Introduction

The Medical Council of India (MCI), the apex regulatory body for the regulation of medical education in India, requires medical graduates to become exemplary citizens and respond to national aspirations by observing the mores of medical ethics, and fulfilling social and professional obligations (1). The fact that the council was dissolved, and its president removed unceremoniously in 2010 on charges of corruption, makes us believe that the preachers themselves never followed the ‘code of ethics’ (2). Such happenings have an enormous impact on the minds of medical students, in that they can influence them to embrace unethical behaviour. The existence of major conflicts between what is preached and what is practised can make it extremely difficult for tomorrow’s doctors to ‘believe in’ and imbibe medical ethics.

Though medical ethics is not a separate subject, it is being taught as a part of Forensic Medicine in the second year of the MBBS (1). However, most students view it as something they need to know merely to pass their examinations. They do not see it in terms of mandatory and statutory regulations that can safeguard doctors and their patients. The purpose of this study is to highlight awareness regarding the ‘ethical code of conduct for medical practitioners’ among medical undergraduate students.

Methodology

A cross-sectional study was conducted at the Sri Lakshmi Narayana Institute of Medical Sciences in July 2010. A total of 172 medical students in various years of undergraduate studies, barring the first year, were enrolled randomly. Following pretesting in a small group, a questionnaire on medical ethics, based on the chapters on ‘unethical acts’ and ‘misconduct’ in the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, was administered to the students. In the questionnaire, the students were presented with 10 scenarios and asked whether these were ethical (Questionnaire 1). They were given the option of responding with a ‘yes’, ‘no’ or ‘don’t know’. The demographic details gathered included age, sex and year in medical college.

The study was conducted in compliance with the “Ethical principles for medical research involving human subjects” section of the Helsinki Declaration. Verbal consent was obtained from all the participants before the administration of the questionnaire and their anonymity was maintained. Clearance was obtained from the institute’s ethics council. Data entry and analysis were done using SPSS for Windows Version SPSS 16.0 (SPSS Inc, Chicago, IL, USA).The mean ± SD scores of students were compared using unpaired t test.

Results

Only 128 (74.4%) of the 172 students enrolled in the study returned the completed questionnaire. Ten of the response sheets were incomplete and were excluded. Of the 118 students who were finally included, 45 were male and the rest (73) female. Thirty-two students were in the second MBBS and 43 each in the third and final MBBS. The characteristics of the sample are shown in Table 1. None of the individuals could answer all 10 questions correctly. The maximum number of questions answered correctly was eight out of ten. The 10 scenarios presented, the expected correct responses and percentage of correct responses are given in Table 2. The maximum rate of correct responses (more than 50%) was to questions 1, 2, 4, 5, 8 and 9. For the remaining questions, the correct response rate was less than 50%. The overall mean score was 6.13, with a standard deviation (SD) of 1.362. The mean scores for second-, third- and final-year students were 6.19, 5.95 and 6.26, with an SD of 1.330, 1.447 and 1.311, respectively. There were no significant differences between second-, third- and final-year students (p = 0.568). The mean scores for boys and girls were 6.42 and 5.95, with a SD of 1.234 and 1.413, respectively. There were no significant differences in the performance of boys and girls ( p = 0.64).

Discussion

Our study had a skewed sex ratio (male: female = 1:1.6), probably because more male students did not return the response sheets. Most medical students were clear about the fact that acts of self-advertisement and the prescription of unknown drug compounds are unethical. This is a healthy sign. Many students also indicated that doctors should display their registration numbers on their prescriptions, maintain medical records for three years and refuse gifts or favours from medical representatives. However, most students were unaware that physicians should not own or be associated with open pharmacies, should not perform mercy killing on the basis of unilateral decisions, and should not conceal signs of domestic violence to protect the assailant or prevent marital discord. Most students were also unaware that disclosing a patient’s secrets is ethical when these pose a risk, which is serious and has been identified, to a specific person. Although the students were aware of the important issues, the majority of them were unclear about matters related to decision-making and communication, which are important in the practice of ethical medicine. The results of this study indicate clearly that medical students are not fully aware of what is required of them by society in terms of being good doctors.

The objective of ethics education in medical schools is to impress upon the student the moral nature of the art and science of medicine and to sensitise the learner to ethical issues (3). It is not only medical students who lack knowledge of the medical code of ethics, but doctors as well (4). To produce doctors who are aware of the ethical aspects of medicine, medical ethics should be introduced as a separate and compulsory discipline in the undergraduate curriculum and it should be mandatory for students to pass the subject before they graduate from medical school. In order to get a degree, students should be required to pass an examination in the subject by securing the minimum stipulated marks. Otherwise, they may not take it seriously (5). Making ethics an elective course in medical schools has not been found to fulfil the basic objectives of such courses (6).

The concept of introducing medical ethics in the curriculum has been criticised in certain quarters. Leget points out that the ‘evasion of ethics teaching’ is a major obstacle that needs to be overcome (7). Many educationalists believe that ethics has got more to do with the overall moral development of the individual and can be difficult to impart through instruction in the later years of a person’s life. Some common arguments against the view that ethics should be taught are that there are no absolutely right or wrong answers in the sphere of ethics (scepticism) and that a person can justify whatever he feels is right (subjectivism) (8). Though academicians’ opinions are divided, we find that in this era characterised by a boom in private-sector medical education, there is an emerging trend towards the dilution of the ethical principles that have been the cornerstone of the doctor-patient relationship all these years.

There is a growing awareness of the need to include medical ethics as a major subject in the regular undergraduate curriculum. Many universities have already started working on the development of an ethics curriculum. The Indian Council of Medical Research (ICMR) is also planning to introduce a certificate and master’s course in medical ethics (9). The MCI, in whatever form it may be reconstituted in the future, should not limit itself to ‘advocating ethical principles’, but also introduce credible measures for the ‘enforcement’ of these principles with an iron hand.

Conclusion

There are major deficiencies in the understanding of medical ethics among medical undergraduates. This can be rectified partly by teaching ethics as a separate subject. It should be taught as a mainstream subject during the first few years of under graduation. Role play and other methods of teaching can be used to teach the subject effectively.. Medical teachers should set an example for the undergraduates by practising medicine ethically. Ultimately, the onus of understanding the principles of ethics and incorporating these into clinical practice lies on the medical students.