Teaching Medical Ethics in Medical Schools
2003; King Faisal Specialist Hospital and Research Centre; Volume: 23; Issue: 1-2 Linguagem: Inglês
10.5144/0256-4947.2003.1
ISSN0975-4466
AutoresFadheela Al-Mahroos, Raja C Bandaranayake,
Tópico(s)Clinical Reasoning and Diagnostic Skills
ResumoEditorialTeaching Medical Ethics in Medical Schools Fadheela Al-Mahroos and MD, FAAP Raja C. BandaranayakeMBBS, PhD, MSEd, FRACS Fadheela Al-Mahroos Address reprint requests and correspondence to Dr. Al-Mahroos: P.O. Box 11602, Manama, Bahrain. E-mail: E-mail Address: [email protected]. From the College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain. and Raja C. Bandaranayake From the College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain. Published Online:1 Jan 2003https://doi.org/10.5144/0256-4947.2003.1SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionIt has been well established that to practice "good medicine," doctors do not just need sound knowledge and skills but also the right attitude, conduct, and the ability to make difficult ethical decisions about the care of their patients. From time immemorial, doctors have always confronted ethical questions during their practice. In the present era, ethical dilemmas in medicine are widespread and complex, and touch the most sacred values of society. Decisions about medical ethics are no longer limited to medical professionals. Lay people, legislators, ethicists, theologians, politicians and policy makers, all play a role in influencing decisions taken in hospital wards.New doctors swear the Hippocratic oath (or an equivalent professional statement) to adhere at all times to high standards of medical practice and ethics, and to protect the right of every patient to life, dignity, and confidentiality.1 Yet, it is not certain how this oath is reflected in the curriculum of medical studies. The purpose of this report is to review the literature related to the teaching of bioethics in the undergraduate medical curriculum and to suggest some guidelines for its introduction in the Arabian Gulf countries.HISTORY OF MEDICAL ETHICSThe issue of medical ethics dates back to around 500 years BC, when the great Greek philosopher Plato expressed his deep concern about the inappropriate behavior of the doctor who acts "with the self confidence of a dictator," and who shows no respect or consideration for his patient's needs and feelings. He called for a code of ethics, which "makes a doctor a better healer," and thus laid the foundation for the core ethical values for doctors to practice good medicine. Among the earliest and most comprehensive statements on medical ethics in Islam is 'Adab al-Tabib' (the ethics of the physician), the work of Ishaq ibn Ali Al-Ruhavi who detailed the code of ethics required by any doctor. Al-Ruhavi emphasized the interrelationship between spiritual and bodily health: "The virtuous physician can improve both body and soul."2Driven by the many perplexing medical ethical issues confronting physicians in Islamic culture, the first International Conference on Islamic Medicine adopted the Islamic Code of Medical Ethics which addressed the patient-doctor relationship, doctor-doctor relationship, professional secrecy, doctor's duty in wartime, responsibility and liability, the sanctity of human life, doctor and society, bio-technological advances, medical education and the oath of the doctor.3In recent times, interest in teaching medical ethics took a major turn after the 1947 Nuremberg trials that uncovered the participation of some German doctors in the crimes committed against humanity during World War II. This raised the awareness about the importance of physicians' conduct and the need for the teaching of medical ethics to medical students.4In the last 40 years, scientific advances in medicine, and the application of scientific methods in managing patients' problems have undoubtedly transformed medical practice and brought longevity and better life to mankind. Nonetheless, medicine has lost much of its humane aspects, and this conflict between technology and basic human values has led to the emergence of bioethics and an acceleration in the introduction of medical ethics courses in the curricula of medical schools throughout the world, especially in the US. Other forces for medical ethics education include the ethical dilemmas in the field of research, the rapid advances in human genome and genetic intervention, in vitro fertilization and, more recently, the issue of animal and human cloning. As well, improved access to information and the increased cost of medical care have contributed to this dilemma. The recent emergence of managed care and market forces in the US represented a major challenge to the medical profession. Physicians found themselves obliged to meet the demands of third-party payers in making decisions, which