Testing the validity of a scenario-based questionnaire to assess the ethical sensitivity of undergraduate medical students

BACKGROUND: Although medical educators acknowledge the importance of ethics in medical training, there are few validated instruments to assess ethical decision-making. One instrument is the Ethics in Health Care Questionnaire--version 2 (EHCQ-2). The instrument consists of 12 scenarios, each posing an ethical problem in health care, and asking for a decision and rationale. The responses are subjectively scored in four domains: response, issue identification, issue sophistication, and values. GOALS: This study was intended to examine the inter-rater and inter-case reliability of the AHCQ-2 and validity against a national licensing examination of the EHCQ-2 in an international sample. METHODS: A total of 20 final year McMaster students and 45 final year Glasgow students participated in the study. All questionnaires were scored by multiple raters. Generalizability theory was used to examine inter-rater, inter-case and overall test reliability. Validity was assessed by comparing EHCQ-2 scores with scores on the Canadian written licensing examination, both total score and score for the ethics subsection. RESULTS: For both samples, reliability was quite low. Except for the first task, which is multiple choice, inter-rater reliability was 0.08-0.54, and inter-case reliability was 0.14-0.61. Overall test reliability was 0.12-0.54. Correlation between EHCQ-2 task scores and the licensing examination scores ranged from 0.07 to 0.40; there was no evidence that the correlation was higher with the ethics subsection. CONCLUSIONS: The reliability and validity of the measure remains quite low, consistent with other measures of ethical decision-making. However, this does not limit the utility of the instrument as a tool to generate discussion on ethical issues in medicine.