Introduction

Ethics teaching has been shown to have a profound influence on medical professionals’ attitudes (1, 2). It has been suggested that ethics training should be introduced during medical school and residency, including the surgical residency (3, 4). Today, institutions all over the world have developed guidelines for ethics in clinical teaching and surgical residency programmes (4, 5, 6).

This survey to assess the knowledge, attitude and practice of medical ethics among surgical team members of university hospitals was conducted in three university hospitals of Karachi, from December 2003 to March 2004.

Survey of medical ethics

A standardised questionnaire was developed and tested, containing 10 questions on consent, confidentiality, knowledge of the law pertaining to trauma victims presenting in the emergency department, teaching and knowledge of ethics. The correct answers were based on the Pakistan Medical and Dental Council’s code of ethics. The questionnaire also included a section on demographic data such as age, sex and years of clinical experience.

The questionnaire was distributed to surgical team members in two government university hospitals and one private university hospital in Karachi. Potential respondents included recently graduated interns and residents under training of different grades, registrars, senior registrars, consultants, assistant and associate professors. Respondents were selected on the basis of convenience sampling, and approached by at least one of the four authors in person. The questionnaires were completed by the respondents in private and were handed back to investigators in sealed, unmarked envelopes.

The responses were analysed on SPSS10.0 for frequency and correlations. Chi square test was applied on the answers to evaluate significant differences between gender and clinicians working in the public and the private sectors.

Results

120 participants were approached and filled the questionnaires, out of which 101 were included in the study. 19 questionnaires were excluded, as the information provided was either incomplete or incomprehensible. 68 of the 101 respondents were male. Sixty-nine were residents, registrars and specialists and 32 were interns. Fifty-four of 101 were from the public sector and 72 of 101 graduated after 1995.

More than half of respondents had heard of the Code of ethics published by the Pakistan Medical and Dental Council. However, only 44 of 101 had read the code either partially or fully. Seven had no knowledge of its existence. Forty-seven of 101 respondents reported that they took consent from their patients before surgery. Those who reported taking consent stated that they took consent between 50% and 75% of the time.

Forty-two of 101 respondents provided correct answers (conforming to the PMDC’s code of ethics) on questions concerning confidentiality and the law relating to trauma victims. Respondents with more years of clinical experience were more likely to give correct answers in this section.

Only 11 respondents reported having been taught ethics in medical school. Four did not feel the need for having ethics taught at the undergraduate level.

There was a significant difference (p < 0.005) between responses from public and private sector surgeons to questions regarding consent, confidentiality and knowledge of the law pertaining to trauma victims. In the public sector, consent was mostly taken by junior, non-operating members of the team. In the private sector, the operating surgeon primarily did it personally. Out of the 42 respondents giving correct responses to questions on confidentiality and the law pertaining to trauma victims 34 were from the private sector.

Nine out of 29 (32%) surgical team members who graduated before 1995 took consent more than half of the time. 22 of the 72 (30.5%) graduating after 1995 did so. 21 out of 41 in the senior group and 30 out of 59 in the junior group had not obtained knowledge of clinical ethics through reading. However, the senior group was much better at answering direct questions (table 1).

There was no significant difference in responses between male and female surgical team members.

Discussion

Both knowledge of medical ethics and its application were poor among surgical team members in the Karachi hospitals surveyed. We suggest that medical ethics should be a part of the undergraduate curriculum. Similarly, interactive workshops, discussions and perhaps continuing medical education programmes on medical ethics, arranged on a large scale, will educate practicing professionals.

Pakistan as a Muslim country with a specific socioeconomic and cultural environment has its own code of medical ethics encompassing the daily problems faced by medical professionals. This must be implemented.

Our study revealed that only 44 of 101 respondents actually read the code of ethics. As these were professionals belonging to university hospitals one would imagine that they would have maximum exposure to discussing ethical and legal issues related to medical practice. These professionals are also responsible for educating medical students and junior team members (8), as students are expected to learn about morality through their association with their teachers (9).

If there is a single ethical concept more closely related to surgery than to any other aspect of medical care, it would be informed consent (4). All surgical procedures are predicated on the patient having decided to give the surgeon permission to operate. It is at the core of clinical practice and has universally been recognised as an essential safeguard, to ensure the preservation of individual rights (10). Our study showed that only 47 of 101 surgical team members took consent, and even these did not do so consistently.

In another study conducted in Karachi, a lack of awareness of informed consent was seen in patients (11). On the other hand, several reports suggest that surgical residents often do not proceed with an optimal consent process because of time constraints (12, 13). Other reports suggest that people obtaining consent may not understand the procedure for which they are obtaining consent — even though they are supposed to explain the procedure to the patients. (14, 15, 16, 17). These studies highlight the need to better educate surgical residents in the operative procedures in a way that enables them to obtain meaningful consent.

Breach of confidence by a doctor is a highly unethical practice, though numerous debates related to confidentiality arise on issues of confidentiality vs. law, communicable disease confidentiality vs. spouse knowledge of the disease, information to be given to police regarding trauma or assault of any kind vs. treating the injured. Confidentiality outweighs all except where danger to life of another individual is present; only then must the law enforcers be informed. In our survey the majority of respondents were not clear on these issues.

Still it was heartening that all except 3% of respondents were willing to participate in workshops on medical ethics and agreed that it should be taught in the undergraduate curriculum.

Conclusion

Overall, this study reflects the current situation of knowledge, attitudes and practice of ethics by clinicians in Pakistan where ethics is not taught as a subject at the undergraduate or postgraduate level. Though the PMDC guidelines clearly state that medical students must be taught ethics and evaluated, none of the public or private sector medical colleges in the country have made it a mandatory part of their curricula. Similarly, ethical issues are not touched upon during postgraduate training and examinations. The only guidance our students and clinicians get on ethics is through seminars and workshops conducted by a handful of concerned individuals in the city. Through these efforts along with awareness among the clinicians and patients, ethics is becoming a popular concern. During the last five years we have seen developments like Hospital Ethics Committees in a few institutes, ethics awareness programmes, and reports in the media asking for ethics to be made a mandatory part of curricula. A much broader effort at the national level is needed.

Internationally, discussions centre on ‘micro ethics’ like cloning and euthanasia. In our country we are grappling on the basic questions of ethical professional practice (2). The importance of moral and ethical issues in surgical programmes is not new. The Accreditation Council for Graduate Medical Education has endorsed the need to address ethical issues in medical practice. These issues deserve more attention in future.

Table 1: Correct responses in varying seniority groups