3
2
2022
1682060070609_2993
179-188
https://journal.smdc.edu.pk/index.php/journal/article/download/129/73
https://journal.smdc.edu.pk/index.php/journal/article/view/129
INTRODUCTION:
Ethics is a science of morals and encompasses the rules of conduct governing
human interactions. Ethics has an important place in medicine and has been a prominent topic of discussion for a long time. The role of Medical Ethics (ME) comes into play in a
situation where there are two or more possible and justifiable paths to take in difficult situations.1 It includes the methods, procedures, and the perspectives which are used for deciding how to act after analyzing complex problems and issues in medicine.2 "The Hippocratic Oath", penned down in the 4th Century BC, laid the foundation of ME. Since this oath is 2400 years old, World Medical Association adopted the Geneva Convention, also known as "The Physician Pledge" in 1948, which was revised in 2017.3
The importance of ME cannot be undermined. Medical Ethics Education (MEE) is now vital as we are progressing in a world of complex ethical situations and dilemmas faced by healthcare professionals daily. The application of the principles of the moral philosophy, where ME helps in analyzing and solving ethical issues arising in medicine and health care provision.4 According to the Federation of State Medical Boards (FSMB), disciplinary action is taken against 0.5% of the physicians each year, of which 0.1% are subjected to serious action that involves license revocation, suspension, or surrender.5 Extensive data regarding the disciplinary actions taken against physicians is not available in Pakistan. However, a cross-country survey in Pakistan showed that the frequency of informal payments to public health care providers (which should be free of cost) amongst the users of services is 96% in Pakistan most of these are demands from the providers at the health care facilities which highlights the lack of awareness about ME and unethical practices in healthcare professionals in Pakistan.6
Most universities in the developed world teach ME as part of their curriculum, but in
Pakistan, this subject is not given the right amount of importance. Despite numerous efforts by the Pakistan Medical Council (PMC), ME is not taught with due attention and is not a mandatory part of the undergraduate medical curriculum. Previous studies support the opinion that ME should be included as a compulsory part of the undergraduate medical curriculum. There is insufficient application of ME on surgical floors due to a lack of knowledge and experience.7 Keeping up with the need for ethics education for undergraduate medical students, Shalamar Medical and Dental College, Lahore (SMDC) established a Bioethics Department in 2017. ME is being taught to medical students as a longitudinal curriculum throughout medical school.
This study was conducted to explore the perceptions and experiences of medical students about MEE. Their opinions will be valuable in designing courses for future students and starting the department of ME in other medical colleges of Pakistan.
METHODS:
The mixed-method study was designed to gain medical students' perspectives and explore their experiences with ME. This approach allows for detailed contextualized data from the qualitative study and generalizable insight from the quantitative study, therefore the mixed-method approach was adopted to better get an in-depth understanding of the medical ethics. The quantitative component of it is a cross- sectional study, while the qualitative component of it is a Phenomenological study. The phenomenological approach is ideal to explore the experiences of the research participants. In the quantitative component, a self-administered survey questionnaire was used with the permission
of the author.8 The study included all students of SMDC, who have attended ME lectures and excluded students who have never attended a ME lecture. The students who did not attend any classes had no experience to share with the researchers, therefore they were excluded. Ethical approval was approved by institutional review board (SMDC/IRB/08-07/182). The data collection for the study started in August 2019 and finished in March 2020.
The questionnaire was filled out by undergraduate students of all five years at SMDC. SMDC has 700 undergraduate students. All students voluntarily agreed to participate in the study by agreeing to a written informed consent, with a 410-sample size, and confidence interval of 99%, while keeping the margin of error about 4%. A qualitative study was conducted for the detailed experiences, which included focus group interviews with medical students. A total of three focus groups of seven medical students were carried out by the principal
data to generate themes and analyze the results.
RESULTS:
A total of 410 medical students from Shalamar Medical and Dental College participated in this study. In the quantitative component, the demographic factors of medical students were also noted. Table 1 reports the demographic characteristics of the participants. The responses of the medical students regarding knowledge and attitude towards MEE have been shown in Table 2. It also shows how different aspects of MEE have significant association with the students' year of study.
