Survey of ethical issues reported by Indian medical students: basis for design of a new curriculum
Anuradha Rose, Kuryan George, Arul Dhas T, Anna Benjamin Pulimood, Gagandeep Kang
Education in ethics is now a formal part of the undergraduate medical curriculum. However, most courses are structured around principles and case studies more appropriate to western countries. The cultures and practices of countries like India differ from those of western countries. It is, therefore, essential that our teaching should address the issues which are the most relevant to our setting. An anonymised, questionnaire-based, cross-sectional survey of medical students was carried out to get a picture of the ethical problems faced by students in India. The data were categorised into issues related to professional behaviour and ethical dilemmas. Unprofessional behaviour was among the issues reported as a matter of concern by a majority of the medical students. The survey highlights the need to design the curriculum in a way that reflects the structure of medical education in India, where patients are not always considered socio-culturally equal by students or the medical staff. This perspective must underpin any further efforts to address education in ethics in India.
Preparing physicians-in-training to become independent decision-makers dedicated to the well-being of their patients is the focus of clinical education (1). Formal medical training often emphasises the acquisition of knowledge and skills. However, these achievements, while necessary, are not the only attributes of a good doctor (2). Traditionally, medical learning is based on an apprenticeship model, in which more experienced physicians provide mentoring and transmit essential knowledge, skills and attitudes relating to clinical practice by serving as role models for behaviour (3). In recent years, there has been a growing conviction that medical education should include formal ethics curricula with the aim of inculcating the clinical and ethical decision-making skills and professional values, which good doctors need to possess (4, 5,6). Many universities in India are in the process of developing ethics curricula for their students, and the Indian Council for Medical Research (ICMR) has introduced certificate courses in ethics, aimed mainly at faculty and researchers (7).
Topics such as “Principles of medical ethics” and “History of ethics”, though interesting, do not address the issues faced by students and physicians on a day-to-day basis. Furthermore, the curricula tend to be based on western literature and experiences. Studies have shown that effective education in medical ethics must be driven by the participants and should be specific to the stage of development (8). India needs to develop curricula appropriate to the needs of the medical students in our cultural setting. A curriculum which addresses the different ethical issues faced by students in the various phases of their education is likely to be relevant and, therefore, more acceptable to Indian medical students.
In this article, we report the results of a survey of the ethical issues faced by medical students during the clinical years of their MBBS training at a medical college in south India. At present, the students receive training in ethics through lectures, role plays and small group discussions during the foundation course, Community Orientation Programme (COP) and the first clinical year, during specific postings such as medicine and obstetrics, and during their internship. However, training in ethics is imparted in accordance with the needs of the relevant faculty and the ethics curriculum is not formally structured as a separate entity. This was among the activities undertaken to help redesign the curriculum.
Design and setting: The survey was conducted in 2012 at a medical college in south India that has an annual intake of 60 students. A semi-structured, anonymous questionnaire was distributed to students in the four clinical years (Appendix 1). The questionnaire was developed after discussions with the faculty teaching undergraduate students. Since this was a preliminary survey, the scale was not validated, but there are plans to do so for future assessments. The questionnaire had eight questions with subdivisions. The basic demographic data on gender and year of college were collected. Questions on teaching and learning ethics were graded on a five-point Likert scale. Open-ended questions sought information on the ethical issues encountered by the students in the last year.
Participants: Students from the four clinical years (n=242) were requested to participate. This survey was part of a series of larger surveys on the quality of our medical curriculum and was conducted to improve our present curriculum and teaching. It was not planned as a research study and was, therefore, not submitted to the Institutional Review Board for approval. Consent was obtained for the survey from the institutional administration, as well as for the publication of the anonymised results of the data analysis.
Analysis: The data were entered on Epidata and basic analysis was done with SPSS v15. The open-ended questions were analysed and coded into those causing distress/discomfort and those causing dilemmas, and further coded into those relating to professional behaviour and those relating to ethical issues.
Of the 242 students contacted, 189 (78%) responded. Of the respondents, 38% were men and 60% women. Thus, women had a better response rate than men (Tables 1 and 2).
Fifty-five per cent of the participants reported facing ethical issues during their student period. A total of 358 reported instances of coming up against ethical issues (Table 3), with 70% of the final year students and 14% of the first clinical year students reporting one or more issues. A similar trend was noticed in the responses related to questions about whether the students had witnessed ethical issues in the past year – 20% of the first clinical year students reported that they had, whereas the corresponding figures for pre-final and final year students were 60% and 44%, respectively.
