Using a mock legal trial to debate a controversial subject

This is a downloadable case study on the use of a mock legal trial to debate a controversial subject within the School of Medicine

Using a mock legal trial to debate a controversial subject: a variation on flipped teaching

Aims

This session forms part of ME3055 “Cardiovascular Medicine: An Evidence-based Approach”, a final year module for BSc Medical Pharmacology and Intercalated BSc students.  It aims to immerse the students in the subject, encourage them to be critical and skeptical and to form their own opinions around a controversial subject area in a fun and interesting way.  This presents an ideal environment for active deep learning.

Disclaimer

This is a mock trial and procedures have been altered/may be very different to those in UK law.

Argument

“Statins” (cholesterol-lowering drugs) are in the dock accused of “doing more harm than good”.

Background

These drugs constitute the most commonly prescribed medicines in the UK today. If you don’t take one yet, it probably won’t be too long before you do! National Institute for Health and Care Excellence guidelines now recommend statin therapy for anyone with a 10 per cent risk of developing cardiovascular disease within the next 10 years.

However, this extended use comes with significant controversy surrounding the increased incidence of reported (and often debilitating) side effects.  Hence the question whether they are doing more harm than good.

Wider pedagogy

While this session lends itself very well to an in depth study of the clinical implications of increased drug therapy, in reality it could easily be adapted to other controversial/debatable subject areas/academic disciplines.

The Flip

One week before the session, guidance on the trial process is uploaded to Learning Central (LC) along with a specific set of Learning Outcomes.  Importantly the brief informs the students that they have to get together in teams to plan their legal case.  The class of 32 students is split in to four legal teams (two Defence and two Prosecution) for Trials A and B (two consecutive 80 minute sessions). Both are “trials by Judge” (me!) and no jury was put in place (potential to do this for bigger classes perhaps).

At the same time a number of peer-reviewed papers that illustrate both sides of the statin argument are uploaded to LC. As such all ”evidence” is open to be viewed by both Defence and Prosecution teams. Giving the students time to cover background material in this way, and become conversant with it, before the related teaching session is what appeals. It puts ownership of the scholarship in their hands, with the educational focus being on peer-to-peer cooperative learning.

Building the case

Using the papers and articles uploaded to LC (and/or the much wider literature available through PubMed https://www.ncbi.nlm.nih.gov/pubmed), the Defence and Prosecution teams then formulate their case before coming to the formal session. The Prosecution team chooses three people to act as witnesses – a patient (highlights the debilitating side effects on their quality of life), a general practitioner (sees lots of patients presenting with side effects, questions cost-benefit of increased prescribing) and a diabetes specialist (statin treatment is associated with an increased incidence of Type 2 diabetes).

The Defence team also chooses three people to act as witnesses – a professor of cardiology (highlights the benefit of statins with regard to cardiovascular disease prevention), a pharmaceutical company representative (many statins are now off patent and potentially present a very cost effective treatment option) and a professor of pharmacology (details the effect of lowering plasma cholesterol on the progression of atherosclerotic vascular disease).  The barristers (different people to those who made the opening statements) then ask the witnesses a maximum of 3 questions each to build the case.  The team should construct the questions in the week before the case in conjunction with the witness.

All occupations are chosen deliberately to make it easier for the respective teams to build their cases and formulate the cross examinations.

The Prosecution teams are told that they must show enough evidence to make the Judge feel really sure that the defendants (statins) are guilty. If the Judge is not sure then they must give a "not guilty" verdict. Under the principle that statins are “innocent until proven guilty”, the Defence teams are told they do not have to prove the accused is innocent. Rather they should present information that puts the accused in the best light while casting doubt on the Prosecution's potential arguments.

The Trial

Opening statements. The Prosecution and then the Defense make opening statements to the Judge. These statements provide an outline of the case that each side expects to present.

Each team chooses one or two members to act as presenting barristers but the whole team must make a contribution to putting the case together.  The case may be delivered by giving a speech or using Powerpoint slides.  Either way this should last no longer than 10 minutes for each team.

Prosecution case-in-chief. The Prosecution presents its main case through direct examination of Prosecution witnesses. The barristers (different team members to those who made the opening statements) ask the witnesses a maximum of three (previously constructed) questions each to build the case.

Cross-examination. While the Prosecution barrister is questioning each witness, members of the Defence team come up with three response questions for their barrister to present. These questions may also include examples that have been previously constructed given the knowledge of the witness’s “area of expertise”. Again this barrister can be anyone from the Defence team. During this questioning, both legal teams are allowed to object, and depending on their reason, the Judge will sustain or over-rule.

Prosecution rests

Defence case-in-chief. The Defence presents its main case through direct examination of Defence witnesses. The barristers (different team members to those who made the opening statements) ask the witnesses a maximum of three (previously constructed) questions each to build the case.

Cross-examination. While the Defence barrister is questioning each witness, members of the Prosecution team come up with three response questions for their barrister to present. These questions may also include examples that have been previously constructed given the knowledge of the witness’s “area of expertise”. Again this barrister can be anyone from the Prosecution team. During this questioning, both legal teams are allowed to object, and depending on their reason, the Judge will sustain or over-rule.

Defence rests

Closing arguments. Each legal team chooses one or two people to present their closing arguments, but all must make a contribution to putting it together.  This may be delivered by giving a speech or using Powerpoint slides. In both cases it should last no longer than 10 minutes. While these can be prepared in advance, a short break is allowed to add anything that has come to light during the trial.

Prosecution closing argument. The Prosecution makes its closing argument, summarising the evidence as the Prosecution sees it and explaining why the Judge should render a guilty verdict.

Defence closing argument. The Defence makes its closing argument summarising the evidence as the Defence sees it and explaining why the Judge should render a "not guilty" verdict.

The Verdict

As the trial proceeds, the Judge makes an evaluation of how well each legal team presented and questioned their witnesses and also how effective each cross-examination was. The verdict is then based on which team performed best overall, the Judge being careful to explain why that decision has been reached.

Reflection

As the Judge, it is very interesting to sit and watch the students presenting their cases in a very passionate way.  Their level of “buy in” shows how much effort they have put in to formulating their cases. The questioning and cross-examination sections are always enthralling.  Allowing them to object (for good reason) forces the opposing team to think on their feet in having to reword a question or ask a different one. This demonstrates the working knowledge of a complex subject that the students have developed within a short time frame.

Asking more than three questions, or having more than three witnesses each, draws the session out too much.  In the structure described about a good pace can be established, thus maintaining the interest of the participants.

The students do not react very well to a hung verdict.  They become quite vehemently attached to the case they are presenting and are excited by the competitive element of this mock trial. The Judge should always take time to carefully explain their decision in full.

End of module exam

If a question is set on this topic in the end of module exam, it is always open-ended and asks for the students to express their opinions.  Importantly the latter should be thoroughly supported by evidence from the published literature.  As a result, a whole variety of answers can be presented and the level of detail furnished by wider reading of the literature is very evident. This more than fulfills the aims of this activity outlined above.

Take home message

Without doubt, this is one of the most rewarding teaching sessions I have ever been involved in.

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