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

Dr. Abdulaziz F. Al-Kaabba, Associate Dean, Faculty of Medicine, King Fahd Medical City, Riyadh Saudi Arabia.

INTRODUCTION

Despite a history in 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⁾ The Health Professions Council of South Africa (HPCSA) subsequently realised the importance of medical ethics education and encouraged the introduction of such teaching in all medical schools in the country.⁽³⁾

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 are lacking ethicists to teach the material. The General Medical Council (GMC), in “Tomorrow’s Doctors,” has 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.”⁽⁴⁾ The focus on medical ethics extends from the undergraduate student to the rest of society.

In a 2002 study⁽⁵⁾ 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.

The study seems to confirm that there is inadequate formal instruction on medical ethics in our developing country. The data also implies that we are lacking 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.^(2,4)

CURRICULUM DEVELOPMENT: What content should be included?

The GMC's recommendations on improving the medical curriculum include 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:⁽⁶⁾ 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.⁽⁷⁾ 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. But what is the best are integrated modules across the curriculum. Proper evaluation of the efficacy of this approach is critical, and there are several international scientific assessment methods highly adapted to KSA medical colleges. The increase in bioethics education in preclinical curricula enables medical students to recognize ethical issues and determine right action. The authors sought to explore the ethical dilemmas medical students experience during clinical clerkships .Clinical clerks' experiences of ethical dilemmas might be mitigated if residency education and professional development mirrored the increase in preclinical ethics education, if ethics training included encouraging students to discuss ethical issues as they arise, and if educators developed innovative models of student evaluation.⁽⁸⁾ Teaching medical ethics to medical students requires a mixture of the moral, legal, psychological and philosophical aspects of the subject. The experiences of a teaching programme at Hannover Medical School will be described. The didactic concepts derived from these experiences are given under five headings: Ethics education should take place continuously from the first year of medical school onward. Ethics teaching should progress from concrete cases to more abstract and theoretical considerations. Real cases are preferable to paper cases. Practising skills is as important as teaching knowledge. Participation is guaranteed by small-group-teaching. The concept is supported by data from the evaluation of the Hannover courses.⁽⁹⁾

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.⁽⁵⁾ Accordingly, students' integrity and character should also be properly assessed: Medical ethics extends from the medical colleges and well into the broader community.

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