The asymmetry in power relations that exist between physicians and patients also exist between teachers and students. Thus, the dimensions of student care are analogous to those of patient care. The interactions between teachers and students are analyzed using the framework of the principles of beneficence (non-maleficence), autonomy, and justice, which have been generally applied to physician-patient interactions.
Educational enterprises are intrinsically optimistic. Underlying all such endeavors is the belief that changes that occur in knowledge, skills, and attitudes are not only possible but desirable. The precise combination of desirable changes in the three components is obviously dependent on the particular context. Consideration of the desirable changes in each of the three components requires answers to the following questions: a) What needs to be learned (content), b) how is it to be learned (process), and c) why should this occur (ideology).
The answers to these three simple questions do not yield precise or unambiguous answers because educational enterprises can be seen from more than one perspective: from that of the teacher, the student, and society at large. Conflicts that arise often can be traced to fundamental disagreements between the perspectives of each of the participants. Thus, students may enroll in biology courses to help them pass entrance examinations to medical schools, whereas their teachers (often researchers) may want to instill in them a passion for the subject and provide details that may seem utterly superfluous. Some societies may prefer that certain key biological concepts (evolution) not be taught at all.
It could be argued that the most important component in the educational matrix is the students, and taking their perspective would appear to be the most logical approach. In recent years, much emphasis has been laid in designing curricula that shift the locus of control from the teacher to the student. For the past dozen years, I have been involved in a variety of courses that seek to do just that. These courses fit loosely into the category of problem-based learning (PBL) 11 courses, although I would prefer to think of them as student-centered ones. Although these have included courses in the liberal arts, undergraduate science, and health professional programs, they have occurred while I have been in a Department of Medicine, in a Faculty of Health Sciences. As such, my views have been necessarily colored by discussions concerning health care, and it appeared to me that much of the arguments raging around health care and physician-patient interactions can be fruitfully applied to teacher-student interactions.
The tone of optimism that underlies the educational enterprise and the establishment of modern universities can also be sensed in modern hospitals. In one setting, students enter with the expectation that the education they receive will improve their lot in life. In the other setting, patients enter with the hope that they will get better. Failures in both settings do occur, but the continued presence and growth in both institutions testifies to society's willingness to invest in such enterprises. Health care and education share other things in common. In both there is a certain asymmetry in the power relationships between those who seek help and those who give it. Because these asymmetries are real and cannot be wished away, in the discussion that follows I use the terms “teacher-student” or “physician-patient” interactions, rather than the other way around. However, it is becoming increasingly clear that without the active participation of the seekers, care would be less than optimal. Thus, the discussions in health care in recent years have emphasized the empowerment of patients much as new curricula emphasize student-centered learning.
THE PRINCIPLES OF HEALTH CARE AS APPLIED TO PATIENT-PHYSICIAN INTERACTIONS
At the roots of the debate underlying physician-patient interactions is a tension that springs from the difference between respecting the freedom of persons and securing the best interests for them as patients. Patients often engage in behaviors that are detrimental to their well being, but health care givers must often tolerate these behaviors. On the other hand, as health care professionals, they have chosen a profession that entrusts them with the task of achieving the best interests of their patients. Thus, respecting individual autonomy may conflict sharply with the requirements to either benefit them or at the very least not do them any further harm . In addition, health care workers consider not just one patient but many. Three overarching principles frame the discussion in health care . These are: a) beneficence or non-maleficence (i.e. either doing good or not doing harm); b) respect for autonomy: the right of individuals to be self-determining; and c) justice: treating similar cases similarly, with fair allocation of goods and services.
These principles can be interpreted from two different frameworks: deontological or teleological. In deontological analysis, individuals are to be respected as ends in themselves and not merely as means to an end. So the principles mentioned above will be interpreted as duties (to cause no harm, respect autonomy, and treat similar cases similarly). In the teleological framework, the consequences of specific choices and deeds are considered. In this analysis, the same principles will be interpreted as ends to be achieved such that autonomy, benefit, and justice are goods to be maximized . The two frameworks do not yield the same answer to specific issues. Physicians often operate from a deontological (duties) framework, as they focus their attentions on their duties and obligations to the individual who seeks their help. The health care system of which they form a part often operates on the teleological (ends) framework, because it is concerned with all those who form part of the patient pool. In this analysis, consideration of economic issues is inescapable . In some sense, similar problems emerge with respect to education. Teachers interested in their students may prefer small classes in which individual attention can be given. Administrators on the other hand, who are more acutely aware of costs, may prefer larger classes and the use of cost-saving technologies. Approaches based on principles (disparagingly called principilism) seems far too idealistic, and other approaches such as casuistry [2, 3] have been proposed. Nevertheless, as a first approximation, I will apply the above principles to teacher-student interactions.