were not necessarily the best to meet their patient's needs.CONCEPT OF MEDICAL ETHICSThe concept of medical ethics is broad and not easy to define. Extensive debate exists in the literature about which ethical theories or ethical principles or values pertaining to the standard of medical practice should be adopted. A discussion of the different views is beyond the scope of this review.Concern about medical ethics education and practice is worldwide. However, the best documentation in the literature about the trend in medical ethics education is from the United States and the United Kingdom. Most hospitals in the United States and in many other countries, have ethics committees (usually mandated by accreditation agencies), made up of lawyers, social scientists, theologians, philosophers and physicians.3 Medical ethics teaching in the United States started as simple isolated courses concentrated in the pre-clinical stage. The first started at the Milson S. Hershy Medical Center in Pennsylvania in 1967, but the various ethical issues facing the profession and the public outcry for ethical standards in the practice of medicine led to changes in medical school curricula and the introduction of structured medical ethics courses, a trend which has continued to date. Recently, the AMA's Institute for Ethics developed an online course in Physician Ethics and Professionalism, based on the AMA "Code of Medical Ethics."In the UK, medical ethics teaching has been increasing since 1987.4 However, it escalated rapidly in 1993, when the General Medical Council (GMC), in an attempt to reform medical education, formulated its recommendations on undergraduate medical education.5 In 1998, a Consensus Group of Teachers of Medical Ethics and Law in UK Medical Schools formulated a consensus statement about teaching medical ethics and law within medical education and proposed it as a model for the UK Core Curriculum in medical ethics. It included 12 themes: informed consent and refusal of treatment, the clinical relationship: truthfulness, trust and good communication, confidentiality, medical research, human reproduction, the new genetics, children, mental disorders and disabilities, life, death, dying and killing, vulnerabilities created by the duties of doctors and medical students, resource allocation and rights.6 In many countries, the integration of medical ethics into the formal curriculum has become the standard. A study by Miyasaka et al. in an international survey of medical ethics in 13 Asian and Oceanic countries reported that 89% of medical schools had some courses in medical ethics.7In the Arabian Gulf University, medical ethics is taught in the pre-medical year as part of the subject "Islam". In the following pre-clinical and clinical years, there are no systematic medical ethics courses or structured integration in the curriculum, except for a vertically integrated preclinical course in communication skills, which combines cognitive and practical skills.8 Similarly, a recent report from Saudi Arabia indicated that medical ethics education is lacking in some Saudi Medical Colleges.9It is obvious that the need for medical ethics education is recognized in most countries and has become a component of undergraduate formal medical training in most medical schools. Most ethical problems faced physicians throughout the world are similar, with some unique issues pertinent to some countries. The teaching of medical ethics has been given high publicity in two recent international initiatives, which have laid down standards and global essential requirements in medical education.10,11Course ContentWhile most disciplines in medical education are expanding and changing, they have clear boundaries. Medical ethics on the other hand, is evolving fast and becoming more complex, with many stakeholders who have influence on the discipline. The unifying theme is "the centrality of values and ethics in medical education and the importance of the humanities for dealing with them responsively and responsibly."2 One of the recommendations for medical ethics content was proposed at the De Camp Conference12 of medical ethics teachers in the US. It included the ability to identify the moral aspects of medical practice: the ability to obtain valid consent or refusal of treatment, the knowledge of how to proceed if a patient is only partially competent, fully incompetent, or refuses treatment; the ability to decide when it is morally justifiable to withhold information from a patient, or to breach confidentiality; and the knowledge of the moral aspects of caring for a patient whose prognosis is poor.At Stanford University School of Medicine in California, bioethics is taught as a "vertical thread" throughout the undergraduate medical school curriculum. At John Hopkins University School of Medicine the curriculum comprises diverse elements