Introduction

Does it make sense to teach ethics in an unethical setting? Should one ignore or foster ethics in an unjust environment? Why bother about ethics or morality when the medical establishment does not care much about them? These are important questions for conscientious medical teachers and practitioners who work in morally compromised institutions. In an international meeting on bioethics, the issue of teaching bioethics in an unethical setting came up for informal discussion among participants from some Asian countries (1). Of course, it would be nice to be engaged in ethics education if biomedical ethics was given due recognition and the moral environment of the institution was something to be proud of. Unfortunately, that is not the case at present in several countries, including India, where medical establishments often tarred by published reports of corruption neither encourage nor take pride in good ethical practices of medicine. Worse, they seem to have lost their moral compass (2, 3). In this complex web of unwelcome realities, even well meaning educators may be sceptical about the need to teach ethics. The problem is not about how to develop an ethics curriculum, because to develop an ethics curriculum may be challenging but it is certainly doable. So, what is so special about ethics education? Why does the teaching of ethics in an unethical setting appear to be so problematic? And, more importantly, what should be our vision in such a situation? This article delves into some concrete realities of the Indian scenario and attempts to address the question of why teaching and learning of ethics should be initiated-not pushed aside-in an unethical institutional setting.

Medical ethics in contemporary India-betrayal of moral heritage

In ancient times, India had developed her own indigenous traditional system of medicine, Ayurveda, and had an elaborate code of medical ethics that surpassed the Hippocratic Oath in both “eloquence and moral idealism” (4). Modern western medicine was introduced into the Indian sub-continent in the early 19th century by the British colonialists (5). For sociopolitical reasons, Ayurveda was segregated from modern western medicine during the British era and, significantly, that colonial legacy continued even after India’s independence in 1947 (6). Notwithstanding considerable progress in socioeconomic conditions and the quality of healthcare facilities, gross disparity continues to exist in health status indices and in access to healthcare between rural and urban areas of India (7). With the private sector contributing 75% of the total health expenditure and a well-developed system of modern medicine in cosmopolitan cities, India has been a destination for “medical tourism” that is forecast to become a $2.3 billion business by 2012, while India’s poor continue to suffer second-rate healthcare (8).

For many Indian physicians, medicine is a vocation-a calling-to serve the needy and vulnerable in resource-poor settings, particularly in remote areas. The ethos of the Indian medical establishment, however, has changed for the worse in recent decades. Medicine, historically considered a noble profession, has become a moneymaking enterprise capitalising on human suffering. Sadly, reports of academic dishonesty, gross professional misconduct, moral decay and corruption are commonplace in Indian medicine (3, 9, 10, 11). Statutory bodies and professional organisations have not only failed to promote a culture of humane medicine, they lack moral vision, positive will, and effective mechanisms to regulate unethical practices in medicine which now fall under the purview of the Consumer Protection Act, 1986. The extent of moral degeneration and abuse of power can be gauged by the fact that the president of the Medical Council of India (MCI, the Indian equivalent of the General Medical Council, UK) was removed from his post by an order of the high court on charges of corruption (10, 11).

Few will disagree with the statement that the curriculum of Indian medical colleges is out of touch with the reality of healthcare needs of the Indian people. Bioethics is virtually non-existent in India, both as a subject of academic pursuit and as a platform for public debate on science and medicine. In the land that gave birth to the Vedas and Upanishads, there is no place for philosophy, spirituality, ethics, or the humanities in the medical curriculum. Thus, except for a very few religious minority institutions, medical students in India get almost no exposure to humanistic, philosophical or spiritual worldviews during medical education and training. For all practical purposes, ethics education in Indian medical colleges is limited to learning bedside manners and a few neglected lectures as part of medical jurisprudence.

Ethics is not like differential calculus

Perhaps the first issue to address is the rationale behind the teaching of ethics: can ethics be taught? The philosopher Socrates argued in favour of teaching ethics. His argument was unequivocal: we need the knowledge of what we ought to do. Knowledge can be taught, thus the knowledge of what we ought to do – ethics – can also be taught. Buddha not only taught ethics to his disciples, but also inspired them to live ethics. For millennia, in the Indian sub-continent, the satguru or acharya (the master) gave lessons to their pupils in all spheres of life to live ethically. Since theories of moral development were formulated in the early part of the last century, educators mostly have agreed that ethics can be taught-maybe to varying extent-with moral development taking place in successive stages (12).

