Design Bioethics, Not Only as a Research Tool but Also a Pedagogical Tool

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Design Bioethics, Not Only as a Research Tool but Also a Pedagogical Tool

SADER, Julia, et al.

SADER, Julia, et al . Design Bioethics, Not Only as a Research Tool but Also a Pedagogical Tool. The American Journal of Bioethics , 2021, vol. 21, no. 6, p. 69-71

PMID : 34036889

DOI : 10.1080/15265161.2021.1915416

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Design Bioethics, Not Only as a Research Tool but Also a Pedagogical Tool

Julia Sader, Marie-Claude Audétat, Mathieu Nendaz, Samia Hurst & Christine Clavien

To cite this article: Julia Sader, Marie-Claude Audétat, Mathieu Nendaz, Samia Hurst & Christine Clavien (2021) Design Bioethics, Not Only as a Research Tool but Also a Pedagogical Tool, The American Journal of Bioethics, 21:6, 69-71, DOI: 10.1080/15265161.2021.1915416

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© 2021 The Author(s). Published with license by Taylor & Francis Group, LLC Published online: 26 May 2021.

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Design Bioethics, Not Only as a Research Tool but Also a Pedagogical Tool

Julia Sadera , Marie-Claude Audetata , Mathieu Nendaza,b , Samia Hursta , and Christine Claviena

aUniversity of Geneva;bUniversity Hospitals Geneva

As highlighted by Pavarini et al. (2021), researchers in the field of bioethics have to remain critical and reflexive on the methodology and on the tools they use for their research purpose because they are neces- sarily rooted in preliminary theoretical commitments.

Since Bioethics is a rather “new” research field, it has mostly borrowed methods and tools from other fields.

“Design bioethics” however, is a domain in which bio- ethics can develop its own purpose-built engi- neered tools.

While Pavarini et al. (2021) mainly focus on the importance of rigorous and well thought out develop- ment of design bioethics for research purposes, our interdisciplinary team is currently working on the use of purpose-built digital toolsfor teaching purposes. We investigate the use of serious games in medical educa- tion, their impact, and the ethical challenges they raise (Sader et al. 2021). It is important to identify the advantages and weaknesses of such teaching tools in order to optimize their implementation and transfer- ability. It is also important to identify possible ethical issues raised by the use of such games and address them ahead of their implementation in “real life clin- ical setting” (Kim and Werbach2016).

Serious games as a pedagogical tool are more and more used in medical education (Gorbanev et al.

2018). A serious game is a digital environment in which players can make choices in realistic complex situations under uncertainty. Players’ decisions have consequences in the game and players receive critical feedback on their choices. They can try out various

choice path and while doing it gain knowledge about how to make more appropriate choices. There is a wide range of applications for such tools. For instance, one can use a serious game with the aim of improving moral competences (Katsarov et al. 2020). Or as we do (Sader et al. 2021) one can use serious games for debiasing physicians who are likely to be influenced in their practice and clinical reasoning by unconscious cognitive mechanisms (anchoring bias, confirmation bias etc.).

Serious games as teaching tool have many advan- tages. There is a “fun” component of playing which makes this pedagogical medium attractive. The immersive component of the game allows to make more embodied decisions which are close to players’ true reactions in the real world (Buzady 2017;

Gorbanev et al. 2018). This virtual reality experience increases users’ attention and openness to critical feedback (Gorbanev et al. 2018, 2019; Katsarov et al.

2020; McCall and Baillie 2015; Schrier 2015). Serious games also allow players to explore, at their own pace, various chains of consequences. They provide an equal-quality teaching to large groups of students and can flexibly be implemented in a variety of settings (at home, in class) and timeframes. Serious games also allow for feedback adjusted to individual players’

choices in the game.

Despite all these advantages, given that by design, serious games are predefined in their aim, preliminary epistemological choices, and theoretical content, it can limit pedagogical flexibility and raise ethical issues. It

CONTACTJulia Sader UDREMUnit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Rue Michel Servet 1, Geneve, 1211, Switzerland; iEh2Institute for Ethics, History, and the Humanities, Faculty of Medicine, University of Geneva, Rue Michel Servet 1, Geneve, 1211, Switzerland.

ß2021 The Author(s). Published with license by Taylor & Francis Group, LLC

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License ( nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.



is important to be aware of these issues ahead of the decision to include a serious game in a teaching cur- riculum. Such knowledge provides the opportunity to carefully weight the reasons for or against the use of a given serious game, or of specific design features of a game, and to find solutions to address potential eth- ical issues. In what follows, we will showcase some of the main issues that might arise and how they may be addressed.


