senate Judiciary Committee with a blanket refusal to cooperate. His outright defiance left the Committee with no other choice but to move forward with compulsory process," Dick Durbin, chair of the Senate Judiciary Committee, said in an emailed statement on issuing the subpoena to Leo.

Durbin said Leo "played a central role in the ethics crisis plaguing the Supreme Court" and "has done nothing but stonewall the Committee."

In an emailed statement, Leo called the subpoena "unlawful and politically motivated" and said he will not be "capitulating" to it. In a letter to Durbin, Leo's lawyer also said he will not comply with the subpoena.

Taylor Reidy, a spokesperson for the committee's Republican minority, said the subpoena was "invalid."

If the subpoena recipient fails to comply, Democrats would need 60 votes in the 100-seat Senate to initiate a civil enforcement action, meaning they would need the support of some Republicans in the chamber where Democrats hold a narrow majority.

The Democrats also would have the option to make a referral to the U.S. Justice Department, which could choose to pursue criminal contempt proceedings against the subpoena recipients.

(Reporting by Kanishka Singh in Washington and Nate Raymond in Boston; Editing by Leslie Adler)

Copyright 2024 Thomson Reuters .

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