ORIGINAL ARTICLES

Ethical problems in medical education

F. E. Udwadia


Ethics and morals

Medical ethics is merely one branch of general ethics, therefore it would be wrong to divorce ethics in medicine from the ethics of everyday life. Professor Dunstan gives a succint but good definition of medical ethics- “obligations of a moral nature which govern the practice of medicine” . It is important to dwell briefly on this definition to understand the implications of “obligations of a moral nature” and “the practice of medicine”,“Moral” and “ethical” are for practical purposes interchangeable words. The term “moral” raises the .practical issues of good and evil, of right and wrong, and of one’s obligations as a physician to choose the good or the right course. This is not always easy because one moral obligation may conflict with another different but equally righteous moral obligation in a given situation.

Morals have a basis either in religion, philosophy or sociocultural traditions. Different concepts in religion, philosophy or in socio-cultural traditions will lead to differing moral principles. It can become increasingly difficult to establish an agreed ethical code in a number of situations where there is a wide variation in the moral base. Even so, the absolute values of good and evil, right and wrong, and the belief in the sanctity of human life, are remarkably similar in all societies.

Medicine- a search for truth

Thus, the three basic, accepted, moral obligations in a doctor-patient relationship in all societies are, beneficence (and its companion-in-arms, non-malficence), patient autonomy and justice. It is the judicious balance between these obligations that determines ethical decisions in a given clinical situation.

The practice of medicine, in a very broad philosophical sense, is a search for truth, and ethical and moral principles are in-built and inseparable within this search. In a more pragmatic sense, the practice of medicine is both an art and a science. The aspect of science in medicine is more easily understood. For example, it may constitute accurate, measurable observations that lead to a hypothesis, the truth of which is subsequently validated by relevant observations. The art in medicine is an immeasurable, indefinable quantum. It indeed approaches the realm of philosophy which according to Bertrand Russell is the art of rational conjecture . It is no surprise that physicians have been some of the best philosophers through the ages, and have_ translated abstract theories of classic philosophy into practical philosophic or ethical action at bedside.

Medical education and practice

The practice of medicine requires education, knowledge, and wisdom born of experience. It has to be taught and its path illuminated, so that the student who aspires to this practice is shown the way. It is the moral obligation and ethical responsibility of a civilization or a society to ensure that this is done. The need to equip a physician with the right attributes and to inculcate a breadth of vision that transcends the mere acquisition of knowledge, is even more imperative in a fast changing, increasingly technologyoriented world. If this is neglected, the physician of today and tomorrow may do more harm than good and may well be a hazard to those he ministers. It is unfortunate that this basic objective in medical education seems to be increasingly ignored in our country.

Medical education all over the world involves selection for admission into medical schools, undergraduate study, postgraduate study and qualification, specialist training and research. I shall briefly consider the problems that plague each aspect of medical education in our country.

Admission to medical school

Entry into medical schools necessitates a selection from a large number of applicants. Universally this is attempted through results of a pre-medical examination in basic sciences relevant to medicine, and a personal interview of aspiring candidates. It is the height of absurdity that the average level of marks required for admission to medical school at the premedical entrance exam in Mumbai is over 95%. One would have expected brilliance of an extraordinary character (amounting to genius) from these students.

Far from it, the standard at most is average and often pathetic.. The fault obviously is with the premedical education and the premedical exam. Surely a system of examination can be devised where the exceptional few would get more than 70%, the very bright around 60% and the average pass marks are around 50%. A system of .examination (as it exists today) where the difference of half or one mark decides admission into medical school, and where so many entrants to medical schools in Mumbai, mediocre though they may be, score near about lOO%, is not .only absurd, but morally and ethically unjustifiable. It needs drastic change and with a little effort this is possible. The system of examination again should not only be different, but should be patently fair. It should be so organized and conducted that allegations or leakage of papers and unfair marking practices are laid to rest once and for all.