In the qualitative part of the study, views from medical students on MEE were also recorded. The basic themes of this interview include the experience of ME lectures, the practical use of MEE, and their experiences of facing ethical dilemmas, and finally the suggestions of students based on their experiences.
nvestigator and co-principal investigator. Table 1: Demographic characteristics of the he selection of students for one group is medical students |
|
ased on their availability. The students Characteristics |
|
Female |
98(23.9) |
312(76.1) |
|
Muslim
Atheist |
403(98.2) |
4(1.0) |
|
1(0.2) |
|
2(0.5) |
|
- - |
|
Home Town
Other |
274(66.8) |
136(33.2) |
|
Second year |
32(7.8) |
131(32) |
|
122(29.7) |
|
31(7.5) |
|
94(23) |
Table 2: Viewpoints of medical students regarding different aspects of medical ethics |
||||
Questions asked from the students |
|
n (%) |
mean±SD |
p-value |
Medical Ethics classes are interesting |
Totally agree |
182(44.4) |
1.87±0.940 |
0.000* |
|
Agree |
125(30.5) |
|
|
|
Neutral |
72(17.6) |
|
|
|
Disagree |
28(6.8) |
|
|
Faculty should arrange more classes in Medical Ethics |
Totally agree |
115(28.0) |
2.23±1.003 |
0.001* |
Agree |
133(32.4) |
|
|
|
|
Neutral |
104(25.4) |
|
|
|
Disagree |
52(12.7) |
|
|
Lecture sessions are necessary in Medical Ethics |
Totally agree |
142(34.6) |
2.00±0.928 |
0.124 |
Agree |
153(37.3) |
|
|
|
|
Neutral |
80(19.5) |
|
|
|
Disagree |
32(7.8) |
|
|
Learn Medical Ethics by observing hospital staff and residents |
Totally agree |
122(29.8) |
2.18±1.013 |
0.095 |
Agree |
149(36.3) |
|
|
|
|
Neutral |
80(19.5) |
|
|
|
Disagree |
57(13.9) |
|
|
Physicians can improve patient care with knowledge of Medical Ethics |
Totally agree |
208(50.7) |
1.69±0.824 |
0.354 |
Agree |
132(32.2) |
|
|
|
|
Neutral |
56(13.7) |
|
|
|
Disagree |
13(3.2) |
|
|
After each lecture, my knowledge in Medical Ethics has improved |
Totally agree |
122(29.8) |
2.10±0.935 |
0.160 |
Agree |
162(39.5) |
|
|
|
|
Neutral |
85(20.7) |
|
|
|
Disagree |
38(9.3) |
|
|
Solving ethical dilemma requires organized knowledge not just common senses |
Totally agree |
156(38.0) |
1.93±0.899 |
0.000* |
Agree |
149(36.3) |
|
|
|
|
Neutral |
80(19.5) |
|
|
|
Disagree |
24(5.9) |
|
|
Content from Medical Ethics is useful in national and international exams |
Totally agree |
115(28.0) |
2.18±0.938 |
0.084 |
Agree |
139(33.9) |
|
|
|
|
Neutral |
121(29.5) |
|
|
|
Disagree |
34(8.3) |
|
|
Ethical issues such as abortion & End of Life conflicts with religious beliefs |
Totally agree |
212(51.7) |
1.69±0.833 |
0.062 |
Agree |
120(29.3) |
|
|
|
|
Neutral |
65(15.9) |
|
|
|
Disagree |
11(2.7) |
|
|
Universal ethical principles applicable in Pakistan |
Totally agree |
170(41.5) |
1.77±0.774 |
0.006* |
Agree |
167(40.7) |
|
|
|
|
Neutral |
62(15.1) |
|
|
|
Disagree |
8(2.0) |
|
|
Medical Ethics education enables me to solve ethical dilemmas in real life |
Totally agree |
139(33.9) |
1.97±0.877 |
0.021* |
Agree |
156(38.0) |
|
|
|
|
Neutral |
86(21.0) |
|
|
|
Disagree |
21(5.1) |
|
|
Medical Ethics education should be taught in all clinical rotations |
Totally agree |
174(42.4) |
1.79±0.833 |
0.014* |
Agree |
149(36.3) |
|
|
|
|
Neutral |
59(14.4) |
|
|
|
Disagree |
15(3.7) |
|
|
Medical Ethics education can make a student |
Totally agree |
189(46.1) |
1.80±0.894 |
0.001* |
into a good physician |
Agree |
124(30.2) |
|
|
|
Neutral |
67(16.3) |
|
|
|
Disagree |
20(4.9) |
|
|
Medical Ethics education can bring medical student success in learning & future career |
Totally agree |
169(41.2) |
1.86±0.869 |
0.001* |
Agree |
140(34.1) |
|
|
|
|
Neutral |
80(19.5) |
|
|
|
Disagree |
16(3.9) |
|
|
Medical Ethics education can prevent future malpractices claims |
Totally agree |
184(44.9) |
1.82±0.881 |
0.007* |
Agree |
126(30.7) |
|
|
|
|
Neutral |
78(19.0) |
|
|
|
Disagree |
