Knowledge and attitudes regarding medical ethics among junior medical graduates in a tertiary care hospital, Manipur: A cross-sectional study.

Training in medical ethics has been made mandatory in the undergraduate curriculum (1). The Medical Council of India (MCI) in 2002 released its revised Code of Ethics, a regulatory document on professional conduct, etiquette, and ethics of doctors (2).

That a significant proportion of doctors are still unaware of healthcare ethics has been shown by previous studies (3, 4, 5). We took up this study as there is limited research regarding awareness of medical ethics among doctors in Manipur.

This cross-sectional study was conducted among junior medical graduates of Jawaharlal Nehru Institute of Medical Sciences (JNIMS), Manipur, during the month of November-December 2018. The study aimed for universal coverage of all the target population, and those who were not willing to participate and who could not be contacted after two visits were excluded. A pre-tested, semi-structured, self-administered questionnaire was used. There were 14 knowledge questions and 14 attitude-related questions which were measured on a three-point Likert Scale. Out of the total knowledge score of 17, those scoring more than 10 were classified as having “good/adequate knowledge”. Descriptive and analytical statistics were generated and a p-value of <0.05 was considered as statistically significant. The study was granted an exempt review by the Institutional Ethics Committee (IEC) vide letter No Ac/04/IEC/JNIMS/2018(157) dated November 20, 2018. No direct identifiers were collected and strict confidentiality was maintained for collected data.

Results

Out of the total of 311 junior doctors 257 responded. The median age was 27 years and males constituted 45.9%. Post-graduate trainees(PGTs) constituted 33.1% of the total and about 7 (2.7%) participants passed MBBS before 2010. In response to the knowledge questions about 82.1% were aware of the existence of an “ethics committee” in the institution. Around 43.2% of the participants did not know “who enforces the code of ethics in India.” When asked “What is the apex body in India for the formulation and promotion of biomedical research?” only 42.8% responded correctly. About 52.9% of the participants knew that the approval of the Institutional Ethics Committee (IEC) is required for conducting a medical research project and 26.1% knew that a medical practitioner should participate for at least 30 hours in Continuing Medical Education (CME) programmes every five years to maintain good clinical practice. Very few participants knew about the four principles of biomedical ethics (10.5%).

Overall, 26.1% of the participants were found to have a good knowledge of medical ethics with PGTs scoring the highest (31.8%).A majority (82.5%) disagreed with the statement that “confidentiality is not an important aspect of treatment”. Around one-third (30.4%) of the respondents agreed to the statement that “If a terminally ill patient wishes to die, he/she should be assisted in doing so”. PGTs had significantly higher knowledge scores as compared to non- PG junior residents and interns (p=0.008).

Discussion

More than half the participants were aware that prior approval from the IEC is mandatory before conducting any medical research on human participants, and a majority (82.1%) of the participants were aware of the existence of an IEC, which was higher than the awareness level found in previous studies (4, 5, 6, 7). This could be because of their exposure to medical research projects during undergraduate and postgraduate training in the institute. A majority (82.5%) of the participants disagreed that confidentiality is not an important aspect of treatment. A similar observation (81.3%) was also found among physicians in a study done by Chopra et al (8). More than one-fifth (23%) of the participants had the misconception that physicians are allowed to run their own chemist shops for sale of medicines and surgical appliances. This is an area of concern and needs to be addressed. Almost two-third (61.1%) of the participants were unaware that receiving any monetary grants from the pharmaceutical industry for individual purposes is a violation of the code of conduct for doctors. This further reflects the lack of in-depth knowledge about medical ethics and the influence of pharmaceutical companies. Around 30.4% of the participants agreed that physician-assisted death for terminally ill patient who wished to die is acceptable, similar to the findings in other studies (6, 8).

One limitation of the study is that, during data collection, some participants were busy at their work and so returned the questionnaires late which may reduce the validity of the information provided. There is an urgent need to include practical education about ethics in medical curricula.A test on knowledge of the code of ethics at the time of registration could also be considered.