Second, is ethics like any other subject of study? In what ways is ethics different from other subjects? The teaching and learning of ethics has some unique characteristics that deserve thoughtful consideration. Morality is intertwined with what makes us human-moral development is not necessarily always related to formal school or college education. Thus, a person without any formal education may have sound moral judgements about right and wrong and live perfectly well as a moral person. The purpose of ethics education in healthcare institutions is to emphasise the moral nature of the art and science of medicine and sensitise the learner to ethical issues. Ethics is not something like, for example, differential calculus that one may learn in school or college only to forget it in later years while doing an office job. Moreover, learning the subject matter of ethics does not end in good grades in transcripts or college graduation; rather, the essence of learning ethics lies with ethical practice-being ethical-applying ethical reflection and analysis to deal with a myriad life issues.

Third, who will be the preferred teachers in ethics education? Apart from the uniqueness of ethics as a discipline or field of study, the role of teachers in ethics education-either as role models or as mentors-seems to be of paramount importance. While attributes like conscience, integrity, and character of the teacher are undoubtedly important in education, these qualities are required for instruction of ethics. For example, it isdifficult to imagine that a teacher with a proven track record of unscrupulous activities can teach ethics. To teach ethics you need teachers who value and care for ethics in individual and collective life, practise ethics in their academic and professional worlds, and in a way act as role models or mentors for the learners.

The ethical climate and the hidden curriculum of the institution

What about the context in ethics instruction? Does the workplace-or, more specifically, its moral environment-play any role in the teaching and learning of ethics? If yes, how?

Education is a human praxis and thus quite naturally ethics education takes place not in a vacuum but in the thick of concrete realities. Ethics curricula in healthcare professions may thus differ in aims and methodology of instruction, depending on context and needs (13). The importance of the ethical climate of the institution can best be understood if we ask ourselves whether an ethics department can be funded by “black” money or patronised by an institution that is part of the illegal “kidney bazaar”. I doubt it. It is very unlikely that future healthcare professionals will take a serious interest in ethical reflection and analysis if the workplace reflects such an immoral environment. Thus, the morally lax atmosphere of an institution would be a deterrent in learning ethical behaviour and practice. Educators have also drawn attention to a phenomenon called the “hidden curriculum” in which students learn more about acceptable and unacceptable behaviour from institutional arrangements and non-verbal cues in the classroom and on theward (14). The hidden curriculum, more so in an institution of questionable moral integrity, may pose a serious challenge to ethics education. It is not surprising, therefore, that some wellmeaning teachers will be sceptical about the rationale behind instruction of ethics in an unethical institutional set-up. Does this mean that we should stop thinking and “do nothing” in so far as ethics education is concerned? Is doing nothing a morally sound choice?

While the lack of attention to ethics education in India is understandable-after all, what good does it do to teach ethics in a setting marked by corrupt behaviour and injustice?-it is unjustified and a terrible mistake for medical educators to resign themselves to morally questionable practices in healthcare, for a number of reasons.

Doing nothing is an active decision of moral significance

The choice to do nothing is not necessarily a value-neutral one; it also has a moral dimension, more so when doing something is needed to do good and avoid harm. The apparently harmless position of doing nothing amidst an outbreak of an epidemic, is, in fact, doing something that kills human beings. Similarly, doing nothing when ethics in medicine is needed perhaps more than ever kills the moral nature of medicine.

Ethics education, wherever it occurs, necessarily takes place in a less-than-ideal context, for there is no need for ethics educationin an ideal society, whatever that may mean. It is also true that the noble aspiration of medicine-to do good and serve human beings-influences the mental landscape of learners in myriad ways. Thus, an institution marked with moral integrity is certainly preferable, but not absolutely required, for teaching ethics in medicine. Further, the role of the hidden curriculum must be acknowledged, but need not be exaggerated, because in an unethical setting there may not be anything that is actually hidden.

The choice of doing nothing is also unrealistic and impractical. It means-in reality-leaving things as they are in medical education and practice. On the face of it, this means that no educator would take any serious interest or initiative in ethics education and nobody would put the agenda of ethical values and principles on the table of academic medicine. In that scenario, either we will all be united in hopeless misery, or we will hope that things will get better in the future, without knowing how and why. The first option of endless darkness does not merit any comment. The second, more hopeful, option is wishful thinking, if not daydreaming, that our students will somehow be gifted with moral values and principles and they will simply be inspired to practise medicine ethically even in a morally compromised institution. It means that in the absence of any ethics education, our future healthcare professionals will value, appreciate, and learn ethics in medicine – presumably from nowhere and nobody.

