Introduction

Doctors and health professionals are frequently confronted with ethical dilemmas during their practice. Though bioethics has been recognised as a priority subject in medical education over the past five decades (1, 2, 3, 4), Indian medical curricula do not clearly address how to deal with ethical issues.

The objectives of teaching medical ethics should be to (i) enable students to better understand the implications of ethics in all aspects of their profession, (ii) prepare students to develop the ability to identify underlying ethical issues and problems in regular medical practice, and (iii) equip them to consider alternatives under the given circumstances and make decisions based on acceptable moral concepts and traditional practices. To achieve the broad goal of developing common morality among students, the teaching of bioethics is a continuous and consistent process during undergraduate medical education and beyond.

Classroom teaching of bioethics can focus on professional relationships, the patient–doctor relationship, and issues from the beginning to the end of life. It should also deal with values, ethical concepts and principles. Lectures have long been the standard method of communicating information. This mode of teaching, however, has been strongly criticised as it is associated with a lack of student participation and a loss of interest. Medical education literature supports both case studies and classroom exercises as effective methods of delivery, and these appear to be useful supplements to lectures and discussions (5). Active learning techniques allow students to participate through critical thinking and problemsolving, which are instilled through “instructional activities involving students in doing things and thinking about what they are doing” (6). Therapeutic recreation educators may be keen to consider using a wider variety of teaching methods. For effective teaching–learning of bioethics, it is necessary to integrate theory and practice, rather than merely teach theoretical constructs to students without helping them translate those constructs into practice (7).

Kirkpatrick (8) suggested that using stories for teaching could promote knowledge and values, besides being appealing and enjoyable. In his article, “Telling stories”, R. Ganzei (9) stated: ” …. Stories help us make sense of the world and give structure and order to our everyday lives. They tell us what is important and what is not, and give us a way to connect people’s individual experiences to those of others, as well as to universal truths. Indeed, stories are yet another way we put a human face on the world, which is something we have always needed and valued, whether we admit it or not”. A narrative is a literary work that involves the retelling of a story (10). It is an important discourse phenomenon and one of the ways to understand and learn from each other (11). According to the “homo narrans” theory, a personal narrative is the “paradigm of human communication”, one of the main activities performed on a daily basis (12, 13). It has elements like theme, character, plot and structure, setting and point of view in the structure (14). Various dimensions of the personal experience narrative (PEN) have been well researched, such as the structure of the narrative and its functions, ordinary events in the narrative and patterns of narrative discourse (15, 16, 17, 18, 19). Each of these elements of the PEN serves two purposes: referential and evaluative. Whereas the referential elements focus on the skeleton of the narrative, the evaluative elements explain and ensure that the story is worth recalling and understandable to listeners (11).

The PEN also has its cognitive, cultural, social and psychological functions. People tell stories to do something: to complain, to boast, to inform, to entertain, to explain, and so on (15). Using storytelling to transmit educational messages was a traditional pedagogical method practised in Indian culture, wherein spoken words could add life and meaning in referring to the event or scenario (20). In the context of bioethics in medical education, students may come across incidents, situations and interactions which require ethical judgement and deliberation. There is always scope to create a better learning environment in which students can be trained in ethical problems.

In order to prepare students to develop the ability to identify underlying ethical issues and problems in regular medical practice, the students of Pramukhswami Medical College, Karamsad, Gujarat, have been exposed to bioethics teaching since 2010. Until now, the various modalities utilised for teaching bioethics were lectures, followed by case-based discussion, case vignettes or debate and student presentations. As a part of teaching, the students were directed to observe the ethical behaviours of their peers and teachers and note down any significant moment or event which called for ethical explanation.

Here are a few interesting narratives written by students, now interns of Pramukhswami Medical College, Gujarat, who were exposed to bioethics teaching for the first time in 2011.

PEN 1

Background: The student writes a narrative from a patient’s perspective, based on real experiences during a clinical posting in the surgery ward.

Title: My day in the general surgery ward

I am furious and deeply hurt. I had a horrible day in the ward today. If only I could erase the memory of this day from my mind. I will never recommend admission to this place to anybody who is ill; it can make the sick feel sicker.

It had been just five minutes since I had settled on the cot allotted to me by the ward nurse and suddenly the bustling ward became silent. The nurses, who had been chatting merrily earlier, became serious. My treating surgeon had entered the ward. He is a formidable man. He was accompanied by a group of medical students. The surgeon came to my cot and the curious students surrounded my bed. It felt awkward. “This is a case of hydrocele,” he said. This was loud enough for it to be heard at least three cots away from mine. I had trusted the doctor when I revealed my condition to him. Now I felt betrayed. I was further alarmed by what he said next: “Today, I will demonstrate the physical signs of a hydrocele.” My heart started pounding. With every passing moment, my anxiety grew. He instructed me to go to the dressing room at the rear end of the ward, where he would examine me. He did not even bother to ask if it was okay with me.

Moments later, I lay on a cot in a tiny room, crammed with medical students, including females, exposed waist down, while the surgeon examined my private parts and said things about which I had no inkling. I could hear some of the female students giggling. It was upsetting. I stared at the white ceiling and waited for the rather uncomfortable experience to end.

I had been robbed of my privacy. I felt reduced to a mere body with a disease. I wonder as to how people consider doctors next to God; it is a false belief.

The questions that arise from this narrative are:

1. Do you think that the patient was right in feeling what he felt?
2. What do you think of the manner in which the clinical examination of the patient was conducted?

PEN 2

Background: The student narrates an incident, witnessed in an emergency room, which raises an ethical dilemma.