APPLICATION TO TEACHER-STUDENT INTERACTIONS
In the sections to follow, I will apply each of those principles to student-teacher interactions:
Beneficence implies that, as teachers, our actions should be in the best interests of the students or at the very least we should cause no harm. What does this mean and how can this be achieved? What kind of knowledge, skills, and attitudes can we foster in our students so that they would benefit the most or be harmed the least? Departments and teachers are concerned with designing curricula. Most disciplines design curricula that emphasize knowledge acquisition (content) because these are much easier to define. Will we be really benefiting our students by saturating them with the information that we have accumulated? Would it be wiser to invest time and effort in promoting skills such as information retrieval and critical analysis because these may actually be far more beneficial in the long run?
Will we really benefit our students by being overly protective, telling them all they need to know, and glossing over their errors? Can a little stress judiciously used be far more beneficial in the long run, to practice in an educational sense what Bond  calls “paradoxical pharmacology”? Stimulating students by provoking them may appear exhilarating to the teacher, but many students may not know how to respond appropriately. Unfortunately, there is an inherent asymmetry in the relationship between teachers and students. Boud  has emphasized that the language we use to evaluate students creates tension in them because of the position we occupy. The language used may appear reasonable to the teacher but not to the student. “Teachers,” he notes, “often judge too much and too powerfully, not realizing the extent to which students experience the power of their teachers over them.”
Another element that is not often considered is the issue of time. Sometimes the best thing we can give our students is time so they can talk to us. They often come to query a mark or a note but really want to talk about something else. Given our busy schedules, it is very difficult to gauge what is bothering them or why we should worry about those issues. Clearly, there is a close parallel here to the situation that exists in health care delivery, in which social pressures force physicians to spend less and less time with their patients.
The term autonomy is ambiguous  but, in the context of educational goals, can be considered as a way of encouraging students to make their own decisions. This implies that as teachers, we should treat our students with respect for their individual aspirations and idiosyncrasies. This laudable aim becomes difficult to institute in practice. The tensions in physician-patient interactions, as mentioned earlier, arise from just this point. Simple things become complex. Consider the issues of learning and evaluations. Students often have different learning styles. Thus, to promote individual growth and development, teachers should adopt different learning styles or at the very least create a menu from which students can pick the one best suited to them. This is practically impossible to achieve under most circumstances. Even worse, not all students perform well on the same set of evaluations. To be fair, one must set up different evaluation procedures so that students can be given an opportunity to display their strengths not just expose their weaknesses. Again, given pressures of time and resources, these worthy aims may be very difficult to achieve.
Let us take another issue: deadlines. Several of my students have elevated procrastination to an art form. They try to hand in their essays at the last minute. Sometimes this strategy fails, and they miss the deadlines. They present a variety of excuses varying from the banal to the fantastic. Should or should not a penalty be imposed? The anarchist in me says no, but the responsible teacher says yes. By permitting some students to be slack (thus respecting their autonomy), I will penalize those who meet deadlines. Everyone can do a better job given time. However abilities to manage time in the wake of numerous distractions must be rewarded. Of course, a casuist would say, those who meet deadlines are expressing their own autonomy! These issues become messy in programs that promote self-directed learning. Students often misunderstand the meaning of that term. I have to caution them that it is not self-indulgent learning and that there are clear objectives.
Justice implies that we treat students fairly. Again, the more distant we are from them the easier it is. Large classes are very comfortable in this regard. The teacher looks at a sea of faces and can ignore individuals quite easily, treating them fairly with “objective” exams. This becomes very difficult to do in small classes where one is acutely conscious of personal quirks, idiosyncrasies, aspirations, and hopes. I set up clear criteria and expectations. I have often been more critical of the students who have potential but underplay it and more sympathetic to those with less talent who use it to the fullest. But justice must not only be done but be seen to be done. So formative assessment through self and peer assessments becomes important to capture the changes that occur in student learning, particularly in courses that actively promote student-centeredness. Unfortunately, the proper use of such measures is difficult, and their use becomes rather mechanical and perfunctory.
An attempt to balance these principles for an individual student is difficult; to try and balance them for a class full of students becomes even more difficult. When class sizes become immense, things get easier because we quietly ignore students as individuals and start treating them as numbers, which is the comfortable option that many schools and administrators assume. The greatest good for the greatest number becomes a comfortable mantra; but which number and whose good become highly contentious.
Once again, the problems facing physicians are analogous. Balancing beneficence, autonomy, and justice for individual cases is one thing; to juggle these in the complex web of limited resources is another. Doctors have obligations not only to their individual patients but also to the society in which those patients exist. Often, as is the case with public health measures, these obligations conflict. Lamm  notes that “the ‘moral unit’ of a physician is the patient, while the moral unit of public policy is all citizens.” He argued that one “cannot build an ethical code for a publicly funded system around assumptions ‘that cost is never a consideration.’” A similar dilemma faces those educators who operate under similar conditions.
BARRIERS TO OPTIMAL STUDENT CARE
Teachers interested in their students' welfare face challenges similar to those faced by physicians interested in the welfare of their patients. In both instances, empowering the recipients would help. With particular reference to education, the real issue is the effectiveness with which one can shift the locus of control from teacher to student. Student-centered curricula are not the panacea for all ills, nor do they guarantee wisdom; nevertheless, properly used they go a long way toward the desirable goals of training students for uncertainty. But how feasible are such approaches? What barriers exist?
