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Ethical and Moral Issues in Undergraduate Medical Education: An Exploratory Study |
Journal of Shalamar Medical and Dental College
Journal of Shalamar Medical and Dental College

Article Info
Authors

Volume

3

Issue

2

Year

2022

ARI Id

1682060070609_2988

Pages

142-151

DOI

10.53685/jshmdc.v3i2.109

PDF URL

https://journal.smdc.edu.pk/index.php/journal/article/download/109/65

Chapter URL

https://journal.smdc.edu.pk/index.php/journal/article/view/109

Subjects

Ethical issues Moral issues Medical students Undergraduate

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INTRODUCTION:

Moral values and ethics are strongly attached to society and culture.1 Morals refer to the human behavior whereas morality is the practical activity and ethics describes the theoretical part, systematic, and rational reflection upon that human behavior. Values are linked to beliefs and attitudes and guide human behavior.2

In the context of medical science, three domains of values are present in society: the values associated with education, the values of medical science, and the values of medical science education.

These three values remain nearby and interact or overlap with one another.3 Values

 

Shape2

in medical science education include values associated with teaching science in medical schools and hospitals, epistemic values of science, societal values, and the personal values of students. This will also include the role of educators in the character development of medical students.

Modern educators are also defining character education differently. Anderson stated that character is defined as moral excellence and firmness, whereas integrity refers to a firm adherence to a code of moral values.4 Good character consists of virtues where virtues are objectively good human qualities such as wisdom, honesty, kindness, and self‐discipline.

Virtues provide a standard for defining good character. Thus the more virtues we possess, the stronger our character is.5 It has been suggested to focus on the development of school culture responsive to character development than individual character education.6

Medical students face a variety of situations in which they need to make decisions regarding choosing what is the right thing for them to do, right from the very first day they start their education till the day they graduate after which this ethical decision is expected to come from the new "doctor" and not the student.

These situations may arise at the time when they join the medical school, when their clinical orientation starts, or also at the end of five years and the start of their internship. Hence, it is important to explore various situations where these students may face ethical and moral issues to allow the educators further devise a syllabus in their context as well as to use the identified issues to orient medical students as a way of

teaching values and ethics in undergraduate medical education.

This exploratory study aimed to explore the moral and ethical issues faced by undergraduate medical students during their student life.

METHODS:

This qualitative exploratory study included semi-structured, one-to-one interviews from thirteen participants. Ethical approval was obtained from the institutional ethical committee dated 7/09/2021 (IEC-134/21).

The students were invited via electronic invitation posted on social media which was accessed by medical students routinely. Inclusion criteria included medical students from 1st year to final year MBBS of public or private sector medical colleges in Punjab, Pakistan. Exclusion criteria included medical students who could not spare their time to be involved in an interview or those who had recently graduated.

Thirteen undergraduate medical students volunteered to participate in the study. There was no incentive involved, however, the participants were given a letter of appreciation for participation in the study. After taking informed consent, participants were briefed about the study, and interviews were conducted on an individual basis via the online Zoom platform.

Having individual interviews allowed the participants to express their views freely and without any hesitation. The participants were asked an initial question to answer; "What ethical or moral issues have you faced or have observed your class fellows face in undergraduate medical education since the time you joined Medical School?".

 

Table1: Demographic characteristics of the participants

Group n=13

Age (years)

 

18-19

3

20-21

3

22-23

5

24≤

2

Gender

 

Male

6

Female

7

MBBS Students

 

1st year

2

2nd year

4

3rd year

2

4th year

3

Final year

2

Institution

 

Public

5

Private

8

Level of Study

 

Preclinical

6

Clinical

7

 

Prompts were given where deemed necessary. Each interview lasted for around

40 to 50 minutes. All interviews were converted into recorded after taking consent, transcribed, and stored in a secure online drive. Participants were given codes to maintain anonymity and confidentiality. Data from the participants' interviews began to be repetitive after the eleventh interview; however, two more interviews were conducted to see if any new themes emerged.

Shape3 Based on the social constructive approach and with subjective strategy, thematic analysis with open coding was performed on the obtained data via Atlas-ti software by two individual coders via open and axial coding. The intercoder reliability of the analyzed data was 0.84. The data was then represented in themes and subthemes in the next section.