When playing a digital serious game, users will prob- ably need to log in with their personal identification information. In the medical context, students may be physicians following a continuous training and they may be worried about being judged or possibly disad- vantaged at their workplace if they score badly in the game (McCall and Baillie 2015; Schrier 2015). Thus, a double issue needs to be addressed here: actual confi- dentially and trust, that is, students’ belief that confi- dentiality is secured. This issue is particularly problematic since, as we shall see below, it is import- ant to collect data on users’ behavior in the game in order to assess the relevance of the content and the pedagogical value of the teaching tool.

To address these problems, transparency and informed consent from players are needed. Moreover, confidentiality may require that an independent edu- cation unit or an external company is mandated to process and anonymize users’data.


By design, serious games only allow for scripting a limited number of chain of consequences. Therefore, only selected information and teaching goals can be included in such a tool. Moreover, the development of a digital serious game is costly, and once developed, further content adjustments are difficult to make. This limitation and rigidity may not be problematic if the teaching content is unlikely to change (Gorbanev et al. 2018). But this is not the case in the medical field, especially when the teaching is based on know- ledge and theories from bioethics or cognitive psych- ology. These are moving fields in which long-standing debates occur relating to basic theoretical commit- ments such as what are the required moral competen- ces for physicians, or what biases influence medical practice. Game designers’ choices of content may seem arbitrary and may soon become obsolete.

One way to address this issue, is to plan a strategy of longitudinal feedback, while designing the game and while including the game in a teaching curricu- lum. Well-thought objective efficacy measures help to identify when a given serious game is outdated and how future games could be adapted and improved.


Given the quick advances we see with software, com- patibility issues with existing computers and operating systems may arise. And after several years of use, soft- ware obsolescence and vulnerability to malware may pose security issues.

It is therefore important to make a careful choice of technology, to plan continuous updates, and to elaborate cyber risk mitigation measures.


Depending on the content of the game, it may be dis- turbing for a player to make the “wrong” choice and be confronted with adverse consequences. Students may misunderstand or disagree with the automatic feedback provided by the game. Or even worse, stu- dents may misunderstand the instructions of the game, or choose an option of the game with a differ- ent motivation or rationale than the one envisioned by the game designer, and thus receive a mismatching feedback comment.

To address this difficulty, high-standard quality checks may be conducted before using the game in a teaching curriculum. Moreover, since misunderstand- ings and discomfort are more likely to go unnoticed in serious game teaching than in ordinary in-class teaching, it seems important to plan an effective strat- egy of longitudinal feedback (Dieckmann et al. 2009).

This may be done either technically (ex: possibility to leave commentary in the tool or on an online plat- form) of by complementing the use of the tool with a face-to-face teaching session.


Some serious games are used to set traps for educa- tional purposes (McCall and Baillie 2015; Schrier 2015). For instance, powerfully immersive games may softly manipulate users’ choices in order to induce

“wrong” decisions and thereby, create an awareness experience. This is the case of games designed for making users aware of their own cognitive biases


(Barton et al. 2016), and consequently, more willing to address the issue and to develop practical response solutions. Even though these pedagogical methodolo- gies can be justified, their application may be disturb- ing for students who are not completely free to avoid wrong choices within a teaching context.

Therefore, a tailored feedback is most needed, not only to help participant make something out of this uncomfortable experience, but also in order to explain and justify why they have been led to such deci- sion paths.


It may happen that the tool does not generate suffi- cient gain of knowledge to be pedagogically satisfac- tory. Feedbacks and recommendations implemented in serious games rarely exceed a few sentences. If the teaching aims are complex (ex: to improve critical eth- ical thinking or to mitigate the biases of participants), students may need tailored inputs that the tool does not provide. For instance, if students become aware of one of their bias while playing in a serious game, they may need to think of a way to avoid the expression of that bias in their ordinary medical practice (ex: by preparing a scripted response to specific situations).

In these cases, the tool should be thought as part of a more embedded pedagogical strategy including face-to-face teaching session which allow for human interactions and flexible adjustments.

To conclude, serious games are useful teaching tools but in order to avoid inefficiencies and adverse effects designers have to remain critical and reflexive on the methodology. This involves reflection about their pedagogical aims and assumptions, adjustments to the pedagogical framework, and planned feedback and quality assessments. Some of our comments are generalizable beyond serious games to any kind of design issues for bioethics curricula.


Julia Sader Marie-Claude Audetat 9126-2214

Mathieu Nendaz Samia Hurst Christine Clavien


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