16(3.9) |
|
|
Medical Ethics education cannot be taught because it relies on individual behavior developed since childhood |
Totally agree |
89(21.7) |
2.44±1.053 |
0.002* |
Agree |
130(31.7) |
|
|
|
Neutral |
102(24.9) |
|
|
|
|
Disagree |
81(19.8) |
|
|
Medical Ethics education has no application in residency training |
Totally agree |
65(15.9) |
2.67±1.029 |
0.022 |
Agree |
108(26.3) |
|
|
|
|
Neutral |
128(31.2) |
|
|
|
Disagree |
104(25.4) |
|
|
Malpractice claims result from medical negligence |
Totally agree |
82(20.0) |
2.57±1.065 |
0.007* |
Agree |
109(26.6) |
|
|
|
|
Neutral |
117(28.5) |
|
|
|
Disagree |
98(23.9) |
|
|
Medical knowledge not ethics is the only essential thing for patient care |
Totally agree |
72(17.6) |
2.72±1.091 |
0.000* |
Agree |
96(23.4) |
|
|
|
|
Neutral |
109(26.6) |
|
|
|
Disagree |
128(31.2) |
|
|
Table 3: Views of medical students on medical ethics education |
||||
Themes |
Experience of the Bioethics lectures |
Practical use of Bioethics lectures |
Experience sharing by the students |
Suggestions by the students |
|
"Lectures are quite |
"To some extent it has helped |
A participant shared |
"Teachers cannot take |
informative in nature |
us; we don't have independent |
her experience with an |
us to the hospital and |
|
and sometimes the |
interaction with patients but in |
orthopedic patient who |
present us with a |
|
lectures change the |
supervised situations and there |
had bad experiences at |
dilemma and ask us to |
|
way, we look at |
it has helped us." (We do not |
different hospitals and |
solve it in real life." |
|
things; Lectures help |
break bad news) |
was dissatisfied with |
|
|
us mark the |
|
Drs. He was seeking |
|
|
boundaries." |
|
medical advice from a |
|
|
|
|
medical student which |
|
|
|
|
she was not able to |
|
|
|
|
answer at that moment |
|
|
|
|
despite being a good |
|
|
|
|
medical student and |
|
|
|
|
she just reassured the |
|
|
|
|
patient that the doctor |
|
|
|
|
will soon see him "I |
|
|
|
|
don't know if this was |
|
|
|
|
close, but this is it |
|
|
|
|
experience sharing" |
|
|
|
"Lack of variety of |
"In wards we do not have all |
"We feel confused |
Must be a part of the |
topics & low |
the information about the |
when our seniors do |
institutional curriculum |
|
attendance in lectures |
patients and sometimes this |
not follow ethics, they |
and assessment based |
|
causes lack of |
leads to miscommunication |
were not taught ethics. |
like USMLE part 1. |
|
interest" |
with the families/patients" |
So, we feel childish |
"Attendance should be |
|
"We lack clinical |
|
right now being in a |
mandatory to attend |
|
experience to |
|
hospital while caring |
the lectures. |
|
correlate Bioethics" |
|
towards our patients." |
|
DISCUSSION:
The study has been conducted to capture students' perceptions related to MEE and their experiences of MEE lectures. This will eventually lead to modifications in bioethics curriculum at Shalamar Medical and Dental College. A major issue highlighted in this study was the low attendance of students in ME classes. One of the reasons identified by students was that ME is a non-examining subject. Since it is not required by the university to be taught and examined as a subject in medical school, students tend to pay less attention to these classes as compared to the examining subjects. Since attendance is not mandatory, the students have little interest in attending these classes. The time slot allocated to these classes is also often not ideal as it is either in the late afternoon or near the weekend, so students lose interest. They do not make an effort to attend these classes since attendance is not mandatory. In this study, we also found out that 74.9% of students found ME classes interesting and 72% thought that lecture sessions were important.