RESULTS:

The present study explored ethical and moral issues. Three themes and thirteen subthemes were identified. Demographic characteristics of the participants are shown in Table 1.

A total of twenty-eight codes were obtained after thematic analysis, leading to the formation of thirteen subthemes and three themes. Themes and subthemes obtained from the study are represented in Figure 1.

 

 

 

 

 

 

 

Figure 1: Themes and subthemes obtained in the study

Theme 1: Academic Ethical Issues Subthemes:

  • Attending classes

    Students felt that it was rather convenient to miss classes despite knowing the action translated as ethical misconduct. Participant

    12 said, "At times I missed classes deliberately. It soon became a norm among me and my friends to bunk classes regularly." Participant 4 described it as an activity done "for no particular reason except to suit my convenience specially to avoid waking up early." Another ethical dilemma accompanying this was the students' lack of responsibility to inform their teachers regarding academic fallback due to bunking lectures. "When asked about reasons behind our poor concepts at the time of tests, we were unable to inform our instructors that being absent in the lectures contributed to our poor concepts," said Participant 5.

  • Sharing notes and other academic resources

    Although students experience academic jealousy from their peers, they often felt that this did not affect their classmates' willingness to share academic resources. Participant 5, one of the best scorers of their batch said they felt "no hesitancy in sharing my handwritten notes with other members of my class regardless of them being my friends or not." Similarly, Participant 4 who found medicine quite academically challenging was "grateful to his peers for never holding back information particularly when exams were around the corner."

  • Assignment completion and submission

    Almost every student perceived classroom assignments as burdensome and hence faced difficulty in handling them. Participant 7 was honest in saying "No one takes assignments seriously. Only one or two students make them with effort and the rest of us have made a habit of copying word to word. I feel like the teachers don't even read them so why bother." Similarly, Participant

    6 said, "I have never submitted an assignment on time as I never consider them important enough to be seen by the teachers themselves."

  • Cheating and malingering

    All the students admitted that they were involved in cheating during exams at some point in their medical academia. Most of them cheated in online assessments during the COVID-19 pandemic. Participant 2 said, "No one was taking online tests seriously. We never turned our cameras on and solved questions together in WhatsApp groups. Mostly the toppers would share the answers in WhatsApp groups and we just copy pasted those answers."

    When asked about cheating during in- person, live exams Participant 11 said "This has always been common. Sometimes invigilation is strict, so we must make extra efforts, but cheating has never been impossible." When asked about its ethical implications many students including Participant 9 said they were "well aware of the fact that cheating is a bad thing but failing a test would have affected their academic grades, so they never considered ethical aspect of cheating."

    Theme 2: Social Ethical Issues Subthemes

  • Peer pressure

    This is not something exclusive just to medical academia. However, due to persistent academic pressures students get affected by Students like Participant 13 struggled to 'fit in' as they said, "A lot of us have started smoking only because our friends or roommates are doing it." As colleagues, it seemed easier to be negatively influenced. One participant shed light on how many students were forced to join political groups and unions under peer pressure with the fear of being 'left out, "I was aware I am not allowed to join these protests and rallies but felt like I had no choice. If I tried to skip them all my friends would isolate me, I just knew it."

  • Relationship building

    The ethical dilemma of maintaining their relationships with teachers purely out of interest and opportunities to get leniency was faced by some students. Participant 9 agreed how certain students of his class would "go out of the way to make the teacher believe they are deeply interested in learning whereas it was the complete opposite. Later the same students would admit in friends' groups to doing it for extra marks in viva." Relationship building with patients during clinical rounds held no importance in the students' eyes, as admitted by Participant 7, "We would feel lazy inwards, and no one would volunteer to talk to the patient and take history unless a senior assigned us with it. Still, our goal remained the same: to take history as soon as possible, get our attendance and go."

  • Bullying and harassment

    These two activities are prevalent in almost all academic settings. Participant 5, personally affected by bullying said, "I have

    been bullied all my life for being a good student but here in medical college it is significantly more frequent for the people to pass negative comments on this aspect of my personality." Participant 10 said "Class grouping paves way for bullying. People from one group particularly dislike others and it's not uncommon for certain extroverted students to talk badly to introverted ones." For matters of harassment, many students agreed to hear stories of victims, especially females, facing this problem within the grounds of medical college. However, the main obstacle was how "almost all of these cases go unheard and unsolved as we don't feel like there is any trustworthy authority to report to," as said by Participant 6.