Among the 358 reported ethical issues, a majority (297/358, 83%) were issues that caused distress or discomfort to the student. The responses were categorised into those reflecting problems with professional behaviour and those involving ethical issues. In the former category (Table 4), a large number of responses pertained to the rudeness with which doctors spoke to patients. Other respondents mentioned inappropriate behaviour on the part of students in the presence of patients. This included talking in a language the patient did not understand, laughing when he/she did not share the joke and placing their knee on his/her bed, etc., all of which caused distress or discomfort to the patient. Two respondents reported facing a dilemma over the boundaries that should govern the relationship between the doctor and the patient’s relatives. The students seemed to be clear on the issue of the boundaries to be maintained between patients and physicians, but not on the relationship between patients’ relatives and physicians.
As for the issues related to medical ethics (Table 5), one issue that gave rise to distress and dilemmas among a majority of students concerned the ethical use of patients to learn medicine. The distress stemmed from the discomfort, including pain and the inability to sleep, faced by patients when examined by students. Inconvenience, too, was a cause of distress, as the students’ participation in teaching clinics, etc, made them late for other appointments. The subjective feeling of 28 students was that the consent obtained from the patient was inadequate. The students also felt it was improbable that confidentiality and privacy were maintained during clinics. Twenty-six students were uncertain about the purpose and ethics of obtaining a sexual history from patients with medical conditions the diagnosis and further management of which may not strictly require a sexual history.
Abortion and euthanasia were issues that caused a dilemma and required greater clarity. As expected, while issues relating to patient care, such as abortion, euthanasia and confidentiality, were brought up more often by students in the pre-final and final years, the first clinical year students more frequently reported issues relating to showing disrespect towards cadavers for dissection, copying records and cheating during examinations, etc.
The students reported that they had learnt and thought about ethics during other activities, such as those under the Community Orientation Programme (COP), the Community Health Programmes (CHP) and the Secondary Hospital Programme (SHP). In the COP, the students live in a village for three weeks, with access only to the facilities available in the village. This helps them understand the problems faced by the rural people, in terms of the social determinants of health. In the CHP, the students are given two weeks to plan and implement a health programme, and are exposed to issues such as healthcare rationing, prioritising among the different health needs of populations, when resources are limited and setting limits to care within budgetary constraints. In the SHP, the students visit and spend time in secondary hospitals across the country.
Approximately 83% of the students agreed that ethics education is as important as clinical training. Interestingly, 65% disagreed with the statement that doctors are inherently ethical and 60% disagreed with the statement that being religious makes for sufficient ethical training. Only 42% of the students agreed that ethics could be taught (Appendix 1).
Medical education is a combination of didactic and practical training, in which students learn through exposure to the practice of clinical medicine, predominantly in a hospital setting associated with an academic institution. Every encounter in the medical care setting has an ethical dimension. In most situations in medical education, the art and science of ethics are implied rather than considered formally.
In this survey, we identified that a subset of our medical students was uncomfortable with the professional behaviour of some of their teachers and colleagues. Some doctors and students were reported to have treated patients with disrespect, spoken rudely, shouted at them and made inappropriate jokes reflecting the sociocultural divide that exists between some patients and doctors/ doctors-in-training. These findings are similar to those of student surveys from other colleges (9). This study did not specifically take into account the circumstances under which these issues were encountered – eg, whether doctors were working under highstress conditions due to large patient numbers, – but this is an area that can be explored in future studies.
The other findings related to issues common to all students. These included cheating or copying, reported by 5% of the students, marking proxy attendance (6%), and other issues specific to medical students at different stages of training. Complex ethical issues faced by the doctors, such as those related to transplants, assisted reproduction and experimental therapies, were encountered by the students less frequently. This suggests that issues concerning “everyday ethics”, such as abortion and withdrawal of care, which the students face and consider, should form part of a new curriculum for undergraduate medical students, rather than more complex issues that they rarely encounter. A study by Goldie et al reported that students seem to value ethics curricula that are contextual rather than theoretical (8).
Distribution and response according to gender
|Respondents||72 (67%)||113 (84%)||189 (78%)|
|Total student body||108 (44.6%)||134 (55.4%)||242|
A consideration of what should be taught begins with what is already being taught. There is substantial variation in the time allotted for and the quality of the medical bioethics curriculum. The need for more formal education in ethics has been recognised, but the concept of imparting education in medical ethics is fairly new and there is a dearth of funding. There is also a belief that ethics is best taught through role modelling rather than formal teaching (10). Few colleges have a department of bioethics with a faculty that is trained in bioethics and dedicated to teaching medical students. Hardly any college is engaged in the development and evaluation of an ethics curriculum and staff. Very little effort has been expended in developing programmes for education in bioethics. Consequently, bioethics courses are often poorly developed and meagre in content, and contain mainly case studies and modules borrowed or adapted from western literature.
Another barrier is that most institutions merely pay lip service to the cause of education in bioethics and their efforts lack in substance. Institutions with ethics programmes may only satisfy the minimum requirement of accrediting agencies and do not have adequate services to ensure ethical care of patients. The students were very clear about the need for training in ethics, in addition to clinical training. Since most medical education is imparted through practical teaching, the ethics curriculum should play a role in determining the format of all interactions with other professionals and patients, as well as treatment choices. Physicians who are mentors and teachers must indicate to students and trainees that ethics is a crucial part of what they are learning. In addition to the development of an “everyday ethics” teaching curriculum, two key complementary aspects must also be considered.