The future in that scenario, not very arguably, will be horrendous. With nothing to counterbalance the unethical tilt, and practically no agency to safeguard the moral premise of medicine within the profession, medical educators and practitioners will increasingly behave like merchants of immorality. Professors of medicine will stock black money, surgeons will be involved in organ trade, doctors will keep on taking kickbacks (“percentage” or “cut-money”), and yet, amidst all these medical maladies plaguing the profession, our students, the future healthcare professionals, will remain “pure in character” as promulgated by the MCI code of ethics (15). This kind of pure in character product, manufactured in the process of doing nothing, will perhaps increasingly appear in persons like the former head of the MCI who was stripped of his post for corruption. Doing nothing is potentially – no, not potentially but actually – the prescription for doom, crafted by inaction on our part and approved by the apathy of our medical council and professional associations.

There will be some who will understand

What is the point of telling people the noble truth when they seem not to care and are busy with mundane things? Faced with this question from Mara, the Evil, Buddha replied, “There will be some who will understand.” The spirit of this powerful saying gives one endless hope. When a clinician starts managing a patient, there is hope that the patient will recover. Hope is something that keeps us moving when things are not all right. Historically, medicine is considered the art of healing and hope has justifiably been treated as a cardinalvirtue of medicine (16). The same is true for ethics education. No matter what the nature of ethics practised in an institution, the possibility always exists that there are people who are concerned about ethical lapses and who would like to see a change in the less-than-ideal ethical climate. The humble but spirited efforts of these conscientious physicians and educators may gain momentum and may make a difference to the ethos of medicine. These medical practitioners and educators may not necessarily articulate their thoughts and ideas in bioethical jargon like “deontology” or “utilitarianism”, but they have the potential to pioneer a positive change in the moral environment of institutional medicine. This author is respectfully aware of a few medical teachers who did not draw black money as part of their salary, refused to fabricate patient records to “fool” the MCI inspectors, and declined the request of the management to pass unworthy students in professional examinations. Spirited and not inconsequential efforts by such people may go a long way in sensitising students to issues of ethical significance and pave the way for ethics education.

Educators need not wait for significant structural change in the medical curriculum. They can use existing opportunities such as tutorials, seminars, journal clubs, and clinical grand rounds to touch upon important ethical issues in medicine and engage students in ethical reflection and analysis. For example, the problem of cheating in medical school can be raised for discussion with students. A basic science teacher can touch upon ethical issues arising out of biomedical research with stem cells. A pharmacologist can discuss ethical concerns with reference to drug trials. During clinical rounds, ethicalsocial- legal issues can be discussed along with clinical aspects of patient care. A specialist in critical care medicine may also engage students in discussions on ethical decision-making in end-of-life care. Neuroethics-the neural basis of ethical behaviour-may be on the agenda of seminars on recent advances in neurosciences. Organising and attending seminars, clinical meetings, and journal clubs gives an opportunity to raise important issues pertaining to ethics in medicine. In an unethical setting even a small number of committed individuals may thus function as the nucleus of a core group to further the ethics agenda. Many senior faculty members or those working in administrative posts can also walk the extra mile to put ethics back on the agenda of academic medicine. Sustained initiatives of this nature are likely to gain momentum in due course. The Indian Journal of Medical Ethics, for example, can organise a platform for interaction and exchange of ideas among educators interested in ethics education. The National Bioethics Conference can formulate guidelines, set the framework and foundation of ethics education, and push for its inclusion as part of the medical curriculum. There are many possibilities we can explore once we are convinced that it is necessary to pursue ethics education in spite of, and amidst, unethical institutional settings.

Let us not mince words. The point is-simply-small things also count, and what we do also matters. Whether one believes in the doctrine of Karma, or the western philosophy of consequentialism, the fruits of our thoughts, words, and actions are there in the short or long run, or both. As a profession intimately connected with life and death and with the wellbeing of individual and collective life, medicine is obliged to maintain its moral premise, to keep its allegiance to ethical values and principles both within and outside the profession, even within a morally challenged set-up. We have an obligation of a moral nature-to ourselves, our children and families, our society, our profession, our country-that needs to be fulfilled for the sake of everything near and dear to us and considered sacred in life. Without waiting fruitlessly and endlessly for a change in the deteriorating ethical climate of Indian medicine, conscientious educators need to go ahead and introduce ethics education, taking small steps at a time, because that is just the right thing to do. It is time to take the challenge head-on.