such as bioethics, history of medicine, art, spirituality and medicine, economics, multicultural issues, and law.13At the Bristol Medical School in the UK, medical ethics teaching received a considerable push by the establishment of the Center for Ethics in Medicine in 1997. Brennan 14 summarized the key points of the Bristol Medical School approach in teaching medical ethics as follows: the teaching is student-centered; the content is patient-centered; the course is structured, vertical and incremental; it is case-based and grounded in theory but applied to clinical practice, the approach is inclusive and humanistic; team-teaching is applied whenever appropriate; the sessions are interactive, non-didactic and conducted in small and large groups, with opportunity given for discussion within a safe environment; positive critique is employed throughout.TEACHING MEDICAL ETHICS IN MEDICAL SCHOOLSThe medical school setting represents an ideal place for laying the foundation for professionalism and medical ethics through integration with various subjects in the preclinical stage and during clerkships. Teaching medical ethics is expected to improve patient care and patient and professional satisfaction with improved quality of care. Studies are needed to validate many of these assumptions.Teaching medical ethics will sensitize students and increase their awareness and hopefully, it will lower the threshold of tolerance to the inhumane treatment of patients. It might help to "rehumanize" medicine, ensure that future physician will be a caring and compassionate person who respects the patient's dignity and privacy, and believes that patients are entitled to be told the truth, to participate in decision-making, and most importantly, live and die in dignity.Over-expectations represent a real challenge. It is unrealistic to expect medical ethics education to be a "pedagogical panacea" for medical dilemmas.2 Although medical ethics education aims to sensitize students to ethical issues and to provide the knowledge necessary for morally sound judgment, it will not turn every student into a humane, sensitive and compassionate doctor. Those with personality problems or who are inherently rude are least likely to change. It may not change "students' values and beliefs, or ensure ethical conduct."15 It is the job of medical school admission bodies to function as gate-keeper, to ensure, as much as possible, that the students entering medical schools possess the personal traits and characteristics which meet the expectations of the profession and the society from a doctor. In addition, regardless of what the official curriculum aims and content are, the "hidden curriculum"15 and the institutional culture have a significant influence on the students and determine their attitudes. Undoubtedly, any contemplated change cannot succeed if these aspects are not addressed.BarriersOne of the major hurdles to successful implementation of medical ethics courses is unsupportive institutional culture. As Kenneth Ludmerer states, "an unfriendly institutional culture can easily undermine the well-intentioned efforts of those trying to impart professionalism through the means of curriculum."16 This institutional culture could be a lack of interest and disregard for the importance of teaching medical ethics, improper bedside manners of the teacher and the poor treatment and humiliation of students and residents. Employing a change strategy through faculty involvement and education would be necessary. It would also help to include medical ethics in faculty development programs.One of the challenges to implementing medical ethics courses is the demand on curriculum time and the ability to accommodate them in the face of an ever-expanding curriculum content. There is no easy solution to this problem. However, the need for medical ethics education is so persuasive that it should be integrated horizontally and vertically within the curriculum, employing different teaching methods.Another challenge is agreeing on the syllabus content. It is unusual to disagree about the course content of acute pneumonia, but it will be difficult to get a group of medical ethicists or physicians to agree about a uniform syllabus in medical ethics. The UK Consensus Group statement represents an exception.7 Many of the ethical dilemmas facing doctors do not have a clear correct and wrong answer. Thus, medical ethics courses should aim to teach a set of well-established principles which the future doctors can apply to different settings and circumstances, and to inculcate in the student the attitude of considering both sides of the coin when faced with an ethical dilemma.Efforts to introduce medical ethics courses can be met with a great deal of resistance for different reasons. To some, ethical problems in medicine seldom arise, and when they do, it is obvious