In 1999, the World Medical Association's (WMA) 51st General Assembly suggested that ME and human rights should be taught at every medical institute as a compulsory subject and that students should be assessed from time to time in the subject. Teaching ME to the students from the start of their medical education can result in healthcare professionals with better ethics.9 In Pakistan; however, it should be made a mandatory subject in the undergraduate medical curriculum by Pakistan Medical Counsel. Since there is still room to improve the overall health ethics content at every level, public and private.10
In a study by Acharya RP and Shakya YL 11, 91.3% of the medical interns considered ME to be important. In another study by Sunil Kumar Jatana et al.12 57.9% of students stated that knowledge and implementation of ME are very important among doctors, while only 2% stated that it is unimportant. In our study, 74.9% students found MEE lectures interesting due to the variety of teaching methodologies used during lectures. The curriculum at SMDC includes teaching methodologies like case based- discussions, short videos, movies (with discussions and reflection by students) and role play, etc. D Souza and Vaswani found out that diversity in teaching methodologies is important in teaching ME to undergraduate students.13 We found that 83% of students felt that physicians can improve patient care with knowledge of ME and therefore felt it was important. 80.9% of the respondents also felt that ethical issues like abortion and end of life conflict with religious beliefs while 82.2% still felt that universal ethical principles applied in Pakistan.
An interesting observation was that 53.2% thought that ME could not be taught as it relied on individual behavior developed since childhood, while 19.8% disagreed with this statement. These are important findings as they reflect students' intentions to learn skills that they can incorporate into clinical practices and are patient-centered. Social and culturally relevant cases must be discussed with students so that they can appreciate the practical application of this theoretical knowledge, which seems to be important for them. D Souza and Vaswani found out that many curricula for undergraduate students were locally adapted and included their socio-culturally relevant
case-based discussions.13 Students should be provided with training classes, workshops, and seminars to allow them to be more confident to address ethical dilemmas and adopt ethical principles when they enter professional life. Asghari et al. noted that the most common themes in the needs assessment of undergraduate ME curriculum included professionalism and the patient- physician relationship. They found that despite the technological advancement in medical science leading to clinical ethical dilemmas, the most common need was found to be for medical students to learn the art of healing and patient-centered care.14
To overcome the challenges in ME education, a dedicated effort is required on an individual departmental level to arrange lectures spaced out properly throughout the year so that the students remain interested. A few excerpts from the study are quoted: "ME must be a part of curriculum and assessment based like USMLE 1." "Attendance should be a mandatory criteria for participation in lectures."
Making attendance mandatory is also another way to make sure that students participate and learn from these classes. Making classes more interactive with an emphasis on practical aspects of ethics as well as problem-based learning would make learning more exciting for students. Rabbani MW and colleagues15 compared the knowledge and awareness of ME in medical graduates of two medical colleges in Pakistan. They observed that the students who were taught ME in medical college were better informed than students who did not get the formal education in undergraduate medical training. Therefore, it is important to inculcate principles of ME into the curriculum from the very beginning
to ensure they are trained as good physicians with sound knowledge of ethical issues and principles.