Undergraduate medical education costs

Medical education as I see it today, is confused in method, content and purpose. The old disciplines in medicine continue to expand taking up time and attention, only to be challenged by claims of newer disciplines which have opened fresh vistas of knowledge. Good teaching involves a balance between what is old and trusted and what is new and changing. Medicine knows no frontiers. Even so, the main thrust of undergraduate medical education in our medical schools should affecting the immediate be oriented to the health problems and the people of our community country. Yet the current trend is to lay greater stress on problems afflicting the West, and a passing or poor reference to diseases that ravage our communities. It is of ethical importance to teach medical students various aspects of community medicine, as only then are they aware of practical health problems that beset the people of this impoveris hed country. This of course does not mean that we should turn a blind eye to what goes on in medicine in the rest of the world. It only means that we structure our priorities in teaching and in health care correctly.

The method of teaching in our colleges leaves views, much to current methods and desired. It is dull, dry, didactic and tabulated. techniques, and often does not utilize the more recent modes It takes of imparting education as for example the use of slides,novideo recordings, student seminars, project work, clinico-pathological conferences, the use and study of key references that illuminate a subject or that excite interest and curiosity. Good teaching though concentrating on essentials must question dogma, must arouse and encourage an attitude of inquiry, a thirst for knowledge, and serve as stimulus for further study. Above all, a good teacher should use the patient as the chief source of education. The patient is the centre or the fulcrum on which medical education rests. It is wrong for a teacher to ignore this basic. tenet.Ward rounds should be rounds where the patient speaks and instructs directly or indirectly, and the medical teacher with consummate art serves as the medium through which the patient instructs.

All teaching whenever possible should be imbued with an ethical slant. Ethics in medicine need not be taught in didactic lectures, but should be illustrated at every opportunity at the patient’s bedside. Ethical principles are imbibed by example and precept, so that a good teacher besides teaching well will have a tremendous moral influence on his students.

It is thus both the form and content of teaching that needs to be revamped in all our medical schools. It is the moral and ethical obligation of the medical school that teachers discharge this responsibility to the best of their ability. The sadness of medical education, to my mind, is the paucity of good teachers and good teaching in our colleges. This is ethically indefensible and is the fount of numerous unhealthy trends that beset the medical profession.

Costs

Medical teaching should always be the prerogative medical schools and teaching hospitals. It is morally wrong to allow or to encourage medical teaching at a fantastic cost and price through tuitions or coaching classes outside teaching hospitals. What is even more ethically insufferable is the allegation that some of these expensive coaching are run by teachers currently employed i n medical classes schools. It is one of the tenets of the Hippocratic oath that teacher will teach his students what he knows as a duty and not for a fee.

The practice of coaching classes that claim to assure a successful exam result, and also perhaps ensure marks high enough to get good teaching resident posts, is not only unethical in principle, but is also fraught with numerous other unethical possibilities. . There is always a probability, or at least a possibility, of a nexus between the coaching grades, distinctions and prizes at the university examinations. The tentacles of corruption and nepotism can further undermine a system that already leaves much to be desired. The standard of doctors would further fall,medicine as practiced by these doctors would inevitably be even more oriented towards mere profit, and the profession would degenerate into a mercenary business where patient care may become secondary or even non-existent.

But then we must pause and ask ourselves- could these unethical eyesores (termed coaching classes) ever have come into existence in our city if teaching in our medical school was interesting, stimulating, instructive and comprehensive? Indifferent teachers and poor teaching in medical schools is ethically .wrong, and is undoubtedly a factor responsible for the spawning of private coaching classes. This again illustrates a principle in medical ethics one wrong often begets another and another, so that we end up with a chain of wrongs.

Private medical colleges

Over the last two decades there has been a mushrooming of private medical colleges in our country, charging capitation fees of several lacs of rupees. Should such colleges be permitted and even encouraged, or are these colleges unethical eyesores that make a mockery of medicine?

Private medical schools funded by trusts, foundations or even by individuals are not uncommon in other countries particularly in the United States. On principle there is nothing unethical in privately funded medical education, provided the following criteria are met:

  1. The raison d’etre is altruistic and divorced from all profit motives.
  2. The college has the necessary infrastructure for good teaching, and has a hospital with sufficient number of beds to permit clinical study in all important disciplines of medicine.
  3. The college is well equipped and has qualified teachers in basic sciences and in clinical subjects with an acceptable student-teacher ratio. ”
  4. The funding and all sources of finance are transparently honest, and the fees charged are solely directed towards maintaining and improving medical education and facilities.
  5. There is accountability in the medical school’s administration, and in all its other functions.
  6. The standard is on par with all other schools in the country. There are very few schools that meet these standards. If, as is alleged, business ventures come in the guise of private medical schools, the standard of medicine would be deplorably poor and the practice of medicine an unmitigated disaster.

