Introduction

Doctors attending to patients in an emergency health situation have often had to face assaults on account of the recent increase in the awareness of patients’ rights in India (1, 2, 3). These may be due to the paternalistic attitude of the doctor or a lack of understanding, or may simply be emotional outbursts. Advances in biomedical technologies such as life support and artificial reproductive technologies have brought new ethical dilemmas in their wake and have exacerbated the problem. Ethical dilemmas are usually encountered in areas such as abortion, contraception, treatment of a patient with a terminal illness, professional misconduct, maintaining a patient’s confidentiality, the doctor’s professional relationship with the patient’s relatives, religion, traditional medicine, and conflict of interests. The conventional medical course offers students little help in resolving the ethical dilemmas they will encounter as healthcare professionals. Training in medical ethics has been made mandatory in the undergraduate curriculum by the regulatory body of medical education, the Medical Council of India (MCI); but it has been placed under forensic medicine (4). There are very few medical colleges in India with a standardised ethics curriculum, and with provisions for evaluation (5). The dental curriculum makes merely a passing mention of the principles of ethics (6).

Medical and dental postgraduate students undergo intensive training in their specialties and their focus is chiefly on organ specialisation. Postgraduates need intensive training in bioethics so that they have an appreciation of the patients’ rights, cultural differences and research ethics, and are equipped to resolve ethical dilemmas.

There are varied views on strategising the teaching of bioethics. Most of them emphasise the importance of tailoring the teaching of the subject to the needs of the society concerned (7). The teaching of bioethics should also be holistic. For example, students could be taught about the value of the “heart” over the “mind” of the system of values and beliefs in a community, and of the need to understand the lived experiences of patients; while also incorporating various ethical approaches (8).

The dearth of specialists in bioethics and a lack of organised human resources has led to lack of appreciation of the urgent need to include bioethics in medical education in India. Further, there are concerns that teaching bioethics as an organised science might be problematic and would not be feasible (9). In India, due to the cultural mosaic (10), the teaching of bioethics needs to encompass the various perceptions of morality and ethics unique to people from different cultural, socioeconomic and geographical backgrounds (9). The training in this subject should be integrated with the local social and cultural values.

The first step in formulating an ethics curriculum may be to determine the level of the basic knowledge and attitudes of the postgraduates in the region. Few standard yardsticks have been designed to measure what is known and practised so as to ensure that educational efforts are better targeted (11). The objective of this study was to assess the knowledge of, attitude to and practices in healthcare ethics among medical and dental postgraduates.

Methodology The study was approved by the institutional review committee of the Amrita Institute of Medical Sciences, Cochin, India. Permission was obtained from the deans of all the four institutions that participated in the study.

Study settings A cross-sectional, questionnaire-based study was conducted in two medical colleges in Kerala and two dental colleges. The medical colleges were the Amrita School of Medicine and the Government Medical College, Calicut, while the dental colleges were the RV Dental College, Bangalore and the Government Dental College, Trivandrum. These institutions were selected since, at the time of the study (2010-11), they were offering postgraduate courses in all medical, surgical and dental specialties.

Study population Postgraduate students who had enrolled in the MD, MS, MDS and DNB courses in these institutions were selected. A sampling frame of all postgraduate students in each institution was developed and three from each specialty were selected randomly. For example, three out of 10 were selected from the MD course. In the case of the dental postgraduates, all of them were selected since there were fewer subjects for each specialty. A total of 209 subjects were selected.

Questionnaire We adapted the questionnaire of a previous study (7) to make it suitable to our objectives. The 35-item questionnaire was a self-administered, semi-structured one with both open and close-ended questions, designed to assess the students’ knowledge, attitudes and practices in the sphere of healthcare ethics. The content of the questionnaire was validated before the study. The demographic variables, such as the year in which the student was studying, and his/her specialty, age and gender, were included in the questionnaire.

The second part of the questionnaire consisted of questions regarding the importance of a knowledge of ethics, the source of this knowledge and the source of consultation in case an ethical problem arises. The respondents were asked whether they were aware of the presence of an ethics committee in their institution, and about the role of these committees. The questionnaire mentioned eight roles that ethics committees might play and the respondents were asked to indicate whether they thought the committees played these roles by choosing between “yes”, “no” and “not sure”.