In another study by Humayun et.al, it is observed that ME is inadequate in hospitals in Lahore. Doctors should be imparted formal training in ME and national legislation on ME is needed. Patients should be made aware of their rights to ME.16 Our students' opinions show that they believe that such knowledge will impact their skills and will help them be good physicians. This is important because they would like to be taught ME but they also know that only when it is assessed or examined will they be able to give more attention to this subject. It seems that students are overwhelmed with the assessed subjects that are taught in a very old-fashioned way in the form of lectures and even though they enjoy ME lectures/sessions that use various teaching methodologies, they still find it hard to attend ME classes. Here, D Souza and Vaswani's suggestion of including diverse strategies for teaching and assessment should be used and the impact of ME curricula must be thoroughly reviewed, is deemed significant.13
A number of studies have been done regarding ME and a few of them have taken students' perspectives on teaching it as a subject.17 K Mattick et al. 2006 reported that a combination of large and small group teaching, lecture-based learning, problem- based learning (PBL), project work, and presentations were used in twenty medical schools in the UK. According to this study, students found other methods more interesting for learning ethics. It was found that the small group discussion was the most effective way of learning in order to get a response from students' from his/her
arguments and ethical position.18 This research highlights the importance of teaching ME in an innovative and effective way by assessing the attitudes and exploring the experiences of medical students toward ME as a subject. This study can facilitate universities in designing a curriculum for ME in a way that is effective and beneficial to the students as well as to the health care system and by inculcating the suggestions of students, a more effective curriculum can be designed.
A study from Guatemala showed that teaching strategies including a case-based approach are being successfully used to teach ME. The authors are using students' feedback to improve their practical approach toward ME and to transform educational strategies throughout the country.19
A similar strategy is being applied at Shalamar Institute of Health Sciences, where post-graduate ME education was introduced. The feedback of participants has helped in improving not only the curriculum for post- graduate students but also for the undergraduate students at SMDC.20
Our limitation is that this study was conducted in one private medical college therefore the results cannot be generalized, and more extensive studies are required for better understanding. Besides student education, it is also necessary that the faculty development programs on MEE for clinical teachers. Additionally, further studies can be conducted on the actions that need to be taken to help students internalize the ethical issues and feel the need of learning more.
CONCLUSION:
The department of Bioethics was established as an institution-wide pillar in November 2017 in a private medical college (SMDC). ME is being taught to students with the aim of preparing them to apply it in clinical settings. This will add up to improve the quality of healthcare in the country. It is recommended that ME should be taught in a practical manner where the theoretical concepts are applied in different scenarios. This is because students stated that observing hospital staff and residents would help them learn more effectively. Further studies are required to explore the need and ways to incorporate ME in medical education are required.
Recommendations
Based on the study results, following are some recommendations for the medical institutions in Pakistan:
Clinical experience to correlate with Bioethics is being neglected in the curriculum. Further studies can be conducted on the actions that need to be taken to help students internalize the ethical issues and feel the need of learning more. ME should be taught in a practical manner where the theoretical concepts are applied in different scenarios. This is because students stated that observing hospital staff and residents would help them learn more effectively.
The course should be taught in all clinical rotations and must be assessed. Lecture participation should be mandatory. The Higher Education Commission (HEC) of Pakistan and the Pakistan Medical Council (PMC- earlier referred to as PMDC, the status of the institution was changed to PMC in 2019) should enforce ME education in medical institutions throughout Pakistan.
Acknowledgements
We are extremely thankful to the medical students who participated in the study.
Conflicts of interest
We have no conflicts of interest to declare.
Contributors
SS: Substantial contributions to the con- ception, data analysis, Final approval of the version to be published
IGR: Manuscript writing, interpretation of data for the work
ON: Literature search, data Collection
SRR: Manuscript writing, formatting, proofreading
SN: Literature search, data collection, data analysis
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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