  • Gender discrimination

    Although packed with a female majority in recent times, medical colleges are still grounds for gender discrimination. Participant 8 said, "Almost every other day some teacher or student makes comments on how females are not made for medicine but rather getting degrees and sitting at home." Participant 2 said about rotations in surgery departments, "Mostly the instructors would trust male students more with stitches, etc. as it was evident, they do not think females can be capable surgeons."

  • Social media ethics

    The positives of social media came with their negatives. There is a significant impact of social media usage on students' social lives. For example, Participant 3 quoted "We do feel connected as peers thanks to social media applications, but it comes with a price. Many false rumors have been spread through them that have caused depression to

    those affected." Further, they added "It is highly disgraceful for students to use patients during rounds and operations…they take photos without consent and post without hesitancy. But what can we say, social media use is mostly pretentious, and they just want to show off?"

    Theme 3: Clinical Ethical issues Subthemes

  • Lack of respect for human tissue

    Starting from human dissection, many students forget the element of respect that must accompany this practice, as said by Participant 13 "But what shocked me was how so many of my class fellows did not for a single moment realize they were dealing with an actual human body, not just dead meat." Participant 1 added "I was in my first year doing dissection and the girl doing it with me started cutting brutally, without any orientation. Even her hair was falling inside the carcass. She called her friends and made a joke about the body too. It was pathetic."

  • Lack of respect for patient privacy

    Most students agreed that they saw patient privacy as being least prioritized during ward rounds. "Seniors would ask us to examine patients without any privacy screens. If patients or we were uncomfortable doing so, they would say we can't do much as the hospital is overburdened. But we students knew this was ethically and morally wrong," said Participant 11. "Our professors would focus a lot on patient privacy and taking informed consent during lectures but practically this was not applied by their subordinates and our seniors," told Participant 13, adding to which they said, "As seniors were so casual about this many of our class fellows also

    developed these habits of examining patients in non-serious ways."

  • Lack of patient confidentiality

    Students strongly felt they were not taught sufficiently to maintain patient confidentiality nor were they able to witness their seniors doing it so much. Participant 8 recalled from his ward rounds, "Doctors discussed patient information very casually. After watching many medical tv dramas I had assumed confidentiality was a big deal but did not witness it happening. Rather patient info was discussed like it was a public matter." Participant 4 talked about lectures delivered by an esteemed professor, "She always talks to us about patients she sees in her private practice. Not just clinical points but goes as far as their demographics and personal details. It makes me uncomfortable, to say the least. It sets a bad example for all of us who look up to her."

  • Disrupted patient care

    Most students did not feel enthusiastic about ensuring proper patient care. Many, including Participant 7, believed, "We will be getting into that in our professional lives anyway and it is not our responsibility to feel burdened about their welfare. We are here to just learn." However, some including Participant 5 believed otherwise when they said, "I think becoming a doctor is also about grooming yourself to become committed to patient welfare. I do not like it when students show up to wards exhausted and unable to engage with patients simply because they prioritize other activities over them." Participant 6 agreed to this and talked about how "if patient dedication is not instilled in us at the grassroots level, we will forever be deprived of it."

    DISCUSSION:

    In our study, we identified that many medical students were familiarized with practices of academic dishonesty such as leaving lectures deliberately and cheating on tests. One survey of ethical issues conducted by Indian medical students supplemented this fact by showing students in their first academic year reported issues such as copying assignments, cheating during examinations, and disrespect towards cadavers during dissection modules.7 Another study reported the prevalence of self-reported cheating to be 19.8%, the odds of which were higher for those who also missed lectures regularly.8 Many participants of our study agreed that they felt cheating was a necessity to compete with their peers and get ahead of them.

