0911P- ARE WE TEACHING MEDICAL ETHICS IN THE RIGHT WAY?

Dr Abdul Aziz al Kabba, Acting Dean of the Faculty of Medicine, King Fahd Medical City, Riyadh Saudi Arabia. <aaalkaabba@kfmc.med.sa>  

Introduction

Despite a history of medical education spanning 2500 years, it has only been in the last 30 years that medical ethics has come of age by being formally included in medical curricula.(1). By 1990, medical ethics had become an integral part of the core curriculum in most American medical schools. At present, most medical schools in the UK include medical ethics as part of their education curriculum. (2)

In Saudi Arabia (KSA), we have only begun to teach medical ethics to our students within the past 10 years. In the past seven years, medical colleges in KSA have also begun teaching medical ethics albeit in a simple, less comprehensive way.

Background: Medical Ethics in Saudi Arabia

As we know, teaching medical ethics to undergraduate students is not easy; rather, it is often challenging. In Saudi Arabia we have 13 medical colleges and unfortunately only six of them teach medical ethics to their students. Among the six colleges teaching ethics there is a focus not on medical ethics per se, but more on ethics relating to cultural Islamic ethics. In fact, even the medical ethics curricula in these six medical colleges contain few topics related to medical ethics; moreover, the method of teaching is mainly traditional with a reliance on summative assessments at the end of these courses. In addition, one of the main challenges is a lack of qualified ethicists to teach medical ethics in KSA medical colleges.

The Future Of Medical Ethics Education: What do we need?

The problem of medical ethics in KSA has been identified above: there is a lack of comprehensive, modern medical ethics curricula at the undergraduate level in medical colleges. Also, we lack ethicists to teach the material. The General Medical Council (GMC), in “Tomorrow’s Doctors,” put forward a workable solution that fits into the medical college curricula in KSA. The GMC proposes that students, by the end of the medical curriculum, should “acquire a knowledge and understanding of ethical and legal issues relevant to the practice of medicine and an ability to understand and analyse ethical problems so as to enable patients, their families, society and the doctor to have proper regard to such problem in reaching decisions.” (3). We can see from this that the focus on medical ethics extends from the undergraduate student to the rest of society.

In a 2002 study (4) out of King Faisal University, researchers reviewed the current status of bioethics teaching in medical schools to determine Saudi students' perception of its coverage in the formal medical education curriculum. Ultimately designed to make recommendations for improvement, the study used a self-administered questionnaire in a cross-sectional study of undergraduate students. In all, 14 clinical departments and 201 students participated in the survey. The researchers found that only 46% of respondents were satisfied with the current coverage of ethical issues in the formal curriculum; 23% were unaware of the value of the subject. [Students' approval rates were highest. – not clear]

The study seems to confirm that there is inadequate formal instruction on medical ethics in our developing country. The data also implies that we lack an optimum curriculum model for teaching medical ethics at the undergraduate level. Moreover, our current curricula in the medical colleges may not be modeled properly. Instead, we need a comprehensive curriculum model aiming to produce doctors that are able to competently and ethically analyse clinical situations. Importantly, ethical decision making would be improved by building upon a range of knowledge and skill of moral concepts in order to identify any inherent moral issues. The experience of medical ethics development in Western curricula (i.e. in North America, Europe and others) may provide a stimulus for our own educational development in KSA. For example, recent proposals on the future of undergraduate medical education in both the United States and the United Kingdom have called for a training process which serves to nurture – not suppress – desired virtues.(2,3)

CURRICULUM DEVELOPMENT: What content should be included?

The GMC's recommendations on improving the medical curriculum includes reducing the burden of factual information imposed on students. They proposed that a core curriculum, encompassing the essential knowledge and skills, and the appropriate attitudes to be acquired by the time of graduation, should be defined. The De Camp Conference helped to define these goals. Prominent medical ethicists in the United States attending this conference produced what they believed to be the essential short-term goals of core medical ethics education, including(5): The ability to identify the moral aspects of medical practice and to obtain a valid consent or refusal of treatment; the knowledge of how to proceed if a patient refuses treatment; the ability to decide when it is morally justifiable to withhold information from a patient; and finally the ability to decide when it is morally justified to breach confidentiality. Shaping these objectives into a culturally-appropriate medical education curriculum for all medical colleges in KSA should be a priority for the GMC.

Education Strategies: What Should We Use?

The S.P.I.C.E.S model developed by Harden et al. (6) can be used as a basis to review the consensus on the educational strategies to be used for medical ethics education. We support the idea that our strategy should be student-centred, involving multiple ways to apply problem-solving methodology grounded in integrated teaching. The format could be offer in a couple of ways: A single discrete course and integrated modules across the curriculum, or multiple courses or seminars with clinical rotations. Proper evaluation of the efficacy of this approach is critical, and there are several international scientific assessment methods highly adapted to KSA medical colleges.

Conclusion

Teaching medical ethics faces many challenges, including curriculum development and methodology. Comprehensive and culturally-sensitive medical ethics in KSA should be taught in clinical settings with scientific curriculum outlining clear objectives and basic (yet comprehensive) content covering the most important topics in medical ethics education. Even as scientific methodology may be adapted from North American or European “best practices,” our medical curricula should include the Islamic perspective on medical ethics. (4) Accordingly, students' integrity and character should also be properly assessed: Medical ethics extends from the medical colleges and well into the broader community.

References [will be formatted according to the journal]

1- Miles SH, Lane LW, Bickel J, Walker RM, Cassel CK. Medical Ethics Education. Coming of Age. Acad Med 1989; 64:705±14...

2- J Goldie. Review of ethics curricula in undergraduate medical education Medical Education 2000; 34:108-119

3- General Medical Council. Tomorrow's Doctors. Issued by Education Committee of the General Medical Counci l. London: GMC; 1993.

4-Umran Al-Umran, Khalid; Al-Shaikh, Basil Abdulrahman; Al-Awary, Bassam Hassan; Al-Rubaish, Abdullah Mohammed; Al-Muhanna, Fahd Abdulaziz. Medical ethics and tomorrow's physicians: an aspect of coverage in the formal curriculum Medical Teacher, Volume 28, Number 2, March 2006 , pp. 182-184(3)

5- Culver CM, Clouser KD, Gert B, Brody H, Fletcher J, Jonse A et al. Basic curricular goals in medical ethics. N Engl J Med1985;312:253-56.

6-Harden RM, Sowden S, Dunn WR. ASME Medical Education Booklet No 18. Educational strategies in curriculum development: the SPICES model. Med Educ 1984;18:284.