First, a knowledge of the humanities and social sciences is of key importance in caring for patients as persons (11) Reading poetry or fiction that explores aspects of human illness and suffering gives a physician exposure to the human element of healthcare, which may be lost in the daily practice of technologically-driven medicine. Exposure to the humanities may thus enrich both the patient’s and physician’s experiences. Second, it is essential for students and physicians to understand law and the legal system (12) A knowledge of the law has profound ethical implications when it comes to the care and well-being of patients.
The most critical barriers to the provision of good-quality education in bioethics in India are the lack of commitment to developing an appropriate curriculum and financial constraints. Most institutions do not have separate budgets or dedicated support staff to run an ethics department. To develop an appropriate curriculum, specific strategies must be formulated to address ethical issues that are locally and universally important, using empirical data from India. Informing faculty members of the findings of surveys conducted among students could induce the former to teach students about the relevant problems more frequently. Other strategies might include encouraging faculty members to explicitly share their knowledge and experiences as a formalised teaching tool. Faculty or staff members could also be asked to keep a log of cases related to everyday ethics and share these with the “ethics faculty”‘, who, in turn, could teach students about these issues or discuss them in designated sessions. Finally, it would be useful to develop an model of teaching that helps teachers and trainers to address and balance the multiple concerns and agendas which arise in a complex and demanding field such as medicine. The findings of this study are limited by the small number of students covered and the fact that they are from a single medical college. Additionally, the questionnaire did not address the circumstances under which the reported ethical issues arose. The issues were reported in an openended section, and issues that were not perceived by the data collection team as being ethical issues were not taken up for further analysis.
Class distribution of respondents (n=187, data missing for 2 respondents)
|Class||% participation in class||% of total respondents|
|Second clinical year||96||31|
|First clinical year||70||22|
This survey is a part of the institution’s effort to develop an ethics curriculum that would be best suited for its students. The findings will be used to develop and match the topics to be considered, and decide upon the training stage during which they are to be taught. We hope that aligning the teaching of ethics to the students’ clinical postings will make the ethics curriculum more relevant and interesting. We plan to evaluate it after its introduction.
Number of reported ethical issues faced by medical students by class
|Class||Ethical distress||Ethical dilemma||Total instances reported|
|Second clinical year||95||26||121|
|First clinical year||15||2||17|
Issues relating to professional behaviour
|Year of joining medical college/ issues identified||2008||2009||2010||2011||Total instances|
|Rude behaviour to patients/junior doctors and staff||10/2||18/1||24/4||2||61|
|Copying in examinations||12||2||0||4||18|
|Proxy attendance, bunking class||11||9||0||3||23|
|Treatment of cadavers||0||0||0||4||4|
|Patient distress at being examined||38||16||11||0||65|
|Consent for examination||9||7||11||1||28|
Issues relating to ethics
|Year of joining medical college/ issues identified||2008||2009||2010||2011||Total instances|
|Ethics of eliciting sexual history*||9||4||13||0||26|
|Care dependent on finances||1||0||10||0||11|
|Waiting time in the clinics||3||0||6||0||9|
|Confidentiality, abortion, euthanasia||4||15||25||0||44|
Medical students face issues related to ethics and professional behaviour throughout their training, as is evident from their responses to the questionnaire. Several of the problems reported do not have a place in the traditionally structured modules on the teaching of ethics since they fall between the areas of ethics and professionalism. The survey shows that there is much to be desired as far as meeting the training needs of students is concerned, and similar surveys should be conducted with an eye to making the curriculum relevant to their needs in different phases of training.
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Appendix 1 Ethics survey
Year of medical college:
- 1st clinical
- 2nd clinical
- List the ethical or moral dilemmas you faced as a medical student.
- List instances in the last year when you witnessed an event which made you feel someone was behaving unethically.
- In your present ethics training, list three components that have helped you deal with ethical dilemmas.
- Can you suggest additional components that can be added to the ethics training?
- Ethics training is as important as clinical training for a medical student. Strongly disagree / disagree / neither agree nor disagree / agree / strongly agree
- Doctors are inherently ethical, so the emphasis must be on clinical training. Strongly disagree / disagree / neither agree nor disagree / agree / strongly agree
- We all learn ethical behaviour from religious activities, so the emphasis must be on clinical training. Strongly disagree / disagree / neither agree nor disagree / agree / strongly agree
- Ethics cannot be taught. Strongly disagree / disagree / neither agree nor disagree / agree / strongly agree
- Ethics should be taught as:
- an integrated course throughout medical college
- as a separate subject
- at the bedside by clinicians
Likert scale questions: