Medical ethics became one of the most important teaching modules in most of the medical schools especially in the last three decades particularly in US7 . Ethics defined as the study of morality, careful and systematic reflection on and analysis of moral decision and behavior4. Hence the medical ethics is the study of ethics related to medical practice. There are four primary principals for medical ethics where all basic medical teaching teaches to medical students. These are non-malfeasance, beneficence, justice and autonomy with sub sectional principals like truth telling and confidentiality.12 Now a day’s doctors are facing more ethical questions and dilemmas in day to day clinical practice, this can be partly attributed to the increase in the knowledge of patients about their health from the media and internet . Studies showed that there is a strong relation between resolving ethical issues and medical errors especially in the area of informed consent and end of life care8. In addition, the court compensation for medico legal cases opened the door for public to find faults for doctors or the health systems to earn some wealth from it! All these made the teaching of how to handle an ethical issue and resolve it very essential to produce a competent skillful physician.
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Medical schools adopted different styles and methods for teaching medical ethics, it included didactic lecturing, small group seminars, case based discussion and simulated patient but without uniformity or consensus as to method or content7. This could be as a result of lack of agreement about what shall we teach in medical ethics7.
At sultan Qaboose University, medical students have a one interdisciplinary activity (IDA) week for medical ethics during their mid of fifth year. During this week speakers from different medical and surgical specialties present to the students a common ethical issues encounter. This week is also attended by Islamic scholar (Professor Albar) to comment on Islamic perspective in selective cases like abortion and end of life care . As co-organizer of the course I introduced the presentation of clinical cases by the student to the entire group. I asked each subgroup of the students to select a case where there is an ethical issue and reflect on what was done and how can we improve it.
I found the reflect practice theory is very suitable for teaching of medical ethics because it stimulates the thinking and give the students the opportunity to analyze the ethical dilemma and how to resolve it.
The theory of reflective practice is attributed primarily to Donald Schön3, 5. In life and based on our knowledge and experience we take decision easily to events that we are expecting and used to experience. However when surprise or unexpected event take place, based on Schön theory, people develop two types of reflection to that event. The first one is “Reflection in action ” and it occurs immediately.”It is the ability to learn and develop continually by creatively applying current and past experiences and reasoning to unfamiliar events while they are occurring”5. The second, “reflection on action,” occurs later. ” It is a process of thinking back on what happened in a past situation, what may have contributed to the unexpected event, whether the actions taken were appropriate, and how this situation may affect future practice” 5. The reflection in action can be considered as an emergency decision in which the physician should take the risk of being mistaken, however, this type of decision should be appreciated by people in authority if later turned to be not the perfect way of handling it and that is because it was taken based on the inputs of that situation and surrounding circumstances unless it is clearly odd approach. In contrast, the reflection on action comes later when the physician finished all duties and started re-calling cases seen and decisions taken. At this point s/he will start to bring other options and thoughts that could serve the situation better than the ones taken. This extremely important because it enables us to spend time exploring why we acted as we did, what was happening in a group and so on13. In addition if this type of reflection done in group (Peer) will lead to even more reasonable and appropriate reaction to the surprise14.
Since this paper discusses the teaching of medical ethics, the following example will illustrate this approach. A 32 years old pregnant lady in her 3rd trimester involved in car accident and sustained severe head injury , brought to the casualty and treating physician confirmed her death but noticed that the baby still kicking !. Limited experience and lack of awareness about the regulation of such the situation made it a surprise for the physician. He used his basic knowledge of saving life and decided to perform postmortem caesarian section (PMCS) and a second surprise came when the husband arrived to refused PMCS!! . Reflection on action for such case is extremely crucial to reach to an approach which is ethical, legal and satisfy the patient. It is usually reached when the case is presented to the peer and each one is discussing different perspective of the case. In the previous example the reflection on action could be asking a senior physician on duty be a good option for the case.