In the final part of the questionnaire, the respondents were asked to answer questions on everyday ethical issues. They were asked if they agreed or disagreed with certain statements concerning ethical conduct, autonomy, paternalism, confidentiality, informing patients about wrongdoing and informing relatives about the patient’s condition, informed consent, and the influence of religious beliefs on the treatment. The respondents were required to grade their responses on a Likert scale ranging from 1 to 5.

Informed consent All the participants selected were given the participant information sheet, which explained the details of the study, and written informed consent was obtained from those who agreed to participate in the study.

Statistical analysis The data were analysed using Statistical Package for Social Sciences (SPSS) – version 11.5. Descriptive analyses were carried out for all the data. The attitudes of the dental and medical postgraduates towards practical ethical problems were compared using a Chi-square test. Statistical significance was fixed at the level of p<0.05. In Table 3, the category of “not sure” was merged with that of “disagree” as the responses in the “not sure” category were less than five or zero. Also, the former category is likely to veer towards the category of “disagree” rather than “agree”.

Results

We contacted 209 postgraduates, of whom 199 consented to participate. A total of 172 subjects returned the completed questionnaire. Thus, the response rate was 83%. The mean age of the medical and dental students was 28.1±1.7 and 29.9±3.6 years, respectively. As many as 83.8% of the participants in the study were males. Table 1 presents the characteristics of the study participants.

Nearly all the medical postgraduates had knowledge of the Hippocratic Oath, but surprisingly, only 23.4% of them had knowledge of the Indian Council of Medical Research (ICMR) guidelines on ethics for research, the Nuremberg Code and the World Medical Association’s Helsinki Declaration. Very few dental graduates knew about these guidelines. Table 2 presents the responses of the medical and dental postgraduates to questions on their knowledge of healthcare ethics.

More medical postgraduates considered knowledge of bioethics important in their daily practice than their dental counterparts. The dental postgraduates had encountered questions related to ethics from their patients less frequently than had the medical postgraduates. Most often, it was the medical rather than the dental postgraduates whom patients asked questions regarding the diagnosis. Of the medical postgraduates, 59.5% always discussed their daily cases with their colleagues, compared to 47.5% of their dental counterparts.

Table 1 Characteristics of study participants

The postgraduates had obtained their knowledge of bioethics from sources such as the Internet and newspapers, followed by their undergraduate training and experience at work. Nearly 68% of them had not attended any bioethics training during their postgraduation.

Nearly 98% of the medical postgraduates knew that their institution had an ethics committee, whereas only 79% of the dental postgraduates were aware of this. Most of the postgraduates were not sure if there was a separate ethics committee for animal and human research. As for the various roles of ethics committees, 76.6% and 75.4 % of medical and dental postgraduates, respectively, felt that the role of ethics committees is to conduct bioethics conferences. Nearly the same percentages thought that the role of these committees is to teach bioethics to students. Table 3 shows the students’ responses regarding the role of ethics committees.

Nearly 46.9% and 80.3% of medical and dental postgraduates, respectively, believed that they knew best, irrespective of the patients’ opinion (Table 4). In case of any wrongdoing in treatment, 80.2% of medical and 62.3% of dental postgraduates informed their patients.

Nearly 83.8% of the medical postgraduates agreed that informed consent was required for treatment such as surgery, but did not feel it was necessary for investigations. The corresponding figure for the dental postgraduates was 77.1%. Of the medical postgraduates, 11.7% agreed that ethical conduct is required to avoid legal issues. The corresponding figure for dental postgraduates was 16.4%. Overall, 92.7% of the participants had obtained informed consent for their research thesis. Thirty-five per cent of the postgraduates correctly expanded the abbreviations IRB, ERB (ethical review board) and IEC (institutional ethics committee), while 51% provided the wrong answers, and 14% reported that they had not heard of these terms.

The seniority of the students and their gender did not make any significant difference to their knowledge of ethics.

Forty-eight per cent of the medical respondents reported that they would respect the decision of their patients to refuse treatment, whereas the corresponding figure for the dental postgraduates was only 27.5%. As can be seen in Table 5, when faced with ethical dilemmas, it was the heads of departments who were consulted most often (by 62.2% of medical and 55.7% of dental postgraduates), followed by the students’ supervisors. The ethics committee was the third choice (9% of medical and 1% of dental respondents).

