The six-thinking-hat technique for decision-making in biomedical ethics

Within the densely packed undergraduate medical curriculum, Biomedical Ethics, the soul of medical profession, is often underestimated in favour of a strong emphasis on clinical decision-making. Biomedical ethical dilemmas are intricate and complex, and clear-cut solutions are frequently not found. Decision-making is further complicated by balancing ethical and legal considerations with multifaceted human factors such as emotions, fears and societal expectations. In this context, cultivating critical thinking skills is crucial in preparing students to navigate the inherent complexity of bioethical dilemmas.

De Bono's Six-Thinking-Hats (6TH), with the six-coloured hats representing six unique thinking approaches, provides a versatile framework to enhance critical thinking.¹ For the last 5 years, we have used the 6-TH to simplify decision-making in Bioethics for pre-final-year medical undergraduate students. One topic is ‘Disclosure of Medical errors’, wherein we utilize a clinical vignette involving a patient mistakenly implanted with an Intraocular lens of wrong power. Students are guided to brainstorm systematically, focusing on one aspect at a time, symbolized by the hat's colour, to make an ndividualized decision. The blue hat is the overview and summarizing hat; red hat represents emotions (How would you feel if you had been the patient or part of the operating team?); white hat represents facts and information (Which factors caused the error?); black hat represents judgements and cautions (What are the consequences of delayed/no disclosure?); yellow hat for positive criticism (What are the positive implications?) and green hat for creativity (What should be done now?).

Understanding the 6-TH's governing principles and each hat's strategic sequence and timing is key to its successful implementation. Though there is no rigid sequence, a pre-set order of hats must be set up under the blue hat and followed consistently. In our disclosure scenario, we follow blue-red-white-black-yellow-green-blue. In such emotionally challenging scenarios, the red hat is preferred immediately after blue because of the significant emotional and fearful dimensions involved. Black, the usually feared hat, is crucial here for identifying potential consequences for the patient and the surgical team.

Pre-deciding each hat's time is vital; in a 60-min session and a class of 30 students, we give 6−7 min for each hat. Starting with limited time is generally more productive. In our case, the red hat has always taken the shortest and green the longest, because emotional responses are often prominent and devising a solution can be particularly complex.

Students often deviate from the designated hat, making it difficult for the facilitator to keep them within the designated thinking boundaries. Maintaining focus can thus be challenging while simultaneously fostering a safe space for open student dialogue.

Drawing from our 5 years of experience utilizing the sequential, focused thinking approach of 6-TH and feedback from over 400 students, the technique effectively helped students navigate decisions in bioethical dilemmas. However, challenges like difficulty establishing session outcomes, lack of evaluation norms, and the overall temporal demands associated with design and implementation phases were of significant concern to the teaching faculty.

Sumita Sethi: Conceptualization; methodology; formal analysis; supervision; writing—review and editing; writing—original draft; resources. Renu Garg: Conceptualization; methodology; writing—review and editing; formal analysis; supervision.

There is no conflict of interest to declare.