Examinations

There is even today a great deal of mistrust over the fairness of both undergraduate and postgraduate examinations. We read of favouritism, nepotism and even corruption. The degree of canker afflicting the honesty and propriety of examination results is impossible for an outsider to determine, but again it is the moral obligation of the universities to ensure that exams are fair and impartial, on par with those conducted in teaching centres all’over the world.

Postgraduate education

If undergraduate education in the doldrums, post graduate education is bound to suffer. Unfortunately, the majority of graduates if they could, would elect to do their postgraduate studies and specialize. Freedom of choice needs to be ‘tempered by ability, aptitude and resources. Ethically speaking it is preferable to have fewer but well trained postgraduates and specialists, rather than have a veritable army of postgraduates and specialists whose training by international standards leaves much to be desired. It is our ethical responsibility to ensure this is so. An inadequately trained specialist is an even greater danger to health than the poorly taught and trained general practitioner or community doctor. Such a specialist often practices in an uncritical workshop of technocracy, pays homage to and feeds the machine which benefits him, looks at his patients in specialist frenzy but with blinkers, and loses the all important holistic approach to medicine.

It is ethically imperative that all invasive procedures, diagnostic or therapeutic, in specialist medicine should be taught and then supervised by peers in their respective fields. It is imperative, as in most countries in the world that to independently qualify to do a potentially dangerous invasive procedure, a specialist needs to do and thereby practice, a minimum acceptable number over a period of a year, and then continue to do so. This is sadly lacking in some specialties today and unquestionably contributes to iatrogenic morbidity and mortality.

Research

The last, yet, an important aspect of medical education is research. There are undoubtedly some who are born to research rather than patient care. Research again should be on subjects of topical interest. There is indeed great scope for clinical research in our country because of the wealth of clinical material we possess. There is also an equally tremendous scope for epidemiological research- an aspect of disease that is shrouded in ignorance. Is it morally justified to allocate sparse funds for research on some aspect of disease which has already been researched upon a hundred times over? This has more often than not become the rule rather than the exception in our country. It is important for concerned authorities to realize that one good research publication is superior to a hundred research papers which repeat what has been said many times over. Integrity in research has deteriorated the world over; the motto “publish or perish” is the sword of Damocles hanging over the researcher’s head. He compromises on scientific standards, on truth, on honesty, and often also on his ethical approach to methods employed to further his research.

In summary, ethics should relate not only to the practice of medicine but to all facets of medical education. Only then will the practice of medicine flower and flourish as it should. That “there is something rotten in the kingdom of Denmark” is obvious in relation both to the practice of medicine and to medical education. I shall not dissect the cause of this canker except to state that this is due to a sharp, progressive fall of values all over the world, more so in our country. When one loses one’s sense of values, when the value system is corrupt, the edifice this system supports and embellishes, crumbles and disintegrates. One cannot expect the profession of medicine in all its varied aspects to remain a bastion of virtue and probity when it is surrounded by a sea of filth and corruption. The bastion slowly and surely is bound to be eroded and may well be submerged beneath this sea.

References

  1. Dunstan CR, Dunstan GR: The Artifice of Ethics. London: SCM Press 1974
  2. Dunstan GR: In: Eds.: Duncan AS, Dunstan GR, Welbourn RB.Dictionary of Medical Ethics. London: Darton Longman and Todd 1981
  3. Johnson AG: Pathways in Medical Ethics. London: Edwin Arnold 1990
  4. Russel B: The art of philosuphising. Totowa, NJ.: Helix Books 1974

The significance of the intimate personal. relationship between physician and patient cannot be too strongly emphasised, for in an extraordinarily large number of cases both the diagnosis and treatment are directly dependent on it. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.

Dr. Francis Peabody

About the Authors

F. E. Udwadia

Consultant Physician

Breach Candy Hospital, Bhulabhai Desai Road, Mumbai 400 026

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