DISCUSSION
Medical ethics and medical education: some thoughts
Avinash N Supe
Medical ethics and medical education could mean different things to different generations, different students. So we sought people’s experiences, and their comments on what medical ethics mean in the lives of students and teachers today. The questions were constructed so as to identify the links between medical education and ethics.
We carry, below, an essay by a professor at KEM hospital, Mumbai. This is followed by the comments made by a medical student and practising doctors. The reflection from persons working in rural areas are meant to broaden the picture. Finally, we present a reprint from the National Medical Journal of India on a programme on medical ethics. The process of gathering these comments suggested that medical ethics is not a concern of the medical education system.
We urge readers to send in responses on this issue.
A teacher’s perception about education of ethics in medicine
The concept of imparting formal education on ethics in medicine is fairly recent in our country. The word ethics meant to me a set of moral values one should follow during one’s professional or social life. In short, I thought it was an unwritten code of conduct or norms to be followed by everybody in society. As far as I remember, this topic was never discussed in my school.
Twenty years ago when I was a medical student, the word ethics was used by forensic specialists twice or thrice. Though the issue of ethics did come up in casual conversation once in a way, there was no formal education imparted or discussion held on these topics. There used to be some private discussion about unethical medical practices in the form of unnecessary investigations and surgeries performed in private practice. This was usually during teatime or in the canteen, more in the form of a chat or sharing information with each other. There were occasional comments during ward rounds regarding ethical dilemmas in patient care.
Bad memories
As a student, I was once greatly disturbed by the behaviour of a medical registrar under whom I was doing my clinical term. There was a poor old man who had bilateral lung tuberculosis. He was admitted with a pleural effusion, which was treated in the ward. When he was advised discharge from the hospital, he could not go home for two days because there were no relatives to take him away.
My registrar got very angry and passed a Foley’s catheter in him, gave him an injection of furesemide and clamped the catheter. The patient had retention of urine and suffered in severe agony for two or three hours until the clamp was released. The next day, the patient ran away from the ward.
The same registrar used to hit patients routinely while examining them in the emergency ward, especially if they were drunk or unco-operative. We were extremely scared of our registrar and therefore kept quiet.
Later on when I worked as a resident I used to get disturbed by the behaviour of some of my seniors with patients. One of my bosses was extremely corrupt and used to openly demand money from patients by asking them to visit his consulting rooms. As I never had any definite evidence of such dealings, this could not be openly discussed with the senior teachers.
However, this is changing. Over the last 10 years there has been better awareness about ethics. Formal discussions have been held in open conferences and institutional programmes. Some articles have been published in various journals regarding patients’ rights and malpractice.
Ethics education
To introduce education of ethics in our college, we have included two topics in our co-curricular programme, SHIDORI, which has been conducted every year for the last four years, for every intern and second year MBBS student.
The first topic (for interns) deals with ethical aspects of behaviour with medical representatives. This is conducted by showing a videocassette (prepared by the department of pharmacology, JIPMER, Pondicherry) of an interview with a medical representative and followed by a discussion on various critical issues such as accepting costly gifts and sponsoring trips.
The second session (for second-year MBBS students) includes a discussion on ethical problems associated with clinical practice. This programme is carried out by inviting reactions from students on various common clinical situations.
Group discussions
Both sessions are conducted as small group discussions. The emphasis is placed on autonomy of patients, their rights, and justice. Students have rated most of these sessions as useful and interesting. However, it is necessary to evaluate the long-term effect or impact of these sessions on students’ behaviour, something which is very difficult to assess.
Though these ethical dilemmas are discussed, students continue to get exposed to corruption and malpractice in every field, such as university examinations and entrance examinations, by witnessing full-time teachers practising privately, and so on. Malpractice in examinations has worsened since the introduction of coaching classes.
Therefore students do not get motivated. In fact, they get frustrated and forget about these discussions in the loHEADLINE: Medical ethics and medical education: some thoughts Absract: Medical ethics and medical education could mean different things to different ng run. Surprisingly most of the students thought that there was nothing wrong in accepting gifts or going on trips sponsored by pharmaceutical companies.
The basic problem appears to be a lack of appropriate role models. Such role models alone can promote the development of honest and non-greedy attitudes.
Discussions on ethical dilemmas have very little influence on medical practices or medical practitioners. These considerations are never taken seriously by them. Most practitioners continue to practice as it suits them. This becomes apparent when various aspects are considered such as consent for research trials, explaining to patients about treatment and alternative methods, unnecessary investigations and their harm to patients and cut practices.
Capitation fees and ethics
I agree that students who have paid a high capitation fee or tuition fees are likely to take steps, even if they are unethical, to recover the money. However, I feel this is not restricted to students from capitation colleges. Some students from non-capitation medical colleges behave in the same manner. The behaviour depends, upon the individual moral values.