In discussing such barriers, I will use the metaphors that Francis Bacon  used when he considered the “Obstacles that lay in the Path of True Directions in the Interpretation of Nature.” His analysis has a particular meaning for those of us who are involved in the teaching of science, which in its present form was largely a creation of the 17th century. Bacon referred to these obstacles as idols, “false notions which are now in possession of the human understanding and have taken deep root therein,” and which work against true understanding. These were:
The Idols of the Tribe—
Stem from the inherent limitations of the human mind and senses, our tendencies to draw conclusions from limited evidence, and our search for certainty where none can be expected.
The Idols of the Cave—
Arise from the blinkers provided by our upbringing, culture, and training, which reinforce the idols of the tribe in drawing conclusions to fit our prejudices.
The Idols of the Theater—
Are the false notions perpetuated by the great systems of thought that defy questioning.
The Idols of the Marketplace—
Bacon felt, were the most troublesome of all. These are errors that arise from the conventional usages of words as they evolve over time. Habitual modes of expression become applied to situations and those using them do not realize the inappropriateness of so doing.
The idols remain, but the trappings have changed. It is ironic that Bacon referred to the market place, which has given education the most pervasive, annoying, and demeaning metaphor. The market metaphor has become pervasive. Patients become clients, physicians become salesmen; teachers are in the marketplace, and students shop around. But patients are not customers, and students are not clients. The application of inappropriate metaphors distorts the essence of education. Teaching and learning require care and consideration, not a quick sales job and a trip to the bar with a bonus. Unfortunately, both society (governments/funding agencies) and often students want quick fixes.
Teachers, however motivated and sincere, are only part of the educational enterprise. For the entire enterprise to work effectively, we must engage our students in their learning. Whether we choose to foster such engagement is to some extent dependent on the kind of society we wish to create. An open, libertarian society espouses certain values, often implicitly, sometimes made explicit. Giving participants a voice is an important consideration in such societies because it provides an important mechanism to counter decline or deterioration.
OPTIONS: EXIT AND VOICE
Hirschman  explored the ways in which different organizations responded to decline or failure. He argued that with time most organizations developed slack and experienced deterioration in their output. The management of such organizations could recognize this decline if a) some members left the organization and/or customers stopped buying the product (i.e. the exit option), or b) members or customers expressed their concerns (i.e. the voice option).
Effective response by the organization would stem the rot. The mix of exit and voice options differs considerably among organizations. The extremes are where one or the other option is either marginal or nonexistent. Thus, the voice option is minimal in competitive business enterprise as far as customers are concerned. The exit option is difficult in families, tribes, or religious groups. There are also organizations in which both exit and voice options become problematic, as in totalitarian states, criminal, or terrorist gangs.
It is interesting to apply these notions to educational endeavors. One would anticipate that the relative importance of each of these options would depend on whether the courses were teacher or student centered (Fig. 1). In the former case, one would expect the exit option to predominate. True students are asked to evaluate courses, but whether such evaluations are seriously considered is a moot point. Some courses may persist for years despite indifferent teaching, as these are service courses that students may be required to take. Where students have an option, they may just choose not to register. The situation is different with programs that are believed to be more student centered. These include programs in which a significant portion involve PBL. In such courses, student opinions are assiduously sought. Often, students are told that appropriate evaluation of the tutor and the course is part of fostering responsible learning. But here again, action may or may not be taken based on the evaluations received. Poor tutors continue to be foisted on unwilling students, and well-recognized course deficiencies persist. Nevertheless, in most of the PBL courses that I have been involved with do attempt to take student input quite seriously. Sometimes, the reaction to student comments leads to changes that are puzzling to a subsequent class. I have occasionally told students that they should really take a course twice, the second time to suffer the consequences of the changes they wanted. However a sin of commission in this instance is preferable to one of omission. It sends a clear message that student comments are valued. If input is asked but never acted upon, a sense of cynicism prevails that does not bode well for meaningful education.
Much of the discussion in this essay has related to student-teacher interactions. I have tried to apply to these the notions that have emerged from discussions around physician-patient interactions. Clearly, such analogies have limitations. Patients are often more vulnerable than students. The latter, through their unions, have often a greater voice in university affairs than patient groups. Patients or patient groups are becoming increasingly vocal, although many may exercise the exit option by seeking alternative medicines. Nevertheless, in both instances it is society at large that creates the framework in which such options are made possible. It is society that invests in education in general and university education in particular. What students need to learn and how they should learn depends to a large extent on the ideological underpinnings of society at large. I have taken the perspective of one who is fortunate enough to live in a society that is ostensibly open and libertarian. Other societies may hold other views that would decide the operational details of a teacher's involvement with their students. Whatever the context, I would submit that the dimensions of student care must include in some form or the other a respect for a students' autonomy, a willingness to benefit them, and a certain measure of justice.
A sincere thanks to the large number of students who have kept me wondering whether I am doing the right thing. I am also grateful to the Canadian public that continues to fund public universities and to my department, which generally leaves me alone. Thanks to Liz Penney for making this readable.
The abbreviation used is: PBL, problem-based learning.