that what should be done is "trivial." To some, ethics is taught, not as a formal course but on ward rounds in the context of discussing individual patients (redundant). To others, there are no right or wrong answers with regard to ethical issues, and, therefore, ethics is about attitudes and moral character and not amenable to teaching the impossible.6 Another difficulty is the skepticism about teaching others to be compassionate through courses.GUIDELINES FOR IMPLEMENTATION IN ARABIAN GULF COLLEGES OF MEDICINERecognition of the Need for Medical Ethics EducationOpen and transparent discussion throughout the institution, including faculty and students, about the rationale for the change, to try to reach a consensus about the need for medical ethics education is crucial. A survey to identify the needs and perceptions of faculty and students about medical ethics education might be a good starting point. If a goal of the institution is "to promote humanistic values as the basis of medical practice," it is implicit that students should acquire a knowledge and understanding of "ethical and legal issues relevant to the practice of medicine" and an "ability to understand and analyze ethical problems so as to enable patients, their families, society and the doctor to have proper regard to such problems in reaching decisions."5Curriculum Design and Course ContentThere is no consensus on what makes a well-rounded curriculum in clinical bioethics. Much variety exists in what is taught, how, when and by whom. The most elaborate core curriculum, which can be adopted and adapted for each college, is that proposed by the recent UK Consensus Statement, which included the 12 themes.6When medical ethics education was first introduced, the method of education was mainly in the form of didactic courses. It was soon recognized that formal courses alone would not reshape human behavior and attitudes, and schools adopted different methods. In addition to didactic teaching in large groups, small groups discussion and problem-based teaching, students need role models. At the University of Chicago, teaching of medical ethics is based on six principles: clinically-based, case-based, continuously reinforced in class, coordinated with clinical clerkships, cognitive training in the fundamentals of ethics, and clinicians functioning as instructors and role models.15 Clinical relevance and meeting the needs of the community are other considerations in whatever teaching method is adopted. According to the UK Consensus Statement; it should begin early and be reinforced throughout the course. Sufficient curriculum time and resources should be explicitly allocated to its teaching.17Responsibility for Teaching Medical EthicsSchools differ in this respect. In the beginning the subject was taught by either a physician with interest in ethics or by an ethicist with or without clinical experience. In either case, it should be taught by those who do it well and who have the capacity to motivate students. Most importantly students need teachers who are good role models, who practice what they preach in their interactions with patients, students and colleagues. The UK Consensus Statement proposed that the teaching of this subject be widely shared within medical schools, but "its adequate provision and coordination requires at least one full-time senior academic in ethics and law with relevant professional and academic expertise."17Assessment of Educational OutcomeDespite the fact that ethics education is offered throughout the world, there is no evidence that such education has influenced the attitude and behavior of doctors, or improved patient-doctor relationships and the outcome of patient care. On the contrary, the image of doctors (real or perceived) is deteriorating, and physicians are increasingly seen as greedy, insensitive, and providing impersonal care. Kass summed this up recently, in a critical look at medical ethics education in the US, that "though originally intended to improve our deeds, the practice of ethics, if truth be told, has at best improved our speech."21There is a pressing need for well-structured research to identify: first, why the good intentions of imparting medical ethics and professionalism on medical school graduates do not seem to be fruitful or tangible; second, what the intended learning outcomes of medical ethics courses are; and third, how we will assess and measure the impact of the course on doctors' behavior, patient care and satisfaction. The UK Consensus Group recommended that assessment of medical ethics should be formal, as are all other core subjects within the curriculum, and should have the same importance as assessment in any other core subject. "Without such assessment, ethics and law applied to medicine cannot be taught successfully within the medical schools. The teaching itself should