I feel is unrealistic for any practising medical doctor to remain ethical and honest and prosper economically as well, in a corrupt society like ours. At best, they can probably reduce the degree of corruption or avoid crass unethical behaviour. I greatly appreciate and respect the effort in producing a journal like Issues in Medical Ethics, but I feel that this will have very little impact on the health practices in society.
As a teacher I have occasionally wondered whether by trying to nurture moral values in my students, I am making them unhappy. If consciousness of such values is not developed, students becoming practitioners will adjust to a corrupt society by rationalising their acts. They will not feel guilty; they will try to balance morality and practicality, a task which would leave them unhappy and frustrating.
In spite of such doubts, I will continue to work to spread ethics education, whether or not I succeed.
A student’s reflections
Nishant Kumar
What did the word ‘ethics’ mean to you before you joined medical school? Can you remember if and how the concept was discussed in school?
The word ‘ethics’ meant rules of conduct, moral principles, science of morals. Moral Science, which is taught in Std V to X, relates to various ethical issues linked with religious scriptures.
Did your medical education include any discussion of medical ethics?
Very little time was spent on medical ethics per se. But a few lectures were held in the first year and in the third year under “Preventive and social medicine”.
How much time do you estimate was spent in any discussion of ethics, in all your years of medical school?
Four to five hours. Spread across the course of the medical education.
What did this discussion consist of? Did it concern ethical medical practice or ethical dilemmas in patient care?
Discussions were vague, and came up only during clinics when any such topic came up, it was usually a passing reference and little attention was paid by the students or the professors.
Where did this discussion take place, and in what form? What was the content? Official classroom lectures? Seminars? Comments on cases during ward rounds? Consultation with senior doctor about a specific case?
In the first year, two to three lectures were delivered on the conduct of doctors and their relationship with society and their patients. In the following years no special attention was paid in the form of seminars, but there was some discussion during lectures, clinics and debates held on various problems which plague the medical system.
Students do discuss issues which bother them, about their future, or about their immediate conduct. The issues discussed are very broad-based including things like: counselling before and after testing for HIV, responses to a pregnant woman testing HIV positive mothers, subjecting patients to unnecessary investigations because of the nexus between doctors and laboratories.
There were other various issues discussed about our day-to-day conduct as doctors and what was expected of us from our seniors, colleagues and patients.
Please describe a situation in medical school in which you had to make a decision which was not based on medical knowledge alone. How did you resolve it? What do you think were the principles you used to resolve it? What do you think was the contribution of your medical education – formal and informal – in helping resolve it? Do you think you would have resolved it differently?
In the second year of medical school I was in the OPD Clinic where I had to deal with an HIV positive man. The dilemma was whether to tell his wife who was completely dependent on him, that her husband had cheated on her and was therefore HIV positive, and that there could be a risk to her and their unborn kid. Neither husband nor wife knew what it meant to be HIV positive. This was real dilemma for me. Finally I told the wife that her husband was not too well, and that they should therefore abstain from intercourse for a while, till he got better.
Today in my final year in medical school I would be more direct in my approach and would tell the patients what they are suffering from in a compassionate way, and explain to them the seriousness of their ailment.
Have you ever been disturbed by practices by your seniors and teachers, their behaviour with patients and their relatives? Were you able to discuss your discomfiture with them and seek their explanation for their actions?
Sometimes due to being overworked the attitude towards the patients does tend to get callous.best example is the ease with which we sometimes give up on certain patients, because they have been with us for too long in the wards, as in certain debilitating diseases. No discussion was held in this matter in medical school, because I think the medical staff is just too over-worked, and this is something natural which could happen to anyone.
Do you see any connection between the discussion of ethical dilemmas in medical practice and the discussion of unethical practices in medical care?
There is a certain grey area between an ethical dilemma and unethical practice. The best example is over-charging patients and subjecting them to unnecessary laboratory investigations. This is something which is ethically wrong. The dilemma being between the survival of yourself and the economy of the patient.
The fact that students entering capitation fee colleges make a huge capital investment that must be recovered as soon as possible after graduation is said to be behind many medical malpractices. Do you agree?
Yes. Just like any other profession even doctors need to earn their bread at the end of the day, and expecting overwhelming charity from them is absurd.
During discussions on medical ethics and malpractice, we are often told that it is unrealistic to expect medical doctors to remain honest and ethical when the rest of society is corrupt. Do you agree with this view?
Yes. When the whole social fabric is corrupt, to expect certain individuals to stand out is expecting too much.
Do you feel there is a place for a journal devoted to medical ethics in India?
Yes. In such a fast -paced world where ethics do tend to be neglected in the race to reach the top, such a journal provides a breath of fresh air and acquaints us again with our duty as doctors.
Nishant Kumar, final year MBBS student, Seth G S Medical College, Parel, Mumbai 400 012)