Table 2 Participants’ knowledge of healthcare ethics

Table 3 Responses regarding ethics committees

Discussion

This is probably the first study to assess the knowledge, practices and attitudes related to healthcare ethics among postgraduates in medicine and dentistry in India. While the results of the study show that there is a difference between the dental and medical postgraduates’ knowledge and attitudes, it is not significant. The responses are reflective of categories such as different subspecialties, ie medical, surgical, preclinical and dental, year of study and gender.

Table 4 Attitudes of participants towards healthcare ethics

Dental postgraduates encounter ethical dilemmas less frequently than their medical counterparts. This probably explains the difference between the two as far as appreciation of ethical issues is concerned.

The respondents had obtained their knowledge of ethics from various sources. Though it appeared that their postgraduate training was a key source of knowledge, it did not contribute more than their experience at work, their own reading and what they learnt by attending seminars. One reason for the difference in knowledge between the medical and dental postgraduates could be that perhaps only those who had encountered ethical issues may have explored other sources of knowledge, such as continuing medical education or workshops. The undergraduate ethics training does not adequately equip postgraduates to deal with the complex ethical issues they encounter in their daily work, which involves direct and often crucial intervention in others’ lives (12). A separate module for bioethics, accompanied by evaluation, needs to be incorporated into the medical and dental curricula. The present medical and dental curricula, drawn up by the MCI and Dental Council of India, do not prescribe evaluation either by a written or oral examination (4, 5, 6). Unless such evaluation is incorporated, medical teaching institutions and students will not feel that the learning of bioethics is important.

Bioethics or medical ethics has to be taught by a specialist in medical ethics. At present, the forensic and community medicine faculties teach medical ethics and they focus more on medical jurisprudence (4, 5). There is a need to encourage training of medical faculty in ethics or bioethics and eventually, to create a separate and independent department of medical ethics or bioethics. Bioethicists from different backgrounds, such as the social sciences, philosophy and medical sciences, could be faculty members in the department of bioethics.

It is interesting to note that though both the medical and dental postgraduates were aware of the difference between animal and human research ethics committees, they did not know about the functions of the ethics committee in their institution. A similar observation has been made by studies conducted elsewhere (7,13,14). This could be due to the committees’ limited role, which perhaps relates only to research ethics and not to clinical ethics training.

Most of the research carried out in dentistry is by postgraduates and very few studies are carried out by independent researchers or faculty members (15, 17, 18). Most ethics committees review the research proposals, unless the study is funded. Sometimes, a subcommittee of the main IRB is formed to review postgraduate research. The data available in 2003 showed that only 3% of dental teaching institutions in India (n=292) had effective research ethics committees (19). This is bound to result in a lack of knowledge of the functions of ethics committees among postgraduates. The master’s programme in dentistry does not have a mandatory module on bioethics or research ethics (6).

Unlike the dental postgraduates, the medical postgraduates knew about most of the issues pertaining to the practice of ethics. The difference in their responses to issues such as adherence to the patient’s wishes, confidentiality, the paternalistic attitude of doctors and the need to obtain consent for procedures can be traced to differential training in bioethics.

The majority of the respondents chose to consult their head of department to resolve their ethical dilemmas, while the thesis supervisor was the next preferred option. Another study (7), too, found that most students preferred to resolve ethical issues with the help of their departmental heads rather than by approaching the ethics committee or bioethicist consultations. The expertise of the heads of department and thesis supervisors on ethical issues is uncertain, and it is doubtful whether they would consult the ethics committee to resolve ethical dilemmas.

Most of the bioethics expertise in India is concentrated in research ethics, which is different from clinical ethics. The majority of the ethics committees focus on the ethical protection of human beings in research settings. The existence of clinical ethics committees in hospitals is very important for moral deliberation on clinical cases. We suggest that healthcare personnel be trained to use different methods of deliberation on the moral issues (20) involved in clinical cases – a standard practice in western medical training. These methods need the expertise of clinical bioethicists who can form a part of comprehensive training in bioethics for healthcare personnel.

We could assess the basic knowledge and attitudes of postgraduate medical and dental students regarding healthcare ethics in order to obtain basic information for the framing of a bioethics course in the medical curriculum. This study has the limitation that it does not cover a wider range of postgraduates, as well as the fact that it is only descriptive in nature.

Conclusion

Medical and dental postgraduates frequently encounter ethical issues in their training, but lack the sensitivity to resolve these dilemmas. The dental postgraduates have less knowledge of healthcare ethics and the practices related to it, compared to their medical counterparts. The incorporation of a bioethics curriculum in the initial period of the graduation and post graduation programmes would be beneficial.