also be assessed in the same way as is teaching in other core subjects."18CONCLUSIONSThe rapid advancement in scientific technology and the phenomenal expansion in knowledge have posed several ethical dilemmas, which doctors are required to deal with. In addition, despite all the scientific advancement and improvement in medical care, medicine cannot achieve miraculous cures and avoid the inevitable. The physician can, however, provide comfort and empathy, which are essential skills for every physician.Public dissatisfaction with doctors is rampant with patients complaining that doctors are careless, impersonal, greedy, and unethical. Recapturing the doctor's trustworthiness is a pre-requisite for establishing a healthy patient-doctor relationship. Inculcating ethical values in medical students improves the quality of patient care, in terms of both the process and outcome of care, patient-doctor relationships and patient satisfaction with the process of care. The best time to implant the seeds of medical ethics is in the undergraduate stage when the students are receptive and not overwhelmed by the daily demands and stresses of postgraduate training. Identifying why we need medical ethics education is important to convince all stakeholders to introduce it in the curriculum. Identifying the goals and aims of medical ethics education will clarify the expected outcomes and what will be assessed. The content of the course should be relevant to the culture and based on societal needs, while the accumulated international experience should be taken advantage of. Methods of teaching need to be variable and integrated throughout the curriculum. Introducing this vital change mandates both human resources and curriculum time. Most importantly, however, the medical student must be exposed to role models who practice ethical medicine. "The innovation of teaching human values and ethics is not simply a transient pedagogical fashion. It is a recognition that the physician as scientist and the physician as humanist must converge if medicine is to be a boon and not a threat to individuals and society."2ARTICLE REFERENCES:1. Microsoft Encarta Encyclopedia 2000. "Medical Ethics" . Microsoft Corporation. Google Scholar2. Pellegrino ED. "A concept of professional ethics in medical education" . Medical Ethics and Medical Education. Proceedings of the XIV Round-table Conference, Mexico City, Mexico, 1980. Google Scholar3. Fletcher DB. "The ethics of bioethics" . The Center of Bioethics and Human Dignity, http://www.cbhd.org/. Google Scholar4. Pond D. Report of a Working Party on the Teaching of Medical Ethics. Institute of Medical Ethics. London, 1987. Google Scholar5. General Medical Council. Tomorrow's doctors. London, 1993. Google Scholar6. Hope T. "Ethics and law for medical students: the core curriculum" . J Med Ethics. 1998; 3:147-8. Google Scholar7. Miyasaka M, Akabayashi A, Kai I, Ohi G. "An international survey of medical ethics curricula in Asia" . J Med Ethics. 1999; 6:514-21. Google Scholar8. College of Medicine and Medical Sciences, Arabian Gulf University. Prospectus, 2002-2004. Google Scholar9. Alshehri MY. "Medical curriculum in Saudi medical colleges. current and future perspectives" . Ann Saudi Med. 2001; 21:320-3. Google Scholar10. World Federation for Medical Education. "WFME Task Force on Defining International Standards in Basic Medical Education" . Medical Education. 2000; 34:665-75. Google Scholar11. Core Committee. "Institute for International Medical Education" . Medical Teacher. 2002; 24:130-5. Google Scholar12. Culver CM, Clouser KD, Gert B, et al.. "Basic curricular goals in medical ethics" . N Engl J Med. 1985; 312:253-6. Google Scholar13. De Angelis CD. The Johns Hopkins University School of Medicine Curriculum for the 21st Century. Baltimore: Johns Hopkins University Press, 1999. Google Scholar14. Brennan MG. Ethics and attitudes. In: Dent and Harden , editors. A Practical Guide for Medical Teachers. London: Harcourt Publishers Ltd., 2001. Google Scholar15. Hafferty FW, Franks R. "The hidden curriculum. Ethics teaching and the structure of medical education" . Acad Med. 1994; 64:861-71. Google Scholar16. Ludmerer KM. "Instilling professionalism in medical education" . JAMA. 1999; 9:881-2. Google Scholar17. Consensus Group of Teachers of Medical Ethics and Laws in UK Medical Schools. "Teaching Medical Ethics and Law within Medical Education: a Model for UK Core Curriculum" . J Med Ethics. 1998; 24:188-92. Google Scholar18. Kass L. "Practicing ethics" . Where's the action? Hastings Center Report,. 1990; 20:5-12. Google Scholar Next article FiguresReferencesRelatedDetails Volume 23, Issue 1-2January-March 2003 Metrics History Published online1 January 2003Accepted5 January 2003 InformationCopyright © 2003, Annals of Saudi MedicinePDF download
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