    Absenteeism without genuine reasons proves to be another ethical dilemma at the forefront of students' academic lives. A study conducted at an Ethiopian medical university revealed that nearly 43.7% of its students had missed three or more lectures in one month giving reasons such as lack of interest, inconvenient schedules, or preparation for other examinations.9 Many studies have indicated that student absenteeism in medical colleges has indeed become an alarmingly rising trend.10

    The phenomenon of peer pressure has found its way into many tertiary institutions including medical universities. Participants in our study said they felt pressured to adopt certain practices of their peers to live in a socially secure environment, even if they were aware of the ethical disgrace they were committing. The medical students feeling obligated to choose a competitive field for residency to not let down their peers even

    though they were personally interested in a different course of study.11 In a study directed towards exploring difficulties faced by first-year medical students, students ranked peer competition as the most ethically challenging.12

    In the context of social dilemmas, the ethical conundrum of bullying in the stressful life of a medical student remains constant at every level of academia. Participants admitted to witnessing and experiencing bullying leading to social occlusion. 6 A survey report conducted at a private medical college in Lahore, Pakistan revealed 66% of its participants were bullied in the past six months within the premises of their institution.13

    Participants felt the weight of bullying when it impacted their academic progression. Another study observed that bullying in the form of verbal abuse indeed negatively affects the student's confidence, mental health, and academic endeavors.14 Other forms of mistreatment reported by participants are gender discrimination and sexual harassment. A study involving fourteen medical schools showed these unethical activities to be extremely prevalent in undergraduate medical education, with females being exposed to gender discrimination and sexual harassment significantly more than their male colleagues.15

    Students also faced worries in the clinical learning environment. Lack of patient privacy and autonomy, lack of respect for patient confidentiality, patient mistreatment and disrupted care were a few moral conflicts witnessed by them during clinical experiences. One study highlighted the dual nature of such conflicts; not only were the

    doctors rude and careless towards their patients but the medical students were also found to behave inappropriately with patients by talking loudly, making jokes, and invading their personal space.16 Studies show that such clinical teachers who act repulsively with patients are negative role models and interaction with them remains the most frequently cited ethical dilemma amongst students who are keen to learn.17, 18,19 One study carried out in the setting of the emergency department confirms that medical students do encounter day-to-day ethically based issues coded with autonomy, beneficence, and non-maleficence.20

    The presence of these various ethical dilemmas suggests that awareness regarding ethical principles in medical education is lacking or b) there may be a gap between ethical issues being discussed in classes and those being encountered. It is therefore imperative to understand the nature and process of ethics discussion and moral deliberation for ethics teaching, especially in different settings. To fight this moral plight, there is a need for ethical education that is not only participant-driven but also developmental stage-specific and one that empowers students to make decisions as much as practicing physicians.

    This study is limited by a low number of participants and is exploratory in nature. As a start, participants were invited from social media voluntarily which may lead us to believe that the issues that have surfaced may only be the tip of the iceberg. To avoid the implications of the study on any single institution, the participants were invited voluntarily via social media groups. Future studies can be done with in-depth institutional-based case studies to identify

    and compare issues among different institutions and also allow them to develop strategies to aid students in solving such problems, as they face.

    CONCLUSION:

    Undergraduate medical students face a myriad of ethical and moral issues during their study period in their institutions, in academics, in social life, and in a clinical context. It is paramount to create awareness among the students about such issues that they may face and more importantly, develop strategies to face such issues if they arise.

    Conflicts of interest

    All authors declared no conflict of interest.

    Contributors

    NKN: Initial idea, data analysis, revised, and finally approved the article.

    ZFN: Acquisition of data, primary draft writing, reviewing and editing

    AA: Data collection, primary draft writing, interpretation, and investigation

    All authors approved the final version and signed the agreement to be accountable for all aspects of the work.

    Grant support and financial disclosure

    Authors declared no specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    Data sharing statement

    The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Issue Details
Showing 1 to 10 of 10 entries
Article TitleAuthorsVol InfoYear
Volume 3 Issue 2
2022
Volume 3 Issue 2
2022
Volume 3 Issue 2
2022
Volume 3 Issue 2
2022
Volume 3 Issue 2
2022
Volume 3 Issue 2
2022
Volume 3 Issue 2
2022
Volume 3 Issue 2
2022
Volume 3 Issue 2
2022
Volume 3 Issue 2
2022
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