At college of medicine in sultan Qaboose University, medical students are divided in group each composed of about 10 to 15 students (Boys and Girls). Each group will be asked to prepare a clinical case seen in practice where there was an ethical issue (e.g. breaching confidentiality) and one or two of the group members will present the case to whole group during the medical ethics week forum. Students will be informed in advance about the objectives and strategies of this approach and each group will linked to a facilitator who is usually senior medical/paramedical faculty with experience of making difficult medical decisions6. The group will keep in touch with facilitator either in person or online (e.g. email) to show the contents, structure and suitability of the case for presentation and discussion. The facilitator will guide the students in selecting the case and how to formulate the ethical issue and its resolution and use steps in table-1 adopted from Catherine Myser.9, 11
S/he will also teach them some basic ethical principal like doctors should refrain from being judgmental, patronizing or minipulative2. S/he will direct them to the appropriate resources and personals whenever required. In Oman, many decisions of ethical dilemma are driven by Islamic teaching and this is very prevalent in medical field, hence students will be directed to Islamic scholars who have some medical background in order to help them understanding Islamic teaching in medical field. During the medical ethics IDA week forum, each group will present their case to the entire group in the presence of the facilitators. The presentation will be briefing about the case, the ethical issue, what was done, and how can we do better? More time will be given for discussion and comments by other students who are not member of the presenting group. The discussion will be regulated and guided by the facilitator supervising the presenting group. At the end of discussion the facilitator will resolve any argument and give the final comment summarizing the ethical issue and the best way to deal with it.
Medical schools around the world used different models in teaching medical ethics; the variation in selection of teaching model could rise from the availability of resources, number of students and curriculum design. For example, both university of Pennsylvania and university of Washington used small group facilitation and peer interaction while uniformed services university introduced a novel model called ” SCOOP ” which stand for Students’ Clinical Observation Of Preceptors11 . A SCOOP reverses the process of evaluation by giving the students evaluation form and ask them to evaluate the teachers. This gives them the opportunity to identify the teaching skills and methods reflect on them and hence acquire the appropriate one and avoid the other one. Shaheen and his group wrote in commentary about time to unified approach to medical ethics where he advocated for unified framework of ethics education justifying that ” it will ensures measurable and accountable basis for the complex of far-reaching ethical issues present in the medical field”7 . However, it is difficult and impractical to unify the contents and materials of medical ethics for different parts of the world where there is a diversity of culture, believe and traditional values. That is because most of the ethical decisions are driven by these factors. For example, In Oman (and other Muslims countries) it is forbidden to drink any amount of alcohol as per the Islamic teaching, hence it is unethical to advice patient to drink alcohol as part of heart protection advice while the same advice can be carried out normally in non-Muslim country. However, I support the statement of Rameshkumar in his paper “Ethics in medical curriculum ” when he said “The structure of ethics education has to be closely monitored and the curriculum goals have to be well defined”.10
The strength of this proposal is that there is national and international move toward teaching of medical ethics to both pre and post graduates students. Most of the senior physicians who did not have training in medical ethics realized that it made a gap in their qualification and they urge the new generation in order not to miss the chance. In Oman the support of the current and previous deans of college of medicine at sultan Qaboose University along with other many medical faculties will make this proposal overcome any obstacles. In addition, there interest of health care providers from different medical disciplines in any activities in medical ethics (workshop, seminars and lectures) will prepare the ground and the environment for the proposal to grow up at the university. This interest always clears during our annual medical ethics week where we get several requests from different institutes and departments asking for registration to the event although the week primarily designed for medical students.
The challenges that this proposal might face is the limited resources that include trained personals and teaching material. The later is easier to overcome since it merely financial and the college is ready to provide any recommended teaching material as long as there is a clear vision and mission of its utilization. In term of training personals, there are already two faculties sent abroad for master in bioethics. In addition, there are several faculties who has special interest in teaching of ethics, all these will make the overcome of human resources obstacles more feasible.
In order to implement this theory in teaching medical ethics to medical students I recommend the college to consider the following points:
- Identify and train people interested in teaching of medical ethics. The training should be for high degree ( Master , PhD ) and it is preferred to be in a center where culture and value of people are close to Oman.
- Provide teaching resources and materials to students. It should include textbooks, journals, video … etc.
- Instruct the clinicians to integrate teaching of issues related to medical ethics in their daily patient care.
- Include assessment of medical ethics in the standard summative and formative methods of assessment in the college.
- Regular evaluation and audit of the program in order be developed farther .