Title: An intern’s narrative

It was about eight in the morning when I had come for my assigned duty at the hospital. Just when I was putting my bag away and readying myself with my stethoscope, notepad and pen for the day’s work, a nurse called out to me. I rushed to the nurse’s station, assuming that the staff nurse needed my assistance. As I approached the nurse’s station, I found a group of about five nurses, gathered around the computer screen, engrossed in a discussion. They were laughing about something. One of the nurses invited me to come closer to the computer screen. I saw an X-ray of someone’s pelvis and noticed a foreign body in the rectum. One of the nurses explained to me that the patient had come to the hospital complaining that there was a foreign object in his rectum. The nurse suggested that the patient might have inserted a small glass bottle into his rectum and would not have been able to take it out it by himself. As I tried to grasp this odd clinical scenario, the nurses were laughing away and clicking pictures of the X-ray.

As an intern, my questions in this situation are:

1. How does the behaviour of the nurses make you feel?
2. What would you have done if you were in that situation?

PEN 3

Background: A student’s narration from the perspective of an old man who is expressing how exhausted his day at the hospital has left him.

Title: A tiring day at the hospital

That day I went to a hospital. Despite being a little scared, I walked in with faith. As soon as I entered, I noticed a humungous poster on medical ethics and values.

I approached the registration desk, where I was asked which department, I wished to consult. A case paper was then handed to me and I was asked to leave.

After asking about half a dozen people, I finally reached the area I was supposed to go to. After a long wait, I was called upon to see the doctor.

Me: Good morning, sir! Umm, for past few months, I have been feeling a little … (patient narrates his complaints)

Doctor 1: Yes, all that is fine, but what’s your problem now?

Me: Actually, I have this problem of … (patient explains his present problem)

Doctor 1: Okay. Only a portion of your problem is related to me, for which I will definitely treat you. However, you also need to consult this other speciality before I can further proceed with your management.

Me: So after I consult them, I come back to you?

As advised, I went to a see the second doctor. After hearing about my problem, he directed me to another doctor. This time, I considered it to be my last stop. But to my surprise, I was advised to consult a 4th speciality. At this point, I got a little frustrated. Thus, I decided to ask the fourth doctor, “Sir, what is the matter for which I need to consult all these people?”

Doctor 4: See, there are specialists dealing with various types of problems and this is how it works.

Me: Oh, I totally understand that, but all I am saying is if you all know that so many people need to be consulted, then why can’t it be a bit more organised? I am an old man, and being tossed around so much is extremely tough on me.

Doctor 4: You are not that sick that we will all come to you and treat you at one go. This is how we treat here and if it’s a problem, then you may figure it out your way.

Well then going home was the best option. I picked up all my documents and started to head out. Suddenly, I collapsed. Moments later, I was in a bed, surrounded by 10–12 people trying to examine me or do something I did not really know about. “Where am I? I was going home,” I said, while a voice from the crowd yelled, “Sir! You collapsed a while ago in the hospital. We are all trying to treat you”. AHHH, finally. At that moment, I just laughed and said, “At least now you guys feel I need some attention.” If only I had known earlier…!

Point of discussion on ethical issues from this narrative:
Enumerate the ethical issues hidden in this scenario.

Discussion

All the narratives above are based on certain situations in different settings and they depict unethical practices that reflect certain conflicts in the characters with reference to specific attributes of behaviour in a particular situation. The narrators, in our case, are interns who are trying to communicate their insights into different ethical principles. For example, ethical issues related to the privacy and confidentiality of a patient are reflected in PENs 1 and 2, and those of autonomy and non-maleficence in PEN 3. These questions were raised by the writers of the narratives on the basis of the feelings they experienced while witnessing the event and the application of the knowledge gathered after learning the principles of bioethics via lectures and case discussions. The sharing of such narratives in the classroom, followed by discussion, can help to add different perspectives and help the narrator and the class learn more about a scenario. These narratives reflect on cognitive, cultural, social and psychological functions and behaviour to complain, to boast, to enquire, to explain and so on (15). This approach of writing and sharing students’ experiences integrates theoretical teaching with actual practice, which can help students focus better on the goal of learning bioethics.

The affective domain is of the utmost importance and has to be given more emphasis in the teaching of bioethics.

The advantages of narratives are as follows:

First, in the process of reflecting together during teaching – learning of ethical issues, students can analyse, clarify and do some re-thinking on classroom situations and real-life experiences, and this can lead to a confirmation of or change in their ideas and practices.

Second, students would prefer an experiential approach to lectures, and the two approaches would complement each other and facilitate successful teaching (21), thereby helping in the development both of the cognitive and affective domains of educational objectives. Vygotsky also pointed out the relation between learning and social interaction. Engaging in reflective dialogue with one’s peers allows one to refine one’s ideas with respect to learning ethics (22).

Conclusion

Real-life personal experience narratives of interns, when used as case or situation analysis models for a particular ethical issue, will provide the other students with greater insights than would otherwise be the case. Doing this can change the classroom atmosphere, enhance motivation, improve the students’ aptitude and improve their attitude towards learning bioethics. This type of narrative can also change a student’s perspective as there are often implicit morals in stories or narratives which are authentic and can play a potent role in helping to look at problems from other viewpoints. It allows our minds to think outside the box of our own experiences and to develop creative ways to solve problems (23).

Students may be asked to maintain a journal of such narratives. Though challenging, it can be used as a tool to assess a student’s understanding of ethical practice. Real-life narratives of interns, when used as case or situation analysis models for a particular ethical issue, will enhance other students’ insight and give them a morale boost. Also, by using reflective narratives, we can create the possibility of bringing about changes in ourselves and the students, both in the learning and practice of bioethics.